An activity program for the cognitively impaired.

This facility brought disciplines together to solve the problem

Cognitively impaired, low-functioning residents need structured activity programming to meet their psychosocial needs. When these needs are not met, undesired behaviors can result, including verbal outbursts, rummaging, pillaging, agitation and depression. Despite our having a comprehensive activity program at our 220-bed facility in Tacoma, Washington, some residents from the general units display these behaviors daily, necessitating a new management approach.

It is known that utilizing known methods of activity-focused care - including cueing, validation, refocusing, redirecting and retreating - in a structured environment can diminish anxiety and agitation and increase resident satisfaction.[1-3] Further, with a lessening in anxiety and the potential for catastrophic reactions, some resident-versus-resident altercations have been reduced. With this in view, the Tacoma Lutheran Home (TLH) Dementia Education Committee proposed an Interdisciplinary Activity Program (IAP). As an interdisciplinary team, the departments of Resident Services (which includes Activities and Social Services) and Nursing were responsible for the program's development, implementation and evaluation.

The program is located in an existing modern lounge with large windows and bright furnishings. The program runs from 9 a.m. to 4 p.m., Monday through Friday. The program director is the Director of Resident Services, and the committee members include individuals from Nursing, Activities and Dietary departments.

The types of residents who benefit from this structured activity program include those with a Global Deterioration Score (GDS) of Stage 5 to 6[4, 5] or a Mini Mental Score of 5 to 20.[6,7] Wheelchair-bound residents are eligible. Those with violent behaviors or tendencies are not allowed in the program or are returned to their unit for other options if their behavior becomes unmanageable.

Though the room accommodates 14 residents, the program is designed for up to eight regularly scheduled, preselected residents who have been assessed and qualify for daily participation. "Drop-ins" are welcome for selected activities or for a certain length of time. The staff-to-resident ratio is no more than seven residents per assistant. Daily activities include coffee hour, baking, rhythm band, bowling, pet therapy, movies, "glamour girls and guys," sing-along, bingo and sensory stimulation. A monthly calendar of times and events is posted outside the room.

A generous donation provided the program with a video cassette recorder, small portable stereo, activity equipment and additional wall hangings for the room.

One full-time employee (FTE), budgeted as one-half Resident Services, one-half Nursing, has been hired to run the day-to-day program offerings. Current modified-duty certified nursing assistant (NAC) staff are rotated into the area for a period of two to four weeks. These individuals do not work their regular schedules or units, but work Monday to Friday, 8:30 a.m. to 4 p.m. as the second assistant in the IAP. If there is no nursing staff on modified duty, current NACs and our student Nursing Assistants are rotated into the program on an as-needed basis.

The program opened its doors February 3, 1997. As of four months later, seven regularly scheduled residents had participated on a daily basis and over 925 "drop-ins" had enjoyed activities in this therapeutic environment. Of the originally selected individuals, one had behavior that could not be managed and was dropped from the program and subsequently referred to an outside agency where his needs could be better met.

Objective data disclosed during the initial resident assessment included: (a) inability to initiate purposeful activities, (b) decreased or inappropriate social interaction, (c) inconsolability at times, despite validating, refocusing or redirecting, (d) limited physical ability, (e) long-term care placement, (f) verbalized feelings of abandonment, (g) deteriorating cognitive process (as evidenced by GDS), (h) wandering, rummaging and pillaging or (i) long periods of inactivity.

Pertinent nursing diagnoses or problems based on the data included: (a) hopelessness, (b) impaired social interaction and (c) diversional activity deficit.[8] Outcomes that are evaluated quarterly (and whenever necessary) include: (a) increased social interaction, (b) decreased number of verbal outbursts or (c) verbalization of increasing well-being.

The program is incorporated as a behavioral intervention and is placed as such on the resident's Care Plan and noted on the quarterly Minimum Data Set (MDS). The P-2 section of the MDS allows: (a) our program to be noted as a resident-specific intervention, (b) re-orienting (e.g., cueing) as a common technique utilized and (c) the behavioral evaluation, which is included in our assessment protocol.[9]

Toileting is managed by the individual NAC who is initially assigned to the resident. The residents go to their respective dining rooms for lunch four of the five days each week; this enables them to leave the lounge area and move about the facility. Fruit, cookies and juice are available and stored in the area, as well. Plans include having a weekly luncheon provided by the dietary department to facilitate socialization.

Residents experiencing fatigue may need to return to their room for a nap. The program area has one lounge chair (and can accommodate two) in which residents may recline, thereby allowing them to remain in the room for most of the seven-hour day.

Program evaluation is performed via verbalized resident responses and surveys of residents, families and staff as to: (a) its meeting of psychosocial needs, (b) reduction in noise and congestion and (c) overall satisfaction. Two months after initiating the program, the staff was surveyed regarding various facets of it. Fifty-six percent (56%) of the staff rated their overall satisfaction as "very good," while 44% rated it as "good" (i.e., none found it to be "fair" or "poor.")

The program-specific staff's ratings were even higher. Ninety-two percent (92%) of the staff felt the program was "very good" or "good" at meeting the residents' psychosocial and activity needs. Comments ranged from "keep it going and make it grow" to "let's have a second area."

This well-developed and successful program has benefited our residents by instilling in them a sense of worth and improved social interaction abilities and has pleased family members who have witnessed their loved ones' improvement. Rotating current NAC staff through the program has enabled those individuals to have a better understanding of the importance of activities and how to individualize them to improve residents' well-being and quality of life. Utilizing modified-duty staff has offered them meaningful work and an opportunity to learn and grow.

References

1. Feil N. The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimer's-Type Dementia. Baltimore: Health Professions Press, Inc., 1994.

2. Hellen CR. Alzheimer's Disease: Activity Focused Care. Boston: Andover Medical, Publishers, 1992.

3. Jones M. Gentlecare: Changing the Experience of Alzheimer's Disease in a Positive Way. Burnaby, BC, Canada: Moyra Jones Resources, 1996.

4. Reisberg B, Ferris SH, Leon MJ, Crook T. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatr 1982; 139: 1136-1139.

5. Reisberg B, Ferris SH, Sclan SG. Empirical evaluation of the global deterioration scale for staging Alzheimer's disease. Am J Psychiatr 1993; 150 (4): 680-681.

6. Folstein M, Folstein SE, McHugh PR. "Mini-Mental State": A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12 (30): 189-198.

7. Folstein M, Anthony JC, Parhad I, et al. The meaning of cognitive impairment in the elderly. J Am Geriatric Soc 1985; 33(4): 228-235.

8. Kim MJ, McFarland GK, McLane AM. Pocket Guide to Nursing Diagnoses (4th ed.), St. Louis: Mosby-Year Book, Inc., 1991.

9. Health Care Financing Administration. Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual (for use with Version 2.0 of the Health Care Financing Administration's Minimum Data Set, Resident Assessment Protocols and Utilization Guidelines. Health Care Financing Administration, Baltimore, 1995.

Carol Taft ARNP, MS; Mary Rusdal, ACC; Beth Nutt, ADC; Kristi Graham, ADC; Virginia Hilton, RN, MN; DeAnna McNeal, RN; and Chris Fisher, RD, CD, CMA, were, at the time of this writing, on the staff of Tacoma Lutheran Home & Retirement Community, 1301 North Highlands Parkway, Tacoma, WA 98406