Memory and Movement
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.
The following is a list of acronyms and meanings you will see in this post.
- AC: Activities Coordinator
- ADL: Activities of Daily Living
- ALF: Assisted Living Facility
- SV-ALF: Sunny View Assisted Living Facility (name changed to protect participants)
- CNA: Certified Nursing Assistant
- DPT: Doctorate of Physical Therapy
- LTC: Long-Term Care
- MCU: Memory Care Unit
- SCM: Special Care Manager
- UNC: University of North Carolina at Chapel Hill
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:
- Through literature review followed by trial, identify 5-10 unique activities that enable participation by older adults with severe memory loss.
- 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.
- Provide staff at an ALF with the education and materials needed to independently support an activity program in their memory care unit.
- 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.
- 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:
- A notebook with activity suggestions and directions for staff:
- Volunteer recruitment assistance:
- Volunteer Request Letter Template
- Recruitment of 4 regularly scheduled volunteers and 6 volunteers who provide occasional activity assistance
- Material Donations:
- Request and acquisition of 8 dolls including 4 from Paradise Galleries
- Used CD player donated by DPT classmate
- CDs with oldies music donated by committee members Drs. Fraser and Giuiliani and organized by category for easy use
- In-Service to Staff:
- Hour-long in-service offered to staff twice in one day
- Three handouts embedded in presentation link above
- In-service was created using health literacy considerations for expected audience
- Certificate of attendance provided to staff members
- Hour-long in-service offered to staff twice in one day
The following outcomes were identified for measurement in November with final counts obtained in mid-April.
- Number of activities provided without my assistance as reported by AC and Special Care Manager
- Average 1-3/week in November 2013
- Average 7-8/week in April 2014
- Number of staff assisting with or providing activities without my assistance as reported by AC and Special Care Manager
- Approximately 4/activity in November 2013
- Approximately 6/activity in April 2014
- Observation Guide Reports:
- Number of activities provided with my assistance.
- Number of residents present for activities.
- Number of residents who actively participated in activities for more than ten minutes.
- Number of staff present during activities.
- Number of staff assisting during activities.
- Descriptive log of activities provided with my assistance.
- Pre- and post- presentation survey completed by staff
- Final survey to staff to obtain their views on intervention effect
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.
- 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.
- 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.
- 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: http://www.ncbi.nlm.nih.gov/pubmed/12598862.
- 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: http://libres.uncg.edu/ir/uncg/f/L_Buettner_Promoting_2009.pdf. Accessed March 16, 2014.
- 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.