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THERAPEUTIC RECREATION-NURSING TEAM:
A THERAPEUTIC INTERVENTION FOR NURSING HOME RESIDENTS WITH DEMENTIA
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.
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
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.
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.
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
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.
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
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.
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>
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
Table 1. Repeated Measures Analysis of
Variance: Group and Time Interaction
||Time and Group
* significant at .05 level
** significant at .01 level
***significant at .001 level
Table 2: Results of t-tests for independent
* 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
||Testing on all variables - assignment to experimental
or control group
||CTRS - Nursing Design and Implement Coordinated
Program for Experimental Group - Activities Dept. Staff Assisted
Control Group received regular nursing home
||Re-testing on all variables
|Week 11-20 -
||CTRS and Activities Dept. 50% each Implement
Coordinated Program with Nursing
Control Group received regular nursing home
||Re-testing on all variables
|Week 21-30 -
||Activities Department Staff and Nursing Implement
Control Group received regular nursing home
|Week 30 -
||Re-testing on all variables
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).
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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.
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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,
Meyers, C. & Blesh, E. (1962). Measurement
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disease: unraveling the mystery (NIH Publication No. 95-3782) Silver
Spring, MD: ADEAR Printing Office.
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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,
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functional outcome in older people. Principles of Geriatric Medicine.
New York, NY: McGraw-Hill Publishers.
A†degree†in†nursing†can position you for a long career in any region of the country. One of the most convenient ways to earn your Master's in Nursing Degree is through an accredited online†nursing degree program.
Statement of Purpose: To facilitate opportunities
for involvement in supportive, maintenance, and empowerment experiences.
Sample Goal Statements:
- Resident will participate in sing-a-long
one time weekly.
- Resident will participate in chair exercise
one time weekly.
- Resident will sing at the monthly birthday
- Resident will identify one additional
activity preference in the next 90 days.
- Resident will suggest one idea during
resident council meetings in the next 90 days.
- Resident will identify two familiar
smells during sensory stimulation program.
- Resident will stay in the program for
- Resident will state time, place, or
person verbally daily during morning orientation.
- Sing-a-long/Rhythm band
- Sewing/Crafts Club
- Monthly Birthday Parties
- Finger Nails Grooming Group
- Resident Council
- One-to-one Sensory Stimulation
- Morning Orientation Program
- Entertainers or Pets visit
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):
- Resident will improve strength as evidenced
by an increase in monthly grip strength test score.
- Resident will improve flexibility as
evidenced by an increase in monthly sit-and-reach test score.
- Resident will improve functioning during
therapeutic recreation programs as evidenced by increased attention
- Resident will improve self-mobility
skills as evidenced by an improved ability to walk or wheel self to
- 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.
- Resident will display a decrease in
agitated behavior during therapeutic recreation programs as evidenced
by the CMAI score.
- Resident will experience success and
contentment during therapeutic recreation programs as evidenced by
a pleasant expression and calm demeanor.
- 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.
- Morning Dressing and Grooming - Nurses
- Cardiovascular Fitness through walking
- Morning Hydration - Health Assessment
- Pancake Cooking Group - CTRS
- Graded exercise to music - CTRS/Activities
- Hydration and Snack Cart - Nursing and
- Sensory Air Mat Therapy - CTRS/Activities/Nursing
- Sensory Handwashing Program/Sensory
table cloths - CTRS/nurses aides
- Outdoor dining/regular dining program
- Leisurely Look Newsletter Program- Nursing/CTRS
- Sensory Stim Box Program/Gross Motor
Arts & Crafts - CTRS/nurses aides/activities
- Sensory Special Events - Everyone
- Sensory Herb Garden/Adapted Garden
- Sensory Cooking Program - Pie bakers,
finger foods, blender cooking - CTRS
- The Price is Right Cognitive Therapy/Feelings
- Wanderer's Leisure Lounge (Area set
up for independent leisure pursuits)-Everyone