Strength-Based Person-Centered Dementia Care: Activities of Daily Living

Abstract

Given the complex framework described throughout this text, it is helpful to see examples applying the outlined principles. This chapter is an extended illustration of an interdisciplinary team using strength-based and person-centered care for a person living with dementia. Completing activities of daily living (ADLs) is one of the most challenging, yet important, tasks that occurs multiple times per day for those with advanced dementia. Decreased ability to complete activities of daily living (ADLS) is a hallmark of major neurocognitive disorder (NCD).

According to the DSM-5, loss of function in daily activities is a main indicator of the transition from minor to major NCD. By completing and documenting a strength-based assessment, a person-centered care plan for ADL completion can be developed for those living with dementia. Specific strategies for feeding, hygiene, dressing, and bathing need to be matched to the skills of an individual living with dementia. This chapter will outline specific strategies, isolate impairments, and emphasize a strength-based approach to person-centered ADL completion.

Appendices

Appendix A: Occupational Therapy Individualized Care Plan Report

Occupational Therapy Individualized Care Plan Report

Background Information

Date of report: Client’s name or initials:

Date of birth:

Therapists:

Reason for referral:

Occupational profile:

Individual and/or caregiver report of decreased occupational performance (self-reported goals):

Assessments performed:

Findings and analysis (fill out the table below for summary of current occupational engagement):

Interpretation :

Areas of occupation (strengths and challenges):

Behavioral/emotional concerns based on evaluation:

Priorities for intervention (at least three priorities):

Plan :

Specific client-centered activity recommendations:

Specific ADL recommendations:

Specific communication recommendations (give suggestions to staff and caregivers to support care of client):

Recommend reassessment of resident (timeline):

_____________________________ Date

Reviewed by OTR/L

Appendix B: Example Occupational Therapy Individualized Care Plan Report

Occupational Therapy Individualized Care Plan Report

Background Information

Date of report: N/A Client’s name or initials: XX

Date of birth: Patient unable to report

Therapists: OT

Reason for referral: Lack of engagement in meaningful occupations and difficulty transitioning.

Occupational profile:

XX is an older woman who lives in an assisted living facility. She enjoys sitting on a couch in the lobby (close to the window) and is welcoming to others sitting next to her for company. XX reports she enjoys conversing with others and independently moves chairs to talk with other ladies sitting in the lobby. She notes how she will not be a great conversationalist, due to her memory. XX short-term memory is impaired, but she is aware of her memory struggles and sometimes calls herself “stupid” or “idiot.” One way she copes with this is by saying she doesn’t like to live on memories and does not like to dwell on the past.

The staff at Happy Care guide XX, everywhere. The activity director reported XX has a routine of staying in the lobby for most of the day, attending meals, and then calling her daughters in the evening once she is back in her room. As people walked by, she became confused as to who was who. She thought she saw her daughter and asked if one man was the pastor. XX easily loses track of her thoughts and has a hard time thinking of what she wants to say. She gets up numerous times a day to ask the front desk when the next meal is or what she is supposed to be doing, unsure if she is in the correct place. Some information we obtained about XX’s past includes:

• Picked hops in Independence XXX with her brothers and went to an all-girls high school.

• In the Air Force, she was a corporal in the Women’s Army Auxiliary Corps, and she was stationed in Newport News Virginia for a time.

• Used to be a hairdresser.

• Likes getting her nails done.

• Loved drinking beer.

• Husband was an artist.

• She and her husband owned a Tavern in Oregon.

• She has two daughters, one of which lives in Oregon.

Room environment:

• Clear floors, with no tripping hazards.

• Television with Christian sermon on.

• Phone with raised numbers and high contrast to help with low vision.

• Digital clock on her nightstand, along with a water bottle and flashlight.

• Crossword books on multiple tables and shelves.

• Books and a deck of cards on a shelf in her living room.

• Pictures of loved ones on shelves.

• Walk-in shower with grab bars and a shower chair (receives step-by-step directions for all self-care tasks).

• Clothes are organized by type (i.e., short sleeve, long pant, etc.).

• Bedtime clothes placed on a chest directly in front of her bed.

• Many small objects in the cupboards, such as a headband, empty chip bag, and a wireless phone.

• Fridge filled with Ensure and water.

• Two types of signs inside room:

  • 1. What she should not worry about – placed in four different places in her room and is a pink paper with all capitalized black lettering; includes waking up in the morning, call at 6:30 am from Marilyn or staff will get her up; paying bills, daughter takes care of finances; laundry and sheets; taken care of by Happy Care staff; and people at Happy Care take her to meals, exercise class, and entertainment.

  • 2. Daily schedule in all capitalized black letters on white paper, stuck on her fridge.

Individual and/or caregiver report of decreased occupational performance: Lack of engagement in leisure activities and difficulty transitioning from one location to another.

Assessments performed: OT performed an occupational profile on XX and gathered information through interviewing XX, the activity director, and certified nursing assistants (CNA’s). Considering the degree of XX cognitive impairment, informal observations were used as XX engaged in various activities.

Findings and analysis

Areas of occupation	Level of independence (observed)	Level of independence (reported)	Reporter of information
Leisure	Max cognitive, verbal, and physical cues	Max cognitive, verbal, and physical cues	Activity director
ADL	Max cognitive, verbal, and physical cues	Max cognitive, verbal, and physical cues	CNA’s
IADL	Max cognitive, verbal, and physical cues	Max cognitive, verbal, and physical cues	CNA’s

Interpretation

Areas of Occupation

Strengths:

XX has an extensive history in many occupations, from living in the country where she helped grow and pick crops to entering the armed forces and later becoming a hairdresser, as well as a wife and mother. These occupations can be used to guide activity choices for XX to engage in. XX also enjoys being with others and wants to converse and participate with the right guidance and reassurance.

