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A behavioural approach to the maintenance and rehabilitation of independent functioning with the institutionalized… Campbell, John Alexander 1978

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A BEHAVIOURAL APPROACH TO THE MAINTENANCE AND REHABILITATION OF INDEPENDENT FUNCTIONING WITH THE INSTITUTIONALIZED ELDERLY by JOHN ALEXANDER CAMPBELL B.A., York U n i v e r s i t y , 1972 M.A., U n i v e r s i t y o f Guelph, 1974  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Department o f Psychology)  We accept t h i s t h e s i s as conforming to the r e q u i r e d s t a n d a r d  THE UNIVERSITY OF BRITISH COLUMBIA September, 1978  (c)John Alexander Campbell, 1978  In p r e s e n t i n g t h i s  thesis  in p a r t i a l  f u l f i l m e n t o f the requiremen  an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, the I  Library shall  make i t  freely available  f u r t h e r agree t h a t p e r m i s s i o n  for  r e f e r e n c e and stud-  f o r e x t e n s i v e copying o f  this  the  s c h o l a r l y purposes may be granted by the Head of my Departmen  by h i s of  for  I agree  this  representatives. thesis  It  i s understood that copying o r p u b l i c a  f o r f i n a n c i a l gain shall  written permission.  Department of The  University of B r i t i s h  2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5  Columbia  not be allowed without my  ii  ABSTRACT  R e h a b i l i t a t i o n programs f o r t h e i n s t i t u t i o n a l i z e d e l d e r l y have o f t e n proved u n s u c c e s s f u l .  Recent b e h a v i o u r a l  research provides  some t e n t a t i v e  answers c o n c e r n i n g t h e components needed f o r a s u c c e s s f u l program. A b a s i c problem, however, i s t h e g e n e r a l i z a t i o n o f t h e s e b e h a v i o u r a l l y based programs t o t h e n a t u r a l environment. T h i s s t u d y f o c u s e d on t h e development and e v a l u a t i o n o f a program (CARE) w h i c h encouraged t h e maintenance and r e h a b i l i t a t i o n of various a c t i v i t i e s of d a i l y l i v i n g  (ADL) w h i l e becoming a r e g u l a r  and permanent p a r t o f t h e i n s t i t u t i o n a l l i f e o f t h e p a t i e n t .  Two f a c i l i t i e s s e r v e d as t h e s e t t i n g s f o r t h e s t u d y . These f a c i l i t i e s were a r c h i t e c t u r a l l y i d e n t i c a l as were t h e s t a f f i n g p a t t e r n s and p a t i e n t c h a r a c t e r i s t i c s . F a c i l i t y A was randomly chosen as t h e e x p e r i m e n t a l and  contained  facility  127 r e s i d e n t s 60 y e a r s o f age and o l d e r (39 male, 88 female)  w i t h a mean age o f 82 y e a r s . F a c i l i t y B, t h e c o n t r o l f a c i l i t y , housed 130 r e s i d e n t s 60 y e a r s o f age and o l d e r (47 male, 83 female) w i t h a mean age of 79 y e a r s . No s i g n i f i c a n t d i f f e r e n c e s were found between t h e two f a c i l i t i e s on sex, p r i m a r y d i a g n o s i s , l e n g t h o f s t a y o r degree o f c o n f u s i o n . F a c i l i t y A s u b j e c t s were s i g n i f i c a n t l y o l d e r (p< .01)  However,  and more ambulatory  (p_<.03) t h a n t h o s e s u b j e c t s i n F a c i l i t y B.  A l l s u b j e c t s were a s s e s s e d on f o u r measures e v a l u a t i n g v a r i o u s of d a i l y l i v i n g ( d r e s s i n g , grooming, e a t i n g and a m b u l a t i o n / t r a n s f e r as w e l l as a: g l o b a l measure o f t h e s e a c t i v i t i e s  ( g l o b a l ADL).  activities skills)  Assessments  were conducted a t p a r a l l e l p o i n t s i n t i m e , j u s t p r i o r t o t h e b e g i n n i n g o f t r e a t m e n t i n F a c i l i t y A and a f t e r 3 and 6 months. F a c i l i t y B r e c e i v e d no  iii  s p e c i a l treatment. F a c i l i t y A r e c e i v e d a treatment program which o f : 1) s t a f f  consisted  t r a i n i n g i n b a s i c r e h a b i l i t a t i o n and b e h a v i o u r change t e c h n i q u e s ;  2) a treatment manual o u t l i n i n g s p e c i f i c s t e p s i n r e h a b i l i t a t i o n and  behaviour  change w i t h v a r i o u s a c t i v i t i e s o f d a i l y l i v i n g ; and 3) a v i s u a l c h a r t  used  to communicate data as w e l l as treatment g o a l s .  . . I n t e r - r a t e r r e l i a b i l i t y measures were o b t a i n e d and were above .89 all  dependent measures over the t h r e e assessment  on  p e r i o d s . D u r i n g the course  of the study 15 s u b j e c t s were l o s t from F a c i l i t y A and 22 s u b j e c t s from F a c i l i t y B due to death or t r a n s f e r to more i n t e n s i v e c a r e . These s u b j e c t s were not i n c l u d e d i n the d a t a a n a l y s e s . No  s i g n i f i c a n t pre-treatment  f e r e n c e s were found on any o f the dependent measures o t h e r than transfer s k i l l s .  Two  measure - ambulatory  subgroups  were formed  dif-  ambulation/  and a n a l y z e d s e p a r a t e l y f o r t h i s  s u b j e c t s ( F a c i l i t y A, n=100; F a c i l i t y B, n=78) and  w h e e l c h a i r s u b j e c t s ( F a c i l i t y A, n=12;  F a c i l i t y B, n=30). Repeated  a n a l y s e s of v a r i a n c e y i e l d e d s i g n i f i c a n t d r e s s i n g and grooming s k i l l s  'facility'  effects for global  ( a l l p_<.04), as w e l l as s i g n i f i c a n t  time' i n t e r a c t i o n e f f e c t s f o r g l o b a l ADL,  measures ADL,  'facility  d r e s s i n g and grooming s k i l l s  by  (p<.001)  and a m b u l a t i o n / t r a n s f e r s k i l l s f o r w h e e l c h a i r s u b j e c t s Cp_<.04) . Tukey  tests  i n d i c a t e d t h a t , a l t h o u g h t h e r e were no s i g n i f i c a n t d i f f e r e n c e s w i t h i n  either  facility  over time, t h e r e were s i g n i f i c a n t d i f f e r e n c e s i n f a v o u r of F a c i l i t y  A f o r g l o b a l ADL. ,,and grooming s k i l l s a t the 3 month assessment ADL,  grooming and d r e s s i n g s k i l l s a t the 6:.month assessment  The r e s u l t s demonstrated e f f e c t i v e treatment approach h a b i l i t a t i o n was  and i n g l o b a l  ( a l l p<.05).  t h a t t h i s program i s a f e a s i b l e and  potentially  and methodology. I n c r e a s e d maintenance and r e -  a c h i e v e d under c i r c u m s t a n c e s t h a t l i m i t e d the p o t e n t i a l  impact  of the program. These r e s u l t s a r e d i s c u s s e d i n terms of the l i m i t a t i o n s of the study and f u t u r e d i r e c t i o n s f o r r e s e a r c h .  iv TABLE OF CONTENTS Page ABSTRACT  ....  TABLE OF CONTENTS  ..'  iv  LIST OF TABLES  ....  vi  LIST OF FIGURES  .... v i i  ACKNOWLEDGEMENT  ....  viii  ....  1  ....  5  CHAPTER 1 - Problems of the E l d e r l y  i i  in a  Modern S o c i e t y - The I n s t i t u t i o n a l S o l u t i o n  CHAPTER 2 - The P s y c h o s o c i a l Environment o f G e r i a t r i c Care F a c i l i t i e s .... CHAPTER 3 - B e h a v i o u r a l Approaches t o Problems o f the I n s t i t u t i o n a l i z e d E l d e r l y ....  13 20  CHAPTER 4 - G u i d e l i n e s f o r R e h a b i l i t a t i o n and Maintenance Programs i n G e r i a t r i c Facilities  ....  34  CHAPTER 5 - CARE - A Program of Care and R e h a b i l i t a t i o n f o r the E l d e r l y  ....  44  ....  45  Assessment ..I. Communication .... I s o l a t i n g t a r g e t behaviours •••• The r e h a b i l i t a t i o n program .... Maintenance of change .... G e n e r a l i z a t i o n of change .... T r a i n i n g program .... O r g a n i z a t i o n a l behaviour m o d i f i c a t i o n . . .  45 48 50 52 53 55 56 60  Components o f the Program  CHAPTER 6 - Procedure S e t t i n g and Subjects Confusion Dependent Measures General Procedures  .... 62 .... 62 ..... 63 .... 68 . . . . . 69 ;  V  Table o f Contents  (con't)  Page  CHAPTER 7 - R e s u l t s .... R e l i a b i l i t y of ADL S k i l l Scores .... Sample A t t r i t i o n . . .. Generation and S t a n d a r d i z a t i o n of Raw s c o r e s Comparison o f Pre-Treatment A s s e s s m e n t s * Treatment E f f e c t s .... Reduction and improvement i n Independent F u n c t i o n i n g • * •«  74 74 76 76 ^ 77  CHAPTER 8 - D i s c u s s i o n  • • •*  88  • • • •  1 03  • « • •  113  « • • *  119  BIBLIOGRAPHY  86  APPENDIX A  ADL v i s u a l  APPENDIX B  ADL treatment  APPENDIX C  F l o o r p l a n f o r F a c i l i t y A and B  • • • •  179  APPENDIX D  Logbook  • • « •  181  APPENDIX E  Government long term care  • » • •  184  APPENDIX F  Primary  « • • «  189  APPENDIX G  ADL assessment  • * • •  1 92  APPENDIX H  Raw data scores - F a c i l i t y A  « * •*  1 95  APPENDIX I  Raw data scores - F a c i l i t y B  * • •*  200  APPENDIX J  Demographic i n f o r m a t i o n - F a c i l i t y A  • • • •  -206  APPENDIX K  Demographic i n f o r m a t i o n - F a c i l i t y B  * * •«  209  APPENDIX L  R e l i a b i l i t y data f o r c o n f u s i o n measure - F a c i l i t y A  • • • *  21 2  R e l i a b i l i t y data f o r c o n f u s i o n measure - F a c i l i t y B  • « * •  214  R e l i a b i l i t y data f o r ADL Assessments Facility A  » • • •  216  C o r r e l a t i o n data f o r mean r a t e r score and v i s u a l c h a r t assessments  • * « •  222  R e l i a b i l i t y Data f o r ADL Assessments Facility B  • • « •  228  APPENDIX M APPENDIX N APPENDIX 0 APPENDIX P  explanation manual  criteria  diagnosis categories criteria  vi LIST OF TABLES Page TABLE 1  S e l e c t e d a c t i v i t i e s of d a i l y l i v i n g used i n CARE program  (ADL)  ....  46  TABLE 2  Demographic i n f o r m a t i o n  ....  64  TABLE 3  Assessment of c o n f u s i o n  ....  66  TABLE 4  D i s t r i b u t i o n of c o n f u s i o n scores  ....  67  TABLE 5  I n t e r - r a t e r r e l i a b i l i t y of ADL assessments...  75  TABLE 6  Comparisons of pre-treatment assessments ( t - t e s t s )  ....  78  Comparisons of ambulatory and wheelchair s u b j e c t s ( t - t e s t s ) on pre-treatment a m b u l a t i o n / t r a n s f e r s k i l l scores ....  78  TABLE 8  Summary of mean scores f o r F a c i l i t y A and B..  79  TABLE 9  Repeated measures analyses of v a r i a n c e comparing ADL s k i l l scores over t h r e e assessment p e r i o d s i n F a c i l i t y A and B ....  80  Number of s u b j e c t s i n F a c i l i t y A and B showing improvement, maintenance and i n c r e a s e d dependence i n g l o b a l ADL over s i x month p e r i o d  87  TABLE 7  TABLE 10  ....  yii  LIST OF FIGURES Page FIGURE 1  V i s u a l wall chart  FIGURE 2  Group means (z-scores) f o r r a t i n g s on g l o b a l ADL over the t h r e e time p e r i o d s  FIGURE 3  FIGURE 4  49  83  Group means (z-scores) f o r r a t i n g s on d r e s s i n g s k i l l s over the three time p e r i o d s Group means (z-scores) f o r r a t i n g s on grooming s k i l l s over the t h r e e time p e r i o d s  83  • •« «  84  FIGURE 5  Group mean raw scores f o r r a t i n g s on eating s k i l l s  84  FIGURE 6  Group mean raw scores f o r ambulatory . s u b j e c t s on a m b u l a t i o n / t r a n s f e r s k i l l s over the three time p e r i o d s  85  Group mean raw scores f o r wheelchair s u b j e c t s on a m b u l a t i o n / t r a n s f e r s k i l l s over the t h r e e time p e r i o d s  85  FIGURE 7  viii  ACKNOWLEDGEMENTS  I wish to express my who my  a s s i s t e d me  g r a t i t u d e and a p p r e c i a t i o n to the many people  i n so many ways w i t h t h i s p r o j e c t . To Dr. J e r r y W i l l i s ,  t h e s i s s u p e r v i s o r , I wish to express s i n c e r e a p p r e c i a t i o n f o r h i s  encouragement, guidance, p a t i e n c e and of t h i s  c r i t i c i s m throughout  the d u r a t i o n  project.  I want to thank Dr. G l o r i a Gutman, not o n l y f o r her guidance support, but f o r h e r : . r e s p o n s i b i l i t y i n .drawing my f a c e d by the e l d e r l y and  thereby, i n s t i l l i n g  group o f p e o p l e . For t h i s I am deeply My  thanks  and  attention..to the problems  i n me  a deep concern f o r t h i s  grateful.  go to Drs. Park Davidson  and David Lawson f o r t h e i r a s s i s t a n c e  and a d v i c e i n the c o m p l e t i o n o f t h i s p r o j e c t . I am a l s o g r a t e f u l to Mr.  .,  R. Wand arid,the s t a f f of Dogwood Lodges f o r t h e i r c o - o p e r a t i o n throughout  the p r o j e c t . S p e c i a l thanks a r e due  to Ms.  H a z e l B r o a d l e y f o r p a r t i c i p a t i n g i n the  p r o j e c t and p r o v i d i n g v a l u a b l e s u g g e s t i o n s and h e l p f u l a d v i c e i n the program. I am a l s o g r a t e f u l to Mr. i n i t i a l a r t i s t s d e s i g n s used  Gordon Worsley who  p r o v i d e d the  i n the p r o j e c t .  To my w i f e , A n n e t t e , I want to express my  g r a t i t u d e and a p p r e c i a t i o n  f o r her encouragement and h e l p throughout  the l a s t y e a r . The  l i f e were made much e a s i e r w i t h her at my  side.  To my  f r i e n d s who  implementing  t r i a l s of student  p r o v i d e d support and u n d e r s t a n d i n g , I o f f e r my  sincere  appreciation. F i n a l l y , but most important, I wish to thank the r e s i d e n t s o f Dogwood Lodge f o r t e a c h i n g me  so much about  so many t h i n g s .  Page 1 CHAPTER 1  PROBLEMS OF THE  ELDERLY IN A MODERN SOCIETY  Aging i s perhaps the most u n i v e r s a l of a l l b i o l o g i c a l phenomena. Through time, the aging process  leads to a  gradual  d e c l i n e i n performance; i t a f f e c t s most of our organs, and i t leaves us v u l n e r a b l e to a v a r i e t y of p h y s i c a l and p s y c h o l o g i c a l d i s a b i l i t i e s . S u s c e p t i b i l i t y to d i s e a s e , e s p e c i a l l y c h r o n i c d i s e a s e , i n c r e a s e s d r a m a t i c a l l y i n the l a t e r years of A r t h r i t i s and pressure elderly  rheumatism, heart c o n d i t i o n s and  high  blood  are the most p r e v a l e n t c h r o n i c d i s e a s e s a f f e c t i n g  the  (Kimmel, 1974).  L e v e l s of motor performance i n v o l v i n g a g i l i t y and o r d i n a t i o n decrease with o l d age, processes  life.  as do many of the  such as v i s i o n , r e a c t i o n time and  1964). With i n c r e a s e d age,  hearing  sensory (Birren,  there i s a r e d u c t i o n i n the amount of  environmental i n f o r m a t i o n r e c e i v e d . Each sensory i t s e l f appears to show an age dark a d a p t a t i o n ,  co-  element by  r e l a t e d decrement: v i s u a l a c u i t y ,  a u d i t o r y t h r e s h o l d and  olfactory sensitivity.  S i m i l a r changes occur at higher l e v e l s of p e r c e p t u a l f u n c t i o n i n g such as f l i c k e r f u s i o n t h r e s h o l d and p e r c e p t i o n of v e r t i c a l i t y (Lawton and Nehmahow, 1974). Environmental i n f o r m a t i o n i s processed now  at a slower r a t e as age progresses,  although  evidence  seems to i n d i c a t e t h a t , g i v e n time, the h e a l t h y o l d e r  s u b j e c t ' s performance q u a l i t y may  be equal to the younger  Page 2 person's  The  i n many t a s k s  ( E i s d o r f e r , 1969).  elderly  experience  often  b o t h b r o u g h t on and c o m p l i c a t e d experience. percent  I n t h e 65 a n d o v e r  multiple diseases  by t h e degenerative  disabilities.  a l s o more prone t o t e m p o r a r y d i s a b i l i t i e s such as colds  changes  segment o f t h e p o p u l a t i o n  have one o r more c h r o n i c  illnesses  which are  and i n f l u e n z a  they  83  The e l d e r l y a r e  w h i c h accompany  common  (Busse and P f e i f f e r ,  1969).  In the everyday  lives  of the elderly,  a b i l i t i e s make i t d i f f i c u l t demands o f d a i l y ,  routine activities.  person once performed difficult daily an  as a matter  or impossible.  living  often  independent  lifestyle  an  the elderly  physical  an i n s t i t u t i o n a l  t o care  living  f o rthemselves i s  more p r e v a l e n t  stereotypes,  and p e r v a s i v e  i nthe  f a c t o r w h i c h makes f u n c t i o n i n g  Regardless  who h a s r e a c h e d  cultural  expectancies. on  decline, while  society difficult.  individual  standing  the activities of  to reluctantly relinquish  and t o accept  i s n o t , however, t h e o n l y  i n modern  become  and expected.  Physical elderly  to the  Chores that t h e e l d e r l y  t o perform  the elderly  inability  and a d j u s t  of course often  Inability  forces  environment where t h e i r anticipated  t o cope w i t h  declining physical  of the physical health of  6 5 , he o r s h e m u s t d e a l a t t i t u d e s , stigma  and  with  long  societal  These f a c t o r s themselves have a tremendous e f f e c t and v e r y  decline  often  (Birren,  produce, rather  1964).  than  follow  I n our s o c i e t y , aging i s  Page 3 p o p u l a r l y viewed as a s e r i e s of r a t h e r abrupt stages. E x i t from one  stage and  t r a n s i t i o n s between  e n t r y i n t o the next i s g e n e r a l l y  a c h r o n o l o g i c a l p a t t e r n i n the minds of most. The  later  are d e f i n e d i n terms of a p r o g r e s s i v e l o s s of r o l e s and decreased life  p h y s i c a l and mental a b i l i t y and  (Bruhn, 1971). That i s the popular  The  21), 'old'  status,  t e r m i n a t i o n of  view.  s i x t y - f i f t h year of l i f e has o f t e n been designated  the t h r e s h o l d of r e t i r e m e n t and other age  eventual  stages  based stages  the beginning  as  o f " o l d age".  (e.g. adolesence at 13 and  Like  adulthood  at  s i x t y - f i v e i s a c t u a l l y q u i t e a r b i t r a r y . Some people are at age  55 while o t h e r s are a c t i v e and  independent a t  age  80. While there i s no magic number t h a t marks e n t r y i n t o " o l d age",  the e l d e r l y as a group do f r e q u e n t l y experience  similar  s o c i o c u l t u r a l problems, i n c r e a s i n g l e v e l s of p h y s i c a l d e c l i n e and are a l l s u b j e c t to strong and widely held p r e j u d i c e s . Because of these  f a c t o r s , i t i s both convenient  the "problems of the  and reasonable  to speak of  elderly".  In r e c e n t years these problems have r e c e i v e d i n c r e a s i n g a t t e n t i o n from r e s e a r c h e r s , a l l l e v e l s of government and g e n e r a l p u b l i c . P a r t of the i n c r e a s e i n i n t e r e s t i s due f a c t t h a t the e l d e r l y are a l a r g e and growing segment of p o p u l a t i o n . In 1971,  f o r the f i r s t  S t a t e s was  our  equal to the  number of b i r t h s (Dancey, 1977). T h i s p r o p o r t i o n of  other  to the  time, the number of people  reaching the age of 65 i n the United  p o p u l a t i o n continues  the  the  to grow at a r a t e f a s t e r than t h a t of  segment of the p o p u l a t i o n  any  ( S c h r e i b e r , 1972). In Canada  Page 4 there were 1.7  m i l l i o n c i t i z e n s over the age of 65 i n 1971.  f i g u r e w i l l r i s e to 3.3  m i l l i o n by the year 2000  This  (Statistics  Canada, 19741.  The  changes i n p o p u l a t i o n p a t t e r n noted  dramatic  above w i l l have a  impact on North American s o c i e t y . Whereas the  present  l e v e l of p o p u l a t i o n growth i s accounted f o r by the improvement i n h e a l t h measures a f f e c t i n g i n f a n c y and c h i l d h o o d , f u t u r e growth may  be accounted f o r , i n l a r g e p a r t , by trends toward i n c r e a s e d  l i f e expectancy i n o l d e r i n d i v i d u a l s . With major advances i n the treatment  of cancer  and c a r d i o v a s c u l a r d i s e a s e , i t may  a n t i c i p a t e d t h a t the next  set of medical  be  advances w i l l i n f l u e n c e  the e x t e n s i o n of l i f e of the o l d e r , r a t h e r than younger populations medical  ( E i s d o r f e r , 1973). A l r e a d y , with c u r r e n t l e v e l s of  technology  and  r e t i r e m e n t of a person his  s e r v i c e s , the average number of years of r e a c h i n g 60 i n 1975  or her c o u n t e r p a r t i n 1900  i s three times t h a t of  (White House Conference on  Aging,  1961).  The  changing p r o p o r t i o n s i n the p o p u l a t i o n which favour  the  e l d e r l y , i n s t e a d of the young, have a l r e a d y begun to i n f l u e n c e the supply and demand balance groups. Many c i t i e s , classrooms  i n s o c i a l s e r v i c e s f o r these  f o r example, have empty elementary school  and crowded, i n a d e q u a t e l y  n u r s i n g home f a c i l i t i e s .  s t a f f e d h o s p i t a l s and  In the United S t a t e s , the 10 percent  the p o p u l a t i o n t h a t i s over the age of 6 5 r e q u i r e 2 0 percent  of of  the acute h o s p i t a l care p r o v i d e d and consume an even g r e a t e r p r o p o r t i o n of p h y s i c i a n s ' o f f i c e p r a c t i c e and o u t p a t i e n t c a r e . In  Page 5 a d d i t i o n , an estimated 5 percent of those over age  65 are so  p h y s i c a l l y o r p s y c h o l o g i c a l l y d i s a b l e d t h a t they r e q u i r e long term care i n i n s t i t u t i o n s . A s i m i l a r p a t t e r n i s e v i d e n t i n Canada w i t h those over age  65 i n 1970  utilizing  over 33 percent of a l l  government supported h o s p i t a l beds (Weaver, McPhee and  Lambert,  1 975)..  While of  the e l d e r l y a l r e a d y consume a s i g n i f i c a n t p r o p o r t i o n  the m e d i c a l , p s y c h o l o g i c a l and  the demand i s l i k e l y  s o c i a l s e r v i c e s i n our  society,  to grow d r a m a t i c a l l y . In the next 25 years  the 55-64 age group w i l l  i n c r e a s e by 10 percent, the 65-74 group  by 23 p e r c e n t , and the most v u l n e r a b l e , the 7 5+ age group by 6 0 percent  (-Brotman'  1  977) . A f u r t h e r c o m p l i c a t i o n t o t h i s a l r e a d y  complex p i c t u r e i s the f a c t t h a t , while the e l d e r l y tend t o need more s e r v i c e s , a s u b s t a n t i a l p r o p o r t i o n are poor and have b a r e l y enough income t o s u b s i s t  The  (MacBonald , 1 973) .  Institutional Solution  Almost 100 years ago, Charcot  (cited i n H a l l ,  1975)  the need f o r a s p e c i a l study of the d i s e a s e s of o l d age claimed t h a t " s e n i l e pathology too has i t s d i f f i c u l t i e s ,  outlined and which  can o n l y be surmounted by long experience and a profound knowledge of i t s p e c u l i a r c h a r a c t e r s " . Progress  has,  u n f o r t u n a t e l y , not been r a p i d s i n c e Charcot c a l l e d f o r a g r e a t e r understanding has noted, age  of the problems of the e l d e r l y . As Loether i s a complicated concept w i t h b i o l o g i c a l ,  C1967)  Page 6 p s y c h o l o g i c a l and s o c i o l o g i c a l c o n n o t a t i o n s . While Bromley and Lidz- (1968) both compare the adjustments make t o some of the c r i t i c a l developmental  (1972)  an aged person must  t a s k s experienced  d u r i n g adolescence, e f f o r t s t o develop a t r u l y comprehensive model of the aging process have not been s u c c e s s f u l (Botwinick, 1 973).  Much of the r e s e a r c h on aging remains o n l y d e s c r i p t i v e . In Canada, the s i t u a t i o n was c o n s i d e r e d alarming by t h e Canada C o u n c i l , a major funding agency f o r s o c i a l s c i e n c e r e s e a r c h . In a review of support f o r r e s e a r c h s i n c e the 1960's, i t concluded t h a t t h e r e was an almost complete e x c l u s i o n o f any r e s e a r c h r e l a t e d t o aging was  (Report on Research  i n Gerontology,  1976). I t  a l s o noted t h a t t h i s s i t u a t i o n has shown no s i g n o f changing  d e s p i t e the f a c t t h a t "Canada i s e n t e r i n g a stage where a c o n s i d e r a b l e percentage  o f i t s p o p u l a t i o n w i l l be aged".  While we have no s u b s t a n t i a t e d t h e o r e t i c a l base f o r l o o k i n g a t t h e o v e r a l l process o f aging, we do have a c o n s i d e r a b l e amount of s o c i o l o g i c a l and e p i d e m i o l o g i c a l data on the r e s u l t s o f aging and the e f f e c t s o f c u r r e n t e f f o r t s t o d e a l w i t h the problems of the aged. When the d i s a b i l i t i e s o f an e l d e r l y person  interfere  with h i s or her competence i n the b a s i c a c t i v i t i e s r e q u i r e d f o r independent  e x i s t e n c e , the person's  f a m i l y are o f t e n c o n f r o n t e d  with a d i f f i c u l t d e c i s i o n . With the breakdown o f t r a d i t i o n a l f a m i l y p a t t e r n s , the c e n t r a l i z a t i o n of people i n towns and c i t i e s , e a r l y r e t i r e m e n t , and the movement of women i n t o t h e j o b market, f a m i l i e s are no longer i n a p o s i t i o n t o p r o v i d e f o r t h e i r  Page 7 aging r e l a t i v e s i n the home. A common s o l u t i o n i s admission o f the e l d e r l y d i s a b l e d t o a n u r s i n g home, c h r o n i c h o s p i t a l , o r other long stay f a c i l i t y where p a t i e n t s are p a s s i v e r e c i p i e n t s of 24 hour c a r e . S o c i e t y has,  thus, taken over the r e s p o n s i b i l i t y t o  p r o v i d e f o r many aged by e s t a b l i s h i n g i n s t i t u t i o n s throughout the country  t o accomodate v a r y i n g l e v e l s of aged p a t i e n t s with  their  problems of f i n a n c e s , h e a l t h and reduced l e v e l s of a c t i v i t y . And, as p o i n t e d out by Burnside  (1976), with the i n c r e a s e i n the  p r o p o r t i o n o f t h e v e r y o l d , the problem o f i n s t i t u t i o n a l care and i t s f i n a n c i a l and s o c i a l c o s t s may assume even g r e a t e r importance.  The  e f f o r t t o s o l v e a growing s o c i a l problem with  i n s t i t u t i o n s i s a f a m i l i a r p a t t e r n with f a m i l i a r r e s u l t s . The d e v a s t a t i n g and long term e f f e c t s of poor i n s t i t u t i o n a l care f o r c h i l d r e n were documented years ago (Skeels and Dye, 1939). In t h a t case t h e problem was one o f u n d e r s t i m u l a t i o n The  and n e g l e c t .  l e s s the c h i l d r e n were t a l k e d t o , played w i t h and cuddled,  the more d e t r i m e n t a l was the i n s t i t u t i o n a l environment  (Mussen,  Conger and Kagen, 1963). I n s t i t u t i o n s f o r the e l d e r l y a r e a l s o frequent c o n t r i b u t o r s t o d e c l i n e i n the e l d e r l y who l i v e and  f o r some of the same reasons.  there,  There i s an extremely low l e v e l  of p a t i e n t - s t a f f i n t e r a c t i o n i n many f a c i l i t i e s  (MacDonald,  1973). I n s t i t u t i o n s f o r the e l d e r l y a l s o work a g a i n s t the h e a l t h of t h e i r r e s i d e n t s i n another way - a tendency t o d e f i n e the e l d e r l y person as a s e r v i c e consumer and t o p r o v i d e an e x c e s s i v e l y h i g h l e v e l o f s e r v i c e s t o many e l d e r l y p a t i e n t s . Doing e v e r y t h i n g f o r the e l d e r l y p a t i e n t r a p i d l y impairs the  Page 8 i n d i v i d u a l ' s c a p a c i t y f o r independent d e c i s i o n making, a significant  step towards becoming " i n s t i t u t i o n a l i z e d "  (Bayne,  1971 ) .  The  i n s t i t u t i o n a l i z e d e l d e r l y are described  withdrawn, unresponsive and u n i n t e r e s t e d 1961;  as a p a t h e t i c ,  in activities  (Charles,  Lieberman, 1969). In many cases the i n s t i t u t i o n a l i z e d  person, r e g a r d l e s s of p h y s i c a l c o n d i t i o n f u n c t i o n s a t a much lower l e v e l a f t e r e n t e r i n g an i n s t i t u t i o n than b e f o r e . A number of r e s e a r c h e r s  have, thus,  become i n c r e a s i n g l y concerned about  the damaging e f f e c t s of prolonged i n s t i t u t i o n a l i z a t i o n and  B u t l e r , 1974). Apathy, l a c k o f m o t i v a t i o n ,  (MacDonald  passivity,  dependent behaviour, hastened d e t e r i o r a t i o n and induced are a l l byproducts o f t h e " i n s t i t u t i o n a l i z e d " p a t i e n t and  Zilli,  1969; E u s t e r ,  As noted b e f o r e ,  senility  (Lowenthal  1971).  the q u a l i t y o f l i f e  i n many i n s t i t u t i o n s  leaves much t o be d e s i r e d when compared t o the q u a l i t y o f l i f e a v a i l a b l e t o n o n - i n s t i t u t i o n a l i z e d people. Townsend member of Ralph Nader's study group on n u r s i n g  (1971), a  homes, suggested  t h a t i n s t i t u t i o n a l environments f o r the e l d e r l y a r e o f t e n d e f i c i e n t i n meeting the human needs of t h e r e s i d e n t s . Many behaviours thought t o c h a r a c t e r i z e the e l d e r l y , such as s e c l u s i v e n e s s , dependence i n s e l f - c a r e , i n c o n t i n e n c e , personal  communication, are very o f t e n e n v i r o n m e n t a l l y  (Labouvie-Vief,  lack of determined  Hoyer, B a l t e s and B a l t e s , 1974; Lawton and  Nahemow, 1973); they are learned  behaviours and consequences of  environmental d e p r i v a t i o n i n c l u d i n g i n t e l l e c t u a l ,  s o c i a l and  Page 9 emotional  understimulation.  I n s t i t u t i o n s , including nursing  homes, o f t e n c o n t r i b u t e t o t h e d e p r i v a t i o n s t a t u s o f t h e e l d e r l y (Euster,  1971).  Why s h o u l d e x p e n s i v e s o c i a l s e r v i c e s such as n u r s i n g homes produce such d e t r i m e n t a l e f f e c t s on t h e i r c l i e n t s ? One answer l i e s i n t h e model used i n o r g a n i z i n g and p r o v i d i n g s e r v i c e s . E f f o r t s t o p r o v i d e human s e r v i c e s t o t h e e l d e r l y l i v i n g i n n u r s i n g homes have t r a d i t i o n a l l y used a m e d i c a l and have f o c u s e d  o r i l l n e s s model  p r i m a r i l y on b i o l o g i c a l and m e d i c a l  modes. O l d age was, and s t i l l  treatment  i s , p e r c e i v e d as a ' s i c k ' o r  'abnormal' s t a t e i n l i f e which was l a r g e l y due t o b i o l o g i c a l deterioration .1 9 7 4 )  ( E i s d o r f e r and Lawton 1 9 7 3 ;  and (thus t r e a t e d a c c o r d i n g l y w i t h  p h y s i c a l techniques.  MacDonald and Butter;* .chemical, and:  "  A p e r s o n was, and i s p e r c e i v e d as ' o l d ' when  he o r she e x h i b i t s s i c k b e h a v i o u r assumed t o r e f l e c t a s p e c t s o f b i o l o g i c a l d e t e r i o r a t i o n . I n our s o c i e t y , o l d people a r e a c t u a l l y encouraged t o f u l f i l l t h e ' s i c k ' r o l e as t h e i r l e g i t i m a t e s o c i a l role  (MacDonald and B u t l e r ,  1974).  T h i s i s what we e x p e c t o f  them.  Eisdorfer  (1 969).  i s one r e s e a r c h e r who has c o g e n t l y made t h e  p o i n t t h a t , i n o u r s o c i e t y , t h e 'aged' s t e r e o t y p e w i t h being  i s synonymous  s i c k . The c o n t e n t i o n t h a t i l l n e s s w i l l accompany and  i n d i c a t e t h e o n s e t o f o l d age i s a p o w e r f u l prophesy (MacDonald,  1973).  The p e r s o n over  s i c k n e s s and p h y s i c a l d i s c o m f o r t  self-fulfilling 65  often expects  t o accompany a g i n g n a t u r a l l y  (Kastenbaum, 1 9 6 4 ) and, because i t i s s o c i a l l y a p p r o p r i a t e and  Page 10 consequently accepted by s o c i e t y , the o l d e r person i s l i k e l y t o take on t h i s  'aged-sick' r o l e w i t h l i t t l e r e s i s t a n c e .  C u l t u r a l l y , the ' s i c k ' r o l e f u n c t i o n s t o p r o t e c t and b e n e f i t persons i n temporary  s t a t e s of decreased c a p a b i l i t y .  (.cited i n Ullman and Krasner, 1 969)  identified  Parsons  four  c h a r a c t e r i s t i c s of the s i c k r o l e i n our s o c i e t y : 1. The person i s exempted from the performance o f c e r t a i n of h i s or her normal  social  functions.  2. The person i s not held r e s p o n s i b l e f o r h i s or her condition. 3. There i s a s o c i e t a l e x p e c t a t i o n  f o r the person t o  r e t u r n t o a s t a t e of h e a l t h as q u i c k l y as p o s s i b l e . 4. The person i s o b l i g a t e d t o cooperate w i t h persons are s o c i a l l y sanctioned  who  t o 'help' the s i c k person.  The c h a r a c t e r i s t i c s of t h i s r o l e p r o v i d e reasonable b e n e f i t s f o r persons i n a temporary  s t a t e of decreased c a p a b i l i t y . However,  prolonged f u l f i l l m e n t of t h i s r o l e r e s u l t s i n s o c i e t a l devaluation  and r e j e c t i o n of the i n d i v i d u a l as a person  cannot overcome h i s or her d i s a b i l i t y , and Who,  who  t h e r e f o r e , cannot  a c t i v e l y p a r t i c i p a t e i n s o c i e t y . Once t h i s assumption has been made, e f f o r t s to improve the person's l e v e l o f performance  are  d e f i n e d not o n l y as hopeless, but a l s o as i n a p p r o p r i a t e .  Research, t r a i n i n g and d e l i v e r y i n h e a l t h c a r e i n t e r v e n t i o n have been dominated  u n t i l r e c e n t l y by c o n c e p t u a l i z a t i o n s  derived  from t r a d i t i o n a l medicine and from knowledge bases d e r i v e d the p h y s i c a l and b i o l o g i c a l s c i e n c e s . C o n s i d e r i n g  health  from  Page 11 i n t e r v e n t i o n f o r the e l d e r l y as p r i m a r i l y a m e d i c a l p r o c e s s c r e a t e s an o r i e n t a t i o n towards s e r v i c e t h a t i s c h a r a c t e r i z e d by a focus on i n t e r v e n t i o n to c o r r e c t a l r e a d y e x i s t i n g problems r a t h e r than attempts t o prevent d e t e r i o r a t i o n i n the f i r s t p l a c e . I t a l s o means t h a t h e a l t h care d e l i v e r y p e r s o n n e l are t r a i n e d i n the b i o l o g i c a l and  p h y s i c a l s e r v i c e s r a t h e r than the b e h a v i o u r a l  s o c i a l sciences  Recently,  and  ( B a l t e s , 1 976)..  however, the concept of  a l a r g e l y unidimensional multidimensional,  ' h e a l t h ' has  evolved  from  b i o l o g i c a l concept i n t o a  m u l t i d i s c i p l i n a r y one.  Terms l i k e environmental  h e a l t h , mental h e a l t h , school h e a l t h and  community h e a l t h are a l l  examples of the expansion of the h e a l t h concept i n t o a m u l t i p r o f e s s i o n a l c o n s t r u c t . Medical attacked  because of t h e i r primary emphasis on  c o r r e c t i o n and fact,  h e a l t h a c t i v i t i e s are  cure, r a t h e r than p r e v e n t i o n  and  being  remediation, optimization.  "the predominant focus of the medical p r o f e s s i o n on  In  cure  r a t h e r than o p t i m i z a t i o n of h e a l t h has o f t e n been seen as the a t t r i b u t e of what has  been c a l l e d the m e d i c a l model"  key  (Baltes,  1 974) .  