My mother has been living with us since May. She is on her second round of PT and OT and has a home health aide. Any advice?

What are the specific goals for PT and OT? Is there progress toward these goals? The therapists have to measure and keep track of progress. Ask to see their reports, and compare it to your own observations.

If there is noticeable improvement, possibly being shot for the rest of the day is worth it -- possibly, but you are in a better position to judge that than the therapist is. Discuss your concerns with each of the therapists. Perhaps they can make adjustments if they understand what this is taking out of your mom. But if the therapy isn't helping at all, stopping it makes more sense than adjusting it.

My husband like doing his exercises with his PCA better than doing it with me. ("She's not as bossy.") But no one can really force someone to do exercises if they don't want to. Encouraging the caregiver makes some sense. Reprimanding her is over the line!

No amount of exercise is going to cure arthritis. My mother's geriatrician told us not to try to get our mom to walk more than she was comfortable with or to try to do exercises with her. Just keep her out of pain! I don't think that means therapy is never good for people with arthritis, but I do think I'd want to know just what the goals are!

Medicare is paying for this, right. If there is no improvement then they will have the homecare discharge her. They also don't have the right to reprimand your aide, unless she is from their facility. I have been saying this a lot lately...these people are coming into your home. They can suggest but not demand. You have a right to ask for another therapist if u don't like them.

I am a PT. I work in another setting, but I know PT. The PT should not have reprimanded the caregiver as such, but unless the PT knows the exercises are too much, they expect them to be done. Not doing a home program means there is no time to strengthen the muscles, because the PT coming over 2x a week isn't going to do it. It sounds like they are doing too much with her and they need to either modify the exercises or decrease the time of the program.
As far as therapy for arthritis, it is a frustrating diagnosis to treat. Strengthening the muscles around the joint and keeping the joint mobile is the goal, but I agree causing more pain is not the answer.

Ambly, you do have options and I think at this point it's time to consider them.

1. Who selected this particular home care agency? Was it a rehab social worker? Hospital discharge planner? You do have the right to substitute agencies, and it should be your choice.

And I think at this point that's a good plan to consider, but there is another option before doing that.

2. Home care agencies have become much more business savvy. Some have permanent reps at hospitals, who visit patients approaching discharge and market their services. That's what they do, but marketing can have its advantages.

When I learned about these reps, I met with them at the hospital, watched how they interacted with my father, asked them questions from a master list I had prepared. It isn't easy to select a home care agency w/o knowing anything about it or the therapists, but I tried to judge based on how professional, and especially how flexible the company was. Years in business was also a factor, as was having a former nurse marketer.

3. One company marketed not only in hospitals but at rehab facilities as well. I'm sure they have a business plan, for current and future activities, and since they're expansion oriented, I felt I had a better chance negotiating with them if problems arose.

4. After I learned more about the professional level of the various agencies, their marketing plans, scope of service (some also offer Hospice care, one was applying for Palliative Care), I then also made the selections. I wouldn't allow any hospital discharge planner or anyone else to choose a home care agency for my father.

5. You have 2 options right now:

a. Have a heart to heart discussion with the therapists and ask specifically what their goals are; that should have been noted in the plan of care. If you don't think they're realistic, ask about revising them. I don't know how feasible that is once therapy has been started, but it's worth a discussion.

b. Ask for different therapists, and make it clear that scolding a caregiver was unacceptable behavior and you won't tolerate that.

And you do have the right to call the agency and speak with a manger or supervisor about these issues.

Last year, one of the physical therapists was really gung ho about exercising to the max. All her family were military except her; I had the impression she was trying to prove something, in the way she pushed my father to work out until he was exhausted.

And she also insisted that there was no reason a 98 year old man couldn't have therapy twice a day. I disagreed.

She refused to back down; I called the agency and asked for a different therapist, and got a real gem, an older, more experienced, male therapist who got along very well with my father. He called me with recommendations, realistic recommendations and not pie in the sky goals.

6. If these suggestions don't work for you, contact the physician who scripted for the therapy and explain the situation, indicating that you want her to continue to have therapy, but with realistic goals. Hopefully he'll script for an extension of therapy, after you find a company with which you're comfortable.

7. I wouldn't conclude it's a waste of time; there are various levels of therapy that can be done, and some are probably more appropriate for your mother and whatever conditions she has. I suspect that the PT she's been given is way beyond her level at this point.

8. If she needs to strengthen her legs, there are little "bike pedal" machines that can be purchased for about $15. My father used to sit in his chair and pedal his "bike". He had the benefit of support, sitting down and not standing, and could really get going on those pedals!

Google "stationary pedalers" and you'll see some examples.

Good luck, and please follow up and let us know how this situation worked out.

