Research e-journal Issue 11 (scientific version)
Which activities are most engaging for people with dementia living in care homes?
Clive Ballard, Professor of Old Age Psychiatry
Wolfson Centre for Age-Related Diseases, King's College London, Guy's Campus, London SE1 1UL
High quality approaches to providing meaningful and enjoyable activities are a key part of enabling people residing in care homes to 'live well' with dementia (Department of Health, 2009). This is also an important part of preventing and treating behavioural psychiatric symptoms associated with Alzheimer's disease. We know from several Alzheimer's Society research studies using Dementia Care Mapping, ie the collection of feedback from service users, that many care home environments are very unstimulating for people with dementia. For example, in an evaluation of 17 care homes across three regions of the country, people spent less than 13 per cent of the waking day engaged in any meaningful activity (Ballard et al, 2001).A subsequent study across 12 care homes suggested that people on average spent only two minutes a day participating in meaningful social interaction (Brooker, 2008). This clearly highlights that in many care home settings, the social needs of residents with dementia remain unmet. This sets up a negative social environment in which people are bored and frustrated, precipitating challenging behavioural symptoms such as restlessness, irritability and aggression and frequently leading to the prescription of sedative antipsychotic medication.
The benefits of participation in activitesJiska Cohen-Mansfield and colleagues have been international leaders in emphasising and evaluating the benefits of simple activities and interactions such as conversations, joint participation in games or physical activity, and personalised music. The group have conducted a couple of excellent randomised controlled trials demonstrating that these interventions are significantly more effective than usual care in improving overall symptoms of agitation (Cohen-Mansfield et al, 2007), and the specific distressing and troublesome symptom of shouting (Cohen-Mansfield et al, 1997). Relatively short periods of shared activity and social interaction achieved a 25 per cent improvement in behavioural symptoms. The interventions were based upon a standardised framework, but personalised to the current interests, previous occupation and interests, cognitive and functional abilities, and symptoms of the individual.
Although these approaches have been very successful, they do rely upon a certain level of understanding of the principles of person-centred care by the care staff and also rely upon a certain investment of time in planning and delivering the intervention. These approaches are therefore likely to be most successful in care settings where person-centred care training is already in place. Whilst this is an important goal, it is also important to develop approaches that require less skill to implement and can be undertaken with less time commitment from care staff.
Brief Psychosocial Therapy (BPST)
One approach to try and tackle this problem is to simplify the intervention. Brief Psychosocial Therapy (BPST), is a more structured method for implementing social interaction based upon the same principles. A therapist works with a member of care staff in a residential or nursing home to help them plan and implement a ten minute a day social interaction programme.
The intervention uses a very simple set of principles, based upon the Cohen-Mansfield intervention. The therapist provides structured help to plan the details of the intervention, provides further telephone contact to help refine the intervention, and offers positive feedback to reinforce the intervention. The therapy provides a regular social interaction to the person with dementia, but also teaches the care assistant skills to enable more positive communication. This provides a social environment to facilitate the development of a more person-centred relationship between the care assistant and the person receiving the therapy.
BPST was developed to use as a four-week psychological therapy in the CALM-AD trial, jointly supported by the Medical Research Council and Alzheimer's Society. This trial was predominantly designed to test whether donepezil (Aricept) was more beneficial than placebo in the treatment of clinically significant agitation in people with dementia (Howard et al, 2007). However, as a first stage, participants received a four-week BPST intervention. The intervention was successfully delivered to more than 90 per cent of the 200 people eligible to receive the therapy, and those individuals experienced a significant improvement (6 points or higher) on the Cohen-Mansfield Agitation Inventory (Ballard et al, 2009). As there was no placebo intervention for this lead-in phase of the trial, it is difficult to know whether this was more effective than doing nothing or some other intervention. What it does show us however, is that if we follow the recommendations of most good practice guidelines and implement a simple psychological intervention for four weeks, it is safe, and overall people will experience a significant benefit avoiding the need for drug therapy. The study also demonstrated that it was feasible to successfully deliver this simple and practical psychological intervention in a wide range of typical UK care home settings.
Cohen-Mansfield and colleagues have taken a different and innovative approach. They assessed the degree to which people with dementia are 'engaged' with different types of activity and interaction (the Observational Measure of Engagement, Cohen-Mansfield et al, 2010). This was measured by looking at a combination of the positive impact that the activity had on the person's mood, and the length of time which the person would continue to undertake the activity. Their goal was two-fold, firstly to provide an evidence base to enable the selection of the activities that are perceived most positively by people with dementia, and secondly to investigate whether activities that do not involve such a high degree of one-to-one input from carers can also be engaging.