The m e d i c a l model, as a p p l i e d to the aged, i s p a r t i c u l a r l y detrimental  s i n c e there  e l d e r l y t o take the  i s a general  tendency to expect  s i c k r o l e permanently. The  the  r e s u l t i s often a  program of s e r v i c e s t h a t m i n i s t e r to the h e a l t h problems of e l d e r l y with l i t t l e expectation  the  or e f f o r t to help the e l d e r l y  person improve or m a i n t a i n t h e i r l e v e l s of f u n c t i o n i n g . While s e v e r a l s t u d i e s have shown t h a t the e l d e r l y can make major  gains  Page 12 in r e h a b i l i t a t i o n  programs, i n the t y p i c a l  are inadequate, are not reaching not making f u l l use  institution  the a p p r o p r i a t e  people and  of the a v a i l a b l e r e h a b i l i t a t i o n  The  need today i s f o r more r e s e a r c h  and  s e r v i c e s but a l s o toward the  i n f l u e n c e the e x i s t e n c e them" (Gottesman, 1970).  "services are  techniques.  d i r e c t e d not o n l y a t programs  i d e n t i f i c a t i o n of f a c t o r s which  of s e r v i c e s and  changes t h a t occur i n  Page 13 CHAPTER 2  THE PSYCHOSOCIAL ENVIRONMENT OF GERIATRIC CARE FACILITIES  In a comprehensive survey of nursing and  Gorman (.1 975)  home r e s i d e n t s , Kosberg  found t h a t the r e s i d e n t s had negative  attitudes  towards themselves as w e l l as age p e e r s . T h i s tendency toward a low  s e l f and peer esteem may be the r e s u l t of the constant  reminder of i l l n e s s , d i s a b i l i t y , A l t e r n a t i v e l y , these negative a t t i t u d e s of others  s e n i l i t y and death.  a t t i t u d e s may be r e f l e c t i o n s o f the  such as s t a f f and r e l a t i v e s . Kahana and Coe  (1969) concluded t h e i r study of s t a f f and r e s i d e n t a t t i t u d e s by commenting t h a t " s t a f f e x p e c t a t i o n s to the d e p e r s o n a l i z i n g  Factors  and a t t i t u d e s may c o n t r i b u t e  process o f i n s t i t u t i o n a l i z a t i o n " .  t h a t c o n t r i b u t e t o the low s e l f - e s t e e m  are not found s o l e l y , however, i n the i n s t i t u t i o n a l 'Old age' i s p e r c e i v e d  o f the e l d e r l y environment.  as beginning a t age 65 and i s accompanied  by r u l e s such as mandatory r e t i r e m e n t  and c u l t u r a l  expectations  and models t h a t e x p l i c i t l y d e f i n e the e l d e r l y as d e b i l i t a t e d and i n e f f e c t u a l . The e n t i r e c u l t u r e sets the stage f o r d i f f i c u l t adjustment i n the l a t e r years of l i f e .  The e l d e r l y a r e o f t e n  f o r c i b l y removed from a f u n c t i o n a l and independent r o l e i n t h e i r own l i f e valued  and t h a t o f t h e i r s o c i e t y without p r o v i d i n g a s o c i a l l y  a l t e r n a t i v e . The r e s u l t can be a negative  self-label  self-image and  (Kastenbaum, 1964). The o l d e r person i s r e q u i r e d t o  stop working, because of a r b i t r a r y r e g u l a t i o n s and/or d e c l i n i n g  Rage 1.4 health, At  the  and a  i n a s o c i e t y whose v a l u e  system degrades the  same t i m e , f a c t o r s s u c h as  the  health,  the  non-worker.  death of  friends  i n c r e a s i n g geographic d i s p e r s a l of c h i l d r e n c o n t r i b u t e  social  isolation  G i o r d a n o and work and  of  the  such  as  ( 1 9 6 9 ) b e l i e v e t h a t the w i t h d r a w a l from  Giordano  social  e l d e r l y . Many r e s e a r c h e r s ,  to  contact  directly  contributes  to  psychological  deterioration.  care  T h u s , when t h e  e l d e r l y person reaches the  facility  she  he  or  to r e a c t n e g a t i v e l y there  i s a morbid  community  already  often  the  exposure to  Behavioural  a l t e r n a t i v e s to the  expected of  the  institutions  good m e d i c a l  gone' and  an  with f a m i l y or  stimulating  activities  aged and  with l i t t l e  opportunity  (Hoppa and  s e n i l e to respond  that  t o any  psychological  B r o d y , K l e b a n , Lawton and  or  1967).  1973).  Emphasis  been p l a c e d  1 9 7 4 ) . Many f a c i l i t i e s  the  e l d e r l y are  restorative  'too  far  activities,  social.  Silverman  (1971),  K l e b a n and  Brody  (1 972)„, and K l e b a n , B r o d y and Lawton ( 1 9 7 1 ) o b s e r v e d i n t h e i r surveys of g e r i a t r i c  care,  that  on  f o r engagement i n  Roberts,  philosophy  younger  sick r o l e behaviours  traditionally  e l d e r l y has  end'.  opportunities  (Turner,  f o r the  implicit  whether m e d i c a l ,  'close to the  (MacDonald,  meaningful a c t i v i t i e s o p e r a t e on  is  e l d e r l y are minimal  care  psychologically  i s o l a t e d without  interactions, contact  home o r  institutionalization,  resident  socially  p e r s o n s and  in  been p r e p a r e d  t o what f o l l o w s . Upon  sense t h a t  Residents are very for  has  nursing  functional incapacity i s  Page 15 f r e q u e n t l y g r e a t e r than t h a t warranted by the a c t u a l  impairment.  Kahn (1965) found t h i s p a t t e r n t o be widespread among aged persons l i v i n g  i n i n s t i t u t i o n s . He used the term "excess  d i s a b i l i t y " t o i d e n t i f y the phenomenon. Lieberman  (.1969) a l s o  found t h a t i n s t i t u t i o n a l i z e d o l d e r people are l e s s competent  than  those i n the community w h i l e Lieberman, Prock and T o b i n (1968) reported  t h a t those i n i n s t i t u t i o n s were s i g n i f i c a n t l y poorer i n  v a r i o u s c o g n i t i v e , a f f e c t i v e and s o c i a l f u n c t i o n s when compared w i t h community r e s i d e n t s of s i m i l a r demographic s t a t u s . I t would  and  health  seem t h a t f a c t o r s other than a c t u a l p h y s i c a l  d i s a b i l i t y must be considered  t o account f o r the low l e v e l of  f u n c t i o n i n g t h a t i s c h a r a c t e r i s t i c of t h i s group. Most r e s i d e n t i a l treatment programs, opportunities  however, p r o v i d e few  f o r a c t i v i t i e s incompatible with s i c k - r o l e  b e h a v i o u r s . As noted e a r l i e r , s t a f f members, e s p e c i a l l y nurses and nurses a i d e s , are t r a i n e d t o t r e a t r e s i d e n t s as i f they were s i c k . Even the s t y l e and arrangement h o s p i t a l - l i k e atmosphere  of the f u r n i t u r e suggests a  (Kosberg and Gorman, 1975). B a l t e s and  Lascomb  (1 975). and Gottesman  nursing  environment can be c h a r a c t e r i z e d as a s o c i a l l y and  p h y s i c a l l y deprived  (1 973) have demonstrated t h a t the  environment.  I t has been demonstrated by s e v e r a l i n v e s t i g a t o r s 1972)  that nursing  (Harel,  home s t a f f do a c t u a l l y adopt the s o c i e t a l  c o n c e p t i o n o f the e l d e r l y as ' s i c k * . In p a r t i c u l a r , i t appears t h a t the o c c u p a t i o n a l personal  groups who  have the h i g h e s t  l e v e l s of  i n t e r a c t i o n w i t h the i n s t i t u t i o n a l i z e d e l d e r l y have  Page J 6 predominantly  n e g a t i v e a t t i t u d e s and e x p e c t a n c i e s . Handschu  (1973) found n o n - p r o f e s s i o n a l s t a f f had the most n e g a t i v e a t t i t u d e s while Kahana and Coe  (1969) r e p o r t e d t h a t the a t t i t u d e s  of the e l d e r l y r e s i d e n t s about themselves  were, u n f o r t u n a t e l y ,  v e r y c l o s e t o those of the n o n - p r o f e s s i o n a l s t a f f .  Finally,  Kosberg and Gorman (1975) found t h a t 86 percent of the n o n - p r o f e s s i o n a l n u r s i n g s t a f f i n t h e i r study h e l d n e g a t i v e a t t i t u d e s toward the aged p o p u l a t i o n ' s p o t e n t i a l f o r improved f u n c t i o n i n g , as d i d 44 percent o f the t h e r a p i s t s and of the housekeeping  100  percent  staff.  Perhaps the c o r r e l a t i o n a l s t u d i e s c i t e d above are merely r e f l e c t i o n s of r e a l i t y . Perhaps the i n s t i t u t i o n a l i z e d e l d e r l y are a s e l e c t e d segment of the g e n e r a l aged p o p u l a t i o n  those who  are  most d e b i l i t a t e d and t h e r e f o r e u n l i k e l y t o respond  t o attempts  to  p r o v i d e therapy or r e h a b i l i t a t i o n . I f such were the case,  then,  the n e g a t i v e a t t i t u d e s of s t a f f and the low s e l f - e s t e e m of r e s i d e n t s would be a somewhat a c c u r a t e r e f l e c t i o n of a bleak r e a l i t y . There are s e v e r a l s t r a n d s o f evidence which would argue a g a i n s t the h y p o t h e s i s o u t l i n e d above. S e v e r a l i n v e s t i g a t o r s have concluded t h a t many of the behaviours of the e l d e r l y i n i n s t i t u t i o n s are e n v i r o n m e n t a l l y determined Hoyer, B a l t e s and B a l t e s , 1974;  In theory, environmental  (Labouvie-Vief,  Lawton and Nahemow, 1973).  c o n d i t i o n s can e i t h e r aggravate  compensate f o r aging l o s s e s (Chapanis,  1974;  or  McClannahan, 1973).  Environments can thus c o n t r i b u t e t o f u r t h e r d e t e r i o r a t i o n or  Page 17 f a c i l i t a t e maintenance of e x i s t i n g  s k i l l s and r e h a b i l i t a t i o n o f  those s k i l l s which have a l r e a d y been l o s t . In a c t u a l f a c t , the d e p r i v e d environmental  c o n d i t i o n s experienced by the  i n s t i t u t i o n a l i z e d e l d e r l y a r e r a r e l y r e h a b i l i t a t i v e . These environments are the products o f s e v e r a l f a c t o r s i n c l u d i n g the dominance of the medical model, c u l t u r a l l y sanctioned p r e j u d i c e s on t h e p a r t o f s t a f f and r e s i d e n t a l i k e , and the l o s s o f p h y s i c a l and c o g n i t i v e a b i l i t i e s . The i n d i v i d u a l i n a n u r s i n g home i s expected  t o be s i c k and t o remain so. The c a r e p r o v i d e d i s based  on t h a t expectancy  and the l i m i t e d s k i l l s o f the e l d e r l y r e s i d e n t  prevent them from o b t a i n i n g a normal l e v e l o f s t i m u l a t i o n through normal channels. Residents o f t e n experience a permanent change i n reinforcement p a t t e r n s upon entrance i n t o a n u r s i n g home. Losses to the r e s i d e n t a r e both extreme and permanent. These l o s s e s i n c l u d e t h e absence o f s i g n i f i c a n t o t h e r s who served as powerful r e i n f o r c i n g agents, the l o s s of valued p e r s o n a l p r i v a c y , l o s s o f the a b i l i t y t o make d e c i s i o n s f o r o n e s e l f and l o s s o f access t o p r i v a t e p o s s e s s i o n s t h a t are, themselves,  S i g n i f i c a n t others  strong r e i n f o r c e r s .  (e.g. s t a f f and family), i n the  environment of the e l d e r l y g r a d u a l l y withdraw t h e i r  attention,  support and encouragement. A r e s u l t of t h i s i s the e x t i n c t i o n of many a d a p t i v e behaviours which were maintained  by t h e r e i n f o r c i n g  a t t e n t i o n and c o n t a c t w i t h s i g n i f i c a n t o t h e r s . In a d d i t i o n , a d e t r i m e n t a l reinforcement p a t t e r n i s a common component of i n s t i t u t i o n a l c a r e . Many n u r s i n g homes and g e r i a t r i c  care  f a c i l i t i e s make a t t e n t i o n and sympathy c o n t i n g e n t upon ' n e g a t i v e  1  Page 18 behaviours  such as d i s c o m f o r t , p a i n , complaint and i n c r e a s e d  dependence. In the context of a v e r y low l e v e l of reinforcement, the primary way  t o o b t a i n valued human a t t e n t i o n from  behave i n a dependent manner. In essence,  t a k i n g on  s t a f f i s to  the  "aged-sick" r o l e i s the primary means of o b t a i n i n g r e i n f o r c e m e n t i n the n u r s i n g home.  L i k e the teacher who  attends to a temper tantrum  and  thus,  i n a d v e r t e n t l y rewards i t , the n u r s i n g s t a f f of many f a c i l i t i e s may  a c t u a l l y " k i l l with kindness" or "help the r e s i d e n t t o  death". S e v e r a l s t u d i e s show t h a t , i n many i n s t i t u t i o n s f o r the e l d e r l y , the s t a f f tend to t r e a t the r e s i d e n t s as i f they were s i c k and pay a t t e n t i o n t o them o n l y i f m e d i c a l a t t e n t i o n i s required  (Turner, 1967;  MacDonald and B u t l e r , 1973). In many  cases, s t a f f a c t u a l l y encourage the r e s i d e n t t o u n n e c e s s a r i l y adopt the s i c k r o l e through the p a t t e r n of care and adopted  reinforcement  i n the f a c i l i t y . Encouragement and r e i n f o r c e m e n t of  obedient and thus, dependent behaviours,  i s a l s o common because  i t a l l o w s the i n s t i t u t i o n t o run more smoothly. Much of the reinforcement f o r dependent behaviour may  occur without the  being aware of the e f f e c t s i n c e g e r i a t r i c  institutional  staff  staff  r e p o r t t h a t dependency i s one of the most d i f f i c u l t management problems (Geiger and Johnson, 1974). The  environmental  c h a r a c t e r i s t i c s of n u r s i n g homes d e s c r i b e d thus f a r , however, are major f a c t o r s i n determining the behaviour of the r e s i d e n t . T h e i r potency  elderly  i s so s t r o n g , i n f a c t , t h a t  r e h a b i l i t a t i v e e f f o r t s i n these s e t t i n g s have g e n e r a l l y been  Page 19  u n s u c c e s s f u l (Ochberg, Zarcone and Hamburg, 1972; Penchansky 1965).  and Tauberhaus,  Page 20 CHAPTER 3  BEHAVIOURAL APPROACHES TO PROBLEMS OF  THE  INSTITUTIONALIZED ELDERLY  Some models of the aging  process assume t h a t  behavioural  d e f i c i t s of the e l d e r l y are the i r r e v e r s i b l e products of i n e v i t a b l e b i o l o g i c a l d e t e r i o r a t i o n . Prock  (1 9 69),  however, concluded t h a t "a g r e a t d e a l of r e h a b i l i t a t i o n may accomplished i f i t i s r e c o g n i z e d  be  t h a t many, i f not most,  components of the body have the c a p a c i t y f o r normal f u n c t i o n " . X T h i s author b e l i e v e s t h a t many o l d e r people are m i s t r e a t e d inadequately  or  t r e a t e d because of the p r o f e s s i o n a l a t t i t u d e t h a t  l i t t l e can a c t u a l l y be done to improve t h e i r c o n d i t i o n . F i l e r O'Connell aging,  and  (1 964). a l s o remarked t h a t "a g r e a t e r percentage of  d i s a b l e d , d o m i c i l i a r y r e s i d e n t s would a t t a i n and  maintain  ' d e s i r a b l e ' standards of behaviour i f they were subjected  to a  s t i m u l a t i n g , demanding environment w i t h d e f i n i t e e x p e c t a n c i e s t r a n s l a t e d i n t o a system of c o n s i s t e n t and d i s c r i m i n a n t and  rewards  restrictions".  A number of the t h e o r e t i c a l p o s i t i o n s used as f o r the development of t h e r a p e u t i c  foundations  systems make assumptions t h a t  focus a t t e n t i o n on the c h a n g e a b i l i t y r a t h e r than the permanency of the e l d e r l y person's d i s a b i l i t i e s . Proponents of the  'social  l e a r n i n g ' approach assume t h a t b e h a v i o u r a l  be  d e f i c i t s may  Page 21 lessened or overcome through environmental m o d i f i c a t i o n (Hoyer, Mishara and R e i d e l , 1 9 7 5 ) . L i n d s l e y (.1 964) was  one of the  first  to suggest the use of environmental m a n i p u l a t i o n t o overcome b e h a v i o u r a l d e f i c i t s among the e l d e r l y . He argued  t h a t operant  techniques are u s e f u l i n determining the extent t o which b e h a v i o u r a l d e f i c i t s are e i t h e r b i o l o g i c a l l y based i r r e v e r s i b l e or e n v i r o n m e n t a l l y based r e i n f o r c e m e n t . An operant strengthened, maintained  and due  to  and inadequate  i s d e f i n e d as any behaviour  that i s  or weakened by the events which  c o n t i n g e n t l y f o l l o w i t . An operant approach techniques used t o d e s c r i b e and modify  i s a s e t of  behaviour. The management  of c o n t i n g e n c i e s i s the b a s i c t o o l . Contingent  environmental  events are d e l i v e r e d or w i t h h e l d i n order to s t r e n g t h e n , m a i n t a i n or weaken behaviour.  The use of b e h a v i o u r a l technology to change  behaviour  assumes t h a t the a p p r o p r i a t e f o c u s f o r i n t e r v e n t i o n i s the i n d i v i d u a l ' s environment. T h i s s t r a t e g y i s geared towards t h r e e main problem areas:.1) the a c q u i s i t i o n of new  behaviours;  maintenance of a l r e a d y e x i s t i n g behaviours but under new  2) stimulus  c o n t r o l ; and 3) the e x t i n c t i o n or r e s t r i c t i o n of unwanted behaviours. Well known i n t e r v e n t i o n techniques such as  token  economies and contingency c o n t r a c t i n g have been s u c c e s s f u l i n a number of s e t t i n g s i n c l u d i n g p s y c h i a t r i c wards, classrooms prisons.  Although treatment programs based upon p r i n c i p l e s of  and  Page 22 behaviour have been used by a wide v a r i e t y of c l i e n t p o p u l a t i o n s :(Sherman and. Baer,  V'969)  \ t h e r e have a c t u a l l y been v e r y  few  r e p o r t s of t h e i r use w i t h e l d e r l y groups. And those t h a t are r e p o r t e d i n the l i t e r a t u r e have d e a l t almost e x c l u s i v e l y w i t h the m o d i f i c a t i o n of simple operant behaviours of e l d e r l y c l i e n t s are c l a s s i f i e d as p s y c h o g e r i a t r i c or r e s i d e i n mental The f a c t t h a t they were e l d e r l y was Treatment  of l i t t l e  who  hospitals.  importance.  methods and t a r g e t behaviours were s i m i l a r t o those  r e p o r t e d i n the g e n e r a l p s y c h i a t r i c l i t e r a t u r e and i n work with the m e n t a l l y r e t a r d e d . D e s p i t e t h e i r l i m i t a t i o n s , however, the a v a i l a b l e s t u d i e s r e p o r t encouraging  Mishara  (.1 973)  results.  hypothesized t h a t the occurrence of  non-adaptive behaviour i n the e l d e r l y  ( s e c l u s i v e n e s s , b i z a r r e or  unusual behaviour, dependence i n self^-care, i n c o n t i n e n c e , l a c k of p e r s o n a l communication,  l a c k of r e s p o n s i b i l i t y , and so on) may  a f u n c t i o n of the q u a l i t y of the environment  i n which the  i n d i v i d u a l r e s i d e s . A t t e n t i o n from s t a f f may  be d e f i n e d as  rewarding and non-adaptive behaviour may  b r i n g about  a t t e n t i o n . The unwanted behaviour, t h e r e f o r e , may  that  be c o n t i n u a l l y  r e i n f o r c e d and thus i n c r e a s e i n frequency. In order t o change t h i s p a t t e r n , i t would be necessary t o be aware of the c o n t i n g e n c i e s t h a t are i n e f f e c t and change these, so t h a t the behaviour i s no longer r e i n f o r c e d .  Mishara and Kastenbaum  be  (1 973). documented a case i n which a  g e r i a t r i c mental h o s p i t a l p a t i e n t r e f u s e d t o wear c l o t h i n g f o r  Page 23 many y e a r s . T h i s behaviour was  changed by g r a d u a l l y r e q u i r i n g  the  p a t i e n t t o wear a d d i t i o n a l p i e c e s of c l o t h i n g f o r longer p e r i o d s of  time each day. The p r o v i s i o n of beer c o n t i n g e n t upon t h i s  i n c r e a s e i n c l o t h e s wearing was  used as r e i n f o r c e m e n t .  A d d i t i o n a l l y , the p a t i e n t ' s v e r b a l i z a t i o n s concerning " v o i c e s " , which had been t e l l i n g him not to wear c l o t h e s , were extinguished.  These r e s e a r c h e r s a l s o attempted m o d i f i c a t i o n s t r a t e g i e s a t a group  to apply behaviour  l e v e l . E i g h t y s u b j e c t s were  s e l e c t e d from a m e d i c a l u n i t i n a mental h o s p i t a l and randomly assigned t o two treatment wards. Each ward c o n s i s t e d of 20 males and 20 females and was activities, c h o i c e " . One  e n v i r o n m e n t a l l y e n r i c h e d w i t h "more  c h e e r i e r surroundings and o p p o r t u n i t i e s f o r f r e e treatment ward- a l s o used a token economy. Tokens  were used t o reward  i n d i v i d u a l s f o r engaging  behaviours. The r e s u l t s demonstrated  in desirable  t h a t both treatment programs  were s u c c e s s f u l i n i n c r e a s i n g d e s i r a b l e behaviours when compared to matched s u b j e c t s on a c u s t o d i a l c a r e ward. There were no major d i f f e r e n c e s between the two treatment wards.  B a l t e s and Lascomb demonstrate  (1975) used an  'ABA'  r e v e r s a l design to  a change i n the c h r o n i c 'screaming' behaviour of an  8 0 year o l d n u r s i n g home r e s i d e n t . Two  c o n t i n g e n c i e s were  employed. P o s i t i v e r e i n f o r c e m e n t , u s i n g both t a n g i b l e and  token  r e i n f o r c e r s , was made c o n t i n g e n t upon the occurrence of any desired  'normal' behaviours which were i n c o m p a t i b l e w i t h  Page 2 4 screaming. A l s o , when screaming d i d occur, the p a t i e n t was p h y s i c a l l y withdrawn from the s i t u a t i o n so t h a t no  reinforcement  could be a p p l i e d t o t h i s nonadaptive behaviour. These techniques r e s u l t e d i n the e l i m i n a t i o n of screaming behaviour i n the patient.  Disturbed  s o c i a l i n t e r a c t i o n i s a common phenomenon among  r e s i d e n t s i n g e r i a t r i c care  s e t t i n g s . The r e s i d e n t s may be  observed s i t t i n g o r l y i n g i n bed, a p a t h e t i c , l e t h a r g i c and withdrawn. Communication between r e s i d e n t s i s minimal and very o f t e n avoided. Some c o n t a c t  occurs with s t a f f , but t h i s i s  f r e q u e n t l y i n i t i a t e d by s t a f f . Hoyer, Kafer,  Simpson and Hoyer  (19741 hypothesized t h a t the absence of v e r b a l among e l d e r l y r e s i d e n t s represented by e x i s t i n g reinforcement not  communication  operant behaviour maintained  contingencies.  H o s p i t a l environments do  support v e r b a l communication but, i n s t e a d , r e i n f o r c e i t s  absence.  Hoyer e t a l ( 1 9 7 4 1 r e p o r t e d  on a study w i t h f o u r e l d e r l y  male mental h o s p i t a l r e s i d e n t s drawn from an age i n t e g r a t e d ward of a l a r g e mental h o s p i t a l . These p a t i e n t s d i s p l a y e d no v e r b a l behaviour w i t h e i t h e r s t a f f o.r other p a t i e n t s . The s u b j e c t s met w i t h the experimenter f o r eleven 4 5 t o 5 5 minutes. The f i r s t  bi-weekly s e s s i o n s  f i v e sessions  served  lasting  from  as.a b a s e l i n e  assessment p e r i o d . In the next s i x s e s s i o n s there were two 1 0 minute reinforcement  i n t e r v a l s a l t e r n a t i n g with  three  non-reinforcement o r e x t i n c t i o n i n t e r v a l s . During the  Page 25 reinforcement i n t e r v a l s token r e i n f o r c e r s  (pennies), were made  c o n t i n g e n t on the number of words emitted by two of the four s u b j e c t s . These tokens were exchangeable cigarettes  f o r e i t h e r candy or  a t the end of the s e s s i o n .  The i n v e s t i g a t o r s r e p o r t e d t h a t d u r i n g the r e i n f o r c e m e n t i n t e r v a l s , tokens were e f f e c t i v e i n i n c r e a s i n g v e r b a l output. V e r b a l behaviour decreased d u r i n g e x t i n c t i o n , demonstrating the c o n t r o l of v e r b a l responses by the immediate r e i n f o r c e m e n t c o n t i n g e n c i e s . A second experiment conducted by Hoyer e t a l 0 9.741 used a d i f f e r e n t experimental d e s i g n . Four c h r o n i c s c h i z o p h r e n i c p a t i e n t s served as s u b j e c t s . These  subjects, a l l  male, met w i t h the experimenter i n bi-weekly s e s s i o n s l a s t i n g 45 to 55 minutes. The f i r s t  f i v e sessions constituted  'baseline' i n  which no r e i n f o r c e r s were d e l i v e r e d . The next seven s e s s i o n s were r e i n f o r c e m e n t s e s s i o n s , u s i n g the same c o n t i n g e n c i e s as i n the first  experiment. S e s s i o n s t h i r t e e n through seventeen were  e x t i n c t i o n phases  i n which no r e i n f o r c e m e n t was g i v e n .  Reinforcment procedures were again implemented  during sessions  e i g h t e e n through twenty-four. Group f a c i l i t a t o r s used TAT cards as s t i m u l u s m a t e r i a l s and presented the same s e l e c t i o n o f c a r d s i n a d i f f e r e n t sequence  t o each of the p a r t i c i p a n t s i n each  s e s s i o n . Although each s u b j e c t was questioned i n d i v i d u a l l y , the experiment was conducted  i n a group s e s s i o n i n order t o maximize  any modeling e f f e c t s . Each v e r b a l operant i n response t o a q u e s t i o n was f o l l o w e d d i r e c t l y by a r e i n f o r c e r  (candy or a  c i g a r e t t e ) . The r e i n f o r c e m e n t c o n d i t i o n s produced  increases i n  Page 26 v e r b a l behaviour  f o r a l l s u b j e c t s w h i l e v e r b a l behaviour  when r e i n f o r c e m e n t  procedures  declined  were not i n e f f e c t .  Another b e h a v i o u r a l approach to m o d i f y i n g was r e p o r t e d by L i n s k , Howe and P i n k s t o n  social  behaviour  (1975). They attempted  to i n c r e a s e a p p r o p r i a t e v e r b a l i z a t i o n s by d i r e c t i n g t a s k - r e l a t e d questions t o i n d i v i d u a l p a t i e n t s i n a group c o n t e x t . The study was conducted on a ward of a home f o r the aged and i n c l u d e d 31 female r e s i d e n t s with a mean age of 85 y e a r s . A l l r e s i d e n t s were i n v i t e d t o p a r t i c i p a t e i n three group a c t i v i t i e s : a r e s i d e n t s ' meeting, a f o l k - t a l e a c t i v i t y and a newspaper r e a d i n g During  a b a s e l i n e p e r i o d , the behaviours  of r e s i d e n t s i n these  groups were c l a s s i f i e d as v e r b a l or nonverbal i n a p p r o p r i a t e by means of a time sampling treatment  activity.  and a p p r o p r i a t e or  procedure.  During the  phase, frequent q u e s t i o n s about the m a t e r i a l being  d i s c u s s e d were d i r e c t e d t o i n d i v i d u a l members o f the group. A r e v e r s a l p e r i o d was then implemented, i n which the number of q u e s t i o n s was reduced treatment  c o n s i d e r a b l y . A f t e r seven s e s s i o n s the  program was begun a g a i n . The r e s e a r c h e r s found  number of responses by r e s i d e n t s doubled  under  t h a t the  treatment  conditions.  Other i n v e s t i g a t o r s have a l s o r e p o r t e d improvement i n s o c i a l behaviours  when b e h a v i o u r a l methods were used. M u e l l e r and A t l a s  (1973) used food t o reward the s o c i a l i n t e r a c t i o n s o f f i v e regressed male s u b j e c t s while Blackman, Howe and P i n k s t o n i n c r e a s e d r e s i d e n t i n t e r a c t i o n i n small a c t i v i t y areas by  (1976)  Page 27 p r o v i d i n g refreshments to those who  attended.  Attendance  at  s o c i a l f u n c t i o n s has a l s o been i n c r e a s e d by u s i n g prompts cues (e.g. announcements and p r i z e s contingent  signs) and  upon attendance  and  by making snacks and  (McClannahan, 1973).  Researchers have, i n r e c e n t years, become concerned about the e f f e c t of the design of the l i v i n g environment on l e v e l s and p a r t i c i p a t i o n . McClannahan and  activity  R i s l e y (1975)  demonstrated t h a t engagement with equipment, m a t e r i a l s or persons c o u l d be t r e b l e d by p r o v i d i n g m a n i p u l a t i v e (e.g. games and  craft  s u p p l i e s ) and  other  materials  prompting r e s i d e n t s to  use  them. Merely making equipment a v a i l a b l e and w a i t i n g f o r r e s i d e n t s to take the i n i t i a t i v e i n r e q u e s t i n g , s e l e c t i n g and u s i n g m a t e r i a l s r e s u l t e d i n low l e v e l s of  In a more ambitious  the  participation.  p r o j e c t , Gottesman  (1973) developed a  m i l i e u treatment program implemented i n a s t a t e mental h o s p i t a l housing  p s y c h o g e r i a t r i c p a t i e n t s . The  r e s e a r c h e r s attempted to  a l t e r the t o t a l environment i n ways t h a t would change the behaviour of persons who behaviour.  Emphasis was  were demonstrating i n a p p r o p r i a t e  placed on a c t i v i t y , money management and  s e l f - c a r e . A s h e l t e r e d workshop, doing i n d u s t r y , was  social  i n t r o d u c e d . The  small p a r t s jobs f o r l o c a l  p h y s i c a l environment was  changed  with the a d d i t i o n of m i r r o r s , p i c t u r e s , c u r t a i n s , new f u r n i t u r e and  b r i g h t c o l o u r s . The money which p a t i e n t s were p a i d from the  workshop r e s u l t e d i n the opening of a ward s t o r e , a ward bank and shopping t r i p s t o the community. While the program d i d c r e a t e  new  Page 28 s o c i a l r o l e s f o r the p a t i e n t s , observable  symptoms d i d not  decrease d u r i n g the two  period.  year experimental  A s i m i l a r study was  conducted by F i l e r and  O'Connell  (1964)  on the e f f e c t i v e n e s s of a more s t i m u l a t i n g environment. T h i s p r o j e c t , however, combined g e n e r a l  environmental changes with  an  operant behaviour m o d i f i c a t i o n program. T h i r t y - s i x male p s y c h o g e r i a t r i c p a t i e n t s formed Group A and ward which had  were assigned  a " b e t t e r environment", monetary pay  c l u b memberships, i n c r e a s e d p r i v i l e g e s and  to a  f o r work,  feedback f o r t h e i r  performance, i n the form of r e p o r t c a r d s . Another group of matched s u b j e c t s , Group B, were assigned  to a s i m i l a r ward but i n  a d d i t i o n , r e c e i v e d r e g u l a r reinforcement  contingent  on  their  performance i n e i g h t t a r g e t areas. These areas i n c l u d e d : management of medications,  self  d e p e n d a b i l i t y i n keeping appointments,  p a r t i c i p a t i o n i n some p r o d u c t i v e work, housekeeping maintenance of t h e i r own  living  area, p e r s o n a l  appearance and  hygiene,  r e s p o n s i b i l i t y f o r maintenance of t h e i r c l o t h i n g , management of personal  f i n a n c e s , and  At the end had  of the  not being  a d i s c i p l i n a r y problem.  16 week experimental  p e r i o d , both groups  improved compared to t h e i r pretreatment l e v e l s . Group B,  however, a t t a i n e d s a t i s f a c t o r y l e v e l s of performance more o f t e n , more q u i c k l y , and maintained them f o r a longer p e r i o d of time than Group A. Group B was  s i g n i f i c a n t l y b e t t e r than Group A i n  three behaviour c a t e g o r i e s - c o n s t r u c t i v e work, p e r s o n a l appearance, and  d e p e n d a b i l i t y i n keeping appointments.  Page 29  There have a l s o been s e v e r a l other s t u d i e s t h a t used techniques i n combination  with other approaches i n the treatment  of the e l d e r l y . S a l t e r and S a l t e r o r i e n t a t i o n program pTaulbee structured a c t i v i t i e s ,  operant  (1975) used a r e a l i t y  and Folsom, 1966) c o n c u r r e n t with  i n c l u d i n g the a c t i v i t i e s o f d a i l y  living  and r e c r e a t i o n a l a c t i v i t i e s , t o develop a s t i m u l a t i n g environment. They attempted  t o determine  i f t h i s kind of  s t i m u l a t i n g environment was e f f e c t i v e i n r e h a b i l i t a t i n g a p s y c h o g e r i a t r i c p o p u l a t i o n . R e a l i t y o r i e n t a t i o n i s a program which attempts  t o b r i n g confused p a t i e n t s back t o r e a l i t y by  r e o r i e n t i n g them t o b a s i c i n f o r m a t i o n on a r e g u l a r b a s i s . Current and p e r s o n a l i n f o r m a t i o n i s presented over and over t o t h e p a t i e n t , beginning w i t h h i s / h e r name, l o c a t i o n and date. Each c o n t a c t wih the p a t i e n t i s u t i l i z e d t o improve awareness of person, time and p l a c e .  Twenty-one m e n t a l l y d e f i c i e n t and/or m e n t a l l y d i s t u r b e d male p a t i e n t s , w i t h a mean age o f 68, served as s u b j e c t s . Eighteen were d i s o r i e n t e d , confused and unable t o c a r r y out b a s i c a c t i v i t i e s of d a i l y l i v i n g , ambulation  such as d r e s s i n g , grooming,  and e a t i n g . A treatment  team developed an  i n d i v i d u a l i z e d a c t i v i t y schedule f o r each s u b j e c t based upon an e v a l u a t i o n o f h i s c a p a b i l i t i e s . The behaviour o f t h e s u b j e c t s had to be g r a d u a l l y shaped through reinforcement t e c h n i q u e s . S u b j e c t s were g i v e n p o s i t i v e r e i n f o r c e m e n t , i n the form of a p p r o v a l , candy, or c i g a r e t t e s , f o r even minimal  attempts  at participation  Page 3 0 i n the r e a l i t y o r i e n t a t i o n , a c t i v i t i e s of d a i l y l i v i n g  and  r e c r e a t i o n programs. Beyond t h a t , p a t i e n t s were g i v e n l a r g e rewards f o r improved  responses and c o n s i s t e n t l y g i v e n s m a l l  rewards f o r repeated responses a t the same l e v e l . At the beginning of the treatment program o n l y f o u r s u b j e c t s were participating  i n some of the e d u c a t i o n a l and  recreational  a c t i v i t i e s a v a i l a b l e . W i t h i n f o u r months, t h i s number g r a d u a l l y i n c r e a s e d t o s i x t e e n . There  i s , however, no i n d i c a t i o n of the  degree of r e h a b i l i t a t i o n or success o b t a i n e d .  Another major problem  area f o r the i n s t i t u t i o n a l i z e d  i s self-maintenance s k i l l s . Operant  elderly  techniques have a l s o been  used to i n c r e a s e behaviours i n t h i s c a t e g o r y . Libb\and Clements (1969) i n d i v i d u a l l y r e i n f o r c e d f o u r g e r i a t r i c p a t i e n t s on a p s y c h i a t r i c ward f o r e x e r c i s i n g on a s t a t i o n a r y b i c y c l e .  Three  s u b j e c t s i n c r e a s e d t h e i r r a t e s of e x e r c i s i n g . Geiger and Johnson (1974) used a p o s i t i v e r e i n f o r c e m e n t procedure w i t h 6 g e r i a t r i c i n p a t i e n t s w i t h v e r y low r a t e s of c o r r e c t e a t i n g . The  average  number of meals eaten c o r r e c t l y i n c r e a s e d from 12 percent to 84 p e r c e n t over the d u r a t i o n of the study. B a l t e s and Zerbe were a l s o concerned  (1976)  w i t h the e a t i n g behaviour of 2 e l d e r l y  p a t i e n t s . Using shaping, r e i n f o r c e m e n t and time-out they helped both p a t i e n t s r e a c q u i r e and m a i n t a i n  procedures,  self-feeding  behaviours.  