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“Callie” An Acute Care Patient with Alzheimer’s: Occupational Profile & Intervention PlanLauren A. HawkinsTouro University NevadaOccupational ProfilePatientThe patient is a pleasant 82-year-old female named “Callie”. Callie is a patient who has a history of Alzheimer’s dementia, most likely in the beginning to middle stages. Before her admittance to Centennial Hills Hospital, Callie received the diagnoses of bronchitis and a urinary tract infection (UTI) in an urgent care clinic in Las Vegas, Nevada. The physician prescribed her Levaquin in order to manage the bronchitis. Even after the medication, Callie reported chills, fever, unproductive cough, and stopped eating and drinking. Soon after receiving those diagnoses at the urgent care clinic, Callie woke up with pain in her right shoulder and a large bruise on her right cheek. Her daughter and son-in-law took her to the emergency department for an examination. In the emergency department, she received an x-ray for her shoulder pain. In addition, the doctor completed a quick assessment of her current mental status. She was admitted for a right displaced distal clavicle fracture and declining mental status. Her family reported that her mental condition has been deteriorating. She has a history of a wrist fracture and hip fracture, both with unknown causes. She also has a history of smoking cigarettes and hypertension. The medical report stated that she currently smoke. However, it is unsure how much or if she is receiving assistance from her family to continue this habit. Callie was unable to recall falling or the cause of the injuries. Her family noted that she had been hallucinating for several days prior to her hospital admission. Upon admittance, Callie reported living with her daughter and son-in-law in a single-story home. She is retired and has been for at least 15 years and is a native to the Las Vegas area. Callie had been on the orthopedic floor of the hospital for one day prior to the occupational therapy evaluation. Her hallucinations were minimal after one day and she was not a risk to herself or others.Purpose of Evaluation and Patient ConcernsThe patient was referred to occupational therapy services by her admitting physician for education on clavicle fracture precautions and skilled instruction in activities of daily living (ADLs) while maintaining those precautions. In addition, the doctor needs an assessment on Callie’s level of cognition and mental status, as it has been recently declining. The therapist recommended providing strategies for the patient to increase independence and safety due to her dementia. The patient was unable to voice her concerns regarding her occupations, however her daughter was concerned about her mother’s ability to return to living in her household and complete ADLs with modified independence to minimal assistance. Again, Callie was unable to express her barriers, but with information from her daughter and clinical observation, the therapist can infer some barriers. The patient’s dementia and general body weakness has made it impossible for her to live independently and complete many activities without assistance. She requires verbal cues from her daughter and son-in-law in order to complete ADLs. Due to her body weakness and impaired balance, she does not complete any IADLs such as meal preparation or driving, as her family considers it too dangerous for her. Callie did not state when she felt successful, as she was confused throughout the treatment session. Success should come for her when simple activities are completed with minimal dependence. Prior to her accident, she was able to dress herself occasionally and bathe herself with modified independence. Continuing these skills would be a success for Callie.Due to Callie’s dementia, she has difficulties completing her role as mother. Currently her daughter takes care of her, reversing their roles. She has not been a worker for some years. The patient was unable to recall her career when she was younger. Callie’s daughter stated that as her dementia has progressed and she has become more debilitated, her roles and occupations have changed. She has spent less time talking and playing on the computer. Her daughter stated that when she feels good, she would play her computer game for hours on end. Since her injury, she has been unable and uninterested in playing. She spends most of her time indoors and enjoys completing crossword puzzles and word searches. She watches television with her family at the end of the night prior to going to sleep.Callie was unable to state her interests and occupations completed at her home. According to her daughter, there is a dog in her house, but Callie does not have any part in caring for it. Her daughter said on her better days she enjoyed taking short walks around the neighborhood, watching television at night, but mostly she played the computer game. She said this game has been her main source of entertainment for the past 15 years. Other than the few activities mentioned, Callie does not have any other stated interests. Patient and Family GoalsCallie’s daughter was able to discuss her goals for her mother, as she serves as her caretaker. Her daughter would like her mother to return to live with her. Discharging Callie to a skilled nursing facility or memory care unit will be last alternatives. She would like Callie to be able to complete her ADLs with modified independence to minimum assistance as she was before her injury. In addition, her daughter wants to prevent another injury similar to this one. Her daughter worries about leaving her mother unattended, however, she works full-time in the community, validating this concern. Since Callie’s dementia has progressed, her muscles have weakened and her body overall is debilitated. This may be