Client Scenario
Mr. Nueve: Dementia & Allen's Cognitive Level 3
Incidence – In 2019, 487,000 individuals over the age of 65 will develop Alzheimer’s dementia in the U.S. (AA, 2019). Twice as likely in African Americans and 1.5 times as likely in Hispanics than Caucasians (CDC, 2019).
Prevalence – An estimated 5 million Americans are living with Alzheimer’s disease. Predictions are that this number will triple to 14 million by 2060 (CDC, 2019).
Symptoms- Can vary greatly, but generally include difficulty with memory & attention, communication, judgement & problem-solving, and visual perception (CDC, 2019).
Prognosis- Progressive disease with no known cure or treatment (AA, 2019). :
Mr. Nueve Problem List
- Personal Safety/ Fall Risk
- Aggressive Behavior
- Incontinence
Problem Statement 1. Impaired orientation, memory, and higher level cognitive functions results in wandering which leads to concerns for personal safety and increased fall risk.
Evaluation Tools
1.Safer Home Evaluation
(Piersol et al., 2018)
- TUG -Timed Up and Go
(Ayan et al., 2013 ; Marx et al., 2019)
Intervention 1:
Approach: Prevent & Modify
Type: Prepatatory Method & Occupations
(AOTA, 2014)
Intervention 1: After the Safer Home Evaluation the OT will identify modifications that may be made to the home environment to reduce falls and reduce wandering.
A. Remove rugs and excess clutter.
B. Install mirrors, camoflage or coverings to exit doors to reduce attempts to wander. Also, Install a bell at the door jam to alert the caregiver if the client opens the door to exit.
C. Provide the client an identification bracelet (possibly electronic) in case the client sucessfully wanders from caregiver.
D. Increase lighting to porch and increase contrast on stairs to the front entry.
E. Allow time for client to wander freely in a safe area such as a park.
F. Keep everyday used items in view and in the same location for ease and to promote continued use.
(Struckmeyer & Pickens, 2016; Jarvis et al., 2017; Jensen & Padilla, 2017)
Outcomes
1a. Improved personal safety and reduced incidence of wandering.
LTG 1a: Client will reduce unacommpanied wandering as evidenced by less than 3 attempts to exit the residence over a 5 day period within 6 weeks.
1b. Improved personal safety and reduced fall risk.
LTG1b:Client will mobilize independently with less than 2 verbal cues for safety a day within 6 weeks.
(AOTA, 2014)
Problem Statement 2. Impaired communication skills, memory, emotional state, and temperment result in aggressive behaviors that reduces his ability to participate in ADLs & IADLs. It also reduced his receptance to assistance in ADLs and IADLs and cause safety concerns for caregiver and family.
Evaluation Tools
1.DAD -Disability Assesment for Dementia (Piersol et al., 2018)
- CMAI- Cohen Mansfield Agitation Inventory (Piersol et al., 2018)
Intervention 2:
Approach : Modify, Prevent, Maintain
Type: Preparatory, Education & Training, Occupations
(AOTA, 2014)
Intervention 2: To encourage and promote improved behavior of the client, the OT will educate and train the caregiver ways to simplify ADLs including simplified instruction to the client for increased participation in ADL & IADLs. Modifications to the home environment will also be promoted for increased client awareness and engagemnet.
A. OT and caregiver will collaborate to simplify verbal instructions, provide tactile cues, and adapt functional activites for ADLs & IADLs.
B. Establish and adhere to a routine of wake, sleep, and meals to promote client orientation.
C. Promote memory recall by providing visable pictures and mementos of the client's past
D. Provide music familiar to the client that coincides with a specific time of day to support orientation to routine. Limit excess
E. Provide opportunities for exercise such as walking, gardening, or stretching to support mental well-being
F. OT will provide caregiver education to improve and simplify communication with client including interpreting non verbal communication.
(Struckmeyer & Pikens, 2016; Jensen & Padilla, 2017; Piersol et al., 2018)
Outcomes
- Improved behavior toward caregiver and family and increased well-being.
LTG2: Client will display improved behavior and reduced agitative state as evidenced by less than 2 or more outburst per week in 6 weeks. (AOTA, 2014)
Problem Statement 3. Impaired perception, attention, lack of communication, and absence of bowel and bladder routine contribute to client's lack of bowel and bladder control.
Evaluation Tools
1.Incontinence Diary (Dowling-Castronovo & Spiro, 2013)
Intervention 3 :
Approach: Establish / Restore & Prevent
Type: Preparatory, Education & Training, Activities
(AOTA, 2014)
Intervention 3: OT will provide education and training to establish a bowel and bladder routine for the client to reduce incidence of incontinence and prevent UTIs. The incontinence diary can assist the caregiver in establishing the routine to promote client adherence and reduce likihood of incontinence.
A. Client will implement bowel and bladder routine and verbal cues for the client to use the restroom at the same time everyday.
B. Increase fiber and water intake to promote regular bowel movements and reduce dehydration.
C. Caregiver & OT collaborate with PCP to investigate possible causes and if medication is appropriate.
D. Removing functional barriers to the bathroom, such as leaving door open and a nightlight for during the evening hours.
(Price, 2011; Dowling-Castronovo & Spiro, 2013)
Outcomes
- Improved adherence to bowel and bladder program resulting in increased quality of life.
LTG 3 Client will adhere to bowel and bladder routine to reduce incontinence as evidenced by less than 2 incidence of incontinence in a week within 6 weeks. (AOTA, 2014)