Going Beyond Diagnosis Case Scenario #1 Palmetto GBA
A beneficiary with moderate Alzheimer’s Disease is unable to bathe and groom herself. The family describes the beneficiary as “uncooperative”. The primary caregiver is a daughter who is trying her best to provide assistance and feels frustrated by the situation, but would like to learn how “to work with her mother” and keep her at home. The beneficiary’s physician has determined that the “uncooperativeness” is the result of receptive language impairments, perceptual misinterpretations, and impairments in learned motor skills – all due to the Alzheimer’s Disease. The teaching services are reasonable and necessary for the beneficiary’s treatment, and to maintain proper hygiene and skin care.
Description of scenario using ICD-10:
G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease
G30.9 Alzheimer's disease, unspecified (Used as a secondary diagnosis)
R48.1 Agnosia
R48.2 Apraxia
R48.8 Other symbolic dysfunctions (Used as a secondary diagnosis)
Additional description of scenario using ICF:
ICF Component: Body Function and Structure
ICF Domain: Mental functions
b117 – Intellectual functions
b167 – Mental functions of language
b1670 – Reception of language
b16700 – Reception of spoken language
b156 – Perceptual functions
b1560 – Auditory perception
b176 – Mental functions of sequencing complex movements
ICF Component: Activities and Participation
ICF Domain: Self-care
d510 – Washing oneself
d5101- Washing whole body
d520 – Caring for body parts
d5200- Caring for skin
d5201- Caring for teeth
d5202- Caring for hair
ICF Component: Environmental Factors
ICF Domain: Support and relationships
e310 – Immediate family
ICF Component: Environmental Factors
ICF Domain: Attitudes
e410 – Individual attitudes of immediate family members
ICF Component: Environmental Factors
ICF Domain: Services, systems and policies
e580 – Health, services, systems and policies
e-5802 – Health policies
Potential Behavioral and Environmental Interventions:
1. Teach the patient’s daughter the primary symptoms of Alzheimer’s disease (amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can influence the patient’s level of cooperativeness with bathing and grooming activities. A learning objective for the daughter would be to define amnesia, aphasia, apraxia, and agnosia, and to give a clinical example of each symptom that she has encountered while caring for her mother.
2. Teach the daughter how to simplify the patient’s environment to maximize the chance for successful activities of daily living (ADL) encounters. (Examples include, but would not be limited to: daughter having all bathing and grooming supplies ready and available for use before approaching patient, unnecessary items that clutter the bathroom/bedroom are moved out of the way, if a shower is used then add a hand-held shower nozzle so water can be directed and will not frighten the patient by spraying on her face, put liquid soap on washcloths ahead of time, so they can be handed to the patient to use, make sure the environment is the appropriate temperature, bath sponges are often easier for patients to hold and use than washcloths).
3. Use a method of bathing that is familiar to the patient. For example, if the patient always took baths and did not take showers, use a bath now. Consider the time (e.g., morning or evening) that the individual habitually bathed. If she resists shampoos in the home, but historically had her hair done at a beauty shop, consider taking her to one for a shampoo. Consider separating bathing from hair washing, if doing them both together causes agitation.
4. Keep communication simple. Break activities down into steps. Provide one direction at a time. Keep verbal instruction to a minimum and “model” (i.e., demonstrate on yourself) what you want the patient to do, such as pretend to wash your face then hand the patient the washcloth and nod telling her “now you try”. Alternatively you could try guiding the individual’s hand in doing the activity, then removing your hand and letting them try.
5. Be creative with your approach. If she won’t get in the shower or tub on a particular day, wait and try again, or have her wash up at the sink, or wherever she is comfortable. Tell her that mother and daughter are having a “spa day of beauty”. Start with a manicure, which is often less threatening, then move to a facial, pedicure, etc.
6. For dressing, lay clothes out in the order in which she should put them on and have other clothes out of the way.
7. Teach the daughter that the patient will easily pick up on her daughter’s emotions, so the daughter should try to remain as calm as possible, appear relaxed, and smile.
8. The nurse should first demonstrate these techniques to the daughter by doing them with the patient first, then on another visit, the daughter can provide a return demonstration for the nurse to observe.
