As many as 4 million older Americans suffer from Alzheimer’s and related dementing diseases. It has been estimated that this number could double or even triple in the next century (National Institute on Aging, 1990
). Although nursing homes report that 50–75% of their residents have some degree of dementia (Linderborn, 1988
), systematic investigation of the efficacy of specific behavioral interventions for this population has been extremely limited (Beck & Heacock, 1988
; Buckwalter, 1989
). Jirovec (1991)
observed that there is an “obvious and urgent need for development of more nursing approaches to address the limitations of the cognitivety impaired, institutionalized elderly” (p. 149). The purpose of this study was to test the effectiveness of group-based skill training in improving the demented older adult’s ability to perform the basic activities of daily living (ADLs) and progress toward meeting individual ADL-related goals compared with a more commonly used group stimulation approach and with the regular care received by nursing home residents with dementia.
For a clinical diagnosis of dementia, memory disturbance must be present and more than one type of cognitive function must be impaired without a clouding of consciousness (American Psychiatric Association, 1987
; World Health Organization, 1987
). The individual with a dementing disease evidences progressive intellectual deterioration in memory, attention, calculation, abstract thinking, and judgment (Office of Technology Assessment, 1987
) affecting ability to perform, first in work and social situations, and later at home. Eventually, the individual becomes unable to perform the basic functions of everyday life independently, including dressing, grooming, eating, toileting, walking, or communicating with others (Berg, 1984
; Traber & Gispen, 1985
). This functional decline presents a considerable challenge to effective nursing management in long-term care institutions.
It has been theorized that the profound decline in ability to perform the basic activities of daily living in the advanced stages of dementing diseases may be greater than is justified by the underlying neuropàthology. The existence of this excess disability
, defined as the “gap between actual function and judged potential function,” (Brody, Kleban. Lawton, & Silverman, 1971
, p. 125), is supported by numerous clinically based reports and a growing body of research (Dawson, Wells, & Kline, 1993
; Reifler & Larson, 1989
). Nurses may play a prominent role in preventing excess disability and assisting the demented individual to retain more of his or her ability to engage in the activities of daily life (Dawson et al., 1993
It also has been suggested that psychomotor skill learning or procedural memory is relatively spared in people with Alzheimer’s and related diseases (Eslinger & Damasio, 1985
). Procedural memory, as opposed to declarative memory, involves learning tasks rather than facts or events. It is characterized as more automatic and less accessible to conscious recollection than declarative memory (Squire, 1987
). Procedural memories are thought to be retrievable despite the deterioration of hippocampal function that appears to affect declarative memory in Alzheimer’s disease (Shepherd, 1988
Activation of the particular structures involved in learning tasks usually requires practice and repetition (Squire, 1987
). Most self-care activities are overlearned behaviors (Dawson, Kline, Wiancko, & Wells, 1986
) that are acquired in this manner and may be regained through the intensive practice and repetition of the type of skill training (Cicerone & Tupper, 1991
) tested in this study.
The possibility of achieving improved function in a severely demented population given sufficient and appropriate treatment is supported by the results of a number of intervention studies clone with this population. Although the multiple approaches within a given treatment modality make it difficult in some cases to identify which aspects were responsible for the improvement achieved, there is some evidence to support the use of targeted rather than generalized interventions and the use of prompting and reinforcement of appropriate self-care behaviors.
One of the earliest intervention studies done with a demented population found that focused treatment directed toward meeting specific individualized goals related to function led to significant improvement in the focus areas in 32 demented older women when compared with 32 matched controls. Treatment group improvement over a list of 109 variables, however, was not found (Brody et al, 1971
failed to demonstrate significant improvement in ability to perform basic ADLs using a physical exercise intervention. Using a combined program of memory training, reminiscence, social interaction, and physical activity, Panella, Lilliston, Brush, and McDowell (1984)
also failed to achieve statistically significant improvement in cognitive or physical function in clients attending an Alzheimer’s day care program, although some early but nonsustainable gains were observed clinically.
Principles of operant conditioning, which are thought to operate within the procedural memory system (Squire, 1987
), were used in some of the early work with a demented population. Baltes & Zerbe (1976)
, for example, reported the efficacy of continuous, immediate reinforcement on feeding ability using a single subject ABAB design. Similar effects on self-feeding ability were found with four nursing home residents who initially were unable to feed themselves (Stevenson & Gray, 1981
The effectiveness of five training modules utilizing a prompting and reinforcement system was tested on 15 demented and 15 nondemented psychiatric patients by McEvoy and Patterson (1986)
. The demented patients showed significant improvement in the basic ADLs but not in the higher level activities of daily living. The researchers concluded that people with moderate dementia can relearn these basic skills and that improvement is facilitated by emphasis on physical practice, feedback via multiple sensory systems, and a deemphasis on cognitive involvement.
It has been observed that nursing home staff who are not trained in these or other techniques make virtually no systematic attempts to elicit self-care behavior. For example, self-feeding behavior is not encouraged other than frequent verbal prompts to open the mouth (Phillips & Van Ort, 1990; Van Ort & Phillips, 1992
). In addition, Osborn and Marshall (1993)
found that demented nursing home residents were capable of significantly more independence in feeding than they usually demonstrated when graded assistance techniques (similar to those used in this study) were used by the researchers.
In summary, the more general stimulation or exercise interventions were generally found to be ineffective in terms of improving functional levels. Use of prompting, reinforcement, and graded assistance, however, generally has been found to be effective, particularly in regard to improving self-feeding performance.
In the present study, a targeted program of skill training in the basic activities of daily living (grooming, eating, bathing, dressing, toileting, standing, and walking) was compared to a more traditional general stimulation program that utilized adult games, music, and conversation and to regular nursing home care, which included no group activities for this very impaired population. It was hypothesized that the group receiving the skill training would show the greatest improvement in basic ADLs, that the stimulation group would maintain their current level of ADL performance, and that die control group’s overall level of ADL performance would decline. The skill training approach is described in more detail in the Procedures section.