In a f r e q u e n t l y c i t e d  study by MacDonald and B u t l e r  (1974),  the authors used b e h a v i o u r a l techniques to i n c r e a s e the walking  Page 31 behaviour of n u r s i n g  home r e s i d e n t s . Walking i s an important  t a r g e t behaviour amongst the e l d e r l y s i n c e a t l e a s t 2 5 percent of the nursing  home r e s i d e n t s who can walk need help  (Trends i n Long  Term Care, 1970) and these persons a r e very o f t e n encouraged, by s t a f f i n t e r a c t i o n s , t o be wheeled about i n w h e e l c h a i r s ' r a t h e r than t o walk (Turner, two  nursing  1967). In the MacDonald and B u t l e r  home r e s i d e n t s who had been t r a n s p o r t e d  study,  by wheelchair  f o r s e v e r a l months, although f u n c t i o n a l l y unimpaired, served as s u b j e c t s . With the use of p r a i s e and prompting t o walk, they were e f f e c t i v e l y encouraged t o walk.  T h i s review demonstrates the r e l a t i v e focus of a b e h a v i o u r a l method as a p p l i e d t o h e a l t h care i n t e r v e n t i o n . I n t e r n a l i n d i v i d u a l processes a r e secondary t o e x t e r n a l , environmental processes i n the attempt t o prevent and c o r r e c t i l l n e s s and enhance h e a l t h s t a t u s . T h i s focus  emphasizes t h a t a more s t a b l e  i n t e r v e n t i o n may be found by attempting t o modify the p h y s i c a l and  s o c i a l environment and the s i g n i f i c a n t o t h e r s  i n order  t o achieve b e h a v i o u r a l  i n that  system,  change i n a t a r g e t person or  group. An operant model does seem t o be one o f the more adequate approaches p r o v i d i n g both a r e s e a r c h model  ( B a l t e s , 1976; L a b o u v i e - V i e f ,  and a l s o an i n t e r v e n t i o n Hoyer, B a l t e s and B a l t e s ,  (1974).  One  f a c t o r which i s o f t e n overlooked o r ignored i n  behavioural  i n t e r v e n t i o n s t u d i e s i s the e f f e c t of the wider  i n s t i t u t i o n a l environment on p a t i e n t s and s t a f f a l i k e . I f there  ?age 32 i s a weakness i n the operant model as a p p l i e d t o i n s t i t u t i o n a l i n t e r v e n t i o n , i t i s i n t h i s a r e a . Lawton and Nahemow (1969) have defined  'ecology' as the study of n a t u r a l systems,  the interdependency of one element  emphasizinq  i n a system upon every other  element. An e c o l o g i c a l p e r s p e c t i v e c o n s i d e r s a m u l t i p l e a r r a y of antecedents t h a t are f u n c t i o n a l l y r e l a t e d t o s i c k as w e l l as h e a l t h y behaviour. A c c o r d i n q t o B a l t e s (1974), t h e r e are f o u r key aspects to the e c o l o q i c a l p e r s p e c t i v e : 1) the i n t e r a c t i o n interdependence between behaviour and environment; environment  and  2) the  as the area of change; 3) the immediate change i n  behaviour by chancre i n the environment;  and 4) the t r a i n i n g of  c a r e - q i v i n g p r o f e s s i o n a l s t o t h i n k i n terms of g a i n s r a t h e r than cures.  T h i s approach produces  i n t e r v e n t i o n and r e s e a r c h  geared toward p r e v e n t i o n of s i c k n e s s as w e l l as h e a l t h and maintenance.  endeavours promotion  I t i s compatible w i t h an operant model and  p r o v i d e s a needed e x t e n s i o n of t h a t model;"In combining b e h a v i o u r a l and an e c o l o g i c a l approach,  a  the focus should expand  to examine s i c k n e s s and h e a l t h , not o n l y as a f u n c t i o n of the p a t i e n t , but i n r e l a t i o n s h i p to environmental i n c l u d i n g the m i c r o e c o l o q y the macroecologv environment  determinants  (human s e r v i c e s personnel) as w e l l as  ( c o n d i t i o n s and persons i n the l a r a e r  life  of the p e r s o n ) . The r e s e a r c h reviewed i n p r e v i o u s  c h a p t e r s i n d i c a t e s t h a t many e l d e r l y people l i v e i n extremely d e p r i v e d environments, and Lascomb, 1971;  both a t the micro and macro l e v e l s  Gottesman, 1973;  (Baltes  L a b o u v i e - V i e f . Hover, B a l t e s  Paqe 33 and  B a l t e s , 1974; Lawton and Nahemow, 1973) and t h a t .  institutionalization  i n general  1971). A b e h a v i o u r a l - e c o l o q i c a l of g u i d e l i n e s f o r developing  hastens d e t e r i o r a t i o n framework p r o v i d e s  (Euster,  a g e n e r a l set  treatment programs t o d e a l w i t h the  problems of the i n s t i t u t i o n a l i z e d  elderly.  Page 34 CHAPTER 4  GUIDELINES FOR REHABILITATION AND MAINTENANCE PROGRAMS IN GERIATRIC FACILITIES  "The  major r e h a b i l i t a t i o n g o a l i n i n s t i t u t i o n s f o r the aged  i s not v o c a t i o n a l , r a t h e r i t i s of r e h a b i l i t a t i o n f o r independent living,  t o help the p a t i e n t help h i m s e l f  to h i s f u l l e s t  p o t e n t i a l i t i e s f o r whatever s a t i s f a c t i o n s he wants i n l i f e and i s able t o a t t a i n " ( H e f f e r i n , 1968). Regardless o f the g o a l , however, most attempts a t r e h a b i l i t a t i o n w i t h a g e r i a t r i c population  have g e n e r a l l y been u n s u c c e s s f u l  1974). L i n s k , Howe and Pinkston pointed  (Kahn and Z a r i t ,  (1975) support t h i s argument and  out t h a t most o f the a v a i l a b l e r e s e a r c h  treatment e f f i c a c y has made use of c l i n i c a l uncontrolled  supporting  t r i a l s and  experiments.  With those few s t u d i e s t h a t have demonstrated an e f f e c t i n t a n g i b l e terms, improvements i n f u n c t i o n i n g have very o f t e n been t r a n s i t o r y , w i t h the t a r g e t e d  behaviours d e c l i n i n g f o l l o w i n g the  c e s s a t i o n of the i n t e n s i v e therapy and W i l l i a m s ,  (Cosin, Mort ,Post, Westrupp  1958; Brody, Kleban, Lawton and Moss, 1974). T h i s  has been the case even when the i n s t i t u t i o n ' s s t a f f have been e s p e c i a l l y t r a i n e d i n methods t o c o u n t e r a c t of c u s t o d i a l treatment  the harmful e f f e c t s  (Penchansky and Tauberhaus, 1965).  Page 3 5 It  seems c l e a r t h e n ,  from research Future  on  research  concerning  rehabilitation should  the  rehabilitation crucial  m u s t be a  firmer  i s s u e w h i c h m u s t be studies  least successful  implementation.  which  The  i s required  and  the  research  The the  research  programs w i l l  increased  find  such  may  s l o w and  dressing  assistance,  staff  i n an  social  reported  tended  to  lack  for  one  that  that or  more  successful approach o u t l i n e d  currently available components needed  deterioration is a  and  is a  the  serious  p a i n f u l task  assistance,  to  fact  chapters provides  in  provide  for  a  degree to which the  f o r the  But  and  resident  cannot  function  of  for  example,  resident  w e l l . That  staff needs  attention  barren with  specifically  of  and  persons. With  when t h e  i s generally  i t i s based  staff  Dressing,  f o r many o l d e r  for  rehabilitative  performance  s p e c i a l a t t e n t i o n as  environment which  reinforcement,  support  likely  addition,  problem.  i s made e a s i e r .  give  In  a t t i t u d e s of  Dependency, p a r t i c u l a r l y  activities,  occurs  The  s e t t i n g s h o s t i l e environments because  philosophy  everyday a  i n previous  institutionalization.  operating  residents.  cited  that  consequence of  be  considered.  program.  conclusion  their  the  conclusions  e l d e r l y . There i s ,  behavioural-ecological  chapter  derived  accepted.  footing for  r e s u l t s suggests  some t e n t a t i v e a n s w e r s c o n c e r n i n g successful  conclusions  cautiously  programs to date g e n e r a l l y  ingredients  previous  the  programs f o r the  more r i g o r o u s l y c o n d u c t e d  demonstrate  the  provide  rehabilitation  however, another the  t h a t most of  on  respect the  independently.  This  Page 3 6 a t t e n t i o n may i n c l u d e warm p h y s i c a l gestures expressions 1973;  and/or  sincere  of concern f o r the p a t i e n t ' s w e l l being  (Mishara,  Hoyer and Mishara, 1 975).. In a world o f c u s t o d i a l care,  dependency may be one o f the few e f f e c t i v e behaviours a v a i l a b l e to a p a t i e n t i n order and  to obtain  r e c o g n i t i o n from n u r s i n g  To c i t e a concrete o c c a s i o n a l request  some form o f p e r s o n a l  attention  staff.  example, the dependency may s t a r t w i t h an  f o r a s s i s t a n c e . T h i s o c c a s i o n a l request  becomes h a b i t and f o l l o w s a p a t t e r n of spreading  soon  from one  a c t i v i t y t o the next. I t may s t a r t w i t h t y i n g l a c e s . But, as time passes the r e s i d e n t comes t o ask f o r or demand complete a s s i s t a n c e i n d r e s s i n g . In a d d i t i o n , the l a c k of s t i m u l a t i o n i n the i n s t i t u t i o n may encourage a sedentary p a t t e r n which does not provide  the r e s i d e n t with an adequate l e v e l o f e x e r c i s e . As body  processes slow down, the r e s i d e n t may experience problems w i t h e l i m i n a t i o n , r e s p i r a t o r y and c i r c u l a t o r y d i f f i c u l t i e s and muscular atrophy  (Comstock, Mayers and Folsom, 1 9 6 9 ) . A v i c i o u s  c y c l e i s thus e s t a b l i s h e d s i n c e f u r t h e r d e t e r i o r a t i o n b r i n g s more a t t e n t i o n , w h i l e attempts t o r e g u l a r l y perform the simple process of d r e s s i n g would i n v o l v e muscles t h a t otherwise would be i d l e i f someone e l s e was d r e s s i n g  the r e s i d e n t . The nursing home  environment i s c l e a r l y s t r u c t u r e d i n a way t h a t works a g a i n s t the r e s i d e n t ' s independent f u n c t i o n i n g and f o r i n c r e a s e d  dependency.  D i f f i c u l t y w i t h s e l f - c a r e i s a common problem o f the i n s t i t u t i o n a l i z e d e l d e r l y . Because t h i s problem i s so widespread,  Page 37 it  i s o f t e n t h e case t h a t a new p a t i e n t w i l l i m i t a t e o r model the  behaviour of those p a t i e n t s i n h i s immediate environment. According  t o Giordano and Giordano  (1969), many p a t i e n t s have  adopted the s i c k r o l e and s u f f e r e d i r r e v e r s i b l e p h y s i c a l d e t e r i o r a t i o n as a consequence. These p a t i e n t s , i n t u r n , serve as 'aged-sick' r o l e models and provide the i n s t i t u t i o n  the normative s t r u c t u r e of  (Nahemow and B.ejinett, 1 967).  Since the dependent  p a t i e n t i s q u i c k l y r e i n f o r c e d f o r t h a t behaviour, he or she i s a powerful model of i n s t i t u t i o n a l behaviour f o r the new p a t i e n t .  A further complication f r e q u e n t l y so u n d e r s t a f f e d non-existant  or minimal  i s the f a c t t h a t f a c i l i t i e s a r e t h a t r e h a b i l i t a t i o n programs a r e  (McKnight, 1971; Macdonald, 1973). The  average u n i t has b a r e l y enough s t a f f t o care f o r the p a t i e n t ' s hygiene and f e e d i n g  ( P o l l o c k and Lieberman, 1974).  Understaffing  makes i t extremely d i f f i c u l t f o r s t a f f members t o know the i n d i v i d u a l c h a r a c t e r i s t i c s of a l l p a t i e n t s t h a t come under the care o f i n d i v i d u a l s t a f f members. Residents vary c o n s i d e r a b l y i n t h e i r a b i l i t y t o perform the a c t i v i t i e s of d a i l y l i v i n g  (Hoyer,  1974)  requires  and p r o v i s i o n o f the proper l e v e l o f nursing  accurate,  s p e c i f i c and complete i n f o r m a t i o n  care  on each r e s i d e n t . In  many s e t t i n g s , however, the only r e l i a b l e i n f o r m a t i o n to s t a f f i s the request  available  f o r a s s i s t a n c e or help from the p a t i e n t .  While r e l i a b l e , these requests  f o r help may not be v a l i d  indices  of the a c t u a l l e v e l of p h y s i c a l a b i l i t i e s of the r e s i d e n t . Other and  p o t e n t i a l l y more v a l i d means o f o b t a i n i n g  information  such as n u r s i n g  individual patient  assessments are o f t e n not c a r r i e d out  Page 3 8 systematically obtained  ( H e f f e r i n and Hunter, 1975)  by one  and  information  s t a f f member i s not r e g u l a r l y communicated to  other s t a f f members. There i s o f t e n , i n f a c t , no v e h i c l e f o r systematic  communication of such data between s t a f f .  Frequently,  the r e s u l t i s almost t o t a l r e l i a n c e on the o n l y r e l i a b l e of i n f o r m a t i o n , the p a t i e n t h i m s e l f . The unfortunate is  i n c r e a s e d dependency and  The  source  consequence  further deterioration.  problem of communication i n g e r i a t r i c care  facilities  goes w e l l beyond the need to o b t a i n accurate i n f o r m a t i o n on  level  of f u n c t i o n i n g of i n d i v i d u a l r e s i d e n t s . Attempts at r e h a b i l i t a t i o n are a l s o l i k e l y to f a i l  without  proper  communication of i n f o r m a t i o n . A t y p i c a l p a t t e r n of begins with an i n d i v i d u a l s t a f f member who  rehabilitation  attempts  r e h a b i l i t a t i o n with a p a r t i c u l a r g o a l i n mind. U n f o r t u n a t e l y , because of problems i n communication of the treatment p l a n  and  g o a l , i t i s o f t e n u n l i k e l y t h a t other s t a f f members are aware of these e f f o r t s . R e h a b i l i t a t i o n may is  be i n i t i a l l y  l i k e l y to be q u i c k l y undone by s t a f f who  s u c c e s s f u l , but i t  have no knowledge of  what i s being attempted or what has been achieved.  This i s  e s p e c i a l l y t r u e of r e h a b i l i t a t i o n e f f o r t s t h a t p r o v i d e a concentrated  p e r i o d of t r a i n i n g each day  (e.g. s e s s i o n s  o c c u p a t i o n a l t h e r a p i s t s or p h y s i o t h e r a p i s t s ) without i n v o l v i n g s t a f f who of the day.  lived  be l i t t l e  g e n e r a l i z a t i o n from such  the g e n e r a l i z a t i o n t h a t does occur may  (Kahn and  directly  work with the r e s i d e n t d u r i n g the remainder  There may  programs, and  with  Zarit,  1974). Without accurate  be  short  i n f o r m a t i o n about  Page 39 l e v e l of f u n c t i o n i n g , program g o a l s and methods of  maintaining  g a i n s , the u n i t s t a f f are o f t e n e f f e c t i v e agents f o r anti-therapeutic  change.  I t would thus be c l e a r l y d e s i r a b l e to have r e g u l a r i n v o l v e d i n any  therapeutic  not have the s k i l l s and  e f f o r t . But  staff  f r o n t - l i n e staff often  do  techniques needed by e f f e c t i v e change  agents. S e t t i n g u n o b t a i n a b l e g o a l s , attempts t o b r i n g about improvement too r a p i d l y , f a i l u r e t o use behaviour change, and f a c t o r s t h a t may f r u s t r a t i o n and  e f f e c t i v e p r i n c i p l e s of  l a c k of c o o r d i n a t i o n between s t a f f are a l l  a c t u a l l y c o n t r i b u t e to the c o n f u s i o n , depression  anxiety,  t h a t i s o f t e n d i s p l a y e d by  the  i n s t i t u t i o n a l i z e d e l d e r l y (Laurence, 1976). F a i l u r e s are to r e i n f o r c e stereotypes  likely  and make f u t u r e attempts a t  r e h a b i l i t a t i o n more d i f f i c u l t .  Even when r e h a b i l i t a t i o n i s s u c c e s s f u l , the p a t i e n t may t h a t these newly acquired withdrawal of valued s t a f f . P o l l o c k and  s k i l l s are a c t u a l l y punished by  a t t e n t i o n and  Lieberman  care on the p a r t of  F a i l u r e to provide  an a l t e r n a t i v e means o f o b t a i n i n g  r e i n f o r c e r s t h a t were a c q u i r e d  the  nursing  (1974) have shown t h a t the  w i t h the l e a s t problems g e t s the l e a s t a t t e n t i o n from  find  patient  staff. the  by adopting the aged-sick r o l e can  c r i p p l e an otherwise e f f e c t i v e program.  While i t i s c l e a r from the l i t e r a t u r e t h a t  institutions  produce d e l e t e r i o u s e f f e c t s , i t must be emphasized t h a t  Page 4 0 i n s t i t u t i o n s a r e merely s e t t i n g s i n which events e i t h e r happen or do not happen. The d e f i c i e n t behaviour be m o d i f i e d  ( B a l t e s and Zerbe,  of the e l d e r l y p a t i e n t can  1976; Rebok and Hoyer, 1977). An  a p p r o p r i a t e focus f o r the treatment  o f the e l d e r l y  individual  i n v o l v e s a systematic program of r e h a b i l i t a t i o n and maintenance t h a t focuses on reprogramming the  behaviour-environment  r e l a t i o n s h i p s so as t o c o n s i s t e n t l y strengthen and m a i n t a i n optimal f u n c t i o n i n g .  Such a program should be grounded i n the g e n e r a l data base of psychology  and s o c i o l o g y and make use o f the treatment  technology which has strong e m p i r i c a l support. I t should a l s o have an e m p i r i c a l e v a l u a t i o n component i t s e l f . U n t i l  1971, v e r y  few a p p l i e d r e s e a r c h s t u d i e s on aging had been r e p o r t e d  (Tobin,  1971). Although many i n n o v a t i v e programs have been i n t r o d u c e d s i n c e then, few have been evaluated e x p e r i m e n t a l l y i n r i g o r o u s research  (Carsyn, Fergus and York, 1977). Bennett,  Blumner and Furman (1977),  Wilder,  i n a review o f the p u b l i s h e d s t u d i e s  on i n n o v a t i v e i n s t i t u t i o n a l programs, found t h a t few, i f any, r e p o r t e d any long-term  follow-up data. Most of the r e p o r t s d i d  not i n d i c a t e whether they were i n c o r p o r a t e d i n t o the r o u t i n e s e r v i c e s o r programs o f the i n s t i t u t i o n s i n which they were i n t r o d u c e d or whether they were disseminated  t o any o t h e r  i n s t i t u t i o n s . Without t h i s i n f o r m a t i o n , Bennett  and h i s  c o l l e a g u e s b e l i e v e t h a t i t i s d i f f i c u l t t o assess whether these programs a r e i n t r i n s i c a l l y u s e f u l or whether they were s u c c e s s f u l f o r other reasons. A s i m i l a r p o i n t was made by Hoyer  (1973), who  Page 41 s t a t e d t h a t "much time i s spent on expensive, demonstration  short-term  p r o j e c t s t h a t are e f f e c t i v e under t i g h t l y  c o n t r o l l e d l a b o r a t o r y c o n d i t i o n s and t h a t have a l i m i t e d g e n e r a l i z a b i l i t y to n a t u r a l i s t i c contexts".  B e h a v i o u r a l p s y c h o l o g i s t s (Baer, Wolf and R i s l e y , 1968; R i s l e y , 1970) have a l s o been concerned  about the need f o r  b u i l d i n g g e n e r a l i z a t i o n i n t o r e h a b i l i t a t i o n p r o j e c t s . One method of  accomplishing t h i s g o a l i s t o make r e h a b i l i t a t i o n a r e g u l a r  p a r t of the day-to-day p r a c t i c a l care of the e l d e r l y . The program d e s c r i b e d i n the next chapter used  j u s t t h a t approach. The  behaviours t a r g e t e d f o r r e h a b i l i t a t i o n are g e n e r a l l y r e f e r r e d t o as the a c t i v i t i e s o f d a i l y l i v i n g such f o r the purposes  (ADL) and w i l l be designated as  of t h i s program. I n a b i l i t y t o perform  these  tasks i s a c e n t r a l problem i n h e a l t h c a r e f o r the e l d e r l y ( S i l b e r s t e i n , Kossowsky and L i l u s ,  1977). I t i s a l s o the d e c i s i v e  f a c t o r i n determining the need f o r long term c a r e . With an aged p o p u l a t i o n , the h i g h e s t r i s k of becoming f u n c t i o n a l l y dependent i s i n the area o f s e l f - c a r e . S e l f - c a r e i s r e p r e s e n t e d i n the A c t i v i t i e s of D a i l y L i v i n g  (ADL) and i n c l u d e s d r e s s i n g , grooming,  e a t i n g and a m b u l a t i o n / t r a n s f e r s k i l l s .  These behaviours demand a  high degree of c o o r d i n a t i o n and are g e n e r a l l y the f i r s t  to suffer  w i t h time. The i n s t i t u t i o n a l i z e d e l d e r l y , as a group, have an "excess d i s a b i l i t y "  i n the areas o f ADL  (Brody, Kleban, Lawton  and Silverman, 1971) and thus, have c o n s i d e r a b l e p o t e n t i a l f o r rehabilitation.  Pa,ge 4 2 ADL  i s not o n l y a p o t e n t i a l t a r g e t f o r r e h a b i l i t a t i o n , i t i s  an important one. Breslau,  1966;  mortality  I t i s an o b j e c t i v e measure of h e a l t h  Shanas, 1968)  and  i s an a c c u r a t e p r e d i c t o r  ( S i l b e r s t e i n , Kossowsky and  been accepted as the best way functioning  Lilus,  " q u a l i t y of l i f e "  of  1977). I t has  to a s s e s s p h y s i c a l and  i n the e l d e r l y (Grauer and  measure of the  (Rosow and  also  mental  Birnbom, 1975). ADL  s i n c e i t r e f l e c t s one  of  is a the  most important a s p e c t s of an i n d i v i d u a l ' s s e l f - s u f f i c i e n c y and self-worth  (.Yates, 1 976).  I t i s highly correlated with  s e l f - r e p o r t s of extreme l o n e l i n e s s and and  a l i e n a t i o n (Shanas,  1968)  p r o v i d e s an i n d i c a t i o n of most of the mental h e a l t h problems  seen i n the e l d e r l y (Weissman, P r u s o f f Burnside, 1976). Independence i n ADL, worthwhile g o a l  and  Pincus,  1975;  then, i s a r e a l i s t i c  i n the treatment of the  and  institutionalized  elderly.  To  summarize, a s u c c e s s f u l program of r e h a b i l i t a t i o n i n a  geriatric f a c i l i t y  should s p e c i f i c a l l y d e a l w i t h s i x major  problems t h a t have had  a d e l e t e r i o u s e f f e c t on much of the work  to t h i s p o i n t :  1). There are o f t e n no c o n s i s t e n t , communication between s t a f f Schwartz, 1974;  H e f f e r i n and  c l e a r and  r a p i d channels of  (Comstock, Mayers and  Folsom,  Hunter, 1975).  2) Lack of consensus between s t a f f on present l e v e l of f u n c t i o n i n g produces c o n f l i c t i n g p a t t e r n s rehabilitation  1969;  (Comstock, Mayers and  patient  of c u s t o d i a l c a r e  Folsom, 1969;  Hefferin  and and  Page 43 Hunter, 1975). 3) F r o n t - l i n e s t a f f must c a r r y the load of any major, ongoing r e h a b i l i t a t i v e and maintenance e f f o r t but o f t e n l a c k the t r a i n i n g and s u p e r v i s i o n t o choose a p p r o p r i a t e (Laurence, 1976; Gottesman,  goals f o r r e h a b i l i t a t i o n  1970).  4) The i n s t i t u t i o n a l environment o f t e n p r o v i d e s and c o n t i n g e n c i e s  t h a t work a g a i n s t  both r o l e models  the development  and  maintenance of an e f f e c t i v e program of r e h a b i l i t a t i o n by  staff  (Repucci and Saunders, 1969; Nahemow and Bennett, 1967; Giordano and Giordano, 1967). 5). Chronic  u n d e r s t a f f i n g of f a c i l i t i e s c r e a t e s a work p a t t e r n  t h a t emphasizes accomplishment of d a i l y r o u t i n e s transporting patients) t h e r a p e u t i c manner  i n the f a s t e s t r a t h e r than the most  ( P o l l o c k and Lieberman,  1969).  6) Most f r o n t - l i n e s t a f f l a c k the knowledge incorporate  (e.g. f e e d i n g ,  needed to  a treatment program i n t o t h e i r d a i l y r o u t i n e s w h i l e  well trained s t a f f ,  such as o c c u p a t i o n a l  therapists, generally  have such high p a t i e n t loads t h a t they cannot provide continuous program themselves (Gottesman,  The program d e s c r i b e d these problems.  an ongoing,  1970).  i n the next chapter attempted to d e a l with  Page 44 CHAPTER 5  CARE - A PROGRAM OF CARE AND  REHABILITATION FOR  THE  ELDERLY  Since the i n s t i t u t i o n a l i z e d e l d e r l y are c h a r a c t e r i z e d "excess d i s a b i l i t i e s " , the g o a l of t h i s study was evaluate  to develop  a program which encouraqed the maintenance  r e h a b i l i t a t i o n of the A c t i v i t i e s of D a i l y L i v i n g  by and  and  (ADL)  i n a group  of i n s t i t u t i o n a l i z e d e l d e r l y .  Accomplishing t h i s g o a l  i n v o l v e s at l e a s t two  major aspects  at the r e s i d e n t l e v e l . Many e l d e r l y , because of d i s a b i l i t i e s disuse,  l a c k independence i n v a r i o u s ADL s i n t h e i r 1  behavioural  repetoire. Retraining  i n order  or  current  t h a t the r e s i d e n t i s  capable of performing the ADL's t h a t are important i n h i s / h e r d a i l y l i v i n g pattern important aspect  i s one major focus. Another, e q u a l l y  of the program, i s the c r e a t i o n of a l i v i n g  environment where the c o n t i n g e n c i e s  of d a i l y l i f e  encourage  r a t h e r than d i s c o u r a g e performance of the ADL's which are the r e s i d e n t ' s b e h a v i o u r a l  within  r e p e t o i r e . " E l d e r l y p a t i e n t s must be  r e h a b i l i t a t e d to do f o r themselves these d a i l y n e c e s s i t i e s of s e l f - c a r e t h a t are learned a d u l t , but and  as a c h i l d , done a u t o m a t i c a l l y  sometimes n e g l e c t e d  program d e s c r i b e d  the  by the e l d e r l y " (Comstock, Mayers  Folsom, 1969).  The  by  here attempted to r e d i r e c t and  Page reprogram of  care  the  i n s t i t u t i o n from a c u s t o d i a l to a  with  a minimum of  institutional  routine  interference with  and  without  therapeutic  the  45  model  regular  creatina costs  to  existinq  programs.  Components of  The  Program  Assessment The evaluate  first  i n any  each r e s i d e n t ' s  functioning. an  step  According  appropriate  and  information  f o r measuring  information  should  long  term patterns to  comDonent o f  this  resident's  patient  short  of  change.  D r o a r a m  and  what s u p e r v i s i o n  and  level  Hunter  is  help  to  (1975),  the  To  be  involved  i n the  involves  an  deficits,  a l s o be  what the  i s n e c e s s a r y and  of  and  performance easilv  Droaram. T h e  evaluation  the  specific  term v a r i a t i o n s i n  of  useful  useful  reliable,  I t should  use  greater  assemble  orogress.  to  of  might w e l l promote  obtainable,  both  a l l staff  abilities  tool  j u d g m e n t and  easily  reflecting  communicated  himself,  be  rehabilitation  pattern  H e f f e r i n and  systematic  i n nursing  and  current  to  objectivity  capable of  program of  assessment  the  resident  can  what h e l p  is  do  for  actually  given.  In t h i s inclusion general,  study  i n the they  functioning  are  (e.g.  35 different  program.  These are  ADL's r e q u i r e d ability  a c t i v i t i e s were listed  selected  i n Table  f o r normal  t o wash hands, use  1.  for  In  independent a  spoon, walk,  put  Page 46  TABLE 1  Selected Activities of Daily Living Used in CARE Program Dressing  (ADL)  Skills 'Off  Activities  ability to put on pants/dress ability to put on underpants ability to put on an open-faced garment n-thru dress, shirt, cardigan, etc.) ability to put on shoes ability to put on socks/stockings ability to do up laces ability to do up buttons ability to put on brassiere (fa amies only)  to take off to take off to take off  'On' ability ability ability (butto ability ability ability ability ability (for f  Activities  to to to to to nal  t t u u t es  a a n n a  k k d d k  e off e off o lac o but e off only)  pants/dress underpants open-faced garment shoes socks/stockings es tons brassiere  ability to select and asssrible clothing Groaning  Eating  Skills  Skills  ability to wash  hands  ability  to use a  spoon  ability to wash  face  ability  to use a  fork  ability  to use a  knife  ability to ccmb and do up  hair  a b i l i t y t o s h a v e ( e l e c t r i c o r m a n u a a bl i -l i t y males only)  to use a cup or  glass  ability to take self to toilet when necessary and cleanliness (not physical transfer) ability to brush teeth or clean  dentures  Airibulatign/Transfer Skills ability to walk with or without  aids  ability to use a wheelchair  appropriate  ability  to transfer  if  into a chair  ability  to transfer  out of a  chair  ability to transfer into bed  ability to transfer out of  bed  ability to transfer onto toilet  ability to transfer off of  toilet  Page 47 on p a n t s ) . These s p e c i f i c a c t i v i t i e s were chosen because they are most s u b j e c t to d e t e r i o r a t i o n , d i r e c t l y i n f l u e n c e d by contact,  e a s i l y observable and measurable and  t a r g e t s f o r r e h a b i l i t a t i o n and behaviours was Benjamin  assessed u s i n g  (1 976). and  are  attendant  appropriate  i n t e r v e n t i o n . Each of these 3 5 a three  l e v e l code developed  s i m i l a r to t h a t of Katz  L e v e l 1 ^ T o t a l Independence - ' _The  bv  (1 963):  p a t i e n t ' has'\ the  a b i l i t y to perform an a c t i v i t y without s u p e r v i s i o n , d i r e c t i o n or a c t i v e a s s i s t a n c e . A p a t i e n t who  personal  r e f u s e s to perform  a function i s defined  as t o t a l l y dependent,  even though he or she  i s deemed a b l e .  The  p a t i e n t mav  choose anv method or a i d to  perform the  activity.  L e v e l 2 - P a r t i a l Dependence - The  p a t i e n t can  perform  the g r e a t e r p a r t of the a c t i v i t y himself h e r s e l f , but needs a s s i s t a n c e  or  (verbal or  p h y s i c a l ) or s u p e r v i s i o n to complete  the  activity.  L e v e l 3 - T o t a l Dependence - The f o r the  The  a c t i v i t y i s c a r r i e d out  patient.  assessment t o o l developed thus c o v e r s 3 5 d i f f e r e n t behaviours  w i t h three  l e v e l s of f u n c t i o n i n g - a p o s s i b l e 105 u n i t s of  Page 48 . information.  Communication Once an i n d i v i d u a l been c a r e f u l l y everyone who  r e s i d e n t ' s a b i l i t i e s and d i s a b i l i t i e s have  assessed,  the i n f o r m a t i o n must be communicated to  comes i n c o n t a c t with him  or her. The  importance of  t h i s aspect of communication between s t a f f has been noted several writers  (Comstock, Mayers and Folsom, 1969;  1974) . Techniques t y p i c a l l y relating  to ADL  employed to communicate  by  Schwartz, information  most o f t e n use a w r i t t e n form, p l a c e a major  emphasis on d e f i c i t s r a t h e r than a b i l i t i e s , l a c k s p e c i f i c i t y p r o v i d e o n l y a minimum of i n f o r m a t i o n 1975) . A c c e s s i b i l i t v limited  and  time consuming, whether i t i s kept a t the bedside  For t h i s  study,  a visual  wall chart  recognizable  qrooming, e a t i n g and coding,  (see F i g u r e 1)  was  information. This chart  d i s p l a y s t h i r t v - f i v e a c t i v i t i e s of d a i l y usinq e a s i l v  in  station.  to communicate the necessary  A ) . Colour  Hunter,  to such i n f o r m a t i o n systems i s q e n e r a l l y  a c h a r t or a t the n u r s i n q  desiqned  ( H e f f e r i n and  and  living pictoriallv,  symbols. I t shows d e t a i l e d d r e s s i n g ,  ambulat'ip.h/transfer  activities  (see Appendix  i n the form of s t i c k on d o t s , i s used t o  i n d i c a t e the degree of independence and needed i n each of these a c t i v i t i e s . A  the amount of a s s i s t a n c e  'green' dot i s p l a c e d  beside the a c t i v i t y d e p i c t e d on the c h a r t when the r e s i d e n t i s t o t a l l y independent w i t h regard to t h a t ADL. represent p a r t i a l dependence and  'Yellow' dots  'red' r e f e r s to  total  Page ,49 Figure 1 VISUAL WALL CHART  ( a c t u a l s i z e - 9 3/4" b y 14")  Page 50  dependence,  The v i s u a l c h a r t i s an economical and e f f i c i e n t means o f communicating i n f o r m a t i o n .  I t i s a l s o e a s i l y updated as the  r e s i d e n t ' s l e v e l of performance changes. The most common methods of changing c h a r t s  seem t o be c r o s s i n a through, rubbina  w r i t i n g over e x i s t i n g i n f o r m a t i o n .  out, or  The r e s u l t i s o f t e n a r a t h e r  messy and i n e f f e c t i v e communication d e v i c e . An a l t e r n a t i v e i s t o develop a new l i s t of i n f o r m a t i o n ,  but acrain, there  i s a problem  w i t h c o n t i n u i t v and w i t h the time r e q u i r e d t o do the task. With the v i s u a l c h a r t , changes a r e e a s i l y i n d i c a t e d by simply a new c o l o u r dot, r e p r e s e n t i n g the a l r e a d y but not a l l . information  placing  the new l e v e l o f performance, over  e x i s t i n g c o l o u r . By p l a c i n g the new dot over most, of the o l d d o t i t i s p o s s i b l e t o r e t a i n e a r l i e r as w e l l as t o make a judgment as t o the p a t t e r n of  improvement or d e t e r i o r a t i o n i n the r e s i d e n t . The v i s u a l c h a r t i s placed  by the r e s i d e n t ' s bed and i s a r e a d i l y a v a i l a b l e ,  continuously  a c c e s s i b l e method of communication.  I s o l a t i n g Target  Behavioural  Behaviours  s t r a t e g i e s must n e c e s s a r i l y s t a r t w i t h a p r e c i s e  d e f i n i t i o n o f t a r g e t o r g o a l behaviour. The w a l l c h a r t to meet t h i s requirement bv reducing L i v i n g t o kev b e h a v i o u r a l ( i . e . dressing)  attempts  the A c t i v i t i e s of D a i l y  events. Complex chains  must be reduced t o b e h a v i o u r a l  of behaviour  events t h a t can be  Page. 51 e f f e c t i v e l v modeled, shaped and r e i n f o r c e d . Each b e h a v i o u r a l event  i scritical  t o s u c c e s s f u l independence and t h i s breakdown  crives the t h e r a p i s t s a base f o r desicming  an e f f e c t i v e  intervention strategy.  