Running Head: OCCUPATIONAL PROFILE AND ANALYSIS

Occupational Profile & Occupational Analysis Kristina Harvey Touro University Nevada

OCCUPATIONAL PROFILE AND ANALYSIS Occupational Profile Joe is a 78 year old man, who retired as aeronautical engineer almost 25 years ago. He has lived in the Las Vegas area for about six years. Joe has advanced Alzheimers disease, and came to Las Vegas to live with his brother Rene shortly after he was diagnosed. Rene and his late wife Pauline cared for Joe for a little over two years until Renes wife became seriously ill with cancer. Joe has been living at The Stafford memory care facility for almost four years. Joes wife Lynnette passed away from a brain tumor about 20 years ago. His two children live in Texas, but visit him as often as they can. Joes brother Rene visits him almost every day. Although Joe is almost completely nonverbal, his docile nature and mild temperament make him a favorite among the staff in the memory care facility. Joe does not receive occupational therapy but is seeking services in the memory care facility because he can no longer live independently. Joe requires moderate to maximum assistance for almost all ADLs. The memory care facility is responsible for giving Joe all his medications as well as ensuring he is safe in his environment. While Joe can no longer communicate his wants and needs about engaging in occupations and daily activities, his brother Rene, spoke about his wishes for Joe at this stage in his life. Rene finds it important to bring in pictures of family members to show to Joe each time he visits. Although Joe shows little emotion when looking at the pictures, he is very attentive during this time. Joe was a pilot in the Vietnam War, and his brother has decorated his room with memorabilia from that time. Rene wants to preserve the memory of Joe before he was diagnosed with Alzheimers. Rene feels Joes care at the memory care facility is good, but he wishes more of the staff members would talk to Joe. Joe is one of the few residents who can still ambulate and often paces the hall a good portion of the

OCCUPATIONAL PROFILE AND ANALYSIS day. Rene wishes someone would walk and talk with Joe more often. Even though Joe cannot engage in conversation, he believes he would really enjoy the company. Alzheimers disease has affected nearly all of Joes areas of occupation. He requires moderate to maximum assistance with all ADLs, except he is able to independently feed himself with extra time and setup. Joe no longer performs any IADLs as he has lost the ability to perform higher cognitive thinking. Living in the memory care facility, many of the IADL tasks Joe may have once performed are now done for him. One example would be meal preparation and cleanup. Rest and sleep has been impacted by Joes disease because he sleeps much more often than he used to. His brother commented that Joe falls asleep almost instantly unless he is receiving some sort of stimuli. This is another reason his brother wishes someone would take more time to walk and talk with Joe. Play and leisure have virtually diminished over the years as Joes Alzheimers has gotten progressively worse. He can no longer physically or mentally engage in play or leisure activities the way he could during the early stages of the disease. Joe does not willingly engage with the other residents. His main form of social participation happens when the staff or family members interact with him. It takes a lot of effort for the staff to get Joe to sit with the other residents, so then often do not even try. The memory care facility can act to both support and inhibit participation and engagement in desired occupations. It acts to support participation by caring for Joe. The staff helps Joe with his ADLs, prepares his meals, and gives him medications. The facility also provides him a safe place to live as he can no longer live independently. This environment inhibits participation and engagement in desired occupations because the residents live very differently than they did when they were independent. The memory care facility is a locked unit; therefore, the residents do not leave unless they are signed out by a family member or doctor. Joe

