© Springer International Publishing Switzerland 2015Ingrid Söderback (ed.)International Handbook of Occupational Therapy Interventions10.1007/978-3-319-08141-0_56
56. Intervention Program Mediated by Recreational Activities and Socialization in Groups for PWA with Alzheimer’s Disease
Neurorehabilitation Unit, IRCCS, Don Gnocchi Foundation, Via Capecelatro 66, 20148 Milan, Italy
Interventions mediated by recreational activities (games and art therapies) are frequently offered to people with dementia in nursing homes or day care centers. These recreational–occupational activities result in behavioral and cognitive gains in people with Alzheimer’s disease compared to those undergoing other kinds of cognitive treatment or receiving ordinary routine care.
The intervention program comprises cognitive activities, exercise, recreational activities (music listening, party games, card games, poster creation, and painting on tissue or pottery), and activities of daily living (setting and clearing the table, preparing tea or coffee, washing hands and dishes, preparing simple cakes or fresh pasta). Caregivers receive educational and psychological support and then support the client to perform physical and cognitive activities at home.
KeywordsAlzheimer’s diseaseOccupational therapyRecreational activities
Behavioral, cognitive and possibly functional gains occur in people with Alzheimer’s disease who participate in occupational therapy interventions mediated by recreational and occupational activities.—Scientist
Background and Definitions
Interventions mediated by recreational activities , such as games and art therapies involving music, dance, and art, are frequently offered to people with dementia and are useful to ameliorate mood and avoid social isolation in nursing homes or day care centers.
Activity is a basic human need expressed in leisure and work pursuits. Unfortunately, dementia leads to boredom and isolation due to a low rate of activity participation, resulting in agitated or passive behaviors and functional loss. Recreational services enable recreational resources aimed at improving PWA health and well-being (Fitzsimmons 2003; Kolanowski et al. 2011). Occupational therapy also demonstrated to be cost-effective, leading to reduction of behavioral and psychological symptoms of dementia (BPSD) , improvement of PWA mood, and empowerment of caregiver’s coping abilities (Gitlin et al. 2008, 2010a, b).
Alzheimer’s disease (AD) is the most common form of dementia. There is no cure for the disease, which worsens as it progresses, and eventually leads to death. It was first described by German psychiatrist and neuropathologist Alois Alzheimer in 1906 and was named after him (Berchtold and Cotman 1998). Although AD develops differently for every individual, there are many common symptoms. Early symptoms are often mistakenly thought to be “age-related” concerns, or manifestations of stress (Waldemar 2007). In the early stages, the most common symptom is difficulty in remembering recent events. As the disease advances, symptoms can include confusion, irritability, aggression, mood swings, trouble with language, and long-term memory loss. As the sufferer declines, they often withdraw from family and society (Waldemar 2007; Tabert et al. 2005). Gradually, bodily functions are lost, ultimately leading to death.
Group therapy: In the case of AD, it is preferable for the PWA to work in group than to work individually for the importance that the factor group embodies. The group sets itself as the “third element” in the therapeutic relationship, allowing PWA to observe and better understand their relational patterns in a more natural and complex way than the simple dyadic interaction with the therapist. The observation of the interactions of other people and those of the group as a whole also allows to derive important inferences about communicative dynamics and each participant’s role. These inferences are often of considerable clinical importance. In the group situation, the client doesn’t feel/feels himself/herself under examination; he/she’s freer to make mistakes and to see others make mistakes without being judged. It’s a more relaxing setting; people are less embarrassed and can look other elderly people doing activities, using them as a model in order to start, continue, or finish works and games.
Recreation means spending time in pleasant activities. Recreational activities are funny and enjoyable activities as party games (e.g., scrabble, bingo, domino, cards games, and table games), collages, poster creation, and painting on tissue, wood, or pottery.
Socialization is the interaction between people with different inclinations, experiences, and intelligences who stay in group and share with others their characteristics in order to work together, have fun, and spend time.
The primary purposes of using recreational activities , according to the guidelines of American Therapeutic Recreation Association (ATRA 2008), are to restore, remediate, or rehabilitate function in order to improve functioning and independence, and reduce or eliminate the effects of illness or disability. According to this definition, the aims of our intervention program are (a) to reduce behavioral disturbances, (b) to improve the PWA’ well-being, (c) to support the maintenance activities of daily living (ADL), and (d) to favor socialization.
