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Therapeutic implications of intergenerational programs with Alzheimer's patients

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Title:
Therapeutic implications of intergenerational programs with Alzheimer's patients
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Roschbach, Jacquelyn
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English
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69 leaves : illustrations ; 28 cm

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Subjects / Keywords:
Alzheimer's disease -- Treatment ( lcsh )
Intergenerational relations ( lcsh )
Alzheimer's disease -- Patients -- Care ( lcsh )
Alzheimer's disease -- Patients -- Care ( fast )
Alzheimer's disease -- Treatment ( fast )
Intergenerational relations ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 66-69).
General Note:
Department of Humanities and Social Sciences
Statement of Responsibility:
by Jacquelyn Roschbach.

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|University of Colorado Denver
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|Auraria Library
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Resource Identifier:
45217380 ( OCLC )
ocm45217380
Classification:
LD1190.L65 2000m .R67 ( lcc )

Full Text
THERAPEUTIC IMPLICATIONS OF INTERGENE RATIONAL
PROGRAMS WITH ALZHEIMERS PATIENTS
by
Jacquelyn Roschbach
B.A., State University of New York at Stony Brook 1992
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Social Science
2000


This thesis for the Master of Social Science
degree by-
Jacquelyn Roschbach
has been approved
by
Date


Roschbach, Jacquelyn (M.S.S., Master of Social Science)
Therapeutic Implications of Intergenerational Programs
With Alzheimers Patients
Thesis directed by Myra Bookman
ABSTRACT
A survey of family members, friends, caregivers, and educators will
demonstrate the positive and negative aspects of current modalities of
communication between Alzheimers patients and caregivers and compare
them in use to intergenerational programs with Alzheimers patients. Research
has shown that interaction between children and Alzheimers patients has
positive therapeutic effects. By combining successful interaction skills utilized
by caregivers, with the positive outcomes from intergenerational programs, a
new approach to communicating with Alzheimers patients can begin to be
developed. The goal is to improve the quality of interactions between
Alzheimers patients and their caregivers, based upon the successes of
intergenerational programming. Special attention will be paid to comparing the
successful intergenerational interaction techniques to the current models of
thought, including Reality Orientation, Reminisce Therapy, and Validation
Therapy.
This abstract accurately represents the content of the candidates thesis. I
recommend its publication.
Signed
in
Myra Bookman


ACKNOWLEDGEMENT
My thanks to the residents, families, and staff at Elms Haven Care Center for
their time, efforts, and patience in helping me complete my masters thesis.


CONTENTS
Figures vi
CHAPTER
1. STATEMENT OF PROBLEM 1
2. RESEARCH OBJECTIVE 3
3. REVIEW OF THE LITERATURE 4
4. DESCRIPTION OF PROJECT 11
Subjects 11
Activity 12
Prior Controls 12
5. EXPECTED RESULTS 13
6. RESULTS 14
7. DISCUSSION 42
APPENDIX
A. STAGES OF ALZHEIMERS DISEASE 50
B. SURVEY AND CONSENT 53
C. PROPOSAL FOR FURTHER STUDY 58
REFERENCES 46
v


FIGURES
Figure
1. Alzheimers Patients are
Uncomfortable with Children 15
2. Reality Orientation 16
3. Validation 18
4. Reminiscence Therapy 19
5. Children Dislike Intergenerational
Programming 21
6. Alzheimers Patients are Friendlier with
Adults Than Children 22
7. Reality Orientation to Current Events 23
8. Children Fear Alzheimers Patients 24
9. Children Using Reality Orientation
Causes Violence 26
10. Success of Intergenerational Programs 27
11. Reality Orientation 2 29
12. Children Use Reality Orientation 30
13. Experience With Alzheimers Patients 31
14. Categories of Respondents 32
15. Overall Reality Orientation 33
16. Success of Reality Orientation,
Beginning Stage 34
17. Success of Reality Orientation,
Middle Stage 36
18 Success of Reality Orientation, End Stage 37
19 Success of Intergenerational Program,
Beginning Stage 38
20 Success of Intergenerational Programs,
Middle Stage 39
21 Success of Intergenerational Programs,
End Stage 40
22 Reality Orientation vs. Childrens Use
of Reality Orientation compared with
Sucess of intergenerational Programs 41
vi


