Case Scenario 2-Home Health Skilled Nursing Care Teaching and Training:
Alzheimer's Disease

**Going Beyond Diagnosis** **Case Scenario #2** **Palmetto GBA**  
  
A physician has ordered skilled nursing care for teaching behavioral
techniques to a care-giving niece of a patient with moderate Alzheimer's
disease to gain the patient's cooperation during mealtime. Due to the
patient's wandering behaviors, she will not stay seated for a meal and the
niece believes she is "trying to be difficult." The patient has been gradually
losing weight (10 pounds over 2 months) and she is less coordinated with her
utensils due to her underlying dementia as well as a new onset tremor. The
teaching services are reasonable and necessary for the patient's treatment and
adequate nutritional intake.  
  
 **Description of scenario using ICD-10:**  
  
G30.0 Alzheimer's disease with early onset  
G30.1 Alzheimer's disease with late onset  
G30.8 Other Alzheimer's disease  
G30.9 Alzheimer's disease, unspecified (used as a secondary diagnosis)  
R25.0 Abnormal head movements (used as a secondary diagnosis)  
R25.1 Tremor, unspecified (used as a secondary diagnosis)  
R25.2 Cramp and spasm (used as a secondary diagnosis)  
R25.3 Fasciculation (used as a secondary diagnosis)  
R25.8 Other abnormal involuntary movements (used as a secondary diagnosis)  
R25.9 Unspecified abnormal involuntary movements (used as a secondary
diagnosis)  
  
 **Additional description of scenario using ICF:**  
  
ICF Component: **Body Function and Structure**  
  
ICF Domain: Mental function  
  
b117 - Intellectual functions - General mental functions, required to
understand and constructively integrate the various mental functions,
including all cognitive functions and their development over the life span.  
  
Inclusions: functions of intellectual growth; intellectual retardation, mental
retardation, dementia  
  
ICF Domain: Functions of the digestive, metabolic, and endocrine systems  
  
b530 - Weight maintenance functions - Functions of maintaining appropriate
body weight, including weight gain during the developmental period.  
  
Inclusions: functions of maintenance of acceptable Body Mass Index (BMI); and
impairments such as underweight, cachexia, wasting, overweight, emaciation and
such as in primary and secondary obesity  
  
ICF Domain: Neuromusculoskeletal and movement-related functions  
  
b760 - Control of voluntary movement functions  
b7602 - Coordination of voluntary movements - functions associated with
coordination of simple and complex voluntary movements, performing movements
in an orderly combination.  
  
Inclusions: right left coordination, coordination of visually directed
movements, such as eye hand coordination and eye foot coordination;
impairments such as dysdiadochokinesia  
  
  
b765 - Involuntary movement functions  
b7651 - Tremor  
  
  
ICF Component: **Activities and Participation**  
  
ICF Domain: Self-care  
d550 - Eating - Carrying out the coordinated tasks and actions of eating food
that has been served, bringing it to the mouth and consuming it in culturally
acceptable ways, cutting or breaking food into pieces, opening bottles and
cans, using eating implements, having meals, feasting or dining.  
  
d560 - Drinking  
  
ICF Component: **Environmental Factors**  
ICF Domain: Support and relationships  
e315 - Extended family  
  
ICF Domain: Attitudes  
e415 - Individual attitudes of extended family members  
  
ICF Domain: Services, systems and policies  
e580 - Health, services, systems and policies  
e-5802 - Health policies  
  
  
 **Potential Interventions**  
  
1\. Teach the patient's niece the primary symptoms of Alzheimer's disease
(amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can
influence the patient's functional ability and level of cooperativeness at
mealtime.  
  
2\. Explore strategies to decrease the patient's wandering at mealtime (toilet
before meals; take the patient for a walk before meals to expend excess
energy; wait to seat patient when the meal is actually ready and on the table;
position the patient in a comfortable, supportive chair positioned directly in
front of the table).  
  
3\. If wandering persists or if the use of utensils is challenging for the
patient due to apraxia, consider adding finger foods such as sandwiches,
slices of fruit, chicken strips, etc.  
  
4\. Limit the number of utensils and items on the table to decrease confusion
and distractions.  
  
5\. Give the patient one item of food at a time, so that the presentation of
the food is not overwhelming and then the patient is less likely to become
frustrated and walk away from the table.  
  
6\. Limit verbal cueing to one step at a time. Physical cueing such as putting
the cup in the patient's hand, initially guiding the spoon to the patient's
mouth may also be helpful for initiation of the self-feeding activity.  
  
7\. Eliminate unnecessary environmental stimulation that may distract or upset
the patient (turn off television, avoid eating with large numbers of other
people, etc.).  
  
8\. Consider fortified supplements after a meal if intake is poor. Or consider
multiple small meals or other finger foods throughout the day, to ensure
adequate intake.  
  
9\. Initially to stimulate appetite, give the patient her favorite foods to
eat.  
  
10\. Consider adaptive feeding equipment such as weighted utensils, no spill
cups, bumper plates to increase the patient's independence with eating.  
  
11\. Cut or prepare food in a manner and consistency that maximizes the
patient's ability to eat it.  
  
12\. Look for signs of poor dental hygiene, gingivitis and refer to dentist
when appropriate. Pain when chewing may be affecting the patient's oral
intake. If the patient has oral heat and/or cold sensitivities, provide
liquids and some food more at room temperature. If the patient routinely wore
dentures, make sure the patient has them in her mouth and that they fit
properly.  
  
13\. Assess the patient's medication regimen to see if any of the medications
could be contributing to the patient's tremor, or poor appetite and notify the
physician.  
  
14\. Check the patient's bowel habits to make sure constipation is not causing
loss of appetite.  
  
15\. Monitor the patient's weight at regular intervals.  
  
16\. Try to have someone else eat at the same time the patient is eating so
that behavior modeling can potentially occur.  
  
17\. Assess for psychiatric symptoms (depression, paranoid delusions) that
could result in a decreased food and fluid intake and notify the physician.