The following question was asked of the readers of the Journal of Gerontological Nursing:
We will address in this response the needs of 29 residents on our Special Needs unit who have a diagnosis of dementia, many with the Alzheimer's type dementia. These residents are in moderate to severe stages of the disease. We continually emphasize programming, environment, and use of resources to create a nurturing place to live.
The staff of St. Anne Hospice is searching for keys to rekindle a memory and have a "feel good" experience, however fleeting, on a daily basis. Upon admission and assessment, we find it important to look to family or caregiver for the key to rekindle those memories that we can use to develop a plan of care for the individual.
Strategies for programming include establishing a routine for each resident related to assessed interests, offering consistency in every aspect of their day, and integrating activities of daily Uving into their daily activities with flexibility to change as needed. As the day begins, residents are assisted with dressing and grooming by nursing staff before sitting down to breakfast. They continue the routine of grooming related to former experiences with a bit of makeup offered by activity staff, nursing, or volunteers from a traveling cart with a huge tool box filled with blush, lipstick, lotion, and aftershave. The routine continues with mass or music, games, arts and crafts, exercise, nourishments, beverage breaks, and mealtimes.
St. Anne Hospice is striving to provide an environment which offers hospitality and comfort to residents and their loved ones. The different behaviors and moods of our residents are approached as symptoms of the disease. Clusters of resident rooms around a solarium create a neighborhood atmosphere that residents may enjoy throughout the day. These neighborhood areas provide a sight for activity programming throughout their day.
Staffing levels are determined by the amount of nursing care needed by the individual resident. All disciplines are involved in this holistic approach for the care of the residents. Housekeeping may have an interested resident help with dusting. Nursing deters from the traditional role by taking a resident outdoors for a visit or a cup of coffee. Pastoral Care staff brings together residents of all faiths who may wish to say the Lord's Prayer. Activity staff and volunteers offer a variety of scheduled events.
Multiple disciplinary programming offers hospitality in a nurturing environment with consistency in their lives to daily rekindle the memories for many "feel good" experiences.
Chris Schafer, RN
Marie Baertsch, ADC
Saint Anne Hospice, Inc.
Dementia is a term which is used to describe many different mental states. As the level of mental disability increases, the abiUty of the staff to structure the day decreases. Taking care of activities of daily living, which is easily done on less demented residents, can be extremely challenging on severely demented residents. A key to completing care on the resident with severe dementia is to reapproach the resident until the goals are achieved. A positive attitude must be maintained.
Secured Dementia Unit
Iowa Veterans Home
In our facility we have found the the ever changing needs of our residents outweigh the importance of a rigid, task-oriented schedule. Caregivers do not get the residents up and have them bathed and dressed by a specific time; instead the residents are awakened by their own inner clock and have their breakfast when they are ready.
Activities of daily living are performed by the residents, focusing on their remaining strengths and capabilities, which provides a sense a independence. Each day is filled with various activities that reflect the individual personality, preference, and ability level. The residents' social lives are kept thriving with routine social activities such as Sunday church services, Bible studies, Book of the Month Club, Gentleman's Coffee Hour, and monthly birthday and anniversary parties. Residents also have physical wellness activities, which keeps them active, feeling productive, and can decrease anxiousness. We provide a shallow water exercise program to increase body awareness and evening walks to help reduce "sundowning syndrome."
Our facility is a homelike environment with a kitchen, dining room, living room, and garden. Having a homelike setting produces spontaneous household tasks that are familiar to some residents, which reinforces self-esteem while relieving boredom. Some examples are setting the tables for meals, caring for pets, watering plants, or folding towels.
The staff also schedule outings to dinner theaters, local museums, or a ride in the country. The residents enjoy being entertained and have a feeling of being a part of a group and a sense of belonging.
Evening is a time for our residents to wind down and relax after a busy day. Comforting activities are done at this time, such as aromatherapy, music therapy, or just swinging on a bench watching the sun set. The key to structuring a day for residents with dementia is to offer flexibility and spontaneity, while keeping a daily pattern to maintain a routine and familiarity.
Sandra Gonzalez, LVN
Lead Care Giver
Freedom House Alzheimer's Care and Research Center
San Antonio, Texas
This question was submitted by Dolores Alford, PhD, RN, FAAN, Gerontologic Nursing Consultant, Dallas, Texas. Her Commentary follows:
We can no long just put locks on the door of a wing in a long-term care facility and dump 30 or more residents with dementia there under the care of untrained aides with only "on call" nurses from other areas of the facility. Dementia care is complex and ever changing. Nurses and other professional caregivers should have a knowledge base that includes the pathological mechanisms of dementia and how to address human responses to pathology. Also needed is a strong ethicolegal knowledge base, including end-oflife care that provides dying individuals with dignity.
Staff must be flexible enough to cope with their residents' changing moods, disruptive behaviors, loss of motor function, short attention spans, and inability to stay oriented to reality.
Individuals with dementia need structure, simplicity, predictability, and routine. Staff working as a team must make 24 hour dynamic daily life schedules for each resident. The schedule (or care map) should include patterns of sleeping and waking, toileting, food and fluid intake, and personal hygiene and grooming preferences. The schedule should also include when and what activities interest, entertain, amuse, and socialize the residents over each 24 hour period. Activities should be chosen to capitalize on the resident's strengths to promote successes. Staff should avoid creating stressors and boredom. All activities must be consistently supervised, especially for safety.
Environment is crucial to optimizing the quality of life for individuals with dementia. Traditional "multipurpose" activity rooms with crowding, clutter, and noise pollution do not meet the needs of the residents with dementia. Several rooms with various types of seating and activity clusters are preferable. Activities in these rooms should be appropriate to the status and interests of the residents.
Through the use of the daily care schedule, staff can determine the residents' ability to participate in activities and their response to various stimuli. Triggers that warn of stressors can be determined and addressed more easily.
The search for better ways of caring for individuals with dementia, especially in the area of active therapy, should have as its goal the optimization of the quality of life at each stage of decline (Mace, 1991). My thanks go to our colleagues who have shared the work they are doing to meet this goal. Their efforts should give us hope and ideas for promoting the personhood of this challenging group of older adults.
Mace, N. (1991). Principles of activity therapy for people with dementia. In P. Sloane and L. Mathew (Eds.), Dementia units in longterm care (pp. 201-213). Baltimore, MD: Johns Hopkins University Press.