Interventions: Elderly

KNR 253

Interventions

• Reminiscence– Austin, 2009– Dattilo & McKenney,

2011

• Reality Orientation

• Validation Therapy

• Sensory Stimulation

• Remotivation– Austin, 2009

Interventions

• Montessori Technique

Theoretic Foundations

• Role theory– How well one adjusts to aging depends on

how well the role changes of later life are accepted

• Rosow, 1976

• Disengagement theory– Older adults have a natural tendency to

withdraw from society and become more introspective

• Cumming & Henry, 1961

Theoretic Foundations

• Activity theory– People who are active will be more satisfied and

better adjusted than those who are less active• Havinghurst, 1968

• Continuity theory– As we age we become more of what we already

were in our youth. We deliberately continue familiar patterns

– Could be positive or less positive patterns• Atchley, 1993

Reminiscence

Dattilo & McKenney (2011) calls it Therapeutic Reminiscence

Population

• Dementia/Alzheimer’s• Depression• Older adults• People in transition or life crisis

• People who – Have mild to moderate cognitive functioning– And have at least a 5 minute attention span

Definitions of Memory

• Memory• Recording of feelings and emotions• Knowledge about self, world, & experiences• Many are involuntary

– Sensory• Comes through sense of smell, touch, taste,

hearing and seeing• Imprints quickly

– Smell word burning & think of campfire– Smell lavender perfume & think of Grandma

Definitions of Memory

• Short term memory (immediate)– Working memory – Lasts for a few seconds or minutes– Can only keep 6-7 items at once in STM– If retain longer, must be rehearsed &

connected to other memories• Look up phone number• Follow directions to a room

Definitions of Memory

• Long term memory– Information that has been rehearsed & connected

• Could be recent (what had for lunch)• Could be distant (first dog’s name)

– 4 parts to transfer from STM to LTM• Registration: Information perceived• Encoding: Attach new memory to previously stored

memories• Storage: Collection of what retained• Retrieval: Recall information previously registered,

encoded, and stored

Reminiscence

• Excursion into one’s memory of the past – Weiss, 1989

• Act of relating personally significant past experiences

– Koffman, 2000

• Activity in which the leader assists and guides a person to recall previous life experiences and facilitates the affirmation of the value of these experiences– Could be individual or group– Could be written or recorded

Reminiscence

2 types of life experience recollection:1. Simple/informative/story-telling

Recollection of previous life experiences Remembered for pure pleasure of

experiencing occasions and to pass information on to others

2. Life review• Focused on analyzing, evaluating and coming

to terms with unpleasant or unhappy previous life experiences

Reminiscence

Process:– Quiet, comfortable room free of

distractions, table– Same times and day of week, 2x week is

best, 30-60 min• Enough time for all to share

– For groups, s/b under 10-12 members. With some groups may be 5-6.

Reminiscence Topics

• Vacations• Favorite games• First playmate• First pet• School days• Olympics• Floods• Engagements

• Seasons• Holidays• Seasons• Childhood• Adolescence• Music• Dance• Others

Reminiscence TopicsCurrent Events: Now & Then

• Engagements– Here is a picture of a man who rented a

billboard to ask his girl friend to marry him– How did you (your husband) propose?– Did you give (get) a ring?– What did your parents say?– How long had you known each other? – How long were you engaged?

» Dattilo, 2000, p. 320

Reminiscence Guidelines(See sample)

• Intro – welcome, introduce topic– Mr., Mrs., Dr., unless permission for first name

• Initial cue – present an item associated with theme (make cues multi-sensory, present one at a time, use verbal and nonverbal cues)

• Prop/artifact #1 – focus on past experiences

• Prop/artifact #2 – focus on current experiences

• Related activity (time permitting) – slides, movies, cooking, etc.

