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Memory and Movement

Gabrielle Scronce

balloon toss


Thank you for visiting my UNC DPT Capstone site. The overall goal for my Capstone was to increase physical activity opportunities provided to residents with dementia in a Medicaid-funded Assisted Living Facility through staff education. This experience gave me a greater understanding of the influence of staff education, facility funding, and severity of disability in creating and sustaining positive changes for older adults in long-term care. I have briefly investigated these topics through previous courses, but the Capstone experience offered answers as well as new questions related to my professional interests in caring for older adults and people with neurological disorders. I look forward to receiving your comments and feedback about this project.

Acronym Guide
The following is a list of acronyms and meanings you will see in this post.

Older adults who participate in regular physical activity experience reduced disability and risk for falls with prolonged maintenance of function.1,2 People with dementia who participate in structured activities exhibit cognitive improvements, reduced depression, reduced apathy, and reduced agitation.3-5 The need for increased physical activity programming in the Memory Care Unit at “Sunny View Assisted Living Facility” was first identified in June 2013 when I assisted Carol Giuliani, PT, PhD in a presentation regarding exercise for care providers in long-term care facilities. Following the presentation, Dr. Giuliani and I received a request from two SV-ALF staff members for assistance with the development of a physical activity program in their facility. Community members and aging advocates in the triangle area reiterated the need for increased physical activity programming at SV-ALF, particularly in their locked unit for people with dementia called the Memory Care Unit or MCU. A visit with Dr. Giuliani to the SV-ALF MCU in November 2013 further illustrated a need for physical activity programming: a few residents wandered aimlessly up and down the windowless hallway while the majority sat in sagging chairs staring into space or with their foreheads resting on a tabletop.

First Literature Review
The first step in assisting SV-ALF with their physical activity program was to locate published literature related to exercise options for older adults in LTC. I compared two exercise interventions that I had observed during a clinical rotation at a continuing care retirement community: walking and yoga. Through my literature investigation, I determined that both walking and yoga exercise programs offer benefits to older adults in LTC. For a more detailed look at the results, please review the Initial Evidence Table, Initial Literature Review, and Initial Literature Summary.

Second Literature Review
My first visit with Dr. Giuliani to SV-ALF in November 2013 reinforced the need for physical activity programming but challenged the feasibility of a structured walking regimen or yoga class. In addition to the reality of residents with severe dementia, we were presented with another obstacle. The AC who had asked for assistance in June no longer worked for SV-ALF. The new AC had no experience developing activity programs for people with memory loss and expressed difficulty identifying activities to offer considering the facility’s limited  funding from Medicaid. The initial site visit and subsequent meetings with Capstone committee members helped me shape an intervention focused not on a walking or yoga program but on educating staff to offer physical activities appropriate for residents’ physical and cognitive abilities. A Second Evidence Table evaluates articles with interventions more applicable to residents at SV-ALF MCU.

After the clarifying introduction to Sunny View Assisted Living Facility MCU staff and residents, I identified the following personal and project goals:

  1. Through literature review followed by trial, identify 5-10 unique activities that enable participation by older adults with severe memory loss.
  2. Observe daily operations at Charles House Daytime Eldercare Center in Carrboro and Yorktown Charles House Eldercare Home in Chapel Hill to gain ideas for enriched and supportive programming for older adults with mental and physical care needs.
  3. Provide staff at an ALF with the education and materials needed to independently support an activity program in their memory care unit.
  4. Prepare and present an in-service on physical activity through activities of daily living (ADLs) to staff at an assisted living facility (ALF) that increases their understanding of the importance of physical activity for older adults with memory loss as demonstrated on a survey.
  5. Develop a letter/template for an assisted living facility that can be used to ask local churches and organizations for volunteers to provide residents with regular visitors, performances, and opportunities for engagement.

