Running head: OCCUPATIONAL PROFILE AND ANALYSIS

Occupational Profile and Analysis Chrys Quiroz Touro University Nevada

OCCUPATIONAL PROFILE AND ANALYSIS Occupational Profile Client The client, Ella, is of Caucasian descent and 83 years old. She currently lives in a one bedroom space within the Memory Care Unit of an Assisted Living Facility (ALF). She has one daughter, who appears to be in her late 40s, and frequently visits Ella in the Memory Care Unit. The daughters name is Cindy and spoke on behalf of her mother during the initial evaluation. Ella, Cindy, and Ellas husband were originally from Northridge, California. However, due to the infamous Northridge earthquakes, their family relocated to Las Vegas and has been living here since 1994. Prior to moving to the Memory Care Unit on June 21, 2013, Cindy performed all caregiver obligations related to Ella. They lived together in a three bedroom house. Ellas husband of 50 years passed away almost three years ago. She has a cat and two dogs, which have been left at her old home for her daughter to take care of. Ella has maintained close relationships with her girlfriends, though she is unable to communicate with them as often as she would like. This is due to her current living situation and the lack of electronic use at the Memory Care Unit. Ellas chosen career path as an adult was a seamstress. There was no statement of whether Ella was involved in outside populations or a member of other organizations. Client Concerns Ella is seeking services secondary to dementia, though it was not discussed as to the type of dementia Ella was diagnosed with. Cindy insisted that Ella move to the Memory Care Unit of the ALF, primarily due to her mothers tendency to wander, and associated moderate cognitive decline. Cindy shared that she could no longer provide supervision to the extent that was necessary. Cindy stated that Ella required assistance in showering but was independent in other activities of daily living (ADL) such as grooming, feeding, and dressing.

OCCUPATIONAL PROFILE AND ANALYSIS Ellas concerns deal with adjusting to her current living situation. Since her move to the facility is still relatively recent, Ella still has not found her social niche in relation to the other residents, and chooses to not participate in the group activities. She is having difficulty engaging in occupations and daily life activities because of her preoccupation with going back home. She has stated that the Memory Care Unit is not her home. An additional concern Ella has expressed is she fears her daughter will leave her alone to pass away in this hospice. Cindys current concerns involve her mothers independence in areas such as showering, functional mobility, use of adaptive equipment and her overall sentiment. Cindy has communicated that she feels her mother is still distraught over the passing of her husband and has since not recovered. Moving her mother to the Memory Care Unit has only increased Ellas grief. Areas of Occupation Ellas current level of functioning has caused her difficulty in almost all areas of occupation, secondary to the cognitive decline that is associated with dementia. However, it would be ideal to remain optimistic in regards to the areas of occupation that are still functional for Ella. Play and education are areas of occupation that were not discussed with Ella. The areas of occupation that are currently causing problems include her ADLs, instrumental activities of daily living (IADLs), rest and sleep, work, leisure, and social participation. The ADLs that are affected involve showering and functional mobility. Ella is unable to shower independently due to her decreased safety awareness. In addition, Cindy shared that Ella currently uses a front wheel walker due to decreased standing balance and activity tolerance. Cindy stated that Ella is able to independently dress, eat, feed, groom, complete toilet hygiene,

OCCUPATIONAL PROFILE AND ANALYSIS and personal device care. She does not have any issues with bowel and bladder management. Sexual activity was not discussed with Ella. The IADLs that are affected include care of others, care of pets, communication management, community mobility, financial management, health and home management, meal preparation and cleanup, and shopping. A majority of the IADLs are difficult for Ella due to her current living situation in the Memory Care Unit and the progressive nature of dementia. For example, the Memory Care Unit staff does not allow Ella to bring and care for her pets, or maintain the use of a communication device such as a cellphone or laptop, while at the site. In addition, community mobility is a problem because she is confined to the Memory Care Unit unless a guardian escorts her out. Financial management and shopping is completed by Cindy. Meal preparation and health and home management is accomplished by the Memory Care Unit staff. Child rearing was not discussed since it was apparent that Cindy is now an adult. In addition, the caregiving role has changed to Cindy caring for her mother, Ella. Religious observance and emergency maintenance was not discussed. In the area of rest and sleep, it was discussed that these activities are often disrupted due to the schedule that is set by the Memory Care Unit. The wake up time conflicts with Ellas normal rising patterns. The Memory Care Unit insists that all residents be awake for breakfast but Ella prefers to wake up later. Therefore, Cindy has requested that her mother be woken up last, to allow her extra time to sleep in. Work has also been affected since she currently lives in the Memory Care Unit, and she has not pursued further employment. Leisure exploration and participation is affected, which can be associated to her discontent with living in the Memory Care Unit. Social participation has also declined which can be attributed to the aforementioned

