an inTeRlink feature article

Linda L. Buettner, CTRS, Ph.D. and Joyce Ferrario, RN, Ph.D.

This research was completed with a National Alzheimer's Association Pilot Research Grant. Authors can be reached at Alzheimer's Disease Assistance Center, Decker School of Nursing, Binghamton University, Binghamton, NY 13902-6000

Alzheimer's disease is characterized by progressive cognitive impairment, associated functional decline, and often severe behavior problems( Warshaw, Gwyther, Phillips, & Koff, 1996). The interaction of these phenomena present challenges to all disciplines in the nursing home setting. Nursing staff and activities staff seem to have an especially difficult challenge of working together to provide integrated care and treatment of these individuals.

The purpose of this paper is to describe and discuss a study, funded by the National Alzheimer's Association, designed to assess the impact of an interdisciplinary intervention on the function and behavior of nursing home residents with dementia. The intervention, a highly structured program of sensorimotor activities developed by a recreation therapist, was integrated into the daily plan of care for the randomly selected experimental group and applied by both nursing and recreation therapy. Outcomes were assessed using standardized measures of cognitive status, function, mood, and behavior.

Literature review

Nursing home residents with dementia are especially susceptible to boredom unless special programs are provided to meet the residents' needs and interests. Cohen-Mansfield, Werner, & Marx (1992) found that nursing home staff felt boredom triggered agitated behavior 55 percent of the time. Cohen-Mansfield went on to note that it was during the time when the resident was unoccupied that the most problematic behavior occurred and during structured activities the fewest behavior problems occurred. It appears from this study that a full schedule of activities programs is important to reduce boredom and the agitated behaviors that often ensue.

A recent study of recreational interventions (Aronstein, Olsen, & Schulman, 1996) explored the feasibility of nursing assistants using recreational items as diversionary interventions for individuals with dementia and agitation. This study showed that an environment enriched with appropriate recreational items can provide stimulation and opportunities for interaction with others and thus less self stimulating or inappropriate behavior. Although the sample size was small and no control group existed, the study found that that recreational interventions are important adjuncts in the handling of boredom and agitation.

A randomized trial of dementia care (Rovner, Steele, Shumley, & Folstein, 1996) used a special activities day program within a nursing home, guidelines for psychotropic drug usage, and educational rounds focusing on the residents' status as an experimental intervention. The day activities program included music, crafts, exercise, relaxation, reminiscence, food preparation, and games designed for individuals with dementia. The goal of the program was to provide structure as well as mental and physical stimulation. The control group received the regular nursing home activities program of discussion groups, arts and crafts, entertainment, and bedside sensory stimulation. After six months the individuals in the experimental group showed a significant positive change in behavior disorders, less psychotropic medication and restraint usage, and were much more likely to participate in activities.

Another study (Buettner, Lundegren, Lago, Farrell, & Smith, 1996) evaluated two programs of activities on the behaviors of nursing home residents with dementia in a cross-over design. Residents were assigned to treatment Group A or treatment Group B. Group A received sensorimotor activities matched to functioning levels for four weeks, while Group B received a program of traditional nursing home activities. After four weeks the groups switched. Group B then received the sensorimotor activities based on functioning level and Group A received the traditional activities. The results showed that there was a significant improvement in grip strength, flexibility, and a reduction in agitation during functionally-based sensorimotor recreational programs for both groups. This brief intervention did not find any improvement in overall functioning, cognitive status, or agitation outside of program time. During the traditional program no significant changes were found in any variables. Additionally, this study made no attempt to train staff nor to involve other disciplines.

Although many clinicians and researchers have described the progression of Alzheimer's disease, and the functional decline that follows, specialized programs to slow the decline have not been tested. The research project reported in this paper goes beyond providing diversional items or group activities for older adults with dementia. It was designed with the interdisciplinary goal of maintaining or improving functioning. Each program component was designed to match the participant's current level of assessed functioning and to fit into the routine of the nursing home unit. Nursing and recreational therapy provided coordinated care and co-treatment to the experimental group.