The educational intervention of this Capstone was directed to the Activities Coordinator, Special Care Manager, CNAs, and Medical Technicians who worked in the Memory Care Unit. These people provided all direct care for the residents since SV-ALF does not employee registered nurses, physicians, or therapists except through contract on a limited basis. There were two primary components of the educational intervention. The first was a weekly activity with a proposed gradual transition from 100% my responsibility to 100% staff responsibility. The second was a staff in-service to connect with staff who did not work at the time of my weekly Tuesday morning visits.

Weekly activity interventions as well as content of the staff in-service were based on evidence and through 13 meetings and consultations with UNC-CH faculty members, Capstone committee members, SV-ALF staff members, UNC-CH OT and PT students, and staff and participants from Charles House Association. Through these resources, I found evidence-based and time-tested interventions that applied to clinical work with people with dementia and could be easily shared with SV-ALF staff members. Despite the many resources, I did uncover gaps in evidence and knowledge. For example, few articles directly addressed physical activity for people in assisted living facilities with severe dementia. Articles that did address physical activity often required equipment and excess staff members not available at SV-ALF. Additionally, some activities recommended as popular with Charles House Association participants failed to elicit the same response from the SV-ALF population. In particular, reading and discussing current events, while interactive at Charles House, often contributed to drowsiness in residents at SV-ALF. The reason for this difference could be as simple as individual preference, but other possibilities could include differences in baseline educational status, progression of dementia, or environmental influences on behavior and participation.

Products created for this Capstone include the following:

The following outcomes were identified for measurement in November with final counts obtained in mid-April.

Qualitative reports from Sunny View Assisted Living Facility staff members and community experts on aging demonstrated an overall positive influence from this Capstone on physical activity programming for residents in the MCU. In fact, all 5 of my original objectives were met. However, quantitative reports from the final survey and staff in-service surveys did not suggest significant improvements based on my interventions.
The in-service provided an outlet for staff members to share frustrations and barriers to implementation of activities for residents. One barrier perceived by staff that I also experienced through my Capstone was the instability of the Activity Coordinator position at SV-ALF. The AC who initially asked for assistance in June was replaced by November. Another change in AC occurred in January 2014. The AC who began in January had admirable intentions and eagerness to improve activity programming in the memory unit, but by March she found her time stretched thinly with other responsibilities such as transporting residents to medical appointments and overseeing pest control in the facility. Other requirements of her job were so great that she was frequently unable to spend even one to two hours a week offering activities in the MCU while I was there. As a result, my hope to transition my once-weekly activities to her lead was not accomplished.

The lack of an Activities Coordinator who only coordinates activities has been explained by SV-ALF administration as the result of decreased Medicaid funding to the facility and therefore decreased staff to provide necessary services. Such cuts are felt by staff as well as residents. My approach to solving this problem was to recruit outside volunteers and to educate staff regarding physical activity methods that can actually save time such as asking residents to assist with folding laundry or asking residents to perform ADLs with as much independence as possible. Based on staff reports, it appears that visits from volunteers and a small increase in staff involvement have continued for at least one week after my Capstone intervention end-date. Volunteers have reported sharing my own sentiments of a compelling desire to offer movement and stimulation to residents at SV-ALF. These residents easily forget who or where they are, but this is not a reason for them to be forgotten by our community. Their lives have meaning, and they clearly experience joy and happiness as well as sadness and loneliness. With the right activities, we can bring smiles to residents who are sad and peace to residents who are restless. The ability to make this difference in the lives of people so vulnerable is as simple as it is special.

Last week, when I was asked by a resident, “Why are we here?” I replied, “We are here to take care of each other.” And we are.

I am grateful to many who contributed their time, knowledge, and energy to this project as I negotiated for the first but not last time the challenge of applying an intervention to real people(!): Sunny View Assisted Living Facility staff and residents; committee members Carol Giuliani, Cherie Rosemond, Mary Fraser, and Prue Plummer; Charlotte Terwilliger; Tom Generous; Renee and Cora Van Raay; Vicki Mercer; OT student Shannon Carey; and PT students Caitlin Gallagher and Austin Leedy.


