5487 Jongsma 01.mj · 1999-07-27 · 14. Patient, family, and staff agree on care plan to improve function as much as possible. (19, 20, 21, 22) 15. Comply with recommenda- ... malnutrition

ADL/IADL DEFICITS

BEHAVIORAL DEFINITIONS

1. Decline in ability to accomplish one or more basic Activities ofDaily Living (ADLs) independently: bathing, dressing, grooming,eating, toileting, mobility/transferring.

2. Decline in ability to accomplish one or more Instrumental Activi-ties of Daily Living (IADLs) independently: shopping, cooking,housekeeping, financial management, transportation, medicationmanagement.

3. Confusion or conflict among family, staff, and patient about causefor, or amount of, decline in ADL/IADLs.

4. Threat to patient’s safety due to decline in ADL/IADLs, such asfalls, malnutrition, adverse drug reactions, or infections.

5. Confusion or conflict among family, staff, and patient about level ofsupervision required in residence.

6. Conflict between expectations for and actual recovery of functionafter stroke, hip surgery, or other medical event.

7. Patient is unwilling or unable to use adaptive equipment to com-pensate for decreased function.

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LONG-TERM GOALS

1. Identify cause(s) of decline in ADL/IADL functions and barrier(s)to recovery of function.

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SHORT-TERMOBJECTIVES

1. Consent to participate inevaluation of functionaldecline if decisionally capa-ble; surrogate consents ifthe patient is not decision-ally capable. (1)

2. Patient, staff, and familydescribe decline in functionin specific detail. (2, 3)

3. Cooperate with immediatemeasures to improve safety.(4, 5)

4. Cooperate with a medicalevaluation. (6)

5. Cooperate with a psycholog-ical evaluation. (7)

6. Comply with a neuropsy-chological evaluation. (8)

7. Attend a physical therapyevaluation. (9)

ADL/IADL DEFICITS 13

THERAPEUTICINTERVENTIONS

1. Obtain consent from thepatient or surrogate toaddress problem of func-tional decline, includingconsent to discuss issueswith others involved.

2. Explore with the patient,staff, and family their per-spectives on the decline inthe patient’s function (e.g.,sudden versus gradual; pre-cipitated or accompanied bya specific illness, medica-tion, or event; the patient’sreaction to the decline).

3. Administer a structuredinstrument, such as thePhysical Self-MaintenanceScale (Lawton and Brody,1969) to objectively measure

2. All involved persons (staff, family, physician, patient) reach con-sensus on cause(s) for disability, prognosis, and a care plan.

3. Increase supervision/assistance to enhance safety.4. Resolve depression and anxiety that may be interfering with moti-

vation to recover function.5. Maximize capacity for independent functioning in ADL and IADL

spheres.6. Identify and implement compensatory strategies, such as adaptive

equipment, that support independent functioning.7. Adapt to current and expected level of function.

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8. Participate in an occupa-tional therapy assessment.(10)

9. Cooperate with aspeech/language evaluation.(11)

10. Accept and participate in areferral to a dietician. (12)

11. Cooperate with a recre-ational therapy assessment.(13)

12. Patient, family, and staffverbalize an understandingof cause(s) for decline infunction. (14, 15)

13. Patient, family, and staffaccept prognosis regardingrecovery of function. (16, 17, 18)

14. Patient, family, and staffagree on care plan toimprove function as muchas possible. (19, 20, 21, 22)

15. Comply with recommenda-tions to change medica-tions, dosage, or schedulingto improve function. (6, 23)

16. Complete treatment for con-founding or coexistingdepression and anxiety. (24)

17. Complete treatment forrehabilitation of function.(25, 26)

18. Use adaptive equipmentthat can compensate fordecreased function. (25, 26, 27)

19. Comply with rehabilitationrecommendations for ongo-ing changes in lifestyle, andneed for increased assis-

14 THE OLDER ADULT PSYCHOTHERAPY TREATMENT PLANNER

the patient’s and others’reports of functional decline.

4. Evaluate the possibility ofimminent danger to self,such as infections, malnu-trition, falls, adverse drugreactions, and so forth.

5. Arrange for the patient’simmediate protectionthrough installation ofsafety devices (e.g., grabbars), addition of services(e.g., home health aide), orin severe cases, transfer toa safer environment.

6. Refer to a physician forevaluation of medical condi-tions (e.g., Parkinson’s dis-ease, stroke, arthritis) andmedications (prescribed andOTC) that could be causingdecline in function.

7. Conduct or refer for psycho-logical evaluation to assesspossible contributions ofdepression and/or anxiety todecline in functional ability.

8. Conduct or refer for neu-ropsychological evaluationto determine if functionaldecline is associated withcognitive decline.

9. Refer to physical therapistfor an evaluation of mobility-related declines in function,such as balance, gait,endurance, ability to trans-fer, and range of motion.

10. Refer to occupational thera-pist for an evaluation ofADLs (e.g., bathing, groom-ing, and hygiene) and


tance with ADLs/IADLs.(28, 29)

20. Verbalize an acceptance ofincreased level of supervi-sion or help necessary toassure safety or to compen-sate for decreased indepen-dent functioning. (29, 30)

21. Verbalize and resolve feel-ings surrounding increaseddependency on caregivers.(30, 31, 32)

22. Identify activities that canbe performed as substitutesfor those activities that cannot be performed. (33, 34, 35)

23. Reminisce about formeraccomplishments and rela-tionships that built self-esteem. (36)

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IADLs (e.g., driving andcooking).

11. Refer to speech/languagetherapist for an evaluationof communication skills andswallowing function.

12. Refer to dietitian for anevaluation of suspectedmalnutrition.

13. Refer to recreation thera-pist for an evaluation ofleisure activity function.

14. Discuss and integrate theresults of the evaluationswith the physician andrehabilitation professionalsas appropriate.

15. Meet with the patient, fam-ily, staff, and other profes-sionals as appropriate togive feedback about thenature, severity, scope, andcauses of the functionaldecline.

16. Explain, or have rehabilita-tion professionals explain,the prognosis for recovery offunction.

17. Encourage the patient, fam-ily, and staff to voice doubtsand raise questions aboutcauses/prognosis.

18. Explore with the patientand family their emotionalreactions to evaluations,including denial, grief, feel-ings of hope or hopeless-ness, anger, and so forth.

19. Introduce concept of excessdisability to the patient andfamily, explaining thatoften negative psychological



or environmental factorsproduce disability beyondthat which is expected fromphysical or cognitive causes;by addressing the causes ofexcess disability, thepatient’s function can oftenimprove.

20. Establish with the patientand family what functionsmight be improved throughaddressing psychological orenvironmental factors.

21. Establish with the patient,family, and rehabilitationprofessionals what func-tions might be improvedthrough a formal rehabilita-tion program.

22. Propose and obtain agree-ment to a care plan thatcombines all relevantmodalities, professionals,and family support.

23. Reinforce physician’s recom-mendations regarding medi-cations and othertreatments that could posi-tively impact ADL/IADLfunction.

