Name /7890/fm

11/25/97 03:05PM

Plate # 0

7890 NISSENBOIM (HPP)

pg 5 # 3

ontents

About the Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Overview of the Disease Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Stages 0.51: QuestionableMild Cognitive Impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Stage 2: Moderate Cognitive Impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Stage 3: Severe Cognitive Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Outline of the Positive Interactions Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Activities Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Activity Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Activities for People in CDR Stage 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Activities for People in CDR Stage 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Activities for People in CDR Stage 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Preparation of the Activity Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Implementation of the Activities Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Working with a Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Activities Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

S
N
L

Your Approach to the Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Familiarizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Naming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Demonstrating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Encouraging and Rewarding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Guidelines for Clear Communicating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Dealing with Disruptive Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
v

Name /7890/fm

11/25/97 03:05PM

vi

S
N
L

Plate # 0

7890 NISSENBOIM (HPP)

CONTENTS

The Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Creative Arts Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Baked Dough Art (Magnets, Beads, Garland) (CDR Stages 1 and 2) . . . . . . . . . . . 43
Creative Drawing to Music (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Dried Flower Bookmarks (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Eggshell Mosaic (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Embossed Stationery (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Fabric Printing (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Leaf Prints (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
No-Bake Dough Art (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Painting with Marbles (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Stained Glass Pictures 1 (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Stained Glass Pictures 2 (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
String Art (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Vegetable Prints (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Wet Paper Watercolors (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Woodworking (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Daily Living Skills Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Baking Cookies (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Brushing Hair (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Brushing Teeth (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Caring for Pets (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Clipping Coupons (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Dressing (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Dusting Furniture (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Enjoying the Mail (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Food Preparation (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Labeling Cabinets and Drawers (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . 68
LaundrySorting (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
LaundryFolding (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Making Beds (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Setting the Table (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Showering (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Vacuuming (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Washing/Drying Dishes (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Physical Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Ball Games/Balloon Games (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Balloons/Punch Balls (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Bean Bag Toss (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Bouncing Balls (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Gardening (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Kick Ball (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Raking Leaves (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Squish Ball (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Stretching and Kvetching (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Sweeping Floors (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Velcro Darts (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Walking (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Walking a Par Course (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Watering Plants (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

pg 6 # 4

Name /7890/fm

11/25/97 03:05PM

Plate # 0

7890 NISSENBOIM (HPP)

pg 7 # 5

CONTENTS vii

S
N
L

Sensory Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Color Matching (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Colored CubesCreating Patterns (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . 92
Colored Cubes with Patterns (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Comparing Different Balls (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Connect the Dots (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Familiar Sounds (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Family Photographs/Videotapes (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . 97
Find the Incorrect Shape (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Finding Objects in Sand (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Finger Paints in a Plastic Bag (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Flavor Identification (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Fruits and Vegetables (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
Hand-Cut Puzzles (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
HandEye Integration with Markers (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . 104
HandEye Integration with Scissors (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . 105
Height Discrimination (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Identifying Objects by Touch (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Identifying a Scent (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
Latching/Unlatching Locks (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Listening to Music (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
Lotion and Massage (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Matching Foods and Ingredients (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . 112
Matching Jars and Lids (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113
Matching Object to Outline (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Matching Related Objects (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
MeasurementRice and Jars (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Modeling Clay (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
Number Matching 1 (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Number Matching 2 (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Number Matching 3 (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Nuts and Bolts (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Object Matching (CDR Stages 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122
Outlining Shapes (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Pattern Matching (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124
Peg Board (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Petting Animals (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126
Replicating Sounds (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
Shape Determination (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
Size Discrimination 1 (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
Size Discrimination 2 (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130
Sound Discrimination (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Tea Aromas (CDR Stages 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Tea Tasting (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Texture Matching (CDR Stages 1, 2, and 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134
Topical Pictures (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135
Zippers, Buttons, and Velcro (CDR Stages 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . 136
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137

Name /7890/fm

11/25/97 03:05PM

Plate # 0

7890 NISSENBOIM (HPP)

pg 11 # 1

reface

S
N
L

The Positive Interactions Program was conceived in 1984 out of our interactions and
frustrations in working with older adults with cognitive impairment in adult day centers. The catalyst was a client named Ruth. Ruth would sit at a table each morning,
welcoming staff members and program participants as they entered the room. Although she was able to initiate this pleasant social interaction, she was unable to
process the verbal information she received in return. Ruth was the first client in our
adult day program to be identified as having Alzheimers disease.
Before our encounter with Ruth, we simply did not have programs suited to the
needs of people with Alzheimers disease or a related dementing disorder; we did little
more for our participants than to maintain them in as comforting an environment as
possible. Slowly, day center staff became aware of the growing number of incoming
participants who, like Ruth, were in varying stages of dementia. This awareness of the
lack of suitable caregiving tools justified a conscious shift in programming in order to
better serve these participants.
Conventional programming in adult day settings incorporates various discussions
and verbally centered activities. Because verbal skills deteriorate early in people with
dementia, this type of programming is far too complex and demanding. Our response
was to develop a program that did not depend solely on an individuals verbal skills.
Through much trial and error, we identified four activity categories in which positive
interactions can be achieved: creative arts activities, physical activities, daily living
skills activities, and sensory activities.
The Positive Interactions Program provides the person who is cognitively impaired
with opportunities to achieve success and to interact appropriately with other people.
Success is not based on completing a task but on the positive dynamic created as a
result of participating in an activity. The by-products of this success are enjoyment,
excitement, and feelings of self-worth. This structured, individualized program consists
of various activities in four categories that focus on providing these opportunities.
Creative arts activities stimulate and reinforce experiences of generativity and ability.
Activities of daily living, such as meal preparation, household chores, and personal
xi

Name /7890/fm

11/25/97 03:05PM

xii

Plate # 0

7890 NISSENBOIM (HPP)

PREFACE

grooming, may still be familiar to the person with cognitive impairment and, through
these activities, can be reinforced. Physical activities are both enjoyable and reduce
agitation, and they are staples of any successful activities program for older people
with a dementing disorder. Sensory activities, which focus on sight, hearing, touch,
taste, and smell, can stimulate experiences in a nonverbal mode. We have found that
this program has not only positively affected people with cognitive impairment but
has indirectly benefitted people who are cognitively intact.
The Positive Interactions Program and this book of activities help professional
caregiverssocial workers, activities directors and staff, home health caregivers,
nurses, nursing assistants, and volunteers in adult day programsto recognize and
capitalize on the remaining abilities of their clients or residents. Also, because this
line of work requires an endless supply of compassion, enthusiasm, humor, and hope
in the face of clients decline and deterioration, the many types of activities provide
professionals with ways to avoid burnout and to take care of themselves, thereby
freeing them to provide older adults with high-quality care. Finally, the realization of
some success and satisfaction in working within their remaining abilities may set off
other positive occurrences in the midst of the escalating sense of impotence, anxiety,
and confusion felt by people with dementia.
No less a focus of this book are the families of people with Alzheimers disease and
other dementing illnesses, because they, too, struggle to find ways in which to participate positively in caregiving. They need help in restructuring the means available to
interact with their loved ones with dementia, so that it becomes supportive of and
positive for the loved one and themselves. Often, they look to the professional caregiver for this help. It is the responsibility of the professional reading and using this
book to relay information such as that contained here that will assist the family in
finding ways to interact positively with the person with dementia and to meet their
caregiving challenges.
...
As a final note, for the sake of clarity we have chosen to refer to the person with
cognitive impairment as he or him, rather than to use unwieldy constructions or
pejoratives such as victim.

S
N
L

pg 12 # 2