Candidates for the Intervention
The inclusion criteria are (a) a diagnosis of AD (McKhann et al. 1984), (b) with or without associated cerebrovascular lesions, and (c) mild or moderate cognitive impairment between 0.5 and 2 on the clinical dementia rating (CDR) assessment (Hughes and Berg 1982).
The exclusion criteria are (a) severe cognitive dysfunction (Mini-Mental State Examination (MMSE) score less than 15/30; Folstein et al. 1975), (b) severe aphasia (token test score less than 20; Spinnler and Tognoni 1987), (c) severe auditory or visual loss, or (d) overt behavioral disturbances (delusions, hallucinations, agitation).
Cohort longitudinal studies (studies where a disease-free population is followed over the years) provide incidence rates between 10 and 15 per 1000 person-years for all dementias and 5–8 for AD, which means that half of new dementia cases each year are AD. Advancing age is a primary risk factor for the disease, and incidence rates are not equal for all ages: every five years after the age of 65, the risk of acquiring the disease approximately doubles, increasing from 3 to as much as 69 per 1000 person-years (Bermejo-Pareja et al. 2008; Di Carlo 2002). There are also sex differences in the incidence rates: women having a higher risk of developing AD particularly in the population older than 85 (Di Carlo 2002; Andersen 1999).
Prevalence of AD in populations is dependent upon different factors, including incidence and survival. Since the incidence of AD increases with age, it is particularly important to include the mean age of the population of interest. The World Health Organization estimated that in 2005, 0.379 % of people worldwide had dementia, and that the prevalence would increase to 0.441 % in 2015 and to 0.556 % in 2030 (World Health Organization 2006). Other studies have reached similar conclusions (Ferri 2005). Another study estimated that in 2006, 0.40 % of the world population (range 0.17–0.89 %; absolute number 26.6 million, range 11.4–59.4 million) was afflicted by AD, and that the prevalence rate would triple and the absolute number would quadruple by 2050 (Brookmeyer 2007).
Recruiting Method and Setting
Our typical referral method entails recruiting PWA from the Alzheimer Assessment Unit of “S. Maria Nascente,” Clinical Research Center, Don Gnocchi Foundation, Italy. They are then treated and periodically tested in the center’s day care unit.
Sessions are performed in a large room with a kitchen area, including cooking equipment and eating utensils, tables and chairs, and all the material necessary for the recreational and occupational activities .
The Role of the Occupational Therapist in Applying the Intervention
The intervention program is administered by an occupational therapist (OT), who is a member of a multidisciplinary team (Teri et al. 2003). He/she performs a functional and psychological assessment of the subjects in order to define the activities to include in the intervention program, specifically for the group that was formed. The OT chooses the occupational and recreational activities from a list of standard activities, preferring those which are significant for the PWA (see Case Study “Occupational Therapy Intervention” paragraph). He also chooses activities that can be started and completed in the session time available in order both to respect PWA’ time (above all slowness) and show the results (i.e., baking cakes and eating them during the work sessions or taking home slices to eat with caregivers). Important elements of the intervention program are (1) the close interaction between PWA and OTs (Wood et al. 2005), (2) an attractive environment (see “Recruiting Method and Setting” paragraph), and (3) an educational program for caregivers (see “Intervention Program Organization” paragraph).
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Intervention Program Organization
PWA participate in groups of six in the intervention program. The group constellations are organized according to the mix of women and men (ideally three males and three females, but, if it’s not possible, we prefer six people of the same sex) and their dementia severity.
The PWA follow a multidimensional program which includes cognitive exercises, physical activity, and, in large part, occupational ADL and recreational activities .
Close interaction between participants and therapists is very important; all proposed activities try to respect the cognitive and functional potential of each group component (if the person with dementia cannot make or complete an activity, the therapist accompanies him/her towards the solution with all the necessary help in order to avoid sense of frustration and inferiority to others group members).
Caregivers have a support interview with a psychologist at the beginning and at the end of the program (1.5 h for two sessions). This procedure ensures psychological support to the caregiver to face the disease and gives him/her useful ways to interact positively with the client.
