Rules of engagement

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Knowing residents' interests and capabilities is an important component of dementia care.
Knowing residents' interests and capabilities is an important component of dementia care.

With nearly 60% of nursing home residents living with Alzheimer's or other forms of dementia, and another third of residents experiencing mild cognitive impairment, operators can't afford to ignore the importance of effective dementia care. 

Not only has well-planned programming been shown to improve resident quality of life and keep residents in place longer, it can boost employee satisfaction and give facilities a competitive edge.

Successful programs don't always come easily, however. The biggest challenge, experts say, is that each resident has different needs — and, depending on the level of dementia or cognitive impairment involved, these needs frequently change. That means programming must change, too.  

“If you've seen one person with dementia, you've seen one person with dementia,” explains Ed McMahon, Ph.D., national director of quality for Golden Living. “To be successful, an individualized approach is a must.”

Limited resources can get in the way. When resident needs grow, staffing levels don't always match. And when it comes to dementia care programming, meager resources can translate into diminished resident participation and staff and resident frustration. The good news is that with proper planning, preparation and due diligence, operators can see a return on investment.

“Senior living operators profit more when their residents function at higher levels,” stresses Dan Michel, CEO of Dakim Inc. “I can tell you that when a senior living community has a vibrant culture of wellness, you can feel it when you walk through the door.” 

Even more good news: Some tried-and-true strategies can help operators eliminate guesswork and immediately begin improving dementia care programming. 

“Today, we have very good information on what works well and what does not. Some of the most effective strategies are really quite simple to implement,” assures Robert Winningham, Ph.D., professor and chairman of Western Oregon University's Behavioral Sciences Division. 

Tap the right tools

Experts agree that the best dementia care programs start with a thorough resident assessment to learn habits, preferences and routines. Comprehensive assessments also help staff determine each resident's level of cognitive function and likely degree of participation. The goal, according to Linked Senior CEO Charles de Vilmorin, is to help staff keep residents connected to what they enjoy most. 

“You do this by learning who the resident is, where they are from and what they like,” he says.

Long-term care operators have a number of tools at their fingertips to do just that, but the tools are not always used to their best advantage. MDS 3.0 Section F, customary routines and preferences, is a prime example.

“This is a valuable resource that should be completed immediately instead of only in conjunction with the MDS schedule,” says Scott Silknitter, founder of R.O.S. Therapy Systems. “Combined with activity and social service department assessments, you have a foundation to build a plan.” 

 Any activity chosen for a resident with Alzheimer's or related dementia should have a purpose that is obvious to the participant, and should also be voluntary and enjoyable, socially- and age-appropriate, and set up in a way that capitalizes on strengths, notes Kathleen Weissberg, MS, OTR/L, educational director for Select Rehabilitation. If a community has a large group of fishermen, for example, Weissberg says offering a casting class, spending time tying flies, or perusing fishing maps might be in order. “Any activity, no matter how many parts or steps to it, can be tailored to the person with dementia,” she says.

Ditching a plan based on a strict medical model for one that factors in a resident's strengths and preferences also can mean fewer F-tag violations, Silknitter adds. F-tag 248, for example, requires facilities to provide an ongoing program of activities designed in accordance with the comprehensive assessment, interests, and physical, mental and psychosocial well-being of each resident. 

Operators also should rely on the Mini Mental State Exam. Having a trained professional administer the MMSE or a similar test to gauge each participant's level of functioning helps improve engagement and outcomes, according to Winningham. 

An MMSE score between 21 and 25 is indicative of mild impairment; between 26 and 30 indicates questionable impairment or intact functioning. Knowing these scores is important because research shows that mixing groups of varying cognitive function can prove frustrating. 

“Based on our experience, people with scores between 25 and 30 benefit from participating together in the same class, as do people with scores between 18 and 24,” Winningham says. 

These scores also can help determine the appropriate group size. In Winningham's experience, those with MMSE scores between 17 and 24 should be limited to groups of five per instructor. If participants have MMSE scores above 24, groups can increase to 12 per instructor. If staffing resources are limited, he says, college psychology or health department interns can prove invaluable. 

Given the daily stresses that staff members routinely face, Michel warns it's easy to underestimate the capabilities of residents in memory care or treat them all the same way. “Clearly, this can have a serious and detrimental effect on the kinds and levels of stimulation provided to those residents,” he notes. 

Rehabilitation professionals and other trained caregivers who provide personalized and specific resident activities and programs may find that they can mitigate some of the learned dependence and functional loss common to residents with dementia, says Michelle Tristani, MS/CCC-SLP, clinical performance specialist for RehabCare. 

“Capitalizing on resident interests and familiar routines within functional therapeutic activities is the most positive approach to maximize resident participation,” she says.

