Case Scenario 1 Home Health Skilled Nursing Care Teaching and Training:
Alzheimer's Disease

**Going Beyond Diagnosis** **Case Scenario #1** **Palmetto GBA**  
  
A beneficiary with moderate Alzheimer's Disease is unable to bathe and groom
herself. The family describes the beneficiary as "uncooperative". The primary
caregiver is a daughter who is trying her best to provide assistance and feels
frustrated by the situation, but would like to learn how "to work with her
mother" and keep her at home. The beneficiary's physician has determined that
the "uncooperativeness" is the result of receptive language impairments,
perceptual misinterpretations, and impairments in learned motor skills - all
due to the Alzheimer's Disease. The teaching services are reasonable and
necessary for the beneficiary's treatment, and to maintain proper hygiene and
skin care.  
  
 **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)  
R48.1 Agnosia  
R48.2 Apraxia  
R48.8 Other symbolic dysfunctions (Used as a secondary diagnosis)  
  
 **Additional description of scenario using ICF:**  
  
ICF Component: **Body Function and Structure**  
ICF Domain: Mental functions  
b117 - Intellectual functions  
  
b167 - Mental functions of language  
b1670 - Reception of language  
b16700 - Reception of spoken language  
  
b156 - Perceptual functions  
b1560 - Auditory perception  
  
b176 - Mental functions of sequencing complex movements  
  
ICF Component: **Activities and Participation**  
ICF Domain: Self-care  
d510 - Washing oneself  
d5101- Washing whole body  
  
d520 - Caring for body parts  
d5200- Caring for skin  
d5201- Caring for teeth  
d5202- Caring for hair  
  
ICF Component: **Environmental Factors**  
ICF Domain: Support and relationships  
e310 - Immediate family  
  
ICF Component: **Environmental Factors**  
ICF Domain: Attitudes  
e410 - Individual attitudes of immediate family members  
  
ICF Component: **Environmental Factors**  
ICF Domain: Services, systems and policies  
e580 - Health, services, systems and policies  
e-5802 - Health policies  
  
 **Potential Behavioral and Environmental Interventions:**  
  
1\. Teach the patient's daughter the primary symptoms of Alzheimer's disease
(amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can
influence the patient's level of cooperativeness with bathing and grooming
activities. A learning objective for the daughter would be to define amnesia,
aphasia, apraxia, and agnosia, and to give a clinical example of each symptom
that she has encountered while caring for her mother.  
  
2\. Teach the daughter how to simplify the patient's environment to maximize
the chance for successful activities of daily living (ADL) encounters.
(Examples include, but would not be limited to: daughter having all bathing
and grooming supplies ready and available for use before approaching patient,
unnecessary items that clutter the bathroom/bedroom are moved out of the way,
if a shower is used then add a hand-held shower nozzle so water can be
directed and will not frighten the patient by spraying on her face, put liquid
soap on washcloths ahead of time, so they can be handed to the patient to use,
make sure the environment is the appropriate temperature, bath sponges are
often easier for patients to hold and use than washcloths).  
  
3\. Use a method of bathing that is familiar to the patient. For example, if
the patient always took baths and did not take showers, use a bath now.
Consider the time (e.g., morning or evening) that the individual habitually
bathed. If she resists shampoos in the home, but historically had her hair
done at a beauty shop, consider taking her to one for a shampoo. Consider
separating bathing from hair washing, if doing them both together causes
agitation.  
  
4\. Keep communication simple. Break activities down into steps. Provide one
direction at a time. Keep verbal instruction to a minimum and "model" (i.e.,
demonstrate on yourself) what you want the patient to do, such as pretend to
wash your face then hand the patient the washcloth and nod telling her "now
you try". Alternatively you could try guiding the individual's hand in doing
the activity, then removing your hand and letting them try.  
  
5\. Be creative with your approach. If she won't get in the shower or tub on a
particular day, wait and try again, or have her wash up at the sink, or
wherever she is comfortable. Tell her that mother and daughter are having a
"spa day of beauty". Start with a manicure, which is often less threatening,
then move to a facial, pedicure, etc.  
  
6\. For dressing, lay clothes out in the order in which she should put them on
and have other clothes out of the way.  
  
7\. Teach the daughter that the patient will easily pick up on her daughter's
emotions, so the daughter should try to remain as calm as possible, appear
relaxed, and smile.  
  
8\. The nurse should first demonstrate these techniques to the daughter by
doing them with the patient first, then on another visit, the daughter can
provide a return demonstration for the nurse to observe.