This article, the second in a series of four, looks at how carers and activity providers can achieve and maintain a sense of wellbeing for individuals living with moderate to severe dementia. The focus is centred on how to support a person at the sensory level as defined by the QCS PAL instrument.
In any care setting it is important to create an environment that helps a person achieve their optimum level. To do this, we focus on abilities, what individuals can do, and not only what their challenges are.
The PAL tool, a widely used framework in care settings across the UK and around the world, assists with this. Using a strengths-based approach, it comprises a series of questions that define the functional and cognitive ability of the individual at four different levels: Planned, Exploratory, Sensory and Reflex.
The tool assesses the individual’s overall level of cognitive and functional capability. It helps design care and activity plans that champion the person’s unique abilities while supporting them with their difficulties.
In the previous article, we looked at people at the Reflex level, who only respond to stimuli through their reflex zones. Those operating on a PAL Sensory level are concerned with sensations and move their body in response to those sensations. This is a higher level of ability than the reflex response of people with very advanced dementia.
At this level, the person doesn’t have many thoughts or ideas in terms of planning or carrying out the steps of an activity or seeking a connection with somebody. But they are able to respond to sensations such as touch, taste, sounds, visuals, smells and the sensory feedback in joints and tendons from movement.
They are unable to complete complex tasks. The onus is on care partners therefore to really understand an activity, break it down into simple steps and offer multi-sensory experiences and support one step at a time.
Putting on a cardigan, for example, is quite a complex task when you boil it down. You have to take hold of it, pass each arm other through the sleeves while manouevering the garment across the shoulders and finally do the buttons up.
To promote a sense of wellbeing with this more complicated type of activity, you need a single step approach. You might complete some of the steps for them, while using encouraging communication techniques such as simple action words and a warm tone of voice. They can complete a finishing touch such as doing up the last button or admiring themselves in the mirror when their cardigan is on. That way, they experience both the sensory component of the activity as well as a real sense of achievement.
Creating a multisensory environment is important at this level. To achieve this, we draw on sensory integration techniques, bringing different sensations together into a whole.
For example, if you are trying to stimulate someone to be more alert in the dining room, play some music with a fast beat, make sure the food on a person’s plate is colourful and use a bright yellow tablecloth.
If somebody is showing signs of anxiety, try a combination of calming sensory experiences. Play relaxing music or perhaps a recording of bird song, use lavender essential oils, place a comfortable armchair in a quiet corner that is decorated in calming colours.
When it comes to activities such as having a meal, ensure there is physical contact between the object and the person. For example, put a fork into their hands so they can feel it. This may stimulate a reaction whereby they move the fork and eat by themselves.
If it doesn’t, then the ‘hand under hand’ technique might help. This is when the carer puts their hand under the person’s to guide them, for example, raising their hand to their mouth. This not only stimulates a tactile sensation but also a kinesthetic one. The initial movement may act as a trigger for the individual, providing a sensory cue to help them continue with the activity.
Using reassuring sensory objects is helpful in creating a sense of comfort, safety and belonging. For example, HUG, a comforting device designed to be cuddled, includes a beating heart and a music player within its soft body. It provides an effective vehicle for a carer to connect better with a person, and to ensure a rewarding experience for both.
If not HUG, an old teddy bear, or a comfort blanket, can be equally effective. What’s essential is that the object is important to the person and that it provides a sense of attachment. But sensory objects can also be used to stimulate alertness. Highly textured objects such as pine cones, for instance, can be great for exploration through touch.
The PAL Guides provide a number of ideas for carers to stimulate the five senses as well as suggestions that focus more on movement. These include single step activities such as wiping the table, winding balls of wool or sweeping outside. If the person has good balance and mobility, then gentle movements to music with the care giver are a good vehicle for therapeutic interaction.
What’s key is that the activity must be something that the person would enjoy. The PAL instrument includes a Life History section which enables a carer to document the individual’s past, their character, personality, career, home life and interests. By accessing this information, the care giver will be able to create an individually tailored plan that delivers multi-sensory activities that promote wellbeing.
You can also read part I of the series here.