RECTH 4310

Recreation Therapy Assessment of an Older Adult

PART 1:
Identifying Data
Client name John Doe
Age 93
Gender Male
Date of Admission to Facility 2015
Primary Diagnosis Major Neurocognitive Disorder
(The dx/s that caused the admission of the client)
Secondary Diagnoses Hearing loss
(Other dx/s that are still active – the person is still experiencing – that are Vision loss
not the primary reason for admission of the client) Delirium
Past medical history None
(Other dx/s that the client had in the past that are no longer active)
Precautions Minor fall risk
Minor PTSD risk
Diet Soft foods only
Medications n/a
Education (highest level achieved) Bachelor’s degree
City & state of residence; characteristics of home & living situation Salt Lake City, UT
Client resides in the facility
Employment status & occupation Retired
Social roles/social support Has a wife, three children, and nine grandchildren—wife and daughter visit
Sundays and Wednesdays
Religious and cultural values LDS
Life habits Wakes up mid-morning, goes to bed at eight pm
Spends his time socializing with staff and other residents
Participates in all activities
Client goals (what the client states he/she hopes to achieve) “enjoy the rest of my days”
Reasons for admission Client has a severe NCD and is in the memory care unit
(What is the main reason the person is at your particular facility; e.g., Decreased independence in functioning
respite, decreased independence in functioning, rehabilitation)
Reason for referral to RT Client referred to RT for social, cognitive, and physical stimulation in effort to
(Reason for referral will vary by setting. Even if a formal referral is not made, maximize independence and quality of life.
explain what is hoped to be accomplished through Rec Therapy services for
this individual at this facility?)

Disability Review
Review one of the client’s primary and secondary diagnoses, and answer the following questions. Use professional sources (journal articles, professional
texts, health organization websites) to gather your information, cite the sources within the text, and provide the full references in APA format.
Primary Diagnosis Review: Review the “specific” diagnosis of the client (e.g., R CVA, instead of CVA; Lung Cancer, instead of Cancer). Review one diagnosis.

Primary Dx: Major Neurocognitive Disorder

Cause:

Alzheimer’s disease 
Frontotemporal lobar degeneration 
Lewy body disease 
Vascular disease 
Traumatic brain injury 
Substance/medication use
HIV infection 
Prion disease 
Parkinson’s disease
Huntington’s disease 
Another medical condition 
Multiple etiologies 
Unspecified

Symptoms: memory decline (inability to retain short-term memory or loss of long-term memory)
 Anxiety
Confusion
Headaches
Difficulty expressing emotion
Trouble performing routine tasks
Loss of balance
Dependence on others to perform basic daily tasks

Treatment: no cure
Medications
Activities to assist in short-term memory---memory card games, name game, puzzles
Activities to assist in long-term memory---trivia, Story Corner (where residents will share a memory from their past)
Activities to increase movement---yoga, catch with a ball, Penny Pitch
Activities to increase social interactions---Lunch Bunch, activities upstairs with the other residents, one-on-ones

Prognosis: if caused by neurodegenerative disease (as is the case with client)---no improving memory, condition will worsen over time
If caused by injury, infection, etc---memory may be partially or completely restored

References (APA format):

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders  (5th ed.). Arlington, VA: American Psychiatric Publishing.

Secondary Diagnosis Review. Select one secondary diagnosis to review. Use the information provided above in the primary diagnosis section to guide your
writing in this section.

Secondary Dx (1): Unqualified Visual Loss, both eyes

Cause: macular degeneration; retinitis pigmentosa; diabetic retinopathy, etc.

Symptoms: Limitation in visual functions

Reduced ability to perceive visual stimuli
Vision considered inferior to normal vision

Treatment: can be partially corrected with refraction (glasses)

Prognosis: non-fatal
Condition cannot be reversed and may worsen over time
References (APA format):

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and
diagnostic guidelines. Geneva: World Health Organization.

