David: overcoming anxiety to maintain independence

David, a retired factory worker aged 70 years, lived with his wife Julie on the outskirts of a small town. Both were involved in numerous community activities. David had been diagnosed with Alzheimer’s disease a few months prior to joining the trial.

Although quite capable in everyday activities and household tasks, David was afraid to use appliances of any kind for fear of making a mistake and getting things wrong. He found this tremendously frustrating. It was severely compromising his independence, and his increasing reliance on Julie was causing friction between them. Julie felt frustrated when she tried unsuccessfully to explain how things worked, and she regretted that at times she could be very impatient with David. At the same time, she felt that David was capable of managing better and that she should be pushing him to do more for himself. David and Julie wanted to work on this area of difficulty.

The therapist’s assessment showed that David had the capacity to manage daily activities with only a small amount of guidance or support but was functioning considerably below this level. David’s anxiety needed to be understood in the context of his previous experience of episodes of anxiety and depression, and the therapist noted that he was currently taking antidepressants to try to stabilise his mood. The results of his cognitive tests indicated that he would be able to direct his attention to a task or activity but would need extra support with taking in information or remembering instructions, as it would be difficult for him to take in and retain information or instructions given verbally, especially if the surroundings were distracting. Although David was worried about his memory, the therapist found that he had some good strategies for managing memory difficulties; for example, when he needed to learn new songs for the choir he belonged to, he would break down the lyrics and learn a couple of lines at a time, building up to the whole song. This suggested that David had good potential to develop new ways of coping and should be able to learn to overcome his anxiety and manage to use various appliances. Both David and Julie were keen to try out any strategies that might help. The therapist’s work with David and Julie therefore focused mainly on enabling David to achieve his aim of being able to use various appliances without experiencing crippling levels of anxiety, with the wider aim of allowing him to function more independently.

We illustrate this here in relation to one of the goals: for David to be able to use his mobile phone whenever he wanted or needed to. Being able to use the mobile phone would give David the confidence to be out and about on his own, either to do shopping or errands or to participate in his chosen activities, knowing that he could contact Julie if he needed to. At the start of therapy, David could ‘wake up’ the phone and display the contacts list on the screen, but could not get beyond this step as he developed feelings of panic at the thought that he might do the wrong thing and then the phone would not work at all. David, Julie and the therapist all independently rated his current use of the phone at 2 out of 10. Julie was sceptical that any progress could be made as she had already obtained a simple ‘Doro’ phone for David and tried to teach him to use it, without success, but the therapist convinced her that it was worth trying to apply more specific learning techniques.

The first priority was to find a way to reduce David’s extreme anxiety. This was done by identifying a single key-press that would always take David back to the main menu if necessary. The phone had two smart keys. One of these was for cancelling choices and returning to the main menu; David and the therapist called this the ‘No, go back’ key. The other was for confirming choices on the display; David and the therapist labelled this the ‘Yes, go ahead’ key. The therapist initially taught David, using action-based learning with spaced retrieval, the functions of two smart keys on the phone. The left-hand key was designated ‘Yes’ and the right-hand key was designated ‘No, go back’. David was encouraged to use the ‘No, go back’ key to return to the main menu at any time, so that he did not need to fear that he would make a mistake.

Once the use of the ‘No, go back’ key was well established, the therapist and David identified the different ways in which David needed to use the phone. Initially, the focus was on receiving and making calls, and this was later extended to receiving and sending texts. Each activity was taught in sequence, with an appropriate set of learning strategies applied. The therapist worked with David to list the steps involved in the activity and develop step-by-step instructions that made sense to David. David had to engage in thinking about each step and write down the instructions for himself, reflecting effortful processing of the information. He kept these instructions together in a folder that he could refer to at any time.

