Annals of Long Term Care

LTC staff can easily be taught to integrate a basic musculoskeletal evaluation during daily care by assessing muscle strength and range of motion.^7,14,25 In addition to required LTC assessments such as the Minimum Data Set or the Outcome and Assessment Information Set (OASIS), or required assisted living assessment forms, LTC staff may also want to utilize standardized measurement instruments to more comprehensively and quantitatively assess physical function, such as the Barthel Index,⁶³ the Katz Index of Independence in Activities of Daily Living,64 and/or the Tinetti Performance Oriented Mobility Assessment.⁶⁵ These baseline measurements can be compared with future outcome measurements to help track the effectiveness of function-focused care interventions.

Interpersonal Factors
A variety of interpersonal care approaches can be used to successfully motivate NH residents with moderate-to-severe cognitive impairment to actively participate in functional and physical activities. Some of these interpersonal care approaches include the use of: (1) modified communication strategies; (2) enhanced sensory stimulation; (3) motivation through humor and play; and (4) functional goals consistent with past life experiences. Communication strategies meant to effectively motivate residents with more advanced dementia to participate in functional and physical activities include the use of short, simple verbal cues given after gaining the resident’s attention.⁶⁶ Short-term memory impairment will require the use of repetition of directions, as well as frequent encouragement and praise. Using physical gesturing and role modeling can also be helpful for residents with symptoms of receptive aphasia.^16,25,36 For example, it may be helpful to seat a more independent resident with a cognitively impaired peer who needs more visual cues at mealtimes, or have a physical therapy staff member demonstrate a chair rise to a cognitively impaired resident who is working on improving balance during transfers, rather than giving extended verbal instructions. Seeing a peer or staff member perform the activity often helps the resident with moderate-to-severe cognitive impairment to model the behavior and initiate the functional activity.

When attempting to overcome apathy and passive behaviors that are seen in approximately two-thirds of older adults with dementia,^67-70it is helpful to selectively enhance sensory experiences that motivate them to actively participate in their own care.^71,72 For example, the use of familiar “big band” or “swing” music with a rhythmic beat can help to motivate cognitively impaired residents to dance and move.^73,74 Petting or throwing a ball for a visiting dog or cat can encourage active range of motion for residents’ arms and hands. Serving meals on dishes that provide visual and color contrast with the food may help to focus a resident’s attention on the task of eating.^23,35 An exercise program that incorporates sensory stimulation in multiple domains (visual, auditory, tactile) helps cognitively impaired residents to be more engaged in physical activity.³¹

Humor and playful activities are often used to prevent catastrophic behavioral outbursts among cognitively impaired NH residents.^70,75 This same strategy can also be employed to motivate residents with dementia to be actively involved in their own ADL.^35,76 One possible strategy is to use a playful competition. For example, when assisting a resident with bathing, a nursing assistant can playfully challenge the resident to do better than the nursing assistant. While the resident washes his/her leg, the nursing assistant can wash the other, and when they are finished, the nursing assistant congratulates the resident on a job well done.