Case Study: Team Helps Young Stroke Survivor Return to Living Alone
Work Setting: Health Care
Summary
A 38-year-old woman had a stroke that resulted in aphasia and some physical limitations. Her treatment team developed an interprofessional plan to target community access and support communication so that both she and her family were confident that she could live by herself again.
Meet the Team
Background
Kanika was a 38-year-old right-handed woman who was working as a social media coordinator for an international organization when she had a stroke in early June. Prior to the stroke, Kanika lived alone and frequently saw her sister and nieces, who lived in a nearby state. Her apartment was on the second floor, and there was no elevator. She enjoyed socializing with friends at great restaurants, taking group exercise classes at the gym near her home, and traveling on the weekends. She spoke English as her first language but was fluent in French, which she used frequently in her work. She drove to most places she went to but would sometimes take the subway or a ride share accessed from her smart phone. She did not have any trouble with her vision or hearing and did not have any functional physical limitations. She thought of herself as active and healthy.
A few months into the pandemic, Kanika noticed some respiratory symptoms and mentioned to her friend that she was concerned about COVID-19. A few days later she was video chatting with her sister when she suddenly developed difficulty talking and moving her right arm. Her sister called 911 and Kanika was transported by ambulance to a nearby hospital where an MRI revealed a left-hemisphere ischemic stroke consistent with those seen in young COVID-19 patients. Kanika received tPA, a clot-busting medication, and was admitted to acute care. She tested positive for COVID-19. Once medically stable, Kanika was transferred to inpatient rehabilitation but was discharged after only a few days—even though she had significant aphasia—because she was able to walk with close supervision. Her sister came to stay with her in Kanika’s home at discharge. Kanika began outpatient rehabilitation in an interdisciplinary day treatment program once she was no longer testing positive for COVID-19 with the goal of returning to independent living.
In the days following the stroke, Kanika was appreciative of her sister’s help but wanted to be alone. She was worried about what would happen to her job if her aphasia did not resolve, and how she would be able to financially support herself if she was not able to work. Kanika’s sister had concerns about Kanika’s safety as she moved through her daily routines. She noticed that Kanika needed assistance with tasks that required both hands and with walking longer distances, and she wasn’t sure if Kanika’s vision had changed or if she was having trouble reading because of the aphasia. Her sister understood that Kanika’s independence was a part of her personal identity and that Kanika felt overwhelmed and uncertain about the future.
How They Collaborated
The treatment team met and discussed their assessments to develop a plan to help Kanika reach her goal of living alone. Kanika and her sister attended this meeting, asking questions and offering additional background throughout the discussion. The team set a plan for the SLP and OT to target communication during routine tasks in the community and instrumental activities of daily living (IADLs) requiring reading and typing. OT and PT would collaborate on increased endurance for community mobility, like climbing stairs while carrying things. The OT would team with the neuro-ophthalmologist to implement strategies to address a right visual field deficit that all the team members would reinforce. The social worker would partner with the family to work on short-term disability and preparation for long-term disability to allay concerns about finances.
The team developed a list of activities at home and in the community for Kanika and her sister to practice on days when Kanika did not come to therapy and over the weekend. They agreed on a strategy that her sister would step in to help only if Kanika asked for assistance or if there was an imminent safety risk; otherwise, Kanika requested an opportunity to problem-solve obstacles on her own. Kanika would keep notes on her iPad and bring them to therapy to keep the team informed of her challenges and successes.
Outcome
Kanika was highly motivated and worked hard in all of her therapies and practice assignments outside of therapy. After 3 weeks of the day program, her aphasia and apraxia improved, and she became proficient in using communication support. She developed and practiced a script to let others know about aphasia and to advocate for her own communication needs, like asking her communication partner to slow down and requesting that her partner give her time to respond. She used technology tools such as screen readers, templates, voice dictation, and word prediction to read and send emails and text messages to friends and family as well as to schedule appointments and access her medical portal. She was able to walk from the subway station in her neighborhood and up the apartment steps to her home carrying a bag in her left hand and her purse on her right shoulder. She used visual strategies consistently to make sure she had seen everything in her right field of vision in the community. Both Kanika and her sister reported decreased stress related to her financial status once short-term disability was established, and they had a long-term disability plan in place with Kanika’s employer.
Ongoing Collaboration
The weekend before her last week in the day program, she stayed alone in her apartment over the weekend with her sister checking every 4 hours on the first day and every 8 hours on the second day. The team reviewed how both Kanika and her sister thought the weekend went and spent the last of days of the program challenging Kanika’s skills through community access to unfamiliar locations. At the time of completion of the day treatment program, Kanika and her family agreed that (a) Kanika was ready to return to living independently with frequent check-ins and supervision for complex tasks like financial management and (b) Kanika would continue to participate in single-service outpatient speech-language therapy and complete a follow-up appointment with her physiatrist 1 month after discharge from the program.