due to the actual progression of the disease or her decrease in physical activities due to more time spent in bed and less interest in activities. This has decreased her health and wellness. Her current smoking habit also contributes to this decrease.Occupational AnalysisContext of Occupational Therapy EvaluationThe occupational therapy session occurred in the patient’s hospital room for 30 minutes. The reason for the session was an evaluation. During the evaluation, the therapist focused on the impact Callie’s dementia had on her overall cognition. The therapist was concerned with her ability to return home safely, recall and follow her precautions secondary to her clavicle fracture, and her levels of independence with various tasks. When we first entered Callie’s room, she alerted us that she had wet herself. The therapist utilized the task of changing her adult undergarment to evaluate Callie’s abilities. This activity is considered an activity of daily living (ADL) in the Occupational Therapy and Practice Framework (OTPF; American Occupational Therapy Association [AOTA], 2014). It is under the category of toileting and toilet hygiene.Occupational PerformanceCallie was able to follow directions if repeated several times by the therapist. She required verbal cues throughout the task. She was able to use her arm strength to roll to one side with the assistance of the bedrails. The therapist asked Callie to stand in order to put a clean undergarment on her. She was considered contact guard assistance for standing, but when asked to take several steps forward, she required minimal assistance. Standing and walking both were quite uncomfortable for Callie as evidenced by her grimacing and repeated asking if she can sit down yet. Due to the nature of the activity of assisting the therapist with the undergarment change, the therapist was able to able to assess her cognition in addition to her physical abilities. It was positive that Callie was able to recognize that she soiled herself. It shows that she still has recognition and communication abilities. While the therapist was preparing to change the undergarment, she assessed Callie’s memory and recall ability. She was asked the date and why she was in the hospital in order to evaluate her alertness and orientation. She was unable to provide the date, but was able to state that she “broke her shoulder” in reference to why she was in the hospital. To evaluate her memory further, she asked questions about her home life including whom she lived with, what type of house, and how she injured herself. She was able to provide whom she lived with and that they lived in a one-story house. As previously mentioned, she was unable to recall the cause of her injury. She was quite confused throughout the session and only answered questions about 50% of the time, sometimes only with additional prompting from the therapist. Overall, her memory was consistent with her diagnosis of Alzheimer’s dementia as she lacked awareness to the present and struggled with long-term memory. Key ObservationsThere were several key observations I picked up from this evaluation session. First, was that Callie’s body was quite debilitated. She was weak in both her upper and lower extremities, making standing extremely difficult when she is unable to use her upper extremities to assist in rising out of bed. This poses a great safety risk, as her standing balance is poor. Though she cannot remember the cause of her clavicle fracture, her family believes she tripped or fell and was unable to right herself. In comparison to her standing balance, her sitting balance was acceptable as evidenced by her ability to sit on the edge of bed for several minutes while the therapist was cleaning her and changing her undergarment. Another observation was that her memory and attention was quite impaired, as was expected for her diagnosis of Alzheimer’s dementia. This is important for several reasons. The first is that she has precautions to maintain for her right clavicle fracture. According to the occupational therapist, with her right arm, she is unable to raise it, extend it, or cross midline with it. She is unable to recall these precautions due to her confusion and difficulties with memory, which increases her risk for further injuring her clavicle. Her memory impairments also make medication management difficult, as she is unable to remember to take her medications without prompting from her daughter. Callie also does not complete any cooking in the house, most likely because she lacks the attention span and short-term memory to complete the task safely. This raises questions of the occupational therapists referral for Callie’s placement post-discharge since Callie has difficulty completing basic ADLs independently or even with supervision.Affected DomainsDue to the deficits caused by the rehabilitation diagnosis of right broken clavicle, several of Callie’s domains are affected as specified by the OTPF. Callie’s occupations are most affected. She was able to complete most of her ADLs with modified independence prior to her clavicle fracture. Due to the clavicle precautions imposed on her, she is unable to use both hands to complete tasks as she had previously, such as face washing, dressing, and bathing. Her increased debility has negatively affected her endurance, lifting ability, and flow while completing simple tasks. In combination with her debility, her balance makes it difficult to stabilize herself while walking and navigate through a room, which may be the cause of her clavicle fracture. Her diagnosis of Alzheimer’s was also a reason she was admitted to the hospital. Within the past week, her memory and overall cognition has significantly decreased, affecting the performance of her occupations. Callie is unable to complete her role as a mother due to her cognitive