A "small group" approach to Alzheimer's care; residents and staff benefit from this unusually structured SCU.

As the Small Group Program, designed at Sunset Manor Alzheimer's Care Center in Brush, Colorado, nears its third anniversary, it is exciting to see how far we have come. The past three years have brought Alzheimer's care from simply an approach to an attitude, an attitude of being a friend first, a caregiver second.

The Small Group Program facilitates the "friend first" attitude. Each Small Group consists of eight residents in the middle stages of dementia and one consistent group leader. The group leader is responsible, foremost, for the social and emotional well-being of their residents as well as for their grooming and personal care. This may sound like double-duty, and in many ways it is. However, friends understand needs and find ways to meet them.

Program Structure

The day begins with social interaction, grooming, and exercise, and continues with facilitated social dining, small group activities, assisted interaction in large group activities, and one-on-one times together. The thread that ties the day together for the residents is the group leader who provides the cues for moving from one activity to another. In many cases, interaction with the group leader is the main focus of the activity.

The structure of the day is supplied by scheduled times for gathering in groups. However, periods of quiet, visits, and individual walks are key elements in the climate. The schedule is structured, but group leaders modify it as they need with additions and deletions. The main constants in the program are change and the ability to adapt.

Criteria for Resident Selection

The most important criteria for resident selection for the program remains their ability to benefit from the Small Group structure. An interdisciplinary team makes this initial decision.

Because group leaders are skilled at adapting activities to allow residents to be successful, most residents benefit from, and are able to be included in, the Small Group Program. If a resident needs the safety of a secure unit, they usually also need the structure of the Small Group Program.

Program Objectives

Five main program objectives were established and are maintained, primarily through the attitude and climate of the unit:

* Provide residents with opportunities to succeed and build their sense of self esteem and dignity. It is easy to provide residents with opportunities for success because the definition of success is tailored to the individual.

* Maintain a restraint appropriate environment. A restraint appropriate environment is achieved through affording the resident the freedom to express frustration in an acceptable manner with a caring person present to maintain their safety and that of others. The main premise for intervening in any situation is the answer to the question, "Do I really need to intervene here?"

* Provide a supported social environment for interaction and for bonding. The social environment is fostered in every facet of the day. Social responses are often retained after other skills are lost. The comforting, "I want to be here with you" attitude is a winner.

* Integrate residents into a psychosocial rather than a task-oriented mode of care. Rather than being something done for them, the tasks of daily living become activities the resident can participate in. While participation may be as limited as simply holding the comb during personal grooming, the resident is involved in his or her daily care.

* Increase the caregivers' level of job satisfaction and provide them more opportunities for success. Increasing the caregivers' level of satisfaction is an added benefit for everyone. Successful group leaders like what they are doing. Because they know their residents better than anyone else in the facility, they are able to advocate for their needs, comfort them when confused, and help families appreciate what their loved one is capable of doing.

Having responsibility for only eight residents makes the job manageable. And having the opportunity to develop activities and see them succeed makes caregiving rewarding. Group leaders plan how they will spend the day with their group and supervisors help make it happen. Families get to know the group leaders and go to them when they want to know how "Mom" is doing.

Caregiving is a difficult job, but a rewarding one. Where else can you walk down the hall and always find a hand to hold, always find someone who wants to be with you, and always be assured you have made someone feel safe and more comfortable?

Training and Orientation

Group leaders receive a basic eight-hour orientation to Alzheimer's disease including insight on how to communicate with the memory impaired as well as how NOT to communicate with them. Orientation is followed, with training specific to the Small Group Program and additional emphasis on behavior intervention and communication. If communication is not effective, the resident remains locked in his or her confusion, so this skill is paramount. Because it takes time to communicate effectively, supervisors provide group leaders with this additional time.

Group leaders must learn to read their residents' moods and feelings when word-finding ability is impaired. Leaders are encouraged to know the histories, likes and dislikes of their group members, and what works with each person so interactions can be consistent.

Group leaders are trained to lead activities and given tips to facilitate participation. The type and tempo of an activity may change three times within an hour. Fitting all this into an even flowing day is an ongoing challenge.

Frequent meetings are held where group leaders share successes and ask for help in problem solving. These meetings play a critical pan in developing and maintaining the attitude and climate of the unit.

Change Within Structure

The changing nature of the disease dictates change within structure. As the program developed, we quickly learned that the residents really do set the direction of the day. We have relaxed our expectations, realizing that brief periods of involvement meet the needs of some residents. The important thing for them is having a purpose and a place to go. The program is truly resident-driven. The staff and facility adapt to residents' needs. This does not happen without complications, but once the attitude of "friends first" is adopted, compromise comes more easily.

Since May, 1992, Living Centers of America has been helping facilities develop Small Group Programs. Of LCA's 44 facilities with Alzheimer's units, 20 are in varying stages of implementing the Small Group format. We have learned that each facility and each unit puts its special touch on the Small Group Program and makes it their own.

The unit coordinator is a key player in each facility. The background of the unit coordinator may vary from experience in therapeutic activities or gerontology to nursing or Alzheimer's care, but their enthusiasm and commitment make the program happen. They believe in the benefits of the program and assist, encourage, relieve, and applaud the group leaders. Nursing and activities work hand in hand and administration opens doors.

Continuing Developments

We believe we have something quite special to offer to persons suffering the overwhelming losses of Alzheimer's disease and continue to strive to find new ways to help the days flow more easily for them.

The staff at Sunset Manor recently took another step forward with the development of the Team Program for residents requiring higher levels of care. Because these residents are more comfortable with lower key activities and gentle, sensory interactions, team leaders concentrate their activities during morning hours, with fewer scheduled activities and a posted quiet time in the afternoon. There is less emphasis on gathering together and more emphasis on meeting the residents where they are.

The Team format has its own personality and leaders look at success differently. If residents appear relaxed and physically comfortable, that is counted as success. The response of a family member to the resident' s condition is often shaped by the resident' s appearance. Family members feel more confident in the quality of care and appreciate the extra effort expended to bring comfort to their loved one.

While each team leader is responsible for eight residents, two leaders "team" together to provide care. This is especially helpful with the physically demanding care of non-ambulatory residents and with those who are uneasy during personal care. Team leaders have enthusiastic involvement in the direction of their program and a commitment to the Team format.

A Segment of the Rainbow

The benefits of the Small Group Program are measured individually and day-to-day. Overall, the environment is relaxed, adaptable, comfortable, and predictable through the consistent flow of the day.

The people who devote their lives to Alzheimer's care generally receive as much as they give. They see those rare glimpses of their residents as the people they once were and learn to know and love the special people they are now. It is only a segment of the rainbow, but to someone with a disease that takes away most of the life they have known and to their families, that segment is enough.

Linda Henry is a specialist in Alzheimer's care and was instrumental in the development of the Small Group Program at Sunset Manor Alzheimer's Care Center in Brush, Colorado. She currently works with other Living Centers of America facilities in the implementation of this program in their Alzheimer's Care Units.