CHAPTER 1
STATEMENT OF PROBLEM
Three main paradigms teach caregivers how to communicate
therapeutically with Alzheimers patients: Reality Orientation, Reminisce
Therapy, and Validation Therapy. Each of these methods has benefits and risks
in determining the success of an interaction. The goal of any interaction
between caregiver and patient is one where messages are communicated
effectively and both partys mood remains positive. When one is interacting
with a confused person, such as a patient diagnosed with Alzheimers disease,
communicating can become difficult and tedious. When two people without
cognitive deficits interact, it is assumed that they both the same perception of
reality. Both individuals are aware of the time, location, and the social
expectations involved in communicating in a particular situation. When an
individual has Alzheimers disease all of these factors have been compromised.
The three paradigms that currently exist are designed to help caregivers cope
with these deficits.
Reality Orientation was initially designed to help mentally ill individuals
cope with reality and become productive members of society. This method
involves correcting the person and making them aware of the expectations of
the particular situation. Critics of this approach state that there are no benefits
in orienting an Alzheimers Patient to reality. Reality Orientation causes


additional unneeded stress and re-integration into society is not necessarily a
reasonable goal.
Reminiscence Therapy has the same primary goal as Reality
Orientation. The methodology varies in that the caregiver is encouraged to
discuss old memories with the confused person and gradually orient them to an
understanding of present day reality. For example, a caregiver would reminisce
with the Alzheimers Patient about their wedding day and their life with their
spouse, with the objective of reminding them that are currently a widow.
Caregivers continue to argue that the goal of this model has no benefit,
orienting a confused person to reality.
Naomi Feil created Validation Therapy for caregivers to focus on the
importance of the patients emotions and not their orientation to reality. She
argues that with memory loss, reality orientation is frightening and not
therapeutic. Validation Therapy continues to grow in acceptance and its use is
encouraged by the National Alzheimers Association (Feil 1993).
With all of the experts being unable to agree on a single method of
interaction, caregivers are left in a quandary. They use different pieces of all
three methods interchangeably and hope for successful interactions. The one
thing that all three theories agree upon, is the positive outcomes achieved
during interactions with Alzheimers patients and children. This is perplexing,
because children are focused on their own reality and tend to impose their
reality on others around them. An in-depth study of current approaches
utilized by caregivers and their impressions of intergenerational interactions
may yield implications for a new therapeutic model of interaction.
2


CHAPTER 2
RESEARCH OBJECTIVES
The objective of this study is to help begin to create new approaches for
caregivers to utilize to successfully interact with Alzheimers patients.
Interactions between caregivers and demented individuals can be disruptive and
painful for all involved, if not carefully negotiated. Alzheimers patients have
lost their ability to comprehend abstract reasoning. The socially constructed
rules of what you can and can not say or do in certain situations no longer exist
for these individuals. This can cause great amounts of stress on caregivers.
Caregivers are always searching for answers on how to handle even the simplest
of situations without upsetting the confused person or emotionally burdening
themselves.
Alzheimers patients typically respond well to interactions with children.
Research has proven time and time again that intergenerational contact can
create positive interactions for Alzheimers patients. Is there something
inherent in the way that children act towards individuals that are confused?
Can these methods of interaction utilized by children, be taught to caregivers to
help them improve the quality of their interactions with Alzheimers patients?
How do caregivers view intergenerational interaction in comparison to then-
own methods of interaction? I hope that this research study will be beneficial in
providing some answers to help improve the quality of interactions between
Alzheimers patients and their caregivers.
3


CHAPTER 3
REVIEW OF THE LITERATURE
Alzheimers Disease is defined by the National Alzheimers Association
as a progressive, degenerative disease that attacks the brain and results in
impaired memory, thinking, and behavior. It is the most common form of
dementia. Dementia is the loss of intellectual functioning so severe that it
interferes with an individuals daily functioning (thinking, remembering and
reasoning) and eventually results in death (see appendix A for information
about the stage of Alzheimers Disease). The time period between diagnosis
and death can range from anywhere between three and twenty years.
Cause of this disease, despite extensive research remains unknown.
Diagnosis itself is considered to be a rule out process. Physicians test for other
related conditions and when no other conclusive results can be reached an
Alzheimers Diagnosis is established. The only conclusive test for Alzheimers
Disease is a post mortem autopsy of the brain. As of today there is no cure.
As the disease progresses individuals with Alzheimers disease require
increased care and supervision to the point where twenty four hour supervision
will become mandatory. The individual will eventually require assistance with
all activities of daily living including dressing eating and toiling. Currendy a
billion dollars a year is being spent nationally on the care needs of Alzheimers
Patients alone (Alzheimers Association, 1994). This figure does not include
4