Using an action-learning approach, each step was taught in turn, with the therapist demonstrating the actions needed and David repeating them, using an expanding rehearsal approach, with practice spaced at gradually increasing intervals. David was encouraged to practise in a quiet environment without distractions and to allow plenty of time in order to help him stay focused. Simple steps were taught first and more complex ones were taught later, following the principle of graded activity. For example, David first learned to access the text screen, and then when he was confident in doing this, he learned to write a text. This was followed, in sequence, by learning to sending the text, then receiving a text and reading it. David then practised the full sequence of steps, including sending texts to the therapist between sessions and receiving texts from the therapist. As David became more confident, Julie demonstrated how to add punctuation to his text messages and taught him how to delete old messages. She did this using expanding rehearsal strategies, focusing on one instruction at a time.

Having learned how to carry out a task, such as making a call, the next stage involved gaining confidence in using the phone through graded exposure to increasingly demanding situations. David began to practise using the phone in the house. First he used it in staged situations, such as making a test call to Julie or to the therapist, and then moved on to using it for real-life purposes, such as making a call about one of his activities or to a company representative. David then practised using the phone while out in the garden, with Julie on standby in the house in case he needed help. Finally, he practised using the phone while he was out and about, initially contacting the therapist and then using it for real-life purposes. Julie helped by identifying situations in which David could use the phone and encouraging him to do so. Julie gave verbal prompts to ensure that David took his phone with him and had switched it on before leaving the house; these prompts were gradually faded out as the routine became established.

At this stage, one last issue emerged. Now that David had largely mastered the skills of using his phone, he needed to remember to always take it with him when he went out, so that he could contact Julie if needed. A solution-focused problem-solving approach was used to develop a strategy to help David remember to take the phone with him. The method David and the therapist selected involved creating a cue card as a reminder. When going out, he usually remembered to take his bus pass and his wallet, both of which he kept in the same specific place, so the cue card was placed in the same location. The card contained the mnemonic BMW, standing for Bus pass, Mobile phone and Wallet and had ‘I’m taking the BMW’ written on it. David first had to learn the mnemonic and this was achieved by Julie prompting him twice daily, with the prompts gradually faded out once David was reliably able to respond.

By the end of the intervention period, David, Julie and the therapist all found that David’s ability to use the mobile phone had improved considerably. David and Julie both rated his ability to use the phone as 7 out of 10, and the therapist as 8 out of 10. David’s ability and confidence continued to improve throughout the 6-month maintenance period, as he regularly practised his new skills. He still experienced occasional anxiety, but was much better able to manage it. In session 14, David and Julie both gave attainment ratings of 8 out of 10 and the therapist rated his goal attainment as 9 out of 10. Using predefined goal attainment descriptors, the therapist rated the goal as 100% achieved in both session 10 and session 14, as David was able to use the phone routinely to make and receive calls and return to the home screen when any difficulties arose, and in addition he was using the phone to send and reply to texts.

During the therapy, David and Julie also worked on David’s ability to use other appliances independently, and similar improvements were seen in these other areas. Julie gained some valuable new skills to help with learning and relearning, and during the course of the therapy she applied these to help David to learn to use the cooker and the washing machine, using compensatory strategies, such as colour-coding controls.

At the end of therapy, David said that his ‘fear has gone’. The anxiety around using appliances had considerably abated and he was much less afraid of making mistakes. David felt more confident to try things out and gain new skills, knowing that he could determine how to learn at his own pace. Julie felt that she had become more willing to allow him to complete activities at his own pace and was much more patient with him, which meant that there were fewer tensions between them.

Doris: staying safe and in control

Doris, aged 63 years, lived independently in an inner-city area. She had a large extended family, many of whom would call in during the course of each day. Doris said she had been experiencing memory problems for around 4 years, and these had worsened considerably over the past 2 years. She had been diagnosed with vascular dementia within the previous month. Her eldest daughter, Dawn, was the main carer and was very protective of Doris, being justifiably concerned about her safety. Dawn frequently expressed anger about other family members who she felt were not doing enough to support her. Doris also frequently dealt with her feelings of stress by expressing anger at Dawn and other family members.

