Applying the Person–Environment–Occupation Model to ...

1 Applying the Person environment Occupation Model to Improve Dementia CareEarn .1 AOTA CEU (one contact hour and NBCOT PDU).See page CE-5 for Wong, MS USC Mrs. Chan Division of Occupational Science and Occupational Therapy in the Herman Ostrow School of Dentistry University of Southern California, Los AngelesNatalie E. Leland, PhD, OTR/L, BCG, FAOTAUSC Mrs. Chan Division of Occupational Science and Occupational Therapy in the Herman Ostrow School of Dentistry University of Southern California, Los Angeles This CE Article was developed in collaboration with the AOTA s Productive Aging Special Interest purpose of this article is to introduce the Person Environ-ment Occupation (PEO) Model as a framework to improve dementia care in nursing homes and provide examples from literature that can be framed within the Model .

2 The interaction between the person, environment , and occupation is described to promote participation and provide quality care for residents with dementia. The PEO Model can be used by occupational therapy practitioners to develop innovative approaches to dementia care and improve quality of life. LEARNING OBJECTIVESA fter reading this article, you should be able the components of the PEO the relationships within the PEO the different components that consist of the person, environment , and strategies for engaging nursing home residents withdementia within the PEO ModelCASE EXAMPLEThe charge nurse on the nursing home unit entered the dining room at lunchtime and observed Mrs.

3 Jones sitting at her table, but she was not eating. The food on her plate had not been touched. Mrs. Jones had previously been able to eat inde-pendently after food was set up in front of her, although she required additional time to do so. After observing Mrs. Jones for a few minutes, the charge nurse approached the certified nursing assistant (CNA) and asked about Mrs. Jones s status. The CNA stated that this pattern of behavior had been occurring for a few weeks. The CNA and other CNAs had tried to feed her, but Mrs. Jones would get agitated, start yelling, and try to hit the staff. The CNA went on to describe that this behavior disrupted the other residents trying to eat in the dining room.

4 In response to the escalation of behaviors, the CNA reported that they had stopped trying to feed her and left her alone. Concerned about Mrs. Jones risk for weight loss, an occupational therapy screen was observing Mrs. Jones in the dining room, the occupa-tional therapist (OT) noticed that she was sitting at a table with a white tablecloth, and her food included mashed potatoes, cauliflower, and diced chicken served on a white plate. When observing Mrs. Jones and the CNA staff, the OT also noticed that the staff positioned themselves to either Mrs. Jones left or right when trying to encourage her to eat, as they were often also encouraging other residents to eat and/or feeding other residents at the same time.

5 When interacting with Mrs. Jones, it was evident that the staff had startled her, which then triggered her agitation and yelling. The OT determined that the barriers to feeding included lack of contrast among the table, plate, and food, as well as staff being positioned outside of Mrs. Jones line of sight, thereby limiting initiation of self-feeding and facilitating the negative behaviors. On completing the occupa-tional therapy evaluation, the therapist determined three areas relating to feeding that needed to be addressed: (1) the environ-ment ( , adding more color contrast to the place setting), (2) Mrs. Jones positioning during meals, and (3) staff training on strategies for feeding.

6 Occupational therapy addressing the environment . Based on her knowledge of dementia and understanding of the envi-ronment s role in self-feeding for persons with dementia, the OT identified that limited color contrast was an issue. Specifically, as dementia progresses, an individual s vision changes, resulting in greater difficulty distinguishing objects of similar color. Thus, a white plate on a white tablecloth with mostly white food was difficult to see. To address this barrier, the OT worked with the kitchen and CNA staff to provide a colored plate for Mrs. Jones to create contrast between the food and table. Occupational therapy enhancing resident-staff interac-tions during eating positioning and approach.

7 Based on her clinical training, the OT knew that it was more effective to sit directly in front of the individual with dementia so as not to startle them. As dementia progresses, peripheral vision can decrease over time. Thus, sitting to the side of the resident is confusing, as the staff person is not in a direct line of sight and has an unfamiliar voice, which triggers anxiety and resistance. In response, the OT educated and trained the day shift CNAs on the recommended place to sit when working with Mrs. Jones, CE-1 ARTICLE CODE CEA0518CE-2 MAY 2018 ARTICLE CODE CEA0518 Continuing Education Article Download the CE Exam Click here to purchase and take the exam for CE credit.

8 Including suggestions for positioning for the CNAs and Mrs. Jones. Specifically, in the dining room, there were tables set for up to six people as well as smaller caf tables for two people. The OT and CNAs tried having Mrs. Jones eat at one of the caf tables during her meals, which was deemed successful, as the agitation and yelling decreased and feeding improved. To ensure follow through, the therapist worked with the various CNA shifts to promote carryover and ensure that the staff sat directly in front of her, providing one-step prompts to eat. Finally, a training session was scheduled with the family members that came in each weekend for Sunday lunch to educate them on the new strategies for meals.

9 Before discharge from occupational therapy services, the therapist provided one-on-one training sessions with each of the CNAs in the facility and documented the resulting maintenance program, summarizing the recom-mendations for Mrs. Jones. Copies of the detailed document were placed in the CNA communication log as well as Mrs. Jones chart and served as a guide for CNA staff caring for her in the future. The guidance included: Using a colored plate for all meals Sitting at one of the caf tables for two, with the CNAsitting across from Mrs. Jones, directly in her line of sight Limiting communication to simple, one-step commandsin an effort to prompt Mrs. Jones to eat, thereby limitingexcessive side conversations, which were a distraction andconfusingINTRODUCTIONAs the population ages, the number of people with demen-tia will continue to increase (Alzheimer s Association, 2014; Ortman et al.)

10 , 2014). As dementia progresses from the early to late stages of the disease, it causes cognitive decline, the inability to make decisions or communicate, and a decrease in functional and cognitive abilities (McDonald et al., 2010). As the disease advances, people require more assistance with their ADLs and other unmet care needs, which can lead to long-term nursing home placement (Zimmerman et al., 2013). As of 2012, residents with dementia made up of the nursing home population, a percentage that is expected to increase as the pop-ulation ages (Harris-Kojetin et al., 2013; Ortman et al., 2014). This client population is at risk for poor outcomes, including weight loss, accidental falls, morbidity, and mortality (Navar-ro-Gil et al.