the non reimbursed costs of families caring for loved ones at home. This
disease process does not only effect the life of the individual diagnosed, but also
has drastic effects on those who are a part of their lives and most particularly on
the family unit.
Coping and Caring (1993) a publication by CARP for caregivers of Alzheimers
disease patients published some vignettes that provide excellent examples of the
caregiving experience.
Caregiving involves the most intimate tasks feeding, bathing, helping a
loved one use the toilet, and in some cases changing underclothes. It is
non-stop on-call care.
Eighty percent ofall caregi vers, and almost all spouse caregivers, pro vide
care seven days a week. Families caring for loved ones age 70 and over
spending an a verage of 80 hours a week in caregiving activities. Caring for an
Alzheimers patient is a 24 hour a dayjob. It is like running a marathon
without ever coming to the finish line.
Our friends stopped calling, said an Arizona man whose wife received a
diagnosis ofAlzheimers disease. You just get cut offfrom the community,
isolated.
These examples, unfortunately, are the normal attitudes of families and
the community when someone is diagnosed with Alzheimers Disease. Social
ties are generally the first to disintegrate. This generally is true, because the first
losses that occur in the Alzheimers patient brain effect their ability to think
abstractly. Social rules fall under this category. Individuals diagnosed with
Alzheimers disease tend to act like small children at times. They will say or do
5


what ever is on their mind. For example: A woman was with her mother
(who had Alzheimers disease) in a restaurant standing on line waiting to pay
the bill. When the daughter looked over, her mother had her skirt hiked high
over her head and was pulling up her stockings. When her daughter, very
embarrassed, asked her why she was doing that there, her mother responded
simply by stating her stockings were falling down so she picked them up.
Behaviors such as this, while innocent and harmless can have drastic effects on
social and family ties. It becomes too embarrassing to have the family member
with Alzheimers disease attend family events, be around when there is
company over, or be around young children, because society does not
understand or allow these types of behaviors to occur in public.
Alzheimers Disease is a neurological condition causing deficient
thinking and remembering (Alzheimers 1992). Individuals with this diagnosis
progressively become disoriented to time, place, and person. This disease
effects not only the individual diagnosed, but also their caregivers and family.
Caregivers use several methods to interact with individuals suffering from
Alzheimers disease. Professional caregivers vary in their belief as to the
successes and failures of each model. The three most common models used
today are reality orientation, reminisce therapy and validation therapy.
Reality orientation is the oldest of the three models (Holder and Woods
1982). Current authors such as Greed Murphy Jr. in Treating of the Elderly
(1996) continue to emphasize the success of this modality. The creation of this
model was based upon the successes of using reality testing and behavioral
modification with the mentally ill. Proponents of this theory argue that self
6


respect and self esteem are based upon an individuals ability to comprehend
and predict reality (Reeve & Evasion 1985). Theorists assert that the
Alzheimers patient must remain oriented to reality for as long as possible and
then be re-oriented on a regular basis. Date, time, place, recognition of family
members, and current events should be the focal point of the Alzheimers
Patients day. According to these theorists, reminding these individuals about
reality will help maintain their self esteem and memory. Proponents encourage
that caregivers identify themselves (i.e.: Hi, Im Jacki, your nurse) with each
interaction. If the person is in a nursing home and asks to go home, they are
told that they are home. They are told they are at Happy Hills Nursing Home
and they will live there until they die, because they have Alzheimers Disease.
With reality orientation it is important that the individual be aware of the
diagnosis and prognosis and be reminded of it as necessary.
Reminisce Therapy was created in correlation with the reality
orientation model (Sheridan 1991). The concept of this modality is based upon
the notion that people who reminisce tend to shift their self concept to make
present self concept more consistent with past self concept (Hanley and Hodge
1984). It is proposed that this rational can be beneficial in maintaining self
esteem and memory with individuals who are disoriented, related to the
diagnosis of Alzheimers Disease (Head et al 1990). This allows the individual
to identify with who they are today based upon who they were historically
(Thornton & Brotchie 1987). Reminiscing is used as a spring board to help
propel the patient towards comprehending their current reality. Caregivers are
told to reminisce with Alzheimers patients and follow though on the memories
7