• Closure – thank yous, time for social interactions between participants

Outcomes

• Increase self esteem as review history of competence• Increase life satisfaction• Reaffirm sense of identity• Bring pleasure from sharing the past with others• Increase socialization• Stimulate cognitive processes• Provide feelings of competence as person relates LT memories• Allow for expressing of feelings• Come to terms with old disappointments• Discover similarities with others• Decrease loneliness• Increase self awareness about leisure• Others

Outcomes

• Decrease depression & confusion

• Decrease boredom• Increase self-esteem• Increase well-being• Enjoyable• Develop friendships

• Engage in conversation• Maintain family contacts• Teach & inform• Identify & solve

problems• Prepare for end of life• Increase socialization• Maintain cognitive

functioning

Activities

• Grab Bag– Therapeutic Recreation Directory

• Leisure Lifeline

• Scrapbook

Reality Orientation (RO)

Population & Settings

• Population– Older adults – Moderate to severe disorientation &

confusion

• Settings– Nursing homes– Geriatric units in psychiatric hospitals

Purpose

• Prevent cognitive decline

• Reverse cognitive decline

• Maintain cognitive functioning

Definition

• Involves a technique of regular repetition of basic facts – Time, place, names, events of day, things

in environment, etc.

• The technique is used to help overcome symptoms of confusion and disorientation

Types of RO

• 24 hour a day RO– Everyone who comes in contact with the person – Asks questions like:

• What is your name?• What is the name of this facility?• What city are we in?• What is your hometown?• How is the weather today?

– Clues in environment• Signs• Clocks• Calendars, activity calendar

Types of RO

• Daily RO Classes– 4-6 residents– 15-30 minutes– Same time each day– Quiet well-lighted area– Uses RO board

• Location• Date• Time• Weather

Types of RO

• Daily RO Classes Routine– Greet residents

• Would you like to tell the group your name?• What is your name?

– If correct answer “good,” if incorrect probe or tell

– Introduce ourselves• Tell leader’s name. May ask to repeat

– Read the reality orientation board• Ask each patient to read

– Perhaps another activity• Write menu & have residents help spell words• Have pictures of food & ask residents to identify• Flash cards

– Remind about time of next meeting

Types of RO

• Incorporate in TR programs– Repeat your name at beginning of groups – Tell what you do– Review programs did in past– Work time in introductions– Talk about seasonal events– Highlight upcoming activities– Review monthly activity calendar

– Austin, 2004

Validation Therapy

Naomi Feil

Population

• Same as RO

• Alzheimer’s

• Old-old clients who need help resolving pasts

• Not for people who have:– Chronic mental illness– Intellectual disabilities– Alcoholism

Rationale

• Developed because some folks reacted negatively to RO– Agitation– Withdrawal

• Basic premise is that reality underlies the behavior of even very disoriented clients– Resolve past relationships– Resolve unfinished life tasks– Express suppressed feelings

Process

• Accept people as they are and be empathetic toward them– Maintain eye contact– Rephrase – Speak with caring tone of voice– Use appropriate touch– Avoid “why” questions– Communicate that what they said was heard and

respected– Agree but steer without them knowing they are

being redirected• Austin also describes phases for groups

• Chuck: "I have to find my car keys."Me: "Your car keys..." ( I don't tell him he doesn't have a car and he hasn't driven for years)Chuck: "Yes, I need to get home - lot's of work to do, you know!"Me: "You are busy today?" (I don't tell him he is at adult day care and isn't going home for hours)Chuck: "Hell, yes. I'm busy every day, girlee."Me: "You like being busy?" (I'm trying to find a topic of conversation that he might accept discussing)Chuck: "What planet do you live on? I didn't say I LIKED it. I just have to work - like most of the rest of the world, ya know?" (He's getting a little frustrated, but seems to have forgotten the keys.)Me: "I know about work, Chuck. I do some of that myself. In fact, I'm getting ready to fix some lunch for us. Care to join me?"Chuck: "Lunch, huh? What are you having?"

» http://www.ec-online.net/community/Activists/difficultbehaviors.htm

Sensory Training

Sensory Stimulation

Sensory Training

• Originally developed for work with children with perceptual motor problems (sensory integration)– Autism

• Frequently used with regressed & disoriented older persons– Psychiatric facilities– Nursing homes– Long term care facilities

Sensory Training

• Goal is to improve perception & alertness in responding to the environment

• Attempt to maintain or improve functioning of regressed patients

• Stimulate all senses each session

Sensory Training

• Kinesthetic awareness exercises– Flex & extend parts of body while sitting

• Tactile stimulation activities– Feel objects (e.g., balls, sponges, wood, etc.)– Answer questions about sensations, preferences,

and feelings

• Smelling activities– Smell sharp or distinct substance– Answer questions about feelings & uses of

substances

Sensory Training

• Listening activities– Sounds through media like records,

clapping, songs, etc.

