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He just doesn't want to do the physical therapy. He is eating well, doing occupational therapy and speech therapy but doesn't won't to do much walking. They seem to want to drop him from trying.

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Yep- my Dad was in rehab but dementia affected his therapy- either couldn't remember instructions or didn't want to cooperate. In rehab they cut him off of therapy and off to SNF where he never walked again (we tried therapy there a few times without success). Sad- it is easy to see that therapy would benefit him but without cooperation no real gains were possible.
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My mother broke her hip last month and refuses PT. Funny thing is she gets up (beeper beeping like crazy) and walks through the whole place. Her dad lived to be 99. I know she comes from good stock and all, but she's headed for another fall as the place can't get to her to stop her from walking unassisted (she refuses or can't remember the walker)... it's a nightmare. She won't participate and doesn't get it. She says it makes her tired. She only needs 3 weeks of PT for her broken pelvic bone so her leg can get stronger but she is so nasty to the therapists when they come. I'm afraid they are just going to send her home to her 24/7 caregiver. What can you do. :(
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With dementia patients, they can not understand that PT will heal them, because it hurts. If it hurts, they're not going to do it. If they don't do the exercises, they will certainly fail to improve. If they don't improve, Medicare will stop paying. This is a story PT people live many times a day with many, many patients.

My mom did this twice. The beds in rehab are in very high demand, so there's no point letting someone camp there when they are not going to try and not going to improve.

My mom could not give a rat's patoot about getting better, at least trying to go along to be able to stay in the less expensive bed for as long as possible, or keeping herself from losing abilities. Her brain could not process information like that anymore.

So, they tried. The bribed her, cajoled her, and tried every legal trick in the book, but the day came about 2 weeks in where she was absolutely N O T going to do it and would hurt the person who tried to make her. So it was back to her more expensive bed in the memory care unit.
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I learned this recently as my 94 year father was cranky and uncooperative with the PT staff because he would rather be in his recliner at the rehab center napping and watching tv. The upside is the PT folks worked MIRACLES and got him out of a wheelchair and upgraded to a walker. The downside is that he got stubborn and started to refuse to do the excercises. PT folks got tired of his negativity and said "we are done"! Under Medicare, he could have stayed in this wonderful rehab center another 70 days at the reduced rate if he would have not been so crusty and at least a little more cooperative! In hindsight, I have been told that I could have appealed the therapist's decision to cut him loose and I could have requested less aggressive schedule of therapy! Oh well, live and learn!
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Oscar, this is a bit different that the NY homeless issue you refer to.

Let us say that the patient with dementia has been declared incompetent to make medical decisions and his medical proxy says, "Yes, he must have physical therapy even though he insists he doesn't want it." How are you going to force a cognitively-impaired person to do what the therapist shows him and tries to help him to do?

If they were given the authority the NY police COULD physically round up those in danger of freezing to death and hold them in a warm place overnight. But even with the authority to make the decisions, I don't see how someone could make someone else do exercises. It is not about legal consideration or authority, it is about the very practical matter of how to do it.

My mother (with dementia) kept pulling her catheter out. (Ouch!) She could understand an explanation of why that wasn't a good idea but she could remember it for only a few minutes. The issue was not about whether I had the authority to stop her or not, it was about HOW to stop her. I didn't give two hoots for her autonomy at that point -- I was only interested in protecting her health. (We solved that issue by having the staff always put pajama bottoms on her, and took all her nightgowns home.)

How would you go about making someone with dementia cooperate with physical or occupation therapy?
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This is all very special. Patients who are not in their right minds cannot be forced to do physical and occupational therapy. This is like the New York judges who won't allow police to remove from the streets the schizophrenic homeless when the temperature is 25 degrees below zero.

We wouldn't want to threaten their autonomy, would we?

What a wonderful world the slimy plaintiff's bar has wrought. We allow people to die rather than force adequate rehabilitation.
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Sorry, I meant to ask a question, not reply .
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My dad is in a very nice rehab but fell a few times but did not get hurt. He was told not to try to get up without calling for help, but either he is stubborn, or felt he could do it, or just did not want to wait, but now they are forcing us to hire an aide or companion ($500.00 a day) or they will move him to another location. He does not want to move. The other location may have one additional aide for the same number of patients, not sure, I have been told different things from different people at the location. They are telling me they are not equipped to handle 'non-compliant' patients. Their location is for more Independent patients. If the other building only has one extra aide, how are they able to handle 12 patients that need extra help, when the one he is in, can't help just one, him? He does all the therapy, and is getting stronger, are they allowed to force him out. Just a note, they are at capacity, and the other building is not.
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My mom did this. She could not understand that PT was so important to her mobility and well being, and it was critical in her being able to stay classified as rehab for the full 100 days of coverage. I think her rehab stints have lasted just a few weeks at the very most, never the whole 100 days because she refuses to cooperate. Cognitively, there is no reasoning with her.

If the patient won't do the therapy, then therapy isn't helping, and you have failure to progress. Rehab is too expensive and there is so much demand for it, they can't let people linger there. No coverage will pay for something that obviously isn't working.

I would do all the things mentioned above to encourage dad, but be smart and have a backup plan for the day the therapists determines failure to progress. He can't go back home and resume "normal" most likely.
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Gibbs is right, if there is progress, the therapy continues. When you visit, get him to "walk" in the wheelchair, up and down the hall. Push his limits and then let him rest. If he refuses, tell him straight out he is headed for long term care.
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A medical facility cannot continue billing insurance for services that aren't doing any good. If Dad won't cooperate with the physical therapy then at some point the rehab place has to stop billing for it, and stop offering it. If he is making progress in occupational therapy and speech therapy they may continue him there for those therapies.

It would really be best, of course, if Dad maintains at least enough mobility to walk short distances with a walker and to transfer easily from the bed to a wheelchair. What you can do about it is the tough question. Would it help if you promise him you'll never expect him to walk around a shopping center, but that you do want him to be able to walk from his tv chair to the refrigerator? That it would be good if he could get to the bathroom by himself? If the goal is presented more modestly would he be less likely to feel overwhelmed?
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