Doris valued her independence and it was important to her to feel in control. She was worried about her difficulties with memory and decision-making, found that her thoughts were muddled and felt that she had trouble making herself understood. She often experienced feelings of fear, even panic, as if something awful was about to happen, and was especially anxious in new situations or situations in which something was expected of her. She used to be very sociable and outgoing, and enjoyed going into town or to the pub but was now uncomfortable in crowds and had almost completely stopped going out alone. Even going along the road to the local post office could produce feelings of panic, which Doris could not account for.

The therapist’s work with Doris focused largely on enabling her to safely remain in control and be as independent as possible, both in and out of the house. Doris readily adopted the problem-solving approach; she considered solving problems one of her particular strengths. One important consideration for the therapist was the discovery that Doris had struggled at school as a child and had never learned to read or write, other than her name.

Doris usually forgot to lock her door when she went out or went to bed, creating a security risk, and Doris and Dawn agreed that this was an important goal to work on. They, and the therapist, all scored current attainment at 1 out of 10. The therapist worked with Doris to rehearse the procedure of locking the doors, followed by telephoning Dawn to confirm that she had done it, using an action-learning approach. To stimulate this behaviour, visual prompts were created, consisting of a photograph of the door keys, and these were placed next to the front door, in the living room and at the top of the stairs where Doris transferred off the stair lift. Family members were asked to prompt Doris to lock the door whenever they were leaving at the end of a visit, and to telephone Doris at night to remind her to lock the door before going to bed, although this did not happen consistently. In session 10, Doris and her daughter both rated attainment as 6 out of 10 and the therapist rated it as 7 out of 10. All of these ratings increased to 8 out of 10 at session 14, and at this stage the therapist rated this goal as 75% achieved, as Doris was mostly locking the door independently but still required some prompting on occasion.

Doris used a cash machine at the local post office to withdraw money but found that this was anxiety-provoking and was unable to remember the PIN (personal identification number) she had to enter into the cash machine to retrieve her money, describing herself as ‘stupid’. She had written the number on a piece of paper and placed it in her purse under a clear plastic window visible on opening the purse. This was very unsafe, especially as she tended to misplace her purse. She was increasingly anxious about using her card and inclined to avoid going altogether. Instead, family members had started to withdraw money on her behalf. Current attainment was rated by Doris, Dawn and the therapist as 1 out of 10. Doris could recognise numbers and indeed was considered to be ‘good with numbers’, and the therapist judged that she was capable of learning the PIN to enable her to use her bank card independently, while removing the risk of financial exploitation. She herself was very motivated to work on this, as she found it important to be in control of her finances and saw this as a marker of independence. This was a sensitive area, however, for the therapist to work with, and one that required extra safeguards. The approach to be taken was discussed in depth with Doris, with her family and with the trial team. Doris was deemed to have the capacity both to choose the goal and to give an opinion about the proposed strategy; had there been concerns about capacity for these specific decisions, a best-interests decision would have been needed. It might have been possible to work indirectly through the carer, but Doris’s daughter preferred the therapist to work on this goal directly with Doris rather than providing her with strategies to assist Doris and guidance on implementing them. In weighing up all of these factors, everyone involved agreed that given the risks Doris was exposed to currently, sharing the PIN with the therapist represented a safer option and, in this instance, was the best way to proceed. Full details of the circumstances and the team’s discussions were also recorded in Doris’s clinical notes held by the NHS memory service.

To help Doris learn the PIN, the number was first changed to something that would be relatively easy to remember. Chunking the information meant that initially the first two numbers were learned using expanding rehearsal, followed by the second two numbers, and finally all four digits. Visual mapping of the numbers on the key pad was attempted using action-based learning to set up a habitual pattern of movement. By session 10, Doris and Dawn rated attainment as 5 out of 10, with the therapist selecting 6 out of 10.