24. Address the psychologicalcomponents of excess dis-ability. (See Depression andAnxiety chapters in thisPlanner.)

25. Motivate the patient tocomply with rehabilitationtreatment, providing anoutlet for ventilation offrustration, but also provid-ing encouragement andreinforcement for completedsessions.



26. Communicate regularlywith rehabilitation profes-sionals regarding thepatient’s goals, progress,and psychological status.

27. Provide follow-up for reha-bilitation professional’s rec-ommendations regardingadaptive devices (e.g., walk-ers or electric carts, commu-nication boards, adaptiveutensils, dressing andgrooming aids, specializedphones or computers,household safety devices,etc.).

28. Provide follow-up and moni-toring for rehabilitationprofessional’s recommenda-tions regarding lifestylechanges (e.g., patterns ofphysical exercise, dietaryhabits, leisure activityschedule).

29. Provide follow-up and moni-toring for rehabilitationprofessional’s recommenda-tions regarding increasingassistance with ADLs/IADLs by working with thefamily to decide on whetherassistance is provided byfamily, friends, neighbors,or formal caregivers.

30. Explore feelings aboutincreased dependency andfeelings toward those pro-viding assistance.

31. Provide an emotional outletfor the patient to discussambivalence toward, andconflicts with, caregivers.

32. Help the patient resolve



conflicts with the caregivers(see Interpersonal Conflictschapter in this Planner) andadapt to greater depen-dency.

33. Have the patient, family,and caregivers identify allareas of preserved function.

34. Work with the patient, fam-ily, and caregivers to iden-tify substitute activities forthose that can no longer beperformed, such as windingyarn in place of knitting.

35. Find alternative sources ofself-esteem; for example,even if arthritic hands can’tperform old tasks, they canbe beautifully manicured.

36. Use reminiscence to iden-tify and elevate thepatient’s lifelong sources ofself-esteem. Teach caregiverto encourage reminiscencethrough verbal descriptionof events and people, look-ing at photographs, playingmusic from earlier eras,and/or handling objectsfrom earlier eras.

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DIAGNOSTIC SUGGESTIONS

Axis I: 293.0 Delirium Due to (Axis III Disorder)290.xx Dementia of the Alzheimer’s Type or Vascular

Dementia294.1 Dementia Due to (Head Trauma, Parkinson’s

Disease, Huntington’s Disease, or Axis IIIDisorder)

290.10 Dementia Due to Pick’s Disease or Creutzfeldt-Jakob Disease

294.8 Dementia NOS291.2 Alcohol-Induced Persisting Dementia294.9 Cognitive Disorder NOS296.xx Major Depressive Disorder309.xx Adjustment Disorder293.89 Anxiety Disorder Due to (Axis III Disorder)300.02 Generalized Anxiety Disorder300.00 Anxiety Disorder NOS316 Psychological Factors Affecting Medical

Condition995.2 Adverse Effects of Medication NOS


AGGRESSION/HOSTILITY


1. Several episodes of explosive, aggressive outbursts resulting inassaultive acts or destruction of property.

2. Verbally abusive or threatening language directed at caregivers orother residents.

3. Catastrophic reaction, including angry outbursts, thrashing, cry-ing out, and extreme agitation when overwhelmed, frustrated, orembarrassed.

4. Significant tension and anger are evident in body posture and language (e.g., clenched fists or jaw, glaring looks, bulging eyes,hunched shoulders, tensed large muscles in legs and arms).

5. Blames others for misplacing objects or being unable to carry outtasks.

6. Easily becomes impatient and hostile while waiting.7. Easily becomes frustrated and hostile when unable to complete

task.8. Refuses personal care (toileting, dressing, bathing, grooming),

using hostile and threatening manner.9. Planned hostile actions taken against other residents, such as run-

ning into another with wheelchair, pouring water on the floor tocause falls, or setting room temperature or television volume con-trols to annoy another.

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1. Consent to participate inevaluation of physical and/orverbal aggression if decision-ally capable; surrogate con-sents if the patient is notdecisionally capable. (1)

2. Cooperate with necessarysafety precautions to pro-tect self and others fromharm. (2)

3. Cooperate with evaluationto identify medical, neu-

AGGRESSION/HOSTILITY 21


1. Obtain consent from thepatient or surrogate toaddress problem of physicaland/or verbal aggression,including consent to discussissues with other involvedparties (e.g., family, staff,and physician).

2. Evaluate severity of dangerto self and others; takeimmediate safety precau-tions (including adding staff

LONG-TERM GOALS

1. Reduce intensity and frequency of aggressive behaviors and ver-balizations, treating others with civility and respect.

2. Identify early warning signs of explosive outbursts or catastrophicreaction.

3. Avoid situations that produce feelings of frustration, embarrass-ment, or impatience.

4. Substitute prosocial ways of expressing frustration, embarrass-ment, or impatience.

5. Resolve conflicts that underlie planned hostile actions towardothers.

6. Complete personal care tasks without verbal or physical aggres-sion.

7. Enjoy warm and caring relationships with personal caregivers,including staff and family.

8. Enjoy mutually satisfying and supportive relationships with otherresidents, especially roommate, in residential facility.

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ropsychological, and/or psy-chological causative factorsof the verbal and/or physi-cal aggression. (3, 4, 5, 6)

4. Complete treatment for con-founding or coexistingdepression, anxiety, medicalconditions, and/or adversedrug reactions. (6)

5. Cooperate with an evalua-tion to identify the specificbehavioral pattern of verbaland/or physical aggression.(7, 8)

6. Caregiver identifies andavoids possible antecedentsto (“triggers” for) aggressivebehavior. (8, 9, 12)

7. Caregiver ensures safety ofthe patient and self. (10, 11)

8. Caregiver ensures thepatient’s physical comfort.(13)

9. Caregiver ensures thepatient’s emotional comfort.(14)

10. Caregiver ensures suitabil-ity of environment for thepatient. (15)

11. Caregiver presents tasksappropriately for thepatient’s level of frustrationtolerance, comprehension,and physical ability. (16)

12. Caregiver communicates ina calm, pleasant manner, inspite of the patient’s hostil-ity. (17, 18)

13. Caregiver implements com-munication skills of calm,distinct, deliberate, simple,polite speech. (19)


or family coverage, removalfrom current environment,or medication) as needed.

3. Refer to the physician forevaluation of medical condi-tions and medications (pre-scribed and OTC) that couldbe causing hostility andaggression.

4. Conduct or refer for psycho-logical evaluation to assesspossible contributions ofdepression and/or anxiety tohostile and aggressivebehavior.

5. Conduct or refer for neu-ropsychological evaluationto determine if verbaland/or physical aggressionis caused by the patient’sinability to inhibit aggres-sive impulses due to a braindisorder; if so, work withthe caregivers to controlstimulus conditions.

6. Discuss the results of theevaluations with thepatient, family, physician,and staff as appropriate;develop and implement aplan to address treatablemedical and psychologicalcauses for the aggression.

7. Conduct a behavioral analy-sis through direct observa-tion, patient, and/or proxyreport; detail frequency ofepisodes, time of day, loca-tion, precipitants and conse-quences, observed/reportedmood and rationale, andresponse to suggestions forchange.


