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Rehab after a Stroke
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Rehab after a Stroke

My father had a hemmoreagic (Sp) stroke on May 10.  He has paralysis on the left side.  He is able to speak and eat fine.  THe stroke has really affected his short term memory though.  He is currently in a Nursing/Rehab center.  Medicare has stopped the rehab therapy after 3 weeks because they say he is not progressing enough.  My question is if anyone else has had this problem with medicare?  They have him in a restorative nursing program at this point, but we really want him back in therapy.  He is definately stronger today than he was when they stopped the therapy a few weeks ago.  We feel like the therapists have given up on him because he is 80 years old.  But before the stroke he was very active.  All we want is for him to be able to go home with some in home health.
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I have some other posts you might want to look through. They cut off benefits to my 101 year old patient and returned her a complete mess, having completely given up. The insurance guidelines do not necessary reflect reality. You are going to have to take on part of the burden, which is a tremendous load. There is a book called the "thirty six hour day". Believe it. Go to the rehab center and ask permission to watch a rehab session, or better yet videotape it. I trained non-medical personel to administer this therapy. It isn't rocket ship science. The rahab centers have lots of stuff that you don't have at home, however. Look at what they have. Much of it you can replicate. In the case of my 101 year old stroke patient she is mostly no longer incontinent, and they said that would never go away. When rehabing be careful not to over-exercise. You can strain muscles that have not been used very easily, and develop shinsplints. You need tokeeep an exerciselog, and think "spaced exercise", with long periods of rest. Ask the rehab specialist to show you things that can be done at home. You are going to need two wheelchairs and the people who write "certificate of necessity" do not always do this. You need a small four-wheeled wheelchair with smallplastic wheels for the room and a soft-tired wheelchair for outdoors. Often the ones obtained by a certificate of necessity have a single large plastic set of wheels and they are neither fish nor fowl. Structure the day to encourage movement. Do not permit bed feeding under any circumstances. Transfer the patient to a wheelchair, then wheel the wheelchair to a table for a "dining experience".Make the transfer part of the exercise program. Learn how to lift! You can hurt your own back very easily. You will need a transfer table for the bathroom to take a shower. They sell for about $120 and this is a rip-off, however Craigs list often has them. Install a handicapped rail in the bathroom. Home Depot has them for about $35. If you hire an aide through an agency, they often will refuse to perform any rehab therapy. This doesn't make sense, but what is, is.  The best thing is to hire aides independently, and then they will do what you tell them to do. Don't be afraid to do battle with the rehab facility. Your job is not to be "a nice guy". The squeaky wheel gets the grease. Feel free to contest any decisions that adversely affect care. Also, if they say the patient cannot benefit from rehab, remember that stroke patients can vary tremendously in their responses, depending on the time of day or week they are evaluated in. Request a second evaluation and request to be present that day. Almost without exception patients in nursing homes and rehab centers are dehydrated. There are complex reasons for this, but dehydration can make a tremendous difference in the patient's ability to respond to rehab therapy. Dehydration can create confusion and attention deficit,among other things. Very few institutions pay adequate attention to hydration. Just because the patient refuses a drink does not mean they don't need hydration. Try a different choice ofliquid, and then a third or a fourth choice. If hot chocolate doesn't work, try hot tea, then chilled juices. Aspiration of food during eating is a number one problem. You have to pay close attention to the menus.
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Thanks so much for all the info.  I've read alot of your comments and for the record, my fathers stroke I feel was caused by being on coumadin.  I never understood why they put him on it but they said that his heart went into afib at some times and the coumadin was to prevent a stroke.  Well he had a stroke anyway.  Do you have any other recommendations to help my dad stay awake during therapy.  Today they took him for some one on one restorative therapy and he kept falling asleep.  
It is very frustrating.
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Avatar_n_tn
Beta blockers make my husband fall asleep.  Is your dad on beta blockers?  I got doctor to reduce my husband's beta blocker from 75 mg/day to 50 mg/day (offset by increasing ace inhibiter) and he stays awake better.
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I will definately ask about beta blockers.  I don't think he's on one, but I will check.  Where is your husband now?  Is he still in rehab?  I also told my mother to make sure he is drinking alot for the dehydration.  My problem is I live in Virgina and my father is in Pennsylvania so I cannot be very hands on with the situation.
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You are correct.  When my dad was being discharged from the hospital we tried to get him into the acute rehab program, but we were denied because they didn't think he could handle it.  (Even though all the neurolgists said this was the therapy he needed)  Anyway we ended up in the SNF with rehab.  That lasted for 3 weeks until they said he was not progressing.  We then found out that they were giving him vicodin 2 times a day.  We feel that this was knocking him out for therapy.  We have been trying to get him back in therapy with the argument about the vicodin, but have not had any luck.  

