Long-Term Care Survey Alert

Alzheimers Disease:

USE VERBAL, NONVERBAL CUES TO HELP SLOW ADL DECLINE

Published on Mon Apr 01, 2002

Functional decline is an inevitable effect of Alzheimer's disease and other forms of progressive cognitive impairment. But facilities can help slow the progression of this decline and demonstrate to surveyors that they're giving residents the highest level of care by using a variety of strategies developed by experts.

First, perform a baseline assessment to see what the resident can do on his own. To get an accurate picture, "it's vital to actually observe someone do ADLs in an unobtrusive manner as part of the functional assessment," says B.J. Collard, a restorative nurse specialist and principal of CTS Inc. in Westminster, CO.

As part of the assessment process, Steven Littlehale, chief clinical officer of LTCQ Inc. in Bedford, MA, teaches caregivers to use a decision tree in determining the level of ADL support required by a resident, as follows:

Self-Care with simple one-step commands: Can the resident follow simple one-step commands?

Self-Care with physical prompts (reminders): Does the resident know what to do with items handed to her? Does she continue the activity?

Self-Care by imitation: Can the resident copy the activity when demonstrated by caregivers?

Self-Care by "jump starting": Can the resident continue an activity once you start it? Can he withstand distractions? Complete the activity?

"CNAs who are educated in these methods will say, 'I didn't know this person we have been dressing all along could dress herself if we just laid out the clothes in the right order,'" Littlehale says.

"Caregivers may find that residents with cognitive impairment can still participate in performing their own ADLs by following one-step verbal prompts," Littlehale tells Eli. "However, caregivers need to be educated on how to provide these type of prompts, so they can better engage residents in activities." For example, "Go to the dining room for lunch now, please" does not qualify as a one-step verbal prompt, he cautions.

The resident with mild to moderate cognitive impairment might be able to follow that same request, however, if it were broken down into four directives: "Please stand up. Walk with me. Sit here. Enjoy your lunch."

Other residents might require the directive to be broken down into even smaller bytes. "The key is knowing what works best for the individual resident," Littlehale says.

Moving Down the Decision Tree

Once verbal prompts no longer work for a resident, the caregiver can move to different levels of nonverbal interventions. "For example, some residents can perform an activity through mimicry if the caregiver mirrors it first," says Littlehale. Or the caregiver may have to physically guide the resident through the first part of the activity. "Often, once you 'start' the activity, the resident can finish," Littlehale explains.

Once residents are at the stage where nonverbal prompts work best, they will be distracted by verbal intrusions or prompting, Littlehale cautions. "So it's best to control the environment for distractions, turning off the TV or radio or ensuring privacy in the room, so the resident can focus his attention solely on performing the ADL.

"Caregivers also have to learn when nonverbal reinforcement, such as a smile or therapeutic touch, works better with a resident than a verbal reward or praise."