Creativity Can Make a Difference

Unit staff came up with their own activity program for demented residents.

EILEEN H. TOUGHILL

S tan Maxwell stopped spitting and gained three pounds. So what, you say. Let me explain.

Mr. Maxwell is blind, 86 years old, and suffers from heart disease, arthri- tis, and dementia. He has been a resi- dent of a long-term care facility for seven years, spending his days alone, confined to a geri-chair, spitting on the floor. Until recently, that is.

The change came about after my staff and I set up a program on the unit to "recreate" the clients with de- mentia. The unit had 50 residents, half of whom suffered from some form of dementia. The facility sought to provide all residents with an active social calendar. An excellent recrea- tion department developed the activ- ities. Clients with dementia were reg- ularly included--included, but not able to participate.

The scope of activity was too high for their level of functioning, and even a dedicated recreation staff could not provide the one-to-one at- tention they needed. So residents with dementia spent their days in geri-chairs in the hallway, watching the world go by, and receiving little words of affection from the staff as we bustled past.

We wondered, what is to become of our clients with dementia? Are they to remain sitting in the corner of their bedrooms, lined up in hallways, on the fringe of life forever?

I called the staff together ~ talk about how we could improve life for these residents. It wasn't a cheery group that presented itself. The staff were frustrated by the lack ofsuccess

Eileen Helblg Toughill, RN, MSN, is a grant supervisor at the MCOSS Foundation, Manas- quan, NJ.

they felt, plus, like so many who work in long-term care, the six nursing as- sistants (NAs)found it difficult to feel pride or a sense of accomplishment in their work. Our society values pro- ductivity. The "unproductive" work of caring for the older chronically ill adult is often seen by society as less valuable than nursing the acutely ill back to health.

All of us agreed a problem existed, but what could we do about it? Of course, we were all very busy. The

staff balked at taking on any extra as- signments, especially an assignment they felt by rights belonged to the re- creational department. Yet the re- creational department couldn't han- dle the needs of our special clients, and the administration said we could not hire any more staff. What was the solution?

We decided to try an independent recreational program for four months. One NA, Pat, volunteered to be the recreational aide during the

276 Geriatric Nursing November/December 1990

pilot study, and the other staffagreed to perform her regular duties so she could concentrate full-time on the new project. We hoped that assigning oneNA would lend continuity to the program. From the outset, it was em- phasized that Pat had total responsi- bility for the program, while I would be available for guidance, support, and administrative linkage.

What Do the Patients Need?

We realized our residents were inactive. In fact, what our clients were actually experiencing was sen- sory deprivation.

Stimulation is an on-going need across the entire lifespan. As stimula- tion diminishes, a patient's environ- ment shrinks. A gradual decline in physical activity can cause a slow- down in all bodily processes: Respi- rations may not be as deep; the car- diovascular system can be affected; muscles may atrophy from disuse; and ambulation and elimination problems can occur.

Over the years, there is a gradual change in all the senses. Vision be- gins to decline in the fourth decade. Approximately 35 percent of those over aged 75 have decreased hearing. Two thirds of elders' taste buds no longer function. And the senses of smell and touch are diminished.

What little stimulation our clients were receiving might have been lost because of sensory changes. Little wonder that we noticed aggressive behavior, disorientation, hallucina- tions, refusal to eat, aimless wander- ing, and resistance to physical care. Our resident's world was shrinking, causing them to become more physi- cally and emotionally dependent.

On the First Day

Our goal for the first day was sim- ple: Get the residents out of their rooms and out of the hallway. We de- cided a private room would be best for the program. Isolating dementia patients has been viewed by some as negative segregation, but we found privacy gave our participants the freedom to walk around when they got restless, without fear of verbal or physical abuse from mentally alert clients. And it made safety and activ- ity easier to control too.

We began with just our five highest functioning residents. Led by our study recreational aide, they worked with clay, sang songs, and colored. Nothing dramatic or outstanding, but by the end of the first day, Pat and the five participants were hooked.

Lessons Learned

Inadvertently, we stumbled across another very important aspect of care: Clients with dementia require the intensive one-to-one attention that can only be found in a small group setting. We tried larger groups, but they resulted in client withdraw- al, emotionally or physically, and ne-

Even with one less nursing assistant

giving physical care, staff were able to

complete assignments in less time.

gated the purpose of the program. So instead of increasing the group size to involve all of the patients, we rotated clients through the program for short periods while keeping group size at five or less.

For eight hours each day, Pat worked with small groups of clients with dementia for 15 to 30 minutes at a time. Short activity periods, rotated with periods of rest, allowed stimula- tion without restlessness. Since at- tention waned and fatigue developed after 10 to 15 minutes, we looked for programs that could be completed in a short time or in stages.

Any activity that was stimulating, but safe, could be included. And any- thing that stimulated many senses at once was best because of our client's low functional level. In the end, we found that it wasn't the type of activ- ity that mattered, it was simply the activity, stimulation, and one-to-one interaction themselves that were im- portant.

After the first few weeks, we de- cided to include group dining in the activity room as an added recreation- al period. We played background music and encouraged client interac-

tion. After awhile, group dynamics became apparent, and manners and conversation, as well as appetites, improved.

Remember Mr. Maxwell, the blind 86 year old? He was not in the origi- nal program, but after a few weeks, Pat decided on an activity for him. Every day, he would place large plas- tic rings on a plastic dowel. Hour af- ter hour, he sat patiently in the group "working" at getting the rings on the dowel. When he filled the dowel, Pat emptied it and he began again. Aim- less work? Maybe--but the change in him was remarkable. He gradually stopped spitting, began feeding him- self, and even walked with help. The staff felt he believed he had a job, a responsibility, and a purpose, and that he responded.

Beyond Expectations

The changes in the patients were totally beyond our expectations. Over a four-month period, all resi- dents in the program gained at least two pounds; antisocial behavior such as spitting and pacing stopped; and bladder and bowel control im- proved. A program begun purely for recreation had led to improvement in many spheres.

As the clients improved, the entire staff became staunch supporters of the program. Even with one less NA giving physical care, staffwere able to complete assignments in less time. The residents were occupied and not undoing what the staff had already done. They also required less super- vision. As residents improved, our jobs become easier.

With the improvement in client functioning came a bonus: a marked difference in staff functioning and morale. There was less griping, less illness, less injury, and more Smiles. The nursing staffgained a sense of ac- complishment. The diversity in the routine provided an incentive, and the quality of care and life satisfac- tion ofall participants improved.

Although robbed of the ability to function independently, residents with dementia deserve a life of quali- ty. We can provide the stimulation that broadens their world and helps them be as physically and mentally active as they can be. GN

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