Facilitating meaningful activity for people with dementia within residential facilities

Facilitating meaningful activity for people with dementia
The development of credible health innovations are the result of research and experimentation (Australian Institute of Health Innovation AIHI 2005). This essay examine a health innovation within the social environment. The innovation involves facilitating meaningful activity for people with dementia within residential facilities. This exploration will begin with a description of the innovation, followed by a critical analysis of supporting evidence. Finally, a synthesis will be presented of recommendations for individual and group practice, based on the evidence presented.

Dementia is a collection of symptoms resulting from specific diseases and conditions which affect the brain, for example; Alzheimer’s disease (Morris & Morris 2010, p. 3). Symptoms of dementia include various degrees of cognitive and memory decline, as well as decline in the ability to communicate (Cohen-Mansfield, Parpura-Gill & Golander 2006, p. 202). This historical ‘biomedical’ understanding of dementia focuses on the degenerative and irreversible aspects (O’Connor et al. 2007, p. 121). Morris & Morris (2010, p. 85) highlight that this biomedical view of dementia is still evident in today’s society, whereby health care service delivery is focused on individuals’ ‘physical’ health status.

Self-identity is defined as the perception of the roles individual’s espouse throughout their lifetime with growing evidence suggesting that self- identity can survive throughout dementia including the later stages (Cohen- Mansfield, Parpura-Gill & Golander 2006, p. 202). Facilitating meaningful activity for people with dementia has grown from this research, showing that it can lead to improved ‘wellbeing’, a term which encompasses an individual’s achievement of a satisfactory existence (Harris, Nagy & Vardaxis 2006, p. 1827). As such, the notion of ‘facilitating meaningful activity’ involves the recognition of the importance of expressing self identity and individuality through developing and participating in meaningful occupation and activity which brings meaning to each individual. Facilitating meaningful activity involves assisting people with dementia achieve personal goals of activity, made meaningful through aligning them to their individual values, past roles, interests and cognitive ability (Harmer & Orrell 2008, p. 552).

It is important to critically analyse evidence surrounding the facilitation of meaningful activity to people with dementia, in order to discuss the benefits to people with dementia in residential facilities. A qualitative study undertaken by Clare et al. (2008) analyses the subjective experience for people with moderate to severe dementia living in residential care facilities. 10 facilities were incorporated, increasing the generalisability of the results (Crookes and Davies 2004, p. 86). Interviewed were 71 people with moderate to severe dementia, calculated through utilising the Mini- Mental State Examination (MMSE). The results are presented in three broad themes. The theme ‘nothing’s right now’ was conveyed by 89% of participants, which showed expressions of; suffering, loss, isolation, fear, worthlessness, and loneliness (Clare et al. 2008, p. 714). Feelings of loss were associated with loss of abilities, loss in participating in meaningful contribution and sense of little control of one’s own life (Clare et al. 2008, p. 716).

The theme ‘ I still am somebody’ extrapolated from 76% of participants has particular relevance to facilitating meaningful activity, whereby participants showed reflection of ones life and self- identity. The theme ‘it drives me mad’ extrapolated from 48% of participants, showed feelings of frustration, anger and boredom and a desire to engage in appropriate activity. Clare (2008) demonstrates that people with dementia living in residential care experience emotions of loss in life engagement and experience loneliness and boredom. The research in Clare (2008) indicates that residents with dementia living in facilities express a desire for meaningful activity and occupation. This research gives evidence to the value of engaging in appropriate activity from the perspective of people with dementia living within residential facilities.

A study undertaken by Harmer and Orrell (2008) explores the concept of meaningful activity for people with dementia within residential aged care facilities. 17 residents, 8 family members and 15 staff were included in 3 separate focus groups, from a range of 3 residential aged care facilities. Residents expressed enjoyment in engaging in reminiscence, whereby they talked about past experiences, roles, occupations (Harmer & Orrell 2008). Secondly residents expressed value in social engagement, particularly in the involvement of ones family. Some individuals expressed the value and interest in previous activities and roles, as well as the lack of opportunity, sense of boredom and poor opportunity for quality interactions (Harmer & Orrell 2008, p. 552).