OCCUPATIONAL PROFILE AND ANALYSIS reason, and the limited access to communicate with established friends via technological communication. Context and Environments The personal and temporal aspects of Ellas context and environment can be viewed as supporting her participation and engagement in desired occupations. The personal context involving Ellas age and socioeconomic status provide her the services that she needs and accommodates her decline in mental function. Living in a Memory Care Unit requires extensive funding on a monthly basis, which would not be feasible if Ella was of lower socioeconomic status. The temporal aspect that supports her participation in occupations involves the stage of life that Ella is in. She can be identified as a middle-older adult. Since it can be assumed that Ella had more obligations and responsibilities during her adult years, it would have been detrimental to her overall participation had her condition begun in an earlier stage of life. However, she has lived a relatively long life and the responsibilities have been smoothly transitioned to her daughter, Cindy. Ellas cultural and virtual context and environment can be viewed as inhibiting her participation and engagement in her desired occupations. The culture of the Memory Care Unit that she currently lives in is not conducive to her prior activity patterns. For example, she cannot cook whenever she desires. Also, the sleeping schedule that is adhered to at the Memory Care Unit is not what Ella is accustomed to. Virtually, Ella no longer has access to a communication device to keep in touch with her lifelong friends. In addition, Ella expected to have cable in her room, but unfortunately she does not, which affects her participation in leisure. Physically and socially, the new context and environment of the Memory Care Unit has both a supportive and inhibiting effect on Ellas overall engagement in occupation. Physically,

OCCUPATIONAL PROFILE AND ANALYSIS the environment of a locked down facility is keeping Ella safe by ensuring that she no longer wanders. However, the unfamiliar physical environment has left Ella to feel dissatisfaction since it does not provide her the feeling of home. Socially, the residents could prove to be a support system for Ella since they are all going through similar experiences. However, difficulties finding her place in the population may hinder her from developing relationships with the residents. In addition, the extreme supervision that is provided to Ella by the staff may hinder her independence by facilitating learned nonuse of activities, such as grooming and home maintenance. Occupational History As stated above, Ella had a career as a seamstress. Her previous patterns of engagement mostly dealt with household activities involving cooking and cleaning. She finds going to the casino and playing the penny slots worthwhile but does not like Bingo. She enjoys watching movies at the theatre, is interested in politics, and likes getting her nails done. Ella also mentioned enjoyment while listening to music, especially Elvis. The meanings behind all of these activities and interests remind Ella of her younger, happier days, and when she was more agile and active. Priorities and Desired Outcomes Ella mentioned her priority is to go home. However when I asked what functions she essentially wanted to regain, she informed me that she would like to be able to find friends within the Memory Care Unit. In addition, Cindy and Ella both agreed that they desire increased strength to eventually ambulate with durable medical equipment that is less cumbersome than a front wheel walker, such as a cane. Another priority would be to shower independently. The desired outcome that Cindy discussed was to have her mother back home. Cindy mentioned

OCCUPATIONAL PROFILE AND ANALYSIS having Ellas overall independence to a status where the caregiver burden would not be too extensive, but did not delve into details. Further probing was not utilized due to the apparent body language and nonverbal cues that displayed Cindys distress. Occupational Analysis The activity that is being analyzed is showering. This activity falls under the area of occupation of ADLs. This task is appropriate to analyze because this is one of the few ADLs that Ella is having difficulty with. It was not noted whether Ella takes daily medication, and if it had already been given to her, which may influence her overall performance in this task. Deficits The current deficits that were observed primarily involved decreased mental function. Ella had difficulty with memory and attention related to recalling what the next step was in the process of showering. However, she was able to execute complex movement when prompted. Ellas decreased judgment and safety awareness was noted when verbal cues were given to sit down in order to prevent any falls or slips. She had adequate global mental functions. She appeared to be conscious and oriented throughout the activity and her temperament and energy remained constant. Sensory functions that displayed deficits include vision and hearing. As expected with the environment of a community shower, the water and surrounding noise made it difficult for Ella to see or hear. In addition, Ella utilizes the assistance of eyeglasses, which were not being worn during the shower. Vestibular, proprioceptive, and touch functions appeared to be in tact as observed with her ability to maneuver herself within the shower. Taste and smell were not explicitly observed. The client did not vocalize any pain during the shower and appeared to have normal thermal and pressure awareness from the water.