Implications: Having reviewed the symptoms and other relevant information about your client’s primary and secondary diagnoses, how does this
understanding impact the services you will provide for the client? Answer both questions below based on your understanding of the diagnoses.
Tip: Go back to your diagnosis review. What symptoms should you be focused on? Review Identifying Data again. Anything you need to investigate more?
Based on your understanding of the diagnoses, how does this information guide/inform your assessment process (Will you pay particular attention to an
area of functioning or look for a specific deficit based on this information)? This should be a comprehensive bulleted list to reflect your full understanding of
the client’s diagnosis as a whole.
 Look for ability to pay attention for duration of assessment
 Pay attention to memory retention
 Notice whether client can read assessment or if it needs to be read to him
 Pay attention to how many questions client asks during assessment
 Notice if facts provided are accurate when compared to medical chart

Based on your understanding of the diagnoses, how do you foresee this information affecting the design and implementation of your treatment plan (What
interventions might you employ and why? What might you want to consider in how you approach your interventions with the client --- e.g., precautions that
need to be taken, interactions with the client that need to be carefully considered? This should be a comprehensive bulleted list to reflect your full
understanding of the client’s diagnosis as a whole.
 Interventions to assist in short-term memory retention—memory card games
 Interventions which help long-term memory recall—Story Corner
 Ensure physical interventions (such as Penny Pitch to increase mobility in arm) are implemented at a close enough distance that client can see
target
 Client may not remember information accurately—validate rather than correct to prevent angry outburst or frustration

Functional Skills Assessment

Using the facility RT assessment tool, secondary sources (e.g. chart, family, staff, etc.), and/or a standardized RT assessment tool, conduct a functional skills
assessment of your client and list your assessment findings in the chart below.
 This should be a detailed/comprehensive list and should include strengths as well as limitations.
Assessment Methods Assessment Domains Assessment Findings Interpretation of Findings
Instructions: What assessment Instructions: The assessment Instructions: Report measureable Instructions: After reviewing your
tool/source/method did you utilize domains you need to consider are assessment findings. After each assessment findings, what
(e.g., medical chart review, listed below. You do not write finding, indicate the source where you preliminary conclusions can you draw
observation within activity, anything in this column. obtained the information using the from the assessment data? How do
discussion with a specific team below codes: (e.g. Hard of Hearing – you foresee the client’s
member/team/physician, client or O,MC; Loneliness – SR; R Hemiparesis strengths/weaknesses impacting
family interview, standardized – O, MC, P) his/her recreation/leisure
assessment tool, etc)? What O Observation engagement, health, and quality of
specifically did you look for/do? MC Medical Chart life (RT scope of practice)?
Why did you do this (how does it T Standardized Assessment Tool *Pay careful attention to when it is
relate to the client’s diagnoses)? (administered by you) appropriate to use absolute (e.g.,
P Pt hx (anything told you to by will) verses flexible (e.g., could,
the family, other team might, may) terms.
members, etc.)
SR Self Report (items told you to
you by the client)
 Observation within activity Physical functioning Hard of hearing, low vision—O, T Could need assistance reading
—assess engagement levels directions, look at client when
and attention span speaking to him, ensure use of larger
 Standardized Assessment objects for easier visibility (larger
Tool—assess memory and ball)
Cognitive functioning Little short-term memory retention— Instructions may need to be repeated
physical functioning
O, T several times before being
 Client Interview—assess
understood
memory and engagement
Speech/language/communication Able to communicate without issue— Know that client will ask for
functioning O, T assistance when he needs it (he
understands his needs)
Psychological/emotional Recognizes emotions and is able to Client will recognize all emotions,
functioning express them—O,SR including anger. Be aware of this, but
also use it as a strength. He feels

