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Healthcare Training Institute - Quality Education since 1979

Section 11
Activity Programs for your Semi-Comatose Residents

Table of Contents | NCCAP/NCTRC CE Booklet

URGENT! STOP!
Read this before you proceed!
As you page through the rest of this Manual, you will probably notice the diagrams of Activity Projects, like the Mobile on the next page.  You may be thinking to yourself, “Gee, these are simple ideas!  I can just look at the diagram of the Mobile and figure out what that idea is!” 

Please do not make this mistake of confusing a simple idea with a simple implementation concept.  Since this course focuses on activities for the semi-comatose and low-functioning portion of your resident population, by the very nature of these residents, the projects have to be, well… “simple.” However, after viewing the DVD, I’m hoping it will be abundantly clear to you that the subtleties of implementation with semi-comatose and low-functioning residents can be, in fact, quite complex.  I guarantee that if you overlook the subtleties in implementing, for example, the three types of Mobiles to be described, you will end up saying to yourself…
            “This idea didn’t work with my Effie, who is in the advanced-stages of Alzheimer’s!” or
            “My resident did not respond!” or
            “He cannot do a thing!  All he does is lie there!  The Mobile idea doesn’t work!” or
            “Nothing can be done for these totally 'out of it' residents!”

And guess what?  You have just created a whole plethora of excuses…. why you do not have to work with, in fact, any of your Low-Functioning and Alzheimer’s residents!  So here you sit!  You have purchased this course, and it has ideas, as validated by the DVD, that work with the semi-comatose and low-functioning portion of your resident population. If you “blow these ideas off,” by flippantly paging through this Manual, glancing at the diagrams, saying to yourself, “Oh, is that all there is?!  I knew all this anyway,” you might end up tossing this Manual aside.  It will get buried under a stack of papers or activity catalogues on your desk...  And guess what?  Your Hazel, Millie, and Ernest, who are some of your Lowest-Functioning residents that comprise probably at least 60% of your resident population, sit there and lie there hour after hour, week after week, and month after month, with the Activities staff walking past them, and saying, “Nothing can be done for him!  Nothing can be done for her!” 

Are you writing some residents off as being unreachable?  I am being very strong here in my wording here,  by using the phrase “writing some residents off” because my goal is to verbally grab you by your shirt collar, shake you, and say, “Look at these ideas!  Read this material!  Don’t just flip through the Manual, look at the diagrams, and say ‘I know all this!’”  I am trying to get your attention by saying to you…

You know from the material in the DVD interviews what can be done, and I am about to tell you in this Manual in specific step-by-step detail exactly how to have a successful program with this lowest-ability segment of your resident population.  I hope this portion of the Manual has succeeded in convincing you to read through the explanation of the construction, implementation, and sample Care Plan goals and approaches for each idea.  However, don't just stop there.  After reading collect or purchase the materials needed, and construct the projects.  Then…
implement them with your Semi-Comatose and Low-Functioning Residents!

I’ll get off of my soapbox now and trust that you know where I am coming from, which is having a genuine concern for your Semi-Comatose and Low-Functioning residents, as well as, in an indirect way via this course, being an advocate for them.  If you are saying, “What’s the big deal? I plan to read this Manual anyway and implement the ideas”… Good for you!  Let's literally roll up our sleeves and get started with the "3 Types of Mobiles."

Heavy-care Residents
Before reading this section, you might view again Elizabeth on Track 7, Lillian on Track 8, and Mary on Track 9 of the DVD.  Elizabeth on Track 7, Lillian on Track 8, and Mary on Track 9 provide you with video examples of portions of the following Assessment Processes regarding implementation of programs for some of your heaviest care, semi-comatose residents.

Eyes - Openness, Movement, and Focus
1. Eye Openness (The last track of the DVD contains a slide illustrating implementation of this activity with a resident)
I have found that there are four key areas of assessment regarding a Semi-Comatose resident for purposes of activity program implementation.  Those four areas are: Eyes, Breathing, Gestures, and Vocalization.  In developing a Success Therapy® One-to-One Activity Program for a heavy-care resident related to eyes, you might assess first the amount of your resident’s eye openness.  (Success Therapy® refers to providing a resident with a successful experience, for even the heaviest care resident.  See Volume One in this Series should you wish more information regarding the Success Therapy® basics.  However, if use of this term is confusing to staff, do not use it.) 