14. Verbalize interpersonal con-flict issues with others (e.g.,spouse, roommate, familymembers). (20)

15. Complete psychotherapeu-tic treatment for resolutionof interpersonal conflict.(21)

16. Engage in mutually satisfy-ing, pleasurable activitieson a daily basis with pri-mary significant others whobecome targets of aggres-sion (spouse, family members, caregivers, roommates). (22, 23)

17. Verbalize or demonstratepositive feelings toward thecaregiver or roommate. (24)

18. Verbalize or demonstratefeelings of security with,and appreciation for, care-giver. (25, 26, 27)

19. Caregiver feels supportedand able to enjoy the bene-fits as well as endure theburdens of a caregiver role.(22, 23, 28, 29)

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8. Teach caregivers (familyand/or staff) to keep behav-ioral records, establishingat least one week of base-line recording.

9. Analyze with caregivers thebehavioral patterns, devel-oping hypotheses about pos-sible “triggers” of aggressiveepisodes.

10. Analyze with caregivers theearly warning signs of ver-bally and/or physicallyaggressive incidents.

11. Teach caregivers to ensuresafety of self and others:stay calm, call for help fromonly one other person, neverfight back, don’t pull awayif grabbed (distractinstead), be alert to troubleand get a safe distanceaway, try to get patient to aseated position, then leavearea for cool-down period.

12. Teach caregivers to preventaggressive episodes byavoiding trigger (or identi-fied negative stimulus) con-ditions.

13. Teach caregivers to avoidpossible physical triggers bydoing the following: reposi-tion the patient frequently;add or remove a sweater;take the patient to the toi-let; offer water or a snack;check for constipation; giveOTC pain medication; pro-vide hearing aid, glasses,dentures.

14. Teach caregivers to avoidpossible emotional triggers



by doing the following:spend at least five minutesletting the patient talk itout, give backrubs, holdhands, sing or hum together,listen to quiet musictogether, encourage remi-niscing, gently groom withhairbrushing or applicationof lotion, read a storytogether, take a walktogether.

15. Teach caregivers to avoidpossible environmental trig-gers by accommodating thepatient’s preferences: adjustnoise and stimulation level(TV, radio); lighting; tem-perature; social environ-ment (being with more orfewer people); activity level(doing more or fewer activi-ties); environment (goingfor a walk or a ride, allowthe patient to feel fresh air,rain, or sun).

16. Teach caregivers to presenttasks by introducing onestep at a time; the caregiverdoes the task with, not to,the patient; distract thepatient during personalcare with something famil-iar to hold; praise often;stop if hostile, aggressivereaction is building and tryagain later.

17. Teach caregivers that emo-tions are highly contagiousand communicated nonver-bally—if the caregiver ishostile and angry, thepatient is likely to become



hostile and angry.18. Use role-playing and behav-

ioral rehearsal to teachcaregivers: Never argueback!

19. Teach caregivers that it isimportant to communicatewith a calm and cheerfulmanner; with respect; withguidance, not control; at eyelevel; from the front, notfrom the side or the back;by speaking slowly andclearly; by speaking with aloud, low voice if the patientis hearing-impaired; byalways offering simplechoices when possible.

20. Ask the patient to identifythe issues in the interper-sonal conflict: differingexpectations, needs, goals,or values; differing or difficult personal styles, cultural differences, under-lying anger.

21. Explain psychotherapeuticapproach to resolution of aninterpersonal conflict, andobtain a commitment fromthe patient and the otherparty to participate in reso-lution process. (See Inter-personal Conflict chapter inthis Planner.)

22. Instruct the patient and theprimary significant other todevelop a list of mutuallysatisfying, pleasurable, feasible activities (e.g., tak-ing a walk, eating a treattogether, feeding birds,looking at photographs,



going to an activitytogether, talking on thephone, grooming nails orhair).

23. Help the patient and signif-icant other to engage in onesmall pleasurable activityper day together.

24. Work with the individualwho is the target of aggres-sion to identify positivestimulus to consistentlypresent at the beginning ofinteraction with patient(minicandy; newspaper ormagazine; furry puppet).

25. Advise facility to use pri-mary assignment staffingpattern (i.e., the same staffattend to patient every day)so that personal relation-ships can develop betweenstaff caregivers and patient.

26. Teach staff caregivers tolearn about patient’s his-tory by encouraging remi-niscing and talking with thefamily.

27. Teach staff and family care-givers to ask questions thatan individual with demen-tia can usually answer:multiple-choice or yes/no,tapping remote versusrecent memory, askingabout emotionally meaning-ful memories (e.g., name ofa childhood pet).

28. Encourage caregivers tocare for themselves: seekout social support; userespite care; don’t take hos-tility personally (“it’s the



disease”); manage stresswith diet, exercise, diver-sions, relaxation, and care-giver support groups.

29. Recommend to the facilitythat staff caregivers shouldbe provided with a supportgroup.

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Axis I: 293.0 Delirium Due to (Axis III Disorder)290.xx Dementia of the Alzheimer’s Type or Vascular

Dementia, with Behavioral Disturbance294.1 Dementia Due to (Head Trauma, Parkinson’s

Disease, Huntington’s Disease, or Axis IIIDisorder)


294.8 Dementia NOS291.2 Alcohol-Induced Persisting Dementia294.9 Cognitive Disorder NOS310.1 Personality Change Due to (Axis III Disorder),

Aggressive Type296.xx Major Depressive Disorder309.xx Adjustment Disorder293.89 Anxiety Disorder Due to (Axis III Disorder)300.02 Generalized Anxiety Disorder300.00 Anxiety Disorder NOS316 Psychological Factors Affecting Medical



ANXIETY


1. Excessive fear and worry about life and health circumstances.2. Inability to control worries about health, family members, social

relationships, volunteer or job responsibilities.3. Fear, worry, and other symptoms cause social withdrawal and

sleeplessness.4. Fear of doing or saying something embarrassing in a social situa-

tion, especially due to actual or feared memory or hearing impair-ment.

5. Fear, worry, and other symptoms significantly interfere with dailyfunctioning at home, work, volunteering role, with family, or insocial situations.

6. Symptoms of autonomic hyperactivity, such as palpitations, chestpain, shortness of breath, sweaty palms, dry mouth, trouble swal-lowing, nausea, or diarrhea.

7. Symptoms of motor tension, such as restlessness, fatigue, trem-bling, or shakiness.

8. Symptoms of altered cognition, such as difficulty concentrating,mind going blank, feelings of unreality, or feelings of being detachedfrom oneself.

9. Symptoms of hypervigilance, such as feeling constantly on edge,sleep disturbance, and irritability.

10. Development of a dependence on substances to control anxietysymptoms.

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1. Identify the specific anxietysymptoms that are person-ally most disturbing or mostcontribute to impaired func-tioning. (1, 2)

2. Verbalize an understandingof the general physical andcognitive manifestations ofand causes for anxiety. (3, 4, 5)

3. Keep a daily journal of anx-iety symptoms for one weekto establish frequency,

ANXIETY 29


1. Assign the patient to ver-balize or list all specificanxiety symptoms in detailand to rank-order the symp-toms on the basis of howdisturbing they are.