deficits secondary to the dementia. Most aspects of her processing skills are affected. She is unable to attend and heed to tasks due to decreased attention. In addition, she demonstrates difficulty sequencing simple tasks as demonstrated by difficulties following directions for bed mobility to assist the therapist with changing the undergarment. These cognitive deficits in combination with the physical deficits make her a safety risk, as she is unable to attend to tasks, such as walking in her room, while also having poor stabilization while walking. Callie also displayed several bouts of frustration throughout the session, which is expected due to her altered orientation to people and place. While the therapist was providing her directions to assist her in the changing task, Callie commented, “I’m frustrated. I hurt and I don’t know what to do”. This indicates the difficulties Callie has with understanding reality and the impact that has on her as a person. She is surrounded by unfamiliar faces and in a strange place, which is difficult for her to comprehend as it has broken her familiar routine. In addition to the inability to adapt and generalize to different situations, Callie has difficulty with social interaction skills. She does not look or turn toward the social partner. She also has difficulty replying to questions asked by the therapist, as evidenced by her needing prompting to respond to questioning. She consistently repeated the same questions throughout the session, which is an example of regulation. All of these deficits together exemplify her difficulties participating in her daily occupations. The physical and cognitive deficits pose a safety and independence concern while her social deficits demonstrate her difficulties with getting the necessary care, including medical care, due to her inabilities to express her thoughts and needs. Patient ProblemsFrom the evaluation of Callie, I can infer several problems that are relevant to her and are affecting her daily life. The following are in order of importance of the patient.Callie requires moderate assistance while completing grooming tasks due to right clavicle precautions and decreased short-term memory.Callie requires minimal assistance for functional ambulation due to decreased balance and overall weakness due to increased time in bed.Callie requires >three verbal cues in order to complete a simple task due to deficits in sequencing. Callie requires minimal assistance for self-feeding due to incoordination while utilizing her non-dominant hand to feed and weakness.Callie requires minimal assistance for bed mobility due to body debility and a right broken clavicle.Justification of Patient ProblemsOne of the goals her daughter mentioned was that she wanted her mom to return home and to complete her ADLs as she did previously with modified independence. This is a problem as her daughter has difficulty providing her the moderate assistance she currently needs. Due to this increase in assistance, an increase in the caregiver burden on her daughter and son-in-law has occurred. The cause of the increase comes from her inability to employ the precautions during the activities, causing her pain and discomfort. In addition to the pain, it is a necessity to maintain the precautions for the healing process. Therefore, this ranks as first on her problem list due to the need to instruction and education from the therapist on compensatory strategies to maintain the precautions with the potential implementation of adaptive equipment (A/E). Completing her ADLs is one of the few tasks she can will be able to complete with only modified independence. Therefore, assisting her to rehabilitate her abilities will decrease the caregiver burden and help Callie feel successful. Difficulties with functional ambulation ranks second on Callie’s problem list due to the safety risk it creates. From the evaluation, it became obvious that when she stands, it is difficult to right herself. This becomes more troublesome for Callie when she tries to walk. Her daughter stated that they have various types of durable medical equipment (DME) at home, but her mother does not use it. That information, in combination with observations, makes her therapist aware that she is a fall risk. If she did fall to fracture her clavicle, then we need to work on her balance and potentially reeducate her and her family on the importance and proper use of DME. In addition, Callie would benefit from exercises improving her balance and endurance.The need for caregiver cues and prompts to complete simple tasks again increases the caregiver burden due to the increased time needed to complete tasks. This is an issue because she requires supervision for nearly every task she completes. This is ranked third on her list due to the need for her to correctly sequence tasks in order to increase her independence. Sequencing is involved in many ADLs such as brushing teeth, bathing, and toileting and toileting hygiene. For her to increase her independence and return to her previous level of functioning as modified independent, she needs to improve on her sequencing abilities and potentially adopt strategies for assistance. When discussing Callie’s medical history with her daughter, she noted that Callie has not been eating as much lately. This may be due to her bronchitis and overall “feeling sick” as she reported. However, many patients with Alzheimer’s struggle to eat when the disease manifests. Callie and her caregivers need to receive education on the dangers of malnutrition and extreme weight loss which many persons with Alzheimer’s experience. In addition, there are several strategies such as creating a dinner routine and modifying the textures of food to encourage Callie to begin eating once again. Due to the simple suggestions that could be implemented when she returns