Purpose of Study

The primary goal of this study was to enhance the physical and cognitive function and reduce problem behaviors in nursing home residents with dementia through a highly structured therapeutic recreation-nursing intervention. The intervention consisted of the design, implementation, and evaluation of an interdisciplinary program of activities based on the resident's assessed level of function that flowed into the routine of care. The treatment group received a special type of functionally-based sensorimotor programming (Buettner, 1988, Buettner, Kernan, & Caroll, 1990) known as neurodevelopmental sequencing (NDSP). The control group received traditional nursing home activities and a regular schedule of care. No attempt was made to integrate nursing programs.

A secondary goal of this project was to train the activities department staff to carry out this type of programming after the research project ended. It was hoped that the modelled education method used in this study would provide greater carry over value than previous nursing home interventions.

Method

Setting and Sample

Sixty-six individuals from a nursing home in rural upstate New York with a diagnosis of dementia had family consent and agreed to participate in this study. To be eligible to participate individuals could not be on the medication Tacrine, and had to be stable on other medications. Fifty-eight of the participants were female, eight were male. The average age was 86.2 years, with a range of 54-100 years. Average mental status score was 7.5 with a range of 0 to 19 on the Mini-Mental State Examination. All participants had been in the home for at least three months. The subjects were randomly assigned to either the treatment group (n=33) or the control group (n=33) by name draw without replacement.

Procedures

Baseline testing for the 30 week study was completed in November of 1994, with retesting every 10 weeks during the intervention (See Figure 1. for design and time table). Variables measured included: grip strength, flexibility, timed 50' walk, cognitive status, depression, overall functioning, and agitation. A team of master's level geriatric nurse practitioner students and therapeutic recreation students from outside the facility completed the cognitive, depression, strength, flexibility, and ambulation testing under the supervision of the principal investigators. The unit nurse managers evaluated overall functioning and agitation levels of the subjects. All evaluators for this study were blind to group assignment.

During the first 10 week period, the experimental group's therapeutic programs were designed by a certified therapeutic recreation therapist in collaboration with the unit nurse manager based on the residents' level of functioning, personal care schedule, and their past interests. Small activities groups (n=6-8) were established with residents of similar functioning levels. A certified therapeutic recreation specialist with extensive dementia training and experience implemented the program and trained the activities department staff and the nurses aides to assist during the first 10 weeks of the 30 week intervention. A coordinated schedule of care was established for the treatment group, which included all aspects of care and therapeutic programming (See Figure 2. Neurodevelopmental Sequencing Program). All staff were encouraged to walk with residents, interact socially, and promote functional independence during activities. For example, walking residents to and from programs became an activity as well as the program itself. All residents, regardless of functional level, received therapeutic programming and diversional activities/stimulation throughout the day and evening hours. Every aspect of the day was considered programming and was outcome based; hand-washing, walking to meals, dressing, exercise, cognitive games and other sensorimotor activities.

The control group received the regular schedule of nursing home activities and standard nursing care (See Figure 3. Traditional Program). The programs provided consisted of birthday parties, finger nail painting groups, entertainment, current events, bedside visits and sensory stimulation, bingo, visits with pets, and movies.

During the second ten week period the certified therapeutic recreation specialist worked closely with the activities department to co-plan and co-implement programs, with the nursing home staff taking over 50% of the programming. After 10 weeks of the therapist and nursing home activities department staff equally splitting the programming, retesting of all variables was completed by the evaluation team.

The final 10 week period was designed so the nursing home activities department staff took over all aspects of the programming, including planning and implementation. In addition, nurses aides were assigned to implement programming as well. The therapeutic recreation specialist served only as a consultant during this 10 week period. Final testing was completed by the evaluation team at the end of the 30 weeks.

Instruments

The Mini-Mental State Examination (MMSE) was used to determine each individual's level of cognitive functioning. Its convergent validity with other procedures has been documented as .902 or better (Folstein, Folstein, & McHugh,1975). It correlates highly with overall intellectual functioning, as measured with the Wechsler Adult Intelligence Scale (Farber, Schmitt, & Logue, 1988).

Cohen-Mansfield's Agitation Inventory (CMAI) was completed by unit nurse managers to evaluate overall agitation prior to any intervention, after 10, 20, and 30 weeks of programs. Validity correlations on the CMAI with independent psychometric and mental status tests were acceptable, ranging from .88 to .93 (Cohen-Mansfield, Marx, & Rosenthal, 1990). Interrater reliabilities were reported as .92.