2. Help the patient to identifywhether and/or how eachsymptom interferes withdaily functioning and/orrelationships.

3. Teach the patient the anxi-ety symptom clusters: auto-

LONG-TERM GOALS

1. Significantly reduce the overall frequency and intensity of the anx-iety symptoms so that the patient can improve daily functioning.

2. Decrease worry and fearful thoughts and increase optimistic, problem-solving thoughts.

3. End substance use as a means of escaping anxiety and increaseconstructive coping behaviors.

4. Decrease fear of social embarrassment and learn adaptive socialskills.

5. Learn stress management skills to prevent anxiety response.6. Learn problem-solving skills to resolve anxiety-producing prob-

lems.7. Manage environmental stressors in a way to reduce psychological

pressure.8. Accept help as necessary from formal and informal support sys-

tems to reduce stress.

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intensity, time of day, andduration of symptoms. (6)

4. Compile a list of all pre-scribed and OTC medica-tions, dosage, and time ofday they are taken. (7)

5. Compile a list of all medicalconditions, approximatedate of diagnosis, and thetreating physician(s). (8)

6. Give consent for physi-cian(s) and/or designatedfamily members to be contacted if necessary. (9, 10)

7. Accept referral to physicianto review possible relation-ships between anxietysymptoms, illnesses, andmedications. (11, 12, 13)

8. Comply with physician-ordered changes in medications, dosages, oradministration schedules toalleviate anxiety symptoms.(14, 15)

9. Keep a daily journal of anx-iety symptoms to documentthe frequency and intensityof anxiety symptoms, andspecific situations, events,people, thoughts, moods,and behaviors that precedeor follow the anxiety symp-toms. (16, 17)

10. Identify and clarify the pat-terns to anxiety precipi-tants and consequences.(16, 17, 18)

11. List the negative conse-quences of anxiety symp-toms, such as impaired


nomic, motor, cognitive, andhypervigilant.

4. Assist the patient to iden-tify how his/her personalanxiety symptoms fall intoclusters.

5. Discuss with the patient thepossible etiologies of thesesymptoms: illnesses (suchas endocrine, cardiovascu-lar, respiratory, metabolic,and neurological condi-tions), prescribed and OTCmedications, and maladap-tive responses to stressors.

6. Assign the patient to gatherspecific data on anxietysymptoms for one weekthrough daily recordings ofsymptom occurrence, timeof day, intensity (rated 1 to 10), and duration ofsymptoms.

7. Assign the patient to pro-duce a list of all prescribedand OTC medications,dosage, and time of daythey are taken. If thepatient is unable to com-plete this task, ask that allmedication containers bebrought to next session.

8. Assign the patient to pro-duce a list of all medicalconditions, approximatedate of diagnosis, and thetreating physician(s).

9. Discuss with the patient thenecessity for working withthe primary care physicianto determine if there maybe a biological etiology tothe anxiety symptoms.


daily functioning and loss offriends because of socialwithdrawal, and identifythe highest priorities forchange. (19)

12. List the apparent positiveconsequences of anxietysymptoms, such as help andattention from family andfriends, and avoidance ofstressful situations. (21, 22)

13. Verbalize how the apparentpositive consequences even-tually lead to negative consequences; make a com-mitment to learn more con-structive ways to achievepositive goals. (20, 22, 23, 24)

14. Identify specific thoughtsthat precipitate anxietysymptoms. (25, 26)

15. Verbalize a plan to reason-ably address rational con-cerns that generate someanxiety, changing thingsthat can be changed andunder the patient’s own con-trol, while accepting thingsthat cannot be changed.(27)

16. Replace anxiety-producingthoughts with constructivethoughts. (28, 29)

17. Identify specific stimulussituations, events, or peoplethat precipitate anxietysymptoms. (30)

18. Avoid situations that pro-duce anxiety and in whichavoidance does not havelong-term negative conse-quences. (31)

ANXIETY 31

Obtain written consentfrom the patient to speakwith the physician.

10. Discuss with the patient theneed or desire to involvedesignated family membersin treatment. If the patientis unable to produce accu-rate medical information,obtain consent to speakwith a family member to getinformation. If the patientreports that anxiety symp-toms are negatively impact-ing family relationships,obtain permission to contactfamily member(s).

11. Collect, organize, and ana-lyze data on anxiety symp-toms, medical conditions,and medications. If medicaletiology seems possible,refer to primary care physi-cian for medical evaluation.

12. Suggest to the primary carephysician that if no medicaletiology is uncovered (i.e., ifanxiety appears to be pri-marily psychogenic in ori-gin), the first-line treatmentapproach will be psycho-therapeutic rather thanpharmacological.

13. Keep the primary carephysician informed of thepatient’s progress in reduc-ing anxiety symptoms, andthe desirability of avoidinganxiolytics if possible.

14. Obtain from the physicianthe ordered changes in med-ication, dosages, or admin-istration schedules to


19. Use assertiveness to dealconstructively with situa-tions that need to be con-fronted to reduce anxiety.(32)

20. Use adaptive techniques tominimize anxiety. (33)

21. Practice and implementrelaxation techniques toreduce anxiety. (34)

22. Identify daily routine activi-ties that have been effectiveat reducing anxiety in thepast. (35)

23. Make lifestyle changes indiet, exercise, and pleasur-able habits that will reduceanxiety symptoms. (36)

24. Learn and practice thoughtand behavioral controlmethods to minimize andcontrol anxiety symptomsonce they have begun. (37, 38)

25. Use cognitive methods tocontrol anxiety symptoms.(39, 40)

26. Cooperate with a substanceabuse evaluation to deter-mine the extent of chemicaldependence. (41)

27. Eliminate reliance on sub-stances on which a depen-dence has developed andthat have been abused tocontrol anxiety symptoms.(41)

28. Adjust living situation (e.g.,move from large home tosenior apartment) to reduceenvironmentally inducedstress. (42, 43, 44)


reinforce the patient’s com-pliance with the changes.

15. Review the physician-ordered changes with thepatient (and if involved, thefamily member), makingsure that new medications,dosages, and administra-tion schedules are writtendown in checklist form tofacilitate compliance.

16. Develop a simple chart forthe patient to record the fre-quency and intensity (rated1 to 10) of anxiety symp-toms, and to record the pre-cipitating and consequentsituations, events, people,thoughts, moods, andbehaviors that are associ-ated with anxiety symp-toms.

17. Assign the patient to com-plete anxiety symptomchart on a daily basis.

18. Help the patient to recog-nize patterns associatedwith anxiety symptoms:sort out precipitants fromconsequences; identify themost intense or frequentprecipitants; and identifythe consequences that helpto perpetuate maladaptivepatterns.

19. Help the patient understandthe negative functional con-sequences of anxiety (e.g.,physical toll on body; nega-tive mood) and currentdestructive and self-defeating anxiety reductionmethods (e.g., social with-


29. Evaluate realistically theneed for additional supportin performing activities ofdaily living, and develop aplan to obtain such supportto reduce worries about personal inadequacies. (45, 46, 47, 48)

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ANXIETY 33

drawal, substance depen-dence, disturbed family orother relationships).