OCCUPATIONAL PROFILE AND ANALYSIS cannot engage in many of the occupations he enjoyed before he became ill. Joe loved to work on planes and go fishing in his spare time. Rene commented that Joe enjoyed the outdoors. Unfortunately, Joe cannot perform any of his former occupations in the memory care facility. That being said, mentally Joe is no longer able to perform these activities even if the memory care facility was equipped for these desired occupations. As previously mentioned, Joe is a retired aeronautical engineer. He was a pilot in Vietnam because of his love for aviation. Joe engineered the Patriot Missile which was used during the Vietnam War to attach to any type of engine and deactivate it. Rene commented that Westinghouse patented the missile and Joe received an honorary award for his innovative invention. Joe is originally from Maine. He moved to Maryland when his wife passed away and lived there until he moved to Las Vegas shortly after his diagnosis. Rene describes Joe as a family man. He was a very hard worker and was very well liked. Rene commented that it is difficult to watch his brothers disease progress, and why he feels so strongly about preserving the memory of what Joes life used to be. At this point in time, Renes priorities and desired outcomes for Joe are for him to have the best quality of life he possibly can. He believes Joe is in good hands at the memory care facility, but he wishes he did not have to live the rest of his life in the facility. Rene wishes the staff would engage more with Joe, even though he realizes they have a number of other residents to attend to. Rene makes Joe a priority by visiting him almost every day. Joe still smiles each time Rene visits. He mentioned that the visits help to improve both brothers qualities of life.

OCCUPATIONAL PROFILE AND ANALYSIS Occupational Analysis As previously discussed, Joe requires significant assistance for all ADL tasks except for feeding. I observed him during several different meals to understand how his Alzheimers disease, as well as neck contracture, have impacted this ADL. Joe experiences significant mental function deficits. His advanced dementia has taken away his ability to perform higher cognitive thinking. He can no longer remember people, places, or events. Joe has a short attention span and is unable to sequence complex movements because he can no longer recall the learned patterns of movement. For example, he will stand in front of the table until someone pulls out the chair and directs him to sit down. This learned pattern of movement is likely something Joe did routinely before his disease, but now he cannot sequence the steps of sitting at a table. Though Joe still smiles and had a docile temperament, he does not express any emotions associated to what is going on in his environment. Joe is unaware of self and time because he no longer has the mental capacity to understand his body image, self-concept, or self-esteem. He is no longer oriented to person, place, or time, and only experiences energy and drive during walks, visits from family, and mealtime. Joe does not appear to have any sensory function impairments separate from his Alzheimers disease. He still has the ability to see, hear, feel, taste, smell, and touch objects in his environment. This was assumed through observation. Joe had a very large appetite which also indicated smell and taste were not significantly impacted to the point of decreasing his desire for food. Joe did not appear to be in any pain; however, with his lack of verbal communication it may be difficult to sense pain, temperature, and pressure he may feel. It is important for the staff members to monitor Joes vitals, skin integrity, and behavior to note any changes that may be due to pain or pressure.

OCCUPATIONAL PROFILE AND ANALYSIS Joe experiences neuromusculoskeletal and movement deficits in his neck muscles. He has a severe neck contracture which produces a pronounced flexion of the neck. Joe looks as though he is constantly tucking his chin to his chest. The RN in the memory care facility does not know why Joe developed the contracture. She said he receives massage therapy once a week, but it has gotten progressively worse over time. Due to the contracture, he is no longer able to range his atlanto-axial joint to move his head and neck through full flexion and extension. The tone in his anterior neck muscles appear to be very spastic causing his posterior neck muscles to become permanently elongated and weak. He often sits in a pronounced posterior pelvic tilt to help bring his head closer to an upright position while eating. This posture accounts for a fair amount of food landing in his lap instead of making it to his mouth. Assessing Joes control of voluntary movement, he has surprisingly good fine motor control. Though he does experience a slight tremor while feeding himself, his finger dexterity is still very much intact and his hand to mouth pattern is relatively smooth. Joes gait pattern was observed as he was walking to and from the table, and around the facility. He shuffles his feet and walks very slowly. However, the staff commented that helping Joe with self-care tasks is easier because he is able to walk, sit, and stand independently. No deficits were noted in regards to Joes cardiovascular, hematological, immunological, and respiratory systems. He can still ambulate and loves to walk around the facility. Joe is not on oxygen and has a large appetite indicating these areas of body function seem to be functioning adequately. One staff member noted that Joe has blood drawn about every three weeks to monitor his health. To date, he has not suffered any major illnesses while in the memory care facility.