In t h i s program the g o a l s f o r r e h a b i l i t a t i o n a r e chosen by front-line staff  (nurses, a i d e s and attendants)  i n consultation  with the o c c u p a t i o n a l t h e r a p i s t . These g o a l s a r e determined on the b a s i s of " p r o b a b i l i t y o f success" and r e s i d e n t p r i o r i t y t h a t i s , the needs and wishes o f the r e s i d e n t s themselves. A r e s i d e n t , f o r example, may wish t o be a b l e t o t r a n s f e r out o f bed r a t h e r than be able t o nut h i s / h e r shoes on. A l l ADL which a r e 'yellow' or 'red' are p o t e n t i a l g o a l s . F r o n t - l i n e s t a f f  decide  which of these a c t i v i t i e s has the h i g h e s t p r o b a b i l i t y of beinq s u c c e s s f u l l y r e h a b i l i t a t e d . T h i s d e c i s i o n i s based on both the complexity  of the a c t i v i t y and the r e s i d e n t ' s d i s a b i l i t y . F o r  many, e a t i n g s k i l l s a r e l e s s complex than t r a n s f e r i n q which a r e l e s s complex than d r e s s i n g s k i l l s  (Katz and Akpom,  1975). The r e s i d e n t ' s d i s a b i l i t y i s an important determining  the complexity  skills,  factor i n  of t h e a c t i v i t y . Whether r e s i d e n t s a r e  h e m i p l e g i c s . p a r a p l e g i c s , amputees or b l i n d has a b e a r i n g on t h e complexity  of the a c t i v i t y .  Goals f o r r e h a b i l i t a t i o n a r e designated 'blue' dot p l a c e d adjacent  on the c h a r t bv a  t o the symbol of t h e a c t i v i t y . No more  than one blue d o t i s p l a c e d on the c h a r t a t any one time. The r e s t r i c t i o n o f one r e h a b i l i t a t i o n g o a l a t a time was based on the  Page 52 work of Comstock, Mayers and Folsom  (1 969)  many e l d e r l y people need more than average  who concluded t h a t time t o complete one  simple t a s k b e f o r e being assigned another. Too many demands or too many g o a l s mav o n l y lead t o f r u s t r a t i o n and f a i l u r e . Thus, i f a r e s i d e n t i s comnletelv dependent upon s t a f f f o r d r e s s i n g , a s p e c i f i c component o f d r e s s i n g i s chosen as the f i r s t r e h a b i l i t a t i o n t a r g e t . F o r example, the procedure may begin w i t h • p u t t i n g on shoes'. When the g o a l i s achieved a green dot i s p l a c e d over the blue dot and a second  blue d o t i s p l a c e d beside  the next g o a l , perhaps ' p u t t i n g on s t o c k i n g s ' . Thus, bv moving from one s m a l l r e h a b i l i t a t i v e g o a l t o the next, t h e end r e s u l t i s independent  dressing.  The R e h a b i l i t a t i o n Program  Once a t a r g e t behaviour  has been s e l e c t e d by s t a f f ,  each  person who comes i n c o n t a c t w i t h t h e r e s i d e n t i s a member of the treatment  team. The treatment  program i t s e l f  i s described i n  d e t a i l i n Appendix B. which c o n t a i n s a copv o f the treatment manual a v a i l a b l e t o a l l s t a f f , and i n a s e c t i o n of t h i s  chapter  which d e s c r i b e s the s t a f f t r a i n i n q component. Stated b r i e f l y , t h r e h a b i l i t a t i o n program has two maior components. The f i r s t i n v o l v e s the use o f r e h a b i l i t a t i v e procedures r e h a b i l i t a t i o n medicine  taken  from  and o c c u p a t i o n a l as w e l l as p h y s i c a l  therapy. S p e c i f i c suggestions f o r r e h a b i l i t a t i o n o f each o f t h e p o t e n t i a l ADL t a r g e t s are a v a i l a b l e i n the treatment manual. The  second component i s a b e h a v i o u r a l standard  behavioural  one which i n v o l v e s the use of  procedures such as reinforcement,  shaping,  c h a i n i n g and modeling i n the r e h a b i l i t a t i o n e f f o r t . Through a t r a i n i n a program and by reading incorporate behavioural  tne manual, s t a f f l e a r n t o  p r i n c i p l e s i n t o t h e i r everyday  i n t e r a c t i o n p a t t e r n s w i t h the r e s i d e n t . Thus, each s t a f f member has  access  to information  about the ADL behaviour o f the  resident,, the c u r r e n t r e h a b i l i t a t i o n g o a l and the methods t h a t can be used t o reach t h a t g o a l .  Maintenance of Change  As p r e v i o u s l y mentionedyafter the t a r g e t e d behaviour has become a p a r t of the r e s i d e n t ' s r e p e t o i r e and he o r she i s independent i n t h a t a c t i v i t y , a green dot i s p l a c e d on the c h a r t so t h a t i t covers most, but not a l l .  of the blue dot.  (A new  t a r g e t mav a l s o be s e l e c t e d i f the a v a i l a b l e treatment methods do not prove e f f e c t i v e on the s e l e c t e d ADL.) The purpose of overlapping  the green and blue dots on the v i s u a l c h a r t i s t o  s e n s i t i z e s t a f f t o the newly r e h a b i l i t a t e d a c t i v i t y and p r o v i d e a cue  f o r s t a f f behaviours t h a t w i l l m a i n t a i n  t h i s change.  Maintenance i s e s t a b l i s h e d i n two ways. S t a f f a r e d i r e c t e d , bv the c o l o u r cue, t o attend t o and acknowledge newly  acquired  behaviour through p r a i s e and encouragement. Second, when any a c t i v i t y i s designated  by a green dot, no a s s i s t a n c e i s g i v e n . A  green dot d e f i n e s t h a t a c t i v i t y as being  t o t a l l y independent. Not  Page 54 o n l y does t h i s r u l e help t o m a i n t a i n newly r e h a b i l i t a t e d behaviours but i t serves to m a i n t a i n a l r e a d y e x i s t i n g  independent  behaviours.  The c h a r t i s a means of a s s i s t i n g the s t a f f i n d e v e l o p i n g a uniform and c o n s i s t e n t set of e x p e c t a t i o n s i n r e l a t i o n t o the r e s i d e n t ' s ADL  skills.  Reinforcement,  i n a p p r o p r i a t e behaviour, independence.  which might be g i v e n f o r  i s given f o r resident e f f o r t s  toward  As an a c t i v i t v becomes r e h a b i l i t a t e d , t h a t  comes under environmental  activitv  c o n t r o l w h i l e s o c i a l r e i n f o r c e m e n t from  s t a f f i s d i r e c t e d towards the next t a r g e t e d a c t i v i t y . Newly r e h a b i l i t a t e d behaviours are a t f i r s t f r e q u e n t l y as they are performed  attended t o and  praised  independently. T h i s a t t e n t i o n i s  g r a d u a l l v reduced over time as work on other behaviours becomes the f o c u s . By s h i f t i n g the emphasis of s t a f f a t t e n t i o n  from  negative a t t e n t i o n g e t t i n g dependent behaviours to more d e s i r a b l e a c t i v i t i e s , n o s i t i v e behaviours i n c r e a s e (Hoyer, Mishara  and  R i e d e l , 19751.  It  should be noted, however, t h a t s t a f f t r a i n i n g  emphasizes  u s i n g d i s c r e t i o n i n f o l l o w i n g the r u l e s d e s c r i b e d above. While there i s a standard method of d e a l i n g w i t h r e s i d e n t  behaviour,  the i n c r e a s e d knowledge base p r o v i d e d by the v i s u a l c h a r t enables s t a f f t o use t h e i r own  i n i t i a t i v e i n o f f e r i n g encouragement,  empathy and/or understanding t o r e s i d e n t s on some o c c a s i o n s when a r e s i d e n t asks f o r unnecessary  a s s i s t a n c e . The emphasis i s on  making an informed c h o i c e r a t h e r than simply 'doing f o r ' the  Page resident perform of  at every request or r o u t i n e l y r e q u i r i n g the resident every  behaviour  the chart  performing. Sickness,  are  a l l examples of  understanding. resident  independent replaced  g r i e f and  with  a new  one  she  behaviours  independent, that  that  were  upsets  reflects  and  so t h a t  the  once  the v i s u a l chart  accurately  to  i s capable  demand f l e x i b i l i t y  i f deterioration occurs  to perform  or p a r t i a l l y  or  t r a n s i t o r y emotional  s i t u a t i o n s which  In addition,  i s unable  indicates.he  55  i s  current  functioning.  Generalization  This  issue  rehabilitation particular effects  of  Change  i s of  c e n t r a l importance  programs are conducted  s i t u a t i o n and  within  o f t h e s e p r o g r a m s do  environment.  Developing  p r o g r a m s and  the d a i l y  making  the r e h a b i l i t a t i o n  staff  coming  rehabilitation each  such  In t h i s  program a part  that  and  resident.  permanent p a r t  of  of  to the t h e gap  the  they can  the  The  be  Often,  between  was  such  has  avoided  of the d a i l y Targets  of  of .  for  program t h u s becomes life  by  routine  e a s i l y accomodated  institutional  the  institutional  the patient  resident.  Many  in a  frame.  study the problem  s t a f f member's work r o u t i n e .  regular  bridging  environment  i n contact with  are  time  not generalize  living  been a problem.  specialists  specific  a means o f  always  all  a  by  i n the program.  the  into a  Page 56  T r a i n i n g Program  A l l front-line program. The  s t a f f were i n v o l v e d i n a systematic  components of the t r a i n i n g program i n c l u d e d :  process of aging  and  institutionalization,  t r a i n i n g , behaviour m o d i f i c a t i o n and involved  training the  rehabilitation  program r a t i o n a l e . T r a i n i n g  5 l e c t u r e s of 45 minutes d u r a t i o n as w e l l as weekly  small group meetings h e l d i n each of the four s e c t i o n s of experimental f a c i l i t y  1. The  (see Appendix C f o r f l o o r p l a n ) .  Process of Aging and  I n s t i t u t i o n a l i z a t i o n . Information  g i v e n on the p r o c e s s of aging  (biological, social  p s y c h o l o g i c a l changes t h a t occur w i t h age) of these changes and i n f o s t e r i n g the information  the  the environment. The  s i c k r o l e and  and  and  the r e l a t i o n s h i p  r o l e of the  dependence was  was  institution  also discussed.  The  presented i n the f i r s t three c h a p t e r s of t h i s t h e s i s  formed the b a s i s f o r the i n s t r u c t i o n .  2. R e h a b i l i t a t i o n T r a i n i n g . S t a f f were given b a s i c t r a i n i n g i n s t r a t e g i e s of r e h a b i l i t a t i o n . Information i n c l u d e d d e t a i l s o f b a s i c a i d s and activities  devices  used to promote independence i n v a r i o u s  (velcro fasteners, dressing  s p e c i a l l y designed c l o t h i n g ) and  sticks,  zipper  techniques f o r performing  f o r those w i t h s p e c i f i c d i s a b i l i t i e s  (e.g.  ADL  hemiplegia,  amputations, balance problems). T h i s i n f o r m a t i o n the i n s t i t u t i o n ' s o c c u p a t i o n a l  pulls,  was  provided  t h e r a p i s t . In a d d i t i o n to  the  by  Page -57t r a i n i n g , each s t a f f member had access to a treatment manual t h a t included d e t a i l e d Appendix  'how  t o ' guides f o r each of the t a r g e t ADL  (see  B f o r d e t a i l s ) . Most of the ADL's were broken down i n t o a  s e r i e s of s m a l l e r steps which could be t r a i n e d i n d i v i d u a l l y .  Staff  were taught to determine the f i r s t step i n a p a r t i c u l a r s e r i e s a r e s i d e n t c o u l d not complete  independently and t o begin working a t  that point.  3. Behaviour M o d i f i c a t i o n . T r a i n i n g was techniques of behaviour m o d i f i c a t i o n  a l s o g i v e n i n the b a s i c  (see Appendix  B). Modeling,  shaping, b e h a v i o u r a l r e h e a r s a l and r e i n f o r c e m e n t were  emphasized.  A. Modeling. I t has been e s t a b l i s h e d t h a t one can. l e a r n behaviours or responses by i m i t a t i o n of o t h e r s (Bandura, T h i s process i s c a l l e d modeling and occurs when an l e a r n s a new  new 1969).  individual  response by i d e n t i c a l l y reproducing a response  observed i n another i n d i v i d u a l . A l s o , responses a l r e a d y i n the i n d i v i d u a l ' s r e p e t o i r e may  be cued by a model's behaviour.  Modeling has been shown to be e f f e c t i v e i n many v a r i e t i e s of response a c q u i s i t i o n and has d i r e c t a p p l i c a t i o n to the l e a r n i n g and r e l e a r n i n g of the ADL /.] v  B. Shaping. Where immediate  i m i t a t i o n of a complex behaviour i s  i m p o s s i b l e , s u c c e s s f u l performance may  of s u c c e s s i v e approximations  be i n i t i a t e d . Shaping by s u c c e s s i v e approximations i s o f t e n  u s e f u l i n t e a c h i n g a new  response. In t h i s procedure, the d e s i r e d  t o t a l response i s broken down i n t o a s e r i e s of s m a l l e r steps  Page  which are necessary  f o r mastery of the f i n a l response.  58  Each step  i s completed p r o g r e s s i v e l y , u n t i l the f i n a l or complete  response  i s o b t a i n e d . In shaping, the t h e r a p i s t a t f i r s t r e i n f o r c e s responses behaviour,  which may  have l i t t l e  s i m i l a r i t y to the d e s i r e d  but which are c l e a r l y w i t h i n the s u b j e c t ' s c u r r e n t  b e h a v i o u r a l repertoire' The o n l y behaviours  t h e r a p i s t then r e i n f o r c e s s u c c e s s i v e l y  which are i n c r e a s i n g l y s i m i l a r to the d e s i r e d  behaviour. F i n a l l y , o n l y the d e s i r e d behaviour u n t i l i t a t t a i n s s u i t a b l e s t r e n g t h . Modeling be used i n combination  i s reinforced,  and  shaping may  by breaking the d e s i r e d behaviour  steps and modeling each of these steps u n t i l the f i n a l is  also  into response  obtained.  C. B e h a v i o u r a l R e h e a r s a l . B e h a v i o u r a l r e h e a r s a l i s a t o o l t h a t has been employed i n a v a r i e t y of t h e r a p e u t i c c o n t e x t s w i t h u s e f u l r e s u l t s . T h i s technique  i n v o l v e s a l l o w i n g the s u b j e c t to  p r a c t i c e or rehearse the behaviour  being modeled o r shaped.  R e p e t i t i o n and p r a c t i c e has been demonstrated to be e f f e c t i v e i n the l e a r n i n g and r e l e a r n i n g of behaviours. Rehearsal a l s o p r o v i d e s the o p p o r t u n i t y f o r s e l f - c o r r e c t i o n and o t h e r s . The  i n d i v i d u a l can  s i t u a t i o n s without  ' t r y out' new  feedback from  responses  i n simulated  r i s k i n g f a i l u r e . Rehearsal a l s o permits  the  a n t i c i p a t i o n of d i f f i c u l t problems and ways of h a n d l i n g them.  D. Reinforcement.  The most commonly used technique of  operant  behaviour m o d i f i c a t i o n has been p o s i t i v e r e i n f o r c e m e n t . M i l l e n s o n (1 967). c l a i m s t h a t r e i n f o r c e m e n t  i s "a fundamental p r i n c i p l e i n  the a n a l y s i s and c o n t r o l of a d a p t i v e behaviour". Vroom  (1964)  a l s o s t a t e s t h a t "the p r i n c i p l e of r e i n f o r c e m e n t must be i n c l u d e d among the most s u b s t a n t i a t e d f i n d i n g s of experimental  psychology  and i s , a t the same time, among the most u s e f u l f i n d i n g s f o r an a p p l i e d psychology behaviour",  concerned  w i t h the c o n t r o l o f human  P r a i s e i s a u s e f u l aspect of r e i n f o r c e m e n t .  I n d i v i d u a l s enjoy being p r a i s e d and i t has been found t o i n c r e a s e the occurrence of those behaviours t h a t i t i s d i r e c t e d towards.  'These techniques have been a p p l i e d t o the problems of i n c r e a s i n g behaviours c u r r e n t l y occurring a t low r a t e s , r e i n s t a t i n g behaviours once present but no longer e x h i b i t e d and b u i l d i n g completely new b e h a v i o u r a l r e p e t o i r e s (Sherman and Baer, 1 969).. Using these s k i l l s ,  the new behaviour  r e s i d e n t i s broken down i n t o v a r i o u s steps  t o be taught t o the  (shaping); he or she  i s p r o v i d e d w i t h s p e c i f i c and v i v i d d i s p l a y s o f the s k i l l o r step the t h e r a p i s t i s seeking t o teach  (modeling); he or she i s g i v e n  c o n s i d e r a b l e o p p o r t u n i t y , t r a i n i n g and encouragement t o b e h a v i o u r a l l y rehearse or p r a c t i c e the modeled  behaviour  (behaviour r e h e a r s a l ) ; and he o r she i s p r o v i d e d w i t h p o s i t i v e feedback,  approval and p r a i s e as the enactments i n c r e a s i n g l y  approximate those of the t h e r a p i s t  (social reinforcement).  4. Program R a t i o n a l e . S t a f f were g i v e n a d e t a i l e d e x p l a n a t i o n o f the CARE program, i n c l u d i n g i n s t r u c t i o n i n the use o f the v i s u a l c h a r t s , c o l o u r coding, ADL manual and t h e i r use.  O r g a n i z a t i o n a l Behaviour M o d i f i c a t i o n  I t has been demonstrated t h a t i n s t r u c t i o n i n p r i n c i p l e s of behaviour m o d i f i c a t i o n can e f f e c t i v e l y change n o n - p r o f e s s i o n a l s ' behaviour  (McKeown, Adams and Forehand, 1 975).. There i s some  q u e s t i o n , however, about the permanence o f t h i s change and McNamara, 3 977). A c c o r d i n g  to Rappaport  (Andrasik  (.1 977)., i n s t i t u t i o n a l  change must i n c l u d e p e r s o n a l s a t i s f a c t i o n of the members of  the  i n s t i t u t i o n . Feedback i s an important  in  maintaining  s t a f f behaviour  form of reinforcement  (Panyan, Boozer and M o r r i s , 1 970)...  T r a i n i n g programs f o r s t a f f and  s p e c i f i c procedures t h a t a s s i g n  i n c r e a s e d r e s p o n s i b i l i t y f o r p a t i e n t care a l s o h e l p t o i n c r e a s e morale and  satisfaction  (Schwartz, 1974), S t a f f p a r t i c i p a t i o n i n  g o a l s e t t i n g f a c i l i t a t e s commitment to those g o a l s ; g o a l s g i v e the s t a f f  The  something f o r which to  strive.  program t h a t has been d e s c r i b e d p l a c e s much emphasis on  these f a c t o r s . F r o n t - l i n e s t a f f are exposed to a t r a i n i n g program t h a t p r o v i d e s them with s p e c i f i c s k i l l s t h a t have d i r e c t i m p l i c a t i o n s f o r r e s i d e n t c a r e and a v a i l a b l e t o these  treatment. The  s t a f f and p r o v i d e f o r i n c r e a s e d  procedures are responsibility  and d e c i s i o n making power r e l a t i n g to r e s i d e n t c a r e . In d e f i n i n g s p e c i f i c and  i s o l a t e d ADL  more l i k e l y . T h i s success Recognition  as t a r g e t g o a l s , s u c c e s s f u l change i s i s , i n i t s e l f , rewarding t o  f o r s t a f f performance i s a l s o p r o v i d e d  meetings through feedback on success  staff.  i n the weekly  i n meeting t a r g e t e d g o a l s .  These group meetings i n v o l v e a l l s t a f f members who  provide  care  Page 61  f o r the r e s i d e n t .  A l o g book (see Appendix D) , which c o n t a i n s a r e p l i c a of the i n f o r mation on every r e s i d e n t ' s w a l l c h a r t , s erves as. the f o c u s of the group meetings.  The l o g book p r o v i d e s a s i x month r e c o r d o f ADL f u n c t i o n i n g  f o r a r e s i d e n t on one page. The r e s i d e n t ' s l e v e l o f f u n c t i o n i n g i s a s s e s s e d each week a t the meetings and any changes from the p r e v i o u s week a r e r e corded on the dated page by means o f the a p p r o p r i a t e c o l o u r e d dot. W a l l c h a r t s a r e then updated as w e l l . Each r e s i d e n t ' s p r o g r e s s i s reviewed a t the weekly meeting .and s t a f f have an o p p o r t u n i t y to modify  programs o r  i n i t i a t e new ones. The group meeting i s one means o f d e a l i n g w i t h t h e problem noted by Brody (1976) i n d i s c u s s i n g the use o f d a t a i n h e a l t h c a r e d e l i v e r y systems; " t h e u t i l i t y o f data can be n i l u n l e s s i t i s i n j e c t e d an o r g a n i z a t i o n prepared and p r o b l e m - s o l v i n g  to a d j u s t i t s performance to a p r o b l e m - d e f i n i n g  approach".  into  Page 62 CHAPTER 6  PROCEDURE  Setting and Subjects  Two f a c i l i t i e s served as the setting for the study. They were architecturally identical 152 bed, single story buildings i n Metropolitan Vancouver. Each f a c i l i t y consisted of 4 living units of 38 residents. The residents share a common dining room, a communal lounge and a hobby room. A recreational program at each f a c i l i t y includes such activities as bowling, newspaper readings, outings, films and visiting groups of entertainers. Arts and craft activities are also available. The institutions are publicly  supported and had been i n operation for approximately  two and a half years prior to the beginning of the study. Both f a c i l i t i e s are under the management of the same administrator. The nursing director, dietician and social worker are shared equally between the two buildings and each f a c i l i t y has i t s own occupational therapist. Staffing patterns are identical and include four full-time registered nurses, forty attendants and six activity aides at each f a c i l i t y .  Budgets are also identical as  i s the purpose of each f a c i l i t y - provision of intermediate long term care (see Appendix E for explanation and criteria). One f a c i l i t y (A) was randomly chosen to serve as the setting for the experimental treatment program while the other (B) served as the control. Within each f a c i l i t y a l l persons 60 years of age or over were included i n the study. As shown i n Table 2, 127 (83.5%) at f a c i l i t y A and 130 (85.5%) at F a c i l i t y B were aged 60 or more. Among those residents 60 and over,  Page the mean age at F a c i l i t y A was 82.1 years (s.d.= 8.8 years) and the average length of stay was 11.7 months. At F a c i l i t y B the mean age was 79.2 years (s.d.= 9.9 years) and the average length of stay was 12.7 months. The experimental group consisted of 39 males and 88 females while the control group comprised 47 males and 83 females.  Demographic information i s shown i n Table 2 (age, sex, primary diagnosis, length of stay and ambulation status). This information was obtained from the medical charts. Chi-square or t-tests were used to test the equivalence of the two groups at the beginning of the study. The two groups differed on 2 of the 5 demographic variables - age and ambulation status. The residents of A were significantly older and more ambulatory than those i n B. Since age i s correlated negatively with a l l variables used as dependent measures i n the study, the difference i n age probably biased the results against the treatment group and i n favour of the control group. Ambulation status was considered i n some of the analyses of the dependent measures.  Confusion A l l subjects were rated as to degree of confusion..Assessing confusion among the elderly i s problematic (Slater and Lipman, 1977) . Formal des-/^ criptions of the condition differ markedly and, i n some instances, include factors specifically excluded from other definitions of the same phenomena (Meacher, 1972). In addition, measures of confusion vary i n the method of administration and content. Many geriatric patients cannot undergo the  Page 64  Table  Demographic  2  Information  Facility.A n=127  Age  ( i n years)  Length of stay: ( i n months)  Sex:  B  Significance Test  X=82.1 , s . d . = 8 . 8 X=79 . 2 , s ,d . = 9 , 9 r a n g e 60-102 y r s , r a n g e 60-101 y r s ,  t_=2.5 p_<.01  X = l l • . 7 , s . d . = 9.2 r a n g e 1-24 mon,  t=-0.9 n.s.  X=12 . 7 , s .d ..= 7 . 0 r a n g e 1-26 mon.  Male  39  47  X* =4 . 6  Female  88  83  n . s  110  98  X =4 . 6  17  32  P  32  26  X =9 . 4  37  26  n.s.  8  6  22  27  9  16  11  15  Ambulat i o n : Ambulatory Wheelchair  Primary Diagnosis*: Psychiatric Heart  Disease  Circulatory Cerebral  Problems  Insult  Musculo/Skeletal Metabolic  Disorder  14  Miscellaneous  *  Facility n=13 0  See A p p e n d i x  F  for details  2  < .03  2  Page 65  standard techniques of psychological testing. Usually mental, perceptual, or physical impairment i s present to some degree and the elderly often find the testing^ situation stressful. Lack of cooperation, hostility and d i f f i c u l t y i n understanding the requirements of the task are common (Goya, 1977). One common factor i n a l l tests of confusion, however, i s a disturbance i n orientation to time, place and person (Lawton, 1973). Of these, orientation to place i s the most readily observable by front line staff. Slater and Lipman (1977) found spatial disorientation to have the highest correlation with subjective assessments of confusion by nurses.  In this study subjects were classified into three categories of confusion, based upon the c r i t e r i a outlined i n Table 3. An advantage of this measure i s that the subject's cooperation i s not needed. Staff are able to evaluate subjects on the basis of their observation and experience alone. A l l subjects were rated on the basis of this criteria, prior to the initiation of the study. Two staff: members, primary care-givers for the subject being rated, independently assessed the subject. Reliability of the confusion scores was computed using the following equation:  agreements X agreements + disagreements  10°  Overall rater agreement, using this equation, was 94 percent. Non-occurrence r e l i a b i l i t y , that i s , agreement that no confusion was present (Score 1) was 96.6 percent. Occurrence r e l i a b i l i t y , or agreement that confusion was present (Score 2 or 3) was 88.8 percent. However, agreement on the level of confusion (Score 2 versus Score 3) was only 75 percent and, therefore, no differentiation was made between these two levels. The distribution of  Page  Table 3 Assessment o f  Confusion  Items  Score  1)  i s a b l e t o f i n d way around w i t h o u t g e t t i n g l o s t . Knows where he/she i s a t a l l times  Score as unimpaired i f item 1 applies.  2)  c a n f i n d way t o d i n i n g room, bathroom and h i s / h e r bedroom  Score as m i l d l y impaired i f only item 2 applies.  3)  neither item 1 or 2 apply  score as dLmpaired  66  Page 67  Table 4 Distribution of Confusion Scores no confusion (score 1)  confusion (score 2 or 3)  Facility A  95  32  Facility B  103  27  Page the . confusion scores between the two f a c i l i t i e s appears i n Table 4. A Chi-square analysis showed no s i g n i f i c a n t difference between groups (X  2  = 0.71,  n.s.).  Dependent Measures Subjects from A and B were a l s o evaluated on the l e v e l a t which they c a r r i e d out s p e c i f i c a c t i v i t i e s of d a i l y l i v i n g . This group of behaviours constituted a l l dependent measures i n t h i s study. The World Health Organization (cited i n Schwab, 1976)  has stated that "health i n the e l d e r l y  i s best measured i n terms of function". In t h i s study, resident functioning was evaluated by means of s t a f f ratings of a b i l i t y to complete the s p e c i f i c a c t i v i t i e s of d a i l y l i v i n g outlined i n the previous chapter. A score of 1 was given f o r t o t a l independence while p a r t i a l dependence and t o t a l dependence were given scores .of 2 and 3, respectively (see Appendix G f o r further d e t a i l s ) . These assessments were made i n each f a c i l i t y a t p a r a l l e l points i n time, j u s t p r i o r to the beginning of treatment i n A and a f t e r 6 months. B subjects were a l s o evaluated a f t e r three months. Three month data for subjects i n F a c i l i t y A were taken from t h e i r w a l l charts.  T h i r t y - f i v e d i f f e r e n t a c t i v i t i e s or items have been i d e n t i f i e d f o r evaluation. With the scoring system outlined above, the minimum and maximum scores f o r the four components of ADL are : dressing (17 to 51 f o r females, 15 to 45 f o r males); grccming  (5 to 15 f o r females, 6 to 18 f o r males);  eating s k i l l s (4 to 12 f o r a l l subjects); and ambulation/transfer (7 to 24 f o r a l l subjects) . A f i f t h measure, Global ADL, was calculated by sumrning the scores of the four ADL measures. The itdnimum scores p o s s i b l e f o r males i s 32, while the maximum i s 103 on t h i s measure. For females, the irdnimum i s 33 and the maximum i s 106. Higher values r e f l e c t more negative ratings.  Page General Procedures  Assessment Only Control - Subjects i n F a c i l i t y B received only the pretreatment, 3 month and 6 month assessments.  Treatment Group - After the pre-treatment assessment of a l l subjects was completed, the wall charts were implemented and placed i n each subject's bedroom at their bedside. The training program was then begun. Instruction and training of staff was conducted by the experimenter and consisted of 5 lectures of 45 minutes duration i n addition to weekly small group meetings The formal lectures took place each week for the f i r s t month. In order to accommodate the two time shifts, these lectures occurred at 2:00 and 7:30 p.m.  p.m.  each week. A l l front-line staff (nurses, attendants  and activity aides ) and the cleaning staff were requested to attend.  The purpose of the small group meetings was to informally discuss the content of the lectures and to provide a means of teaching the s k i l l s to be used i n implementing the program. These small group meetings were 45 minutes i n duration and occurred weekly i n each of the four units of the f a c i l i t y . Thirty-eight residents are accommodated i n each unit and staffing patterns included 2 attendants, one activity aide and a licenced practical nurse (LPN) shared between each unit. Only those staff responsible for the residents on that unit attended.  The experimenter used a modeling and verbal instruction format for staff training in the small groups. The particular s k i l l s the staff members were to acquire - modeling, shaping, behavioural rehearsal and social  Page 7 reinforcement - were demonstrated by the experimenter. Hypothetical problems i n the performance of the activities of daily living were used to discuss and demonstrate these s k i l l s . The staff then practiced these behaviours under the supervision of the experimenter before actually applying the s k i l l s with the subjects. Positive reinforcement, i n the form of praise and feedback, was given to staff as they developed these skills.  The schedule of special activities which occurred during the 24 weeks of the study are summarized below:  Week 0. The f i r s t lecture provided an introduction to the program and an explanation of the wall charts: each activity and i t s pictorial representa- . tion, the colour coded c r i t e r i a and the use of the blue dot to designate targets for rehabilitation. A group meeting was also conducted on each unit to informally discuss the content of the lecture and deal with any misconceptions or ambiguities that arose. During this week the experimenter was available to individual staff members to informally discuss the program and explain the use of the wall chart. The wall charts were completed and placed i n each subject's bedroom at their bedside. In addition, a recording sheet was placed beside each wall chart. A l l staff providing primary care to each subject were required to i n i t i a l the recording sheet to indicate agreement with the assessment. If disagreement did occur, the activity/ activities i n question was recorded and discussed with the staff at the group meeting the following week.  Page Week 1. The second l e c t u r e c o v e r e d a g i n g and i n s t i t u t i o n a l i z a t i o n . A m a j o r f o c u s o f t h i s l e c t u r e was t h e way i n w h i c h u n d e s i r a b l e and i n c r e a s e d dependence i s p r o d u c e d a n d m a i n t a i n e d  behaviour  i n an i n s t i t u t i o n .  The s m a l l groups met t o d i s c u s s t h e c o n t e n t o f t h e l e c t u r e and t o r e v i e w any s t a f f d i s a g r e e m e n t s o n ADL assessments r e f l e c t e d o n t h e w a l l c h a r t s . Any d i s a g r e e m e n t s between s t a f f t h a t were u n r e s o l v e d r e q u i r e d t h a t t h e s u b j e c t ' s w a l l c h a r t be changed  t o r e f l e c t t h e l o w e s t l e v e l o f agreement  i n t h e a c t i v i t y i n q u e s t i o n . T h i s p r o c e d u r e was i n s t i t u t e d i n o r d e r t h a t s t a f f agreement be m a i n t a i n e d  and a n a c c u r a t e b a s e l i n e d e v e l o p e d .  S t a f f were a l s o encouraged t o c o o p e r a t e i n d e t e r m i n i n g  rehabilitation  g o a l s f o r each s u b j e c t . T h e i r c h o i c e s were t o be b a s e d o n a c t i v i t i e s t h a t had t h e h i g h e s t p r o b a b i l i t y o f b e i n g s u c c e s s f u l l y changed. S t a f f were d i r e c t e d t o e x p l a i n t h e program t o t h o s e s u b j e c t s who were c a p a b l e o f understanding  and t o c o n s i d e r t h e s u b j e c t ' s cwn c h o i c e i n d e t e r m i n i n g  g o a l s . A l l p o s s i b l e g o a l s were d i s c u s s e d w i t h t h e o c c u p a t i o n a l t h e r a p i s t and r e p o r t e d a t t h e f o l l o w i n g m e e t i n g .  Week 2. The f a c i l i t y o c c u p a t i o n a l t h e r a p i s t c o n d u c t e d a l e c t u r e o n b a s i c r e h a b i l i t a t i o n s k i l l s and a i d s t h a t were a v a i l a b l e t o h e l p i n d i v i d u a l ' s w i t h s p e c i f i c problems. S t a f f were a l s o i n t r o d u c e d t o t h e ADL Treatment Manual and i t s p u r p o s e was e x p l a i n e d . These manuals were f r e e l y a c c e s s i b l e to  s t a f f ; a number o f c o p i e s were p l a c e d i n each u n i t o f t h e f a c i l i t y . The  s m a l l g r o u p s met t o d i s c u s s t h e c o n t e n t o f t h e l e c t u r e and were a g a i n made f a m i l i a r w i t h t h e manuals. S u b j e c t assessments were r e v i e w e d and a p p r o p r i a t e g o a l s were d e s i g n a t e d .  Page 72  Week 3. Basic 'social learning theory was discussed i n the fourth 1  lecture. Specific emphasis was placed on the role of shaping and modeling in behaviour change procedures. Instruction and practice were conducted in the group meetings.  Subjects' assessments continued to be reviewed and  appropriate goals were designated.  Week 4. Basic operant theory was discussed i n the final lecture. Behavioural rehearsal and social reinforcement were emphasized. The group meeting was used to discuss the content of the lecture as well as to practice the techniques under the direction of the experimenter. Assessment reviews were completed and a l l subject wall charts contained one blue dot.  Week 5 to 12. Small group meetings i n each unit continued under the direction of the experimenter. Subjects' assessments were reviewed, progress was discussed and new goals established. A l l changes were recorded i n the log book during the meeting and after review, the experimenter updated the wall charts with the appropriate changes i n colour coding. A 'changes l i s t ' was then forwarded to the occupational therapist for verification. Any problems i n program implementation were also discussed at the meeting.  Weeks 13 to 24. Small group meetings continued but were no longer under the direction of the experimenter. Instead, one staff member i n each unit served as the leader, while another acted as secretary. The leaders were responsible for making sure that a l l subjects were properly reviewed. The secretary completed the 'changes l i s t ' while the leader recorded these changes on the appropriate log book page. Progress i n goal achievement was discussed and new goals were established as appropriate. The leader was  Page 7 3  chosen from the front line staff of the unit on the basis of their interest i n taking on the role and also their a b i l i t y to work cooperatively with others. These leaders reported to the experimenter each week on any problems and a l l progress that occurred.  