2. Eye Movement
In addition to the first area of Assessment, Eye Openness, the second area of assessment is related to Eye Movement.  If your Mary's eyes are open, notice if she is looking to the left, to the right, or straight ahead.  If an advanced state Alzheimer's resident is looking to the right, I would use the following approach.

3.  Eye Focus
The third area of assessment in addition to Eye Openness and Eye Movement is to assess or evaluate your resident regarding the ability to have a focused, as opposed to an unfocused, look.  Sometimes when I am talking to residents, like Elizabeth, Lillian, or Mary in the DVD, and they are looking at me, I feel like they are looking straight through me.  In other words, the Unfocused look in her eyes tells me she is not telling or discerning the difference between my face and the curtains on the wall behind me. 

Residents with whom to try encouraging Eye Movement

Breathing - Depth and Rate
The second area of assessment, upon which you can build a One-to-One Individual Activity Program, is your residents' breathing.  So before you start this program based upon your semi-comatose resident's breathing patterns, you need to establish a baseline by listening to your resident's breathing.  I find that some residents—after I've been talking with them, gently stroking their heads, or having them smell vanilla, mint or lemon extracts—begin to breathe more deeply than they ever have before.  To encourage this response I might say something like, “Elizabeth, you’re breathing more deeply.  I think that you really know that I’m here," or, "That really makes me feel good. I feel by breathing more deeply, you are telling me that you know I am here.”   

I feel that when some residents have a certain level of awareness, perhaps breathing more deeply is the only way that they can communicate their awareness of attention.  The Approaches would be as follows.

Responsibility
Once again, I do need to emphasize that there is an element of responsibility whenever you are working with this Semi-Comatose resident who requires especially heavy-care.  So, encourage CNAs, your staff, and volunteers to ask themselves, "Does this resident normally thrash around and moan?  Or does she only thrash around and moan when I speak directly into her ear?"  She may be indicating her preference to you to stop doing what you are doing.  Only the most sensitive of volunteers and staff should be selected to work with these heavy-care residents, and impromptu, frequent observations should be made of the volunteers’ or staff members’ implementations of the types of programs I am describing here.   Other courses in this series deal with making time for small group activities and how to gain staff  cooperation and support.

Assess Breathing Rate or Speed
The second way to assess breath is related to resident's rate or speed of breathing.  Oftentimes, when I work with a resident, he or she does not start to breathe more deeply, as described in the previous section, but starts to breathe more rapidly. So, the goal might be as follows:

Instruct Staff and CNAs to Stop and Listen!
However, in order to evaluate a change in the resident's Rate of Breathing, you need to stop first and listen to how he or she is breathing before you approach the resident, or else you will probably not notice a change.  This is, I believe, how many advanced Alzheimer's residents are "written off" by a few of your staff as being "hopeless," "unreachable" or "too far gone."  They may state, "Nothing can be done for, or with, certain unreachable residents." 

By not observing what the resident is doing before starting to work with that resident, a CNA or Activity staff member may see no change.  Therefore, since no change is observed, he or she may state or think, "Nothing can be done" or "Nothing gets through to Elizabeth."  Do you agree that these thoughts may be true for some of the staff in your facility?  I feel very strongly that your Elizabeth is "trying" to communicate that she is aware of the staff member’s presence by the only means possible… perhaps by increasing the rate or speed of her breathing, or by a Gesture or Vocalization to be explained next. 

Try this period of observation for a few seconds prior to working with this kind of resident, and see if you agree or disagree with what I have just said regarding attempts at communication with your semi-comatose "Elizabeths."

Residents with whom to try  encouraging Breathing Depth and Rate

Gestures - Hand, Head, and Face  
If a semi-comatose resident can respond with Eye Movement and Breathing patterns, evaluate if he or she can respond with a Gesture. However, some residents whom I have interviewed can “respond with a Gesture,” but never show changes in their eyes or breathing patterns.  I divide Gestures into three sub-categories: Hands, Head, and Facial Expressions.  Let's talk about your resident's hands first.  

1. Close and Open Hand
A Goal regarding an Activity staff member, CNA, volunteer, etc. getting responses from semi-comatose or heavy care residents related to their hands might be as follows:

Several interviews on the DVD that accompany this Manual illustrate how to assess your resident's hand movements.  If you have overlooked the subtle, but important skills for assessing hand movements, consider replaying the DVD to observe how I assess hand skills specifically.  In summary, the first question to ask yourself regarding an activity program built around Gestures is, "Can my resident close and open his or her hand upon request?”  or  “Can my Mary close and open her hand after I have demonstrated what I want her to do?"  If the answer is "yes," then that becomes the basis for your activity program and Care Plan Goal.

