Pioneering Change

Activities for Residents with Dementia
Education Module












to
Promote Excellent Alternatives in Kansas               Nursing Homes
Table of Contents

ACTIVITIES FOR RESIDENTS WITH DEMENTIA		

Course Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..3
Pretest . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Introduction . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
		Case Study: The Court at Overland Park. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Resident Needs . . . . . .  . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
		Attachment . . . . . .  . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
		Comfort . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
		Identity . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
		Occupation . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
		Inclusion . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Meeting Needs . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
		Case Study: The Rest of the Story   . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9
Individualize . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Engagement . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 		Activity: Label Game for Staff . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Staff Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
		Activity: Recognizing Potentially Harmful Interactions .. . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Contrasting Styles . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
		Larksfield Place . . . . . .  . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
		Meadowlark Hills . . . . . .  . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
We Need Ideas . . . . . .  . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Drama Therapy . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Art Therapy . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Time Slips . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Music Therapy . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Montessori . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Multi-Sensory Stimulation Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .26
		Snozelen . . . . . .  . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
		Namaste . . . . . .  . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
		Labyrinth . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
		Activity Boxes  . . . . .  . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Activity is Life . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 
Don't Forget the Family . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Conclusion.  . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31  Post-Test . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Pre-Test & Post-Test Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Appendix A . . . . . .  . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
References . . . . . .  . . . . . . .  . . . . . . . . . . . .  . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

 																														





















Course Objectives


1.)	To develop an understanding of the importance of meaningful activity for people with dementia.

2.)	To create an awareness of the needs of people with dementia and how meaningful activity can help fulfill these needs.

3.)	To demonstrate the outcomes related to various activity programs.
Pretest

The pre- and post-tests included with this module are optional.  The questions provide information about the materials to be covered and can be used for learning self-evaluation.  At some future date, these tests may be used as a part of a continuing education requirement.  Some questions may have more than one answer.

1.	Snozelen is a program designed to stimulate the senses by incorporating all of the following except:
	a.	music
	b.	lighting	
	c.	fire
	d.	textures

2.	Psychological needs of residents with dementia include:
	a.	money
	b.	fame
	c.	security
	d.	social connectedness

3.	Pacing, rocking back and forth, tugging on clothing, and physical aggression may indicate the resident has unmet needs.
	a.	True
	b.	False 

4.	Which of the follow statements about the disruptive behaviors displayed by residents is true?
	a.	Disruptive behaviors are entirely caused by dementia
	b.	Disruptive behaviors may be signals of unmet needs or boredom
	c.	Disruptive behaviors may be reduced through meaningful activity
	d.	Disruptive behaviors should be ignored and will go away

5.	Which of the following is not an example of a potentially harmful resident staff interaction?
	a.	ignoring
	b.	mocking
	c.	prompting		
	d.	restraining

							Answers Found on Page 34Introduction

Case Study: The Court at Overland Park

"Mary, can you say the alphabet backwards?" "ZYX.........." Mary replied before the rest of us in the room could even think about where to start.  As residents sat in the community room reciting poetry, playing the piano, singing and reminiscing about the various facets of 1958, the interaction that occurred between the residents and their interest and enjoyment of the activity was amazing.  Upon completion of a dazzling rendition of Summer Time, residents applauded Jane and talked about her beautiful voice and her experiences as a singer. Residents asked one another questions and carried on complete conversations without any participation of staff. Looking around the room filled with about 20 residents, only one or two were not focused on what was taking place in the room. The activity director was there to provide direction, topics, prompts and a lot of praise as residents shared answers and stories. She asked residents questions about their families, their careers, and their hobbies. She seemed to be reminding them of moments in their lives they really enjoyed.  