Post-Treatment Assessment. At the end of the six month period a l l subjects in F a c i l i t y A and B were reassessed as to their level of functioning i n the designated activities of daily living. Two staff members, primary care givers for the subject being rated, independently assessed the subject. Inter-rater r e l i a b i l i t y measures were computed using Pearson product-moment correlations.  Page 74  CHAPTER 7 RESULTS  Reliability of ADL S k i l l Scores Reliability was computed on the staff assessments of the dependent measures (dressing, eating, grooming, ambulation/transfer  and' global ADL  s k i l l s ) . Assessment occurred i n each f a c i l i t y at parallel points i n time, just prior to the beginning of treatment i n F a c i l i t y A and after 6 months. F a c i l i t y B subjects were also assessed after three months. Reliability was,  therefore  computed at the pre and post-assessments i n each f a c i l i t y and at the three month assessment i n F a c i l i t y B. Two staff members, the primary care-givers for the subject being assessed, independently rated the subject using the ADL c r i t e r i a outlined i n Appendix G. The raters met with the experimenter prior to the assessment, were given instruction i n the scoring c r i t e r i a and content, and practiced i n a simulated situation i n which they rated a resident not included i n the study. The two staff members then independently rated a l l subjects for which they were primary care-givers. In the experimental f a c i l i t y these assessments were conducted prior to the installation of the wall charts and provided the basis for the wall chart assessment. These wall chart assessments were not available to the raters at the six month assessment. In no case did staff members rate subjects more than once during the course of the study. Pearson product-moment correlations were used to compute inter-rater r e l i a b i l i t y and appear in Table 5. These correlations indicated substantial agreement between raters. Reliability was also computed between the mean rater score and the scores derived from the wall chart i n F a c i l i t y A at the six month assessment. Pearson correlations were above .97 on a l l measures and indicated considerable agreement between raters and wall chart assessments.  Page 75  Table 5 Inter-Rater Reliability of ADL Assessments  Facility A Dependent Measure  Baseline  6 mon.  Facility B Baseline  3 mon.  6 mon,  Global ADL S k i l l s  .95  .97  .94  .95  .95  Dressing S k i l l s  .95  .96  .93  .94  .94  Eating Skills  .95  .96  .97  .92  .98  Grooming S k i l l s  .89  .91  .89  .90  .90  Ambulation/transfer Skills  .95  .94  .90  .93  .92  Page 76  Sample Attrition During the course of the study attrition occurred i n both Facility A and B. This attrition was primarily due to the deterioration i n functioning of a number of the subjects and necessitated transfer to more intensive care (extended care - see Appendix E). In a small number of cases death occurred while the subject was residing i n the f a c i l i t y . In Facility A, seven subjects were transferred before the three month assessment while an additional eight subjects (6 transfers, 2 deaths) were lost between the three and six month assessment. Ten subjects (8 transfers, 2 deaths) were lost before the . three month assessment i n Facility B as well as twelve subjects (11 transfers, 1 death) between the three and six month assessments. These subjects were not included i n the data analyses.  Generation and Standardization of Raw Scores The mean score of the two raters' assessments was used as the raw score for the purposes of the study. For the three month assessment i n F a c i l i t y A, raw scores were derived from the visual wall chart assessments. Since males and females were rated i n a slightly different way i n the areas of dressing, grooming and global ADL, scores on these measures were converted into standard scores with a mean of 0 and a standard deviation of 1. Data from the pretreatment assessment was used as a basis for the conversion with male and female data conversion based only on pre-treatment scores of subjects of the same sex. Data analyses for grooming, dressing and global ADL used standard scores.  Comparison of Pre-Treatment Assessments There were no significant pre-treatment differences between Facility A  Page 77 and B on global ADL, dressing, groaning or eating raw score measures (see Table 6 ) . The medical charts had indicated that a s i g n i f i c a n t l y greater proportion of subjects were ambulatory i n F a c i l i t y A. This i s reflected i n a difference approaching s t a t i s t i c a l significance (t = -1.92, p<.06) between ambulation/transfer s k i l l scores computed for the two f a c i l i t i e s . A subject who i s independent and ambulatory receives a ndnimum score of 7 whereas one who i s independent i n transfers and mobility but confined to a wheelchair receives a ndnimum score of 10. Therefore, these two subgroups were analyzed separately. No significant pre-treatment differences were found on ambulation/ transfer s k i l l s i n these two subgroups between F a c i l i t y A and B (see Table 7 ) .  Treatment Effects  Treatment effects were analyzed with repeated measures analyses of variance for pre-treatment, 3 month and 6 month scores. Subsequent comparisons were performed using the Tukey Test.  Mean scores on a l l measures over the three time period are presented i n Table 8. The results of a series of repeated measures ANOVA appear i n Table 9. These results demonstrated a significant main effect due to f a c i l i t y for global ADL (F = 7.17, p<.008), dressing (F = 4.19, p<.04) and groaning s k i l l scores (F = 9.23, p<.003). There was no difference between the two f a c i l i t i e s i n eating s k i l l scores (F = 1.43, p<.23). In the area of ambulation/transfer s k i l l s , no significant between group differences were found f o r subjects who were confined to wheelchairs (F <= 0.05, p<- .82) or those who were ambulatory (F = 2.80, p<.10) . There :  Page  78  Table 6  Comparisons of pre-treatment assessments Facility Mean  A  Facility  S.D,  Mean  ("trtestsl  B  S,D,  df  tr^alue  2.  3 8.15 range  10,62 32-85  3 8 ,35 10,61, r a n g e 3 2-90.5  ^0.41  218  0.8 9  2 0,20 range  08,40 15-51  19.35  +0U0  218  0.42  range  15r-51  04.27 range  00.74 4-8  04,27 range  00,97 4-12  +0,04  218  0, 97  Skills  06,01 range  01,83 5-18  06 50 range  02^76 5<rl8  ^1^.54  218  0 ,17  Ambul./transfer  07.66 range  01,99 7-20  08^12  0l!96  ^l;92  218  Global  ADL  Dressing Eating  Skills Skills  Grooming  t  range  Table  Comparisons  of Ambulatory  on E r e - T r e a t m e n t  07 ,10  0;06  7-24  7  and W h e e l c h a i r S u b j e c t s  Ambulation/Transf er S k i l l  Facility  A  A  Facility  B  Mean  S.D.  n  Mean  S.D.  n  100  07,13  0,43  78  7,20  12  12 , 60  3 . 81  30  i 0,70  (trtest)  Scores  _t-Value  df  p_  Ambulatory Subjects  0,54  -0,98  176  0.33  Wheelchair Subjects  2,05  +1 }43  40  0,16  Page 79  Table  Summary  o f Mean  Scores  93  For F a c i l i t y  Facility T2  Tl  A and  A  B*  Facility T3  Tl  T2  T3  -0 , 08  -o  . 25  -0 ,25  -0 , 04  0:  Dres s i n g * *  -0 . 03  -0 . 23  -0 .22  -0 .10  0.ii  0 .26  Grooming**  -0 ,14  -0 .23  -0 .21  0 . 08  0 . 26  0 ,25  4 . 27  4 .20  4 .20  4 . 27  4 .68  4 .34  7 ,13  7 .20  7 , 24  7 .20  7 .36  7 ,67  10 .75  10 .42  10 . 70 11 ,52  11 .58  Global  ADL**  Eat ing Ambulation/transfer Ambulatory Subjects Ambulation/transfer Wheelchair Subjects  *  Higher  values  **Standard  12 . 00  r e f l e c t more  scores  negative  ratings  :  is  B  0 .32  Page 8 0  Table 9 Repeated measures analyses of variance comparing ADL s k i l l scores over three assessment periods in F a c i l i t y A and B Source  MS  df  F  E  Global ADL Facility Assessment Time F a c i l i t y Assessment Time  19.53 .54 4.28  1 2 2  7.17 2.24 17.74  .008 .108 .001  Dressing Facility Assessment Time . F a c i l i t y Assessment Time  10.25 .51 4.55  1 2 2  4.19 1.99 17.65  .040 .140 .001  Grooming , Facility Assessment Time F a c i l i t y Assessment Time  25.34 .15 1.28  1 2 2  9.23 .86 7.29  .003 .424 .001  Eating Facility Assessment Time F a c i l i t y Assessment Time  6.65 1.92 3.16  1 2 2  1.43 .59 .98  .231 .560 .383  Ambulation/transfer (Ambulatory Subjects) Facility Assessment Time F a c i l i t y Assessment Time  6.30 3.79 1.56  1 2 2  2.80 3.43 1.41  .102 .034 .251  Artibulation/transfer (Wheelchair Subjects) Facility Assessment Time F a c i l i t y Assessment Time  1.15 1.07 15.02  1 2 2  .05 .29 4.01  .823 .754 .024  Page 81 was a significant main effect due to time of assessment for the ambulatory subject group i n ambulation/transfer s k i l l s (F = 3.43, p<.03).  Significant f a c i l i t y by time interaction effects also occurred for global ADL (F = 17.74, p<.001), dressing (F = 17.65, p<.001), grooming (F = 7.29, p<.001) and ambulation/transfer (wheelchair subjects) (F = 4.01, p<.02). The nature of the main effects and interactions are apparent from Figures 2 - 7 and from the Tukey tests performed on the data.  Figure 2 shows the mean z-scores of the two groups on global ADL scores across the three assessment periods.  Comparisons using the Tukey test  indicated that there were no significant within group differences between pre-treatment, 3 month and 6 month assessments. The experimental group, however, was significantly better than the control group on the 3 and 6 month assessments (all p<.05).  Mean z-scores for the two groups on dressing s k i l l s across the three assessment periods are shown i n Figure 3. Again, witliin group comparisons failed to demonstrate any significant differences between assessment periods in either f a c i l i t y . There were no significant differences between the two groups before treatment or at the 3 month assessment. The experimental group, however, was significantly better than the control group at the 6 month assessment (p<-05). In the case of groaning s k i l l s (Figure 4 ) , significant differences i n favour of the experimental group occurred between f a c i l i t i e s at the 3 and 6 month assessments (all g < . 0 5 ) . No significant differences were found on any of the comparisons involving eating (Figure 5) or ambulation/transfer scores (Figure 6 and 7 ) .  Page 82  Global ADL, dressing and grccming scores showed a similar pattern. Although, i n each case, there were no significant within group differences, there was a trend towards improvement i n the experimental group and increased dependence i n the control group. Significant between group differences, in favour of the experimental group, were found on global ADL and grconing scores at the 3 month assessment and on global ADL, grooming and dressing scores at the 6 month assessment. Most professionals expect residents i n geriatric f a c i l i t i e s to show a steady decline in ADL across time. I t appears from the trends shown i n Figures 2 - 4, that the program's effectiveness was due to i t s a b i l i t y to improve scores from the pre-treatment level while patients who did not receive the program became gradually more dependent and their scores increased.  P a g e 83 Figure  2  Group means ( z - s c o r e s ) f o r r a t i n g s on G l o b a l ADL o v e r t h e t h r e e t i m e p e r i o d s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s ) + 0.44 + 0.3  +  ^_ — — F a c i l i t y B  + 0.2+ 0.10.0-0.1T  -0.2-  'Facility A  -0.3-0.4  + 4-  baseline  4_  3 month Fig-uxe  4_  6 month  3  Group means ( z - s c o r e s ) f o r r a t i n g s on D r e s s i n g S k i l l s o v e r t h e t h r e e t i m e p e r i o d s ("higher v a l u e s r e f l e c t more n e g a t i v e r a t i n g s )  + 0,3 +0.2  --  +0.1  --  —- — T a c i l i t y B  0. 0 - -0.1  --  - 0 . 2 --  Facility A  - 0 . 3 --  4-  ba s e l i n e  4_  3  month  6  4-  month  Page Figure  84  4  G r o u p means ( z - s c o r e s ) f o r r a t i n g s on G r o o m i n g S k i l l s over the three time periods (higher v a l u e s r e f l e c t more n e g a t i v e r a t i n g s )  + 0.3 —  Facility B  + 0.2 — + 0.1 — 0.0 — -0.1 — -0.2 —  Facility A  -0,3 —  baseline  _1_ 3 -month  Figure  _1_  6 month  5  G r o u p mean r a w s c o r e s f o r r a t i n g s on E a t i n g S k i l l s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s )  +4.7-+4 . 5 — Facility B  +4.3--  Facility A  +4,1--. +3 . 9-T  + 3 . 7-+ 3 . 5--  baseline  3 month  6 month  Page Figure  85  6  G r o u p mean r a w s c o r e s f o r a m b u l a t o r y subjects on A m b u l a t o r y / T r a n s f e r S k i l l s over t h e three time p e r i o d s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s )  +7.70--  Facility B  + 7 . 60- +7.50-+7.40-+7.30--  Facility A  + 7 .20-+7.10--  i  :  baseline  1  •  3 month  Figure  * —  6 month  7  G r o u p mean r a w s c o r e s f o r W h e e l c h a i r s u b j e c t s on Ambulation/Transfer S k i l l s over the three time p e r i o d s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s )  + 12.5+ 1 2 . 0-1-  Facility B  + 11.5+11.0--  'acility A  +10.5-+ 10.0-*-  J baseline  1  3 month  I. . • 6 month  Page Reduction and Improvement In Independent Fxinctioning  Although the Tukey Test indicated that scores i n F a c i l i t y A were not s i g n i f i c a n t l y d i f f e r e n t across the three assessment periods, the pattern of i n d i v i d u a l scores indicated that a large number of subjects who received the program had gradually increasing scores. Table 1 0 indicates the number of subjects i n each f a c i l i t y whose global ADL increased or decreased by a t l e a s t two points (the score needed to r e f l e c t a change from red ( t o t a l dependence) to green ( t o t a l independence) on a t l e a s t one a c t i v i t y , or vice-versa) over the course of the study. A Chi-square analysis indicated a s i g n i f i c a n t difference i n the d i s t -  2 r i b u t i o n of scores between the two f a c i l i t i e s  (X  = 36.87, p<.001).  The table shows that, f o r the experimental group, f i v e times as many subjects improved instead of becoming more dependent while, i n F a c i l i t y B, three times as many subjects became more dependent than independent. The f a i l u r e of the Tukey Test to show s i g n i f i c a n t changes toward greater independence i s probably due to the f a c t that, while many subjects had small to moderate v a r i a t i o n s i n t h e i r scores, a few had huge differences from one t e s t to another (e.g. because of a stroke or r a p i d recovery from a stroke).  Page  Table  Number  of  subjects  improvement, in  Global  ADL  in Facilities  maintenance over  10  and  A  and  increased  B  showing  dependence  s i x months  Improvement (< 2)  Maintenance  Increased D e p e n d e n c e (> 2)  Facility  A  30  76  6  Facility  B  9  65  34  87  CHAPTER 8  DISCUSSION  D e s p i t e the g e n e r a l acceptance of the e f f i c a c y of behaviour m o d i f i c a t i o n techniques, l i t t l e mention  has been made of these  procedures i n r e c e n t reviews o f the c l i n i c a l psychology o f aging (Busse and P f e i f f e r ,  1973; B u t l e r and Lewis,  g e n e r a l textbooks on aging  1972) o r i n the  (Botwinick, 1973; Burnside, 1 976;  Kimmel, 1973). Apart from those few s t u d i e s r e f e r r e d t o i n Chapter 3, t h e r e remains  i n g e r o n t o l o g i c a l theory and p r a c t i c e , a  tendency t o de-emphasize the r o l e o f environmental c o n t e x t s i n understanding e l d e r l y behaviour A c c o r d i n g t o Hoyer  (Rebok and Hoyer,  1977).  (1973), b e h a v i o u r a l d e f i c i t s i n the e l d e r l y  are not immutable, but a r e p a r t i a l l y a f u n c t i o n of environmental or e x p e r i e n t i a l d e f i c i e n c i e s which can be m o d i f i e d . U n f o r t u n a t e l y , with the i n s t i t u t i o n a l i z e d e l d e r l y ,  reinforcing  events a r e o f t e n n o n - e x i s t e n t o r a r e c o n t i n g e n t upon the e x h i b i t i o n of dependent behaviours. In a world o f c u s t o d i a l c a r e , dependency may be one o f the few e f f e c t i v e behaviours a v a i l a b l e to a p a t i e n t i n order t o o b t a i n some form of p e r s o n a l a t t e n t i o n and r e c o g n i t i o n from the s t a f f .  The CARE program attempted  t o i n f l u e n c e and modify the  environmental determinants of behaviour found w i t h the i n s t i t u t i o n a l i z e d e l d e r l y . The r e s u l t s demonstrated program i s a f e a s i b l e and p o t e n t i a l l y e f f e c t i v e  that  treatment  this  Page .8 9 approach and methodology. There was  a significant  difference  i n favour of the experimental group f o r the g l o b a l ADL for  score,  d r e s s i n g scores and f o r grooming s c o r e s . Although no  s i g n i f i c a n t between group d i f f e r e n c e s o c c u r r e d b e f o r e treatment, the experimental group was  s i g n i f i c a n t l y more  independent  than the c o n t r o l group on each of these measures a t the s i x month  assessment.  Content v a l i d i t y and treatment e f f i c a c y are i n s e p a r a b l e concerns i n therapy r e s e a r c h . A c c o r d i n g to Goldsmith and McFall  (1975), "the u l t i m a t e measure of a program's content  v a l i d i t y i s i t s therapeutic u t i l i t y ;  c o n v e r s e l y , therapy o u t -  come i n e v i t a b l y depends on the v a l i d i t y of the program's content". The combined components of assessment,  wall chart,  r e h a b i l i t a t i o n and behaviour m o d i f i c a t i o n t r a i n i n g , together, demonstrated  s i g n i f i c a n t therapeutic u t i l i t y .  When the treatment group was i t was  demonstrated  compared t o the c o n t r o l  t h a t the CARE program was  p r e v e n t i n g dependence and a c t u a l l y improved independence  taken  group  effective in  the l e v e l of  of a number of r e s i d e n t s .  The CARE program exerted i t s i n f l u e n c e on the environmental determinants of behaviour and i s c o n s i s t e n t w i t h those c h a r a c t e r i s t i c s i d e n t i f i e d by B a l t e s (1976) as necessary i n h e a l t h care r e s e a r c h w i t h the e l d e r l y . T h i s author s t a t e s t h a t  Page 90 the type of r e s e a r c h identification  needed " i s one  t h a t demands c l e a r  of the t a r g e t behaviours f o r i n t e r v e n t i o n , t h a t  r e d i r e c t s the i n t e r v e n t i o n emphasis from b i o l o g i c a l  to  environmental behaviour v a r i a b l e s , t h a t t e s t s the v a l i d i t y of behavioural  i n t e r v e n t i o n s promptly i n i t s immediate  naturalistic  context,  and  t h a t makes the p a t i e n t s or  and clients  a c t i v e p a r t i c i p a n t s i n the process of h e a l t h promotion  and  maintenance".  Hoyer  (1973) and  others  have recommended t h a t  researchers  concern themselves not o n l y w i t h the immediate a l l e v i a t i o n deficient  behaviours but a l s o w i t h the p r e v e n t i o n  of  of f u t u r e  and  f u r t h e r l o s s e s . T h i s program, as a whole, demonstrated t h a t i n c r e a s e d maintenance can be achieved. The was  purpose of the program  to develop a l i v i n g environment where the c o n t i n g e n c i e s  daily  l i f e encourage, r a t h e r than discourage,  the a c t i v i t i e s of d a i l y behavioural  (1 964). b e l i e f  residents'  the program became a r e g u l a r  and permanent p a r t of the i n s t i t u t i o n a l r e f l e c t s Lindsley's  the performance of  l i v i n g which are w i t h i n the  repertoire.-. To t h i s end,  of  l i f e of the r e s i d e n t  t h a t operant techniques  be a p p l i e d on a l a r g e s c a l e i n the design  and  should  of p r o s t h e t i c  environments which m a i n t a i n competent performance i n the aged.  Although operant techniques are g e n e r a l l y a p p l i e d s i n g u l a r l y , t h i s study has demonstrated t h a t they may valuable  be  particularly  as p a r t of a 'package' treatment p l a n when attempting  modify and m a i n t a i n ADL  behaviours. A l l components may  be  to  Page 91  conceptualized  as methods of conveying a b e h a v i o u r a l  - an e x p e c t a t i o n 'sick-aged' the  which i s counter to both the  r o l e and  expectation  societal  the more immediate normative s t r u c t u r e of  facility.  Assessment The  g o a l s of long term h e a l t h care, f o r the e l d e r l y are  to  improve and m a i n t a i n the a b i l i t y of i n d i v i d u a l s to f u n c t i o n independently and  t o cope w i t h impairments and  disabilities  (Brody, 1 9 7 6 1 . T h i s author b e l i e v e s t h a t i n f o r m a t i o n  on  f u n c t i o n a l s t a t u s , the degree to which a p a t i e n t can c a r r y a c t i v i t i e s of d a i l y l i v i n g and  out  other aspects of independent  l i v i n g , i s necessary as a b a s i s f o r a s s i g n i n g  appropriate  s e r v i c e s to t h a t i n d i v i d u a l - e i t h e r to r e s t o r e f u n c t i o n i n g , to improve f u n c t i o n i n g or at l e a s t to m a i n t a i n f u n c t i o n i n g . Brody f u r t h e r b e l i e v e s t h a t , s i n c e t h i s i s an o b j e c t i v e of long term h e a l t h c a r e , i t must be e v a l u a t e d .  Chronic  among the i n s t i t u t i o n a l i z e d e l d e r l y and may  c o n d i t i o n s are common be experienced  symptoms, i l l n e s s e s , handicaps, d i s a b i l i t i e s or  as  impairments.  Information about the p a t i e n t ' s f u n c t i o n a l l e v e l s d e s c r i b e s  their  h e a l t h or i l l n e s s s t a t u s and  and  thus r e f l e c t s both t h e i r needs  outcomes (Katz and Akpom, 1 9 7 6 ) .  The  a c t i v i t i e s o f d a i l y l i v i n g are w e l l s u i t e d to t h i s k i n d  of e v a l u a t i o n . The  s p e c i f i c a c t i v i t i e s chosen f o r assessment i n  t h i s , study were behaviours t h a t are most s u b j e c t  to  d e t e r i o r a t i o n , are d i r e c t l y i n f l u e n c e d by attendant c o n t a c t ,  are  Page 92• e a s i l y observable  and measurable and a r e a p p r o p r i a t e t a r g e t s f o r  r e h a b i l i t a t i o n and maintenance. Regardless reinforcement  p r i n c i p l e s are employed, the emphasis p l a c e d on the  measurement of observable of treatment  o f whether  behaviour  and on the i n d i v i d u a l i z a t i o n  has i m p l i c a t i o n s f o r most, i f not a l l t h e r a p e u t i c  attempts.  The assessment and s c o r i n g system used i n t h i s  was found  t o be a h i g h l y r e l i a b l e instrument.  study  The use of t h i s  k i n d o f e m p i r i c a l data as a t o o l f o r p l a n n i n g and e v a l u a t i n g treatment  has s e v e r a l advantages: i t p r o v i d e s needed i n f o r m a t i o n  f o r p a t i e n t c a r e , i t i n c r e a s e s a c c o u n t a b i l i t y , i t measures b e h a v i o u r a l changes and i t p r o v i d e s a means of comparing i n d i v i d u a l behaviour  a t d i f f e r e n t stages of treatment and  e v a l u a t i n g the e f f e c t i v e n e s s of treatment.  The Wall  Chart  Current i n s t i t u t i o n a l s t r u c t u r e s such as n u r s i n g homes, f o r reasons  both f i n a n c i a l and p r a c t i c a l , a r e not geared  t o deal with  the i n d i v i d u a l , but r a t h e r with the average i n d i v i d u a l  (Rebok and  Hoyer, 1977). U n d e r s t a f f i n g , a common c h a r a c t e r i s t i c of most f a c i l i t i e s , makes i t d i f f i c u l t  f o r s t a f f members t o know the  . i n d i v i d u a l c h a r a c t e r i s t i c s of a l l p a t i e n t s t h a t come under t h e i r c a r e . Residents vary c o n s i d e r a b l y i n t h e i r a b i l i t y t o perform the ADL's (Hoyer, 1974) and p r o v i s i o n of the proper  l e v e l of n u r s i n g  c a r e r e q u i r e s a c c u r a t e , s p e c i f i c and complete i n f o r m a t i o n on each p a t i e n t . There i s o f t e n , however, no e a s i l y a c c e s s i b l e v e h i c l e f o r systematic communication of assessment data between s t a f f . In many s e t t i n g s , the o n l y r e l i a b l e i n f o r m a t i o n a v a i l a b l e i s the  Page 93  request  f o r a s s i s t a n c e o r help from the p a t i e n t . While r e l i a b l e ,  these requests  f o r help may not be v a l i d i n d i c e s of the. ..actual  performance c a p a c i t y o f the p a t i e n t .  The v i s u a l c h a r t used i n t h i s study was designed t o communicate the assessment i n f o r m a t i o n and treatment g o a l s . I t shows d e t a i l e d d r e s s i n g , grooming, e a t i n g and skills.  Colour  ambulation/transfer  coding was used t o i n d i c a t e the degree o f  independence and the amount o f a s s i s t a n c e needed i n each o f the activities,  as w e l l as treatment g o a l s . The w a l l c h a r t , however,  is,.'not c o n s i d e r e d  an end i n i t s e l f .  I t i s a beginning f o r  f r o n t - l i n e s t a f f . I t i s a means of i n d i v i d u a l i z i n g the d e l i v e r y of h e a l t h care; systematic  i t helps i n communicating i n f o r m a t i o n  in a  way; i t c r e a t e s an e x p e c t a t i o n o f h e a l t h promotion  and maintenance. With these c h a r t s , s t a f f members are able t o make use of b e h a v i o u r a l  data  i n formulating  and implementing  treatment i n t e r v e n t i o n . By s h i f t i n g the focus o f s t a f f a t t e n t i o n from negative  a t t e n t i o n - g e t t i n g behaviours t o more d e s i r a b l e  a c t i v i t i e s , p o s i t i v e behaviours a r e more l i k e l y t o i n c r e a s e .  Behavioural It  and R e h a b i l i t a t i o n T r a i n i n g  i s c l e a r l y d e s i r a b l e t o have f r o n t - l i n e s t a f f  i n any t h e r a p e u t i c e f f o r t . Without knowledge of b a s i c t i o n and behaviour change techniques and m a i n t a i n i n g  rehabilita-  d i r e c t e d towards i n c r e a s i n g  independence, f r o n t - l i n e s t a f f are o f t e n  i n promoting dependence r a t h e r than p r e v e n t i n g According  involved  t o B a l t e s and Zerbe  effective  i t s occurrence.  (1976), "permanent changes from  Page 94.. dependence t o independence i n n u r s i n g  home r e s i d e n t s can be  produced i f a d m i n i s t r a t i v e and c a r i n g s t a f f change t h e i r ' a t t i t u d e ' toward n u r s i n g taught b e h a v i o u r a l  home r e s i d e n t s , o r , i n other words, are  s k i l l s and management w i t h the acceptance of  the b a s i c p r i n c i p l e t h a t most behaviours, i n c l u d i n g  undesired  dependent behaviours i n the e l d e r l y a r e l e a r n e d " .  One advantage o f the operant approach i s t h a t treatment i s i n d i v i d u a l i z e d . Hoyer e t a l (1974) have r e p o r t e d t r a i n i n g s t a f f members t o g i v e contingent feedback, b e h a v i o u r a l  t h a t , by  reinforcement  and  f u n c t i o n i n g i n the e l d e r l y can be r e s t o r e d .  With the CARE program i t i s important t o note t h a t the reinforcement  used was s o c i a l p r a i s e d e l i v e r e d by f r o n t - l i n e  s t a f f who were p a r t of the r e s i d e n t ' s everyday n a t u r a l environment. The t r a i n i n g program and ADL treatment manual provided and  a means f o r s t a f f t o i n c o r p o r a t e  behavioural p r i n c i p l e s  r e h a b i l i t a t i o n techniques i n t o t h e i r everyday i n t e r a c t i o n  w i t h the r e s i d e n t s . The e f f e c t i v e n e s s of i n s t i t u t i o n a l programs which employ behaviour m o d i f i c a t i o n under i n c r e a s e d  scrutiny  (Andrasik  s t r a t e g i e s have r e c e n t l y come and McNamara, 1 977)..  to these authors, a common element u n d e r l y i n g  According  many of the  problems with these programs i s the inadequate p a r t i c i p a t i o n of the s t a f f i n performing program r e l a t e d d u t i e s . The CARE program, however, i s the r e s p o n s i b i l i t y o f the f r o n t - l i n e s t a f f and the i n t e r v e n t i o n s are c a r r i e d out s o l e l y by these s t a f f . f o r t h e i r performance i s provided  Recognition  i n the weekly meetings through  feedback on success i n meeting t a r g e t e d  goals.  Page  The change,  experimental / f a c i l i t y ,  although  d i d n o t show s i g n i f i c a n t  dependent measures under program  efficacy,  resources  improvement  study.  T h i s may  new  staff  n o t be  a reflection  and  already  a v a i l a b l e i n t h e n a t u r a l environment, were  f a c t o r s have  reduced  contingencies,  i n t e r v e n t i o n . However,  these  of resources  situation  i s likely  be c o m p a t i b l e the  with  than  were  those  introduced.  the p o t e n t i a l strength of the  behavioural kinds  other  of  limited  a d d e d , no r o u t i n e s  changed  These  reinforcement  were  positive  i n any o f t h e  but r a t h e r , a consequence of the  a v a i l a b l e . No no  demonstrating  95  most  institutions  a v a i l a b l e on a permanent  to continue.  The  the limitations  do  not  have  b a s i s and  this  CARE p r o g r a m was  found  designed  to  i n most i n s t i t u t i o n s f o r  elderly.  Implicit realistic  i n program  evaluation  i s t h e need  appreciation of the cost  of a particular  innovative demonstration  p r o j e c t s are expensive  necessary  resources  and,  thus,  most long  term  facilities  care  and non-human r e s o u r c e s optimize  existing  understaffed central  that  The  reprogramming  limited  Often  rehabilitation  CARE p r o g r a m  the i n s t i t u t i o n  to  are frequently  programs  so  are of  are  non-existant  succeeded i n r e d i r e c t i n g from a c u s t o d i a l to a  to  t h e human  i t i s necessary  facilities  Many  i n terms of  generalizability  f o r the elderly.  Most  a more  program.  t h e p a t i e n t ' s h y g i e n e and f e e d i n g  importance while  or minimal.  have  a r e l a c k i n g and  resources.  to develop  and  therapeutic  Page 96  model of c a r e . The program was implemented u s i n g a l r e a d y resources  and c r e a t e d l i t t l e  existing  i n t e r f e r e n c e with the r e g u l a r  i n s t i t u t i o n a l r o u t i n e or e x i s t i n g programs. The o n l y a d d i t i o n s t o the i n s t i t u t i o n were the v i s u a l c h a r t s each), ADL -manuals  (approximately  (approximately  $0,03  $2.50 each), as w e l l as s t a f f  t r a i n i n g i n r e h a b i l i t a t i o n and behaviour change.  Bennett, Wilder,  \  Blumner and Furman (1977)., remarked t h a t  few i n n o v a t i v e treatment programs p r o v i d e d  any i n d i c a t i o n whether  they were i n c o r p o r a t e d i n t o the r o u t i n e s e r v i c e s or programs o f the i n s t i t u t i o n s i n which they were i n t r o d u c e d . Without t h i s i n f o r m a t i o n , Bennett and h i s c o l l e a g u e s b e l i e v e t h a t i t i s d i f f i c u l t t o assess whether these programs are i n t r i n s i c a l l y u s e f u l or whether they are s u c c e s s f u l f o r other reasons.  The CARE  program has become a r e g u l a r and permanent p a r t of the institutional life  of the r e s i d e n t s a t the experimental  s i n c e the completion  According  of the study.  t o Brody e t a l (1974), maintenance o f g a i n s can  o n l y be achieved was designed  facility  by s u s t a i n e d treatment i n p u t . The CARE program  t o p r o v i d e a continuous  and on-going treatment  s t r a t e g y . The f a c i l i t y has demonstrated a committment  t o the  program. An o r i e n t a t i o n program has been developed f o r new and  staff  c o n s i s t s of a s l i d e - t a p e p r e s e n t a t i o n of the CARE program as  w e l l as v a r i o u s i n f o r m a t i o n o u t l i n i n g i t s procedures and use. The v i s u a l c h a r t s and an e x p l a n a t i o n of the program accompany the  Rage resident  upon d i s c h a r g e  facility  i s presently  instituted various  many r e q u e s t s  of  care,  has  The  the  of  1.  "A  Reppucci  guiding  to,  and  those 2.  "An  and  p r o g r a m and  a  i t has  care.  parts of  the  been  providing  extended  from various  i n changing  i s based  Also,  the  experimental first  on  the  institution  a number o f  to  principles  (19731: or  philosophy,  which  is  understandable  hope f o r , a l l members o f  m u s t be  developed  c o m m u n i c a t i o n and  s t a f f members and  the  in conjunction  with  encourage  cooperation  between  staff  and  between residents  necessity".  " D e c i s i o n making must  their  utilized  strengths  regardless  involve a l l levels  of  staff  in  fashion".  " E m p l o y e e s m u s t be to  institutions  organizational structure that w i l l  meaningful 4.  p r o g r a m and  members",  various  3.  program  provides  consistency,  is  control  by many i n t e r e s t e d g r o u p s w a n t i n g  care  idea  institution,  the  The  program.  the  t h e r a p e u t i c model of by  on  been v i s i t e d  success  outlined  different  have been r e c e i v e d  hand knowledge o f  the  i n c l u d i n g acute  for information  facility  institution.  implementing  i n a number o f  levels  country  to another  of  97  paper  specifications".  and  i n whatever manner  f i l l s  program  qualifications  or  needs, job  plays  a  a  Page 98 The CARE program has implemented these effectively.  The g u i d i n g  a c t i v i t i e s of d a i l y rehabilitation contact,  idea of the program i s t h a t the  l i v i n g are appropriate  and, s i n c e they a r e d i r e c t l y  targets f o r influenced'by  i t i s c l e a r l y d e s i r a b l e t o have r e g u l a r s t a f f  i n any treatment e f f o r t . The v i s u a l encourage c o n s i s t e n c y , various  principles  staff  involved  c h a r t was designed t o  communication and c o o p e r a t i o n  between  s t a f f members and between the s t a f f and r e s i d e n t s .  F r o n t - l i n e s t a f f a r e exposed t o a t r a i n i n g  program t h a t  them w i t h s p e c i f i c  implications f o r  s k i l l s t h a t have d i r e c t  provides  r e s i d e n t care and treatment. They a r e a l s o g i v e n the responsibility  f o r choosing the g o a l s f o r r e h a b i l i t a t i o n .  Regardless o f j o b s p e c i f i c a t i o n ,  a l l s t a f f can p l a y a r o l e  program. T a r g e t s f o r r e h a b i l i t a t i o n easily  i n the  a r e such t h a t they can be  accomodated i n t o each s t a f f member's work r o u t i n e .  