2. Squeeze Hand
This brings us to the second category of Gestures, Squeeze Hand.  Squeeze Hand means exactly that.  The idea behind this activity is for the resident to squeeze your hand.  Rather than opening and closing their hands upon request, as described in the preceding section, you are placing your hand inside the resident’s, as indicated in the drawing above and asking Mary to squeeze your hand.

For the first "total physical assistance" Goal above, here is how you, your Activity Staff, CNA, Volunteer, etc. can implement Squeeze Hand with "total physical assistance":
1. Put your hand inside the resident's hand, as illustrated.
2. Cup your other hand around the outside of the resident's hand.  
3. Squeeze through your resident's hand. 
Since this activity can be totally passive on the resident's part, it is appropriate for a semi-comatose resident and can provide your resident an opportunity to experience success even though "Squeeze Hand with total physical assistance" is a totally passive activity.  The "success" comes in the Care Plan Approach below:

Finding Little Golden Nuggets
I often am amazed at the residents who are labeled by staff as being totally unreachable.  However, they are sometimes able to squeeze my hand upon request.  I challenge you, after reading these four assessment areas regarding Eyes, Breathing, Gestures, and Vocalizations, to go out into the rooms of your most "unreachable" semi-comatose heavy care residents.  Be patient.  Try more than once, try at different times of the day, and I welcome you to be surprised at the little "Golden Nuggets of Ability" you will find.

Share your Golden Nuggets with CNAs!!
The next challenge I give you is to tell other staff what you have discovered.  Share it!  Share it!  Share it!  Talk about how Hazel responded with a hand squeeze in the Care Plan Conference; talk about it in your Activity Room with the other activity staff, to CNAs, and to your volunteers.  Get them excited too. 

By hearing about what you have discovered regarding what Hazel could do, others may feel encouraged to try to get other residents to have successful experiences. 

Give an In-Service to CNAs!  Oops…
Oh gosh, I hope I am not getting too carried away and really scaring you now.  At this point you may be thinking, "An in-service on eyes, breathing, and hand gestures?! Not in my facility!"  So let me take a step back… just try the Breathing, Eye, Gesture, and Head (to be presented next) exercises, and then do what feels right for you in your facility with the level of support you are receiving.  But if you are not receiving the support that you feel you need from the other departments, don't forget about the Team Building course we offer at some point in the future.  Trust your feelings regarding the timing of providing an Inservice.   Now, on to turning heads.

3.  Turn Head
The third category of Gestures that you might try implementing with heavy-care and semi-comatose residents, in addition to Squeeze Hand and Close and Open Hand, is to “Turn Head" with assistance.  For example, if the resident is lying or sitting with his or her head turned to the left, and you are not getting a response, you might stand to the resident's right, and gently slide your hand under the back of his or her head and say something like, “Lillian, can you look in my direction?  Let's see if you can look at me, Lillian.”  Then, you gently cradle Lillian's head towards you.  As you will notice, this procedure is similar to the one outlined above regarding eye movement.

For a more capable resident, of course, if he or she is looking to the left, you stand to the right, and as in the case of eye movements, you would like for your resident to turn his or her head in your direction. 

4.  Facial Expression
The fourth category of Gestures is Facial Expressions.   I find there are three categories of Facial Expressions: a Look of Recognition, a Change of Expression and, finally, a Smile.

a. Look of Recognition
Let's discuss the look of recognition accomplished via a movement of your resident's cheeks, brow line and/or eyes.  

Now, we are moving to a step above the semi-comatose level, as you can tell.  Even though your resident is unable to speak, he or she may have a look of recognition when spoken to.  This look is not necessarily the recognition of you as an individual, as compared to other staff members, but just the recognition of you as a person, as compared to a blank look as if you were no different from the curtain, wall or hallway behind you.  So consider basing your program around reinforcing your resident for having a look of recognition on his or her face when being spoken to. 

