Going Beyond Diagnosis Case Scenario #2 Palmetto GBA
A physician has ordered skilled nursing care for teaching behavioral techniques to a care-giving niece of a patient with moderate Alzheimer’s disease to gain the patient’s cooperation during mealtime. Due to the patient’s wandering behaviors, she will not stay seated for a meal and the niece believes she is “trying to be difficult.” The patient has been gradually losing weight (10 pounds over 2 months) and she is less coordinated with her utensils due to her underlying dementia as well as a new onset tremor. The teaching services are reasonable and necessary for the patient’s treatment and adequate nutritional intake.
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)
R25.0 Abnormal head movements (used as a secondary diagnosis)
R25.1 Tremor, unspecified (used as a secondary diagnosis)
R25.2 Cramp and spasm (used as a secondary diagnosis)
R25.3 Fasciculation (used as a secondary diagnosis)
R25.8 Other abnormal involuntary movements (used as a secondary diagnosis)
R25.9 Unspecified abnormal involuntary movements (used as a secondary diagnosis)
Additional description of scenario using ICF:
ICF Component: Body Function and Structure
ICF Domain: Mental function
b117 – Intellectual functions – General mental functions, required to understand and constructively integrate the various mental functions, including all cognitive functions and their development over the life span.
Inclusions: functions of intellectual growth; intellectual retardation, mental retardation, dementia
ICF Domain: Functions of the digestive, metabolic, and endocrine systems
b530 – Weight maintenance functions – Functions of maintaining appropriate body weight, including weight gain during the developmental period.
Inclusions: functions of maintenance of acceptable Body Mass Index (BMI); and impairments such as underweight, cachexia, wasting, overweight, emaciation and such as in primary and secondary obesity
ICF Domain: Neuromusculoskeletal and movement-related functions
b760 – Control of voluntary movement functions
b7602 – Coordination of voluntary movements – functions associated with coordination of simple and complex voluntary movements, performing movements in an orderly combination.
Inclusions: right left coordination, coordination of visually directed movements, such as eye hand coordination and eye foot coordination; impairments such as dysdiadochokinesia
b765 – Involuntary movement functions
b7651 - Tremor
ICF Component: Activities and Participation
ICF Domain: Self-care
d550 – Eating – Carrying out the coordinated tasks and actions of eating food that has been served, bringing it to the mouth and consuming it in culturally acceptable ways, cutting or breaking food into pieces, opening bottles and cans, using eating implements, having meals, feasting or dining.
d560 – Drinking
ICF Component: Environmental Factors
ICF Domain: Support and relationships
e315 – Extended family
ICF Domain: Attitudes
e415 – Individual attitudes of extended family members
ICF Domain: Services, systems and policies
e580 – Health, services, systems and policies
e-5802 – Health policies
Potential Interventions
1. Teach the patient’s niece the primary symptoms of Alzheimer’s disease (amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can influence the patient’s functional ability and level of cooperativeness at mealtime.
2. Explore strategies to decrease the patient’s wandering at mealtime (toilet before meals; take the patient for a walk before meals to expend excess energy; wait to seat patient when the meal is actually ready and on the table; position the patient in a comfortable, supportive chair positioned directly in front of the table).
3. If wandering persists or if the use of utensils is challenging for the patient due to apraxia, consider adding finger foods such as sandwiches, slices of fruit, chicken strips, etc.
4. Limit the number of utensils and items on the table to decrease confusion and distractions.
5. Give the patient one item of food at a time, so that the presentation of the food is not overwhelming and then the patient is less likely to become frustrated and walk away from the table.
6. Limit verbal cueing to one step at a time. Physical cueing such as putting the cup in the patient’s hand, initially guiding the spoon to the patient’s mouth may also be helpful for initiation of the self-feeding activity.
7. Eliminate unnecessary environmental stimulation that may distract or upset the patient (turn off television, avoid eating with large numbers of other people, etc.).
8. Consider fortified supplements after a meal if intake is poor. Or consider multiple small meals or other finger foods throughout the day, to ensure adequate intake.
9. Initially to stimulate appetite, give the patient her favorite foods to eat.
10. Consider adaptive feeding equipment such as weighted utensils, no spill cups, bumper plates to increase the patient’s independence with eating.
11. Cut or prepare food in a manner and consistency that maximizes the patient’s ability to eat it.
12. Look for signs of poor dental hygiene, gingivitis and refer to dentist when appropriate. Pain when chewing may be affecting the patient’s oral intake. If the patient has oral heat and/or cold sensitivities, provide liquids and some food more at room temperature. If the patient routinely wore dentures, make sure the patient has them in her mouth and that they fit properly.
13. Assess the patient’s medication regimen to see if any of the medications could be contributing to the patient’s tremor, or poor appetite and notify the physician.
14. Check the patient’s bowel habits to make sure constipation is not causing loss of appetite.
15. Monitor the patient’s weight at regular intervals.
16. Try to have someone else eat at the same time the patient is eating so that behavior modeling can potentially occur.
17. Assess for psychiatric symptoms (depression, paranoid delusions) that could result in a decreased food and fluid intake and notify the physician.