OCCUPATIONAL PROFILE AND ANALYSIS Extensive deficits in neuromusculoskeletal and movement-related functions were not detected. The shower activity was completed while sitting. This decreased the difficulty related to standing tolerance for the task. Primary neuromusculoskeletal deficits involve Ellas lower extremities and associated activity tolerance. Upper extremity muscle power, tone, and endurance appeared to be within functional limits. In addition, upper extremity joint mobility and stability, motor reflexes, and control of voluntary movement appeared appropriate. Cardiovascular, hematological, immunological, and respiratory system function all appeared to be functioning appropriately. Ella did not complain of any chest pain or difficulty breathing. Voice and speech functions appeared to be normal as Ella successful vocalized her needs throughout the activity. Digestive, metabolic, and endocrine system function appeared to function normally, though Ella was not actively engaging in a feeding activity. She did not complain of any gastrointestinal issues during this activity. Genitourinary and reproductive functions also appeared normal, as indicated by her ability to withhold from releasing bodily fluid throughout the activity. In regards to skin and related-structure functions, no sores were visible, though a thorough skin check was not administered. Hair and nails appeared healthy and appropriate for those typically aging. Activity Demands In regards to the activity demands of showering, the objects and properties associated to the shower include a bench attached to a wall, a shower head that was detachable, and a waterproof curtain. The bench, which can be identified as equipment, was tan, had a flat surface, and made of durable plastic. The shower head was made of smooth metal and had a long cord attachment to facilitate accessibility and ease of use. The waterproof curtain was thin and

OCCUPATIONAL PROFILE AND ANALYSIS displayed an ocean design. The materials were not set-up within the shower, but rather handed to Ella by the attending staff member. These materials included a combination shampoo/conditioner and soap. These products all had a thin consistency. A washcloth was also handed to Ella. This tool was white, and shaped as a square. The space demands involved a roughly 4 feet by 4 feet space used for showering. There was adequate lighting and ventilation, as addressed by the light bulbs and vents within the shower room. The noise associated with the activity was due to the arrangement of the shower room, since multiple individuals were in the room at one time. The temperature of the water and room was adequate for the activity. Social demands required for showering in this facility included being efficient and speedy, as noted with the combination shampoo and conditioner, and multiple shower stalls within the room. The supplies were also shared among the residents. Due to the nature of showering, it is expected for all parties to be modest and respectful for the entire duration of the activity. For sequence and timing, the activity required Ella to turn on the shower to an appropriate temperature and pressure. Next, she would step inside and rinse her hair and body. After her entire body was wet, she would apply the shampoo/conditioner to her hair and rinse. Once her hair was free of shampoo/conditioner, she would wash her body using the washcloth and soap. She would then rinse off all remaining soap, towel dry, and transfer to a dry bench to proceed with dressing. The required actions and performance skills for showering include feeling and gripping the shower head, vocalizing the appropriate temperature and pressure of the water, and asking for assistance in an appropriate tone, when necessary. Also, Ella would have to determine which

OCCUPATIONAL PROFILE AND ANALYSIS body parts she has already washed, and consider if any have been neglected. Lastly, dexterity is necessary in order to manipulate the materials involved during showering. Performance Patterns Ellas performance patterns regarding showering were not extensively discussed. It was noted that this activity is a part of her routine, though the frequency and time of day was not mentioned. Prior to Ellas cognitive decline, she could bathe independently. The daughter played a role of supervising the activity before Ella moved to the Memory Care Unit. Ella did not elaborate whether she preferred bathing or showering. Further discussion could have been guided by the clients habits, such as whether she washed her hair or body first, and if she preferred night or morning showers. Performance Skills Motor and praxis skills are required for this task since Ella will need to consistently rotate her trunk and facilitate movement of her upper extremities, in order to wash her hair and body. She must adequately pace her movements in order to thoroughly rinse herself. Coordination and balance is an essential aspect of the activity considering the wet and slippery environment. She must also utilize bimanual skills in order to manipulate the various materials and tools required for the activity. Sensory-perceptual skills are also utilized throughout this activity. For example, Ella must be able to identify and respond to the temperature and pressure of the water if it is not appropriate. She must have intact proprioception in order to know where her body is in space, when she closes her eyes for protection from the soap. She must also select the incoming auditory stimuli and identify which is originating from a staff member, and which is unnecessary noise input.