home, this is ranked fourth on her list. Callie requires minimal assistance for bed mobility due to the difficulties maintaining her clavicle precautions and overall body weakness. Callie could not comprehend that she was unable to utilize her right arm to move from supine to edge of bed. Due to her lack of understanding, Callie needs to receive instruction on compensatory methods to move to edge of bed. Numerous strategies can be utilized in addition that this form of bed mobility is only temporary; therefore, this problem is ranked fifth on the list of importance. In addition, many patients with Alzheimer’s experience delirium when entering an unfamiliar place. Once her delirium diminishes, Callie may regain the cognition to understand her clavicle precautions.Intervention PlanLong-Term Goal 1: Patient will utilize a checklist in order to complete grooming tasks for her morning routine with modified independence within five sessions.Short-term goal 1. Patient will type a checklist of her typical morning routine with supervision within one session with less than four verbal prompts. Intervention. Since the patient has knowledge about using technology and is unable to use her dominant hand for writing, she would be able to type the checklist. In addition, she enjoys spending time on the computer as evidenced by her time spent playing her computer game. The therapist will be available for supervision assistance and verbal prompting, but the patient will be in control of typing the list and stating what her morning routine used to and now will consist of. According to research, it is important for patients to keep the same schedule when possible due to memory issues that accompany Alzheimer’s dementia (Abreu & Yancy, 2011). One way to keep this consistent is by utilizing a checklist. In addition, when at all possible, the patient should be given the opportunity to make choices or make their own decisions (Hellen, 1998). However, the therapist will be supervising to make appropriate suggestions or prompt the patient. The intention is that the patient will be more willing to engage in the process due to the use of the computer.The most appropriate intervention approach for this goal is creation. According to the OTPF (AOTA, 2014), creation occurs when the patient is provided with new experiences or techniques in order to enhance occupational performance. Since Callie did not have a checklist or daily schedule prior to occupational therapy, this is a new technique for her. By providing this for her, the therapist hopes to enhance her occupational performance and independence within her natural environment. The expected outcome for this intervention will be participation. Since Callie enjoys spending time on the computer and has been unable to due to her sickness, participating in this occupation should be personally satisfying (AOTA, 2014). Short-term goal 2. Patient will wet the toothbrush, put toothpaste on the brush, and complete the task of brushing teeth using her non-dominant hand with supervision within two sessions with one verbal prompt or less.Intervention. The patient will practice brushing her teeth as a step towards her long-term goal of completing her morning routine with modified independence. The therapist will need to break the steps of this task down, as simplifying the task often helps patients comprehend the task (Hellen, 1998). The patient may struggle initially due to the use of the non-dominant hand, however, the hope is that she will be able to adapt while her dominant shoulder is healing. Wood, Womack, and Hooper (2009) state that encouraging independence and participation in activities, such as hygiene and grooming, can increase a patient’s quality of life. Therefore, when the patient is able to complete a task, staff need to provide the opportunity and the proper support.Modification is the most appropriate intervention approach according to the OTPF (AOTA, 2014). Underneath the term of modification is compensation, which is what Callie is doing with this intervention. The therapist is encouraging her to complete her ADL activity of oral hygiene by utilizing her unaffected non-dominant hand. This strategy is promoting participation in activities by ways of compensating for the disability. The overall outcome of the intervention is to improve her performance in the occupation of oral hygiene. She was able to complete this activity before; therefore by modifying it, we are improving her current level back to where she was prior. Down grading. If the patient is unsure during the task, the therapist may grade the task down by mirroring the task by brushing their teeth with their own toothpaste and toothbrush to demonstrate the task to the patient. The task may further be graded down by having the therapist complete set-up for the patient by squeezing the toothpaste onto the toothbrush and wetting it. Up grading. If the patient is making progress with the task, the therapist may add another step to the task as having to retrieve the toothbrush or toothpaste from the medicine cabinet or drawer in their hospital room. This adds another cognitive component to the task. Long-Term Goal 2: Patient will functionally ambulate at least 20 feet in the hospital waiting room while using a front-wheeled walker with modified independence in five sessions. Short-term goal 1. Patient will complete a dynamic standing activity for three minutes while completing a simple task with supervision within two sessions.Intervention. As stated in the occupational profile, in the past, the patient has enjoyed working on either word searches or crossword puzzles. Though she has not completed any recently due to her acute delirium, she previously enjoyed this leisure activity. Creating interventions around the patient’s interests helps them accept the treatment according to researchers