Quality of Life in LTC’s

The Nursing Home Reform Act was the start of the focus of reforming the regulations in nursing homes to improve on the quality of life of the residents. Over time it has expanded to a much larger focus, with a goal of creating a culture of aging that is life affirming, enjoyable, humane, and meaningful.

Many of the changes have been addressed in the revisions of the Centers for Medicare and Medicaid Services (CMS) in 2006. One important focus is that the facility is required to provide an ongoing program of activities which should meet the interests of the resident along with the physical, mental, and psychosocial well-being of that resident. Another focus is on what is called the ―person appropriate‖ activities which are relevant to specific needs, interests, culture and background of individual residents. One-on-one programming requires the caregivers to assist those who are incapable of organizing and planning their own activities, like patients with dementia. The program designed for each patient should be a combination of large and small groups, one-on-one, and self-directed activities on a daily basis.

The changes focus on the need for the program to contain daily activities that are associated with the patient’s interests, capabilities, and preferences and that the program is implemented in an environment that is likely for success.

Language that is specific to persons with dementia stresses the importance of the staffs’ role in identifying, implementing, monitoring, and evaluating activities and plans for residents to be certain that their needs are met and to determine if changes are necessary.

Training for Encouraging Activity Participation
There are many long-term care facilities that require the assistance in understanding their options for activities and to focus on the mission of quality of life for residents and regulatory compliance. This training specifically focuses on the needs of a patient who suffers from dementia, especially those whose problems affect their communication, problem-solving, and initiation of activities.
The first step to take when modifying programs for dementia patients is to have an understanding of how dementia-related changes may influence the approaches required to meet activity needs and preferences. Some research must be done on the patient to gather important information about them like understanding cognitive losses that are dementia related, which can include showing interest, identifying and planning activities, and remembering how to do activities. It is also extremely important to comprehend the association between behavioral and psychological symptoms of dementia (BPSD), which is very important for daily care providers to understand.
Theory-Driven Activity Involvement
A certain model can be followed to provide an important framework for understanding how caregivers can change their daily routine to avoid chances of BPSD. This model is known as, The Need-Driven Dementia Compromised Behavior (NDB) model. The NDB model proposes that BPSD are the direct outcome of background factors, such as cognitive abilities, health status, and psychosocial factors, and more changeable proximal factors, such as psychological and physiological needs and quality of the physical and social environments.
The NDB model has background factors that represent a profile of strengths, weaknesses, and usual coping style. Activities that are based on the NDB model will match the patients’ current level of cognitive and physical functioning capabilities to ensure that they are at a level that allows them to participate. Activities will also go with the patients’ personality and interests. Matching the background factors to the proximal factors provides an essential structure for daily care providers.
Applying the Methods
According to the NDB model, the type and frequency of activities of a dementia patient are highly similar to the occurrence of BPSD. There more cases than there should be of dementia patients being left alone, having nothing to occupy their time. Deficiencies associated with dementia, such as the use of language, cause issues in their participation in activities. Large group activities should be avoided with dementia patients for several reasons. Larger groups are normally too complex for their level of cognitive functioning, there may be few similarities with their current interests, or the sessions might just be too long for them to handle.
It is very important that the caregivers know the patient very well in order to organize activities appropriate for that specific patient.
Activity Options: Many Choices
In addition to being familiar with the patient, caregivers also need help in thinking of creative ways to keep dementia patients occupied with activities. Research shows that a wide range of recreational therapy interventions is beneficial to persons with dementia. The NEST (Needs, Environment, Stimulation, and Technique) approach, described by Buettner and Fitzsimmons, has shown to be very helpful with over 80 therapeutic protocols that make up 10 different categories, such as feelings, nurturing, relaxation, adventure, physical exercise, cognitive, life roles, psychosocial clubs, and basic pleasures.
The goal of recreational therapy interventions are to minimize identified BPSD and are mostly used in long-term care settings. The NEST approach recommends forming a team of long-term care staff, made up of at least a nurse and recreational therapist, who should meet once a day to focus on the needs of the dementia patients. Some possible topics of discussion can be to assess behaviors, determine what needs have been overlooked, adjust the surroundings to promote function, complete baseline assessments, and to determine activity procedures according to the individual.
The following examples have been tested by Buettner and Fitzsimmons and are explained in more detail in their NEST manual. The major outcomes of these studies show that through the use of therapeutic recreation interventions, individuals with agitation showed signs of more calm behavior (92-100% of the time) and patients with passive behaviors were more alert (79-91% of the time).
Simple Pleasures