20. Convey optimism to thepatient that improvedmethods of anxiety controlwill improve daily function-ing, relationships, and gen-eral quality of life.

21. Assist the patient in identi-fying current methods ofreducing anxiety (e.g., con-stantly telephoning family,physician, or agencies; mak-ing excessive doctors’appointments or going to anemergency room; constantverbalization of worries;social withdrawal) and theapparent positive conse-quences (e.g., feeling better)from current methods ofreducing anxiety.

22. Help the patient under-stand that some anxietyreduction methods can haveapparent immediate posi-tive consequences (e.g.,attention, anxiety reduc-tion), but they are maladap-tive in the long run (e.g.,the physician won’t acceptcalls; friends avoid thepatient because of constantworrying; loss of friends dueto social withdrawal).

23. Brainstorm with thepatient to identify multiplealternative ways of prevent-ing and reducing anxietywithout the long-term nega-tive consequences.

24. Help the patient select a



few methods of preventingand reducing anxiety from among his/her brainstorm-generated alter-natives.

25. Review the patient’s chart ofanxiety symptoms and theirprecipitants to assist him/her in identifying and clari-fying thoughts that precipi-tate anxiety response.

26. Discuss with the patient theextent to which thethoughts reflect a realisticsituational appraisal versusan overly negative or catastrophic situationalappraisal. Facilitate separa-tion of the rational core con-cern from the exaggerated,irrational thoughts thatgenerate an excessive anddebilitating emotionalresponse.

27. Assign the patient the taskof developing a plan toaddress the rational coreconcerns (e.g., health man-agement, safety/securityissues, welfare of familymembers or friends, etc.) bychanging things that areunder his/her control andaccepting things that can-not be changed.

28. Challenge thoughts thattransform rational concernsinto overwhelming and/orunresolvable conflicts; helpthe patient to identify alternative constructivethoughts.

29. Teach the patient to iden-


ANXIETY 35

tify and challenge anxiety-producing, negative self-talk; assign homework topractice identification ofsuch thoughts, and replace-ment with constructivethoughts.

30. Review the patient’s chartof anxiety symptoms andtheir precipitants and con-sequences to help him/heridentify specific stimulussituations (e.g., public gath-erings where it’s hard tohear), events (e.g., doctor’sappointments) or people(e.g., upstairs neighbor;daughter-in-law) that pre-cipitate anxiety symptoms.

31. Help the patient determinewhich situations, events,and people can be construc-tively avoided (e.g., menac-ing neighbor; unsafeareas/times of day).

32. Help the patient determinewhich situations, events,and people can be asser-tively changed to alleviateanxiety (e.g., discussingconflict openly with adaughter-in-law; askingfriends to a quiet dinner at home rather than goingto a noisy restaurant where hearing impairmentinterferes with conversa-tion).

33. Suggest that the patientuse adaptive techniques orassistive devices to mini-mize anxiety (amplifier forone-to-one conversations;



cane or walking stick toreduce fear of falling;reviewing names and facesin photographs beforeattending a social event toreduce the fear of beingembarrassed by memoryimpairment).

34. Teach the patient relax-ation techniques, beginningwith deep breathing andproceeding to progressivemuscle relaxation andguided imagery. Providehim/her with a personal-ized audiotape and suggestthe purchase of a relax-ation videotape if he/sheowns a VCR.

35. Assist the patient in identi-fying the most effective per-sonal stress managementtechniques (e.g., prayer,walking, baking, telephon-ing a friend), and encouragedaily scheduling of theseactivities.

36. Review healthy lifestyleissues with the patient (e.g.,diet, exercise, caffeine andnicotine consumption, plea-surable activities, etc.) andassist him/her in developinga plan to eliminate anxiety-producers, such as caffeine,and improve general well-ness.

37. Teach the patient that afight-or-flight response isdifficult to deactivate onceit has begun; that someanxiety symptoms willoccur in spite of attempts at


ANXIETY 37

relaxation, but that theresponse can be minimizedby use of cognitive andbehavioral control.

38. Help the patient develop aplan of action for specificanxiety situations usingbehavioral control (e.g.,leave the situation if theanxiety becomes overwhelm-ing) and cognitive control(e.g., reassure himself/her-self that the anxiety-producing situation will beover in minutes and that thepatient is capable of tolerat-ing anxiety for that period).

39. Teach the patient toreframe the experience ofanxiety symptoms as a use-ful, friendly “alert” systemthat can be escalated withnegative self-talk and de-escalated with soothing,positive self-talk.

40. Assist the patient in devel-oping soothing, positiveself-talk that effectively de-escalates anxiety response.

41. Evaluate and treat thepatient for substancedependence/misuse. (Seethe Substance Abuse chap-ter in this Planner).

42. Teach the patient the con-cept of finding a good matchbetween an individual’scapacities and the demandsof the physical environ-ment. If the physical envi-ronment is too demandingfor the individual’s capaci-ties (e.g., a frail elder tak-



ing care of a large house),the individual can becomeoverwhelmed.

43. Help the patient to deter-mine if the current livingsituation is appropriate tohis/her capacity, or if achange is warranted giventhe current or anticipatedcapacity.

44. Assist the patient with psy-chological components ofmaking a change in the liv-ing situation (e.g., thinkingabout alternatives, choos-ing, planning, anticipatingand grieving losses, adapt-ing, etc.).

45. Help the patient to deter-mine if additional help isneeded to accomplish theActivities of Daily Living(ADLs such as eating,bathing, dressing, groom-ing, toileting, and mobility)or the Instrumental Activi-ties of Daily Living (IADLssuch as shopping, trans-portation, meal prepara-tion, financial matters,etc.).

46. Refer the patient to agingservices to obtain additionalsupports, such as the AreaAgency on Aging, faith-based aging services, pri-vate geriatric caremanagement, or other com-munity services as avail-able.

47. Discuss the patient’s will-ingness to involve an infor-mal support network (e.g.,


ANXIETY 39

family members, neighbors,religious counselors) in pro-viding additional care andservices; develop a plan toask for help.

48. Monitor the patient’s anxi-ety to determine if the addi-tion of supportive ADL andIADL services decreasesanxiety.

.

.

.


Axis I: 300.01 Panic Disorder without Agoraphobia300.21 Panic Disorder with Agoraphobia300.22 Agoraphobia without History of Panic Disorder300.29 Specific Phobia300.23 Social Phobia300.3 Obsessive-Compulsive Disorder309.81 Posttraumatic Stress Disorder308.3 Acute Stress Disorder300.02 Generalized Anxiety Disorder293.89 Anxiety Disorder Due to (Axis III Disorder)300.00 Anxiety Disorder NOS


CAREGIVER DISTRESS


1. Feelings of being overwhelmed by daily duties and responsibilitiesentailed in caring for another.

2. Feelings of despair as care recipient declines physically and/or cog-nitively.

3. Anger and irritability toward the care recipient.4. Anxiety about the ability to continue caregiving in the face of con-

tinuing or increasing drain on physical, emotional, and financialresources.

