In this article, I want to focus on how carers can achieve the best possible outcomes for individuals living with dementia and all other forms of cognitive impairment by using the QCS PAL instrument. The last in the series of four, we will look at the Planned level of ability.
The QCS PAL Instrument provides a highly effective framework to help carers assess and understand the level of functional and cognitive ability of each individual they are supporting. It shows how it is possible to design activities that ensure the person can achieve their optimum level of achievement.
There are four different levels, each with a guide on how to support the person in personal, domestic and leisure activities including bathing/washing, getting dressed, dining, leisure activities etc. as well as therapeutic activities to promote well-being.
The Planned level of the QCS PAL Instrument describes those at the earliest stage of dementia. At this level, a person can carry out an activity by themselves, although they may need help with activities requiring high-level thinking, such as problem solving.
At this stage, individuals are usually just beginning to lose their highest levels of cognitive function, such as reasoning, forward-looking skills, making links and using their imagination. It’s important to stress here that no two people are alike when they experience dementia. Its presentation depends on lots of different factors, including which area of the brain has been affected first, although we do know that some conditions, such as Alzheimer’s disease, tend to follow a fairly predictable pattern.
One of the first lost skills is wayfinding. If an individual is in a new place such as when they go on holiday or visit relatives, they often struggle to find their way around. It’s often the case that families start to get concerned about their relatives after they’ve been on holiday or have spent time at Christmas together.
People at the Planned level might be very able in most situations, but they usually experience difficulty with high levels of thinking. They are fine when they follow their usual routines, and are in familiar places, but it’s when something goes wrong that they might face difficulties with problem solving.
With all levels, we need to take a person-centred approach. It’s not just about the symptoms caused by the condition, but also about understanding the personality of the individual, their life story and their physical health.
At the Planned level, caregivers should take care not do too much for the person. People often leap in and take over activities that the individual could do for themselves. They are then effectively disabled. So really the caregiver’s role at this level is to be on standby, to be there in background and be ready to step in.
If a problem arises, and the person can’t solve it, just give them a little tip to help with that activity rather than doing the whole thing. For example, if they are using a mobile phone but cannot remember their login number, help them create a technique to remember the number such as linking it to a memorable date or event.
At this level the person will be able to explore different ways of carrying out activities, work towards completing a task with a tangible result and look in an obvious place for any objects.
So if, for example, the person was involved in making a photo collage in the craft room, they would understand what the activity is, know the steps involved to complete it, hold the idea in their head while they are doing it and when they have finished, they will be able to look back to review what they have done.
The caregiver should enable the person by letting them be in control, allowing them to master the steps involved. Their role then is very much as a facilitator and an enabler, creating an environment in which the person can just get on with things.
It’s good to give the individual encouragement through positive recognition and reinforcement. But not sound patronising, as if talking to a child. If the person does hit a problem, then use language to help them solve the issue. Don’t step in and do it for them, rather say: “Shall we do that bit together?” This helps the person to maintain their sense of self-control and independence.
People might have difficulty with complex language because it can include quite ambiguous statements. If it’s too descriptive, people lose the thread. So with verbal directions, keep the language simple and don’t bombard them with too much information.
People at the Planned level can still enjoy all the activities of the other three levels covered in this series, such as the massage and sensory experiences. But at this level what they can do that others can’t are the more intellectual activities such as memory games, newspaper discussions, quizzes, crosswords and card games. Support them to take control, if they wish to, of these types of activities – such as becoming the Quizmaster or keeping score.
With all activities, the most important thing is that they are meaningful to the person and they enjoy doing them. So if someone has always been a keen gardener, they could choose what plants to put in a planter box. The carer could go with them to the garden centre to buy what they need, and be on standby for support.
Carers should make sure objects are in their usual familiar places or in a place that makes sense. For example, in the kitchen, the cups are hanging near the kettle and the spoons are in the drawer below.
A person at this level would have no problem getting dressed. But what would throw them is if they went to their wardrobe and items of clothing weren’t hanging in the right place, or the socks were in the underwear drawer.
The QCS PAL Instrument can be applied across a range of activities, and it helps deliver care that is rewarding for the individual as well as the carer. QCS provides a free download of the PAL Instrument which includes the Checklist that will identify the individual’s PAL level of ability. This then provides a writable PDF Guide on how to support the person in personal and leisure activities at the person’s level of ability. Carers can also include personal preferences and likes and dislikes of the individual and share it with colleagues and family members.
You can read the other 3 articles here.
You can download the PAL Instrument for free here
The article was first published at the Caring Times here