Gentle stretching and basic range of motion exercises in a warm therapy pool helped my Mom a lot! The water supports part of the body weight and provides a gentle resistance while the warmth helps loosen the muscles. Although it helped strengthen the muscles and tendons over time (including core with improved balance), the big benefit was an immediate reduction in pain. You can start with 5-10 minutes in the water. If the pool has an underwater "bench" just sitting in the warm water is helpful for pain reduction. Mom started with a prescribed out-patient arthritis program at a rehab hospital and later moved to a similar program in the local senior center.

I would be very cautious about using therapy pools because public ones are teaming with bacteria and parasites which can kill an elder as there is also risk for slipping and falling. In the water. People with dementia can also be incontinent and pools of any kind are highly likely to stimulate bowel or bladder activity..in the water.

This is just anecdotal. Recently my 97-year-old father was in a rehab facility (now back home and on hospice). PT sessions were for one hour, three times a week. My gut told me this was way too much, but as usual I defaulted to my combined respect of authority, passivity/exhaustion as a long-distance caregiver, and the absolute relief I felt that Dad was in a facility and I was not having to field phone calls and investigate in-home care decisions/funding all day long.

Upon discharge (20 days in rehab), his “walking” distance was allegedly 75 feet (with a walker). Prior to rehab, he would never ever willingly use a walker at home, hence his frequent falls when unsupervised, even for seconds. His weight had dropped seven pounds in rehab. He was thoroughly exhausted. His PCP determined that his kidney failure had progressed, he had pneumonia, and his malnutrition (the type caused by non-absorption, not lack of good food). His dementia increased exponentially. He was recommended for hospice, which I can’t help but feel was precipitated by rehab. Unsettlingly, I am experiencing hospice as a godsend as there are many more compassionate supports in place. Dad’s ability to rally to please the PT so he could be released to home was one of the most heart rending memories I will have in my life.

Sometimes common sense and second guessing common sense clash badly. Your gut PT instincts should be considered, knowing that advocating for one option necessarily closes out other options and opens new ones.

I wish I had read this post about a month ago! There’s lots of good advice and wisdom here.

Another perspective. PT is so important. My mother lived alone and told us she was doing her PT on her own. Even using the same PT company, the PT would be a different person, from time to time. When one particular PT would visit, she would whine and cry and the PT would rub her back in sympathy for "Grandma" and leave. One PT wanted the care givers to do the exercises so Mother would do them on the other days. When mother did walk with her walker, she would shuffle her feet, refusing to pick them up. Well, now she is in a nursing home because she has a mental block about walking. Will not do it. In our experience, the PT that mother likes are the ones who let her get away with doing nothing, and the ones she doesn't like are the ones who are somewhat stern with her and make her do the work. In my wildest imagination, I never expected this.

Let's just go back a bit.

Your mother was living in IL, perfectly happy there until she started falling and the third fall landed her in hospital with a broken hip, 3-ish months ago?

Successful surgery, well-planned discharge after rehab to your home, money thought about carefully, support in place. You've all of you done everything by the book, well done.

Now you're concerned about the PT and the OT - are they doing your mother any good? Are they taxing her unreasonably? Are they likely to achieve any benefit for her?

And your doctor is not giving you any sensible answers. Hmmm. I think that's what you need to push at.

The question is, what led to her falling? Is there anything else going on that might also explain her marked, new level of fatigue?

On the face of it, yes you do want to encourage her to persist with the PT because it'll protect her against further falls. But before you get too cheerleady about it, make the doctor look you in the eye and tell you he has ruled out any other medical issues.

And tell the home care aide that some PTs are just like that and not to take her manner to heart - you'd think some of them trained in the marines. She just wants her patient to do well, that's all.

If she's just 3 months past surgery for a broken hip, she needs to do the PT. Maybe she needs shorter sessions more frequently (though that might cost more) ... or maybe it's okay that she's wiped out for the rest of the day. If she doesn't do her post-surgery PT she will remain disabled, which isn't what she wanted when she went for surgery.

I would hope the PT is aimed both at recovering strength and mobility in the injured limb AND improving her balance. Sometimes that's a matter of retraining the brain's balancing function, but often with elders it's also a matter of strengthening the small muscles that correct for slight off-balance moments so the person can prevent falling.

Separately from that, we sometimes use PT even for people on hospice, because PT can help people maintain a plateau of present function and slow or stop a decline in mobility, even in the presence of life-shortening disease. Since falling is awful for elders, PT to help people learn NOT to fall, as well as learn HOW to fall if it's too late, is enormously useful.

I am a retired PT and worked in home care for years. No matter how professional the therapist is, progress depends on what the patient does between PT or OT visits. If your mother won't do exercises, she should get up and walk with supervision. Stop bringing meals to the bedside. Give her something to do. Nobody gets stronger laying in bed!