Simple pleasures are seen as a starting point for formulating activities that may be used by inactive personnel throughout the day through a group multilevel sensorimotor interventions. Simple pleasures can be used for many purposes, such as passive behaviors, boredom, or even agitation. The amount of ―pleasure‖ is determined by the time that is spent on the task, affective responses, and behaviors. For example, these may include changing those who are passive to be alert and actively participating, or distracting or calming agitated patients. These interventions are meant to be used in small groups or in a one-to-one session and can last anywhere from 5-45 minutes.
Adventure-Based
Wheelchair biking is a very beneficial way of offering considerable opportunities for persons with dementia by combining small-group activities with rides on a Duet bike. Group discussions include questions about past experiences with riding a bike, such as, ―How old were you when you first rode a bicycle?‖ or ―Do you remember what color it was?‖ There are two parts to the Duet bike: a wheelchair and a bike that connects to the wheelchair, allowing the trained therapist to pedal and steer the bike while the patient rides along in the wheelchair. Last, the patients will tell others in the group about their ride.
Life Roles
These activities are more focused on real life situations that most have had experience with before and possibly miss. Therapeutic Cooking is a good family-like intervention that may simultaneously stimulate cognitive skills, improve motor functioning, and reduce anorexia. The activities may include things such as, planning menus, gathering food for the meal, using equipment to prepare food, and indulging in the baked items or meals in a group. Other activities that might be combined with cooking include, gardening, setting or decorating the table, and engaging in conversation about past experiences or current interests.
Physical-Based
Involving dementia patients in several types of physical exercises and/or activities is associated with improved sleep, function, and mood, which will help decrease restlessness and wandering. A commonly used intervention is Exercise for Function, which is a planned physical activity that focuses on range of motion, as well as endurance and strengthening. These exercised are choreographed to music and include exercises from the head all the way to the feet and last about 20 minutes.
Another program is focused on those who wake up early, called the Early Risers Walking Club, which last for about 30 minutes and is conducted five days per week.
Cognitive-Based
The Price Is Right Game can be used to improve on several different areas, such as cognitive stimulation related to guessing prices, appetite stimulation related to thinking about food, socialization by discussing food and their prices, and as a means to engage residents who tend to wander away from the dining room before meals. During small-group intervention, therapists will hold up two food items and which one costs more, then they reveal the actual price and begin a discussion about the price and whether or not it is fair.
Dominoes are another cognitive-based program that can be helpful to dementia patients. Normal rules can be used when playing with higher functioning residents, while mid-functioning residents may use them to set up on their edges and topple them over, and lower-functioning residents will benefit from color-matched dominoes or ones with large pictures.
Psychosocial Club-Based
There are all kinds of club-based activities to get involved in, all of which focus on the different interests of residents, such as birds, bowling, cars, golf, weather, etc. These programs involve patients in small-group socialization, discussion, and activity engagement which are aimed at reducing depression, social isolation, passiveness, sensory deprivation, restlessness, and wandering. Depending on the activity, these meetings usually last about 30-45 minutes and are held 1-2 times per week.
Nurturing
These interventions help residents by promoting caring or nurturing behaviors through activities involving animals. These interventions may benefit residents in several ways whether it be social, motivational, educational, or recreational. Some of the Animal-assisted methods used are Animal-Assisted Activities (AAA) and Animal-Assisted Therapy (AAT).
Each AAT session involves three major parts: 1) the approach, in which visual and verbal contact is made between the animal and the resident, 2) the process, in which the animal-resident interaction is focused on meeting certain predefined goals, and 3) the closure, in which the resident rewards the animal and accomplishments are reviewed.
Teamwork: Making it Work
Teamwork is a very important part of making the activity programs and therapies effective. Research has shown that the success of these programs is more likely when a team has been formed.
Success is also dependent upon building on the strengths and weaknesses of all team members. It is important to use the team members’ natural interests and skills to form and maintain the programs.
Teamwork also involves helping staff members appreciate and assist with common aspects of activity involvement, like helping residents be dressed appropriately for the program, like wearing the appropriate shoes or wearing sunglasses.
It also important that daily staff providers are familiar with the programs and how to execute them because activities can be scheduled for any time of the day, every day of the week. This makes it critical that the staff works together and is able to transition residents from one activity to another and be familiar with each individualized program that they have developed for each resident.
Summary
The 2006 activity revision offers important opportunities to move forward in the value of cultural change. Successful and appropriate programs are dependent upon the cooperation and assistance of all team members, a basic working knowledge of dementia processes, and a sound knowledge of innovative, evidence based activities that coincide with the interests and abilities of each resident. One of the first steps in the success building an interdisciplinary team is developing an ongoing training program that trains the staff and constantly updates them on new discoveries associated with dementia and activity interventions.

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