The therapist introduced controlled breathing techniques that Doris thought she could put into practice quickly and effectively. Doris understood the principles of controlled breathing and was able to demonstrate the technique when relaxed, but found it hard to put the technique into practice when she was anxious. Dawn and Doris used solution-focused problem-solving to identify ways of reducing anxiety about going to the post office and fear of experiencing a panic attack; this included identifying the days and times when the post office was quiet and planning to go at these specific times, so that Doris could use her card independently without feeling rushed. A plan for graded exposure was followed, whereby Doris gradually increased the frequency of visits to the post office to practise using her card. By session 14, Doris could reliably remember her PIN, and Doris, Dawn and the therapist rated attainment as 10 out of 10, with the goal rated as 100% achieved. Doris continued to work on managing her anxiety about going to the post office.

Other work focused on ensuring that Doris remembered to have her mobile phone with her at all times so that she could be in contact with her family, while retaining her independence. Everyone was concerned that she might fall or otherwise need help and wanted to make sure she could summon help if needed. This was achieved by using visual prompts to remind Doris to take her phone with her when going out and return it to a designated place in the house when indoors. Doris made good use of these strategies and her family felt reassured about her safety.

The therapist spent time with Dawn to help her to understand and deal with Doris’s behaviour and to point her towards local resources for carers. As a consequence, Dawn established an extensive network to support Doris’s needs, identified some sources of support for herself and started to allocate time for her own needs. Dawn was very engaged in the intervention and provided considerable support with grading activity and prompting the use of anxiety-management strategies. Following the intervention, she felt that she had a better understanding of Doris’s abilities, and began to apply similar principles to other situations, such as helping Doris to create and use her own shopping lists using visual prompts, such as collecting and storing product labels. Dawn was very positive about Doris’s progress with goals, development of compensatory strategies and general increase in motivation, and felt that participation had been beneficial in terms of helping Doris to maximise goal attainment and maintain independence and well-being.

Doris and Dawn both felt that they had always been ‘problem solvers’ but they found the framework for solution-focused problem-solving used in the intervention particularly useful in that it gave consideration to what had worked in the past. This enabled them to identify and develop strategies to maximise Doris’s independence, self-efficacy and self-esteem and apply these to a range of situations, as well as bringing the family together to support Doris’s goal attainment.

Shahid: re-engaging with people and activities

Shahid, aged 77 years, had worked in marketing prior to retirement. He lived with his wife Sylvia near their daughter and grandchildren. He had previously been actively involved in his local community and an accomplished public speaker. He was a keen photographer but had not done any photography for over 1 year. Shahid had been diagnosed with Alzheimer’s disease around 2 months before joining the trial.

Shahid had lost confidence and had become anxious about engaging with people and activities. One reason for this was his difficulty with word-finding, which made it hard to engage in conversation. He sometimes had trouble finding the correct words to use, which interrupted his flow of speech, and this led to him feeling embarrassed and getting quite frustrated and annoyed with himself. Often Sylvia would supply the word for him, but sometimes she was unsure of the word he was searching for, leading to more frustration. He wanted to be able to speak fluently again, and in particular he wanted to find the right word during a conversation to enable him to participate. Shahid also wanted to take up photography again and meet up with other photographers. However, he was confused and unsure about how to manage the camera settings and lacked the confidence to try.

The therapist’s assessment showed that Shahid was able to carry out most activities independently but he had difficulty motivating himself or initiating activity, and occasionally needed reminding about self-care. He was worried and anxious about his poor memory and lack of concentration and had become quite withdrawn and reluctant to participate in social interactions.

The therapist’s work with Shahid focused on helping him to feel more confident about engaging with people and activities. The first priority was to help Shahid feel better able to find his words during a conversation and hence less anxious about engaging with people. Initially, Shahid and Sylvia rated his current attainment as 5 out of 10, whereas the therapist opted for 4 out of 10. This indicated that his ability in conversation was fair, but reflected his desire for improvement.