Letts and colleagues (2011). Therefore, by including a familiar and enjoyable task during Callie’s treatment, she should be more engaged and willing to stand. Because she is weak, has low endurance, and has deficits in balance, she would not want to stand on her own. By including an enjoyable leisure activity, she should be more engaged to increase her endurance and overall balance, therefore using this intervention as a means to the end goal of functionally ambulating. Therapists are always encouraged to utilize meaningful activities within interventions for this population as it promotes normalization in their life (Hellen, 1998).The most appropriate intervention approach for each idea for this goal is restoration. Before her fall and stay in the hospital, Callie was able to stand and ambulate with no assistance. Due to her increased time in bed and lack of eating, Callie has become weak and her balance has suffered. Since this is an acute impairment rather than a chronic one, the restoration approach is applicable. We can help restore Callie’s dynamic standing balance as should not be permanently impaired due to her fall. This outcome will focus on both occupational performance improvement and participation. We want to improve Callie’s ability for dynamic standing, but in addition, we also want her to participate in occupations, specifically leisure activities, that she previously found enjoyable. By doing this, she could enhance her quality of life and fulfill a desire she has.Short-term goal 2. Patient will functionally ambulate to the restroom in her hospital room utilizing adaptive equipment with modified independence within two sessions. Intervention. The patient will utilize her front-wheeled walker in order to functionally ambulate to the restroom. The purpose of this intervention is to work on the actual activity of ambulating with modified independence of the adaptive equipment. This activity is simpler than ambulating in the waiting room due to the lack of obstacles and varying terrain as the waiting room will have (ex: tile, carpet, etc…). Before her injury and acute onset of delirium, she was able to ambulate to the restroom by herself and complete the activity of toileting and toileting hygiene with supervision. We need to continue to work on this in order for her to increase her independence in this ADL. Since she is a fall risk, this becomes even more important that she gains strength, confidence, and the ability to utilize adaptive equipment for safe ambulation (Hellen, 1998). Researchers Jensen and Padilla (2011) noted successful interventions that utilized standing balance, ambulation, and increasing endurance were all utilized to decrease fall risks. This specific intervention is utilizing the ambulation as a means to an end. Two intervention approaches are most appropriate for this goal instead of a single one. In one respect, we are restoring Callie’s strength and endurance to help her return to functionally ambulating as she was prior to the fall. In comparison, we also are working educating her with adaptive equipment and strategies in order to prevent another fall, which according to the OTPF (2014) would be prevention. These two approaches work together. If we do not restore her previous levels of endurance, strength, and balance, then we cannot prevent an injury from happening. However, providing her with education and equipment will also help prevent it from reoccurring. Therefore, this goal would benefit from two intervention approaches. Similar to the intervention approaches, the outcome will focus on prevention as well. We want to prevent Callie from falling again. By implementing this intervention, we hope to give her body what it needs and the education for equipment to prevent it. Precautions and Contraindications Due to the complexity of Callie’s diagnoses, the therapist must keep in mind several precautions and contraindications while working with her. One precaution a therapist must keep in mind is that persons with Alzheimer’s dementia get distracted very easily. Their attention is limited. Working on improving attention and understanding that it is a normal aspect of dementia will help the session run smoother. Another precaution is that these persons often have poor judgement. They may think they can do tasks that they cannot. The therapist should be supportive if the patient wants to attempt a new task, however, they must be close by, possibly have a helper, and use clinical reasoning and stop the task if it gets too dangerous (Hellen, 1998).Another precaution of working with her is her cognitive and emotional instability. Patients with dementia often have aggression and agitation, though it occurs mostly in the later stages. However, because Callie is in an unfamiliar place and completing things she does not want to do, agitation is a possibility. If this occurs, the therapist should attempt to reframe and refocus the patient and attempt calming strategies (Hellen, 1998). If they are unable to calm down, their agitation turns into a contraindication. The therapist should alert nursing staff, determine the patient is in a safe place, and should stop the session. One contraindication is working with the patient past mid-afternoon (~2:00 p.m.) if the patient is known to sundown. Sundowning occurs is the mid to late afternoon and early evening. The patient will grow restless, agitated, paranoid, and potentially combative (Hellen, 1998). It is contraindicated to complete treatment during this time, as it will be unproductive and potentially harmful. Hyperorality is another symptom of Alzheimer’s that can be dangerous. Hyperorality occurs when the patient has the urge to put all objects in their mouth. Including certain toxic substances or sharp objects within the intervention is contraindicated. Even if these items are not included in the