Peer Leaders Facilitate Social Engagement Among Dementia Patients in Long-Term Care Facilities

Problem Addressed

For a variety of reasons, dementia patients in long-term care (LTC) facilities often do not engage in group activities that are designed to stimulate the intact parts of their memory. As a result, psychosocial well-being and quality of life suffers. There are a number of reasons for this problem, as outlined below:

• The widespread belief among most LTC providers is that dementia patients are not able to learn anything new or to engage in meaningful social interactions. This belief stems in part from providers being overly focused on what patients can no longer do, rather than recognizing that there are intact parts of their memory that can be stimulated.¹
• Caregiving staff members (e.g., nursing assistants) are often too busy caring for patients to help facilitate group activities among patients.² So, activity staff members are often left to be solely responsible for engaging residents in activities. It is quite difficult for a single person to provide quality programming to a large number of residents. 
• Staff members do not have a standard way to judge a resident’s engagement during activities, so it can be difficult to know whether one activity is more successful than another. Filling time with some type of activity, whether engaging or not, can become the priority.²
• Often, there is little or no funding available in LTC to develop new activities.²
• The net result is that dementia patients residing in LTC facilities spend an estimated two-thirds of their time idle.³ Recognizing this problem, the Centers for Medicare and Medicaid Services is now requiring LTC facilities to provide activities “to meet the interests and well-being of each patient.”²

Description of the Innovative Activity

• Group leader training: Each group leader attends three to eight training sessions that last between 30 and 45 minutes, depending on their individual needs. Training sessions occur one or two times per week based on the trainee’s schedule. Initially, the residents work one-on-one with a staff member. They observe the staff member leading the group activities, and then participate by helping the staff member to lead the activities. During the final phase of training, the staff member demonstrates the process of leading the activity, and the resident imitates the leadership role until the resident is ready to take over on his or her own. After the peer leaders take over, staff initially remain available to cue group leaders as needed. Once the peer leaders master the role of group leader (as judged through observation by staff) they lead the activities on their own.
• Peer-led group activities: Once training is complete, leaders conduct the following kinds of group activities for their peers:
  • Reading Roundtable: Peer leaders gather residents for a reading activity. Participants take turns reading a page from a story especially designed for RAMP, and the peer leader facilitates a discussion of the material. For example, one of the stories is about the life of Gene Kelly, which often leads the residents to reminisce about his movies.
  • Memory Bingo: Each player is given four cards, with one word on each card. The peer leader has a stack of cards that each contains a phrase, such as “beauty is only skin  ______.”  Once the peer leader reads the card aloud the residents are prompted to look at their cards to see if they have the word “deep.” The resident who has the card with the missing word then removes it from his or her stack. The player who gets rid of all four cards first “wins.” Peer leaders use the phrases on the cards to facilitate discussions and encourage social engagement and interaction among players.

References/Related Articles

Camp CJ, Breedlove J, Malone M, et al. Adjusting activities to meet CMS guidelines using Montessori-based dementia programming. Activitity Directors' Quarterly 2007;8(1):34-46.

Camp CJ, Skrajner MJ. Resident-Assisted Montessori programming (RAMP): training persons with dementia to serve as group activity leaders. Gerontologist. 2004 Jun;44(3):426-31. [PubMed]

Skrajner MJ, Camp CJ. Resident-Assisted Montessori Programming (RAMP™): use of a small group reading activity run by persons with dementia in adult day health care and long-term care settings. Am J Alzheimers Dis Other Demen. 2007 Feb-Mar;22(1):27-36. [PubMed]

Skrajner MJ, Malone M, Camp CJ, et al. Montessori-based Programming in Dementia. Alzheimer's Care Quarterly 2007;8(1):53-64.

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Results

The RAMP program improves overall quality of life for residents by encouraging social engagement between LTC residents and provides peer leaders with the sense that they are playing a meaningful social role in their community.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps in the planning and development process are described below:

• Designing tools that access older adult's procedural memory: Procedural (or implicit) memory refers to the unconscious and automatic forms of learning and memory. Procedural memory is often contrasted with declarative memory, which relies on conscious and deliberate learning and memory. Patient's with dementia often have deficits in this declarative memory.^4,5 Because the ability to use the procedural memory system is typically intact far into the course of dementia, a person with dementia can learn new procedures if they are practiced over and over again. A perfect example of this phenomenon occurs everyday at nursing homes across the world: a person with dementia living at a nursing home walks directly to his or her chair at lunchtime. This person, whose memory is seemingly devastated, has learned where to sit for lunch. The reason that the person with dementia was able to learn this lies in the fact that the procedural memory system is preserved.
• Development of book content: Using Montessori-based learning principles, MRI created 18 stories that are designed to be of interest to older adults. The content is designed to spark conversation and encourage participants to reminisce. To make the books easy for older adults to read, they have large font and have just a few sentences per page.
• Development of Memory Bingo format: Researchers designed this game to trigger the memory of participants and to provide cues to the peer leader that aid them in engaging their peers. During the early stages of the pilot study, several issues arose that led researchers to modify the game to be more user friendly. For example, peer leaders were having difficulty remembering which cards they had already called, so staff created 2 boxes, one labeled "pickup" and the other "discard," which reduced confusion.

Resources Used and Skills Needed

• Personnel: Although a peer resident is being trained, one staff member (activity coordinator, nursing assistant, social worker, or other person who has experience working with persons who have dementia) or volunteer assists with the group. As the peer leader becomes more autonomous, the staff are not needed for the entire group, just for periodic checks on the group to make sure things are running smoothly and provide assistance if necessary. 
• Materials: Groups should be held at a circle or square-shaped table with room for six to eight participants. Other adaptive materials might be needed depending on the needs of the group (e.g., external cues, document holders, paper trays, etc.).

Funding Sources

Myers Research Institute; Menorah Park Center for Senior Living and Retirement Research Foundation

Tools and Other Resources

Meyers Research Institute Web site. Available at: http://www.myersresearch.org/.

Getting Started with This Innovation

• Find a staff champion to test the program on a small scale with a subset of residents so that other staff members can see the positive changes it makes in residents’ lives. This step can help LTC staff to escape from the traditional mind set that dementia patients are unable to learn anything new.
• Modify the content of activities to meet the needs and interests of their residents and organization.
• Do these activities at a table, and make sure there is ample room for participants to turn pages, etc.
• Focus activities around resident’s strengths rather then designing activities based on their deficits, as this approach reduces the level of learned helplessness among residents.

Sustaining This Innovation

• Regularly update the content of the activities to make sure they continue to meet resident needs and/or interests.
• Constantly evaluate the processes used to facilitate groups so that peer leaders find it as easy as possible to engage residents in group activities.
• Emphasize those activities that enable patients to use the parts of their memory that are still intact. Montessori-based dementia programming is designed to use “external cues and reliance on procedural or implicit memory rather than declarative or explicit memory.”
• Devote the time that is necessary to train residents to lead group activities, as this investment will eventually give staff more time to devote to other aspects of patient care.

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