I agree that your mom's falling could be a result of a change in her system and that could be leading to her exhaustion as well as the fact that she deconditioned after her injury (anyone would, let alone an elderly person!) My mother fell and fractured her hip. It likely was a first sign of adrenal insufficiency due to aging. When you have this, exercise intolerance is part of it. Unfortunately, she did not recover from it. My dad fractured his pelvis due to balance issues. He benefited from a kinder, gentler approach to rehab. I like the idea of the little cycling machine. In his case he stayed in the nursing home under long-term care. The best part of that was that he strengthened by propelling his wheelchair with his feet as he sat in it. Most home settings are tighter quarters but the bike idea might create a similar effect. I also agree with shorter more frequent exercises. Did the PT give your mom (therefore you) exercises to do on the days that the PT didn't come? Many things can be done in bed, seated, or standing at the sink that would be quite simple. If your mom tried this, you would then know if any chance of forward progress is possible. Also, remember that physical improvement isn't a steady thing. There are ups and downs and plateaus. Lastly, try to make it fun for her. Find out what motivates her, then use those things as mini-goals. You know her better than the PT and can tap into those things.

There are no miracles! The older the person is, the more difficult the situation probably will be. Emotional support and positive reinforcement will go along way to help revitalize a person's physical and mental abilities and attitude.

I feel like I'm only seeing part of your mom's history and problem in your question. From what I'm reading, she fractured a hip after a fall. How old is your mother? Does she have any other medical issues?

First, if you're her medical POA, you are in control of this situation. If not, then your mother is. It is absolutely not okay for any therapist to reprimand a client in a way that would make them feel demeaned. The question for both the OT and the PT are this:
What are your mother's goals? Are they relevant to her, measurable in terms of progress, is she able to achieve the goals and are they time limited?

From an OT perspective, her treatment should be aimed at all things functional, including bathing, toileting, bathroom transfers and dressing. Along with this, if your mother is interested in participating in household chores/activities, then OT should be working to make modifications so she can do this. Moving around in the household should also be included as part of self-care and household activities. If the OT is only focused on arm exercises and there's no functional progress, then they're not doing their job.

If you're planning on caregiver assist from this point on, then the OT should be doing thorough caregiver training with instructions to encourage your mom to help with self-care so that she doesn't become overly dependent.

I don't agree with anyone saying that her being exhausted after therapy is a good thing. But I would also be asking the MD if there are any underlying medical issues that would be causing the fatigue now and if there was anything medically going on when she fell.

Finally, you mention she gets confused. Does she have dementia? That in itself is a risk factor for increased falls. 

Be direct with the therapists and make sure their treatment plans and rationale are what your mother wants and needs. Ask if any changes can be made to increase her participation on non-therapy days. Then a trip to the doctor for a thorough check-up and cognitive evaluation to make sure there's nothing else going on.
 

another great answer, Gardenartist. You always provide such thoughtful and thorough insights. We are all grateful.

In some situations, PT can be a cash cow. When mom first settled in to her memory care community, she was offered PT once a week...and no instructions for daily practice. Someone came, they did their thing, and came back a week later. When the suggestion to re up came, I was suspicious. For what was offered, it seemed like a way for the therapy business to make money because Medicare would pay. I declined. Recently, I received an offer by phone for more physical therapy. I asked Mom (91)..explained what activities it would involve...and she declined.

PT and other therapies are wonderful and often greatly needed and helpful services in many situations....but a part of me thinks some senior living communities are targeted to offer services to....despite the reality that any benefits would be minimal at best...especially with moderate to advanced Alzheimer's patients.
If offered and accepted, know why, know the plan, know the expected outcome, and track progress to make sure it is benefiting your loved one.

At Mom's community there are group walks and group exercise activities ( chair yoga, tai chi, stretch band workouts, etc) throughout the week. Mom enjoys those activities.

My mom has had pt in home often for strength building. Yes it is a flurry of activity juggling all the apptments and Mom has never exercised well with me.
Her therapists ALWAYS judged how she was doing to determine how hard they work her. They stop now and then for her to catch her breath and use an oxymonitor to check her pulse and oxygen levels. They never pushed her so far that she was weak and worn out.
It’s true that she didn’t respond well to some personalities but we always had the option to ask for a different therapist.
They should not be pushing her to the extent that she hates to see them coming. On the other hand she may be stronger than you think and is fearful of hurting where she’s had surgery. Good luck to you.

PT and OT are ordered by the elder's physician. The physical therapist does not have the right to critique the caregiver.

Please speak to the PT about your observations. They don't know what's happening unless you tell them. Maybe the exercises are too much and different exercises may be just the thing. I know PT helped my mom and my husband. PT requires feedback. I had to tell the PT person that the exercises they gave ME were too easy!