In response to questioning what focus groups thought made activity meaningful, many residents responded that it involved enjoyment, feeling a sense of belonging and identity connected to their values and beliefs and past roles as well as inclusion in social interaction. Activities which matched cognitive needs were seen as meaningful (Harmer & Orrell 2008, p. 553). A limitation to this study includes the small sample which may impact on statistical significance and generalisability of results. This research makes evident that from the perspective of people with dementia, engaging in meaningful activity encompasses more than simple activity, but more so; leisure, sense of purpose and adds value to a person’s life.

Cohen-Mansfield, Parpura-Gill and Golander (2006) examined the effect of the implementation of identity specific activities for people with dementia. The sample size included 93 people throughout various stages of dementia. The sample size is statistically significant improving confidence in the results (Crookes & Davies 2004, p. 101). Participants, families and caregivers were interviewed in order to collect information about the individual’s role identity, perception of the importance of role identity and cognitive ability and wellbeing. The intervention (activity) was then individually determined from the interview. An example of an intervention includes constructing a family tree for grandchildren, for a person who stated importance of the family- social role.

The results showed that people who received treatment of the individualised activity, had a greater sense of pleasure and interest while performing the activity than the control group who were performing usual activities. In regards to involvement, the treatment group showed significantly greater levels of involvement in activity than did the control group. Disorientation was slightly decreased in the treatment group throughout the intervention. Agitation was decreased for the treatment group, yet no decrease in agitation was observed in the control group (Cohen-Mansfield, Parpura-Gill & Golander 2006).

Cohen-Mansfield, Parpura-Gill and Golander (2006) provide evidence that through the provision of individually developed activities for people with dementia, which incorporate self- identity, then interest, pleasure and involvement are increased and disorientation and agitation are reduced. A limitation to the study includes only including two facilities, possible decreasing generalisability of results. This study shows that providing meaningful activity can significantly improve the wellbeing and quality of life of people with dementia.

Brooker, Woolley and Lee (2007) discuss the implementation of the innovation of facilitating meaningful activity, through a broader innovation, known as the ‘Enriched Opportunities Program (EOP)’. Brooker, Woolley and Lee (2007, p. 361) set an aim to examine the effects 12 to 24 months after the implementation of the EOP program in three dementia specific aged care facilities in the United Kingdom (UK), incorporating 99 residents. The Dementia Care Mapping (DCM) tool was utilised- an observational method of data collection in aim to see the perspective of people with dementia (Brooker, Woolley & Lee 2007, p. 361). However a limitation to this method of data collection includes the chance of the ‘Hawthorn effect’, which is when the subjects may change their behaviour due to observation of the researchers and lack of blinding (Crookes & Davies 2004, p. 228). Results showed a reduction in depression levels and improvement in wellbeing. This implementation of the innovation of facilitating meaningful, individualised activities gives evidence that it can be achieved and that wellbeing and quality of life can be improved.

It is also important to discuss the cognitive abilities of people with dementia, in considering facilitating meaningful activity. A study undertaken by Chung (2004) examines activity engagement and participation of people with dementia. The study sample included 43 participants across six aged care facilities. Results showed that the people with severe dementia were more likely to withdraw and be isolated (Chung 2004, p. 30). People with mild to medium severity dementia, were more likely to be engaged in activities provided in the facilities (Chung 2004, p. 30). A limitation to the study includes that the participants were divided into three groups of level of severity of dementia which equated to a relatively small sample size per group, hence this may decrease the generalisability of results to the wider population (Crookes & Davies 2004, p. 101). The study gives evidence that in order to facilitate engagement and make activity ‘meaningful’, it must be tailored to each individual’s cognitive abilities.