The activity program at The Court at Overland Park, an Emeritus Assisted Living Community, is structured and residents are engaged in a variety of activities throughout the day.  Activities begin after breakfast and continue throughout the day.  One of the care goals at The Court is to have residents engaged and out of their rooms the majority of each day.  The activities include reminiscing, exercise, music, art, gardening, and poetry.   Activities are centered around the long-term memory of residents and are provided in the same format each day because staff members feel the residents do better when they have consistency. Residents are so familiar with the daily routines that they prompt one another and ask questions about the day's activities. Staff attribute the resident engagement to knowledge of each resident as an individual, and using that knowledge to draw out residents during interactions.  The activities are primarily conducted in a community room with a large group of residents.  There are also one-on-one and small groups for those whose needs are better served by this programming.  Staff feel keeping residents connected with their families and the community is essential for keeping normalcy in their lives.  In addition to regular visits, family BBQ's, parties, dances, and open houses are a few events family members look forward to attending.   Residents take weekly trips to eat at local restaurants and can be found shopping and at community events all over the Kansas City area.  Entertainers, as well as volunteers from the community are in the home frequently making cookies, singing, teaching or visiting.  On a recent visit to The Court at Overland Park, a PEAK-Ed staff member had the opportunity to join a group of 10 for lunch at a local restaurant.  Residents looked over the menu and decided what to order. A few residents created a lot of conversation by trying the hot peppers on their sandwiches!  Conversation and laughter filled the area as the residents enjoyed good food, friends and conversation. 

On the first visit to The Court at Overland Park in Kansas, one is amazed by the level of engagement of the residents both with one another and the activity.  It  even leads one to question if these residents have dementia.  The Court at Overland Park is a memory care community offering residents an assisted living environment.  Residents vary widely in age and ability.  They have various forms of dementia, many are in the advanced stages.  While these residents do not have some of the physical health care needs that  those in skilled nursing have, the need and ability to be engaged is the same. 

**Names have been changed to protect the resident's identity.

While many nursing homes have special care units designated for those with dementia, the reality is that an estimated 50% of nursing home residents have dementia (Hebert et. al, 2003).  Some suggest, based on experience, that this number is as high as 80% (Simard, 1999).  Since so many of the individuals being cared for in nursing homes suffer from dementia, the need to understand the factors related to quality of life and meaningful activity for these individuals is a critical issue that goes beyond the "unit."  All staff members must be prepared to provide for the psychosocial needs of these residents.  "Providing opportunities for quality engagement and expression for individuals with dementia is vital in any setting involved 
in supporting their quality of life"  (Huberty, 2006, p49).
Resident Needs

Many nursing homes have reported to PEAK about the difficulty in providing activities for residents with dementia because the residents become difficult to communicate with, combative, drowsy and disruptive. In order for staff members to provide for the psychosocial needs of residents, staff members first need to understand that these behaviors are not always a product of dementia. These behaviors may be the result of boredom, loneliness or lack of self-expression (Huberty, 2006).  It has also been suggested that other behaviors, such as repetitive body movements, rubbing parts of the body, twisting items of clothing, rocking or pinching are forms of self-stimulation to maintain a person's psychological self (Kitwood, 1997).  Nursing home residents spend 60-80% of the hours they are awake with nothing to do.  Research has shown that this is the time that most of the disruptive behaviors occur (Cohen-Mansfield &Warner, 1998).  Conversely, residents who have been engaged in meaningful activities have increased socialization, higher self-esteem and improved health outcomes (Clark-McGarth, 2004).

In the nursing home setting, the problems associated with residents who have dementia are often magnified because both the physical and social aspects of the environment may fail to provide the necessary support (Kitwood, 1997). When staff members begin to view resident behaviors as clues to the person's unmet need(s), staff members are in a position to discover ways to meet those needs, help the resident thrive and make interactions with residents more meaningful.  In order to begin to identify unmet needs, staff must first have an understanding of those needs. The psychological needs of people with dementia are similar to those of other individuals. They include:  attachment, comfort, identity, occupation and inclusion (Kitwood, 1997). Dementia can make these needs more difficult to fulfill.  All of these needs, which are described in further detail below, can be enhanced by meaningful activity.   

Attachment is the human need to be connected to someone or something familiar.  With dementia, people often feel like the environment around them is strange, giving them the need to be connected with someone.  In the perspective of activity, this might include the same person frequently engaging in familiar tasks with the resident.

