Activity Based Alzheimer Care In the Residential Care Facility*
by Catherine Harris PhD, RNCS
Activities are the foundation of Alzheimer care. Every event, interaction or procedure is an activity. It may be an outing, a backrub, a dance or a meal. The principle involved is one of focusing on the person’s retained capacities, flexibility in planning and grading activities to their level of functional ability. Activity Based Alzheimer Care is a philosophy and method of activity developed by expert activity therapists such as Jitka Zgola and Sylvia Nissenboim. The Alzheimer’s Association proposes this philosophy and its operational guidelines as an optimal approach to the everyday care of individuals with Alzheimer’s disease. What this means is that every aspect of care or interaction with an Alzheimer person is viewed as an activity and principles of assessment, planning, implementation and evaluation are integral components.
Planning of an activity starts with an individual assessment that includes life style, interests, and level of functional ability. An activity program requires teamwork, not only of direct care staff but also of clerical, maintenance, dietary staff and families of the person. The idea is to promote a family atmosphere where anyone in the vicinity could interact or participate in the activity.
Any activity must also be evaluated for effectiveness and benefit to the individual. Because Villa Serena residents come from a wide variety of backgrounds with different interests and abilities, it is essential to evaluate their participation in activities on a regular basis. This means to assess activity participation as it is in progress for residents showing fatigue, frustration or agitation and attempt to ascertain the cause of the distraction. It also means to evaluate the activity program through more comprehensive means such as team meetings with staff and families.
STRUCTURE VS. FLEXIBILITY
Persons with Alzheimer’s disease lack organizational ability and function better when there is structure to their surroundings and daily schedule. Plans must evolve from the individual needs and abilities. At the same time, the needs and abilities of other residents, staff and events in the environment must be accommodated. A general structure for the facility that is adaptable to individual differences is most beneficial. An activities program must also adapt to changes that occur in the weather, available equipment, resident and staff health and family visits. These will affect activity plans, whether it is mealtime, an outing, or gardening. Two methods address these seemingly opposing guidelines: Cluster Programming and Activity Grading
Cluster programming refers to a method of assigning residents to an activity based on their functional ability and social skills. An assessment is made of a resident’s abilities, skills and interests and they are invited to join a cluster group based on similar interests and abilities. Activities are rated according to the resident’s ability to tolerate social contacts. The greater the social skills, the larger the group can be.
Examples of cluster groups include: highly sociable, special needs, or one on one intervention. Activities for each cluster group would be planned based on the preserved abilities, interests and social responses of the resident. An individual, who is highly sociable, has good attention span and is able to tolerate considerable noise and interaction could be included in a large group with a more complex activity.
Someone who is only mildly sociable with poor attention span, has a need to pace and easily becomes anxious, could benefit from a smaller group and activities that are physical. Physical activity will reduce the need to pace and promote mastery. Of course, any activity should provide the best opportunity for persons to succeed and feel good about themselves.
Residents may have similar interests but different abilities. Including all interested persons in the activity can be done through activity grading. This means that a resident participates in the activity – any activity – at the level they are capable. It preserves the opportunity of an individual to be included in an enjoyable activity but doesn’t tax or frustrate them with tasks that are too complex. For example, a higher functioning resident may help to mix ingredients for cookies, while a resident with less coordination may listen for the timer to go off. A list of gradients for the task of making cookies may look something like this:
Independent organizer and doer*
Decides on cookies, plans, shops, chooses recipe, bakes
Makes cookies once the ingredients are prepared
Doer of a specific task
Measures, mixers, or pours, depending on ability
Doer of a modified task
Does a repetitive task with help or supervision
Listens for the oven timer to go off
Tells of own experiences
Tastes the cookies
Watches or listens
Zgola has identified three types of activities for Alzheimer residents. Self Care activities include bathing, dressing, grooming, eating and toileting. Productive activities could be folding towels, cutting up vegetables for a salad, gardening or bed making. Leisure activities involve dancing, listening to music, watching a special program on television, an outing, or simple quiet contemplation. The need is to provide reasonable activities that are as near to normal home life as possible and that will give the resident a sense of accomplishment and success. Regardless of the personal level of ability, it is important to plan activities that ensure success and pleasure and maintain cultural identity and self-esteem. Activities can also improve large and small muscle coordination, build physical strength and endurance, enlarge the resident’s social worlds and maintain optimal mental function. Activities need not all be productive, but can include those which are fun and purely frivolous, even silly, promoting laughter and gaiety on the part of staff and families as well as residents.
Appropriately planned and implemented, activities can decrease restlessness and challenging behaviors while at the same time assuring safety, comfort and physical and mental health. However, it is extremely important not to overload Alzheimer residents with too many, too complex, and too long periods of activity. People with Alzheimer’s disease have a lowered stress threshold and can tire and become fatigued easily. This can cause frustration and anxiety leading to agitation and other behavior manifestations. Activities must be interspersed with rest, snacks, or simply passive activity such as watching others in an activity.
In conclusion, LightBridge endeavors to promote understanding and implementation of comprehensive voluntary activity programming that is affirming of dignity, communicates purpose and meaning, reinforces strengths, not inadequacies, and holds opportunities for success. In any care facility we believe it is critical to encourage families of residents to assist in planning activities and to participate in activities at whatever level is possible for them.
*Adapted from the training manual: Activity Based Alzheimer Care: Building a Therapeutic Program. The Alzheimer Association, Chicago, IL.