The therapist, Shahid and Sylvia developed a plan to tackle word-finding problems. This had several elements. The first involved effortful processing and errorless learning. Instead of supplying the missing word, Sylvia instead gave either a cue, such as the first letter, or a clue to help Shahid find the word, so that he was more likely to retrieve the correct word himself. The cues or clues were intended to be precise enough to prompt the desired word, increasing the probability that this would also be recalled in future; this provided a natural opportunity for errorless learning.

The second element involved providing support for naming everyday items and objects. Items around the room were labelled to encourage Shahid to associate each object with its name, and he practised naming both labelled and unlabelled items when requested by Sylvia. The therapist prepared a set of picture cards and Shahid practised naming the items depicted, with Sylvia’s help. As Shahid gained confidence with naming the objects, these activities were graded by gradually increasing the number of items shown in any one session and by presenting them at greater speed.

The third element was the use of word exercises. These were practised during the session and further examples were left for Shahid and Sylvia to practise between sessions. Several different types of exercises were used, including supplying missing words in a sentence, providing antonyms or synonyms, listing items under a given category (e.g. modes of transport), identifying similarities and differences between pairs of words and answering comprehension questions about short stories.

The fourth element involved devising specific strategies for particular words or types of words. Shahid developed mnemonics and used expanding rehearsal within an errorless learning framework to remember specific words that often eluded him.

Shahid seemed to enjoy focusing on word-finding and doing the various exercises, and he made good progress. Sylvia became adept at providing cues or clues whenever he was unable to retrieve a word. By session 10, Shahid felt much better able to engage in conversation, and he no longer saw word-finding or engaging in conversation as a problem. Shahid and Sylvia both rated his attainment as 8 out of 10. The therapist observed that his conversation was much more fluent and rated his attainment as 9 out of 10. Shahid kept up his progress and the ratings made in session 14 were identical. The therapist rated the goal as 100% achieved in both session 10 and session 14, noting that Shahid was more confident about his word-finding ability and was usually able to find the necessary word and able to continue a conversation.

During the therapy, Shahid also worked on re-engaging with his interest in photography. There were technical issues with managing camera settings and using digital cameras, and Shahid preferred to discuss these with his son rather than with the therapist. The therapist’s role was to encourage Shahid to persist with solving the problems. The eventual solution was to provide Shahid with a phone that had a good-quality camera and was easy to link to his computer and TV screen to download and show images. This did enable Shahid to take photographs, and the good results that ensued gave him confidence and motivated him to continue. Holidays and visits to family provided interesting photographic opportunities, and he was able to produce some good photographs. Ratings of attainment improved from 2 at the start of therapy to 8 in session 10 and 9 (Shahid and Sylvia) or 10 (the therapist) in session 14. The therapist identified this goal as 75% achieved by session 10 and 100% achieved by session 14.

Shahid also developed his use of compensatory strategies, such as using a calendar to remember appointments, and began to carry a small notebook in his pocket containing a daily ‘to do’ list. This increased self-determination was mirrored by Sylvia offering prompts rather than doing things for him. He learned a strategy of intentional chanting for times when he might get distracted or interrupted, for example when going upstairs to fetch something, and practised various anxiety-management strategies before settling on using music to calm himself. He managed to motivate himself to clear his computer room and make space for working on his photographs, and this increased motivation also extended to getting other tasks done around the house. Shahid and Sylvia both became more active, developing a routine of playing golf once a week and going for a walk together once a week.

Gareth: managing everyday challenges

Gareth, a 71-year-old widower, had retired from a skilled technical job a few years previously. He lived independently and kept in contact with his daughters and grandchildren, mainly by telephone, although they lived nearby. Gareth had been diagnosed with mixed Alzheimer’s disease and vascular dementia 3 months before joining the trial. He also had some other health problems, which meant that he needed to eat regularly and keep to a healthy diet, and which limited his physical ability. His main source of support was his eldest daughter, Ginny.