Jerry and Matt sit down every weekday morning to read the local newspaper.  During this interaction they develop a friendship, and Jerry feels like he can count on Matt to be there for him.  Jerry is happier because he has his morning routine back and has a connection with Matt.

Comfort can be looked at as a way to provide support for someone when they are in need.  Building relationships with residents can be a source of comfort in their lives, and lets staff members know when the resident needs more support.  By modifying activities to fit the needs of the resident, staff can provide the resident with an opportunity to continue to take part, also providing them 
with the security needed to feel comfortable after having lost some abilities. 
One afternoon, Sara sat down with Gerri ready to engage in another checkers match.  Gerri has always loved checkers. During the game, Gerri seems to be having trouble handling the pieces.  She becomes upset and says she does not want to play anymore.  Sara knows that Gerri really enjoys the game and does not want her to have to give it up, so she makes a larger game board and pieces so Gerri can grab and maneuver them more easily.  When Sara asks Gerri to join her for another game she refuses, but after some encouragement and a preview of the modified game, Gerri decides to try again.   

Identity is the knowledge of self as well as others' knowledge of us.  When residents in the nursing home are not provided with activity that is individualized, their identity and what makes them special is lost to the routine of the home, causing the person to become institutionalized.  While there may be changes in the person physically, most research indicates that there are few changes in personality. People are typically consistent across the lifespan even when compromised by dementia.  To maintain resident identity, staff must know things about the resident's past and present, as well as be empathetic to their current situation.  

When Hazel first arrived at Mountain View Manor she seemed lost.  She wandered up and down the hallways like she was looking for something.  Staff tried to engage her in a variety of activities, but she was not content.  One day a lady came to visit Hazel.  As she was leaving, one of the staff members stopped her and asked if she had any idea what Hazel might enjoy doing.  The lady replied, "She was the school secretary where I used to teach and she liked being busy."  During a team meeting staff members discussed the types of things Hazel might have done when she was a secretary.  They decided she might enjoy typing or even helping a little in the business office.  Hazel now spends a little time each week with the business office staff, working on an old typewriter that a staff member donated.  

Occupation is not a job or career.  It deals with finding something that is meaningful in a person's life and making sure they have opportunities to participate in this activity. When residents do not have this type of engagement they begin to lose self-esteem and become bored. In order for staff to provide for a resident's need for occupation, they must have knowledge of the person. 

Carl spent his days napping in a chair.  He had little interest in doing anything.  As time progressed, he became more discontent.  Some of the other residents thought he needed something to do. They invited Carl to join them when they fold napkins for dinner.  He really enjoyed folding napkins and even took some back to his room to work on later.  Carl may not always fold the napkins in a conventional way, but he takes great pride in seeing people use the napkins he folded. Carl has always enjoyed doing things to help others. This was his opportunity to do something for others.

Inclusion deals with the need to be in contact with others.  As residents' disease processes take hold they are often slowly isolated from their social network.  When residents are not 
provided opportunities for involvement they may pull away even more.  

Peter spends most of his time in his room.  He has trouble communicating and has to have help to get out of his room.  Since he is difficult to move and does not interact well with the other residents, the staff have been doing one-on-ones with him in his room.  Lately he seems to be avoiding eye contact with staff members and does not even acknowledge they are with him.  After attending a training session, a staff member thinks that he could benefit from being around others.  The staff member begins by bringing another gentleman who has a shared interest in fishing into his room to watch and discuss a fishing program on television.  After a few interactions like this, the staff member begins to see a sparkle in his eye again.  Now, he joins several of the groups related to his interests.  He cannot communicate verbally, but his smiles and gestures show he is enjoying the interaction. 


Meeting the Needs

"The primary basis for resident support is the focus on positive, nurturing care that will validate the resident as a worthy human being" (Hellen, 1992 p. 7). One nursing home administrator noted that as the home has progressed on its culture change journey and is applying person-centered care, a decline in the number of "slumpers" has