Caregivers have also an initial 2-h informative meeting about the program schedule and contents and take part in an educational program (1.5 h for three sessions) which deals with a general presentation about dementia, its causes, the current knowledge pathogenesis, the diagnostic flow chart, typical cognitive and behavioral deficits, nursing problems, legal aspects, etc. General principles and strategies to cope with memory and behavioral disturbances, to support the PWA with their ADL, and to make the home environment safer are included. During the psychoeducational meetings, caregivers are also trained by the therapist in order to continue the stimulation treatment at home (e.g., using a calendar, giving phonetic cues to those PWA who can’t find the words in conversation, walk every day for 45 min, playing with “memory cards,” solving crosswords, puzzle together, etc.). It is clear that these “duties” can generate a reduction of compliance towards treatment. Therefore, it’s necessary to strengthen motivation by underlining that a constant application is a fundamental requisite in order to obtain positive results. Both (PWA and caregivers) are subjected to a questionnaire, at the end of the period of interventions, in order to understand the pleasantness of the treatment and obtaining suggestions to improve it.
Recreational and Occupational Activities
The intervention program is mediated, besides cognitive exercises and physical activity, using the following :
Recreational activities, such as
Music listening to melodies and songs typical of PWA’ young years. After listening, they are asked to make comments about the kind of music, the singer, etc.
Party games such as bingo, dominoes, Scrabble, Snakes and Ladders, stick games, etc.
Poster creation with collage and painting
Painting on tissue or pottery.
These proposals have a strong stimulation value because they’re funny and enjoyable and require the activation of multiple cognitive functions (attention, memory, executive functions, language, and visuospatial abilities). These activities include step identification, verbal prompting and modeling, used to assist participants. The PWA work individually inside the group (i.e., painting pottery) or in group, collaborating to the same task (i.e., poster creation).
Occupational ADL, such as
Serving table and clearing the table
Preparing tea or coffee
Washing hands and dishes
Baking simple cakes (e.g., tiramisù, yogurt cold cakes, or sponge cakes) to be served during the “coffee/tea pause”
Prepare fresh “pasta”
The recipes are proposed by PWA or by the therapist, often taking into account the season and the regional origin of PWA or places where they spent their holidays. The aim of this activity is to favor orientation throughout the kitchen activity and execute the recipe in its different steps (Farina et al. 2013).
At the moment of occupational activities, the therapist tries to become an observer only in order to allow PWA to act freely. When necessary, he/she uses step identification: verbal prompting and modeling are used to assist participants. Prompting and modeling are behavioral–cognitive strategies to modify PWA’ behavior in order to reach the goal. Prompting means suggesting to the PWA a step of the whole action they’re making (i.e., suggesting to add an ingredient of the cake that has been forgotten). Modeling means that the OT acts as a model to be followed by the client in order to do something. For example, PWA can look at the OT who gives the right shapes of a type of fresh pasta with fingers or a fork (i.e., in order to produce “orecchiette”). Each client with AD can also act as a model for other participants . In fact, we consider that this kind of group therapy can represent a way to exploit mirror neurons activity in rehabilitation.
Occupational activities should:
Match the PWA’ functional skills (level of dementia) and interests
Provide appropriate stimulation and enrichment
Stimulate the available cognitive resources
Support fulfillment of the performance in the chosen activities avoiding PWA’ frustration
Administration of the Intervention Program
Each session includes the following:
Reality orientation activities and cognitive exercises for about 45 min. In fact, an orientation task is first conducted for about 10 min. Spatial and temporal orientation is trained, and each member is encouraged to introduce himself or herself to other participants. The orientation training follows the principles described in the literature (Olazaràn et al. 2004; Spector et al. 2003). Two reality orientation boards, one for time and one for place, assist the participants. Paper and pencil or, more rarely, computerized cognitive exercises aimed to reinforce attention, reasoning, procedural, semantic, and autobiographic memory and executive functions then follow. We usually begin with the stimulation of memory, and afterwards, we continue with activities which stimulate attention and other cognitive functions.
Reinforcement of spatiotemporal parameters is applied for the whole session using the boards.
The PWA then perform physical activity and psychomotor exercises for about 30 min.
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