Sensory functioning
Social functioning
Self-care functioning
Play/leisure/recreation/community
functioning
Leisure Lifestyle Review
Identify leisure interests and activity patterns for your client. Each activity should be coded as a current, past and/or future interest. Add additional
rows if needed.
Current (C), Past (P), Activity How often
& Future (F) interests
*List in this order
Decline in hearing and sight—O, SR
Engages with staff and other residents
with enthusiasm—O
Requires assistance with self-hygiene
but is not opposed to help—O
Fully functioning, always participates
in interventions—O, SR
With who Where
more confident if he can express
himself.
Increase volume (play music louder),
increase font size on instructions
Be sure to engage with client. He
enjoys social interaction and this is
what motivates him.
Client requires assistance due to
physical health decline but not
because of cognitive decline—do not
shame him or make jokes as he is
aware
HAVE FUN! Client loves to interact
with staff and participate in all
interventions to live a more
wholesome life.
Other Notations (possible
information to include):
1) Provide other specific
notations about the
activity that does not fit
in the previous columns.
2) Explain the barriers (or
foreseeable
barriers/challenges) to
performing the activity.
3) Explain the facilitators
that could enhance the
 client’s ability to
participate in the activity.
4) Explain any reasons to
be concerned about the
activity (e.g., unhealthy,
could cause harm to self
or others).
5) Explain reasons (if
known) about why past
activities are not being
done any more.
6) Explain motivation for
participating in this
activity.
C,P,F looking at daily He enjoys showing In the main living 1. Client feels
photographs staff and other room and his emotional
residents bedroom attachment to
photos and the
memories they
hold.
2. Sight may
decline/memory
may decline and
he may not be
able to view
photos or
remember who
is in them
3. Larger, clearer
photos//captions
on photos
4. No concerns
5. Currently being
done
6. He has an
emotional
attachment to
photos and
 enjoys
remembering his
past. He
especially loves
sharing his past
with new staff
members.
P fishing Once a week His kids Anywhere where the 1. n/a
weather is nice 2. client is no
longer able to
physical
transport himself
to location//lives
at facility
3. could adapt—
put fish in a
kiddie pool on
deck and have
client fish there
4. careful about
slippery ground
5. client has not
been fishing
since he moved
in to the facility
6. he finds it
relaxing and fun,
and enjoyed
spending time
with his kids
C,P,F Playing catch About once a week With his kids in the In the main living 1. allows client to
past, with staff and room work on range of
other residents now motion
2. range of motion
may decline,
sight may decline
3. larger balls,
throwing softer
 and not as far
4. careful not to hit
resident with
ball or allow him
to hit another
resident with
ball
5. currently being
done
6. client enjoys
feeling physically
active and being
social with other
residents, and
this allows him
to do both

Major Concerns

Given your assessment findings, what are three priorities for
treatment/service? List one overarching goal area in each box.
This is not a specific treatment goal for the client. It is an area of major
concern (e.g. Increase Social Interaction, Cognitive Stimulation, etc.)
Cognitive stimulation
Why is this a priority? Explain how it relates to participation in healthy
leisure activities (especially those that are meaningful to the client), as
well as how it relates to health promotion, rehabilitation, and/or quality
of life.
Important for maintaining long-term memories and possibly short-term
memories, maintains quality of life

Increase physical activity Allows client to participate in wider variety of leisure activities,
maintains quality of life and emotional health (immobility can lead to
frustration and depression)

Increase/Maintain social interaction Maintain cognitive abilities, make leisure activities more enjoyable,
maintain quality of life (friends and social network are important,
especially for older adults)

Part 2:
In addition to this assessment, complete one assessment you have learned about in a RT Class and submit it with this assignment. Depending on
the assessment you choose, there may be overlap of information. That is fine. The assessment must be completed on the same client. This is
designed to give you experience using assessments you have learned about in class as well as develop competency in utilizing a variety of
assessment tools and forms.

The VAMC SLUMS Examination was conducted on the client. The results are as follows.
1. What day of the week is it?
a. Wednesday
2. What is the year?
a. 2015
3. What state are we in?
a. Utah
4. Please remember these five objects. I will ask you what they are later.
a. Apple, pen, tie, house, car
5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20. How much did you spend? How much do
you have left?
a. $20
b. $60
6. Please name as many animals as you can in one minute
a. named 6 animals
7. What were the five objects I asked you to remember?
a. Remembered none, but did name five objects
8. I am going to give you a series of numbers and I would like you to give them to me backwards. If I saw 42, you say 24.
a. 87—correct
b. 649—correct
c. 8537—incorrect
9. This is a clock face. Please put in the hour markers and the time at ten minutes to eleven o’clock.
a. Client put the hour on 11 but did not put the minute on 10-to.
10. Please place an X in the triangle
a. Client did this correctly
11. Which of the above figures is largest?
a. Client answered square, which was correct
12. I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask you some questions.
 a. What was the female’s name? correct
b. What work did she do? Incorrect
c. When did she go back to work? Incorrect
d. What state did she live in? incorrect
Client scored a total of 9. A score of 1-20 indicates dementia. This test proved accurate given the client’s primary diagnosis and current living
situation in the memory care unit.