My mom has also been doing the ice cube therapy.  My dad is really responding to it.  Please let me know how the biomove works, I may order one also.  We are ready to try anything.  

Has you husband had any short term memory loss?  This has been my dad's greatest challenge.  He forgets that he even had a stroke, so each day we have to explain to him what happened.  
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Avatar_n_tn
Lahinva, it sounds like your dad may have been bumped down two levels rather than one.  

As I understand it, Medicare pays for three different levels of care after a stroke.  First is a hospital, until medically stabilized.  (My husband was in hosp for a bit over a week after his May 28 brain bleed.)  

If they think the patient can tolerate and will benefit from intensive rehab, Medicare supports up to several weeks of what they call "acute rehab".  (My husband managed to get 4 whole weeks of acute rehab with 2 sessions/day of each of OT, PT, and ST, but we were told that was unusually long.)  

If they're not ready to go home yet and if the powers that be decide they will profit from less intensive rehab, Medicare will support up to 100 days in the rehab unit of a skilled nursing facility.  (My husband has now been 3 wks in rehab unit of SNF which gives him only one session/day of OT and PT.  

I had argument today with physical therapist who had decided that my husband had "plateau-ed" and she wasn't going to continue treating him.  I said I thought he had plateau-ed because a week ago she stopped doing with him the challenging program that had done him so much good.  She was miffed but put him on parallel bars and was impressed by how much he had improved since she last tried that with him a week ago.  (I, on the other hand, was miffed that he hadn't been given any standing or walking training for a whole week!)

I've started Caregiver's recommended ice cube on affected side.  My husband does more toe-wiggling with that than with anything else.

Out of desperation, bcs I'm afraid they're going to say my husb isn't progressing enough to justify continuing to support his rehab, I've ordered the BioMove I asked about earlier on this forum.  I'm so eager to try it that I ordered it 2nd day air, so it will arrive tomorrow.  That will give us the empty (i.e. no therapy sessions on weekend) weekend to get started.  I'll let you know if it helps his affected side.  I just paid the 1st installment for one month, figuring that if he doesn't show any improvement in a month I'll return it and pay no more.  Of course I'll continue to do the icing and exercising with him.
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Avatar_n_tn
Yes, he's had some short term memory loss but sounds like not as severe as your dad's.  Greater problem than memory loss has been general confusion (wanting to get dressed at 4am, trying to brush teeth with hairbrush).  Passage of time seems to be greatly reducing his confusion.

That ice cube thing really seems effective.  I had been scratching his leg and foot with a comb or with my fingernails for some time with little effect.  Ice cube much better.
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Avatar_n_tn
Only suggestion I can make about the falling asleep is the obvious one--a good nap before the therapy session, and wake him in time to give him a chance to wake completely.
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Tressa - How old is your husband?  In reading your comments your situation sounds so similar to mine.  My dad had three good days of the restorative therapy this week.  He stayed awake and followed the commands.  We are hoping that if he keeps this up they will recommend putting him back in therapy.  Is you husband able to transfer himself yet?  That is the other frustrating part, every now and then the nurses will stand my dad when they transefer him, but most of the time they use the lift.  I think if they would make him transfer all the time he would get stronger and learn to help himself more.
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My husband is 69.  

Yes, I agree lift transfers retard progress in learning to stand.  If you offer to help the nurse with the standing transfer they may be more willing to do it.  They understandably want to protect their backs, but with two people transfering, it's easier.

