Adapting Activity Settings For Residents With Dementia

Council Close-Up continues its series on educational sessions featured at the World Alzheimer Congress in Washington D.C. that pertain to the needs of activity professionals. Kevin M. Kavanaugh, the Council's Director of Public Affairs, joined over 5000 scientists, physicians, and care professionals at the World Alzheimer Congress to share innovations and hear about the latest findings regarding the diagnosis, treatment, and care of persons with dementia. This week's Close-Up issue focuses on adapting activity settings for residents with dementia to enable their successful participation in recreational programs.

Planning and Organizing Settings to Promote Effective Activity/Entertainment Programs

Chari K. Weber, I.D.E.A.S., Inc., Rome, Ohio

Mark A Proffitt, Dorsky, Hodgson and Partners, Cleveland, Ohio

The best activity program in the world will fail miserably if the participants are unable to get to the program easily, feel confused and uncomfortable in their surroundings, cannot see what's going on, or cannot properly hear the proceedings.

How do you design an activity environment so that it meets the needs of the elderly -- many of whom have difficulties with their eyesight, hearing, and cognition? Interior designer Chari Weber and architect Mark A. Proffitt offered many practical ideas for successful activity environmental planning during their seminar at the World Alzheimer Congress.

The speakers divided their education session into six sections based on important questions that should be asked in assessing any activity environment. Their recommended questions and proposed solutions are as follows:

Question One: How do you get people to the activity program?

The challenge of encouraging residents to attend activities may begin with the difficulty of these individuals getting to the activity room in the first place.

Persons with dementia face many problems in navigating their environment. Finding one's way around a building can be very hard if the hallways and common areas all look alike. Imagine how confusing these similar-looking hallways and rooms must be for persons with dementia -- who can become easily frustrated as they struggle to make their way through the nursing home.

The speakers suggest that these residents need more distinct visual cues that differentiate one area from the next. For instance, a wall hanging, a display case and a grandfather clock are three suggested items that can help make a hallway easier to identify.

It may be helpful to place photos of the residents when they were younger on their room doors to help them identify their own rooms. Why pictures of when they were younger? It is because these residents may be "living in the past" and can only recognize themselves as they looked years ago. Perhaps it would be beneficial to put their old street address on their doors -- for instance, they might recognize their room if it was labeled "4230 N. Lowell Avenue" -- their Chicago home address from the 1950's.

Residents might find handrails impossible to use because of obstructions. Make sure that there are not wheelchairs, dining carts, or med carts blocking the residents' ability to use the handrails. Another challenge is proper illumination -- the speakers pointed out that an elderly person requires five times the amount of light as a normal adult to see clearly. Be sure to turn on all of the lights in the hallways, resident rooms, and activity areas.

Because of language impairments, residents with dementia may have difficulties understanding what is being verbally expressed. They might not understand the words "Grace, I would like to invite you to the gardening club." Visual cues can help these residents understand verbal messages. For instance, an activity person could bring in a potted plant with a small gardening shovel to trigger the resident's recognition that she is being invited to a gardening activity.

The activity calendar should be low enough on the wall so that it can be read by persons in wheelchairs. Because many residents have vision impairment, the lettering on the calendar should be big and bold. Graphics and "visual clutter" should be minimized -- the calendar should be laid out simply and clearly so that its information is easily read and understood.

Question Two: Does the activity setting make sense?

The speakers point out that the typical activity room means everything to everybody. It is usually a non-descript room with assorted tables and chairs, with few visual cues of the activities that are to take place within its confines. For persons with dementia, this lack of visual description can be disorienting -- they need to see examples of what will take place within their environment.

For instance, can the activity room be divided up into smaller activity areas? As Alzheimer's experts note, smaller group activities are necessary when working with persons who have dementia -- they help keep residents focused, attentive, and involved. Clusters of furniture and simple partitions can help divide up the activity room into smaller group settings.

Each activity area should be made visually distinct -- consider the use of simple props in achieving this goal. For example, pans and utensils could be out for the baking group, dominos set up for the games group, craft materials on hand for the arts group, and a laundry basket with baby clothes waiting for the folding group. The activity leader could have pictures on the wall relating the activity to take place -- such as pictures of pastries for the baking group.

The speakers point out that these visual cues should be ready when the residents walk or wheel themselves into the activity area, not just simply passed out after they sit down. They recommend that activity leaders train their staff to set up these props beforehand in helping residents with dementia understand the activity to take place and their role in the activity.

Question Three: Is the activity setting quiet?

Maintaining a quiet setting is probably the biggest challenge for the activity professional. Many elderly residents have problems with their hearing and cannot understand what is being said to them, especially if there is a lot of background noise.

The speakers recommend taking whatever steps are possible to maintain a quiet activity setting. Make sure televisions and radios are turned off. Keep the doors of the activity room closed.

