Problem Solving: A Teaching and Therapeutic Tool for Older Adults and Their Families

Abstract

Problem solving is integral to clinical reasoning and everyday occupational therapy practices. It can also be a systematic therapeutic modality for identifying client or family caregiver concerns and teaching new approaches to self-management. This chapter presents a systematic approach to help occupational therapists (OTs) identify target problem areas and potential modifiable contributing factors when working with older adults and families. The approach is applicable to a broad range of clinical problems associated with the consequences and management of chronic illness and provides therapists with an important tool for actively engaging clients in self-management.

The OT needs to have effective communication skills, respecting a family’s values and understanding where they’re coming from.… That’s critical, even more than knowing her intervention strategies.Family caregiver

The Case Study of Using Problem Solving for Marie, Living with Alzheimer’s Disease and her daughter Donna

Keywords: Behavioral symptoms, Caregiver burden, Caregiving, Problem solving

Introduction

The theme of this case study concerns family challenges associated with caring for a person with moderate stage dementia and the use of problem solving to identify discrete problem areas and potential solutions.

The students’ tasks include:

• 1. To determine strategies to help Donna manage her mother’s behavioral symptoms and to also be able to take better care of herself.

• 2. To work with Donna to identify underlying patterns and mutable factors that may be contributing to her mother’s behaviors.

• 3. To apply problem solving to come up with a set of strategies Donna agrees to try.

As a starting point, students should use the following references to gather background information.

Important references are:

• 1. Gitlin LN, Hodgson N (in press) Caregivers as therapeutic agents in dementia care: The evidence-base for interventions supporting their role. In: Gauglher J and Kane R (eds) Family Caregiving in the New Normal, Elsevier

• 2. Gitlin LN (2011) Problem solving in health and illness. In: Craft-Rosenberg M, Pehier S (eds) Encyclopedia of family health, Sage

• 3. Gitlin LN (in press) Problem solving: a teaching and therapeutic tool for older adults and family members. In: Söderback I (ed) International handbook of occupational therapy interventions, 2nd edn. Springer, New York, pp 205–216

• 4. Gitlin LN, Winter L, Dennis MP, Hodgson N, Hauck W (2010) Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. J Am Geriatr Soc 58(6):1465–1474

• 5. Prochaska JO, Velicer WF (1997) The transtheoretical model of health behavior change. Am J Health Prom 12:38–48

• 6. Cuijpers P, van Straten A, Warmerdam L (2007) Problem solving therapies for depression: a meta-analysis. Eur Psychiatry 22:9–15

Overview of the Content

Major goal of the actual interventions are to

• Enable the caregiver to prevent, minimize, or reduce behavioral symptoms of her mother

• Enhance the mother and the caregiver’s quality of life

• Enable the caregiver to find time for herself

Learning Objectives

By the end of studying this chapter the learner will:

• 1. Understand how to apply problem solving with families caring for persons with dementia

• 2. Identify potential strategies (behavioral, environmental) that can minimize behavioral symptoms

• 3. Examine the interactions of persons with dementia, their care environment, and impact on families

The Background History of Mary and Her family

Personal Information

Marie is an 80-year-old female diagnosed with Alzheimer’s disease 4 years ago. She lives with her daughter, Donna, and her daughter’s husband and two teenage sons in a ranch house in a suburban area. Marie has her own bedroom, sitting room, bathroom, and kitchenette in an “in law” suite attached to the family home. Marie was a full-time wife and homemaker who never worked outside the home. Her husband passed away in 2000, and she came to live with Donna a year later as she was having difficulty keeping up with her finances, shopping, and other basic tasks of daily living.

Marie prided herself on her homemaking skills. She was a great cook and loved to bake. She enjoyed knitting and was an active community volunteer first with the children’s school and later (as they grew older) with her local church. She stopped driving her car right after her diagnosis, as she was afraid to drive.

Marie’s daughter reports that she appears to be easily agitated, highly anxious, and keeps repeating the same questions over and over with her (e.g., where are you going? When are we eating?). She has been resisting going out of the house for family dinners at the local restaurant or to attend church. She tends to become anxious and fearful when it is time to leave the house for anything (appointments, outings, etc.).

Donna is finding it increasingly difficult caring for her mother and attending to her other responsibilities including a part time job in her local school system, being there for her two sons and husband, attending to her household responsibilities, and taking care of herself. She is feeling very stretched and indicated she is having difficulty sleeping, feels very tired and alone, and feels very sad everyday to see her mom the way she is now. Donna wants help but is reluctant to ask anyone else to help her with her mom. She also can be a perfectionist and wants things done a certain way in her home.

Medical Diagnoses and Prognoses

Marie has dementia , most likely of the Alzheimer’s type. She is in the moderate stage of the disease, which is a progressively degenerative disease process. Her short-term memory is poor and she is having increasing difficulty initiating, planning, and organizing activities she used to do (e.g., cook a meal) demonstrating executive functional challenges. She continues to have some insight, although limited, of her cognitive changes. She is becoming increasingly agitated and confused as she loses her cognitive abilities. She is in relatively good physical condition with no other chronic conditions. Her vision is good with glasses but she is experiencing some hearing loss although she does not wear a hearing aid. While her ambulation in general is good, she did fall 6 months ago—she tripped over the carpet and fell to the ground. She was bruised but no bones were broken.

Reason for Seeking Occupational Therapy

Marie is experiencing behavioral symptoms, which prompted her physician to be concerned about her home safety and daily function. She suggested occupational therapy to assess Marie’s safety at home and to work with the caregiver to teach her behavioral management skills.

Occupational Performance Issues

Marie used to cook but is having difficulty knowing what to do in the kitchen. This frustrates her. She is also having increasing difficulty dressing and bathing herself, but she does not want any help from her daughter. She is starting to look a little raggedy which is not like her previous self.

The Student’s Report

The following guiding questions have been identified in developing possible solutions for Marie and Donna. These questions are generated from the available literature references and our clinical experiences:

Questions

• 1. What specific questions would you ask the caregiver to learn about her mother’s presenting behaviors?

• 2. What would you like to learn about Marie’s day?

• 3. What would you like to learn about the relationship of Donna and her mother?

• 4. What aspects of the physical and social environment would you want to learn about and/or for which you may have potential concerns?