WHY: Adults with dementia have feelings that are often difficult to express due to cognitive impairments in language, memory, and executive function. Communicating frustration, boredom, fear, loneliness, anxiety, or pain may be expressed as resistance, agitation, wandering, frequent requests for assistance, and repetitive calling out. These distressing symptoms experienced by the person are referred to as BPSD which stands for “behavioral and psychological symptoms of dementia”. Up to 90% of persons with dementia experience one or more of these symptoms during the course of their illness (de Oliveiri, Radonovic, de Mello et al., 2015). Apraxia, impaired recall, and the anxiety that accompany cognitive loss often impact the person’s ability to cope with stress, such as care transitions and hospitalizations, making these distressing symptoms more common. Caregiver impatience and rushing, clinician assessments, unfamiliar surroundings, and an overstimulating environment may also provoke distress. Older adults often have periods of intense aloneness in unfamiliar environments, such as hospitals; staff and family members can provide companionship and facilitate purposeful activity. The use of an activity kit provides an opportunity for cognitive stimulation as well as focused and intentional dialogue between caregiver and older person with dementia. It can also make the time spent alone, between caregiver and family visits, meaningful and less frightening.

BEST PRACTICES: Non-pharmacologic methods are first line treatment in the management of non-emergent BPSD. The evidence for the effectiveness of psychotropic medications for distressing symptoms of dementia is modest, at best. In addition, potential side effects of these medications increase the risk of falls, stroke, and extrapyramidal symptoms. Once medical causes for the symptoms are ruled out, activities that may improve mood, function, and behavior are initiated. The use of activities as an intervention to reduce BPSD has been shown to reduce agitation and depression (de Oliveiri, Radonovic, de Mello et al., 2015). Ideally, activities should be person-centered and tailored to an individual likes and interests. An activity kit that has a collection of tactile, auditory, and visual items may provide solace, an opportunity for emotional expression. These activities should be implemented before behavioral symptoms begin. The activity kit includes a wide range of items that are commonly used to provide diversion such as games, audiotapes, and nontoxic art supplies. A family photo book or a “knowing me” book can serve as an effective way families can provide others with a glimpse into the person’s life, character, likes and dislikes. In addition, items such as pieces of textured fabric, cloth to fold, tools, and key and lock boards, are included for the person with more advanced dementia.

TARGET POPULATION: Older adults with dementia during care transitions and hospitalizations with suspected or confirmed dementia, whether or not they exhibit behaviors described above, as well as older adults with depression and/or limited family contact. Knowledge about the person including usual behavior and function markedly enhances the ability to provide person-centered care. Standardized screening for cognitive impairment, including dementia, delirium, and depression, should be performed upon admission and periodically in the hospital, during care transitions, and during follow-up in primary care. [See Try This:^® MoCA, Mini Cog; A Brief Evaluation of Executive Dysfunction; Confusion Assessment Method; Geriatric Depression Scale]. 

STRENGTHS AND LIMITATIONS: Assessment and appropriate selection of activities is critical to avoid overstimulation or agitation. The items should reflect/match the person’s preferences, cognitive capacity, and physical abilities. It is crucial to avoid items that infantilize, insult, or threaten the person’s self-image. The items listed in this publication are suggestions. Families should be encouraged to individualize contents by providing audiotapes, photo albums, videotapes, and activities that the patient enjoys. All kit items should be provided for the person to keep, eliminating the need for cleaning between use, and infection control concerns.

ENHANCING USE OF THE KIT: Nursing and rehabilitation staff work with the person’s family to identify pre-dementia activities and pleasant events the person enjoyed. This facilitates selection of appropriate kit activities and personalization of some items provided by the family.

MORE ON THE TOPIC:

de Oliveira, A.M., Radanovic, M., de Mello, P.C., et al. (2015). Nonpharmacological interventions to reduce behavioral and psychological symptoms of dementia: A Systematic Review. Biomed Research International, Article ID 218980, 1-9. doi: 10.1155/2015/218980 

Conedera, F., & Mitchell, L. (2007). Therapeutic activity kits. Journal of Advanced Nursing, 36(4), 583-590.

Mace, N.L., & Rabins, P.V. (2011). The 36-Hour Day (5th ed.): The 36-hour day: A family guide to caring for people who have Alzheimer’s disease, related dementias, and memory loss Baltimore, MD: The Johns Hopkins University Press.

Mandzuk, L., & Bell, S. (2015). Therapeutic activity kits: A successful strategy for hospitalized patients living with dementia. Perspectives, 38(3), 23-25.

Ricker, J.R., & Mulligan, M. (2017). Activity kits as a first line intervention to care for individuals with dementia.Geriatric Nursing, 38(6), 604-605.

Whitlatch, C J., Zarit, S.H., & Femia, E.E. (2015). Caregiving: Alzheimer’s disease and related disorders. The Encyclopedia of Adulthood and Aging, 1-5.

Yevchak, A., Fick, D.M., Kolanowski, A.M., McDowell, J., Monroe, T., LeViere, A., & Mion, L. (2017). Implementing nurse-facilitated person-centered care approaches for patients with delirium superimposed on dementia in the acute care setting. Journal of Gerontological Nursing, 43(12), 21-28.