The major d i f f i c u l t y i n t h e e a r l y stages of t h e p r o j e c t was an i n i t i a l r e s i s t a n c e on the p a r t o f some s t a f f members t o the program's g o a l s . These s t a f f , who were i n the m i n o r i t y , belief efforts  h e l d the  t h a t l i t t l e c o u l d be done f o r the aged r e s i d e n t s and any t o do so were f u t i l e . These a t t i t u d e s changed,  as these s t a f f  soon began t o see t h a t some r e s i d e n t s were  improving and t h a t c o - o p e r a t i o n \ among. peer pressure consistency  however,  s t a f f had i n c r e a s e d . The  t o f u n c t i o n as p a r t o f the 'team' and t o m a i n t a i n  created  an i n f o r m a l contingency f o r behaviours  compatible w i t h the CARE program. An example o f t h i s was one s t a f f member who i n i t i a l l y c r i t i c i z e d the procedures but, i n t h e  P a g e - 9 9.later  stages of the study,  Some u n e x p e c t e d  became a g r o u p  benefits  also  became e v i d e n t  p r o g r e s s e d . A number o f t h e s u b j e c t s competed w i t h charts. their  each other  families  charts  became  treatment  became a t o p i c  interested  agents  " s i c i a h s - . .valso  assessment and then r e f i n e  1.  wall  t h e improvement expressed  of conversation.  and  useful  Logical  Many o f t h e active  rehabilitation.;.Phy-  i n monitoring  and  F u t u r e r e s e a r c h m u s t make  directions  t h e program  f o r expanding  this  to increase  the procedures  be t o : Provide  staff with  was n e c e s s a r i l y  more t r a i n i n g and i n s t r u c t i o n , sessions.  The t r a i n i n g  l i m i t e d i n t h i s study  and  s h o u l d make u s e o f f i l m s , v i d e o t a p e  extended  t r a i n i n g and p r a c t i c e  to use  additional  program  further  research  Provide  and more  sessions.  s t a f f whose s o l e  responsibilityi s  t h e p r o g r a m . T h e CARE p r o g r a m was l i m i t e d b y t h e of existing resources  increased staff  on  of t h e i n d i v i d u a l program  and extend  making use of 'booster'  2.  on t h e i r  status.  specific contributions  effectiveness.  group  i n t h e p r o g r a m a n d some b e c a m e  components were n o t a s s e s s e d .  would  green dots  the visual charts  health  as t h e study  i n the experimental  i n promoting maintenance  found  communicating  The  i n gaining  W i t h many o f t h e s u b j e c t s ,  wall  leader.  by a d d i t i o n a l  specifically  and e f f e c t i v e n e s s  resources  trained  such as  may  be  additional  i n t h e CARE p r o g r a m a s  well  i t s  Page .1 00 as r e h a b i l i t a t i o n and behaviour m o d i f i c a t i o n procedures. 3, Use o t h e r , more powerful forms of r e i n f o r c e m e n t . S o c i a l p r a i s e was used as reinforcement i n the present study. Future r e s e a r c h might attempt  to b e t t e r equate  r e i n f o r c e m e n t w i t h i n d i v i d u a l f a c t o r s and t h e r e f o r e , i n d i v i d u a l i z e treatment  p l a n s to a g r e a t e r e x t e n t .  4. T e s t the e f f e c t i v e n e s s of the program w i t h newly admitted  r e s i d e n t s , r e s i d e n t s a t d i f f e r e n t l e v e l s of  c a r e , and i n c o n j u n c t i o n with d i f f e r e n t  treatment  programs,  A r e s e a r c h l i m i t a t i o n of t h i s study i s t h a t treatment were a l s o the primary r a t e r s f o r a l l ADL measures. One  staff  must,  t h e r e f o r e , q u e s t i o n the extent of observer b i a s i n r e p o r t i n g ADL assessments.  There are, however, s e v e r a l f a c t o r s t h a t lend  support to the argument t h a t observer b i a s was Inter-rater r e l i a b i l i t y  of assessments was  q u i t e h i g h i n the  experimental f a c i l i t y , both a t pre-assessment post-assessment reliability  (.91  -.97)  and corresponded  minimal.  (.89 to the  - .95)  and  inter-rater  scores obtained from the c o n t r o l f a c i l i t y .  Observer  b i a s would most l i k e l y have l e d to a r e d u c t i o n i n r e l i a b i l i t y s i n c e each r a t e r would have based  the assessment on t h e i r  own  i n d i v i d u a l b i a s e s r a t h e r than on a common f a c t o r such as a c t u a l functioning status.  Secondly,  the mean r a t e r scores c o r r e l a t e d v e r y h i g h l y w i t h  Page 1 0 1 wall  chart  assessments  (,97 t o . 9 9 ) , A v i t a l  CARE p r o g r a m was t h e v a l i d i t y The  chart  reflected  status o f each  It  would  to  have used  in  rating  resources Had  they  subject  instances  capabilities t o o , may  the treatment  approach.  staff,  were c e r t a i n  Primarily, the  may  n o t be  o f p o t e n t i a l f u n c t i o n i n g . Many r e s i d e n t s  t o be more i n d e p e n d e n t t h a n change t h e i r  attendance are l i k e l y  pattern  t o produce novel  r e s i d e n t s and a t t e n d a n t s  alike.  of  p r i v a c y would have posed  ethical  have  i s usually displayed.  o f 'doing  situations with  of  f o r ' and  attending  unfamiliar individualsi n effects,  Also,  both on t h e p a r t  the necessary  and p r o c e d u r a l  invasions  problems i n  cases.  Although  the present  maintenance of s p e c i f i c that  appropriate  A. H o w e v e r , t h e r e  of this  time.  o f day t o day f u n c t i o n i n g b u t , r a t h e r ,  the resident. Novel  many  than  independent r a t e r s observations  isolated  to  other  over  were n o t a v a i l a b l e t o t h e i n v e s t i g a t o r .  reflections  Staff,  i n Facility  i n the f e a s i b i l i t y  accurate  the  on t h e f u n c t i o n i n g  have been e x p e r i m e n t a l l y  independent observers,  necessary  assessments. •  and t h e changes t h a t o c c u r r e d  certainly  been,  wall chart  t h e agreement of a l l s t a f f  the subjects  limitations  of these  component o f t h e  could  behavioural  be u s e d  focused  on t h e r e h a b i l i t a t i o n  ADL, i t d e m o n s t r a t e d  a useful  and  methodology  f o r t h e assessment and communication o f  competence  (interpersonal  study  skills,  i n other social  problem  behaviours  interaction,  of the elderly  confusion,  etc.).  Page. ,1.0.2  Future  r e h a b i l i t a t i o n e f f o r t s c o u l d use t h i s methodology to  develop programs to d e a l with many of the p r e v a l e n t behaviour problems i n the i n s t i t u t i o n a l i z e d  elderly.  Page 103  BIBLIOGRAPHY  Andrasak, F. arid McNamara; J.R. 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S e l f - i n j u r i o u s b e h a v i o r elderly. Gerontologist, Mueller,  i n the  1973, 35-42.  D.J. and A t l a s , L . R e s o c i a l i z a t i o n o f r e g r e s s e d  elderly residents:  a behavioral-management approach. J o u r n a l o f Gerontology, 1972, 27, 3, 390-392.  P a g e 11 0. Mussen, P., Conger, J.T. and Kagan, J . C h i l d development New York: Harper and Row,  and p e r s o n a l i t y .  1963.  Nahemow, L. and Bennett, R. C o n f o r m i t y , p e r s u a s i b i l i t y and c o u n t e r normative p e r s u a s i o n . Sociometry, 1967, 30, 14-25. Ochberg,  F.M.,  Zarcone, V. and Hamburg, D.A.  Comprehensive P s y c h i a t r y ,  Symposium on i n s t i t u t i o n a l i z a t i o n .  1972, 13, 91-101.  Panyan, M., Boozer, H. and M o r r i s , N. Feedback to a t t e n d a n t s as a r e i n f o r c e r f o r a p p l y i n g operant t e c h n i q u e s . J o u r n a l of A p p l i e d B e h a v i o r A n a l y s i s , 1970, 3, 14, 27-32. Penchansky, R. and Tauberhaus,  L . J . I n s t i t u t i o n a l f a c t o r s a f f e c t i n g the  q u a l i t y o f c a r e i n n u r s i n g homes. G e r i a t r i c s .  i  1965, 20, 591-598.  Prock, V. E f f e c t s of i n s t i t u t i o n a l i z a t i o n : A comparison o f ...community, w a i t i n g list  and i n s t i t u t i o n a l i z e d aged p e r s o n s . American  J o u r n a l of P u b l i c  H e a l t h , 1969, 59, 1837-1844. Rappaport,  J . Community psychology:.. V a l u e s , r e s e a r c h and a c t i o n . New  H o l t , R i n e h a r t and Winston, Rebok, G.W.  York:  1977.  and Hoyer,W.J. The f u n c t i o n a l c o n t e x t o f e l d e r l y b e h a v i o r .  Gerontologist,  1977, 17, 1, 27-34.  Report on Research i n Gerontology: Canada C o u n c i l . Toronto: A s s o c i a t i o n on R e p u c c i , N.D.  Canadian  Gerontology,1977.  S o c i a l psychology o f i n s t i t u t i o n a l change: G e n e r a l p r i n c i p l e s  f o r i n t e r v e n t i o n . American  J o u r n a l o f Community Psychology, 1973,  1, 4, 330-341. R e p u c c i , N.D.  and Saunders, J.T. Problems  of implementation i n n a t u r a l  s e t t i n g s . American P s y c h o l o g i s t , 1974, 29, 649-660. R i s l e y , T.R. B e h a v i o r m o d i f i c a t i o n : An e x p e r i m e n t a l - t h e r a p e u t i c endeavor. I n Hammerlynck, L.A., Davidson, P.O.  and Acker, L.E. ( E d s . ) , B e h a v i o r  M o d i f i c a t i o n and I d e a l Mental H e a l t h  Services. Calgary: U n i v e r s i t y  of C a l g a r y P r e s s , 1970. Ros>ow,. I . and B r e s l a u , N. A Guttman H e a l t h  S c a l e f o r the aged. J o u r n a l o f  the American G e r i a t r i c s S o c i e t y , 1966, 14, 556-559. S a l t e r , C. and S a l t e r , C A . E f f e c t s o f an i n d i v i d u a l i z e d a c t i v i t y program on e l d e r l y p a t i e n t s . G e r o n t o l o g i s t , 1975, 404-406. S c h r e i b e r , M. The aged o f the 70's - P e r s p e c t i v e s . I n W i l s o n ,  L . (Ed.)  Report o f the T r a i n i n g I n s t i t u t e f o r D i r e c t o r s o f S e n i o r  Centres.  Ottawa: Canadian C o u n c i l on S o c i a l Development, 1972. Schwab, M. C h a r a c t e r i s t i c s o f p a t i e n t c a r e data i n the n u r s i n g home setting.  I n Long Term Care Data, M e d i c a l  Care, 1976, 14, 5, 27-32.  Schwartz, A.N. S t a f f development and morale b u i l d i n g i n n u r s i n g homes. G e r o n t o l o g i s t , 1974, 14, 1, 50-53. S e l t z e r , M.M. 15,  The q u a l i t y o f r e s e a r c h i s s t r a i n e d . G e r o n t o l o g i s t , 1975,  6, 503-507.  Shanas, E. A note on r e s t r i c t i o n o f l i f e  space: a t t i t u d e s o f age c o h o r t s .  J o u r n a l o f H e a l t h and S o c i a l B e h a v i o r ,  1968, 9, 1, 86-90.  Sherman, J.A. and Baer, D.M. A p p r a i s a l and Status-. New York: McGraw-Hill, 1969. S i l b e r s t e i n , J . , Kossowsky, R. and L i l u s , P. F u n c t i o n a l dependency i n the aged. J o u r n a l o f Gerontology  ,  1977, 32, 2, 222-226.  S k e e l s , H.M. and Dye, H.B. A study o f the e f f e c t s o f d i f f e r e n t i a l stimulation i n mentally  r e t a r d e d c h i l d r e n . P r o c e e d i n g s o f the American  A s s o c i a t i o n o f M e n t a l D e f i c i e n c y , 1939, 44, 114-136, S l a t e r , R. and Lipman, A. S t a f f assessments o f c o n f u s i o n and the s i t u a t i o n o f confused 523-530.  r e s i d e n t s i n homes f o r o l d people.  G e r o n t o l o g i s t , 1977, 17, 6,  Page  S t a t i s t i c s Canada. P o p u l a t i o n P r o j e c t i o n s f o r Canada and 1972-2001, Cat.// 91-514, June, Taulbee, L.R.  and  H o s p i t a l and Tobin,  S.S.  Folsom, J.C.  Reality orientation for geriatric patients. 1966,  17,  133-135.  E v a l u a t i n g program b e n e f i t . G e r o n t o l o g i s t , The  Province,  1974.  Community P s y c h i a t r y ,  Townsend, C. Old age:  the  l a s t segregation.  Trends i n Long Term Care. Hearings b e f o r e  New  1971,  11,  York: Grossman,  Turner, H. and  term  Senate  1970. ( E d . ) . P s y c h o l o g i c a l f u n c t i o n i n g of o l d e r p e o p l e i n i n s t i t u t i o n s  i n the community. New  Ullman, L.P.  York: N a t i o n a l C o u n c i l on Aging,  1967.  and K r a s n e r , L. A p s y c h o l o g i c a l approach to abnormal  Englewood C l i f f s , N.J.:  Prentice-Hall,  Vroom, J.H.  Work and m o t i v a t i o n .  WEaver, H.,  McPhee, M.  Regional  and Lambert, P.  160,  1964.  G e r i a t r i c s Report. Vancouver  1975.  P r u s o f f , B. and P i n c u s ,  p a t i e n t s and  C. Symptom p a t t e r n s  i n depressed  depressed normals. J o u r n a l of Nervous and Mental  1,  Disease,  15-23.  Y a t e s , J.E. Measuring the q u a l i t y of l i f e . Therapy. 1976,  behavior.  1969.  Chicago: W i l e y ,  Hospital D i s t r i c t ,  Weissman, M.M.,  1975,  1971.  the subcommittee on l o n g  c a r e of the s p e c i a l committee on a g i n g . Washington: U.S. USGPO,  196-200.  34,  12,  18-19.  B r i t i s h J o u r n a l of  Occupational  1.1 2  APPENDIX  ADL  VISUAL  A  EXPLANATION  Page .11 4 DRESSING SKILLS LOCATION - UPPER LEFT SECTION OF CHART  ABILITY TO PUT ON  ' DOT  DOT  - ABILITY TO TAKE OFF PANTS  DOT  DOT  - ABILITY" TO TAKE OFF DRESS  PANTS  ABILITY TO PUT ON DRESS  .  ABILITY TO PUT ON BRASSIERE (FEMALES ONLY)  1  DOT  DOT , -ABILITY TO TAKE OFF BRASSIERE  j '  ABILITY TO PUT ON  (FEMALES ONLY)  DOT  DOT  - ABILITY TO TAKE OFF UNDERPANTS  ABILITY TO PUT ON"^ DOT  DOT  ABILITY TO TAKE OFF OPEN-FACED  UNDERPA17JB  '  OPEN-FACED  GARMENT  GARMENT ABILITY TO PUT ON SHOES  DOT  DOT  - ABILITY TO TAKE OFF SHOES  Page 115 DRESSING SKILLS (CONT'D)  ABILITY TO PUT ON 'SCCKS/STOCKINGS  ABILITY TO DO UP LACES  ABILITY TO DO UP BUTTONS  DOT CATEGORY SYMBOL - DRESSING DOT REPRESENTS THE ABILITY TO SELECT AND ASSEMBLE CLOTHING  Page  AMBULATORY/TPANSFER SKILLS  6  LOCATION - LOWER LEFT SECTION OF CHART  ABILITY TO USE A WHEELCHAI ^ DPRIATE)  DOT  &  ABILITY TO TRANSFER  ABILITY TO TRANSFER OUT  INTO BED  OF BED •  ABILITY TO TRANSFER  ABILITY TO TRANSFER OUT  INTO CHAIR  OF CHAIR  ABILITY TO TRANSFER  DOT . - ABILITY TO TRANSFER OFF  ONTO TOILET  OF TOILET  DOT CATEGORY SYMBOL - AMBULATICN/TRANSFERS DOT REPRESENTS ABILITY TO WALK WITH OR WITHOUT AIDS  GROOMING SKILLS TDCATION - UPPER RIGHT SECTION OF CHART  Page _1J  DOT :  - ABILITY TO WASH HANDS  DOT :  - ABILITY TO WASH FACE  DOT  :  - ABILITY TO COMB AND DO UP HAIR  DOT  i - ABILITY TO SHAVE (ELECTRIC OR MANUAL - MALES.ONLY)  DOT  DOT  ;  - ABILITY TO BRUSH TEETH OR CLEAN DENTURES  ABILITY TO TAKE SELF TO TOILET WHEN NECESSARY AND CLEANLINESS (NOT PHYSICAL TRANSFER)  CATEGORY SYMBOL - GROOMING DOT REPRESENTS ABILITY TO FIND WAY TO WASHING AREA (NOT USED AS PART OF RESEARCH CRITERIA)  DOT  Page 118  EATING SKILLS  LOCATION - LOWER RIGHT SECTION OF CHART  - ABILITY TO USE A SPOON  DOT  DOT  ;  - ABILITY TO USE A FORK  DOT  - ABILITY TO USE A KNIFE  DOT  - ABILITY TO USE A CUP OR GLASS  CATEGORY SYMBOL - EATING DOT REPRESENTS ABILITY TO FIND WAY TO DINING AREA (NOT USED AS PART OF RESEARCH CRITERIA)  DOT  INDEPENDENT NEEDS SUPERVISION  T  i  m  m  LEGEND LOCATION - UPPER RIGHT CORNER - ALSO INCLUDES PATIENT'S NAME AND  NEEDS TOTAL HELP TARGET FOR REHABILITATION  PROSTHETIC AIDS USED  APPENDIX B A D L TREATMENT MANUAL  Page J 2 0  PUTTING ON DRESS (FRONT BUTTONING) Pg.13 PUTTING OH DRESS (PULLOVER) Pg. 16-17 PUTTING ON TROUSERS  Pg. 8-10  £AXING OFF TROUSERS  Pg. 10  BACK-FASTENING  Pg. 11-12  BRA  UNDERPANTS  Pg. 8-10  PUTTING ON SHIRT  Pg. 13-14  TAKING OFF SHIRT  Pg. 15  PUTTING ON SHOES  Pg. 18  PUTTING ON SOCKS (STOCKINGS)  Pg. 19-20  LACES  Pg. 21  BUTTONS  Pg. 22  Page 121  MOVING FROM WHEELCHAIR TO TOILET Pg.23-24 MOVING FROM TOILET TO WHEELCHAIR Pg.25-2b  MOVING FROM WHEELCHAIR TO BED  Pg.27-2t;  MOVING FROM BED TO WHEELCHAIR  Pg.29-30  MOVING FROM WHEELCHAIR TO CHAIR  Pg. 31  MOVING FROM CHAIR TD WHEELCHAIR  Pg. 32  TRANSFERING FROM WHEELCHAIR TO STANDING  Pg.  TRANSFERING FROM STANDING TO WHEELCHAIR  PR. 35  33-3  0  Page 1 2 2  f° ° \ ( A  )  ^J!iiitiii.ii[iiiiiiiifii;iiiS.iuj1  HANDWASHING  Pg.  43-44  FACEUJA5HING  P g ..  45t*49  HAIR  Pg.  50-51  Pg.  52-56  COMBING  SHAVING  m  TOOTHBRUSHING  *L  Bid 1  TOILETING  USE  OF  SPOON  Pg.  36-40  USE  OF  FORK  Pg.  41  Page  123 1  A Guide to the A c t i v i t i e s of D a i l y L i v i n g  (ADL).  Methods as d e s c r i b e d i n t h i s b o o k l e t are g e n e r a l l y a p p l i c a b l e to the dents of  and always a r e o n l y i n t e n d e d as a guide.  s h o u l d be i n d i v i d u a l l y a s s e s s e d and a p p r o p r i a t e methods used  resi-  A l l persons f o r them.  Poor muscle s t r e n g t h , l i m i t e d j o i n t m o b i l i t y , c o n f u s i o n o r , perhaps,  a combin-  a t i o n of these f a c t o r s w i l l :causei.lack of achievement of independence i n a c t i v i t i e s of d a i l y  living.  A c t i v i t i e s of D a i l y L i v i n g , where i n d i c a t e d , should be s t a r t e d and as soon as p o s s i b l e a f t e r assessment.  The green area of the v i s u a l  d e s i g n a t e s independence i n t h a t a c t i v i t y and as such.  encouraged schematic  should be t r e a t e d by the  staff  The b l u e a r e a of the v i s u a l d i s p l a y i s the t a r g e t f o r r e h a b i l i t a t i o n  by a l l the s t a f f  coming i n t o c o n t a c t w i t h the r e s i d e n t .  Most people w i l l r e g a i n some s t r e n g t h and m o b i l i t y w i t h any a c t i v i t y . important will  of a l l ,  a f t e r achievement of an a c t i v i t y  regain or maintain t h e i r s e l f - r e s p e c t .  to be r e h a b i l i t a t e d ,  With any  such program,  i e s should be simple enough and j u s t enough h e l p should-:be t h a t the person w i l l succeed.  Once the person has succeeded,  him on t h i s and encourage him to c o n t i n u e . someone who daily  g i v e n to  Never c h a s t i z e or  they  activitensure  congratulate criticize  i s p r o g r e s s i n g , or i s i n f a c t r e g r e s s i n g i n the a c t i v i t i e s  living.  Most  of  Page 124 2 Things to Remember  1.  Spoken i n s t r u c t i o n s must be c l e a r and simple. w h i l e speaking.  I t may be n e c e s s a r y  S t a f f should demonstrate  t o r e p e a t over and over a g a i n ,  always a l l o w i n g time f o r the r e s i d e n t t o respond.  Make sure you have t h e  r e s i d e n t s a t t e n t i o n and t h a t they understand you. v  2.  Work s l o w l y .  T r y and t r y a g a i n .  Accomplishment of each p a r t o f the  a c t i v i t y i s an achievement.  3.  Work w i t h the person a t the a p p r o p r i a t e time and i n the a p p r o p r i a t e p l a c e , i . e . , d r e s s i n g i n person's  bedroom.  4.  Devices and a i d s should be used o n l y when n e c e s s a r y .  5.  When s t a n d i n g and/or s i t t i n g b a l a n c e i s poor some a c t i v i t i e s can be performed  when l y i n g .  Page 125  Techniques f o r R e h a b i l i t a t i o n  Shaping Shaping by s u c c e s s i v e a p p r o x i m a t i o n s behaviour  or a c t i v i t y .  i s o f t e n u s e f u l i n t e a c h i n g a complex  I n the procedure the d e s i r e d a c t i v i t y i s broken  down i n t o a s e r i e s o f s m a l l e r s t e p s w h i c h a r e n e c e s s a r y  f o r mastery o f t h e  f i n a l response o r a c t i v i t y . Each s m a l l e r response i s p r a i s e d by s t a f f i t i s under t h e c l i e n t ' s c o n t r o l .  until  G r a d u a l l y , more and more a c c u r a t e approx-  i m a t i o n s o f t h e f i n a l response a r e r e q u i r e d b e f o r e p r a i s e i s d e l i v e r e d , u n t i l g r a d u a l l y , t h e e n t i r e response i s l e a r n e d .  Thus, t h e r e s i d e n t s h o u l d be  taught a complex a c t i v i t y i n s u c c e s s i v e s t e p s — l e a d i n g t o an a p p r o x i m a t i o n  of the d e s i r e d target  w i t h each s t e p g r a d u a l l y behaviour.  For example, i n t e a c h i n g a r e s i d e n t t o use a f o r k p r o p e r l y , p r a i s e may i n i t i a l l y be g i v e n f o r s i m p l y h o l d i n g t h e f o r k i n t h e r i g h t hand.  Later,  p r a i s e i s g i v e n o n l y when t h e r e s i d e n t b r i n g s t h e f o r k t o h i s mouth, then i n s e r t i n g t h e f o r k i n t o h i s mouth, then u s i n g t h e f o r k t o p i c k up food and put i t i n h i s mouth, and so on.  The i d e a i s : Don't w a i t f o r a p e r f e c t  execution before dispensing p r a i s e . successive approximation in  D u r i n g t r a i n i n g , p r a i s e each s m a l l  of the d e s i r e d behaviour  —  that behaviour  marked  blue.  As you can see t h e s t e p s a r e l i s t e d i n o r d e r from t h e l a s t s t e p i n t h e procedure, which the r e s i d e n t performs f i r s t , to the f i r s t step, which the r e s i d e n t performs l a s t . behaviours  The r e a s o n f o r t h i s i s t h a t i n d e v e l o p i n g most new  we s t a r t w i t h t e a c h i n g t h e l a s t s t e p and then work backward  Page 126 4 through the s t e p - w i s e p r o g r e s s i o n . dent to have maximum o p p o r t u n i t y  We do t h i s because we sant  the r e s i -  t o p r a c t i c e those steps which always l e a d  to completion o f the a c t i v i t y .  There a r e f i v e v e r y  1.  important p o i n t s  t o remember i n d e v e l o p i n g  a new b e h a v i o u r .  Reward the r e s i d e n t w i t h your p r a i s e each time he s u c c e s s f u l l y completes a step.  We want to maximize the r e s i d e n t ' s o p p o r t u n i t y  r e c e i v i n g of p r a i s e and minimize h i s f a i l u r e s .  f o r success and the  We want t h e r e s i d e n t t o l e a r n  i n a.;positive way and, thereby, h e l p him him b u i l d up h i s s e l f - c o n f i d e n c e .  Be  c a r e f u l , however, not to p r a i s e the r e s i d e n t f o r f i n i s h i n g the same step over and over. progress  2.  The r e s i d e n t must a l s o l e a r n t h a t he has t o c o n t i n u e t o make  even i f i t i s slow —  The most b a s i c aspect  o f the r e h a b i l i t a t i o n a c t i v i t y should  Refinements i n the a c t i v i t y should is  3.  i f he i s to r e c e i v e p r a i s e .  be taught  first.  be taught o n l y a f t e r the b a s i c behaviour  learned.  I f t h e r e s i d e n t has d i f f i c u l t y m a s t e r i n g a p a r t i c u l a r s t e p , b r e a k up t h e step ess.  into smaller  components so t h a t the r e s i d e n t can s t i l l  experience suc-  L e t us suppose t h a t a r e s i d e n t i s to be r e h a b i l i t a t e d f o r ' p u t t i n g  on p a n t s ' and t h a t he cannot p u l l up h i s pants from j u s t below h i s  waist.  What c o u l d we do to make the l e a r n i n g e x p e r i e n c e a p o s i t i v e one f o r him? We c o u l d break up t h e step  into smaller  components.  F o r example, we c o u l d  p l a c e our hands over the r e s i d e n t ' s hands and h e l p him p u l l up h i s p a n t s . In t h i s way, he p a r t i c i p a t e s i n the l e a r n i n g p r o c e s s and h i s behaviour a l s o  Page 127 5 l e a d s t o success and p r a i s e .  We c o u l d then repeat t h i s step u n t i l the r e s i -  dent l e a r n s what to do, and then g r a d u a l l y withdraw our a s s i s t a n c e — sure t h e r e s i d e n t s t i l l  Tell  experiences  making  success.  the r e s i d e n t what you want him t o do b e f o r e he a c t u a l l y performs the  behaviour.  You e v e n t u a l l y want t h e r e s i d e n t t o l e a r n to perform  a c t i v i t y w i t h o u t always h a v i n g to p r a i s e him f o r doing i t . t h i s , i t i s necessary tions.  f o r the r e s i d e n t to l e a r n t o respond  the complete  To accomplish to your  The e a s i e s t way f o r him to l e a r n t h i s i s t o p a i r your  instruc-  instructions  w i t h h i s performance o f t h e v a r i o u s s t e p s .  The performance o f s t e p s by the r e s i d e n t should always be f o l l o w e d w i t h praise.  The number o f s t e p s i n an a c t i v i t y i s l a r g e l y determined  by the r e s i d e n t ' s  own c a p a b i l i t i e s and the s t a f f ' s s u b j e c t i v e e v a l u a t i o n o f how many s t e p s t h e r e s h o u l d be i n the program. behaviour  The g e n e r a l r u l e i s t o l e t the r e s i d e n t ' s  guide you i n d e t e r m i n i n g how many s t e p s t h e r e s h o u l d be and when  a d d i t i o n a l s t e p s s h o u l d be added. I n t h i s manual you w i l l n o t i c e t h a t most of the a c t i v i t i e s o f d a i l y l i v i n g a r e broken down i n t o a s e r i e s of s m a l l e r s t e p s which a r e n e c e s s a r y components o f the t o t a l a c t i v i t y . determine  a t which step the r e s i d e n t i s a t i n the s e r i e s  a r e a b l e to complete i n d e p e n d e n t l y )  Staff  should  (which s t e p s  they  and then c o n t i n u e t o work on the remaining  s t e p s , one a t a time, u n t i l the f i n a l response  i s achieved.  These steps may  be broken down f u r t h e r i n o r d e r f o r the r e s i d e n t to a c h i e v e some success a t every stage a l o n g the way t o independence.  Page  128 6  Modeling One  of the most e f f e c t i v e procedures f o r t e a c h i n g a new  resident involves f i r s t  demonstrating  b e h a v i o u r to a  the b e h a v i o u r y o u r s e l f and then p r a i s i n g  the r e s i d e n t f o r s u c c e s s f u l l y t r y i n g to i m i t a t e what you d i d .  Modeling  reduces the amount o f time a r e s i d e n t needs to l e a r n a p a r t i c u l a r Modeling may  be employed to teach new  behaviour.  b e h a v i o u r s by p r o v i d i n g the o p p o r t u n i t y  f o r the r e s i d e n t to observe the b e h a v i o u r without t a k i n g an immediate himself.  T h e r e f o r e , a t each step i n the s e r i e s l e a d i n g to the f i n a l  show them how  you would do i t .  risk behaviour  Demonstrate each step i n the b e h a v i o u r or  a c t i v i t y s l o w l y and p r e c i s e l y and make s u r e they are p a y i n g a t t e n t i o n . to them as you demonstrate.  often  Make sure the r e s i d e n t i s watching  Explain  and can see  what you a r e d o i n g .  Rehearsal R e h e a r s a l a l l o w s the r e s i d e n t to ' t r y out' new  responses i n s i m u l a t e d s i t u -  a t i o n s w i t h o u t r i s k i n g f a i l u r e ; i t p r o v i d e s the o p p o r t u n i t y f o r s e l f - c o r r e c t i o n and feedback  from o t h e r s ; i t p e r m i t s the a n t i c i p a t i o n of d i f f i c u l t  problems  and the r e h e a r s a l of ways of h a n d l i n g them.  Rehearse the s t e p of b e h a v i o u r you a r e c o n c e n t r a t i n g on w i t h the r e s i d e n t . Have him r e p e a t the b e h a v i o u r to do i t .  ( w i t h a s s i s t a n c e . i f r e q u i r e d ) u n t i l he  learns  P r a c t i c e makes p e r f e c t !  Praise P r a i s e i s what may  be c a l l e d s o c i a l r e i n f o r c e m e n t .  People enjoy b e i n g p r a i s e d  or r e i n f o r c e d and i t has been found t o i n c r e a s e the o c c u r r e n c e o f those  Page 129 7 responses i t i s d i r e c t e d towards.  Thus, when one p r a i s e s a p e r s o n f o r doing  'a good j o b ' , a c h i l d f o r f i n i s h i n g h i s d i n n e r ,  o r a r e s i d e n t showing  inde-  pendent b e h a v i o u r , i t has been found t h a t a person does 'a good j o b ' , a c h i l d does f i n i s h h i s d i n n e r , future  and a r e s i d e n t does show independent b e h a v i o u r on  occasions.  P r a i s e can be a p o w e r f u l t o o l i n i n c r e a s i n g the o c c u r r a n c e of a b e h a v i o u r , especially  one t h a t i s b e i n g  taught o r r e l e a r n e d .  Therefore,  approximates the d e s i r e d b e h a v i o u r that you a r e t e a c h i n g , p r a i s e d f o r doing so. I f he does not p r o g r e s s , as t h i s w i l l have a d e t r i m e n t a l  as the r e s i d e n t  he should  say n o t h i n g .  be  Do not c r i t i c i z e  effect.  Examples o f p r a i s e a r e the f o l l o w i n g : "Good";  "I'm g l a d you d i d t h a t " ;  "Very Good";  "I appreciate  "I L i k e  "That's  that";  what you have done";  right";  "That's good";  "Fine"  "You d i d a good j o b " ;  "I'm so p l e a s e d  "You d i d i t . Very good"; "Thank you", "Thank you v e r y  much".  w i t h you", "I'm proud o f you"  Page 130 8 Dressing Trousers/Underpants (when s i t t i n g )  Place strong foot in left pants leg and pull pants up as far as possible. • J[ patient cannot stand without support, lie down and proceed as illustrated in steps 3 and 4.  PUTTING ON TROUSERS  • If patient can stand without support, proceed to step 2a.  •  3. L i e down; bend strong knee and hip pushing strong foot against bed to raise hips. Pull pants up over hips.  Silting on side of bed, with strong hand cross weak leg, pull right pants leg over weak loot.  --fl  4. Fasten front of pants. If sLimliii" balance against bed with-  Note: If patient cannot cross legs, he car. rest his weak fool on a small stool to assist in this activity.  out Mipporl of strong hand is possible, Maud leaning against bed for support  anil pull up p:i"<s  1.  w i U l  s l r o n  S  h  a  n  J  P l a c e one l e g o v e r  '  the knee o f the o t h e r l e g .  w i t h the 'strong hand grasp the weaker l e g o v e r  .2.  3.  (If this i s difficult -  the a n k l e o r j u s t behind  the knee .-ind l i f t  the knee o f the s t r o n g l e g . )  S l i p t h e t r o u s e r l e g ( u n d e r p a n t s ) over  the f o o t t h a t i s e l e v a t e d .  I n s e r t t h e o t h e r f o o t I n t o the t r o u s e r / u n d e r w u a r (Use Step 1 i f n e c e s s a r y ) .  Page 131 9 4. Work the trousers/underwear  up t o the knees.  5. Work the trousers/underwear  up to the h i p s .  6. Stand i f p o s s i b l e .  7. P u l l up t r o u s e r s t o w a i s t .  8. Tuck i n s h i r t .  9. C l o s e the z i p p e r and w a i s t b u t t o n . I f b a l a n c e does n o t permit s t a n d i n g , s i t and p l a c e one hand a t the lower end o f the f l y to s t a b a l i z e the zipper before closing.  Techniques 1. Shaping  - Remember to s t a r t w i t h step 9 and work backwards, making s u r e t h a t t h e r e s i d e n t a c h i e v e s success a t each s t e p . I f success cannot be a c h i e v e d a t a p a r t i c u l a r s t e p , break t h a t step down i n t o s m a l l e r s t e p s thus i n c r e a s i n g the chances f o r s u c c e s s .  2. I n s t r u c t i o n s . - Remember t o i n s t r u c t accomplished  the r e s i d e n t a t every s t e p . T h i s i s  with verbal i n s t r u c t i o n s .  3. Modeling - Demonstrate to the r e s i d e n t the step you want him t o accomplish.  4. R e h e a r s a l - A l l o w t h e r e s i d e n t t o p r a c t i c e the step over and over w i t h o u t  Page  132 10  criticism  3.  u n t i l in- ;;ut.s i t r i g h t .  l ' r a i s c - Kcincinbcr t o p r a i s e completes  the r e s i d e n t  a s t e p and to say to him, "(Name), p u l l  R i g h t b e f o r e he b e g i n s t o p u l l prompt him  NOTIi:  eacli time he s u c c e s s f u l l y  h i s p a n t s up.  pants".  You may have to  t h e r e s i d e n t a few times a t v a r i o u s p o i n t s  completely learn a p a r t i c u l a r  up your  to h e l p  step.  To u n d r e s s , r e v e r s e the p r o c e d u r e .  TAKING OFF TROUSERS  2. Sit on side of bed. Push left • pants leg olf strong leg.  3. Cross weak leg and pull pants off weak leg.  If standing balance is good enough, stand leaning against Ix-d with strong leg and pull trousers down.  la.  If standing balance.is poor, lie down in bed. Unfasten trousers. Bend strong knee and hip pushing strong fool against bed to raise hips. Tush panis down below hips..  Note: Foot stool may be useful in this activity.  Page  133  11  9  Hl'.'lHSlUL'U  PUTTING OH A BACK-FASTENING BRA 2.  T u r n bra around into proper position. Willi strong hand place weak hand inside right strap and pull strap up weak  arm.  cc bra around waist with k in from. Fasten hooks.  3.  Insert strong  hand  strap up strong arm  4. Tush right strap up arm to shoulder. Adjust bra. Tighten, straps if necessary.  C  1.  Pick up brassier and bring one end behind bnck (upright).  2.  Hook the brassier i n front a t waist.  3.  Slide i t around to the back.  4.  Put one a n  (weaker one) through the shoulder strap.  in left  strap; pull  l o shoulder.  Page  134 12  5.  Put the o t h e r arm  ( s t r o n g e r one)  6.  P l a c e both s t r a p s i n proper  through the s t r a p .  position.  Techniques 1.  Shaping - s t a r t w i t h step 6 and work backwards.  2.  Instructions  3.  Rehearsal  4. ! P r a i s e  NOTE:  To u n d r e s s , r e v e r s e the procedure.  Page 135 13 Front F u l l y Opening S h i r t s , S W C J . I ,  Dresses,  PUTTING ON A SHIRT (OR DRESS) V e  .\ \  and J a c k e t s  2. Using strong hand place weak hand in rigln armhole and pull sleeve up weak arm.  I. Spread shirt on lap inside up and collar away from body. 3.. T h r o w ; the rest of the garment behind body and pull right sleeve all Ihc way up  Piessing while silting cm kiilc (if bed is 6,^.•le: easier than in whcckliair if balance is good. IF H A I . A N O - IS POOR. IIAVF. PATIP.NT SIT IN \Vlli:i I.CIIAIK O K H H A V Y A R M C H A I R TOI>KI:SS. A n •ipcn-down-ihc-front dress, sweater or coal is put nn live same way as a shirt hut it is necessary lo slam! tip and straighten the skirt before it can he fastened.  4. Rciich behind with strong hand, and place it in left armhole. Work sleeve into position.  l_argc buttons arc easier lo fasten than snaps.  I.  Hold c o l l a r on neck where l a b e l i s located.  .*.  Allow li> straighten by shaking.  3.  T l a c c t h e ».tncnt on the l a p with the c o l l a r towards the waist and  A.  f u t ane fcand i n s i d e aleove and work i t over the oibow.  trout down.  Page 136 14 5.  Work the garment over t h e s h o u l d e r .  6.  Leaning forward, grasp the edge o f t h e n e c k l i n e and b r i n g the r e s t o f the garment behind the body.  7.  Put the o t h e r arm i n t o i t s arm h o l e and work t h e s l e e v e on.  8.  B u t t o n s t a r t i n g w i t h bottom b u t t o n .  Techniques 1. Shaping - b e g i n w i t h step 7 and work backwards. 2. I n s t r u c t i o n s 3. Modeling 4. R e h e a r s a l 5. P r a i s e  0  Page 137 15  l i u T u  undress,  reverse  Llie  procedure.  TAKING OFF A SHIRT (OR DRESS)  2. Grasp middle or left front edge of shirt and pull it out to the side pulling slii: I o!F strong shoulder.  Using strong hand push shirt oil weak shoulder.  • A.  Using strong hand grasp right cud and pull right sleeve off weak arm.  -Techniques 1.  Shaping  2.  Instructions  3.  Modeling  4.  Rehearsal  5.  Praise  3.  Work strong arm out of left sleeve. (It may be helpful lo tuck tail of shirt under hip when removing strong arm from sleeve.)  Page 138 16 P u l l - Over Garment (Dress, Sweaters, e t c . )  1.  