• Tasting activities– Taste contrasting foods like candy &

pickles

• Visual activities– Mirrors, colorful objects

Sensory Stimulation

• Used as treatment for patients with TBI who are in prolonged comas

• 2 types– Multimodal

• All senses every session

– Unimodal• Treating single sense in a session

• Observe to determine what stimulates consistent responses like hand or head movement or eye gaze

• I have more frequently heard sensory stimulation for both clients who are disoriented or are in comas– Backrubs– Facials– Brush hair– Lotion– Music– Aromatherapy – Pets

Remotivation

Population

• Moderately confused elderly residents

• Often used with folks who have successfully completed RO

• Purpose: to promote discussions of topics that may bring participants closer in touch with the world outside the institution

Remotivation

Process:– Group (8-15) interaction for 45-60 min– Conducted by a trained staff – sometimes

an aid (remotivator)– Attempt to renew interest in environment

by:

Remotivation

• Planning conversations that stress simple, objective features of everyday life not related to their emotional difficulties (e.g. gardening, baseball—avoid controversial subjects such as sex, politics)

• Establish warm, accepting atmosphere• Deal with well parts of client• Encourage rediscovery of interests• Begin to establish control over leisure

selection

Remotivation

• 5 phase process (each 10 min)1.Climate of acceptance

2.Bridge to reality

3.Sharing the world we live in

4.Appreciation of the work of the world

5.Climate of appreciation

Climate of Acceptance

• Greet each participant by name

• Shake hands

• Made some comment about participant’s appearance

• Purpose is to create a warm, supportive environment

Bridge to Reality

• Develop group discussion around a theme

• Start by reading a poem, story or article related to theme

• Ask questions to encourage participants to recall and share ideas related to topic

– When you were little did you have a train set?– What were the cars like?– Read poem “Freight Cars”

Sharing the World We Live In

• Visual aids and questions used to encourage clients to share personal stories

• Attempt to move focus to world as it currently is

– What are some uses of freight cars?– What other cars are in a train?– Show a picture of a train

Appreciation of the Work of the World• Get participants to think about pros and cons

of the topic• Help relate the topic to other things in the

world• Encourage to rediscover past hobbies or

occupations • Projections to the future are encouraged

– Who is the boss of the train?– What are the other jobs on the train?– What jobs are in the freight yard?– Which of these jobs would you like?

Climate of Appreciation

• Review what has been said

• Comment about how each person participated

• Than the people for attending

• Tell about plans for next session

Therapeutic Recreation Directory

• Has some activities for– Reminiscence– Remotivation– Sensory stimulation

Montessori Technique

• Relatively new• Originally with children• Now hybrid version for people with Alzheimer’s• Strength based philosophy• Engages person in meaningful activities• Bypasses deficits• Provides feedback on success to foster self-

esteem• Done 1-1

Concept

• The longer people practice strengths, the longer the skills last

• Theory of first in, last out

• Uses procedural memory vs. declarative– Declarative = episodic memory of past events & autobiographical

information– Semantic memory world knowledge, vocabulary

Procedural Memory

• Preserved abilities in dementia– Habits/skills (reading)– Location learning/environmental cueing– Motor learning– Classical conditioning– Repetition priming

• The ability to improve performance after initial exposure to information

• Montessori-based activities use procedural memory

Program Presentation

• Use cues and templates

• Materials should be set up left to right, top to bottom

• Always demonstrate what needs to be done

• Use as little verbalization as possible

• Use reading skills often– 48-font, plain words in written cues

Program Presentation

• Leader’s movements are slow

• Don’t overstimulate– Fidgeting, looking away, not interested

• Category sorts– Sort cards by suite, color with template– Dice with cue cards…can you roll the same

number? How many 5’s can you roll?

• No wrong answers

• Success is completion, not accuracy