Alzheimer Dis Assoc Disord. 2013 Jul-Sep;27(3):272-7.

Involvement in activities and wandering in nursing home residents with cognitive impairment.

Volicer L, van der Steen JT, Frijters DH.

School of Aging Studies, University of South Florida, Tampa, FL, USA. lvolicer@cas.usf.edu

 

Abstract

OBJECTIVES: Analysis of a relationship between wandering and involvement in meaningful activities in nursing home residents with cognitive impairment.

DESIGN: Cross-sectional analysis of the minimum data set information.

SETTING: The analyses were conducted on 8 nursing homes in the Netherlands.

PARTICIPANTS: The participants were residents aged 65 years and above with an evidence of cognitive impairment.

MEASUREMENTS: Items in the minimum data set related to wandering behavior, involvement in activities, presence of psychotic symptoms, and treatment with antipsychotics. Ambulatory residents who exhibited wandering were divided into: those whose behavior was easily altered [modifiable wandering (MW)] and those whose wandering behavior was not easily altered by the staff [nonmodifiable wandering (NMW)]. The duration of time for which they had opportunity to be involved in meaningful activities was estimated from involvement in activities of nonambulatory residents.

RESULTS: The prevalence of wandering increased with severity of cognitive impairment. MW was present in 3.5% of total residents (8.5% of ambulatory), whereas NMW was present in 11.2% of the total ambulatory and nonambulatory residents (26.6% of ambulatory). The risk of NMW was increased with resistiveness to care and decreased with antipsychotic use. Individuals with NMW were less involved in activities. NMW was more prevalent in facilities in which residents were involved in activities for a shorter duration.

CONCLUSIONS: Involvement of residents in meaningful activities should be tested for reducing the incidence of problematic wandering and for decrease in usage of antipsychotic medications.

PMID: 22975750

 

Supplements:

Results of this study demonstrate importance of involvement in meaningful activities for nursing home residents. Meaningful activities not only increase quality of life but may also prevent adverse effect of problematic wandering, e.g., falls, weight loss, entering other residents’ rooms and taking items that do not belong to them that often result in altercations between residents,  and elopement. Decreased problematic behaviors such as wandering may also prevent treatment of residents with antipsychotic medications that have many untoward effects.

To provide opportunity for involvement in meaningful activities, they have to be “person-centered” designed to meet the unique interests and needs of each resident.  Activities must also be adapted for people in the various stages of dementia.  The three main stages are:  1.mild cognitive impairment and mild dementia, 2. moderate dementia and 3.severe dementia (Figure).

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Fig 1. Activity programs for different stages of dementia. Dotted lines indicate that placement of residents in a program should be flexible depending on their current status.


Memory Enhancement Program (MEP)
(1): Persons with mild cognitive impairment and mild dementia may be still able to participate in some general activities but may be ostracized by other residents when they do not remember how to play games like  bingo and annoy them by asking the same question repeatedly .  The MEP is a program designed for a small group of residents with mild memory loss, is led by an activity professional who designs a daily schedule of programs that stimulate the mind, include physical activities and then address the various interests of each resident so that every day a new program takes place such as cooking, crafts etc. All activities are failure free to enhance residents’ feelings of self-esteem.   Residents in the MEP may attend large group activities with other residents like entertainment shows and religious events.  They are always accompanied by the activity professional so that they are safe and can be helped as needed.

The Club (2): Persons with moderate dementia have a similar program designed for them but all activities are designed to be easy for them to participate in, for instance a popular word game is to write the letters of the alphabet , then ask for a girl’s name that begins with that letter.  The activity professional knows how to cue for the answers and  as in the MEP all activities are failure free.  The Club begins with residents doing a “volunteer” project such as sorting activities , e.g., merchandise coupons or poker chips.   This activity helps residents feel as if they can still give to others and be “helpers”.  As in the MEP, the day is filled with activities that stimulate the mind and body and beverages are provided several times during the day to help increase hydration.  Two settings of continuous activity programming, requiring no additional staffing, resulted in increased number of hours residents were involved in activities, decreased use of psychotropic medications, improved nutrition, and increased family satisfaction without additional staff. When additional staff was available, more intensive continuous activity programming further decreased agitation and improved sleep (3).

Namaste Care™ (4): Residents  with severe dementia are mostly non-ambulatory and non-verbal. However, they benefit from being in presence of others in a comfortable environment.  The Namaste Care™ room is soothing and comfortable with the scent of lavender permeating the air, soft music playing and comfortable seating.  Meaningful activities are activities of daily living (ADLs) provided with a “loving touch”.  Hydration is continuous, decreasing urinary tract infections and skin breakdown.  Agitation and disruptive vocalization decrease as does the need for antipsychotic medications (5).  Family and staff find this program beneficial to residents who are no longer “invisible” (6); no longer isolated in their rooms, sitting in the corridor, or asleep in an activity in which they can no longer participate (7).  Analyses of Minimum Data Set data before the program were implemented and after residents were involved in the program for at least 30 days showed a decrease in residents’ withdrawal, social interaction, delirium indicators, and a trend for decreased agitation (8).

All meaningful activities have to be provided as components of continuing activity program that is provided for most of the residents’ waking hours, seven days a week. Such programs require involvement of interdisciplinary staff, not limited to just activity professionals. For instance, every staff member may help to transport residents to their activity room, and may be also able to get involved in interaction with residents for a limited time. It is useful if several programs are available in a facility because that allows involving resident in a program that is most suitable for him/her that day. For instance, a resident with moderate dementia may have a bad day and Namaste Care™ is more suitable for him/her than The Club.

The Club and Namaste Care may be implemented with no additional staff and minimal expenses for supplies.  Neither program requires a dedicated room.   Effort put into implementation of these programs helps to improve quality of life for not only residents but also for staff and families who are comforted that their loved one is cared for in a way that is individualized (7).

Ladi press picture

 Dr. Ladislav Volicer

Dinnus_FrijtersDr. Dinnus Frijters

Portretfoto 130813-17

Dr. Jenny van der Steen

 

References:

  (1)   Simard J. The Memory Enhancement Program: A new approach to increasing the quality of life for people with mild memory loss. In: Albert SM, editor. Assessing Quality of Life in Alzheimer’s Disease.New York: Springer Publishing; 2000. p. 153-62.

(2)   Simard J, Volicer L. The Club: increasing the quality of life in dementia care. Neurobiol Aging 2002;23(1S):S540.

(3)   Volicer L, Simard J, Pupa JH, Medrek R, Riordan ME. Effects of continuous activity programming on behavioral symptoms of dementia. Journal of the American Medical Directors Association 2006;7:426-31.

(4)   Simard J. The End-of-Life Namaste Program for People with Dementia. 2nd ed. Baltimore, London, Sydney: Health Professions Press; 2013.

(5)   Fullarton J, Volicer L. Reductions of antipsychotic and hypnotic medications in Namaste Care. J Am Med Dir Assoc 2013;14(9):708-9.

(6)   Simard J. Silent and invisible; nursing home residents with advanced dementia . The Journal of Nutrition, Health & Aging 2007;11(6):484-8.

(7)   Nicholls D, Chang E, Johnson A, Edenborough M. Touch, the essence of caring for people with end-stage dementia: a mental health perspective in Namaste Care. Aging Ment Health 2013;17(5):571-8.

(8)   Simard J, Volicer L. Effects of Namaste Care on residents who do not benefit from usual activities. Am J Alzheimers Dis Other Dement 2010;25(1):46-50.

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