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Effective Intervention with Dementia and Difficult Bahaviors
6 CEUs Effective Intervention with Dementia and Difficult Bahaviors

Manual of Articles Sections 8 - 19
Section 8
Strategies for an Integrated Approach to Treating Dementia

Question 8 | Answer Booklet | Table of Contents | Geriatric & Aging CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

Communication is a process by which information or knowledge is exchanged among individuals. Communication is key to creating an effective team and positive outcomes (Heruti & Ohry, 1995). Written patient and specialist communication Dementia mft CEUor oral information about the patient needs to be comprehensible, relevant, and concise to promote healthy communication that benefits the patient, rehabilitation team, and caregivers (Heruti & Ohry). Communication about the patient and about professional roles enhances understanding among health care specialists and diminishes turf battles. For instance, problems can arise when team members use the same words in different contexts (Holden & Woods, 1995). Health care team members who value the relative strengths and limitations of each other's disciplines facilitate healthy communication as one factor that influences a successful integrative approach (Morse & Morse, 1988). Function-oriented communication, individualized to the client, must override the use of discipline-oriented communication (Morse & Morse, 1988). Discipline-oriented communication refers to an exchange of information that is oriented to describe and represent each discipline's own unique efforts (Heruti & Ohry, 1995). Discipline-oriented care reflects a multidisciplinary approach (Jelles et al., 1995). The interdisciplinary team is patient oriented, with the focus of communication and treatment determined less by the discipline's needs and more by the patient's needs. Clear communication that is centered on the patient and focused on the problem is needed to create an environment conducive to collaboration (Holden & Woods, 1995).

Collaboration is the process in which individuals work together to achieve a common goal, such as creating a holistic, integrated, treatment plan. Collaborative assessment may highlight the limitations and strengths of current assessment techniques in both the fields of occupational therapy and psychology. The result of this collaboration may be the development of new methods of assessing abilities that address the needs of the person with dementia and reflect the expertise of both psychologists and occupational therapists. Close collaboration is also needed when gathering information from caregivers and when communicating information to the family (Patterson & Whitehouse, 1990). Collaborative team care is more effective than fragmented health care delivery (Heruti & Ohry, 1995) and may reduce turf issues around overlapping assessment and therapeutic responsibilities (Morse & Morse, 1988). To avoid turf issues and to promote collaboration, Rheame et al. (1988) suggested that interdisciplinary team members develop flexibility. Flexibility is marked by a willingness to modify respective approaches in assessment and treatment through input from others. Through flexibility, occupational therapists and psychologists may be able to develop strategies that create complementing treatment approaches, maximizing potential positive outcomes (Morse & Morse, 1988).
For example, the professional with the strongest skills in any area may lead the team at one time and follow the team at another time when a different skill is needed. The occupational therapist may lead treatment designed to maintain autonomy in self-care, leisure, or even work tasks within the different environmental contexts of the person with dementia. The psychologist might serve as a better team leader in designing strategies for behavioral and emotional modification, staff development, or caregiver support.

Teamwork is defined as work done by several professionals, each doing a part while subordinating personal prominence to the efficiency of the whole (Merriam-Webster's Collegiate Dictionary, 1993). According to Heruti and Ohry (1995), the development and maintenance of an effective team require a commitment of time and effort from its members. Although the primary goal of the team should be the welfare of the patient, the social, emotional, and professional needs of each team member must be considered. In effective teams, members experience team loyalty, which Heruti and Ohry describe as a moral obligation to other team members and to the team as a whole. This loyalty, when it develops, creates a team bonding that facilitates coordination, cooperation, and flexibility and subsequently enhances adaptation to the patient's needs and the needs of fellow caregivers.

For improved teamwork, for example, the social and behavioral goals devised by psychologists should be intrinsically motivating to the patient and may be used to diminish the functional problem areas identified by occupational therapists. The psychologist may direct the development of the team and support team members as they struggle to care for chronically ill patients with dementia. The occupational therapist may develop methods for patients to communicate their choices and build simple choice opportunities into their daily lives to improve quality of life and respect for patient dignity (Duncan, 1998). The occupational therapist may help team members measure and redefine success as small changes improving the quality of life for a patient or for a caregiver.

Shared Value System
Holden and Woods (1995) emphasized that to create an integrative approach in treating persons with dementia, an agreed upon, explicit value system must be established. The explicit value system should include an individualized patient-centered approach to treatment. Valuing interventions that increase the quality of life for individuals with dementia is a shared value that goes beyond the provision of care and assurance of safety (Macdonald, 1993). A major tenet of gerontological care for all health care workers states that the gerontological care provided should help the disabled older person reach his or her highest attainable level of function (Levy, 1996). The health care team also has an ethical and moral obligation to provide medical services with compassion and respect for human dignity (Department of Veteran Affairs, 1989).

The application of the rehabilitation model for understanding patients with dementia may be increasingly important to both psychologists and occupational therapists. In a rehabilitation model, the residual abilities of people with disabilities and the potential for individual compensation or environmental adaptation are valued.  In contrast, the medical model places more emphasis on the disease process and skill deficits (Acker, 1986), with an emphasis on curing the disorder. Staff and caregivers may inadvertently endorse a medical model despite knowing that there is no cure for this disorder; they may need training in the application of the rehabilitation model. Occupational therapists and psychologists may help promote a rehabilitative approach to patient care that emphasizes quality of life, use of abilities, and right to a goal-directed life (Department of Veteran Affairs, 1989; Holden & Woods, 1995; Levy, 1996).  This shared value of a focus on rehabilitation might be enhanced by occupational therapists and psychologists sharing these beliefs while supporting each other when these values are challenged. Both professionals may educate fellow team members on emerging literature and developing issues in their fields and may also set a professional role model for others. Their extensive educational backgrounds may enhance the ability of psychologists and occupational therapists to promote a holistic and humanistic treatment philosophy for a disorder that is sometimes considered hopeless when viewed within the medical model.