Gareth was troubled by difficulties with concentrating, planning and organising his activities, remembering appointments, remembering things he needed to do, such as taking his medication, and finding key items, such as his keys, wallet or phone. His strategy of using a Dictaphone to record notes and messages was only partially successful. These difficulties were making it hard for him to complete everyday tasks independently and safely, manage his health problems and participate in social events. Gareth was particularly frustrated by his difficulties with planning and the impact these were having on his everyday life. He and Ginny identified some basic everyday skills in which improvements would help him to maintain independence and reduce the need to rely on Ginny. The therapist’s assessment showed that although Gareth had the potential to manage many activities and tasks independently, he needed some practical guidance and support to enable him to function optimally.

The therapist’s work with Gareth focused on improving everyday skills to support his independence. The first priority was cooking. Gareth prepared his own meals, but tended to lose track of what he was doing and forget that food was in the oven. This meant that food was often burnt and inedible. To make matters worse, Gareth had lost his sense of smell, so that he could not detect the olfactory cues associated with food overcooking. Gareth often felt tired and would leave the kitchen to sit down comfortably while food was cooking, but he was hard of hearing, so that if he was not in the kitchen, he did not hear the oven timer. In addition, he often fell asleep while waiting for food to be ready and then woke up feeling confused about what he had been doing or what he needed to do. When Gareth was in the kitchen, his tendency to lose track meant that he often picked up trays or plates from the oven without realising that they were hot and burnt himself, and there was a risk of the gas hob being turned on but unlit. Because of these difficulties, Gareth was limiting the extent to which he cooked for himself, either eating out, which was proving to be too expensive, or just having snacks. Gareth was keen to manage his cooking better and Ginny was very concerned about his safety, wanting to make sure that he was able to eat a healthy diet without hurting himself or setting fire to the kitchen. Gareth, Ginny and the therapist rated Gareth’s current ability in cooking his own meals as 4 out of 10.

The strategy that Gareth and the therapist devised involved two main components. First, Gareth was encouraged to focus his attention on the process of planning the meal and to work through a series of steps, reading the food packaging, writing down the cooking instructions, listing what preparation was needed and then recording what time the food went into the oven and when it was due to be ready. For this, Gareth used a whiteboard in the kitchen. Second, a portable timer was introduced to provide an auditory cue to check the oven at the appropriate time. Gareth learned to take the whiteboard and timer with him when leaving the kitchen, so that he would be able to hear it if he was in another room or if he fell asleep. Gareth opted to set the alarm to go off shortly before the food was due to be ready as this gave him time to get to the kitchen.

One additional practical change that the therapist recommended and Gareth and Ginny followed up was to purchase a halogen worktop cooker that turned off automatically, to remove safety concerns about leaving the gas on. This was intended to replace using the oven as it had a built-in timer and so turned itself off and ‘beeped’ when done. Gareth had no difficulty adjusting to using this and was able to demonstrate to the therapist how it worked. The therapist also involved telecare for an assessment of gas safety and provision of additional sensors, over and above Gareth’s two functioning smoke detectors.

Gareth could see an immediate improvement as a result of using the whiteboard and timer and readily adopted the use of these aids. By week 10, he was cooking meals safely without burning the food. He now cooked for himself at home most days. Having got used to the halogen cooker, Gareth gained confidence in using the hob to boil vegetables and rediscovered how to use the microwave. At both session 10 and session 14, Gareth rated his current ability as 7 out of 10, Ginny rated it as 6 out of 10 and the therapist rated it as 8 out of 10. The therapist rated this goal as 100% achieved in week 10.