In order to implement this program:
1) Observe your resident's Facial Expressions prior to talking to him or her.
2) Ask yourself, once you start your monologue:
         a) "Is there a change in my Elizabeth's cheeks? " 
         b) "Is there a change in her brow line?" 
         c) And, as mentioned in the first part of this section, "Is there a change in her eyes?"

b. Change of Expression
The second type of Facial Expression is noting merely a change of expression.  This is a step lower than the previously explained look of recognition.  A change of Facial Expression refers to any change in a resident's facial muscles that happens when you are carrying on your monologue with your Elizabeth, as illustrated on the DVD. Even though the facial parts are the same as above, this reaction lacks the subjective emotional quality of recognition.

c. Smile
However, the change of expression discussed above is not a smile.  A smile indicates a social awareness and an awareness of a feeling of happiness, and so on.  Thus, a smile would be a very high-level Goal for these heavy-care residents.  Thus, these higher levels of Facial Expression Goals and Approaches could be as follows:

Residents With Whom to Try Encouraging Gestures: Hand, Head, and Face

Vocalization - Noise, Sound, and Word
In addition to Eyes, Breathing and Gestures, the fourth area of Activity Program development for an advanced-stage Alzheimer's resident is Vocalization.   I have divided Vocalization into four categories from the lowest to highest levels of ability. The categories are as follows:  Physical Noise, Meaningless Sounds, Meaningful Sounds, and a Word.  First, let's discuss a semi-comatose resident who responds with a Physical Noise.

1. Physical Noise
The first and simplest goal for the heavy-care resident is simply as follows:

A Physical Noise is not to be confused with a higher-level meaningless vowel or a consonant Sound, to be described next.  This Physical Noise may be a moan or a grunt.  However, I feel that, as in the case of breathing, described previously, the Physical Noise can be the resident's way of responding, at the level at which he or she is physically and mentally capable, to a "social" interaction.  Thus, you might develop a program with the following Goals:

Establishing a Baseline is Crucial
Once again, I might remind you that in order to implement these activities, you have to establish a baseline in your mind.  What I mean by baseline is, when you walk up to your Mabel, ask yourself:
--What is he or she normally doing before I approach her?  
--Is she already making a Physical Noise? 
--Or, do I get the feeling that the Physical Noise is being made in relationship to her interaction with me? 

If the Answer is "Yes," Then You’ve Got It!
You've found something upon which to build your activity program!  Tell a volunteer about your successes and see if he or she is flexible enough to visit just one or two of these low functioning residents before he or she conducts their normal group Bible Study, bingo, or other Group Activity.  Incidentally, in our management series we offer a course regarding recruiting volunteers, which includes information on how to get volunteers to work with more than just your high-functioning residents.  Interested?  Obviously the one-to-one activities I am describing here take time.  Volunteers as well as CNA involvement are key.

2. Meaningless Sound
The second Vocalization, at a slightly higher level after Physical Noises, is a Meaningless Sound.  This would be a vowel or a consonant Sound like "ba, ba, ba," "da, da, da," and so on.  The Meaningless Sound is not to be confused with the previous response described, regarding the resident merely making a Physical Noise like a moan or a groan.  

Thus, your resident is provided with a feeling of success!

3.  Meaningful Sound
In addition to Physical Noises and Meaningless Sounds, the third category of Vocalization is Meaningful Sounds.  However, don't be confused. I am not talking about Words yet, but Meaningful Sounds. For example, as you ask your Mary, “How are you today?” she might say, “Ba, ba, ba.”  To me, “ba, ba, ba” is a Meaningful Sound, since it seems to me at that time during that specific interaction to be in response to something I was doing, i.e. asking Mary "How are you today?"  So a "Meaningful Sound" Goal for the type of activity program could be as follows.

If your Mary's "ba, ba, ba" sounds louder and harsher than yesterday, or in any previous sessions, you might decide to reply, "Mary, you are talking louder than usual today.  I am wondering if you are telling me that you are upset about something today."  Use your best judgment.  If the increase in her Sound level is extreme, perhaps nursing should be notified of a potential physical problem she might be experiencing.  As you are aware, sometimes you are put into what can be an uncomfortable position of serving as an advocate to nursing for your lower functioning residents. 

4. Word
The fourth category of Vocalization is the residents’ uses of Words.  Especially when residents are starting to decline from the middle into the advanced stages of Alzheimer's, I feel it is very important to encourage the resident to continue to use as many Words as possible.  So, if Fannie says, "Blah, blah, blah, happy, blah, blah, blah, baby, blah, blah, blah," ask questions, Inservice staff, volunteers, etc. to repeat back to her the few Words you could understand.  Ignore the Sound you cannot understand.  So you might say in a questioning tone, “Happy?" and "Baby?”  It may feel right to then ask two brief questions using your Fannie's Words, “Are you happy today?  Are you thinking about your baby?”  Thus, make up very simple questions, repeating her words back to her. The goal is to try to get Fannie to use as many Words as possible.  This technique is illustrated throughout the DVD interviews.  If you did not notice my repetition of residents’ Words, don't be surprised, because it is a subtle technique.  You might consider replaying the DVD with the specific intention of observing the skill of using residents' words in questions back to them.

