It is well known that tailored activities can generate meaning and purpose in the lives of people with dementia. Emma Sadler explains how the Good Care Group set out to “create meaningful days” for its home care clients.
Our mission is to keep people living well in the comfort of their own homes and communities. Approximately 60% of our home care clients are living with a diagnosis of dementia.
As part of this mission, we introduced an initiative to create “meaningful days,” rooted in Tom Kitwood’s notion that individuals with dementia have needs for inclusion and identity as much as anyone else and that tailored activities can generate feelings of meaning and purpose (Kitwood 1997). It builds on the idea that activity and occupation are bound up with what makes us feel like functional human beings, and are what give purpose and structure to our day.
In our pilot project we worked initially with clients where a perceived unmet need was present. We sought to introduce purposeful activity to create meaningful days in order to minimise distressed behaviours, and to address the unmet needs. In developing and introducing purposeful activities, we considered their relevance, achievability and purpose.
- Relevance – activities should always be relevant to the individual, taking into account their past and present interests and experiences
- Achievability – activities should be pitched at the right level for the client so that they can succeed at the activity and reach their full potential. If the activity is pitched too high or too low, it is likely that the individual will become discouraged and de-motivated
- Purpose – activities should always have a reason and must be meeting a need. For some clients this was to produce something, to stay busy, to feel needed, to achieve or to relax.
We used a range of tools to help us develop purposeful activities. We started with our care plan assessment tool which already has a wealth of information about each client, including life history, previous occupation and routines. The Pool Activity Level (PAL) tool (Pool 2012) also proved useful in identifying the most suitable level of activity based on the individual’s physical and cognitive abilities.
The PAL tool is widely used as the framework for providing activity-based care for people with cognitive impairments, including dementia. It relies on a series of statements to identify the extent to which the person can complete everyday activities. There are four statements for each of the activities, each statement describing a slightly different level of ability.
By selecting the appropriate statement for each of our clients, we were able to identify their overall level of cognitive and functional ability and with this information identify activities suitable for them as individuals.
Case study: Mrs M
Mrs M is physically active and has a diagnosis of dementia, anxiety and depression. She paced around her home and seemed unable to feel settled and relaxed. We looked at her care plan to get a better sense of her life history and key to her sense of identity seemed to be her role as a mother, which became significant when planning a purposeful activity.
We established, using the PAL tool, that Mrs M would be likely to engage at what the tool describes as the “sensory’ level. We asked our professional carers to introduce dolls to Mrs M in a way that she could engage with if she chose. They began by entering the room holding the doll and rocking it gently.
Before long Mrs M started asking if she could help and after a while she initiated rocking the baby to sleep before putting her down. With the dolls we provided relaxation and observed reduced restlessness. A renewed sense of purpose as the matriarch also seemed evident. Mrs M was able to remain still while holding the doll and showed fewer physical signs of anxiety
Case study: Mr S
Mr S has a diagnosis of frontotemporal dementia. He is very mobile and responds well to a busy day filled with activity. If unoccupied Mr S will try to leave his home and cannot be easily distracted.
As with Mrs M, we found out from Mr S’s care plan about his previous occupation as the managing director of a successful company. We also used the Newcastle Model (James 2011) to take meaning from his expressions – “I’m going to be late”, “Got an important day today”.
Mr S clearly felt a sense of purpose when he was engaged in work, so we set his home office back up and provided paperwork to sort and file. He responded well to routine and now heads to his office each morning to begin work. We’ve observed fewer attempts to leave home and Mr S’s days seem to have greater meaning.
For the clients in our pilot scheme, we observed the benefits of specific interventions built on life history work. We were able to create enabling environments in which people with dementia were supported to reach their full potential, as a result of which instances of distressed behaviours were reduced.
We recognise that there are some limitations to a case study approach and so as a next step we are aiming to introduce a specific pathway, led by our in-house occupational therapist, that builds on this work and can easily be implemented at scale to benefit any client using our service.
We are also exploring the possibility of running Individual cognitive stimulation therapy courses for family carers so that they too can play a role in creating meaningful days for loved ones.
James IA (2011) Understanding Behaviour in Dementia that Challenges. London: Jessica Kingsley Publishers.
Kitwood T (1997) Dementia Reconsidered: The Person Comes First. Buckingham: Open University Press.
Pool J (2012) The Pool Activity Level (PAL) Instrument for Occupational Profiling (4th edition). London: Jessica Kingsley Publishers.
Emma Sadler is director of quality assurance at the Good Care Group.