Easy Tasks Satisfy Residents with Dementias
By Loretta Marmer
While OTs know the therapeutic value of occupying time, a team of researchers at Cross Creek Recreational Products Inc., New York, set out to see if sensory stimulation activities would be valuable in helping nursing assistants manage agitated behaviors in nursing home residents with Alzheimer-type dementias.
The study began in April 1994 and lasted until October of that year. A grant from the Small Business Innovative Research, National Institutes of Health, National Institute on Aging, funded the project.
Zelda Aronstein, vice president of the company and principal investigator for the project, said that the work targeted nursing assistants because they are the ones most involved in primary care of residents, becoming “almost like family.”
The study took place at a 551-bed metropolitan nursing home in New York City. Two of the facility’s 12 floors are dedicated to the care of residents with dementia. According to Aronstein, although the facility is progressive, “it is not state-of-the-art in terms of layout. It is more typical of (older) nursing homes found throughout the country.”
The facility doesn’t have a specialized Alzheimer’s unit or an area dedicated to recreational activities. “The dining room is used for both meals and activities,” Aronstein notes. There’s one hour of scheduled group recreation daily with the activity department and some one-on-one intervention, leaving residents with nearly two-thirds of their days unstructured. As revealed in interviews with nursing personnel pre-intervention, most estimated that residents were idle for up to four hours in a typical 8-hour nursing shift.
To identify subjects for the study, the research team used a checklist with a range of behaviors associated with physical and verbal agitation. The study sample consisted of four males and 11 females, ranging in age from 68 to 94 years.
The investigators wanted activities that residents could use independently, with or without a surface, that are self-contained, easy to distribute and set up, and in which residents could engage for long periods of time with minimum supervision and instruction.
They selected products offering a host of tactile, sensory, auditory and visual stimulation, including cuddly kittens, chimes, mini-bead mazes, lacing tiles, molecules, flex-cubes, wood shape sorters and pipe trees. Many items are available in the Cross Creek catalog, and others were selected from other companies on the market.
The researchers trained day and evening shift nursing staff to use the recreational interventions. “We trained every nursing assistant on each floor, not just those working with (residents with dementia),” Aronstein said. This way, she reasoned, nursing assistants who saw agitated or bored residents could engage them in appropriate activities if they chose to.
“We talked about the appropriate way to approach Alzheimer’s patients. Some staff were instinctively good at it and had patience…and some did not,” Aronstein observed. The thrust of these training sessions was to help staff select activities that were appropriate to the cognitive, physical and functional abilities of the residents.
“We stressed that if residents rejected an activity not to force it on them,” Aronstein recalled. Due to the nature of dementia there is a fair amount of unpredictable behavior, she added. “Monday (a resident) might like the activity, and Tuesday he might hate it.”
After collecting pre-intervention data and training staff, the researchers introduced the recreational interventions to the units. Plastic tubs containing the items were placed near the nursing station and in the dining/day room.
In May 1994, the researchers began recording formal observations, which went on for a total of more than 100 hours. Since residents who were not officially participants in the study also engaged in these activities, the investigators recorded several hours of informal observations as well. They conducted the observations during the day, since these hours were generally the most difficult for residents.
Formal and informal observations showed that residents interacted most with manipulative activities (molecules, flex-cubes, bead mazes, tangles, pipe trees) and with music the least. However, nurturing items (dolls, stuffed animals) captivated residents for the longest stretches of time–sometimes nearly 30 minutes–while sewing held their attention for a little more than four minutes, due in part to the fact that many of the sewing activities take only a few minutes to complete.
Even those residents with the most severe dementias were able to use all or some of the recreational interventions.
One unexpected finding was an increase in social interaction when residents were engaged in activities. Researchers found that if a resident was engaged in an activity, another resident would be more likely to stop and chat. Similarly, staff passing by would frequently stop and converse. “The fact that they were doing something made them more (approachable),” Aronstein noted.
The researchers are convinced these simple interventions have restorative qualities as well. “Most (residents) refuse an activity because they are afraid they are not going to be able to do it,” she said. “If you show them what to do and leave it on the wheelchair tray, after a while they may start to work with it. We saw this happen.”
Such activities may have potential in warding off negative behavior, according to Aronstein.
If, for example, “Mary” frequently has screaming fits at noon, staff might try occupying her with an activity at a quarter till the hour, she suggests.
All items were accounted for at the end of the project. “Not one thing disappeared,” Aronstein said.
According to the project summary report, post-intervention interviews revealed 88 percent of the facility staff rated the overall study as very, or fairly successful; 73 percent reported some success in reducing resident agitation.
Although the research team feared that nurses would see the project as “another burden, most felt that it enhanced their jobs.” *