Overall function as measured on one part of the Timed Manual Performance (TMP) instrument known as the "doors test"(Williams & Jones, 1990). Subjects are timed with a stopwatch as they open a variety of fasteners which are mounted on a 2 x 3 foot wood panel.

The computation of a validity correlation between the TMP and actual outcomes measures indicating level of care needed in a nursing facility, yielded a correlation of .95 (Williams & Jones, 1990). The interrater reliability achieved with staff using the instrument was .98. Overall function was also evaluated by nursing staff on the Multidimensional Observation Scale for Elderly Subjects (M.O.S.E.S.). The M.O.S.E.S. has a proven internal consistency reliability of .8 and satisfactory validity correlations with the Zung Depression, Kingston Dementia, and Physical and Mental Impairment of Function Evaluation(Helmes, Csapo, & Short, 1987).

The Geriatric Depression Scale was used to screen for depression in this study. It is a reliable, valid measure of depression that consists of 15 questions answered with yes or no answers. It has a 90% sensitivity in detecting depression in older adults (Yesavage & Brink, 1983).

Strength as measured using a research grade bulb-type hand dynamometer, was expressed in pounds of pressure. Flexibility was measured on the Modified Wells Sit-and-Reach test. Research on the sit-and-reach test yielded a validity coefficient of .90, with the standing bobbing test for flexibility as the criteria (Meyers & Blesh, 1962). Ambulation score was determined in a timed walk over a distance of 50 feet. The individual was timed using a stopwatch as he or she moved in a wheelchair, with a walker, or by walking over the marked distance unassisted. Interrater reliabilities for strength, flexibility, and ambulation were acceptable at above .90.

Results

During the study 12 residents died. Two additional subjects were not stable on their medications. The data from these 14 individuals were eliminated from the final data analysis.

The data were analyzed using a repeated measures analysis of variance to identify significant differences between groups, among time points, and the interaction between group and time.

The Between groups analysis tested for statistically significant differences between the control group and the treatment group regardless of the time element. The Time analysis tested for statistically significant differences among various time points regardless of group membership.

The Group and Time analysis tested for the interaction between group and time. Eight means were compared which involved two levels of the independent variable and four levels of the dependent variable. When group and time interaction is significant, post hoc tests are necessary to identify where the differences lie. Table 1. shows that the results for group and time were significant for all independent variables. Table 2. shows the results of the t-tests of independent samples (control experimental).

<INSERT TABLE 1. ABOUT HERE>

During the first 10 weeks of the study significant positive changes occurred for the subjects in the treatment group on the following variables: right and left grip strength, flexibility, levels of depression, levels of agitation, and cognitive status. Table 1 shows means and significance from baseline for all variable. For the control group there were several significant negative changes noted during the first 10 weeks, and mean scores for all variables were slightly worse than at baseline. The declines were significant for mental status, depression, flexibility, and right and left grip.

During the second 10 week period significant positive changes were again shown from the baseline scores for the subjects in the experimental group on the following variables: cognitive status, agitation, depression, flexibility, and right and left grip strength. Walking time did not significantly change during this period. For the control group mean scores for all variables continued to decline. These changes were significant for mental status, depression, flexibility, and right and left grip strength.

During the final 10 week period depression scores for both the control and treatment groups significantly changed for the worse. Mean strength and flexibility scores declined for both groups as well. Cognitive status showed significant decline in the control group. The treatment group's mean cognitive status score had declined to slightly below baseline measurements for the first time during the 30 week period.

<INSERT TABLE 2. ABOUT HERE>

Discussion/Conclusion

During the first 20 weeks of this 30 week study those residents in the experimental group improved on mental status, level of depression, right and left grip strength, flexibility, and levels of agitated behavior. Although the improvements in physical functioning were expected and supported findings from earlier studies (Eslinger & Damasio, 1986, Buettner, 1988, Buettner, Kernan, & Carroll, 1990, Buettner, Lundegren, Lago, Farrell, & Smith, 1996) the improvements in cognitive status were not expected. This may be the first study to show improvements in MMSE score and depression score without the use of medications. Beyond the variables selected for the study other improvements were also noted from a chart review of the individuals who took part. The residents in the experimental group experienced less falls, less restraints, less infections, and less weight loss that the residents in the control group over the course of the study. Past studies have found that significant improvements in behavior, strength, and flexibility (Buettner, et al, 1996) do occur with sensorimotor programming. Moreover, this study showed that by closely coordinating programs and care with nursing the individuals in the experimental group were busy throughout the day and using /maintaining skills that might normally be lost in a nursing home setting.