session, the therapist should still proceed with precaution with other items if the patient is known for this behavior. Wandering is another typical behavior of patients with Alzheimer’s. Leaving the patient alone, even for one minute, is contraindicated if they are known for wandering. Frequency and DurationI would suggest Callie receives services three to four times per week during her stay in the hospital. This is appropriate because she is in acute care and will be staying no longer than a week according to her estimated length of stay. Each session will be 30-45 minutes, which is typical for Centennial Hills acute care therapy. Primary FrameworkThe guiding frame of reference for this intervention plan was the rehabilitation reference. According to Schultz-Krohn and Pendleton (2013), the rehabilitation frame of reference focuses on getting the patient back to his/her previous level of functioning or at least their highest level of functioning as possible. The therapist must focus on the patient’s current abilities and adaptive equipment to restore their performance (Schultz-Krohn & Pendleton, 2013). This is relevant to Callie as prior to her injury and sickness, she was functioning at an modified independence level.This model helped guide her goals by utilizing information gained during the evaluation. The therapist utilized her current abilities and added equipment to enhance her performance. Since her injury (clavicle fracture) is not permanent as is her delirium and confusion attributed to her hospital admittance, this frame of reference is preferable. In addition, her difficulties with balance and endurance are not permanent; they are able to be attended to during therapy. When her dementia progresses and she declines, then potentially the compensatory model will be utilized, but until her deficits are permanent, we want her to continue functioning at her high level. Creating a checklist, receiving education on DME, and focusing on rehabilitating her balance and endurance, all are strategies that coincide with the goals of the rehabilitation frame of reference. Patient/Caregiver EducationThe patient will receive education and training on DME. She will need to know how to use the equipment properly within the home and throughout the community. The caregiver also needs to receive education on the importance of using the equipment. They both will need to understand how it will help decrease chances of another fall and will help stabilize her mother while ambulating. In addition, the therapist will need to provide the caregiver information on any adapted equipment that will be provided for her mother. The therapist should also give the caregivers realistic expectations for what Callie will be able to complete when she returns home. This may entail them providing her more assistance or verbal prompts for completion of tasks. Last, the caregivers should be provided with options for Callie, whether it be a respite service or an adult daycare so they will have to worry less. This education will be provided prior to discharge. It will not be an issue as Callie’s daughter visits often and is open to receiving suggestions for her mother’s independence. The training for Callie will be provided throughout the therapy sessions. Response to InterventionsCallie’s response will be monitored throughout the sessions. The therapist could utilize the Functional Independence Measure (FIM) in order to document her progress. However, due to time constraints and short stays, this may be too lengthy of an assessment. Using a simple pain scale, such as having her rate her pain 1-10 is an easy way to evaluate and reevaluate her progress. Observations will also be utilized as a form of non-standardized assessments. With the use of clinical reasoning, the therapist will be able to note progress toward the patient’s goals. The patient will be able to verbalize if they are enjoying the intervention and if it is too difficult or hard for them to complete. In addition, Callie’s family can also provide input on how they think the sessions are going and if they would like any changes. ReferencesAbreu, C. B. & Yancy, S. M. (2011). Everyday living for individuals with cognitive deficits after Alzheimer’s dementia and traumatic brain injury. In C. H. Christiansen & K. M. Matuska (Eds.), Ways of living. Intervention strategies to enable participation (4th ed. , pp. 379-404. Bethesda, MD: AOTA Press.American Occupational Therapy Association.(2014).Occupational therapy practice framework: Domain and process (3rd ed.).American Journal of Occupational Therapy, 68(Suppl.1), S1–S48., C. R. (1998). Alzheimer’s disease: Activity focused care (2nd ed.). Boston, MA: Butterworth-Heineman.Jensen, L. E., & Padilla, R. (2011). Effectiveness of interventions to prevent falls in people with Alzheimer’s disease and related dementias. American Journal of Occupational Therapy, 65, 532–540. doi:10.5014/ajot.2011.002626Letts, L., Edwards, M., Berenyi, J., Moros, K., O’Neill, C., O’Toole, C., et al. (2011). Using occupations to improve quality of life, health and wellness, and client and caregiver satisfaction for people with Alzheimer’s disease and related dementias. American Journal of Occupational Therapy, 65, 497–504. doi: 10.5014/ajot.2011.002584Schultz-Krohn, W. & Pendleton, H. M. (2013). Application of the occupational therapy practice framework to physical dysfunction. In H.M. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy. Practice skills for dysfunction (7th ed., pp. 28-54). St. Louis, MO: Elsevier Mosby.Wood, W., Womack, J., & Hooper, B. (2009). Dying of boredom: An exploratory case study of time use, apparent affect, and routine activity situations on two Alzheimer’s special care units. American Journal of Occupational Therapy, 63, 337–350. ................
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