5. Low self-esteem caused by the perception of self as an inadequatecaregiver.

6. Conflict with other family members over caregiving patterns andresponsibilities.

7. Inability to enjoy the potentially satisfying aspects of the caregiv-ing role.

8. Decline in health due to physical and emotional strains of caregiving.

.

.

.

LONG-TERM GOALS

1. Cope effectively with physical, emotional, and financial burdens ofcaregiving while enjoying the rewards of the caregiving role.

40



1. Verbalize the primarysources of stress and dis-tress related to caregiving.(1, 2, 3)

2. Separate sources of distressinto more practical externalareas and more psychologi-cal internal areas. (4, 5)

3. State priorities for attempt-ing to reduce sources of dis-tress. (6, 7)

4. Verbalize knowledge aboutthe care recipient’s condi-tion. (8, 9, 10)

5. Verbalize knowledge aboutcommunity resources avail-able to caregivers. (10, 15)

6. Demonstrate knowledgeabout specific practical tasksinvolved in caregiving (e.g.,cooking meals, cleaning

CAREGIVER DISTRESS 41


1. Obtain a caregiving historyfrom the caregiver, includingthe initial signs and symp-toms of dysfunction in thecare recipient; if, how, andwhen a diagnosis was estab-lished; current functioningof care recipient; help withcaregiving tasks provided byothers or through a formalsupport system (such ashomemaker/home healthaide services).

2. Instruct the caregiver tomake a list of the moststressful aspects of caregiv-ing; reassure the caregiverthat nothing is too insignifi-cant or embarrassing to list.

3. Review the most typicalsources of stress: grievingthe loss of the care recipient

2. Maintain care recipient in optimal environment as long as possible.3. Gain knowledge about care recipient’s condition, prognosis, and

the probable caregiving challenges ahead.4. Maximize the use of formal and informal support systems and

structures.5. Avoid the development of serious mental or physical illness.6. Enhance the safety and well-being of care recipient.7. Resolve family conflicts regarding caregiving.

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house, bathing and dressingof a frail elder). (10, 14)

7. Explore and identify feel-ings about providing per-sonal care. (11, 12, 13, 16)

8. Decide whether to providepersonal care or to obtainassistance with personalcare tasks. (14, 15, 16, 17)

9. Acknowledge the need forcaring for the caregiver,that is, giving importance toone’s own health and well-being. (18, 19, 38)

10. Pursue a professional eval-uation of personal physicaland/or mental health statusas indicated. (20, 21, 22)

11. Cooperate with recom-mended medical/psychiatrictreatments, including tak-ing medications as ordered.(22, 23, 24)

12. Identify and prioritize someopportunities, no matterhow modest, for pleasureand relaxation. (25, 26)

13. Engage in and keep a diaryof pleasurable activities.(27, 28, 29)

14. Join a support group to pro-vide a continuing opportu-nity for information sharingand peer support. (30, 31)

15. Explore and resolve feelingsof anxiety, grief, and depres-sion related to the changingrelationship with the carerecipient. (32)

16. Verbalize knowledge ofbehavior management skillsto enhance feelings of self-


as he/she had once been;loss of the caregiver’s inde-pendence; financial insecu-rity; anger with othersabout task distribution;physical health problems;feeling overwhelmed bydaily task demands; frus-tration sparked by the carerecipient’s behavior, and soforth.

4. Teach the distinctionbetween and interrelated-ness of the two basic aspectsof caregiving: the practicalreality of providing care(e.g., obtaining legal, finan-cial, and/or personal careassistance; changing thephysical environment) andthe emotional reality of pro-viding care (e.g., managingstress, problem solving, cop-ing with grief, depression,etc.).

5. Review the caregiver’s listof stresses, and assist inidentifying which stressorsare in the practical, objec-tive external areas andwhich are in the emotional,subjective internal areas.

6. Assist in rank-ordering thestresses of caregiving,assigning 1 to the leaststressful aspects, and 10 tothe most stressful aspects.

7. Decide with the patientwhich of the highest-priority stressors should betackled first.

8. Ensure that the care recipi-ent has had an appropri-


efficacy in coping withbehavioral problemsencountered with the carerecipient. (33)

17. Practice and implementstress management skills tocope with acutely stressfulperiods or events. (34)

18. Replace distorted beliefsthat exacerbate the stressesof caregiving with realisticthoughts. (19, 35, 36)

19. Family members increasetheir level of providing careto the care recipient andsupport to the primary care-giver. (37, 38)

20. Family members attendconjoint sessions to resolveconflicts/issues that may beinterfering with providingcoordinated care to the carerecipient and support to theprimary caregiver. (39, 40)

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.


ately thorough diagnosticevaluation. If not, refer to amultidisciplinary geriatricassessment program.

9. Teach the caregiver to com-pile a list of written ques-tions before the carerecipient is taken for physi-cian or specialist visits, andto write down (or have thephysician write down)answers.

10. Review how to find moreinformation about the carerecipient’s condition (e.g.,requesting informationfrom the physician; askingfor help at the library orbookstore; searching theWeb [with some guidanceabout reliable sources]; con-tacting disease-specific sup-port groups; calling a localsenior helpline, etc.).

11. Encourage open discussionof feelings and uncertain-ties about providing per-sonal care (e.g., bathing,dressing, grooming, toilet-ing).

12. Reassure that discomfort atproviding personal care is anormal reaction, and that itdoesn’t mean that the care-giver doesn’t love the carerecipient.

13. Encourage discussion offeelings about the carerecipient’s increasingdependency, issues ofadult/child role reversal,and the mutual uncertain-ties and opportunities for



misunderstanding as rolesare changing.

14. Teach or refer to a sourcefor learning personal careskills.

15. Discuss options for the pro-vision of personal care tothe care recipient: informalhelp from family, friends,and neighbors versus for-mal help from home-maker/home healthagencies.

16. Review emotional (includ-ing control and privacy) andfinancial factors involved ininformal versus formaloptions for the provision ofpersonal care.

17. Assist with processing adecision as to whether toprovide personal care orobtain assistance, and fromwhom.

18. Teach the importance ofmaintaining caregiverhealth and well-being; thatif the caregiver becomes dis-abled, the care recipientwill suffer. Offer the exam-ple of airline protocol forparents to use oxygen first,then help the kids.

19. Encourage ventilation offeelings of guilt surround-ing attending to own needsand the belief that the carerecipient should come first;counter with a more ratio-nal belief that effectivenessrequires that the caregivermaintain his/her health andwell-being. Give the care-



giver permission to attendto himself/herself.

20. Conduct or refer for fullpsychological and/or neu-ropsychological evaluation.

21. Refer for medical, psychi-atric, or rehabilitation eval-uation.

22. Obtain consent to discussevaluation results andtreatment plans with otherprofessionals.

23. Discuss results of evalua-tions and recommendedcare plans with caregiverand consulting profession-als.

24. Monitor and follow up oncompliance with treat-ments, adverse drug reac-tions, and other concernsthat should be conveyed toconsulting professionals.

25. Assign the caregiver tomake a list of all pleasur-able activities and events(e.g., special foods, favoriteTV programs, visiting fam-ily, etc.). Prompt from thePleasant Events Schedule(Teri and Logsdon, 1991), ifnecessary.