Consider posting a sign "Quiet please. Activity program in session." It's important to educate staff members in other departments to respect the activity programs that are taking place and to keep noise levels to a minimum. If it's comfortable for the residents, turn down noisy air conditioning units. When possible, turn down the volume level on the paging system.

From an interior design standpoint, there are some tricks of the trade in maintaining a quiet environment. Carpeting helps to muffle noise. Wall treatments are available that reduce noise levels. Furniture in the activity area should include the use of softer fabrics. In addition, some nursing facilities are eliminating overhead paging systems altogether and are using cell phones to maintain a calm and quiet environment.

Question Four: How well can people see?

With their vision impairments, elderly residents can find the nursing home to be a very blurry and frustrating place to navigate. Compounding this challenge is the fact that many persons with dementia have a hard time processing the visual information they see. Hence, every effort should be made to make help residents see their environment more clearly.

The speakers suggest that activity areas have increased levels of lighting to enable residents to participate in activities more successfully. Directional lighting, such as the use of a lamp, can help focus illumination on a specific activity to make involvement easier for the residents.

Glare can easily impair a resident's ability to see. Activity staff should make sure that there is not sunlight glare coming through the windows. Glare can also be present on an activity area's tile floor, impairing resident eyesight and mobility. Activity staff should adjust blinds or drapes if there is too much glare coming into the activity area.

Proper contrast between surfaces is extremely important. For instance, a white plate can "disappear" against a white tablecloth or placemat. Surfaces and objects in the activity area should have contrasting colors to increase visibility.

When persons with low vision make sudden changes from a dark atmosphere to a light one, their eyes have difficulty making the adjustment, and they may experience temporary vision loss. To prevent this complication, try to keep lighting levels even within the activity environment. Three-way bulbs, high-low switches, and dimmer switches can be used to help residents easily control the brightness of the light and make it easier for their eyes to adjust.

Question Five: How do you keep the activity going?

The speakers addressed some additional areas of practicality when planning an activity environment. They recommend that activity areas should always have an adjacent rest room -- residents shouldn't have to go down the hallway to go to the bathroom. In addition, there should be proper storage areas for activity supplies. They recommended including extra shelving, cupboards, bookcases, and closet areas to ensure that there is enough room for all of the supplies that the activity department uses.

The activity area should include furniture that is appropriate to the needs of the elderly. Table heights should be adjustable, to allow clearance for seat arms and wheelchairs.

Chairs should have seats that are high enough, so that residents can more easily get up from their chairs. Activity staff can use foam pads to make existing chair seats higher and to promote resident comfort. The chair cushions should be made of softer fabrics -- there are many fabrics available now that are resistant to stains. These cushions should not be made of vinyl or plastic.

Safety is an extremely important consideration. Make sure that chairs and wheelchairs are not crowded together -- there should always be enough aisle space so that residents can easily get out when necessary. Before every activity, be sure to plan exactly where residents will sit to ensure their comfort and safety.

Extension cords can be very hazardous -- make sure to tape down cords used for an activity so that residents don't trip. Remove any excess clutter from floors to prevent falls. Spills should be wiped up from floors as soon as possible -- set up "wet floor" signs when necessary, such as when an incontinent resident has had an accident. Make sure that such potentially dangerous objects such as knives, scissors, and coffee urns are properly supervised.

Question Six: How do you make the activity setting fun?

The speakers had several creative suggestions on how to make an activity room an attractive setting that will appeal to the tastes, interests, and backgrounds of the residents.

Their first recommendation was an important one -- the activity room should be adult-like in design. Every effort should be made to ensure that the activity area does not seem "child-like." For instance, resident artwork should be presented in a tasteful fashion -- such as having these pieces matted and/or framed.

Facilities can have display cases for art pieces created by the residents or collections reflecting their interests -- such as displays of resident figurines, hats, or jewelry. One nursing facility displayed a collection of the telephones used years ago!

The design of the activity room can reflect the generation of residents for which it serves. For residents that grew up in the 1920's and 1930's, the activity setting can feature reminders of their era -- such as pictures of the "flapper" generation doing the "Charleston" dance, a book about Chicago's "River-view" amusement park on a table, or a room set up like an old-fashioned ice cream parlor.

Perhaps a specific activity area can have a masculine or feminine flair. For instance, an area used for the men's club could feature a pool table, comfortable high-back chairs, and sports and car magazines.

Regional and ethnic backgrounds can be incorporated into interior design decisions. For residents in a small town setting, the activity areas could feature country-like furnishings. A nursing facility serving a primarily Oriental population may want to include such items as fans, orchids, dragons, and calligraphy in its environmental design.

In planning an activity setting, it is crucial to consider the challenges elderly residents face with their eyesight, hearing, and cognition. Activity leaders should in-service their staff about these challenges -- and suggest creative solutions on what can be done to help these residents. Many of the strategies recommended by the speakers at the World Alzheimer's Congress are practical ideas that can make a world of difference in providing a safe, sensible, and comfortable environment for residents with dementia. [pro/newsletters/closeup_new/_private/cufooter.htm]