until the reality of today is reached, to help keep the individual oriented to
today.
The newest model of therapeutic intervention for Alzheimers patients,
Validation Therapy, created by Naomi Feil (1982), has gained wide acceptance
among caregivers. Feil argues that reality is no longer important to the
Alzheimers Patient and orienting them to reality will only cause the patient
undue stress. Validation Therapy focuses on emotions and feelings rather than
reality (Bleatman 1991). Feil reasons that the Alzheimers Patient is living in
the past and attempting to work out unresolved issues. Orienting the person to
reality is only benefiting the caregiver. Having the caregiver join the patient in
their reality, allows the patient to resolve emotional stresses from their past.
Allowing the patient to work out their issues will increase their self esteem and
decrease stress levels (Bleathman 1987). Orienting a confused person to present
reality, Feil argues, will decrease self esteem and cause the person to withdraw
even more from society. In her most recent book (1993) Feil uses similar
examples to illustrate her point.
An disoriented elder repetitively asks for her
spouse who died 8 yr. ago. If the caregiver was to
use reality orientation the woman would be told of
her spouses demise. This information would cause
the woman to grief the loss of her spouse all over
again and to feel inadequate as she did not
remember that her spouse died. Feil encourages
the usage of feeling words in this situation. She
has caregivers ask the woman questions about her
husband (What did he look like? What was his
8


name? Tell me about you wedding.). This
approach allows the woman to explore her feelings
and express the emotions she needs to.
Many Researchers have attempted to determine which model of
therapeutic intervention is superior. The outcome appears to depend on the
researcher. The year of the study does not appear to be of influence as the
results Hanley and Hodges research in 1984 is duplicated by Sheik in 1996. In
the same year as Sheik, Gagnon publishes a study that states that Reminiscence
Therapy is the dominant theory. There appears to be no conclusive data that
states that one model is better than another. The National Alzheimers
Association does support Validation Therapy to some extent. A representative
of the organization states that it is important to utilize the major concepts of
Validation Therapy. She further explains that when interacting with a patient
one should not try and orient them to reality, but not attempt to resolve life
long issues either. Midence and Cunliffe (1996) conclude their research study
by stating that it is not the modality that is important, but the individual
tailoring of the approaches. They go as far as stating that none of the
modalities are satisfactory as a method of intervention.
Regardless of the therapeutic model utilized to govern therapeutic
interactions researchers do agree that intergenerational programs are very
beneficial to the psychosocial needs of the Alzheimers Patient. Short-DeGrafF
and Diamond (1996) studied the increases in positive social interactions when
preschoolers were present. They noted a decrease in all social interactions
9


when the children were not present for the day. They observed benefits based
upon survey responses for all individuals involved in the interactions. Wallach,
Kelley, and Abrahams (1979) also studied the interactions of children (sixth
graders) and the elderly. They noted an increase in social interaction, decrease
in daytime sleeping, increased mobility, and decreased voluntary confinement.
Newman and Ward (1993) studied the intergenerational contact as well and
noted significant increases in eye contact, smiling and attentiveness and
decreases in behavioral outbursts. Based upon these studies and others, adult
and child day care centers are being combined to form one program
Chamberlain, Fetterman, and Maher (1994) studied the effects of these new
types of facilities and found them to effectively increase the psychosocial
aspects of both the adults and childrens lives.
One type of intergenerational interaction was deemed unsuccessful by
Griff (1996). She observed that structured interactions between children and
Alzheimers patients did not always produce positive results. Griff observed
when necessary tasks were limited and parallel play encouraged the success rate
of the interactions soared.
I propose that with new research we would be able to uncover what
makes intergenerational interactions with Alzheimers patients so successful.
Based upon these results a new model of therapeutic intervention can be
created. This new model will incorporate previous concepts from reality
orientation, reminisce therapy and validation therapy, as they apply to the
successes witnessed in intergenerational interactions.
10