Acceptance of Complementary Roles
Rheame et al. (1988) claimed that the interdisciplinary team approach can be successfully achieved only when team members not only communicate effectively but also accept constructive criticism and guidance from each other. Complementing roles are described as equally completing parts that mutually supply or fulfill each other's limitations. This does not mean that one professional assumes a subordinate role; rather, one professional assumes more responsibility or assertiveness in a given situation. A democratic, open-minded leader accents a good team by encouraging decisions by discussion versus by coercion.  Different health care team members emphasize different aspects of behavior and functioning (Holden & Woods, 1995). Specifically, team members are individually responsible for obtaining assessment information in their areas of expertise; this information is then collected and used to develop the interdisciplinary care plan (Department of Veteran Affairs, 1989). The team leader may moderate the integrating discussion.  For example, some practitioners may look at behavioral problems associated with dementia as not purposeful, random, or unpredictable; others, such as Gugel (1994), claim that this behavior is in fact purposeful and predictable. This later approach is consistent with occupational therapy theory, which suggests that all behavior is communicative in some sense (Levy, 1996). The team leader can help members identify a common ground between differing viewpoints.
The main goal of occupational therapy is to promote, enhance, and maintain the patient's functional status and independence as well as to promote the ability of the caregiver to provide needed intervention (Department of Veteran Affairs, 1989). Occupational therapy's main concern is to keep the person functioning at optimal levels physically while responding to perceptual, environmental, and adaptive equipment needs (Fabiszewski, Riley, et al., 1988).
A secondary concern of occupational therapy is to facilitate and support socialization (Atler & St. Michel, 1996). The aim of psychosocial treatments by psychologists is to minimize stress and confusion, encourage the patient to stay in touch, enable the patient to engage in purposeful activities, and provide outlets for energies or emotions (Department of Veteran Affairs, 1989; Greene, Ingram, & Johnson, 1993). The occupational therapist may address higher cortical functions in order to improve the patient's ability to interact, communicate, or maintain independence and quality of life. These roles can be complementary when each team member respects the expertise of fellow colleagues and co-workers.

Therapeutic Relationships
Establishing a therapeutic relationship that links professional caregivers to the patient and his or her family is another essential component of effective interdisciplinary treatment. For caregivers and the patient, development of a therapeutic relationship with a relatively small, consistent group of professionals reduces confusion and improves consistency of treatment (Seltzer et al., 1988). Family adjustment is facilitated in response to successful team approaches, and caregiver burden is also minimized when tough family decisions are shared within the interdisciplinary team (Fabiszewski, Riley, et al., 1988). Jelles et al. (1995) stress that the attainment of patient goals is a collective team responsibility. Patients and their families may need to be seen regularly to provide a continuum of care to counter the progressive decline of dementia and to prevent illnesses. Psychological and occupational therapy services help to minimize caregiver stress (Midence & Cunliffe, 1996), which, in turn, may enable the person with dementia to live longer within a community support system.
Occupational therapists and psychologists are capable and ideally situated to facilitate team and caregiver relationships. A psychologist may assess the well-being of both family members and caregivers to assist in providing supportive educational and coping services (Fabiszewski, Shapiro, & Kern, 1988). Caregiver issues and concerns must be valued and addressed, because ineffective coping mechanisms may not minimize stressors accompanying the care of a loved one with dementia. Psychologists help to identify caregivers at high risk for stress, especially as a preventive function in caregiver support groups (Midence & Cunliffe, 1996). The occupational therapist may provide practical solutions to everyday problems in order to ease the burden and increase the confidence of the caregiver (Atler & St. Michel, 1996).

Knowledge refers to using existing information, increasing the present knowledge base, and sharing this information with others to improve understanding. Effective case management of Alzheimer's disease requires continued assessment of capabilities and needs (Fabiszewski, Riley, et al., 1988) and the development of practice based on evidence. Paralleling paths of knowledge regarding individualized case management and research are important for both occupational therapists and psychologists. Individualized case management involves identifying the needs, desires, strengths, and weaknesses of persons with dementia for treatment planning and research. Research involves testing the effectiveness of specific intervention strategies and identifying the pathological underpinnings of psychosocial symptoms (Holden & Woods, 1995). This knowledge base may be enhanced by understanding typical and atypical changes associated with the human aging process.

In individualized case management of dementia, the lack of knowledge about relationships between brain function and behavior can lead to inappropriate goals or treatments (Holden & Woods, 1995) such as the wholesale use of chemical and physical restraints. Occupational therapists and psychologists are essential to provide interventions that may improve quality of life by alleviating a person's symptoms physically, socially, environmentally, and by developing nonpharmacological behavioral interventions (Greene, Ingram, & Johnson, 1993).

Both psychologists and occupational therapists contribute to understanding caregivers' needs, desires, strengths, and weaknesses in treatment and research. Occupational therapists are experts in the knowledge of cognition as it relates to functional needs, and psychologists are experts in the knowledge of cognition as it relates to psychosocial needs. The sums of this knowledge are complementary and may produce innovative psychosocial and behavioral interventions, environmental modifications, sensory interventions, or pragmatic solutions to problems, such as reducing the need for restraints and medications.
- Keough, Jeremy; Huebner, Ruth A.; Treating Dementia: The Complementing Team Approach of Occupational Therapy and Psychology;  Journal of Psychology; Jul2000; Vol. 134 Issue 4

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 150 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about strategies for an integrated approach to treating dementia. Write three case study examples regarding how you might use the content of this section in your practice.

What are the seven components of the complementing team approach? Record the letter of the correct answer the Answer Booklet

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