There is currently only one FDA approved medication to treat the cognitive symptoms of individuals with Alzheimer's disease (NIH, 1995). This medication is primarily for individuals who are in the early to moderate stages and has side effects that prevent usage for many. Although further research is needed in this area, the treatment of choice for individuals in the later stages may be prove to be highly structured and coordinated recreation therapy-nursing programs.

Unfortunately, the gains that were seen in the first 20 weeks were not maintained during the final 10 week period of the study. This was the period in which the nursing home activities staff was to take over leadership of the program. This finding may be due to the course of the disease, and may show that morbidity can only be compressed for 20 weeks. More likely, this type of programming may have been seen as a threat to current practice. The full support of nursing home administrators and the education of activities providers is needed to maintain interdisciplinary program approaches like this one. Despite the backing of the nursing staff the modelled training technique did not have a positive carry over value in this study.

We have begun to see the importance of therapeutic programs of activities in the care and treatment of older adults with dementia. Unfortunately, the intensity, frequency, and therapeutic value of programs for older adults with dementia varies widely (Buettner & Martin, 1994). This study points out the importance of recreation therapy-nursing teams and shows the powerful impact of interdisciplinary sensorimotor programming for older adults with dementia. In addition it gives some direction for program content and expected outcomes for therapists. Further research is needed to replicate the findings and examine the financial implications of this treatment approach. It is only then that nursing home administrators and reimbursement agencies will recognize the importance of this innovative approach to the care and treatment of older adults with Alzheimer's disease and the related disorders.

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Table 1. Repeated Measures Analysis of Variance: Group and Time Interaction

* significant at .05 level

** significant at .01 level

***significant at .001 level

Table 2: Results of t-tests for independent samples-group means

* Indicates that score is significantly different from baseline at .05 level

** Indicates that score is significantly different from baseline at .01 level

Means having same subscript are not significantly different at .05

Figure 1. Research Design and Time Table

REFERENCES

Aronson, A. Olsen, R., & Schulmn, E. (1996). The nursing assistants use of recreational interventions for behavioral management of residents with Alzheimer's disease, American Journal of Alzheimer's Disease,11(3 ), 26-31.

Buettner, L. (1988). Utilizing developmental theory and adapted equipment with regressed geriatric patients in therapeutic recreation, Therapeutic Recreation Journal,22 (3), 72-79.

Buettner, L., Lundegren, H., Lago,D., Farrell,P., & Smith,R.(1996). Therapeutic recreation as an intervention for persons with dementia and agitation: An efficacy study. American Journal of Alzheimer's Disease,12,(4), 1-8. .

Buettner, L., Kernan, B., Carroll, G. (1990). T.R. for frail elderly: A new approach. Global Therapeutic Recreation I.University of Missouri Press, 1, 82-88.

Buettner, L. & Martin, S. (1994). Never too old, too sick, or too bad for T.R.. Global Therapeutic Recreation III. University of Missouri Press,3, 135-140.

Cohen-Mansfield, J., Marx, M., & Rosenthal, A.(1990).Dementia and agitation in nursing home residents: how are they related? Psychology and Aging, 5,(1), 3-8.

Cohen-Mansfield, J., Werner,P., & Marx, M. (1992). Observational data on time use and behavior problems in the nursing home.Journal of Applied Gerontology,11, 114-117.

Eslinger, P. & Damsio, A. (1986). Perserved motor learning in Alzheimer's disease: Implications for anatomy and behavior. The Journal of Neuroscience, 6(10):3006-3009.

Farber,F., Schmitt, D., & Logue, P. (1988) Predicting intellectual outcomes from the mini-mental state examination. Journal of the American Geriatric Society, 38 (6), 506-510.

Folstein,M., Folstein, S., & McHugh, P. (1975) Mini-mental state: a practical method of grading the cognitve state of patients for the clinician. Journal of Psychiatric Residence, 12, 189-198.