P l a c e garment on t h e l a p w i t h t h e f r o h t ;'f a c i n g downcand t h e .bottom' towards, you  waist.  2.  Gather the garment up the back.  3.  P l a c e one arm i n t h e s l e e v e and push the s l e e v e up p a s t the esbow.  4.  Put remaining  arm i n t o i t ' s s l e e v e  5. Gather the garment up the back —  6.  l e a n forward  and p u l l garment over head.  P u l l garment down the body w i t h hands.  Techniques 1.  Shaping - Remember t o s t a r t w i t h Step 6 and work backwards, making sure t h a t the r e s i d e n t a c h i e v e s success a t each s t e p .  I f success  cannot  be a c h i e v e d a t any o f the 6 s t e p s , break down the s t e p i n q u e s t i o n i n t o s m a l l e r steps so t h a t success may then be a c h i e v e d .  2.  I n s t r u c t i o n s - Remember to i n s t r u c t accomplished  3.  Modeling  the r e s i d e n t a t each s t e p .  This i s  with verbal i n s t r u c t i o n s .  - Demonstrate t o t h e r e s i d e n t t h e step you want him t o a c c o m p l i s h .  Page 139 17 R e h e a r s a l - A l l o w the r e s i d e n t t o p r a c t i c e the step over and over w i t h o u t c r i t i c i s m u n t i l he g e t s i t r i g h t .  Encourage him t o p r a c t i c e .  P r a i s e - Remember t o p r a i s e the r e s i d e n t each time he s u c c e s s f u l l y a step.  NOTE:  To undress r e v e r s e the procedure.  completes  Page 140 18  I'M l l i nn n n  Shoes  I'liniNG Oil SHOES  2.  If shoe cannot he completely slipped on foot, place ii shoe horn al the heel and push up on the heel of the shoe lo lit the fool into the shoe.  • le: Sew tongue to lop ' •'' ''' picecnl it from doubling under. When ice is aliachcd to shoe, he sure that leg is front of hraec when placing fool in shoe. s  , 1 , c  0 1 1 0  s  c  i f f V i r o n i : hniul. cross the weak leg so ijWeak loo! is within easy reach. Slip uic on the foul as far as possible.  I*lace the other shoe on the floor. Slip the strong foot into the shoe. Use a shoe • horn lo prevent rolling in of the leather.  Techniques I.  Shaping,  .'.  Instructions  t. t>. .  fkidi.-i i n , ; Jtohcarsal . l'rnise. . KUTK;  To u n d r e s s r e v e r s e t h e p r o c e d u r e .  3.  If the foot does not go into the shoe easily, place the foot on the floor and push down on the knee being careful lo keep the shoe horn in place.  Note: tivity.  Footstool may be useful in this ac-  Page 141 19 S l o c k in;;s  (socks)  PUTTING ON SOCKS 1-2.  Using the strong liaml, cross weak leg so that foot is free anil in easy ic.acli of strong hand. Using strong hand hold sock at front or the opening and pull over weak foot. Place weak foot on lloor.  3.  I  1 \KI  SOCKS  Cross strong leg so that fool is free and in ease reach of strong hai"l. Using sluing hand pull oliier sock ovei sluing foot in same manner.  ori . ;  •.hour hand, i I O S S weak leg as shown in 2 and i c n i i n c sock. Tiovs s.i• • •• i;; leg. as shown in 3 and remove other siick. Willi  1.  C r o s s one leg, o v e r  Note: II" P A T H - N T ' S U A I . A N C I l IS N O T C.OOI). I I A V I ; IIIM S i r IN Will-1.11.C I I A I I i O K A R M C H A I R . I'ootslool may be useful.  the  other  (If  p r o b l e m , p l a c e weaker l e g o v e r  the  strong  one). 2.  Open t h e  3.  Uitlier  4.  Work t h e  top o f  the  s t o c k i n g by i n s e r t i n g a h a n d  i n s t o c k i n g s up Co t h e  s t o c k i n g onto  the  (strong  hand)  into  the  cuff.  heel.  foot  ensuring  that  t h e r e a r c no w r i n k l e s  left.  Page 142 20 5.  P l a c e the f o o t on the f l o o r .  6.  P u l l the s t o c k i n g s up.  7.  F a s t e n the g a r t e r .  NOTE:  Round g a r t e r s s h o u l d never be used as they may  Techniques 1.  Shaping - s t a r t w i t h Step 7 and work backwards.  2.  I n s t r u c t i o n s - show them the manual i f n e c e s s a r y .  3.  Modeling  4.  Rehearsal  5.  Praise  Impair  circulation.  I ' u L L i i i j ; <>n l a c e s  TYING A SHOE ONE-HANDED  Free end  ying a shoe one-handed: a. Knot one e«wl of (lie shoe- string and lace the shoe leaving the knotted end at the Inwvsl eyelet. Iv In the lop eyelet feed the end of the shoe siiing from outside lo inside and throw the end over the top of the laces. c. Make a loop in the free end of the shoe lace and pull i i loop within a loop as shown in-2. d. Pull the laec light (King careful not to pull the free end all the way through. e. T o untie, pull the free end. Note: lilaslic shoelaces arc available but arc not preferred if patient can lie laces. The above type of shoes arc preferable to loafers.  Technic, ucs 1.  Shaping,  2.  instructions  3.  Modeling,  ti.  Rehearsal  5.  1'raise  Buttons  B r i n g f i n g e r s of dominant hand to bottom b u t t o n .  M a n i p u l a t e b u t t o n back and f o r t h .  P l a c e o t h e r hand a t a p p r o p r i a t e b u t t o n h o l e .  B r i n g b u t t o n h o l e c l o s e to b u t t o n .  S l i p button i n s i d e button hole.  Repeat procedure w i t h next b u t t o n p r o c e e d i n g  Techniques Shaping - b e g i n w i t h Step 5 Instructions Modeling Rehearsal Praise  upwards  23  lovjn;; from Wlieclcliiii' Lo  Page 145  Toilet  MOVING FROM WHEELCHAIR TO TOILET N n i c . If a liar is needed on the other side of I he commode and there is no wall lo attach il to. consider usin^ a i ighl angle bar as illustrated on the next page.  'osition wheelchair facing the loilct. Irakcs on. font rests up.  c: Wall liar can he used for support, paliinl can he taught lo unfasten his • ^ j k ' v f o i c getting out of I lie whcclihev fall when he si.mils, cinalc palienl can si a ml in front of miotic instead of silting down imlialelv aiul either lean against the wall nisii her strong leg against (lie comic for suppoii lo free her strong hand allelic her clothing.  3.  far side of toilet seal if no wall bar is present).  4. Lean forward, turn on strong fool and slowly sit down on toilet seal.  1.  P o s i t i o n w h e e l c h a i r f a c i n g the  2.  Place brakes on,  3.  Stand up.  foot  rests  5.  Lean . f o r w a r d ,  toilet.  up.  rj.-tct!'»trong hand on w a l l bar w a l l bar i s  Place, strong hand on wall liar (or on  (or on f a r s i d e o f  present). t u r n on s t r o n g  foot.  toilet  scat i f  no  Page 146 24 6.  Slowly s i t down on t o i l e t s e a t .  Techniques  1.  Shaping - Remember t o s t a r t w i t h Step 6 and work backwards, making sure t h a t t h e r e s i d e n t a c h i e v e s success a t each s t e p .  2.  I n s t r u c t i o n s - Remember t o i n s t r u c t  the r e s i d e n t a t every s t e p .  This  i s accomplished w i t h v e r b a l i n s t r u c t i o n s .  3.  Modeling - Demonstrate t o the r e s i d e n t t h e step you want him to accomplish.  4.  R e h e a r s a l - A l l o w the r e s i d e n t t o p r a c t i c e the step over and over c r i t i c i s m u n t i l he gets i t r i g h t .  5.  P r a i s e - Remember t o p r a i s e the r e s i d e n t each time he s u c c e s s f u l l y completes  a step.  without  Page 147 Movini; Croin Toilet  75 25  to Wheelchair  MOVING PROM TOILET TO WHEELCHAIR 1. Position wheelchair facing toilet. Brakes locked, footicsts up.  Place strong hand on wall bar (or o r right armrest of wheelchair if no wall bai is present). Stand up as in Number (•.  r : While the patient is sitting on the toilet ran pull his tiousers up above his knees. A s T^K he can spread his knees so that the wi!' ••"! fall. Then l e can lean against wall or push the strong leg back against the it for support and use the strong hand lo pull trouseis up ihe rest of the way. Also the its can be buttoned to the shirt and they will ie up when he stands. Suspenders if used u 111 be placed over the shoulders before iding.  Place strong hand on left armrest of whcelch.iii turn on strong fool ami slowly sit down in wheelchair.  1.  P o s i t i o n wheelchair f a c i n g t o i l e t .  2.  P l a c e s t r o n g hand on w a l l b a r ( o r on a r m r e s t o f w h e e l c h a i r i f no w a l l bar i s present)..  3.  Stand.  Brakes l o c k e d , f o o t r e s t s u p .  Page 148 26 4.  P l a c e s t r o n g hand on l e f t armrest o f w h e e l c h a i r , t u r n on r i g h t  5.  S l o w l y s i t sown i n w h e e l c h a i r .  Techniques 1.  Shaping - s t a r t w i t h Step 6 and work backwards.  2. / I n s t r u c t i o n s 3.  Modeling  4.  Rehearsal  5.  Praise  foot.  Page 149 27  a  Moving  [ruin  Wheelchair  WHEELCHAIR TO BED  MOVING FROM I.  ! ^/s V\  to ttod  l-'ace wheelchair toward head of bed. Keep fionl corner of chair (on palienl'rslrong side) as close lo bed as possible as wheelchair is shown in No. 2. I'osilion Hie wheelchair so ihe patient sils near the center of the bed, closer to the fool for a tall person. Lock brakes, lift foot rests. 2.  Hi  Assume standing position from wheelchair (as in Number d ) .  c •l.  I l.'i'.rl  loiward.  linn  on strong foot and slowly  3.  l o M t l i l l g position.  J.  P o s i t i o n c h a i r from m i d d l e to the  bod.  Move t o w a r d s  P e d a l s up 11 l e a k s on  2.  Sit with  feet  the  foot  front  of  Move strong hand 10 edge of bed for support.  o f bed w i t h s t r o n g the  DI.  side nearest  to  chair.  I  tt  w e l l underneath  and s t r o n g  hand on the arm o f  the  chair.  Page  150 28  3.  Stand up by l e a n i n g forward and pushing w i t h the s t r o n g hand and l e g . Balance.  4.  Put the s t r o n g hand on the bed.  Turn so t h a t backs of l e g s are a g a i n s t  the bed.  5.  Sit.  6.  Put the s t r o n g l e g under weaker l e g .  In one motion  swing l e g s on to bed  l i e back on the p i l l o w .  7.  Grasp the top o f the bed w i t h the s t r o n g hand and bend the knee. P o s i t i o n y o u r s e l f i n bed.  Techniques 1. 2. 3.  Shaping-- Remember to s t a r t w i t h Step 7 and work backwards. "Ihstfuctlohs Modeling  4. . R e h e a r s a l 5. T P r a i s e  and  Page 15J halving from Bed l o W h e e l c h a i r  0  MOVING  2 9  •  INTO A WHEELCHAIR FROM THE BED  lace whcclchaiV al slight angle In bed. on patient's !rong side, facing fool of bed. Keep the right front ninor of the chair as close lo the hcil as possible s shown below.* Ilrakcs locked. I oolrcsls up.  Keep feel beneath body. Iran forward placing strong hand near edge of bed and push lo standing position keeping weight well over strong fool.  v  In vjrn.il i 1  '  . V-dt-'t  V/HfcElCHAIR  ir Note-. A n armchair can he used by the bed instead of a wheelchair, A chair that is heavy enough not lo slide and with a linn scat thai is not too soft or too low will IK suitable.  1.  C h a i r i s p o s i t i o n e d from M i d d l e to  When standing position is steady enough for momentary release of support by strong hand, move strong hand lo farther arm rest of wheelchair. Keeping body weight well forward, l i n n <*n slo-iig foot and lower to silting position.  head o f bed a t a s l i g h t  angle.  Brakes o i l .  2.  R e s i d e n t p u t s s t r o n g f o o t under weaker a n k l e and aoves towards  the  edge o f Che bed.  3.  R e s i d e n t g r a s p s edge o f M a t t r e s s , s l i d e s l e g s o v e r s i d e o f bed a t  the  Page 152 30 _•. .same time r o l l i n g on to t h e s t r o n g  4.  Push t o an u p r i g h t p o s i t i o n . on the f l o o r and a p a r t .  s i d e and s i t t i n g up.  Balance on s i d e o f bed w i t h f e e t f i r m l y  P o s i t i o n f e e t so t h a t t i p s o f toes a r e i n  l i n e w i t h f r o n t o f knees.  5.  Put hand on edge o f bed and stand up.  6.  Place  s t r o n g hand on the n e a r e s t  s t r o n g hand t o o t h e r  7.  arm o f the c h a i r , b a l a n c e ,  arm o f c h a i r .  Turn so t h a t back o f l e g s a r e a g a i n s t  the c h a i r .  8. S i t .  Techniques 1.  Shaping - Remember t o s t a r t w i t h Step 8 and work backwards.  2.  Instructions  3.  Modeling  4.  Rehearsal  5. ' P r a i s e  /  change  Page 153 31  Mn vj HI; I! rum Winn L c l i a i r Lo Armchuji  MOVING FROM  1.  WHEELCHAIR TO  ARMCHAIR  Place llie front corner of the wheelchair (on the patient's strong side) as close lo the armchair as possible, shown in illustrations 1 and 2 above. Brakes on, foolrcsts up.  3.  Place strong hand on farther arm of armchair.  Page 154 32 Moving  I row A r m c h a i r Lo Wheclcha:i  o  MOVING  0  FROM ARMCHAIR TO  WHEELCHAIR  Page 155 33 T r a n s f e r r i n g from Wheelchair  to Standing  1.  Apply both brakes, " s e c u r e l y .  2.  Lift  3.  S l i d e the weaker f o o t on to t h e f l o o r u s i n g s t r o n g f o o t o r hand and lift  4.  the p e d a l on the s t r o n g s i d e w i t h the s t r o n g f o o t .  the p e d a l .  Move towards the f r o n t of t h e c h a i r . until  B r i n g the f e e t under t h e knees  the t i p s o f t h e toes a r e i n l i n e w i t h the knees.  both f e e t a r e f l a t  Ensure  that  on the f l o o r and s l i g h t l y a p a r t .  5.  P l a c e both hands on c h a i r arms and l e a n forward.  6.  Stand by pushing w i t h s t r o n g l e g and arms s i m u l t a n e o u s l y and u s i n g o t h e r arm and l e g when p o s s i b l e .  7.  Balance.  Grasp s a l k i n g a i d .  Techniques 1. 2.  Shaping Instructions  3.  Modeling  4.  Rehearsal  5.  Praise  Balance.  Walk.  Page J 5 6  34  FROM WHEELCHAIR TO STANDING  . 0*. brakes ami lift footrcsls. Place (eel inW^ oil 'lit Unor close to chair, with liecl of ihe strong loot slightly back and directly beneath the edge of scat.  e: If patient is tall, be probably cannot stand t while holding armrest, l i e will have belter, nice leaning lo the strong side and slightly vard.  2. Move forward in the wheelchair. Place Strong hand on front part of armrest. Lean forward over strong leg and push to standing position with stroiie arm and leg.  Stand as straight as possible; hold left arm rest for balance and support. Keep feel slightly separated for belter balance.  Page  157 35  T r a n s f e r r i n g from Standing to Wheelchair  1.  Approach f a c i n g the w h e e l c h a i r .  2.  Ensure  3.  P o s i t i o n walking a i d .  4.  P l a c e the s t r o n g hand d i a g o n a l l y a c r o s s on the arm  5.  Turn u n t i l  6.  S i t down s l o w l y .  7.  Push w i t h s t r o n g arm  t h a t brakes a r e s e c u r e and p e d a l s a r e  up.  of the c h a i r .  the backs o f the knees touch the c h a i r .  Techniques 1.  Shaping  2.  Instructions  3.  Modeling  4.  Rehearsal  5.  Praise  and l e g u n t i l  comfortable p o s i t i o n i n c h a i r .  Page  158 36  Program f o r Independent E a t i n g .  T r y to use  Put  of Spoon.  o n l y foods t h a t the r e s i d e n t l i k e s .  p r a i s e the r e s i d e n t f o r h i s  1.  Use  Throughout the program,  progress.  the r e s i d e n t ' s hand around the handle p o r t i o n of the spoon  and  g e n t l y wrap you hand over h i s .  2.  A s s i s t the r e s i d e n t i n scooping the food and mouth.  3.  Scoop food  i n a motion toward the  A f t e r the r e s i d e n t r e c e i v e s and  d i r e c t h i s hand (and  4.  Repeat Steps 2 and'3.  5.  While r e p e a t i n g on  the food,  Steps 2 and  food,  to h i s  resident.  c o n t i n u e to h o l d h i s hand g e n t l y  the spoon) back to the  food.  3, g r a d u a l l y b e g i n to l o o s e n your g r i p  the r e s i d e n t ' s hand j u s t b e f o r e  Maintain  b r i n g i n g the food  he p u t s the food  i n h i s mouth.  t h i s l o o s e g r i p u n t i l a f t e r the r e s i d e n t has  received  then r e t u r n h i s hand (spoon) to the food w i t h the  the  original  amount of guidance.  6.  Repeating .Steps\2 and' 3, g r a d u a l l y M o o s e n / y o u g r i p on the hand j u s t a f t e r he puts the food on h i s spoon. hand, j u s t l o o s e n you  grip.  r e s i d e n t has  the food,  received  Maintain  resident's  Don't l e t go of h i s  the l o o s e g r i p u n t i l a f t e r the  then r e d i r e c t h i s hand and  to the food w i t h the o r i g i n a l amount of guidance.  the  spoon  i.  Page 159 37 7.  Repeat Step '.6, except l o o s e n your g r i p even more when you r e t u r n h i s hand t o the p l a t e .  8.  Don't l e t go o f h i s hand.  Repeat Step 7 except a l s o l o o s e n your g r i p even more j u s t b e f o r e he p l a c e s t h e spoon i n h i s mouth.  9.  Repeat Step 8. except t h i s time l e t go o f h i s hand c o m p l e t e l y j u s t ; c ': as t h e spoon e n t e r s h i s mouth.  Retake h i s hand witfr.yburvloose g r i p  immediately a f t e r he r e c e i v e s the food i n h i s mouth.  10.  Repeat Step 9, except now p l a c e you hand j u s t under h i s w r i s t immediately b e f o r e he p l a c e s the spoon i n h i s mouth.  I..-:.,  11.  Retake h i s  hand w i t h t h e l o o s e g r i p and b r i n g i t back t o the p l a t e .  Repeat Step 10, except move your hand under the r e s i d e n t ' s w r i s t about halfway between t h e 'scoop' and h i s mouth.  12.  Repeat Step 11, except move your hand under h i s forearm about one q u a r t e r o f the way.  13.  Repeat Step 12-with your hand under h i s forearm about one q u a r t e r o f the way.  14. Repeat Step 13, except move your hand under t h e r e s i d e n t ' s w r i s t  after  the food e n t e r s h i s mouth and then g u i d e h i s hand back t o the p l a t e .  Page  160 38  15.  Repeat  Step 14 except p l a c e your hand under h i s forearm a f t e r  food e n t e r s the mouth.  the  At t h i s p o i n t , t h e r e s h o u l d be f i r m p r e s s u r e  on the r e s i d e n t ' s hand o n l y when s c o o p i n g the food.  There s h o u l d  o n l y be g e n t l e forearm p r e s s u r e f o r a l l o t h e r movements.  16.  Repeat  Step 15 except move your hand t o the r e s i d e n t ' s w r i s t w h i l e  he i s s c o o p i n g f o o d .  ( You may  have to g e n t l y guide him at f i r s t  by  g r a s p i n g h i s hand. )  17.  Repeat  Step 16 except move your hand to j u s t under  elbow immediately a f t e r he scoops the food.  the r e s i d e n t ' s  A f t e r he r e c e i v e s  the  f o o d , keep your hand under h i s elbow, g u i d i n g the spoon back to the plate.  18.  Repeat  Step 17 except l e t go of the r e s i d e n t ' s hand and arm c o m p l e t e l y  about t h r e e - q u a r t e r s o f the way  up from the scoop to h i s mouth.  Continue g u i d i n g the r e t u r n o f the spoon to the food by p l a c i n g your hand under h i s elbow.  19.  Repeat  Step 18 except l e t go o f the r e s i d e n t ' s hand and arm h a l f  way  between the scoop and h i s mouth.  20.  Repeat  Step 19 except l e t go o f the r e s i d e n t ' s hand and arm  q u a r t e r of the way  21.  Repeat You may  one-  between the scoop and h i s mouth.  Step 20 b u t - l e t go c o m p l e t e l y j u s t a f t e r he makes the scoop. have to touch h i s hand g e n t l y to s i g n a l him to move the  spoon.  Page  161 39  to h i s mouth. H i s r e t u r n to the p l a t e should  22.  Repeat Step 21 he's  23.  except p l a c e your hand on  s t i l l be elbow guided.  the r e s i d e n t ' s elbow w h i l e  scooping.  Repeat Step 22 except l e t go of the r e s i d e n t s elbow on to the p l a t e .  (You may  have to touch h i s hand g e n t l y  the r e t u r n to s i g n a l  trip  him  to r e t u r n spoon to food)  24.  Repeat Step 23 except l e t go of the r e s i d e n t ' s elbow c o m p l e t e l y . (You may first)  have to guide the r e s i d e n t ' s hand at v a r i o u s p o i n t s As  the r e s i d e n t continues  remove any  If  gradually  prompting.  the r e s i d e n t drops the spoon a t any  without a s s i s t a n c e  (Step  10),  another o p p o r t u n i t y  p o i n t a f t e r he has  the food and  immediately removed from the t a b l e . be g i v e n  to p r a c t i c e t h i s s t e p ,  at  One  h e l d the spoon  then the r e s i d e n t should  hour l a t e r , the r e s i d e n t  to feed h i m s e l f  using  be should  t h i s program.  A d d i t i o n a l Comments:  1". „  While u s i n g pouchlike  t h i s program i t i s a good i d e a to use  l i p at the bottom.  the food which s p i l l s  2.  I f the r e s i d e n t has  a  T h i s type of b i b u s u a l l y c a t c h e s most of  out of the  spoon.  repeated d i f f i c u l t y  ber of s e s s i o n s , you may  a b i b which has  holding  the spoon over a num-  want to c o n s i d e r m o d i f y i n g the spoon's shape  Page 162 40 to f u r t h e r h e l p him.  F o r example, you can e n l a r g e the handle  spoon by wrapping adhesive develops  skill  tape around i t .  o f the  Then, as the r e s i d e n t  i n h o l d i n g the spoon, you can g r a d u a l l y remove some o f  the tape u n t i l he i s a g a i n u s i n g a spoon w i t h a 'normal' handle. H a z e l B r o a d l e y about o t h e r m o d i f i e d spoons.  See  I f a t a l l p o s s i b l e , you  s h o u l d o n l y use a m o d i f i e d spoon on a temporary b a s i s . As the r e s i d e n t develops  e x p e r t i s e i n u s i n g the m o d i f i e d spoon, you s h o u l d g r a d u a l l y  b e g i n i n t r o d u c i n g him t o the use o f a normal spoon..  Techniques  1. Shaping - S t a r t w i t h Step  1 and proceed  s l o w l y to step 24 e n s u r i n g t h a t  r e s i d e n t succeeds a t each and every step a l o n g the way.  2. I n s t r u c t i o n s - Remember t o i n s t r u c t  the r e s i d e n t a t every  step.  3. P r a i s e - Remember t o p r a i s e the r e s i d e n t each time he s u c c e s s f u l l y a step.  completes  Page 41 Program f o r Independent E a t i n g —  T h i s program w i l l  Use o f F o r k  f o l l o w t h e same format as t h a t of the "Use o f Spoon".  Replace "spoon" w i t h " f o r k " when f o l l o w i n g program. T r y t o use o n l y foos  t h a t the r e s i d e n t l i k e s . Throughout the .program p r a i s e the r e s i d e n t  for h i s progress.  Page 164 42 Program f o r Independent E a t i n g —  Use o f K n i f e  S i n c e most r e s i d e n t s who a r e dependent, i n the use of a k n i f e a r e h e m i p l e g i c due to a s t r o k e —  see the O c c u p a t i o n a l T h e r a p i s t about m o d i f i e d  used f o r c u t t i n g and s p r e a d i n g .  knives  Page 165 43 Program  f o r Independent Handwashing.  Throughout the program, p r a i s e t h e r e s i d e n t f o r any p r o g r e s s . reward him a t the end o f each s e s s i o n w i t h an a p p r o p r i a t e  Also,  amount of h i s  f a v o u r i t e food o r d r i n k i f p o s s i b l e .  1.  Bring  the r e s i d e n t  to the bathroom and stand him i n f r o n t o f the s i n k .  Say to him, "(NAME), wash your hands".  2.  Guide him i n t u r n i n g on the a p p r o p r i a t e  amount o f h o t and c o l d water to  a c h i e v e a warm water temperature.  3.  A s s i s t him i n p i c k i n g up the soap and g r i p p i n g i t i n one hand.  4.  B r i n g h i s hands under the water.  5.  Move h i s hands back and f o r t h over the soap, thus c r e a t i n g a l a t h e r .  6.  Place  soap back i n soap d i s h and move hands to d i s t r i b u t e the l a t h e r to  a l l p a r t s o f the hands.  7.  R i n s e l a t h e r o f f w i t h water.  8.  Turn o f f water.  9.  Use towel t o d r y hands and f a c e .  Page 166 44 Techniques  Shaping - Remember to s t a r t w i t h Step 9 and work backwards, making s u r e t h a t the r e s i d e n t a c h i e v e s success a t each s t e p .  I n s t r u c t i o n s - Remember to i n s t r u c t the r e s i d e n t a t every s t e p .  This i s  /^accomplished -with '.verbal i n s t r u c t i o n .  Modeling - Demonstrate t o the r e s i d e n t the s t e p you want him to a c c o m p l i s h .  R e h e a r s a l - A l l o w the r e s i d e n t to p r a c t i c e the s t e p over and over w i t h o u t c r i t i c i s m u n t i l he gets i t r i g h t .  P r a i s e - Remember to p r a i s e t h e r e s i d e n t each time he s u c c e s s f u l l y  completes  a s t e p and say to him, "(NAME), wash your hands" j u s t b e f o r e he b e g i n s t o wash h i s hands.  You may have to prompt the r e s i d e n t  a few times a t v a r i o u s p o i n t s to h e l p him completely l e a r n a p a r t i c u l a r step.  As the r e s i d e n t p r o g r e s s e s , g r a d u a l l y withdraw  your guidance i n these a c t i v i t i e s — by h i m s e l f .  u n t i l he can perform them  Page 167 45 Program f o r Independent Face Washing.  Throughout;; the program, p r a i s e the r e s i d e n t f o r any p r o g r e s s . reward him a t the end o f each s e s s i o n w i t h an a p p r o p r i a t e  Also,  amount o f h i s  f a v o u r i t e food o r d r i n k i f p o s s i b l e .  1.  Bring Say  2.  t o him, "(NAME)", Wash your f a c e . " Then t u r n on the water.  Bring Say  the r e s i d e n t t o the bathroom and stand him i n f r o n t o f t h e s i n k .  the r e s i d e n t t o the bathroom and have him stand  i n f r o n t of the sink.  to him,"(NAME), Wash your f a c e . " Then guide him i n t u r n i n g on the  appropriate ture.  amount o f h o t and c o l d water to a c h i e v e a warm water tempera-  A s s i s t him i n cupping h i s hands, i n b r i n g i n g h i s cupped hands under  the water, and then i n p a t t i n g h i s f a c e w i t h the warm water ( t h i s p r o c e s s should  3.  be performed i n one continuous m o t i o n ) .  Repeat Step 2.  A f t e r the r e s i d e n t p a t s h i s f a c e w i t h the water, c o n t i n u e  to h o l d h i s cupped hands and g e n t l y d i r e c t them back to t h e water.  4.  Repeat Step 3.  5.  While r e p e a t i n g  Step 3, g r a d u a l l y b e g i n to l o o s e n your g r i p oh the r e s i d e n t ' s  cupped hands j u s t b e f o r e  he p l a c e s  the water on h i s f a c e .  l o o s e g r i p u n t i l a f t e r he has p l a c e d  M a i n t a i n the  the water on h i s f a c e ;  h i s hands t o the water w i t h the o r i g i n a l amount o f guidance.  then r e t u r n  Page 168 46 6.  Repeat  Step 3, but t h i s time g r a d u a l l y l o o s e n your g r i p on t h e r e s i d e n t ' s  hand j u s t a f t e r he gets water  i n h i s hands.  Don't l e t go o f h i s hands,  merely l o o s e n you g r i p .  M a i n t a i n t h i s l o o s e g r i p u n t i l a f t e r he has p a t t e d  h i s f a c e w i t h the water,  then r e d i r e c t h i s hands to the water w i t h the  o r i g i n a l amount o f guidance.  7.  Repeat  Step 6, except a l s o l o o s e n you g r i p on h i s hands as you r e t u r n h i s  hands to the water.  8.  Repeat  Step 7, except t h i s time l o o s e n you g r i p on h i s hands even more,  without l e t t i n g go o f h i s hands e n t i r e l y .  9.  Repeat  Step 8, except l e t go o f h i s hands j u s t as he s p l a s h e s the water  on h i s f a c e , r e t a k i n g h i s hands w i t h you l o o s e g r i p immediately  after  he f i n i s h e s s p l a s h i n g h i s f a c e .  10.  Repeat  Step 9, except p l a c e your hand j u s t under h i s w r i s t  b e f o r e he p a t s water  on h i s f a c e .  immediately  There s h o u l d be no support o f h i s hands  w h i l e he i s s p l a s h i n g h i s f a c e but you s h o u l d r e t a k e h i s hands w i t h t h e l o o s e g r i p and b r i n g them back t o the water.  11.  Repeat  Step 10, except move your hand under  t h r e e - q u a r t e r s o f the way between the water  12.  Repeat  the r e s i d e n t ' s w r i s t and h i s f a c e .  Step 10, except move you hand under the r e s i d e n t ' s w r i s t  h a l f way between the water  and h i s f a c e .  about  about  Page 169 47 13.  Repeat Step 10, except move your hand under t h e r e s i d e n t ' s w r i s t  about  one-quarter of the way between t h e water and h i s f a c e .  14.  Assist  the r e s i d e n t i n cupping h i s hands and b r i n g i n g h i s cupped hands  under the water;  Then as you guide t h e r e s i d e n t ' s hands ( a t the w r i s t ) to  h i s f a c e , move your hand to h i s forearm about  t h r e e - q u a r t e r s o f the way  between the water and h i s f a c e .  15.  Repeat Step 14,^except move your hand under the r e s i d e n t ' s forearm  about  h a l f way between t h e water and h i s f a c e .  16.  Repeat Step 14, except move you hand under t h e r e s i d e n t ' s forearm  about  one-quarter o f the way between t h e water and h i s f a c e .  17.  Repeat Step 14, except t h i s time move you hand t o t h e r e s i d e n t ' s w r i s t r i g h t a f t e r he s p l a s h e s h i s f a c e .  18.  Repeat Step 14, except p l a c e your hand under the r e s i d e n t ' s forearm a f t e r he s p l a s h e s h i s f a c e .  right  (At t h i s p o i n t t h e r e s h o u l d be f i r m p r e s s u r e  on the r e s i d e n t ' s hands o n l y as he begins to cup the water.  Gentle f o r e -  arm p r e s s u r e s h o u l d be p r e s e n t f o r a l l o t h e r movements.)  19.  Repeat Step 14,~.except move your hands t o the r e s i d e n t ' s w r i s t j u s t as he i s cupping h i s hands. h i s hands.)  (You may have t o guide him g e n t l y  f i r s t by g r i p p i n g  Page 170 48 20.  Repeat Step 14, except move your hand to j u s t under the r e s i d e n t ' s j u s t as he cups h i s hands.  After this,  elbow  c o n t i n u e to have your hand under  h i s forearm and g e n t l y guide him through the o t h e r motions.  21.  Repeat Step 20, except l e t go o f the r e s i d e n t ' s forearm c o m p l e t e l y about t h r e e - q u a r t e r s o f t h e way from p l a c i n g water i n h i s hands. guiding his  22.  Continue  t h e r e t u r n o f h i s hands to the water by p l a c i n g your hands under  elbow.  Repeat Step 20, except l e t go o f the r e s i d e n t ' s hand and arm halfway between the water and h i s f a c e .  23.  Repeat Step 20, but l e t go o f the r e s i d e n t ' s hand and arm o n e - q u a r t e r o f the way between  24.  t h e water and h i s f a c e .  Repeat Step 20, but l e t go c o m p l e t e l y j u s t a f t e r t h e r e s i d e n t p l a c e s water i n h i s hands.  You may have t o touch h i s hand g e n t l y t o s i g n a l him t o move  h i s hands to h i s f a c e .  H i s r e t u t n t o the water s h o u l d s t i l l be elbow  guided.  25.  Repeat Step 20, except do n o t g u i d e t h e r e s i d e n t ' s arm back t o the water.' (You may have to prompt  the r e s i d e n t  occasionally.)  Remember to say, "(NAME), wash your f a c e " , and t o p r a i s e the r e s i d e n t f o r the s u c c e s s f u l completion o f each s t e p .  Page 171 49  I f you w i s h t o t e a c h the r e s i d e n t t o wash h i s f a c e w i t h soap and/or a washcloth,  you can extend t h i s program u s i n g t h e same graduated  format.  You can a l s o a p p l y t h i s program ( a f t e r minor m o d i f i c a t i o n ) t o t e a c h i n g t h e r e s i d e n t t o wash o t h e r p a r t s o f t h e body, e.g., neck, underarms.  At t h e end o f each s e s s i o n a s s i s t the r e s i d e n t i n t u r n i n g o f f the w a t e r and i n u s i n g a t o w e l to d r y h i s f a c e and hands.  As the r e s i d e n t  g r a d u a l l y withdraw your guidance i n these a c t i v i t i e s — p e r f o r m them by h i m s e l f .  progresses,  u n t i l he can  Page 172 50 Program f o r Independent H a i r  Combing  Make sure t h a t you use a comb which can be e a s i l y handled by the r e s i d e n t . Throughout the program p r a i s e the r e s i d e n t f o r any p r o g r e s s . the r e s i d e n t a t each step w i t h  Also  reward  s m a l l amounts o f h i s f a v o u r i t e food o r d r i n k  i f possible.  P i c k up the comb and p l a c e i t i n the r e s i d e n t ' s hand, cuping over h i s .  you hand  Say to the r e s i d e n t , "(NAME), .comb.:ybur h a i r . "  4  Repeat Step 1 and guide the r e s i d e n t ' s hand and comb to the r e s i d e n t ' s hair.  Repeat Step 2 ( a g a i n s a y i n g , "(NAME), comb your h a i r . " ) ;  then,  while  h o l d i n g h i s hand over the comb, comb the r e s i d e n t ' s h a i r i n accordance w i t h your  preference.  Repeat Step 3 except s l i g h t l y l o o s e n your g r i p on t h e r e s i d e n t ' s hand.  Repeat Step 3 except l o o s e n your g r i p even more.  Repeat Step 3 except g r a d u a l l y move you hand t o the r e s i d e n t ' s w r i s t and continue  g u i d i n g h i s h a i r conbing.  Repeat Step 6 except move your hand to the r e s i d e n t ' s w r i s t . g r i p s l i g h t l y so t h a t he can have the o p p o r t u n i t y  Loosen your  t o move the comb.  Page 173 51 Repeat Step 6 except move your hand j u s t under t h e r e s i d e n t ' s  elbow.  C o n t i n u e g u i d i n g him whenever i t seems n e c e s s a r y .  Repeat Step 8 except remove your guidance c o m p l e t e l y . guide the r e s i d e n t  (You may have t o  occasionally.)  Remember t o s a y , "(NAME), comb your h a i r . " , and t o p r a i s e t h e r e s i d e n t each t i m e he s u c c e s s f u l l y completes a s t e p .  You may have t o prompt t h e  r e s i d e n t a few t i m e s a t v a r i o u s p o i n t s t o h e l p him r e a c h complete mastery.  Page 174 52 Program f o r Independent  Toothbrushing  Throughout t h i s program p r a i s e t h e r e s i d e n t f o r any p r o g r e s s .  A l s o reward  the r e s i d e n t a t the end o f the s e s s i o n w i t h an a p p r o p r i a t e amount o f h i s f a v o u r i t e food or d r i n k .  1.  B r i n g the r e s i d e n t to t h e washroom and p l a c e h i s t o o t h b r u s h and a tube of open t o o t h p a s t e d i r e c t l y i n f r o n t o f him.  T e l l the r e s i d e n t , " P i c k up  the tube o f t o o t h p a s t e and p l a c e some t o o t h p a s t e on t h e t o o t h b r u s h . " I f the r e s i d e n t f o l l o w s t h i s i n s t r u c t i o n , go t o Step follow this instruction,  10.  I f he does n o t  g e n t l y cover h i s hands w i t h yours and guide him  i n s p r e a d i n g the t o o t h p a s t e on the t o o t h b r u s h and then p l a c e the t o o t h p a s t e down ( t h e t o o t h b r u s h s h o u l d be p l a c e d i n h i s p r e f e r r e d hand)i  2.  Repeat Step  1, except l o o s e n your g r i p on the r e s i d e n t ' s hand.  3.  Repeat Step  1,' except l o o s e n your g r i p even more, b u t do n o t l e t go of v  h i s hand.  4.  Repeat Step  1, except p l a c e your hand j u s t under t h e r e s i d e n t ' s w r i s t  immediately  b e f o r e he p l a c e s the t o o t h p a s t e on the t o o t h b r u s h .  Continue  g u i d i n g him from t h i s p o s i t i o n and p r a i s i n g him (you may have t o grasp one of h i s hands i n i t i a l l y  5.  Repeat Step arm.  to h e l p him spread the t o o t h p a s t e ) .  1, except move your hand down toward the middle  o f the r e s i d e n t ' s  Continue g u i d i n g him and p r a i s i n g him f o r making p r o g r e s s .  Page 175 53 6.  