A second area of concern for which similar strategies were adopted was remembering to take essential medication. Gareth had to take medication both in the morning and in the evening and, although he usually remembered his morning regime, he often forgot his evening medication, especially when he had been out during the day, potentially putting his health at risk. Some tablets were in a blister pack, but others were not, which made it harder to determine whether or not a dose had been missed. Usually one of his daughters would telephone to remind him, but this was not always possible and was proving stressful for the family. Gareth rated his current functioning as 5 out of 10, Ginny rated it as 6 out of 10 and the therapist rated it as 3 out of 10.

The strategy adopted had several components. First, a specific ‘workstation’ was set up on a table in the living room as the special place where medication would be taken. This was clearly visible from Gareth’s favourite chair, as this was where he usually went to take his tablets. The medication was placed permanently on the table along with a bottle of water, so that Gareth would always be able to see his medication and would not be distracted by leaving the room to get a drink of water. An attempt to link evening medication with an established routine, such as watching the 6 p.m. news on television was trialled, but this was not effective, as Gareth often went out in the evening, especially in the summer. As an alternative, an alarm clock was set for 7.30 a.m. and 7.30 p.m. as an auditory cue to remind Gareth to take his morning and evening doses. Gareth chose the timing of the alarm himself as the one that best fitted with his routine, and the therapist taught Gareth to respond to the alarm clock cue by taking medication at the appropriate time. To adapt the strategy for use on days out, Gareth’s mobile phone was also set to give an alarm at 7.30 p.m., and if going out, Gareth took his medication with him in a small container. Gareth found the strategy very useful, and when the alarm went off he would only cancel it after he had taken his tablets, to ensure that he did not get distracted. The therapist rated this goal as 75% achieved in week 10 and 100% achieved in week 14. Gareth rated his current ability as 8 in week 10 and 9 in week 14; Ginny’s ratings were 7 and 6, respectively, and the therapist rated his ability as 8 and 10, respectively.

During the intervention, Gareth also worked on other areas with the therapist, including remembering names of family and friends, staying engaged in conversation and improving attention. He became anxious when confronted with tasks, events or activities for which he was not prepared; to manage this better, the therapist introduced the idea of using a wall calendar to write down appointments and messages and a notebook for details. The therapist modelled the use of these aids and enabled Gareth to incorporate them in his daily routine. Gareth himself used the problem-solving approach to tackle other challenges, such as keeping his paperwork in order, organising telecare documents and managing his financial information. He used filing boxes and made lists, and he reviewed things weekly with Ginny to make sure everything was as it should be.

Gareth tended to get bored on his own at home and this was another area that the therapist focused on. Gareth’s usual strategy for dealing with boredom was to go out for a drive but he did not like to drive in the dark or when the weather was bad. The therapist worked with Gareth to identify activities he could do at home to occupy himself in the evenings or during bad weather. Gareth was also encouraged to practise using public transport, to prepare for a time when driving may no longer be feasible, and he began to try using the bus instead of driving. As Gareth often felt lonely, the therapist introduced him to the local Alzheimer’s Society branch and he started to attend their groups and activities, which he engaged with enthusiastically, feeling that his social life had been greatly improved.

Gareth embraced the CR intervention, was enthusiastic about adopting a range of compensatory strategies and integrated these very effectively into his daily life. He enjoyed working with the therapist and thought that he would miss the regular visits. Ginny and his other daughters were equally enthusiastic and willing to try new ideas. They all gained skills in problem-solving and developing new strategies and felt able to manage daily challenges better.

Concluding comments

These four typical case studies taken from the therapy logs compiled by GREAT therapists illustrate the types of goals participants chose and the way in which participants, carers and therapists worked together to apply a problem-solving approach and to develop strategies to enable participants to improve their functioning and attain their goals. They are consistent with the findings from the qualitative analysis of interviews with participants and carers. These emphasised the key importance of the relationship with the therapist as the vehicle for change and the time taken to understand needs and develop personalised strategies.