An Interdisciplinary Approach to Discover and Promote Best Ability and Quality of Life

As a trainer and consultant I have the very good fortune to work with clinicians to teach them how to discover best abilities and promote quality of life (QOL) in a person with dementia. I often take the interdisciplinary team through a process of discovery that they are quite unaccustomed to but they take to it like a fish in water. I believe it is my Occupational Therapy training that has taught me to look at a client from the perspective of how I can help the person to become healthier and happier. I then use my skills of activity analysis coupled with my knowledge of diseases and conditions to develop an intervention plan. Believe it or not, nurses and others are not taught to think in this manner. These team members often simply discover "what is" during their assessments, then address the symptoms with medications and medical treatments. Also, sadly I find that the activity team members and CNAs are not empowered to understand their role in maximizing client function and QOL. The entire team can implement this perspective of discovery to help facilitate the potential that lies within persons with dementia.


A Successful Process
The process of discovery is fun and exciting as the team dissects the problems and comes up with solutions that the entire interdisciplinary team can implement. Together, we help this person to thrive, not simply exist with problems.


Our Process:


Step 1: Identify the problem areas impacting function, safety, and quality of life


Step 2: Identify the cause(s) behind each problem area


Step 3: Determine whether or not the problem has potential for recovery/improvement


Step 4: Identify the risks associated with the problem


Step 5: Develop a plan of action which can incorporate internal and external resources to reduce the problem, enhance function, safety, and QOL, and to proactively address areas of high risk


Typically, our team members sit together in a room gathered around a large board in which all of the information above is documented. I require participation from nursing, activities, therapy, and dietary and welcome participation from CNAs, activity staff, medical director, pharmacy, and family. Together we analyze, discuss, and develop a service plan. This process can work well in any of our typical work environments including long-term care, home health care, and hospital-based care. The actual work environment will have a direct influence on the members of this discovery team as, for example, a case manager is a key member in home health care but this role does not exist in long-term care. A director of a dementia unit may be present in long-term care and not in others.


Please see the example below that demonstrates how to utilize this process.


Client Name: Bertha, a resident of an Assisted Living Facility


Problem Area Causative Factor Improvement Potential? Risk Association Plan of Action
Cognitive Deficit = Early
Stage/Allen Low 4
Alzheimer's Disease and Possible Delirium due to Poor Nutrition Some—related to delirium and also she is not on a cognitive enhancement med (e.g., Aricept) Safety, QOL loss, impaired function, accelerated cognitive decline, etc. Eval by psychiatrist/neurologist (possible new meds), dietary intervention to incorporate likes/dislikes, OT/ST to create "just-right match"; activities, CNAs and nursing to understand cognitive level related to their care as trained by therapy
Upper- and Lower-Body Weakness Recent hospitalization with prolonged bed rest and general declining activity level Yes Falls, impaired function and safety and potential contracture development and skin breakdown if disuse worsens OT/PT for exercise and creation of maintenance program to maximize function, safety, and activity/exercise on ongoing basis—maximize activity level
Poor Standing Balance Recent hospitalization with prolonged bed rest, general declining activity level, and use of psychotropic meds Yes Falls, impaired function and safety- can lead to immobility (which can cause other problems such as skin issues and contractures) if the problem progresses OT/PT for balance reeducation, environmental adaptations, staff education and development of maintenance program/staff training as needed. Psych/neuro eval to see if we can eliminate the anxiety and depression meds with non-pharmacologic intervention (i.e. meaningful and successful activity)
Poor Activity Tolerance COPD and recent hospitalization with prolonged bed rest and general declining activity level Some- related to decreased activity level Falls, impaired function and safety- can lead to immobility (which can cause other problems such as skin issues and contractures) if the problem progresses PT/OT to: exercise diaphragm, introduce simple energy conservation techniques in which the client will need to be supervised and cued to use, general exercise program and maintenance program development. Refer to pulmonary doctor to address COPD. Activities and others to understand client limitations and abilities as trained by therapy
Depression Not living in a peer to peer living environment/out of place; feels like a failure, no sense of purpose, and is withdrawing Yes Weight loss, failure to thrive, elopement, loss of function, etc. Referral to psych doc to reassess meds. Move to dementia household to live in a peer to peer environment. OT eval to ensure ADLs and activities are performed at "just-right challenge" level and incorporating individual preferences and interests. Goal: Create social and activity successes and provide purpose thru activity and relationships.
Anxiety Same as above Yes Falls, elopement, loss of function, weight loss, etc. Same as above and ensure the client feels loved and safe
Weight Loss and Poor Nutrition Depression, unable to get to meals on time and unable to cook for self Yes Skin breakdown, falls, etc. Dietary consult including incorporating likes/dislikes, OT/ST eval to create "just-right challenge" for dining and nutrition needs. Nursing to check medication reactions impacting appetite and discuss with primary MD as needed. Provide frequent "favorite" high calorie/nutritious snacks throughout day and during activities


If actually sitting in a room discussing this case, all team members would be sharing suggestions and our intervention plan list would likely be much longer. However, this is meant to provide an overview of how we actually tease apart those problem areas destroying the QOL and function of our elderly clients with dementia.


At the end of these sessions, team members feel inspired to help as they now have a strong sense of their role in enabling their clients to succeed and heal. I strongly suggest your team put the time and effort into a process such as the one that I have described. While it might seem time intensive on the front end, imagine the time and money saved over the long run though better health, safety, and function. And of course, let us never forget the magnitude of the gift of discovery and healing for the person who is living with dementia and many comorbid conditions. It is our duty to ensure that each person that we serve can live in well-being.



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