Planning and Preparation for March 20, 2014
Digging-in! Team-based Interventions for Complex Clients with the
Three D’s: Dementia, Depression & Delirium
Guest speaker: Teepa Snow
Supported through the Dean’s Office in Xavier University: College of Social Sciences, Health, and Education
On March 20th, Students from 9 disciplines will gather for an interprofessional teaming symposium. We will hear from a national expert in interprofessional care of clients with dementia. You will learn about the manifestations of dementia, depression & delirium, as well as strategies for interprofessional teaming in the care for these individuals. The afternoon schedule is:
12:30- 12:40 Check -in at the Elements Conference Centre at 11974 Lebanon Rd, Cincinnati, OH 45241
1:00 – 2:40 Keynote Lecture: Digging-in! Team-based Interventions for Complex Clients with the Three D’s: Dementia, Depression & Delirium
(You may sit anywhere during the Keynote)
3:00 – 4:15 Small group: Meet with your assigned team where you will represent your profession in addressing the care of Afsana (see the case study on following page). The faculty intentionally assigned students to specific small groups to promote learning. You may NOT change your group for this seminar. Bring the case study and your suggestions with you to the seminar.
4:15 – 4:45 Networking; refreshments provided
4:45 – 5:30 Large group sharing, discussion and completion of post-seminar survey
Prior to the seminar on March 20th, you will need to:
· Review the case and investigate appropriate service/treatments for Afsana from your professional point of view.
· Read the common reading on working in teams
During the small group session: Your team will review Afsana’s current functioning and recent concerns; develop a plan for her care and treatment, and make specific recommendations regarding current residential placement. You will be representing your profession in determining both needs and care strategies. At the team meeting, the students from each discipline will join together to:
1. Clearly state the major problem/concern in light of their discipline-specific information
2. Identify the patient’s strengths and problems
3. Identify areas of any additional information which you need and determine if another team member has that information
4. As an inter-professional team, develop a comprehensive plan to meet the client’s needs and recommendations for solutions to the current safety and behavior concerns.
A faculty member and/or community clinician will join your small group. Each small group may have a different approach in their plan for this client and differing plans can be appropriate.
During the Large group discussion: The small groups will share their experiences on the process of teaming for an older adult with complex needs.
Case Study
Demographic information:
Name: Afsana Hamid
Age: 84 years old woman of Middle Eastern descent
Diagnosis: 5 weeks status post right hip surgical repair, IDDM, Major Depression
Current living setting: Sunrise Skilled Nursing Unit (Afsana had been in independent living at Sunrise prior to her hip fracture)
Insurance/payer: Medicare
Medical history: Hypercholesterolemia, hypertension, osteoporosis, diabetes, depression. Right hip fracture five weeks ago
Current medications and medical interventions: Lipitor, Lisinopril, Remeron, Boniva, Insulin, Percocet. Currently receiving physical, occupational, and speech therapy but anticipate discharge soon due to continued limited progress.
Social history: Former schoolteacher, widow for four years, four children, 14 grandchildren, 11 great-grandchildren.
Shortly after Afsana’s husband died, she moved from her home into an independent living apartment at a Sunrise Retirement Community. She drove and enjoyed participating in the activities at the facility and in the community.
Six months ago, Afsana’s family began to notice changes. Afsana forgot to take medications for depression and high cholesterol, which she had been taking for years. She made errors in taking her insulin, resulting in under and overdosing, and erratic blood sugar levels. She got lost a few times when driving in the community. Her daughter reports that she appeared confused recently and six weeks ago (just prior to the fall) found Afsana’s purse in the refrigerator.
Five weeks ago, Afsana fell in her apartment, resulting in a right hip fracture. She was taken to the hospital for surgical pinning of the hip and released to the rehab unit at the Sunrise Retirement Community. She was on the rehab unit for two weeks with slow progress noted by both physical and occupational therapy. Following the recommendation of the rehab team, she is now living on the skilled nursing facility (SNF) unit of the retirement community. While her status is only partial weight-bearing on the right leg, it is difficult for her to follow this precaution. This increases her risk for falls. Thus, she often uses a wheelchair. She is now having difficulty with meals. She is refusing to swallow her food and has shown a decline in appetite or interest in meals. Speech therapy has been consulted to evaluate swallowing ability and her risk for aspiration. Family and staff have also observed that Afsana is not able to communicate as clearly, forgetting words or substituting words that are illogical.
Afsana’s family members frequently visit her on the unit and have noticed continued decline in her memory and wonder if she is receiving the correct amount of care from the nurses and aids in the Sunrise Skilled Nursing Unit. As her decline has accelerated, Afsana’s oldest son has become increasingly demanding of the staff.
Behavioral/ emotional functioning: Afsana is not active on the unit as she had been in her independent living apartment; she tends to stay to herself and does not socialize with other residents. One of her best friends in independent living recently had a major stroke and is in a coma. Afsana has stopped calling her children and seems disinterested when they call. She frequently complains that she is in pain and has demonstrated decreased appetite. She was previously impeccably dressed and well-groomed; however, she is typically in the same night gown for days and refuses assistance for daily living skills (e.g., to shower or get dressed). Afsana’s short-term memory has notably declined since the fall.
Spirituality/ routines/ rituals: Muslim: Afsana regularly attended the mosque with her daughter and often spoke with staff about her faith. However, since returning from the hospital she resists any attempts to talk about her spirituality.
Current functioning for daily living and instrumental daily living tasks: Afsana requires max assistance for bed mobility and to move from supine to sit at the edge of her bed. When cooperative, she requires moderate assistance for upper body ADL (i.e., dressing and bathing) when seated at the edge of the bed or in her wheelchair. Afsana requires maximal assistance for all dressing and bathing ADLs for her legs. She requires maximal assistance of 1 for standing and all transfers or maximal assistance of two for steps (i.e. into the shower). She has been incontinent of feces and urine several times in the past two weeks. Afsana is verbalizing that the nurse is giving her the wrong medications. Afsana has convinced her son that one nurse’s aide is trying to poison her. The son has informed the ombudsman and has filed a complaint with the Ohio Department of Health regarding his concerns and his mother’s feeling that she is being poisoned.
Current concerns or issues: Decrease in strength for upper body dressing and wheelchair mobility, steady recent decline in cognitive functioning, incontinence, and decrease in independence. Administration and staff would like family to consider alternatives for additional care. The eldest son (with durable power of attorney) believes Afsana could be cared for more appropriately by the family and should be discharged to live with Afsana’s daughter (his sister). The daughter, who has visited six times in the past two weeks, is not comfortable taking her mom home. The daughter lives in a two-story home with the bathroom on the second floor. She fears that her mother would fall. In addition she has younger children at home and children that she must take to school. There would be no one to stay with her mother when she went out. She does not feel that her home would be safe or that her husband would approve of her mother moving in.
We are grateful to the Dean’s Office in Xavier University College of Social Sciences, Health, and Education for supporting this exciting inter-professional learning opportunity! Planning committee members (listed in reverse alphabetical order by department): Social Work: Jaylene Schaefer; Psychology: Renee’ Zucchero; Occupational Therapy: Joan Tunningley and Nursing: Barb Harland and Debra VanKuiken; Health Services Administration: Edmond Hooker; and Counseling: Michelle Hall. We also thank Dr. Kelly Kleinhans, Speech and Language Pathology at Murray State University, for her help in planning.