Meyers, C. & Blesh, E. (1962). Measurement in physical education. New York: The Ronald Press.

National Institute of Health (1995). Alzheimer's disease: unraveling the mystery (NIH Publication No. 95-3782) Silver Spring, MD: ADEAR Printing Office.

Rovner, B., Steele, C.D., & Schumley, Y. (1996) A randomized trial of dementia care in nursing homes, Journal of American Geriatrics Society, 44 (1),7-13.

Warshaw, G., Gwyther, L., Phillips, L., & Koff, T. (1996) Alzheimer's Disease: An Overview for Primary Care, University of Arizona Health Sciences Center Publication.

Williams, M. & Jones, T. (1990). Predicting functional outcome in older people. Principles of Geriatric Medicine. New York, NY: McGraw-Hill Publishers.

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Traditional Program

Statement of Purpose: To facilitate opportunities for involvement in supportive, maintenance, and empowerment experiences.

Sample Goal Statements:

1. Resident will participate in sing-a-long one time weekly.
2. Resident will participate in chair exercise one time weekly.
3. Resident will sing at the monthly birthday party.
4. Resident will identify one additional activity preference in the next 90 days.
5. Resident will suggest one idea during resident council meetings in the next 90 days.
6. Resident will identify two familiar smells during sensory stimulation program.
7. Resident will stay in the program for 45 minutes.
8. Resident will state time, place, or person verbally daily during morning orientation.

Programming/Modalities Provided:

1. Sing-a-long/Rhythm band
2. Bingo
3. Sewing/Crafts Club
4. Monthly Birthday Parties
5. Finger Nails Grooming Group
6. Resident Council
7. One-to-one Sensory Stimulation
8. Morning Orientation Program
9. Entertainers or Pets visit

Neurodevelopmental Sequencing Program

Statement of Purpose: To facilitate the acquisition and (or) improvement of physical and psychosocial abilities as they relate to recreation participation and overall functioning. To facilitate an improved quality of life for older individuals with cognitive impairments and psychiatric disabilities (Buettner, 1988, Buettner, Kernan, & Carroll, 1990, Buettner & Martin, 1995).

Sample Goal Statements (goals are developed based on level of functioning):

1. Resident will improve strength as evidenced by an increase in monthly grip strength test score.
2. Resident will improve flexibility as evidenced by an increase in monthly sit-and-reach test score.
3. Resident will improve functioning during therapeutic recreation programs as evidenced by increased attention span.
4. Resident will improve self-mobility skills as evidenced by an improved ability to walk or wheel self to daily programs.
5. Resident will show improved means of emotional expression as evidenced by sharing objects/feelings in a small group, and (or) expressing herself through creative media one time per session.
6. Resident will display a decrease in agitated behavior during therapeutic recreation programs as evidenced by the CMAI score.
7. Resident will experience success and contentment during therapeutic recreation programs as evidenced by a pleasant expression and calm demeanor.
8. Resident will improve independent functioning in decision making and initiation of meaningful recreational activities as evidenced by an improved score on the R.T. observation chart in the next 30 days.

Programming/Modalities Provided:

1. Morning Dressing and Grooming - Nurses Aides
2. Cardiovascular Fitness through walking - CTRS
3. Morning Hydration - Health Assessment - Nursing
4. Pancake Cooking Group - CTRS
5. Graded exercise to music - CTRS/Activities Music Staff
6. Hydration and Snack Cart - Nursing and nurses aides
7. Sensory Air Mat Therapy - CTRS/Activities/Nursing
8. Sensory Handwashing Program/Sensory table cloths - CTRS/nurses aides
9. Outdoor dining/regular dining program -Everyone
10. Leisurely Look Newsletter Program- Nursing/CTRS
11. Sensory Stim Box Program/Gross Motor Arts & Crafts - CTRS/nurses aides/activities
12. Sensory Special Events - Everyone
13. Sensory Herb Garden/Adapted Garden
14. Sensory Cooking Program - Pie bakers, finger foods, blender cooking - CTRS
15. The Price is Right Cognitive Therapy/Feelings Group
16. Wanderer's Leisure Lounge (Area set up for independent leisure pursuits)-Everyone

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