Quality over quantity

There's no one-size-fits-all formula for dementia care programming, but evidence shows that a mixed approach works best. Typically, this involves a combination of large and small groups and one-on-one activities, and a blend of traditional and technology-based approaches.  

Programming shouldn't just fall on activity directors' shoulders. McMahon and Winningham stress that direct care staff, including licensed nurses, should be involved, along with Alzheimer's care directors and even dietary, maintenance and housekeeping staff. And don't overlook therapists, urges Tristani. 

“Communication with occupational therapy and speech therapy professionals is paramount. When residents are discharged from skilled services, it's important for the SLP and/or OT to outline effective and individualized strategies and train the activities professionals and other key team members,” she explains. “Therapists select activities for successful engagement based on the resident's level of cognitive ability.”

Successful programs also artfully meld consistency and flexibility. Winningham explains how some residents might wake up hungry and go directly to the dining room because they know that's where breakfast is served. 

“This is called procedural memory. If an activity always comes after breakfast, for example, residents will learn to just get up and go. Consistency can be a good thing for program participation,” he says.

Flexibility vital

Just don't confuse consistency with rigidity, sources warn. Active programming for those with dementia should be available 24 hours a day, in combinations of group, self-directed activities, and short and simple activities that can be done with any staff member at any time, day or night, says Silknitter. 

“Many LTC facilities struggle with residents who are up during the 11-to-7 shift. The activities department can help with activity kits for [residents] who require little staff involvement,” he explains.

There's no hard and fast rule for session or activity duration and scheduling rotation, either. On the therapy side, schedules and session times will be highly individualized and may change from day to day, notes Debbie Ricker, OTR/L, RRD, CDP, certified dementia practitioner and certified geriatric wellness instructor for Life Care Centers of America. 

“When a resident refuses therapy with my staff, I encourage [staff] to try again throughout the day, and to vary the approach. I suggest 30 minutes to an hour, or maybe several 10- to 15-minute sessions throughout the day. You have to watch the individual and engage them according to their ability in the moment,” she says.

 For an idea of appropriate activity length, Weissberg pointed to a 2002 study by dementia care specialist Kim Warchol, ORT/L. This  indicated that the attention span for individuals in early stages of dementia is about 20 minutes, and it becomes shorter in the middle and late stages.

Under the EnerG by Aegis Wellness Services program, cognitive wellness encompasses a combination of group, one-on-one and technology-based programing at least three times a week. Still, “a lot of variations can occur on any given day,” acknowledges Brian Boekhout, VP of wellness services at Aegis. “Sometimes, we break longer programming into shorter periods and mix it up — such as five minutes each of social, cognitive or meditative [programming], for example.” 

Golden Living strives for resident involvement four times a day, although McMahon says daily tolerance assessments are essential. “If someone doesn't want to participate, we don't force them. If they're happier with a shorter session, that's OK, too. It's really about quality over quantity.”

The same goes for technology-based sessions. Michel says Dakim's chief scientific officer, Gary Small, M.D., of UCLA, has recommended three to five sessions per week for about 20 minutes each, but that it is flexible. 

Even two- to three-minute sessions can prove beneficial, says de Vilmorin. He described how one resident who was non-verbal for some time started speaking after watching a video of Frank Sinatra. “Technology, when done right, can help you do more with less, and help residents connect in more meaningful ways,” he says. 

It's not about you

Meaningful connection hinges on caregivers' understanding of residents' unique preferences. “It's easy to impose our own likes and preferences, sometimes subconsciously, on the residents being served. This is especially true when utilizing technology,” says Jack York, CEO and co-founder of It's Never 2 Late. “The key is to focus on the content that [each resident] likes, not what you like.” 

When introducing technology to residents, York also stresses that the words staff use at the outset can impact success. 

He says, “If you ask a resident with no computer experience if they're interested in using the computer, you'll get a resounding, ‘No.' Ask if they want to visit the Louvre [and look at fine art], for example, and you'll get a much different response.”

Sometimes, the best ways to reach residents are also the simplest. Kruse Village, a continuing care retirement community in Brenham, TX, adopts an individualized approach that focuses, in great part, on muscle therapy. The method has had a positive effect on those with moderate to severe dementia, says Lillian Hayden, director of Health Care Services at Kruse Village. When staff learned that a resident once loved to ride bicycles, the community added a stationary bike, which the resident used often.

“We focus a lot on activities that let residents connect with their past,” Hayden says. “One lady was a homemaker who made three meals a day. She loves to set the table every day, and she does it with great care. There's a lady in assisted living who, despite being visually impaired, is back playing the piano. She won't learn new songs, but she remembers how to play the old ones.” 

For some with dementia, it won't be possible to improve memory or cognitive function, so success shouldn't be measured only in that way, reminds Hayden. 

“The ultimate success comes from meeting residents in whatever reality and cognitive state they are in, and connecting with them in a way that improves their quality of life,” she says. “That's a win for everyone.” 


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