26. Assist the caregiver inrank-ordering the list ofpleasant events and activi-ties.

27. Instruct the caregiver tokeep a record for one or twoweeks of engagement inpleasant activities, record-ing mood at the time of theactivity.



28. Identify one or two activi-ties to add to the scheduleor to increase in frequency;specify obstacles to accom-plishment and problem-solve resolutions.

29. Monitor the occurrence andfrequency of pleasantevents, review reasons forsuccesses and solutions toovercoming obstacles; con-tinue increasing levels ofpleasure and relaxation.

30. Refer to a peer supportgroup that is either disease-specific or otherwise pro-vides a connection (based onage, religious affiliation,residence, or other commonfactors).

31. Encourage and monitor reg-ular attendance at, and par-ticipation in, peer supportgroup.

32. Process the difficult emo-tional adjustment to theincreasing frailty of the carerecipient and loss of “theperson I once knew.” (Seethe Grief/Loss Unresolved,Depression, and Anxietychapters in this Planner.)

33. Teach the patient behaviormanagement strategies tocope with the care recipi-ent’s difficult behaviors.(See the Aggression/Hostil-ity, Wandering/Way-FindingDeficit, Memory Impair-ment, and Sexually Inap-propriate/DisinhibitedBehavior chapters in thisPlanner.)



34. Teach stress managementskills of deep muscle relax-ation, positive imagery,physical exercise, deepbreathing, pleasurableactivities, and so forth. (Seethe Anxiety chapter in thisPlanner.)

35. Identify, discuss, andreplace negative and dis-torted automatic thoughtsthat could be contributingto caregiver stress (e.g.,Replace: “He’s doing that toget back at me for what Idid to him 20 years ago,”with “The disease processmakes him do that; it’s notdirected at me personally.”Replace: “I have to stay byhis side at all times,” with“We both need a break fromeach other sometimes,”etc.).

36. Identify, discuss, and chal-lenge all-or-none thinkingthat may be exacerbatingcaregiver stress (e.g., “Theonly way we can be happy isif he/she fully recovers.”).

37. Explore ways that otherfamily members could par-ticipate in the caregiving(e.g., staying with the carerecipient for a few hours toprovide respite; making ameal once a week; sending avideotape of the grandchil-dren; calling once a week;helping with the finances;paying for yardwork, etc.).

38. Encourage and reinforcecaregiver’s assertiveness in



Axis I: 296.xx Major Depressive Disorder300.4 Dysthymic Disorder311 Depressive Disorder NOS300.02 Generalized Anxiety Disorder300.00 Anxiety Disorder NOS309.xx Adjustment Disorder 316 Psychological Factors Affecting Medical

Condition


requesting caregiving assis-tance from other familymembers.

39. Lead conjoint family ses-sions to explore conflictsaround caregiving issuesand to problem-solve thebarriers to coordinated carefor the recipient and sup-port for the primary care-giver.

40. If the family is amenable,resolve historical or deeperconflicts that may be inter-fering with cooperating inproviding care, such aschildhood rivalries and fam-ily roles.

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COMMUNICATION DEFICITS


1. Difficulty expressing needs and wants to family and staff care-givers.

2. Inability to participate in complex verbal social interaction.3. Difficulty comprehending instructions or information given by

family or staff caregivers.4. Frustration due to inability to communicate.5. Behavioral disturbance when frustrated from communication deficit.6. Embarrassment in social situations due to misperceptions of

visual or auditory cues.7. Social withdrawal due to inability to communicate.8. Complaints about inability to recall desired words to use in every-

day speech.9. Sudden decline in communication abilities following stroke.

10. Gradual decline in communication abilities associated with pro-gressive dementing disorders.

.

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.

LONG-TERM GOALS

1. Develop awareness and acceptance of communication deficits.2. Improve sensory, processing, and expressive aspects of communi-

cation to achieve maximum functional capacity.

49




1. Cooperate with a medicalevaluation to assess organiccauses of the communica-tion deficit. (1, 2)

2. Comply with a speech/lan-guage evaluation of thenature of the communica-tion deficit. (1, 3)

3. Cooperate with a psycholog-ical evaluation to assess therole of emotional factors inthe communication deficit.(1, 4)

4. Complete a neuropsycholog-ical evaluation to assesscognitive status. (1, 5)

5. Participate in a hearingexamination to evaluate the


1. Obtain consent from thepatient to participate inmultidisciplinary evalua-tion of communicationdeficit, including consent toconsult with other profes-sionals.

2. Refer the patient for medi-cal evaluation (or obtainrecords of previous evalua-tion) to determine whethercommunication deficit iscaused by medical condition(e.g., stroke, Parkinson’sdisease, Alzheimer’s dis-ease, etc.).

3. Refer, or have the physicianrefer, the patient to a

3. Use devices to compensate for damage to sensorimotor system.4. Reduce or eliminate frustration and embarrassment caused by

communication deficits.5. Reduce or eliminate behavioral disturbances caused by communi-

cation deficits.6. Reestablish functional interactions with family and staff care-

givers in a way that accommodates communication deficits.7. Re-establish social interactions in a way that accommodates com-

munication deficits.8. Family and staff caregivers develop realistic expectations about

patient’s communication abilities and learn to promote functionaland satisfying interactions.

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.


COMMUNICATION DEFICITS 51

role of hearing loss in acommunication problem. (1, 6)

6. Cooperate with an eyeexamination to assess lossof visual cues in communi-cation. (1, 7)

7. Verbalize an understandingof the cause(s) of the deficitand the recommendations ofthe consulting profession-als. (8, 9, 10)

8. Family and staff caregiversverbalize an understandingof the cause(s) of the deficitand the recommendations ofthe professionals. (8, 9, 10)

9. Comply with recommenda-tions for use of adaptiveequipment to compensatefor hearing loss. (11, 12, 13,14, 15)

10. Comply with recommenda-tions for use of adaptiveequipment to compensatefor vision loss. (12, 14, 15,16, 17)

11. Implement the use ofassertiveness skills to askfor clarification of communi-cation. (18)

12. Comply with recommenda-tions for use of adaptiveequipment to compensatefor poor speech/languageproduction. (12, 14, 15, 19, 20)

13. Communicate simply andwith less anxiety and frus-tration. (19, 20, 21, 22)

14. Family and staff caregiverssimplify their level of com-

speech/language therapistfor evaluation of the scopeand severity of the disorderand for recommendationsregarding treatment.

4. Conduct or refer for a psy-chological evaluation todetermine the role of emo-tional factors (either as acause or effect) in the com-munication deficit.

5. Conduct or refer for neu-ropsychological evaluationto determine the extent towhich the communicationdeficit is associated withgeneral cognitive declineand to identify cognitivestrengths and weaknessesthat impact on rehabilita-tion/compensation strate-gies.

6. Refer, or have the physicianrefer, the patient for hear-ing evaluation to identifyscope and severity of sen-sory loss.

7. Refer, or have the physicianrefer, the patient for visionevaluation to assess extentof loss of visual cues in com-munication.