OCCUPATIONAL PROFILE AND ANALYSIS Joe is almost completely non-verbal due to his advanced Alzheimers disease. When he does speak, it is difficult to understand because it is quiet and often raspy sounding. Joe is still able to eat food of normal consistency implying his digestive, metabolic, and endocrine systems are still functioning adequately. His advanced dementia has inhibited Joes ability to use the bathroom independently or indicate when he need to go. Joe is often changed more frequently than other residents because he has a larger appetite than many of them. Joes skin and related structures appeared healthy because no wounds or lesions were visible on his skin. When assessing activity demands for feeding, there are a few objects Joe needs to be successful in performing this task. The tools required include utensils, plate or bowl, and a cup. The materials needed would include the food, beverage, and napkin. The equipment needed for this task include a table and chair. The space demands needed for feeding require a big enough table for the meal and adequate lighting. It may be preferable if Joe is in a quieter environment to promote more concentration on the task. A social demand may include Joe using utensils to eat his meal instead of using his fingers. The sequencing and timing of eating a meal is pretty consistent for each meal. Joe sits in his chair, food is given to him, and he begins to eat. They receive three meals at the same time each day and are given about forty-five minutes to eat. The required action and performance skill of feeding is knowing how to self-feed. Joe must know how to utilize utensils and control his limbs to promote a successful hand to mouth pattern for feeding. A variety of performance patterns were observed during this activity because mealtime is routine for every resident. Joe had the habit of sitting in the same seat for every meal. He would walk near the table, and then need to be guided to the chair. Mealtime is routine for Joe. He seems to still have an idea what time meals are served, and knows to go to the dining hall when

OCCUPATIONAL PROFILE AND ANALYSIS someone tells him a meal is ready. Although Joe may have had the role of feeding his children during one point in his life, he has since given up that role and is now focused on feeding himself. His role has changed to a resident of the memory care facility. There are many performance skills needed for Joe to independently feed himself. He must be able to perform motor and praxis skills such as being able to physically move, and perform skilled purposeful movements like a hand to mouth pattern. Although Joes Alzheimers is very advanced, he can still execute the purposeful movements necessary to self-feed. Joe exhibited a couple sensory perceptual skills during mealtime. He was able to visually look at his food and discriminate when a fork would be more appropriate than a spoon or vice versa. Joe has a very docile temperament. This is especially true during mealtime. He sits patiently and waits for his food and bib to be placed on him. Once it arrives, he calmly begins eating until he is finished. When he is finished eating he waits patiently for a staff member to remove the bib before leaving the table. Even though Joe has lost his ability to perform higher level thinking, he still exhibits enough cognitive skills to independently self-feed after set up has occurred. He is able to select the utensils he needs and sequence the steps necessary to carry out this task. Joe hardly exhibits communication and socials skills at this stage. He communicates with a simple yes/no when prompted by a staff member. He is not interested in socializing with any of the other residents during mealtime. He prefers to sit at the table alone and eat his meal. Issues with Joes body functions during feeding were discussed previously; however, there are a variety of body structures that are also impacted during this task. Structures of the nervous system have been impacted by his Alzheimers disease. The accumulation of amyloid plaques have impacted transmission of neurons and neuron functioning (Wrightsman, 2013). The significant impact of Joes disease is the main reason he can no longer care for himself, and must

OCCUPATIONAL PROFILE AND ANALYSIS receive setup and verbal cueing to prepare to feed during meals. Joes eyes and ears do not seem to be impacted during the feeding task. The structures involved in voice and speech have been impacted because Joe is almost completely nonverbal. When he does speak it is quiet and raspy because the vocal cords are no longer used regularly. Structures related to the cardiovascular, immunological, respiratory, digestive, metabolic, and endocrine systems appear to function properly during Joes feeding task. As previously mentioned, Joe can no longer go to the bathroom independently. Though his reproductive and urinary system seem to function properly, his brain has lost the ability to register when he needs to go to the bathroom, as well as how to sequence the task of toileting. The structures related to movement include Joes muscles, nerves, and joints. He exhibits good praxis skills during feeding. Joe has good bilateral coordination and exhibits symmetry in his movement patterns during feeding. Joes skin and related structures include skin, hair, and nails. These structures did not impact his feeding tasks, but they were noted during observation. Joes skin was free of wounds. His nails were cut short to prevent any accidental cuts. Joe can no longer perform these grooming tasks; therefore, he must rely on a staff member to assist with grooming. There are several context and environmental factors that influence Joes occupation of feeding. Culturally, it is common for Americans to have three meals a day. Therefore, Joe performs the occupation of feeding at least three times a day, possibly more, if he has any snacks. It is also customary to eat a meal seated, at a table. This is beneficial for Joe because sitting gives him more stability to self-feed. Personally, it was observed that Joe enjoys eating. As previously discussed, he has a large appetite and seems alert during mealtime. Joes temporal environment determines when he performs the task of feeding. In the memory care facility, this occupation happens in the morning, at noon, and late afternoon. There is no virtual component