With the resident who has an extraordinarily short attention span of less than one minute…
1) Try a short, reality-based conversation related to something that they see, or
2) Something that he or she is "talking" about with you.
3) Saying your Fannie’s own Words back to her in order to help her to focus. 

Pick out the reality parts
Here's a final example.  A resident with a short attention span might say, "Fannie, Fannie, Fannie, gotta get Fannie.”  You might respond back, “Fannie?  Who is Fannie?", if that is not the resident's name and you do not know who Fannie is.  Stay reality-based.  The resident might then say, “Go to store, go to store, time to eat.”  You might reply by picking up on the reality part of her words, “Time to eat?  Are you hungry?”, thus ignoring "go to store."  In this case, when you have a choice, try only using the resident’s reality-based Words to make a question back.  Clearly, she is not going to the store.  So to prematurely ask, “Are you going to the store?” pushes her more into non-reality and disorientation.

Use what you have.  If Fannie said, "Work, work, I am late to work!", I would ask, "Did you like your job?  What did you use to do?" 

There are not hard and fast rules here, and clearly in the same conversation you may bounce back and forth between reality orientation and validation therapy.  If you don't know about these, a Google internet search should supply you with plenty of information.  However, your main purpose for a resident at this level is to, of course:
Rule #1) Encourage your Fannie to continue to communicate by asking her questions.
Rule #2) Encourage your Fannie to continue to use Words by asking questions using her Words. 

Why ask questions using her words, you may ask?  Because the next step down the ability-scale happens when Fannie stops using Words, as outlined in the preceding section.  She just starts to make Noises and withdraws.  So, Inservice CNAs, Activity Staff, Volunteers, etc. to encourage your resident's use of Words, even though the words may really not make sense most of the time.  If this could be part of basic CNA training and practiced on a regular basis, just think how much capability a resident could retain for longer periods of time.  But how often do two staff members in a room talk to each other, rather than to the resident, seizing that time in the resident’s room as an opportunity to help keep their Fannie mentally alert?  (If you are saying, "Yes, I agree!", at the risk of sounding like a broken record, at some point in time, consider checking out our "Team Building" and "Staff Support" courses.)

Here's How to Avoid Writing Pie-in-the-Sky Goals
In the previous section, we discussed Vocalization, which were subdivided into the categories of: a Noise, a vowel or consonant meaningless Sound, a vowel or consonant meaningful Sound, and Words.  Let's say after reading that section you go to your Care Plan Goal for an extremely disoriented resident, Elizabeth, and the goal you wrote before reading the Manual stated, "To name a picture…" However, Elizabeth does not Vocalize, nor does she have Eye Contact with the picture.  So… you guessed it!

Thus, the key to writing Goals for your semi-comatose, advanced Alzheimer’s residents becomes writing small, obtainable goals.  Do you need to get the pie-in-the-sky, sounds-good-on- paper ideas out of your head?  CMS Survey Teams see through these in a heartbeat.  They will tell you, "You don't know your resident!  I have interviewed her and there is no way Elizabeth can 'name a picture.'  She has no eye contact!  She cannot speak!"  And there goes the ballgame, so to speak.  CMS Surveyors, one, Activity Director, zero.  Now what?   You know what… a possible deficiency for your Department.   Are obtainable goals an area you need to look at?  Do you feel it important to write small obtainable goals for your semi-comatose, advanced Alzheimer’s residents?  If so, good!  The Goal revisions for your Elizabeth might encompass the following sequence:

However, due to the nature of Alzheimer’s disease, dementia, delirium, and so on, many residents progress downward.  So, perhaps your goal revisions will go in reverse order:

Goals obviously always need to be realistic.  I know that you know this.  However, knowing and doing are two different things.  Agree?  And, perhaps some of your Goals are not realistic, because before taking this course you did not know how to develop a program for your lowest-functioning Elizabeth’s, Lillian’s, and Mary’s.  But, guess what?  Now you know. 

So, as each Care Plan is due for revision, consider using this Manual and the other Manuals from the other courses in this Series.

Residents with whom to try Vocalization