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144586_tn?1284669764
The "falling alseep" is not a good thing, but there is not a lot you can do about it. Avoid feeding while there is sleepiness. Easier said than done. Feeding while there is sleepiness often results in aspiration pneumonia. The excess sleepiness often also results in dehydration. So feeding should be done during periods of wakefullness. Don't be afraid to wake him up. Also easier said than done.
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Tressa - Did you start with the biomove yet?  How is it????
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Started with BioMove yesterday.  It ain't great, at least not yet.  I don't even think it's working properly.  They agree it's probably not right and are sending me another one.  I'll let you know.
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Caregiver222, I think you may have stopped following the thread "physical therapy" way down below.  Lahinva and I ask you there how you find your caregivers.  Where do you advertise or put out feelers or post notices?
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144586_tn?1284669764
It is not uncommon with people to become very upset over little things. It is important to recognize that this is not personal. Sometimes, when people have little control over their destiny, the only thing left is to say "no". Routine is very important. I like the 8 A.M., 1 P.M. and 6 P.M. meal schedule because it insures exercise every 5-6 hours, and movement is necessary to reduce the risk of an additional stroke. By the same token scheduling two snacks requiring the patient to move from the chair to the table for the snack provides two additonal opportunities for rehabilitation. The snack is a reward. A small card table can be set up as a snack table within the room. The little four-wheeled chair can be moved around by the patient who can walk and with very limited movement who cannot operate an ordinary wheelchair. This provides the patient with a great deal of pride and self-satisfaction.
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144586_tn?1284669764
You will find people applying for the job who really need the money, but are obviously mentally slow. Your responsibility is to the patient, and not the aide. I also ocasionally hire aperson who is neither "fish nor fowl". The role is to take the patient out for a coupleof hours and have the best time possible. I hired a wonderful Korean girl for this, who, unfortunately,went on to a fulltime job. She would hold and sing to the patient for four magical hours. I got her through a religious community. She had an extreme reverence and respect for an aged person and a 101 year woman "is like a god to me", as she said. She wouldspenf our full hours massaging, kising and singing and playing, and would want to stay for additional time without pay. She would show upfor work dressed in the most delightful Korean traditional costumes, full of color.
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144586_tn?1284669764
I apologize for not following the threads closely. I had a minor stroke myself recently (left tongue deflection, blocked 12rh cranial nerve, so cut me some slack). You could try Craigs list. Or advertisements in ethnic newspapers. Try the Irish newspapers or the newspapers catering to Ukrainians or Georgians. And try the local english language schools for immigrants. Engish speaking ability is a necessity to rehabilitate a stroke patient. You are going to have to meet a lot of people and try them out and fire them if they don't make the grade. This is the hard part. There are some very high quality people available from Korea, but there is usually a language problem.I have had very bad results with Jamaicans and Africans. Part of the problem deals with sanitation standards. Attitudes towards sanitation are very deeply ingrained. The africans were the worst in this respect. Washing the hands after using the toilet, for example. The urge to "save food" is another problem. I have a rule that nothing with mayonaise gets saved for another meal, for example. Ventilation of the room and air exchanges are another issue. You have to find someone who bonds with and enjoys working with an elderly person. They are out there. But they are hard to find.
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I never thought of posting at English language schools.  What a good idea.  

Have to mention that when I was taking care of my dad for the year before his death, his very best caretaker out of the many I hired was African.  I suspect she was sister to the Korean that caretaker222 hired.  She would hold both my dad's hands and sing to him until I wondered she didn't grow hoarse.  

In the SNF where my husband is currently living, the most sanitary aide I've encountered is African.  Sometimes I even say to him "I don't think you really need to change his bedpad/pajamas/sheets/whatever just because his briefs are wet."  And Kwami will say, "Just to be sure."

Most of the aides and nurses here are immigrants (Philippines, Cambodia, Mexico, Kenya, Nairobi).  There are only two I can think of who are European Americans with no accent.  And guess what nationality the most unsanitary of the bunch is?  She NEVER wipes my husband off with a wet washcloth when she changes his wet briefs.  And yesterday she didn't even wipe him after a bowel movement, not even with paper, much less with the warm, wet washcloth Kwami always uses.

So take a good hard look at the person behind the nationality or you may miss a jewel of a caretaker!  It's hard to find good ones (as caretaker222 indicated by the statistics of how many fired out of how many hired).

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