CHAPTER 4
DESCRIPTION OF PROJECT
The core of this project is the evaluation of opinion surveys distributed
to a variety of individuals who would have the opportunity to be involved in
intergenerational programs. In comparing and contrasting indicators based
upon current methodologies utilized and the success of intergenerational
programs a new method of interaction with Alzheimers patients may emerge.
The goal is to take the best pieces of current methodologies and the successes of
intergenerational programs to create a new paradigm of interaction.
Subjects
Approximately fifty survey respondents from various backgrounds will be
asked to participate in the study. Three sub-groupings of respondents will be
examined: family/friends of Alzheimers patients, professional caregivers, and
educators. The subjects participation will be completely voluntary and
identities will remain anonymous. Subjects will be recruited from one major
source: a long term care facility. All respondents will have had hands on
experience with Alzheimers patients.
11


Activity
Surveys and a consent form (see appendix B) will be distributed and
collected over a two week period. Data will be compiled and calculated
based upon several factors:
sub-grouping of respondents
experience with Alzheimer patients
use of reality orientation
use of validation therapy
use of reminisces therapy
stages of Alzheimers disease
success of intergenerational programming
Results will be reported in chart, graph, and discussion format.
Prior Controls
Survey questions have been devised using guidelines indicated in Social
Research Methods (1997) by W. Lawrence Neuman. Several questions are
repetitive, but contradictory in nature in order to establish consistency in
responses. Surveys will be distributed by a variety of individuals in order to
reduce and biases that may occur.
12


CHAPTER 5
EXPECTED RESULTS
The results of the study will have the potential to improve the
relationship between Alzheimers Patients and their caregivers. After analysis
the data is expected to reveal certain results.
Methods of interaction utilized by adults and children will vary
Methods of interaction will vary by stage of Alzheimers disease
Reality orientation will be the preferred method of interaction in the
primary stage
Reminiscence will be the preferred method of interaction in the middle stage
Validation will be the preferred method of interaction in later stages
Intergenerational programs will be generally viewed as positive
The differences between adult and child methods of interaction and their
perceived successes will be the goal of future studies.
Future study would include an observation of intergenerational contact
with Alzheimers patients with the goal of creating a new methodology. This
new methodology would be based upon the results of intergenerational
observations with the result of this study. Please see appendix C for a proposed
methodology of this study.
13


CHAPTER 6
RESULTS
Sixty surveys were originally distributed. Thirty one were completed
and returned with consents signed. The results to each question were tallied
and recorded. Each question was then examined for individual value and then
in combination with other questions to determine results.
Question One: All thirty one respondents answered that they disagree
with the statement that individuals diagnosed with Alzheimers Disease in the
beginning stages appear uncomfortable when interacting with children. One
person reported that they feel Alzheimers Patients in the middle stages of the
disease feel uncomfortable when interacting with children as did three
respondents regarding end stage Alzheimers patients (see figure number one).
Question Two: The results were divided related to whether a person
diagnosed with early stage Alzheimers Disease should be aware of the day and
the date. Eighteen respondents agreed, while thirteen disagreed. The results
were more definitive when it came to patients in the middle stage; seven agreed
and twenty three disagreed. Respondents recorded that they believed twenty
six to four that it was not important for an Alzheimers patient in the end stages
of the disease process to be aware of the day and date (see figure two). Time
appeared to be determined to be an important factor in the beginning stage, but
not in the middle or latter stage.
14


FIGURE CAPTION
Figure 1. Alzheimers Patient are Uncomfortable with Children
Uncomfortability With Children
35
Beginning Middle End
Series 1
15


FIGURE CAPTION
Figure 2 Reality Orientation
Reality Orientation
P- ---f -----PMl (------
Agree DisagrNo Opi Agree DisagrNo Opi Agree DisagrNo Opi
Beginning Middle End
Series 1
16