  1. Baum EE, Jarjoura D, Polen AE, Faur D, Rutecki G. Effectiveness of a group exercise program in a long-term care facility: a randomized pilot trial. J Am Med Dir Assoc. 2003-03;4:74-80.
  2. Taylor L, Whittington F, Hollingsworth C, Ball M, King S. Assessing the effectiveness of a walking program on physical function of residents living in an assisted living facility. J Community Health Nurs. 2003;20:15-26.
  3. Buettner L, Kolanowski A. Practice guidelines for recreation therapy in the care of people with dementia. Geriatr Nurs. 2003;24(1):18–23; quiz 24–5. Available at:
  4. Buettner L, Fitzsimmons S. Promoting Health in Early-Stage Dementia Evaluation of a 12-Week Course. J Gerontol Nurs. 2009;35(3):39–49. Available at: Accessed March 16, 2014.
  5. Ahlskog JE, Geda YE, Graff-Radford NR, Petersen RC. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011;86(9):876–84. doi:10.4065/mcp.2011.0252.

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4 Responses to “Memory and Movement”

  1. Gabrielle Scronce

    Thank you so much for your incredibly kind feedback! I have Carol Giuliani to thank for the recommendation of combining staff comments into my power point presentation outline as well as for many, many other components of this Capstone.

    This was a touching experience, for sure. I should have guessed that you connect with my Capstone based on how your mother was the inspiration for yours! 🙂 Thanks again so much for your encouragement!

  2. Debra Gerber

    Hi Gabrielle,
    What a truly wonderful capstone project! I really enjoyed how you use the ppt format to convey how your workshop went and the staff comments – it’s clear you’re an effective facilitator. I admire your resilience, creativity, and perseverance in bringing this project forward, and was particularly moved by your story about how engagement and memory improved with the Paradise dolls. I vote your capstone the one with the most heart! You’re amazing!

  3. Gabrielle Scronce

    Hi Noelle,
    Thanks very much for your comments and questions. You bring up an excellent point about staff member participation. Their interest and interaction varied based on the individual staff member, but I noticed a trend toward active work during either assisting me or providing resident-care as time progressed. For example, when I first became a regular volunteer in December, only a few different staff members would assist with activities. There were often times when other staff members would play games on their phones (with volume on!), play music from their phones, or have boisterous conversations together that were not work related. As I became a more established part of Sunny View and the tried and true staff members continued to help me, I found that more staff were willing to help when they could. In fact, by the end of my project, nearly all staff members not specifically assisting residents with ADLs or medications would take at least a few minutes to encourage residents to dance, sing, or toss a balloon. This change in staff participation and perspectives was amazing to see.
    As for whether the program will be sustainable, that is a question that only time will tell. I know that staff as a whole appear to have changed at least a small amount toward an overall interest in offering activities. A major objective of my in-service was to empower CNAs and Med Techs to take activities into their own hands or to at least assist volunteers when they visit. At a minimum, I think staff have seen how much joy activities bring to residents, and I hope that they will offer activities more frequently just because they care about the happiness of the residents (and I believe they do.) The facility is in the triangle area, and I hope to visit occasionally for a quick game of balloon toss or dancing to oldies every so often. These visits will help me determine whether my program was maintained.
    Thanks again for your comments and questions!

  4. Noelle Martin

    This is a very well thought out and executed project! Your passion for helping older adults emanates through the website. It is exciting and inspiring to see! Thanks for sharing and bring the issues with the CH-ALF to life. I was unaware of many of these challenges with Medicaid and the condition of these older adults.

    It appears that you made a vast array of products that address many aspects of the resident’s lives. I especially like the notebook with activity suggestions. These are great and creative ways to facilitate interactions between the staff and residents. I think it is also great that you took the initiative to get volunteers involved. I hope they continue to implement all of your hard work!

    When looking at the observation guide report, I noticed that a number of the staff members present were not participating in the activities. Were they watching and learning or not interested? Overall, were they receptive to these activities with the residents or were they too concerned with other aspects of their job and the lack of resources? Do you think the staff will sustain this program?

    It looks like you have made a huge impact on the lives of the staff and residents! Great job!



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