The evidence presented gives rise to resulting recommendations for the improvement of practice of oneself and further health providers. The first recommendation includes the movement towards understanding the importance of holistic health provision. Within this it is crucial to acknowledge that facilitating meaningful activity has been shown to improve wellbeing for people with dementia in residential facilities (Brooker, Woolley & Lee 2007, p. 361). Not only can this recommendation be focussed towards solely the dementia care facility, but it can be generalised for an improvement in practice across all settings. The next recommendation includes individualising activity for people with dementia. Cohen- Mansfield, Parpura- Gill & Golander (2006) made evident in their research, that individualising activities incorporating self-identity, roles and attributes of the person into the facilitation of activity can assist in increased; pleasure, involvement and interest, and self awareness, as well as decreased agitation.

The individualisation of treatments can be facilitated through comprehensive assessment with the person with dementia as well as collaboration with the persons family, in assisting determine the importance and priority of identity roles, values and purpose for that person in the facilitation of meaningful activity (Cohen- Mansfield, Parpura- Gill & Golander 2006). As made evident in Cohen- Mansfield, Parpura- Gill & Golander (2006) collaborating with family can assist determining the most important past roles, occupation, values and interests. In the development of meaningful activity, it is important to provide the recommendation of incorporating cognitive capabilities as Chung (2004) made evident that different abilities determined levels of participation and engagement. Important is to match abilities of the resident with activity development, as overstimulation can cause confusion and under stimulation can cause agitation and boredom (Morris & Morris 2010, p. 98).

Another recommendation for implementation includes acknowledging the importance of quality social interactions and the importance of social inclusion, thus facilitating this in activity planning (Harmer & Orrell 2008, p. 554). This can be achieved through collaborating with community recreation programs, which can result in residents feeling improved sense of; belonging, social inclusion and needs fulfilment (Dupuis, Smale & Wiersma 2005, p. 293). Quality social interaction can also be achieved through developing a sense of community within the residential setting, through introducing residents to one another and encouraging group interaction.

Facilitating meaningful activity for people with dementia has shown to be valid. Presented evidence has shown that improved wellbeing can result from facilitating meaningful activity for people with dementia. Recommendations for practice have incorporated the importance of holistic assessment of individuals including self identity, roles, psychological capability, social inclusion, incorporating family collaboration. In influencing others’ practice this paper has explored five key attributes to successful innovation in transferring evidence and facilitating change and sustainability, and how this may be done within the innovation of facilitating meaningful activity for people with dementia.

Appendix: Learning and implications for present and future clinical practice
Through the understanding of the traditional ‘biomedical’ model of health care provision, I have acknowledged the gap between this traditional care and the evidence based best practice of providing holistic care. This has shifted my clinical assessment and decision making to incorporate a more elaborate approach including individual person’s priorities. One way in which I have put this into practice is by communicating with an individual resident and family discussing their previously enjoyed activity of ‘bingo’. In this scenario the resident identified the previous enjoyment of playing bingo with her friends. Another way I will utilise this learning is through active goal setting, collaborating with the people to develop and facilitate meaningful activity. In the mentioned scenario I identified that this was an enjoyed activity and consequently discussed with the diversional therapist this expression of interest who then developed a ‘weekly bingo playing group’, which ultimately assisted in the reduction of boredom for this resident and an increased engagement interacting within the social residential community .The third component applicable in practice includes utilising evidence-based material to develop best practice. A way in which I demonstrated this is by critically analysing the paper by Cohen-Mansfield, Parpura-Gill & Golander (2006) and suggesting the validity of these results for current practice. From this I learnt to individualise activities, such as the circumstance whereby I engaged with a person in a conversation about horticulture as many cues such as; pictures of flowers and plant books around the person’s room indicated the interest.

Acknowledgements
The original version of this essay was by Lara Moriana and was a prize winner NSW/ACT Dementia Training Student Centre essay competition, 2011.