Assignment Four

As previously outlined in my blog, the goal of my work with R.H. is to lessen his isolation in his inpatient facility. As part of this goal, I hope to draw R.H. out of his room, or at least out of his bed, using the meals that I bring him from McDonalds. R.H. often refuses the in-patient facility’s food and looks forward to the treats that I bring him. I planned on having him eat the food in the ward’s dining hall instead of in bed, as is his norm.

When I entered R.H.’s room, his roommate was also present. R.H. detests his roommate, and hates how the roommate intrudes on the privacy of our conversations. I pulled the curtain separating the two beds shut, in order to at least give R.H. the allusion of privacy in the shared room.

Per usual, R.H. was lying in bed listening to music. I said hello to R.H. and commented on how well he looked. I asked how he was doing. “Horrible,” he replied. I asked if anyone new had come onto the ward with whom he might connect. “No,” he told me. I asked if there was anything else that I could bring him to pass the time, books, magazines, or anything like that. R.H. told me the only thing he wanted was to “get out of here.”

I then showed R.H. the McDonalds that I had brought him. Rather than eating in bed, I suggested, why don’t we take the food into the dining hall so that you can eat at a table. R.H. flatly refused. I again suggested that we take a walk at least, get out of the room. At this suggestion, R.H. became greatly agitated. He became angry with me and walked out of the room. In this manner, I suppose that he was less isolated because his agitation and anger forced him to get up and leave. However, when I followed him he became increasingly angry and refused to speak with me.

I told him I was sorry that he did not want to talk, and that I always enjoy our visits. Rather than walking me to the elevator and saying goodbye, as R.H. normally does, he walked angrily back to his room, with no goodbye or parting greeting.

I am unsure of how to proceed with R.H. I do not know how to implement my intervention when he is so intractable in his refusal to socialize or be around the other residents. R.H. has been in his current facility for years, and for years has spent the vast majority of his time in bed. I do not know how to encourage him to leave his room without agitating him.

In addition, R.H. eats so little that I am cautious about making his McDonalds a stressful experience.

Therefore, I feel somewhat stuck in my evaluation study. I have yet to be able to make any inroads with R.H., or to use any intervention on him. As the vast majority of my clients have severe cognitive impairments, R.H. is my only possible subject. However, I am unsure if I can get him to even attempt an intervention.

Assignment 3

I have decided to focus on my client’s isolation in my evaluation study. At first, I planned on focusing on both his isolation and non-compliance with his AIDS medication. However, I believe a two-prong approach such as that will be more difficult to both implement and evaluate. Thus I will focus on R.H.’s isolation in hopes of both creating increased socialization in his life and lessening his depression. Studies have shown that non-pharmaceutical interventions can be very beneficial for those suffering from both dementia and depression. (Teri et al, 1997)

I am focusing on using behavioral theory in my work with R.H. I believe that his cognitive impairment, as well as his impaired short and long-term memory, prevents the use of other theories of treatment, such as cognitive behavioral therapy or psychotherapy. Most studies of those suffering from dementia follow a behavioral theory of treatment. (Kasl-Godley and Katz, 2000) Therefore, behavioral theory is the most evidence-based practice.

It is also my hope that if R.H. is less depressed, he may be more agreeable to complying with his medication. R.H. desperately wishes to move to another facility, but his non-compliance with AIDS medication makes this wish almost impossible to fulfill. Perhaps if R.H. is less depressed, he will be more able to see that his non-compliance prevents him from a more pleasant existence.

R.H.’s isolation is rooted in his belief that he has nothing in common with the other residents of his ward. This belief is based in reality, as R.H. comes from a greatly different socioeconomic and racial background than the other residents. In addition, R.H. is a very well educated man. He was in-house counsel of a midsize company prior to the onset of his dementia. In contrast, many of the other residents of his ward have a background rooted in homelessness and poverty. In addition, R.H. holds many racist beliefs, which prevent him from positive interactions with the other residents, who are mostly people of color.

I plan on using two forms of intervention in my attempt to lessen R.H.’s isolation. Both of these interventions are based on the notion that increasing the amount of “pleasant events” in R.H.’s life may lessen his isolation, depression and hopefully encourage him to return to his AIDS medication. The implementation of “pleasant events” in the lives of those suffering from the combination of dementia and depression has been “demonstrated in case reports.” (Teri & Gallagher, 1991; Teri & Uomoto, 1991)

First off, I am working to provide him with visitors from outside organizations, especially organizations that work predominately with GLBT nursing home residents. In clinical studies, it has been found that receiving outside peer visitors can lessen a resident’s depression by up to 40 percent. (Snowden, Sato and Roy-Byrne, 2003)

I have researched organizations that provide such visitors, and have found two that are appropriate to R.H.’s situation: Gay Men’s Health Crisis and SAGE (Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders). I am in the process of scheduling visitations from both of these organizations. It is my hope that the visitors will be able to both provide R.H. with mental stimulation and encourage him to leave his bed, where he spends the majority of his time.

My second intervention is based on R.H.’s disgust for the food served in his inpatient facility. Due to his frequent refusal to eat the facility’s food, I always bring R.H. McDonalds, Coke and Hershey’s Chocolate Bars with Almonds when I visit him. R.H. eats the outside food in bed while we talk. On my next visit, I plan to move our visit to the ward’s dining room so that R.H. will eat at a table, in a more normalized fashion. My hope in this change in our visitation schedule is two-fold. One, I hope that having R.H. eat at a table in the dining room will decrease his sense of himself as purely a “patient.” Two, as other residents spend recreation time in the dining room, I hope to cause some socialization between R.H. and other residents.

I am unsure as to the extent that this intervention will work. R.H.’s racist beliefs have been strongly held by him throughout his life. Consequently, he may simply refuse to speak with the other residents, as is often the case. Also, I am unsure if providing R.H. with outside food in front of the other residents will cause agitation among the others, and as a result either prevent R.H. from eating or lessening his enjoyment of the outside food. As R.H. is very thin, and often refuses to eat, I am hesitant to do anything that may cause him to refuse the outside food as well. However, I plan to attempt this intervention on my next visit. If it does not go smoothly, I will not attempt it again.