OCCUPATIONAL PROFILE AND ANALYSIS associated with Joes feeding task. Joes physical environment is the memory care facility. This facility is where Joe performs all of his feeding tasks. Although Joe does not engage socially with any of the other residents, mealtime is the same time for all residents. Therefore, he is engaging in the same occupation as the other residents, even though he is not directly interacting with them. Problem List 1) Client requires Min (A) during feeding task due to executive functioning. 2) Client requires Mod (A) during social participation due to ability to focus on group activities 2 to executive functioning. 3) Client requires Mod (A) during grooming tasks due to executive functioning & neck contracture. 4) Client requires Max (A) during bathing tasks due to safety awareness 2 to executive functioning. 5) Client requires Max (A) during toileting due to bowel & bladder control 2 to executive functioning. The problem statement list was prioritized based on the occupations Joe is still able to participate in. Feeding is the only ADL he still can perform fairly independently; therefore it is important that Joe be as independent as possible in this occupation for as long as possible. The next problem statement is important because even though Joe prefers to walk around the facility and not interact with other residents, he is still able to perform this occupation with assistance. If the memory care facility were to promote group activities that Joe finds meaningful, he may be more inclined to participate with the other residents. One example would be sharing a memory

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OCCUPATIONAL PROFILE AND ANALYSIS book with the group. Although Joe cannot verbally describe any pictures, he does enjoy looking at pictures and would be engaged in the activity. The next problem statement regarding grooming was placed third because this is another area of occupation where Joe can still participate. He has a difficult time brushing his teeth because of his neck contracture, but he can wash and dry his face if a caregiver gives him the washcloth or towel. Joe can also comb his hair if he is given a comb. Joe cannot shave due to the neck contracture and decreased safety awareness. The next two problem statements are occupations Joe requires maximum assistance with. The first is bathing. The bathroom can be dangerous because of Joes decreased safety awareness and Alzheimers disease. Therefore, it is important that he have assistance bathing. Joe is also unable to wash his hair and body. He is able to ambulate to and from the shower and hold the shower head. Lastly, Joe requires maximum assistance for toileting. He no longer has control of his bowel and bladder due to his advanced cognitive impairments. Therefore, he requires a caregiver to help change him. Joe is only able to offer a small amount of assistance with this task such as standing or sitting. In conclusion, Joes advanced Alzheimers disease has robbed him of the ability to perform the occupations he was once easily able to do. Though he requires a considerable amount of assistance throughout the day, it is important to maintain participation in the occupations Joe is still able to perform. Though Alzheimers is a progressive disease, modifications and adaptations will be important for helping Joe remain as independent as possible during feeding and social interaction. Promoting independence and engagement in meaningful occupations will help promote quality of life for Joe, which is exactly what his brother Rene wanted.

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OCCUPATIONAL PROFILE AND ANALYSIS Reference: American Occupational Therapy Association (2008). Occupational therapy practice framework: Domain and Process (2nd ed.). Baltimore, MD: AOTA Press. Wrightsman, W. (2013). Alzheimers Disease. [PowerPoint Slides]. Retrieved from Touro University Nevada website: https://bbtun.touro.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_3_1&url=%2Fwebapps% 2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_1625241_1%26 url%3D

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