One hundred and ninety-three residents with dementia living in seven Maryland nursing homes participated in the study. Engagement was assessed using the Observational Measurement of Engagement with specially designed software installed on a handheld computer. Ratings include: attention to the stimulus during an engagement trial (four-point scale: not attentive to very attentive); attitude to the stimulus during an engagement trial (seven-point scale: very negative to very positive) and duration (the amount of time that the participant was engaged with the stimulus). Stimulus presentation ended after 15 minutes or whenever the study participant was no longer engaged with the stimulus.Each participant was presented with 25 predetermined activities during a three-week period (approximately four activities per day). Activities were categorised as:
- live social stimuli, which included a real dog, real baby, and one-on-one socialising with a research assistant;
- simulated social stimuli, which included a lifelike (real) baby doll, childish-looking doll, plush animal, robotic animal, and a video;
- a reading stimulus, which included a large-print magazine;
- manipulative stimuli, which included a squeeze ball, tetherball, expanding sphere, activity pillow, building blocks, fabric book, wallet (males)/purse (females), and puzzle;
- a music stimulus, which included listening to music;
- artistic task-related stimuli, which included flower arrangement and coloring with markers;
- work-related stimuli, which included stamping envelopes, folding towels, and an envelope sorting task;
- and two different self-identity stimuli that were matched to each participant's past identity with respect to family, occupation, hobbies, or interests.
The results were interesting. The most engaging activities were those involving social interaction, either one-to-one conversation, a visitor with a dog, or a visitor with a real baby. Simulated social interaction, using videos or a lifelike baby doll, or physical activities which were not facilitated by a carer were less successful. The other interesting finding pertained to work-like activities, such as folding towels, stamping envelopes and sorting jewellery. Although less positive than social interaction, these activities did confer a modest positive effect, but more importantly they engaged a substantial proportion of people for the full 15 minutes of the intervention. This probably reflects people's attitudes to work more generally, and potentially offers significant advantages compared to an individual feeling unoccupied, isolated, distressed, bored or exhibiting symptoms of agitation. It also has the advantage of requiring substantially less carer time to implement the activity, although it does potentially raise some ethical issues relating to 'pseudo-work' tasks.
Meeting the social needs of people with dementia is a high priority to help people live well with dementia and to improve and reduce the emergence of behavioural symptoms such as agitation, restlessness and aggression. Important recent work from Jiska Cohen-Mansfield and colleagues clearly demonstrates that social interaction, either involving conversation or visitors with a baby or pet, are the most stimulating and engaging activities conferring a positive mood and engaging people for significant periods of time. This helps considerably when we are planning interventions to maximize the benefits of activities for people with dementia in care home settings.
Approaches such as BPST have been developed and successfully implemented, to enable social interaction to be delivered as part of routine care in a simple, structured and pragmatic way. Jiska Cohen-Mansfield's work also suggests that work-like activities may provide another opportunity to engage people with dementia and reduce feelings of isolation and distress, which should perhaps be considered as an addition to, rather than as an alternative to, social interaction.
- Ballard C, et al (2001). 'Quality of care in private sector and NHS facilities for people with dementia: cross sectional survey', BMJ 323:426-7.
- Ballard C, Brown R, Fossey J (2009). 'Brief Psycho-Social Therapy (BPST) for the treatment of agitation in Alzheimer's disease (The CALM-AD Trial)', American Journal of Geriatric Psychiatry 17(9):726-33.
- Brooker D (2008). 'Development and evaluation of a multi-level activity-based model of care', Alzheimer's Society E-journal Issue 5.
- Cohen-Mansfield J et al (2007). 'Nonpharmacological treatment of agitation: a controlled trial of systematic individualized intervention', J Gerontol A Biol Sci Med Sci 62:908-916.
- Cohen-Mansfield J, Werner P (1997). 'Management of verbally disruptive behaviors in nursing home residents', J Gerontology Series A-Biological Sciences & Medical Sci 52:369-77.
- Cohen-Mansfield J et al (2010). 'Can persons with dementia be engaged with stimuli?', American Journal of Geriatric Psychiatry 18(4):351-62.
- Department of Health (2009). Living well with dementia: A National Dementia Strategy.
- Howard RJ et al (2007). 'Donepezil for the treatment of agitation in Alzheimer's disease', N Engl J Med 357:1382-1392.