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OCCUPATIONAL PROFILE AND ANALYSIS Emotional regulation skills are important to uphold during this activity. Ella must contain any emotional outbursts during showering and she must attempt to display a positive temperament while showering. Since there is a limited amount of time to shower, if Ella were to display depressed symptoms, it may prolong the shower and cause for an uncomfortable situation for all parties involved. She must also persist through the task in its entirety and remain patient if the staff member is assisting another resident. Cognitive skills are critical considering the need for awareness and judgment of ones safety throughout this activity. Ella must sequence the steps of showering and select which body parts have not yet been washed. She must also possess the cognitive skill to multitask. For example, maintaining her sitting balance while facilitating movement of her upper extremities. Communication and social skills are used when responding and listening to the staff member assisting with the shower. Additionally, Ella must maintain social etiquette while showering. Using appropriate social cues and positive acknowledgment towards the staff members would also be desirable with this activity. Body Functions and Body Structures There are multiple body functions and body structures that are primarily influenced by showering. Mental functions are necessary to secure safe performance of this task. Sensory functions and pain are also needed to ensure that this is a comfortable experience for the client. Neuromusculoskeletal function is required to play an active role with independently transferring into and out of the shower, as well as washing ones own body. Cardiovascular, hematological, immunological, and respiratory system function is essential for the client to participate in this activity. Also, intact skin is important as this is a major structure that the task requires to wash. The body structures that are primarily influenced by this task include two eyes which are used to

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OCCUPATIONAL PROFILE AND ANALYSIS see her environment, 10 fingers to manipulate the materials, two arms for reaching the objects, two hands to hold the tools needed while simultaneously rinsing her body, two ears to hear any verbal cues, her mouth to verbalize any requests, her trunk to maintain an upright position, and her lower extremities to secure her onto the shower chair. Contexts Related to Performance The cultural component of context and environment concerns the modesty that is expected while participating in this activity. Another cultural component includes the fact that it is expected by society for individuals to maintain their hygiene by performing routine showers. Temporally, the facility insists that showers are given during the day. This may affect Ellas overall performance in this activity if one day, she prefers to shower during the night time. Physically, the shower is easily accessible and utilizes a small threshold that separates the shower floor from the rest of the shower room. Socially, the activity of showering is currently facilitated by the assistance of a staff member of the facility. Personally, since Ella is a female, it would be appropriate for only a woman to shower her. This factor can also extend to cultural and social context and environment. The virtual context and environment is not applicable to this activity. Problem List Five Problem Statements 1. Client requires SBA to perform shower activities 2 to impaired sequencing & memory. 2. Client unable to engage in social participation 2 to depressive behavior. 3. Client requires mod. VC to perform shower t/f 2 to judgment & safety awareness.

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OCCUPATIONAL PROFILE AND ANALYSIS 4. Client is unable to tolerate more than 10 min. of meal preparation 2 to standing balance & activity tolerance. 5. Client is unable to engage in meal preparation 2 to memory & safety awareness. Justification The top two priorities on the problem list are to address the occupations that were defined as concerns by Ella and Cindy. In addition, these two problems are activities that are vital to engage in while living at the Memory Care Unit. The third problem statement is related to the first, in regards to showering. However, it is not listed in the top two because it is a goal that can be addressed through the caregiver establishing environmental cues to help Ella achieve the goal. For example, signs can be posted to remind Ella to use caution when ambulating on the slippery floor. The fourth and fifth problem statements are important to address in future interventions because these involve leisure activities that could promote enjoyment for the client. These activities would simultaneously exercise cognition and manual dexterity which would be an overall benefit for Ella. However, they are the last priorities since she may not utilize this activity daily, considering the setting that she is in. All problem statements identified, if attained, will increase the overall quality of life for Ella and facilitate a smoother transition while living in the Memory Care Unit.

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OCCUPATIONAL PROFILE AND ANALYSIS References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.

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