Challenges:

XX short-term memory is her biggest challenge. At this time, XX is aware of her declining memory and inability to think clearly. She is easily flustered and gives up, unsure of how to complete a task and concerned with doing tasks correctly.

Behavioral/emotional concerns based on evaluation: The anxiety and decrease in confidence due to XX’s awareness of her severe short-term memory loss are her most significant concerns.

Priorities for intervention:

• 1. Task transition

• 2. Leisure engagement

• 3. Sustained independence in ADLs and IADLs

Plan :

Targeted area of occupation	Baseline supports needed	Observable behavior to watch for when person is experiencing poor performance	Interventions to improve performance and decrease behavioral concerns
Transitions	Max cognitive, physical, and verbal cues	Saying she does not want to get up from couch and that she cannot do “blank” anymore Starts stuttering and cannot get clear words out in response to your question or statement	Introduce yourself, sit down next to her, and then say she should come with you to go check out when lunch is or to see if there are cookies at the front desk If this does not work, wait until she gets up on her own and say, “Let’s go check out when lunch is” and then when you see no one is in the cafeteria say, “Let’s go check out ___” or “Let’s go walk to ___” Give her cues as you are walking, such as “We are going to the elevator” or “We are going to turn right”
Leisure	Max cognitive, physical, and verbal cues	Sitting in lobby: getting up and asking front desk about where to go or what to do; always asking about next meal; looking at her watch; asking if she should get into car outside; looking at her key and stating room number; concerned look on her face (furrowed brows) One-on-one activities: Puts down/ takes out of hands and stops engaging; says she cannot do it because of hands (holding them up and looking at them)	In the lobby: Have a table next to her with the following items: 1. Sign with her name, indicating the objects on the table are hers 2. Sign that indicates when next meal is (i.e., lunch 11:00 AM) 3. Picture that shows how to use nail file and nail cleaner with actual tools directly underneath it 4. Large font crossword puzzle book with one pencil directly next to it During one-on-one activities: 1 step cues Smiling, thumbs up, and touch back or shoulder when guiding her through hallways Words of encouragement and affirmation, such as “You are doing a great job!” or “Thanks for being such a big help!”
ADLs	Max cognitive, physical, and verbal cues	Puts down/ takes out of hands and stops engaging; says she cannot do it because of hands (holding them up and looking at them).	Provide step-by-step verbal cues and demonstrate when needed Encourage and reassure!
IADLs	Max cognitive, physical, and verbal cues	Same as above	Same as above

Specific client-centered activity recommendations

Activity	Environment support recommendations	Supplies needed	Frequency for activity
Exercise group	When she gets up around 10 am to ask when lunch is, go check out the lunchroom with her, but then say, “Let’s go check out the group activity” and guide her upstairs Provide her a chair in the front row and sit in a chair beside her to demonstrate, allowing her to imitate your movements. She will need encouragement (i.e., smiling, nodding, thumbs up) and minimal physical assistance in beginning more complicated movements, such as stretching arms across body	None (chair is located at class)	At least 3x per week
Shelling snap peas or peeling onions	Saying, “The kitchen could use some help with these,” demonstrate shelling one of the peas, and then hand one pea to her Short, simple words of encouragement and affirmation, such as: “This is a huge help,” “Thank you for showing us,” and “I can tell you’ve done this before” Grading down: Peas: opening the peas for her, and then hand them over for her to put into a bowl Onions: start peeling and then hand it to her to finish	Snap peas or onions and two small, brightly colored bowls	As often as possible: this activity requires one-on-one cueing and encouragement
Cleaning underneath fingernails and filing nails	“I know you like to do your nails. Here is a file (or a nail cleaner stick).” Demo how to use the tools (with her own nails), and then place the tool in her hand. If she does not want to use them, set them next to her on the table for her to self-initiate later	Nail file and nail cleaner (wooden)	Daily, while sitting on couch in the lobby
Sorting coins Similar activity to try: sorting silverware or colored buttons	Set up the bowl of coins directly in front of XX on the table and have the other bowls surrounding it Demonstrate what you would like her to do and then hand her a coin. Provide verbal and physical cues (i.e., encouragement, and pointing to the bowl with the coin she is searching for if she verbalizes she doesn’t know)	A variety of coins in a small bowl Four small, colored bowls to use as she separates the coins	As often as possible: this activity requires one-on-one cueing and encouragement
Crossword puzzles	Place next to her on the table in the lobby. Let her know the book is hers as you set it down	Large font crossword puzzle book from her room	Daily, while sitting on couch in the lobby

*Having music playing in the lobby: XX’s foot was tapping, and she crossed her legs showing relaxation and comfort while sitting on the couch.

Specific ADL recommendations :

In the morning before she goes down to the lobby, make sure she has:

• 1. Watch on her wrist

• 2. Keys on her wrist

• 3. Glasses around her neck

• 4. A bottle of Ensure or water

Health literate signs: Colored pictures with minimal font (black letters, 14+ size) on white paper, in her bathroom and bedroom, outlining steps to get ready in the morning/night.

Specific communication recommendations:

• 1. One step cues; calming, short phrases of affirmation, comfort, and encouragement.

• 2. Hold her hand and/or touch her back or shoulder when speaking to her/guiding her from point A to point B.

• 3. Food is a motivator! Use that to transition her from one activity to the next.

Recommend reassessment of resident: Recommend reassessment in 4 weeks to follow up on ease of task transitions and level of occupational engagement.

_____________________________ Date

OT