8. Integrate findings from allconsulting professionalsthrough an interdisci-plinary team meeting if pos-sible; if not, integratefindings by reviewing for-mal and informal reports.

9. Propose an integrated careplan based on the currentand projected cognitive sta-tus. (Include medical treat-



munication and reducedemands for communicationfrom patient. (9, 22, 23, 24)

15. Family and caregiversadapt their communicationto meet the need of thepatient rather than insist-ing on communicationmodes that result in frus-tration. (24, 25, 26, 28, 29)

16. Family and staff caregiversattend conjoint sessions topractice communicationskills with the patient andto problem-solve remainingdifficulties. (25, 28, 29)

17. Family and caregivers usemultiple sensory modalitiesto increase the effectivenessof communication of thepatient. (27, 28, 29)

18. Participate in a creativearts program to learn meth-ods of expression thatreduce frustration fromcommunication deficit. (30, 36)

19. Participate in physical exer-cise programs that reducecommunication frustrationand tension. (31, 36)

20. List pleasurable activitiesthat are not based on lan-guage skills. (32)

21. Participate in pleasurableactivities that are not basedon language skills. (32, 33, 36)

22. Identify and participate insocial settings and interac-tions that are not language-based. (34, 35, 36)

ments, speech/languagerehabilitation to maximizefunctioning, use of compen-satory aids, training forfamily and staff caregivers,and psychotherapy for emo-tional issues).

10. Meet with the patient, fam-ily, and staff caregivers togive feedback on evalua-tions, propose treatmentplan, discuss reactions, andanswer questions.

11. Encourage the patient tofollow through with recom-mendations for adaptivedevices and services to com-pensate for hearing loss(hearing aids, adaptive tele-phone services, closed-captioned televisionprograms, subtitled films,etc.).

12. Help patient problem-solveto overcome physical, finan-cial, and/or psychologicalbarriers to use adaptivedevices and services.

13. Use a low-cost, one-on-onepersonal amplifier (avail-able from an electronicsstore) in sessions with thepatient; encourage thepatient to obtain one forpersonal use in one-on-oneconversations.

14. Monitor the patient’s com-pliance with compensatorydevices and services; con-tinue to problem-solve andencourage ongoing use.

15. Encourage the family andstaff caregivers to monitor



23. Decrease feelings of grief,anger, and sadness thataccompany loss of ability tocommunicate. (37, 38)

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.

.

and support the use ofdevices and services (e.g.,especially to replace batter-ies as needed, reinforcedevice use by patient, pro-vide advice on technology,etc.).

16. Encourage the patient tofollow through on recom-mendations for adaptivedevices and services to com-pensate for vision loss (e.g.,cataract surgery, glasses,lenses, magnifying pages,large-type publications,books on tape, reading ser-vices, voice and other com-puter adaptations, etc.).

17. Use increased verbalexpression in sessions withthe patient to compensatefor the inability to seevisual/nonverbal cues, espe-cially facial expressions.

18. Teach the patient toassertively ask for clarifica-tion when inability to seevisual/nonverbal cues orhear adequately interfereswith understanding; prac-tice in sessions and instructthe patient and family/staffcaregivers to practice athome.

19. Encourage the patient tofollow through on recom-mendations for adaptivedevices and services to com-pensate for speech/languagedeficits (e.g., speech ther-apy, sign language, voicesynthesizer, word processor,communication board,



motoric communication,etc.).

20. Use simple, direct, brieflanguage with the patientto facilitate understanding;give one instruction at atime; check for understand-ing after each instruction;teach the family/staff care-givers to do the same.

21. Decrease patient anxietyduring episodes of word-finding difficulty by sug-gesting or filling in words;teach the family/staff care-givers to do same.

22. When asking questions,offer multiple-choice oryes/no options; teach thefamily/staff caregivers to dothe same.

23. Meet with the family/staffcaregivers to present thepatient’s current andexpected cognitive status ifnecessary; explain thatbrain condition will requirethe caregivers to assumemore burden for effectivecommunication.

24. Teach the family/staff care-givers to lessen communica-tion demands on thepatient: by reducing thenumber/complexity of ques-tions asked, increasing theability to understand non-verbal cues from thepatient, taking an activerole with the patient (e.g.,reading to him/her).

25. Observe the family/staffcaregiver interactions with



the patient to identify areasof stress and dysfunction.

26. Design interventions thatfacilitate everyday interac-tion. For example, if thepatient has reverted to aprimary language and thefamily/staff caregivers donot speak the patient’s pri-mary language, identify keywords for communicationand make a book or postsigns with those key wordsspelled phonetically andtranslated.

27. Teach the family/staff care-givers to use multiplemodalities to optimize com-munication. For example,post instructional signs inthe environment using bothwords (NO EXIT) and a pic-torial representation (redcircle with a line over thepicture).

28. Meet with the family/staffcaregivers and the patientin conjoint session to prac-tice communication skills;use modeling by the thera-pist, role-playing by thecaregivers and patient, andfeedback to improve com-munication patterns.

29. Have the family/staff care-givers and the patient (ifable) brainstorm solutionsto remaining communica-tion difficulties.

30. Encourage the patient andcaregivers to facilitatepatient participation in acreative arts program to



provide for expression ofideas and emotions throughdrawing, painting, sculp-ture, and music.

31. Encourage the patient andcaregivers to facilitatepatient participation inphysical activity programsto provide for the release ofstress and tension thataccompany communicationdeficit through movement(e.g., dance, aerobics, yoga,etc.).

32. Instruct the patient andstaff/family caregivers todevelop a list of non-language-based pleasurableactivities that the patientenjoys individually andwith caregivers (e.g., walk-ing, watching people orbirds, playing or watchingsports, playing or listeningto music, etc.).

33. Assign the patient and care-givers to schedule one non-language-based pleasurableactivity per day.

34. Instruct the patient andstaff/family caregivers toidentify social settingswhere the language-impaired patient could com-fortably participate (e.g.,attending church services,stroke support groups,adult day programs, etc.).

35. Assign the patient and care-givers to schedule one socialactivity every two weeks.

36. Positively reinforce thepatient for increased social



and non-language-basedactivity participation.

37. Help the patient workthrough grief following lossof communication abilities.

38. Encourage the patient touse therapy sessions to ven-tilate feelings of frustration,anger, and sadness duringthe process of adapting tocommunication deficit.

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.


Axis I: 290.xx Dementia of the Alzheimer’s Type or VascularDementia

294.1 Dementia Due to (Head Trauma, Parkinson’sDisease, Huntington’s Disease, or Axis IIIDisorder)


294.8 Dementia NOS291.2 Alcohol-Induced Persisting Dementia294.9 Cognitive Disorder NOS309.xx Adjustment Disorder 293.89 Anxiety Disorder Due to (Axis III Disorder)300.02 Generalized Anxiety Disorder300.00 Anxiety Disorder NOS316 Psychological Factors Affecting Medical



Documents

5487 Jongsma 01.mj · 1999-07-27 · 14. Patient, family, and staff agree on care plan to improve function as much as possible. (19, 20, 21, 22) 15. Comply with recommenda- ... malnutrition