Repeat  Step 5, except remove your hands from h i s arms immediately b e f o r e  he p l a c e s the t o o t h p a s t e down (you may have to guide him o c c a s i o n a l l y on t h i s and l a t e r s t e p s . )  7.  Repeat  Step 5, except remove your hand from h i s arms immediately b e f o r e  he f i n i s h e s p u t t i n g the t o o t h p a s t e on t h e t o o t h b r u s h .  8.  Repeat  Step 5, except remove your hands j u s t as he b e g i n s p l a c i n g the t o o t h -  p a s t e on the t o o t h b r u s h .  9.  Repeat  Step 1. (You may have to guide him g e n t l y a t times u n t i l he develops  mastery o f the s k i l l . )  10.  A f t e r t h e r e s i d e n t s u c c e s s f u l l y completes  Step 1 o r Step 9, he s h o u l d be  t o l d , "Now I want you t o b r u s h your:.teeth." I f the r e s i d e n t does n o t f o l l o w t h i s i n s t r u c t i o n , then you s h o u l d g e n t l y cover h i s hands w i t h yours and guide h i s hand through the f o l l o w i n g a.  sequence:  Turn the water on i n the wash b a s i n to a moderate degree and then b r i n g h i s hand s l o w l y toward h i s mouth.  b.  Touch the t o o t h b r u s h b r i s t l e s t o h i s t e e t h and move the t o o t h b r u s h up and down on the o u t e r s u r f a c e o f h i s f r o n t t e e t h f o r 5 to 10 seconds. (Avoid p l a c i n g undue p r e s s u r e on the r e s i d e n t ' s gums.)  c.  Then g e n t l y move t h e t o o t h b r u s h to one s i d e o f the r e s i d e n t ' s mouth (the r e s i d e n t ' s p r e f e r r e d s i d e ) and b r u s h t h i s s i d e f o r 5 t o 10 seconds i n an up-and-down motion.  d.  iThen g e n t l y move the t o o t h b r u s h to the o t h e r s i d e o f h i s mouth and b r u s h  Page  176 54  t h i s s i d e f o r 5 to 10 seconds e.  i n an up-and-down motion.  Then g e n t l y move the t o o t h b r u s h to the bottom  s u r f a c e s o f h i s top  t e e t h on h i s p r e f e r r e d s i d e and b r u s h them f o r 5 to 10 f.  Then g e n t l y move the t o o t h b r u s h to the bottom  s u r f a c e s of h i s top  t e e t h on the o t h e r s i d e and brush them f o r 5 to 10 g.  seconds.  Then guide h i s hand and t o o t h b r u s h to the upper s u r f a c e s of h i s bottom t e e t h on h i s p r e f e r r e d s i d e and b r u s h them f o r 5 to 10  h.  seconds.  Then guide h i s hand and t o o t h b r u s h to the upper  seconds.  s u r f a c e s of h i s bottom  t e e t h on the o t h e r s i d e and b r u s h them f o r 5 to 10 seconds. i.  Then guide the r e s i d e n t i n b r u s h i n g the i n s i d e s u r f a c e s o f h i s bottom .teeth.  j.  Then guide him i n b r u s h i n g the i n s i d e s u r f a c e s of h i s top t e e t h ,  k.  Then g u i d e the t o o t h b r u s h out of h i s mouth and back toward  the wash  basin. 1.  P l a c e the t o o t h b r u s h under  m.  Then encourage remained  n.  the water, r i n s e i t o f f , and put i t down,  the r e s i d e n t to s p i t out the t o o t h p a s t e which  has  i n h i s mouth,  Then guide him i n p i c k i n g up a cup, f i l l i n g  i t w i t h water, r i n s i n g out  h i s mouth, and p l a c i n g the cup back down, o.  And,  f i n a l l y , g u i d e him i n t u r n i n g o f f the water and w i p i n g h i s f a c e and  hands w i t h a t o w e l . 11.  Repeat  the sequence p r e s e n t e d i n Step 10, except l o o s e n your g r i p on the  r e s i d e n t '• s. hands  12.  Repeat  the sequence  LET GO OF HIS HAND.  i n Step 10, except l o o s e n your g r i p even more. DO  NOT  Page 177 55 13.  Repeat t h e sequence i n Step 10, e x c e p t p l a c e y o u r hand j u s t under t h e r e s i d e n t ' s w r i s t i m m e d i a t e l y b e f o r e he p l a c e s t h e t o o t h b r u s h i n h i s mouth. C o n t i n u e g u i d i n g him from t h i s p o s i t i o n and p r a i s i n g him f o r d o i n g w e l l . Retake h i s hand a f t e r he i s f i n i s h e d u s i n g the t o o t h b r u s h i n h i s mouth.  14.  Repeat t h e sequence i n Step 10, e x c e p t move y o u r hand j u s t under h i s w r i s t about t h r e e - q u a r t e r s o f t h e way up between t h e wash b a s i n and h i s mouth. Retake h i s hand a f t e r he i s f i n i s h e d u s i n g t h e t o o t h b r u s h i n h i s mouth.  15.  Repeat t h e sequence i n Step 10, except move y o u r hand j u s t under h i s w r i s t about h a l f way up between t h e wash b a s i n and h i s mouth.. R e t a k e h i s hand a f t e r he i s f i n i s h e d u s i n g t h e t o o t h b r u s h i n h i s mouth.  16.  Repeat t h e sequence i n Step 10, e x c e p t move y o u r hand under h i s w r i s t about o n e - q u a r t e r o f t h e way up between t h e wash b a s i n and h i s mouth. "Leave your hand i n t h i s p o s i t i o n a f t e r he i s f i n i s h e d w i t h t h e t o o t h b r u s h i n h i s mouth.  (You may have t o r e g r a s p h i s hand o c c a s i o n a l l y  t o a i d him i n ::  r i n s i n g the toothbrush.)  17.  Repeat t h e sequence i n Step 10, e x c e p t move y o u r hand under t h e r e s i d e n t ' s f o r e a r m about t h r e e - q u a r t e r s o f t h e way up between t h e wash b a s i n and h i s mouth.  Leave y o u r hand i n t h i s p o s i t i o n a f t e r he i s f i n i s h e d w i t h t h e  t o o t h b r u s h i n h i s mouth ( a g a i n , y o u may have t o g u i d e him g e n t l y t h r o u g h the remainder o f t h e s e q u e n c e ) .  18.  Repeat t h e sequence i n Step 10, e x c e p t move y o u r hand under t h e r e s i d e n t ' s  Page  178  56  forearm about h a l f way  up between the wash b a s i n and h i s mouth. (Again,  l e a v e your hand i n t h i s p o s i t i o n throughout the remainder of the a l t h o u g h you may  sequence,  have to r e t a k e h i s hand a t c e r t a i n times to f u r t h e r guide  him.).  19. Repeat  the sequence  i n Step 10, except move your hand under  forearm about one-quarter o f the way  the r e s i d e n t ' s  between the wash b a s i n and h i s mouth.  Leave your hand i n t h i s p o s i t i o n throughout the remainder of the program.  20. Repeat  s t e p 10 (you may  v. :parts:of the sequence  21. Repeat  s t e p s 1 and  have to g e n t l y guide the r e s i d e n t throughout v a r i o u s  u n t i l he develops e x p e r t i s e i n b r u s h i n g h i s t e e t h ) .  10 ( a g a i n , you may  have t o guide the r e s i d e n t  occasionally  u n t i l he develops complete mastery o f t h e s e s k i l l s ) .  Remember to p r a i s e the r e s i d e n t each time he completes a step and  successfully  brushes h i s t e e t h .  e x c e r p t s of t h i s manual a r e taken Up and Around: U.S.  from:  A B o o k l e t to A i d the S t r o k e P a t i e n t i n A c t i v i t i e s o f D a i l y  Government P r i n t i n g O f f i c e , Washington,  Living.  1972.  M o r r i s , R.J. B e h a v i o r M o d i f i c a t i o n w i t h C h i l d r e n . Cambridge; Winthrop,  1976.  APPENDIX C FLOORPLAN FOR FACILITY A AND B  A s-ec-Uon  6  scciiorr  From this point to lounge is G5 feet  £RONT ENTRANCE  JSFRVICF  7 7 7 7  7  7  /APPENDIX LOGBOOK  APPENDIX E GOVERNMENT LONG-TERM CARE CRITERIA  Page  Intermediate The B.C.  185  Care  Department of H e a l t h (1972) d e f i n e s i n t e r m e d i a t e c a r e as  type of c a r e r e q u i r e d by persons of any age whose p h y s i c a l are such t h a t t h e i r primary need i s f o r room and board,  "the  disabilities  daily  professional  n u r s i n g s u p e r v i s i o n , a s s i s t a n c e w i t h some of the a c t i v i t i e s of d a i l y l i v i n g and a planned programme of s o c i a l and r e c r e a t i o n a l  activities".  A l s o i n c l u d e d i n t h i s type of care are those persons w i t h mental d i s o r d e r s who  p r i m a r i l y r e q u i r e room and board as w e l l as " d a i l y p r o f e s s i o n a l  super-  v i s i o n by a person w i t h a p p r o p r i a t e p s y c h i a t r i c t r a i n i n g and a programme designed  to a s s i s t  them to r e a c h t h e i r maximum p o t e n t i a l i n the a c t i v i t i e s  d a i l y l i v i n g " . Excluded  from t h i s type of c a r e are those persons who  b e h a v i o u r a l or p s y c h i a t r i c problems which unduly who  r e q u i r e treatment  Those persons  of  have  d i s t u r b o t h e r r e s i d e n t s or  of a s p e c i a l i z e d n a t u r e not needed by o t h e r r e s i d e n t s .  r e q u i r i n g i n t e r m e d i a t e care have the f o l l o w i n g c h a r a c t e r i s t i c s :  1) P h y s i c a l S t a t u s R e s i d e n t s are i n d e p e n d e n t l y mobile, w i t h or without aids  ( h a n d r a i l s , grab b a r s , ramps, canes,  the use of  c r u t c h e s , walkers  mechanical  or w h e e l c h a i r s ) .  They a r e a b l e to eat t h e i r meals i n a d i n i n g room, a l t h o u g h some a s s i s t a n c e w i t h e a t i n g may  be p r o v i d e d . Room t r a y s e r v i c e i s r e q u i r e d o n l y o c c a s i o n a l l y ,  d u r i n g b r i e f p e r i o d s of i l l n e s s . These r e s i d e n t s may  be a t l e a s t  partially  and even f u l l y dependent on o t h e r s f o r many a s p e c t s of s e l f c a r e (ex., d r e s s i n g , grooming,, bathing: and bowel may  t o i l e t i n g ) . I n c o n t i n e n c e of both b l a d d e r  and  be handled w i t h an i n d w e l l i n g c a t h e t e r . V i s i o n and h e a r i n g i s  o f e n d i m i n i s h e d or  absent.  Page 186  2) Mental S t a t u s "Forgetfulness,  periods of confusion,  m i l d l y d i s t u r b i n g behaviour and  a tendency to wander away may be expected, as may v a r y i n g defect  o r d e t e r i o r a t i o n r e s u l t i n g from d i s e a s e ,  disorder  3)  o r mental r e t a r d a t i o n "  degrees o f mental  senility, residual psychiatric  (B.C. Department o f H e a l t h ,  1972).  Services The  services of a consultant  to s u p e r v i s e  the p r e p a r a t i o n  d i e t i c i a n may be needed on a p a r t - t i m e of s p e c i a l d i e t s . Supervision  needed to a s s u r e that p r e s c r i b e d required and  medical, dental  and o t h e r h e a l t h  justment of a colostomy) may be r e q u i r e d . occupational  c a r e appointments a r e made  postural  p o s i t i v e pressure breathing,  (physiotherapist,  i s also  m e d i c a t i o n i s taken as d i r e c t e d and that  kept. S p e c i a l procedures (ex.,  intermittent  basis  d r a i n a g e , oxygen therapy,  p e r i t o n e a l d i a l y s i s o r adServices  of paramedical s p e c i a l i s t s  t h e r a p i s t , p r o s t h e t i s t , or hearing a i d  s p e c i a l i s t ) may a l s o be r e q u i r e d , i n  o r d e r to a t t a i n and m a i n t a i n maximum  function.  The  services offered i n a f a c i l i t y providing  intermediate care are " b a s i c a l l y  those which w i l l m a i n t a i n and, i f p o s s i b l e , improve the h e a l t h  s t a t u s and  f u n c t i o n a l a b i l i t y o f the r e s i d e n t s . A planned programe o f s o c i a l , and  occupational  a c t i v i t i e s i n d i v i d u a l l y adapted t o the age o f the p e r s o n , h i s  needs, c a p a b i l i t i e s and d e s i r e s , i s an e s s e n t i a l component o f these (B.C.  recreational  Department o f H e a l t h ,  1972).  services"  Page  187  Extended Care The  B.C.  Department o f H e a l t h  (1972) d e f i n e s extended care as "the  care r e q u i r e d by persons of any has  age w i t h  a s e v e r e c h r o n i c d i s a b i l i t y , which  u s u a l l y produced a f u n c t i o n a l d e f i c i t , who  s e r v i c e s and resources  type o f  r e q u i r e 24 hour a day  c o n t i n u i n g m e d i c a l s u p e r v i s i o n but who  do not r e q u i r e a l l the  of an acute care h o s p i t a l . Most p e o p l e who  have a l i m i t e d p o t e n t i a l f o r r e h a b i l i t a t i o n and  nursing  need t h i s type of  often require  care  institutional  care on a permanent b a s i s ? .  Those persons r e q u i r i n g extended c a r e have the f o l l o w i n g 1) P h y s i c a l  characteristics:  Status  Residents  a r e unable to get i n or out of bed  or wheel t h e i r own  wheelchair).without  (or w h e e l c h a i r  or to walk  the a i d of an a s s i s t a n t . They u s u a l l y  require considerable  a s s i s t a n c e i n the a c t i v i t i e s of d a i l y l i v i n g  washing, f e e d i n g and  u s i n g t o i l e t ) and  or i n d i n i n g room). A s s i s t a n c e appliances  r e q u i r e tray s e r v i c e (at bedside  i s also required i n adjusting prosthetic  or a colostomy apparatus, and w i t h  (ex., p o s t u r a l d r a i n a g e ,  (dressing,  s p e c i a l m e d i c a l treatments  oxygen therapy or i n t e r m i t t e n t p o s i t i v e p r e s s u r e  breathing). "Some persons w i l l r e q u i r e extended care even though t h e i r f u n c t i o n a l a b i l i t y i s not  s e r i o u s l y impaired  c o n t i n u i n g m e d i c a l s u p e r v i s i o n and ment of H e a l t h ,  2) M e n t a l  because o f the need f o r r e g u l a r professional nursing  and  careV(B.C. Depart-  1972).  Status  "There may  be p e r i o d s of f o r g e t f u l n e s s , c o n f u s i o n  and  restlessness. Varying  degrees of mental d e t e r i o r a t i o n r e s u l t i n g from s e n i l i t y or r e s i d u a l p s y c h i a t r i c d i s o r d e r s may  a l s o be p r e s e n t .  Persons w i t h  s e r i o u s mental problems  Page 188  which a r e d e s t r u c t i v e o r threatening  t o o t h e r s can h o t e b e : c a r e d f o r  i n a f a c i l i t y p r o v i d i n g t h i s type o f c a r e "  3)  (B.C. Department o f H e a l t h ,  1972).  Services. The  s e r v i c e s o f a d i e t i c i a n on a f u l l - t i m e o r c o n s u l t a n t b a s i s i s needed  to supervise  t h e p r e p a r a t i o n o f s p e c i a l d i e t s . S u p e r v i s i o n i s a l s o needed  to a s s u r e t h a t p r e s c r i b e d m e d i c a t i o n i s t a k e n as d i r e c t e d and t h a t required medical,  d e n t a l and o t h e r h e a l t h c a r e appointments a r e made and  k e p t . The p a t i e n t r e q u i r e s 24 hour a day s k i l l e d maintenance n u r s i n g s e r v i c e s as w e l l as t h e s e r v i c e s o f a p h y s i o t h e r a p i s t and o c c u p a t i o n a l t h e r a p i s t on a r e g u l a r b a s i s .  The  s e r v i c e s o f f e r e d i n a f a c i l i t y p r o v i d i n g extended c a r e a r e " t h o s e w h i c h  w i l l help to maintain,  and where p o s s i b l e improve, t h e h e a l t h s t a t u s and  f u n c t i o n a l a b i l i t y o f t h e p a t i e n t s . Programmes must be s p e c i f i c a l l y d i r e c t e d toward m a i n t a i n i n g  maximum independence i n t h e a c t i v i t i e s o f d a i l y  A p l a n n e d programme o f s o c i a l , r e c r e a t i o n a l and o c c u p a t i o n a l  living.  activities i s  an e s s e n t i a l component o f these s e r v i c e s " (B.C. Department o f H e a l t h ,  1972).  APPENDIX F PRIMARY DIAGNOSIS CATEGORIES  Page 1 9 0  PRIMARY  CATEGORY 1 PSYCHIATRIC  DIAGNOSIS  CATEGORIES  CATEGORY 2 HEART D I S E A S E  CLASSIFICATION  A R T E R I O S C L E R O T I C HEART D I S E A S E ANGINA/ISCHEMIA BLOCK/OTHER CONDUCTIVE PROBLEM (PACEMAKER) ARRHYTHMIA ( T A C H Y C A R D I A , BRADYCARDIA, FIBRILLATION EPISODES) C O N G E S T I V E HEART F A I L U R E COR PULMONALE VALVE I N S U F F I C I E N C Y INFARCT  SENILITY S E N I L E DEMENTIA C H R O N I C / A C U T E BRAIN SYNDROME ORGANIC BRAIN DISORDER CEREBRAL A R T E R I O S C L E R O S I S SCHIZOPHRENIA DEPRESSION PARANOIA  CATEGORY 3 CIRCULATORY  CATEGORY CEREBRAL  PROBLEMS  GENERALIZED ARTERIO/ ATHEROSCLEROSIS I N T E R M I T T E N T C L A U D I C A T I O N ,& OTHER FORMS OF P E R I P H E R A L ARTERIOSCLEROSIS HYPER/HYPOTENSION EMBOLUS, THROMBUS, OR OTHER ARTERY/VEIN OCCLUSION RAYNAUD'S D I S E A S E THROMBOPHLEBITIS  CATEGORY  ~  CEREBROVASCULAR ACCIDENT HEMORRHAGE/ANEURISM INJURY/HEMATOMA/CONCUSS ION SMALL STROKES/TRANSIENT ISCHEMIC ATTACKS TUMOUR PARKINSON'S D I S E A S E EPILEPSY TARDIVE DYSKINESIA  CATEGORY 6 M E T A B O L I C DISORDERS  5  MUSCULO/SKELETAL  4 INSULT  PROBLEMS  AMPUTATIONS PE AD R) T) FRACTURES ( U(NLRIEMSBO L V JOINT REPLACEMENTS A R T H R I T I S - OSTEO, RHEUMATOID OSTEOPOROSIS CONTRACTURE OR OTHER STRUCTURAL DEFORMITY (MAJOR) S P I N A L PROBLEMS ( D E G E N E R A T I V E D I S C , T A B E S D O R S A L I S , PAGET'"s"' D I S E A S E , COMPRESSED V E R T E B R A E MYASTHENIA GRAVIS MUSCULAR DYSTROPHY ;  DIABETES - MELLITUS, INSIPIDUS ADRENAL I N S U F F I C I E N C Y HYPO/HYPERTHYROIDISM P I T U I T A R Y PROBLEMS RENAL F A I L U R E  CATEGORY .7 MISCELLANEOUS  /  DIVERTICULITIS ULCERATIVE COLITIS U L C E R (DUODENAL, P E P T I C ) BOWEL F I S T U L A BOWEL O B S T R U C T I O N IMPACTION GASTROENTERITIS TUBERCULOSIS ORGAN F A I L U R E ( K I D N E Y , L I V E R ) STASIS ULCERS OPEN WOUND ( S U R G I C A L OR D E C U B I T I ) ANEMIA ALCOHOLISM SENSORY IMPAIRMENTS ( H E A R I N G OR VISION LOSS) CANCER EMPHYSEMA CHRONIC O B S T R U C T I V E LUNG D I S E A S E  APPENDIX G ADL ASSESSMENT CRITERIA  Page J93 ASSESSMENT CRITERIA (ADL)  Total Independence - Green - Score 1 Total Independence means the a b i l i t y to perform an activity without supervision, direction or active personal assistance. A patient who refuses to perform a function i s defined as totally dependent, even though he or she i s deemed able. The patient may choose any method or aid to perform the activity.  This c r i t e r i a directly applies to a l l designated ADL's with the exception of walking. In this case, green designates the a b i l i t y to walk independently, such that no restriction i s placed on the individual i n carrying out daily routines within the institution or on excursions outside.  Partial Dependence - Yellovj - Score 2 The patient can perform the greater part of the activity himself or herself, but needs assistance (verbal or physical) or supervision to complete the activity.  This c r i t e r i a refers to the degree of dependence i n the designated ADL's. Verbal assistance refers to instruction and direction i n conducting an activity. This may include direction i n what garment to put on next, to pick up the soap to wash hands, to put paralyzed arm into sleeve of shirt before other arm, to put toothpaste on toothbrush, to put brakes on wheel chair when s i t t i n g at a table. Physical assistance refers to minor active personal assistance. This may include handing a towel or soap to the resident while washing, handing t o i l e t paper to the resident when toileting, doing up the pants fastener when putting on pants, steadying a wheelchair during a transfer. Basically Partial Dependence is  designated when one step i n a series of behaviours involved i n the completion  Page J of an activity requires physical assistance from a staff mariner. Supervision occurs when there i s the possibility that the activity may not be completed adequately and, therefore the activity must be supervised. This occurs even though the resident i s able to conduct the activity independent at times. This supervision may occur when a resident i s transfering into bed, when the resident i s dressing or grooming or when he or she i s eating. In the case of walking, yellow refers to the a b i l i t y to walk short d i s tances without assistance or supervision. This may include mobility i n one's room, or within a circumscribed area where miiumum mobility i s necessary. Otherwise, the resident must be assisted i n walking, such as the use of a staff's arm for s t a b i l i t y or the use of a walker.  Total Dependence - Red - Score 3 The activity i s carried out for the patient.  This c r i t e r i a directly applies to a l l designated a c t i v i t i e s . With walking, the resident i s unable and thus, i s required to use a wheelchair for mobility. For those using wheelchairs, the resident must be pushed rather than propelling himself or herself..  APPENDIX H PAW DATA SCORES - FACILITY A  Page 1  Global ADL Groaning 7Ar±»./Trans. Dressing Eating T2 T2 T1 T2 T1 T2 T1 T1 T3 T1 T2 T3 T3 T3 T3 001 22.0 17.0 17.0 04.0 04.0 04. 0 07.0 07.0 05. 0 07.0 07.0 07. 0 40.0 35.0 33. 0 002 18.0 18.0  34.0 34.0  07.0 07.0  07.0 05.0  04.0 04.0  003 49.0 30.0 29.0 06.0 04.0 06. 0 14.0 05.0 10.0 09.0 07.0 07. 0 78.0 55.0 52. 0 004 51.0 39.0 39.5 06.0 06.0 06. 0 13.0 13.0 13.0 09.0 08.0 08. 0 79.0 66.0 66. 5 005 17.0 17.0 17.0 04.0 04.0 04. 0 05.0 05.0 05. 0 07.0 07.0 07. 0 33.0 33.0 33. 0 006 17.0 17.0 17.0 04.0 04.0 04. 0 05.0 05.0 05. 0 07.0 07.0 07. 0 33.0 33.0 33. 0 007 17.0 17.0 17. 0 04.0 04.0 04. 0 05.0 05.0 05. 0 07.0 07.0 07. 0 33.0 33.0 33.0 008 25.0 31.0  07.0 07.0  07.0 05.0  04.0 04.0  i' 43.0 47.0  009 17.0 04.0 05.0 07.0 33.0 010 17.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07.0 07.0 07.0 33.0 33.0 33.0 011 17.5 012 17. 0 013 17. 0 014 17. 0 015 17. 0 016 17. 0 017 17. 0 018 17. 0 019 17. 0 020 17. 0 021 17. 0 022 34. 0 023 17. 0 024 51. 0  17.0 17.0 17.0 17.0 17.0 17.0 17.0 17.0 17.0 17.0 24.0 17.0 43.0 025 17.,0 17.0 17.0 026 37.,0 25.0 027 028 029 030 031 032  15..0 31..0 15.,0 17.,0 17.,0 16.,0 033 23..0 034 27..0  17.0 17.0 17.0 17.0 17.0 17.0 17.0 17.0 17.0 17.0 28.0 17.0 43.0  15.0 15.0 17.0 17.0 17.0 17.0 15.0 15.0 21.0 20.5 19.0 17.0 035 43..0 35.0 51.0  04.0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 06. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04.,0 08..0 04.,0 04.,0 04.,0 04..0 04..0 04..0 04..0  04.,0 04.,0 04..0 04.,0 04..0 04.,0 04..0  04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0  04.,0 04..0 04.,0 04..0 04..0 04..0 04..0  05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 07.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 06.0 07.0 06.0 13.0 06.0 05.0 05.0 06.0 08.0 07.0 13.0  05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0 05.0  07.0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 07. 0 12. 0 12. 0 j  07.,0 10.,0 06.0 06.0 07.,0 07.,0 05.0 05.0 07..0 07..0 05.0 05.0 07.,0 07.,0 06.0 06.0 07..0 07..0 05.0 05.0 07..0 07..0 07.0 07.0 08..0 07..0 15.0 15.0 12..0 12..0  33.5 07. 0 33.0 33.0 33.0 07. 0 33.0 33.0 33.0 07. 0 33.0 33.0 33.0 07. 0 33.0 33.0 33.0 07. 0 33.0 33.0 33.0 07. 0 33.0 35.0 33.0 07. 0 33.0 33.0 33.0 07. 0 33.0 33.0 33.0 07. 0 33.0 33.0 33.0 07. 0 33.0 33.0 33.0 07. 0 52.0 44.0 40.0 07. 0 33.0 33.0 33.0 07. 0 67.0 59.0 59.0 07. 0 33.0 33.0 33.0 59.0 47.0 ",-  v  07.,0 07.,0 07..0 07.,0 07..0 07..0 12..0  32.0 62.0 32.0 33.0 33.0 33.0 42.0 46.0 72.0  32.0 32.0 33.0 33.0 33.0 33.0 32.0 32.0 37.0 36.0 38.0 36.0 66.0 80.0  Page 036 35.0 35.0 19.0 04.0 037 30.0 23.0 18.0 06.0 038 17.0 17.0 17.0 04.0 039 23.0 17.0 17.0 04.0 040 35.0 041 24.0 23.0 17.0 042 17.0 17.0 17.0 043 17.0 17.0 17.0 044 18.0 18.0 17.0 045 046 047 048 049 050 051 052 053 054 055 056 057 058 059 060 061 062 063 064 065 066 067 068 1/069  070  04.0 06.0 04.0 04.0  04.0 09.0 07.0 07.0 06.0 05.0 05.0 05.0 04.0 05.0 05.0 05.0 04.0 05.0 05.0 05.0  17.0 17.0 17.0 04.0 17.0 17.0 17.0 06.0 35.0 04.0 35. 0 18. 0 25.0 08.0 17. 0 17. 0 17.0 04.0 23. 0 21. 0 04.0 41. 0 23. 0 23.0 04.0 23. 0 17. 0 17.0 04.0 51. 0 51. 0 04.0 19. 0 17. 0 17.0 04.0 21. 0 19. 0 17.0 04.0 17. 0 17. 0 17.0 04.0 35. 0 18. 0 18.5 04.0 35. 0 19. 0 19.0 04.0 06.0 40. 0 51. 0 18. 0 17. 0 17.0 04.0 17. 0 17.,0 17.0 04.0 17.,0 17.,0 17.0 06.0 39.,0 33.,0 49.0 04.0 32.,0 19.,0 17.0 04.0 15.,0 15..0 15.0 04.0 17..0 17..0 17.0 04.0  04.0 06.0 04.0 04.0 04.0 04.0 04.0 04.0 04.0 04.0 04.0 04.0 04.0 06.0 04.0 04.0 06.0 04.0 04.0 04.0 04.0  55. 0 48. 0 33. 0 39. 5  55. 0 07. 0 07. 0 07. 0 07 .0 43. 0 07. 0 07. 0 07 .0 33. 0 07. 0 07. 0 07 .0 33. 0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 34. 0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 35. 0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 35. 0 04.0 05.0 05.0 05.0 07.,0 07. 0 07 .0 33. 0 04.0 09.0 09.0 07.0 09.,0 09. 0 07 .5 71. 0 04.0 05.0 05.0 05.0 TO.,0 10. 0 10 .0 36.,0 06.0 05.0 05.0 05.0 07..0 07. 0 07 .0 35.,0  04.0 06.0 06.0 06.0 04.0 04.0 04.0 04.0 04.0 04.0  04.0 04.0 18.0 17.0 17.0 04.0 04.0 19.0 19.0 19.0 04.0 04.0 17.0 17.0 17.0 04.0 04.0 50.0 35.0 28.0 04.0 04.0  07. 0 07. 0 07,.0 07. 0 07. 0 07 .0 07. 0 07. 0 07 .0 07. 0 07. 0 07 .0  04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 06. 0 04.,0 04.,0 04.,0 04.,0  09.0 06.0 06.0 06.0 05.0 05.0 05.0 05.0 05.0 05.0  05.0 07.5 05.0 05.0 09.0 05.0 13.0 05.0 05.0 05.0 05.0 05.0 08.0 05.0 05.0 05.0 10.0 09.0 08.0 05.0  06.0 05.0 05.0 07.0 05.0 13.0 05.0  06.0 05.0 07.0 05.0 05.0 05.0 05.0 05.0 05.0  07.0 07.0 07.0 07.0 20.0 08.0 07.0 07.0 07.0 08.0 07.0 07.0 07.0  05.0 05.0 05.0 05.0 08.0 05.0 05.0 07.0 05.0 05.0 07.0 05.0 05.0 07.0 10.0 10.0 08.5 06.0 06.0 08.0 08.0 06.5 07.0 05.0 05.0 07.0  07. 0 07. 0 07. C 18. 0 08. 0 07. 0 07. 0 07. 0 08. 0 07. 0 07. 0 07.,0 07.,0 07.,0 07.,0 08.,0 08.,0 07..0 07.,0  07. 0 07. 0 20. 0 08. 0 07. 0 07. 0 08. 0 07. 0 07. 0 07. 0 07.,0 07.,0 08..0 08.,0 07.,0 07.,0  51.0 57. 5 33. 0 39. 0 74. 0 40. 0 75. 0 35. 0 37. 0 34. 0 51. 0 51. 0 61. 0 34. 0 33.,0 35. 0 61. 5 53..0 34.,0 33.,0  53. 0 37. 0 41. 0 36 0 33. 0 33. 0 33. 0 33. 0 ?  42. 0 36. 0 33. 0 33. 0 33. 0 33. 0 34. 0 33. 0 33. 0 33. 0 35. 0 34. 0 33. 0 33. 0 57. 0 46. 0 36.,0 36. 0 35.,0 35. 0 35.0 33.0 37.0 52.0 34.0 75.0 33.0 35.0 34.0 35.0 35.0 72.0  42. 0 33. 0 54. 0 34. 0 33. 0 33. 0 34. 0 35. 0 35.0  33.0 33. 0 33.0 33. 0 35.0 35. 0 55.0 71. 0 37.0 35.,0 34.0 32.,5 33.0 33..0  197  Page 1  071 17.0 17.0 17. 0 04. 0 072 17.0 17.0 17. 0 04. 0 073 17.0 17.0 17. 0 04. 0 074 21.0 19.0 18. 0 04. 0  04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 04. 0 04. 0 05.0 07. 0 07. 0 07.0 07.0 07.0 37. 0 37. 0  075 17.0 17.0 17. 0 04. 0 076 17.0 17.0 17. 0 04. 0 077 15.0 15.0 15. 0 04. 0 078 15.0 15.0 15. 0 04. 0  04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0 04. 0  079 15.0 15.0 15. 0 080 15.0 15.0 15. 0 081 15.0 15.0 15. 0 082 17.0 17.0 16. 0 083 17.0 17.0 084 17.0 17.0 085 17.0 17.0 086 31.0 25.0 087 17.0 17.0 088 23.0 19.0 089 15.0 15.0 090 15.0 15.0 091 45.0 45.0 092 15.0 1 5 - 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FACILITY B  "Does  Pft4£  001  MoT  Page  Dressing Eating Groaming 7Arrib./Trans. G l o b a l 7ADL T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 17.0 1 7 . 0 17.0 0 4 . 0 04. 0 0 4 . 0 0 7 . 0 07.0 07.0 1 0 . 0 1 0 . 0 10.0 3 8 . 0 38.0 3 8 . 0 T1  002 5 1 . 0  51. 0 51.0  12. 0 08. 0 08.0  15. 0 15.0  15.0  12.0  16. 5 16.5  003  34.0  5 1 . 0 5-1.0  0 6 . 0 0 6 . 0 06-.0  09. 0 13.0 13.0  14.0  14. 0 1 4 . 0 . 6 3 . 0 8 4 . 0 8 4 . 0  004  17.0  17. 0 17.0  0 4 . 0 0 4 . 0 04.0 0 5 .  005 17.0 1 7 . 0 17.0 0 4 .  006  17.0  17.  0 17.0  04.  17. 0 17.0 04.  0  04.  0 04.0  0 04. 0 0 4 . 0 0 0 4 . 0 04.0 0 04. 0 0 4 . 0  90. 0 90.5  90.5  05.0  05.0  10.0  10. 0 10.0  36. 0 36.0  36.0  05. 0 05.0  05.0  07.0  07. 0 07.0  33. 0  33.0  33.0  0 5 . 0 0 5 . 0 05.0 07.0 0 7 . 0 0 7 - 0  33. 0 33. 0  33.0  33.0  33.0  33.0  0  05.0  05. 0 05.0  05.0 0 9 . 0 0 8 . 0 09.0 3 5 . 0 34.0 3 5 . 0  0 5 . 0 07.0  09.0 09.0  0 9 . 0 10.0  44. 0 55.0  74.0  04. 0 04. 0 04.0  05.  08.0  07. 0 07.0  33. 0 38.0  38.0  011 5 1 . 0  04.  15. 0  012 39.0 2 3 . 0 2 9 . 0  04. 0 04. 0 04.0  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F F.  F F F. F. F: F F F F M F F. F F F F F M M M  M M M F F F F F M M  M  Age 99 77 99 73 85 71; 83 79 84 90 83 83 79 77/ 88 85 85 95 94 92 71: 84 85 66  88  88 79 95 95 85 86 84 62 81 76 69 92 81 78 86 83 90 79 89 82  Length Primary Diagnosis of Stay 6 2 2 5 4 4 1 2 5 1 2 2. 6 4 5 3 2 5 2 3 7 5 1 7 i 1 7 7 1 4 2 3 1 4 2 1 2 6 2 2 4 4 4 2 2  22 mon. 01 23 21 09 15' 01 06. 22 17 01 03 21 14 01 02 01 10 25 23 24 25 04 25 05 06 07 05 03 20 12 25 12 09 01 24 10 21 25 25 06 02 01 01 08  Page  Subj.#  Sex  091 092 093 094 095 096 097 098 099 100 101 102 103 104 105 106 107 108 109 110  M M M M M M M M M M M M M M M M M M M M  Age 66 73 82 68 87 75 87 77 93 90 66 89 84 94 79 78 74 70 72 91  Length Primary Diagnosis of Stay 1 4 2 6 1 1 6 4 2 7 2 2 2 2 4 2 4 2 3 5  12 mon. 18 01 25 24 01 03 02 13 06 01 24 20 23 24 01 25 05 19 20  Subj.#  Sex  111 112 113 114 115 116 117 118 119 120 .121 122 123 124 125 126 127  F F F F F M M M F F F F F F F F F  Age 86 82 91 92 78 85 77 83 85 74 85 61 95 75 62 79 82  Primary Length Diagnosis of Stay 2 1 3 1 5 6 5 6 2 4 1 1 • 1 7 7' 2 1  06 mon. 25 01 21 20 01 13 25 01 10 24 13 01 02 02 05 06  208  /APPENDIX K DEMOGRAPHIC INFORMATION - F A C I L I T Y B  Page 2.1 0  Demographic Information (Facility B) Subj.# 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031 032 033 034 035 036 037 038 039 040 041 042 043 044 045  Sex Age F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F  79 71 71 68 80 76 88 92 80 87 82 85 81 85 68 92 61 78 86 85 74 75 90 70 60 75 83 85 77 79 86 82 85 86 90 62 82 95 82 63 61 72 85 76 91  Primary Diagnosis 1 1 6 1 2 5 6 2 5 2 1 3 4 5 4 4 4 3 2 2 6 6 2 4 1 5 1 7 2 2 1  1 1 4 2 4 3 6  7  6 5 1 1 6 1  Length of Stay 06 15 19 19 10 05 19 19 22 25 22 21 05 18 02 20 15 11 09 05 05 10 13 10 06 21 14 02 16 25 15 16 18 21 15 04 18 18 15 15 17 07 15 04 04  mon.  Subj.# 046 047 048 049 050 051 052 053 054 055 056 057 058 059 060 061 062 063 064 065 066 067 068 069 070 071 072 073 074 075 076 077 078 079 080 081 082 083 084 085 086 087 088 089 090  Sex Age F F F F F F F F F F F F F F F F F F F F F M M M F F M M M F F F M M M M F F M M M M M M M  60 87 86 80 86 94 85 93 93 83 85 95 90 96 96 78 85 64 66 82 80 60 65 79 92 83 62 74 71 92 74 79 83 70 65 75 88 79 68 75 72 65 71 63 88  Primary ./. Length Diagnosis of Stay 9 7 1 2 5 5 2 1 1 2 6 4 5 5 3 2 2 6 4 1 7 ' 7 4  7 7 2 4 4 5 6 2 6 2 7 3 4 7 4 4 1 2 1 6 6 6 6  16 15 17 15 15 22 16 16 07 16 07 19 23 06 06 16 12 15 20 14 01 04 04 04 20 19 01 02 01 06 12 20 03 13 17 15 10 14 19 26 01 19 11 17 11  mon.  Page  3ubj.#  Sex  Age  Primary Diagnosis  Length of Stay  Subj.#  Sex  Age  Primary Diagnosis  Length of Stay  091  M  65  1  20 mon.  111  F  87  5  10 mon.  092  M  65  4  21  112  F  77  5  04  093  M  68  4  18  113  M  85  3  05  094  M  61  1  21  114  M  72  7  06  095  M  88  2  19  115  M  85  4  18  096  F  79  2  02  116  M  88  4  01  097  M  73  7  01  117  M  75  4  18  098  M  65  5  03  118  F  87  1  15  099  M  66  4  04  119  M  72  1  07  100  M  93  1  17  120  M  87  2  19  101  M  77  2  18  121  F  87  1  19  102  F  89  2  18  122  F  99  4  21  103  F  92  5  19  123  M  77  1  22  104  M  86  4  03  124  M  90  1  02  105  F  89  2  01  125  M  74  7  02  106  M  91  2  16  126  M  78  4  22  107  F  84  2  17  127  M  66  4  05  108  M  85  5  18  128  M  80  7  06  109  M  79  4  04  129  M  62  4  17  110  M  84  5  15  130.  M  65  1  02  211  APPENDIX L RELIABILITY DATA FOR CONFUSION MEASURE FACILITY A  Page  R e l i a b i l i t y Data For Confusion Measure 5ubj.# 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031 032 033 034 035 036 037 038 039 040 041 042 043 044 045  Rater 1 3 3 3 3 1 1 1 1  Rater 2 3 3 3 3 1 1 1  1 1 1 1 1 1  1 1 1 1 1 1 1 1 1  1 1 1 1 1  1 1 1 1 1  1 1 1 1 1 1 2 3 3 3 2 1 1 1  1 1 1 1 1 1 1 3 2 3 2 1 1 1  1 1 1 1 2  1 1 1 1 3  Subj.# 046 047 048 049 050 051 052 053 054 055 056 057 058 059 060 061 062 063 064 065 066 067 068 069 070 071 072 073 074 075 076 077 078 079 080 081 082 083 084 085 086 087 088 089 090  Rater 1 1 1 3 1 1 1 3 1 1 3 1 3 1 1 1 1 2 3 1 1 1 2 2 1 1 1 1 1 3 1 1 1 1 1 1 2 3 1 1 1 1 1 1 1 1  Rater 2 1 1 2 1 1 1 3 1 1 3 1 2 1 1 1 1 1 3 1 1 1 1 2 1 1 1 1 1 3 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1  ( F a c i l i t y A)  Subj.# Subj 091 092 093 094 095 096 097 098 099 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127  Rater 1  Rater 2  213  APPENDIX M RELIABILITY DATA FOR CONFUSION MEASURE FACILITY B  Page 2J 5  R e l i a b i l i t y Data For Confusion Measure ( F a c i l i t y B) Subj.# 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031 032 033 034 035 036 037 038 039 040 041 042 043 044 045  Rater 1 1 3 3 1 1 1 1 1 3 1 3 3 1 1 2 3 1 3 1 2 1 1 1 1 1 1 3 1 1 1 3 3 1 1 3 1 1 1 1 1 1 1 1 1 3  Rater 2 1 3 3 1 1 1 1 1 2 1 3 3 1 1 2 3 1 3 1 2 1 1 1 1 1 1 3 1 1 1 2 3 1 1 3 1 1 1 1 1 1 1 1 1 2  Subj.# 046 047 048 049 050 051 052 053 054 055 056 057 058 059 060 061 062 063 064 065 066 067 068 069 070 071 072 073 074 075 076 077 078 079 080 081 082 083 084 085 086 087 088 089 090  Rater 1  Rater 2  1 1  1 3 3 1 1 1 1 1 1 1  1 1 1 1 1 1  1 1 1 1 1 1  1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1  1 1 1 1 1 1 1 1 1 1 ,1 1 1 1 1 1 1 1 1 1 1 1  1 1 1 1  1 1 1 1  1 3 3 1 1 1 1  Subj.# 091 092 093 094 095 096 097 098 099 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130  Rater 1  Rater 2  APPENDIX N RELIABILITY DATA FOR ADL ASSESSMENTS FACILITY A  Page  001  Dressing Eating Grooming Amb./Trans. G l o b a l ADL Tl T2 T1 v \T2 T1 T2 Tl T2 T1 T2 R1 R2 R3 R4 R1 R2 R3 R4 R1 R2 R3 R4 R1 R2 R3 R4 R1 R2 R3 R4 17  27  17  OA  04  07  07  07  07  33  33  002  18  18  04  04  07  07  07  07  003  51  47  31  27  06  06  06  06  15  13  12  08  10  08  07  74  56  48  004  51  51  41  38' 06  06  06  06  15  11  13  13  09  09  81  77  67  66  005  17  17  17  17  04  04  04  04  05  05  05  05  07  07  33  33  33  33  006  17  17  17  17  04  04  04  04  05  05  05  05  07  07  33  33  33  33  007  17  17  17  17  04  04  04  04  05  05  05  05  07  07  33  33  33  33  008  22  28  04  04  05  09  07  - 38  48  009  17  17  04  04  05  05  07  07  33  33  010  17  17  04  04  05  05  07  07  33  33  33  33  011  18  17  04  04  05  05  07  07  34  33  012  17  17  17  17  04  04  04  04  05  05  05  05  07  07  07  07  33  33  33  33  013  17  17  17  17  04  04  04  04  05  05  05  05  07  07  07  07  33  33  33  33  014  17  17  17  17  04  04  04  04  05  05  05  05  07  07  07  07  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05 05 05 05 07 07 07 07 33 33 33  33  054 2 1 2 5 .  04 04  05 05  07 07  •  0 5 5 43 39 24 22 04 04 04 04 10 08 08 06 22 18 21 056  54  29 29 21 08 08 04 04 08 07 06 06 07 07 07 07 64 51 46  0 5 2 41 053  04 04  22 24 17 17 04 04 04 04  057 51 51  04 04  .. • 41  37  19 79 69 53  ' . 55  05 05 05 05 09 07 08 08 39 41 34 34 15 11  07 07  .77 7 3  058 20 18 17 17 04 04 04 04 05 05 05 05 07 07 07 07 36 34 33  33  059  23 19 17 17 04 04 04 04 05 05 05 05 07 07 07 07 39 35 33  33  060  17 17 17 17 04 04 04 04 05 05 05 05 08 08 08 08 34 34 34 34  061  31  39 17 20 04 04 04 04 05 05 05 05 07 07 07 07 47 55 34  36  0 6 2 32 38 18 20 04 04 04 04 05 05 05 05 07 07 07 07 49 53 34 36 0 6 3 42 38  06 06  07 09  07 07  62  60  064 17 19 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 35 33  33  0 6 5 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33  33  05 05 05 05 07 07 07 07 35 35 35  35  51 47 04 04 04 04 1 2 08 08 12 10 07 09 07 63 60 72  70  0 6 8 30 34 17 17 04 04 04 04 11 07 07 05 09 07 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DATA FOR MEAN RATER SCORE AND VISUAL CHART ASSESSMENT  Y - v i s u a l chart assessment  X - mean raters' score Dressing Tl X  Y  X  T2 Y  X  Eating Tl T2 Y X Y  X  Goroaming Tl T2 Y X Y  Amb./Trans.  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