Question Three: Twenty one individuals surveyed agreed with using
validation when a beginning stage Alzheimer's patient is confused. Twenty
seven respondents chose this approach for the middle stage Alzheimers Patient
and twenty eight felt validation was appropriate for responding to an end stage
Alzheimers Patient. Validation appeared to be what intervention individuals
felt was appropriate to use as an intervention regardless of the stage of the
disease progression (see figure three).
Question Four: Five respondents advocated for using reminisce therapy
with beginning stage Alzheimers Patients. Four agreed with using reminisce in
the middle stage of the disease process and three agreed with this approach in
the end stages. In general most respondents were not in favor of using
reminisce therapy with Alzheimers Patients (see figure four).
Question Five: Twenty three individuals surveyed disagreed that
children dislike to be apart of intergenerational programming with Alzheimers
Patients in the beginning stages of the disease process. This was equivalent
with twenty four respondents stating that children do not dislike
intergenerational programming in relation to middle stage Alzheimers
Patients. Eighteen individuals surveyed responded that children also do not
dislike intergenerational programming with end stage Alzheimers Patients. It
should be noted that a total of twenty three no opinion responses were recorded
in relation to this question. It does appear that out of those surveyed that they
believe that children enjoy participating in intergenerational programs with
Alzheimers Patients regardless of the stage of the disease that the patient is in
17


FIGURE CAPTION
Figure 3. Validation
Validation
Beginning Middle End
Series 1
18


FIGURE CAPTION
Figure 4. Reminiscence Therapy
Reminscence Therapy
19


(see figure five).
Question six: Almost all respondents recorded that they believed that
Alzheimers Patients tend to be more cooperative with children than they are
with adults (twenty seven beginning stage, twenty eight middle stage, twenty
two end stage). It should be noted that seven individuals marked no opinion in
relation to end stage Alzheimers Patients in response to this question (see
figure six).
Question Seven: This question is essentially the same as question
number two. Question two asks if Alzheimers Patients need to be aware of the
day and date, where as question seven asks about the importance of current
events. Both questions refer to the use of reality orientation. The pattern of
response in both questions were very similar with twenty individuals believing
that beginning stage Alzheimers Patients should be aware of current events.
Twelve agreed with this statement in respect to middle stage patient and four
were in agreement in relation to end stage patients (see figure seven). This
question reaffirms that the popularity of reality orientation decreases with the
progression the disease process.
Question Eight: Respondents reports were similar irregardless of the
stage of the disease process in regards to answering if they believed that children
who have been involved in intergenerational programs tend to fear the elderly.
Thirty disagreed with this statement in response to beginning stage Alzheimers
patients, whereas twenty seven disagreed in respect to middle stage patients and
twenty four disagreed in respect to end stage patients (see figure eight). It
20


FIGURE CAPTION
Figure 5. Children Dislike Intergenerational Programming
Children Dislike Intergenerational Prog
25 r
Beginning Middle End
SI Series 1
21


FIGURE CAPTION
Figure 6. Alzheimers Patients are Friendlier with Adults than Children
Friendlier With Adults Than Children
Agree Disagr No Op Agree Disagr No Op Agree Disagr No Op
Beginning Middle End
Uni Series 1
22


FIGURE CAPTION
Figure 7. Reality Orientation to Current Events
Reality Orientation / Current Events
Beginning Middle End
BH Series 1
23


FIGURE CAPTION
Figure 8 Children Fear Alzheimers Patients
Children Fear Alzheimer's Patients
Agree DisagrNo Op Agree DisagrNo Op Agree DisagrNo Op
Beginning Middle End
H Series 1
24


should be noted the results for the beginning stage were unanimous with
increasing doubt noted towards the latter stages. This correlates with question
number five in stating that children are not uncomfortable in attending
intergenerational programs.
Question Nine: Most respondents reported that they believed that
Alzheimers Patients do not become violent if children orient them to reality
(twenty six beginning stage, twenty three middle stage, twenty end stage).
It should be noted that respondents became more uncertain of their response
with the progression of the disease (see figure nine). This figure is important as
most respondents disagree with the use of reality orientation in middle and end
stages.
Question Ten: When asked if they felt that intergenerational programs
with Alzheimers Patients are successful (see figure ten). Twenty four
responded that they agreed and the remaining seven had no opinion regarding
beginning stage patients (no respondents disagreed). Twenty three respondents
agreed that intergeneration programs are generally successful with middle stage
patients, with only one respondent disagreeing. Two respondents felt that
intergenerational programs can be unsuccessful with end stage Alzheimers
patients. This correlated with questions one, five, and eight in confirming the
success of intergenerational programs with Alzheimers patients.
Question Eleven: When asked for a third time about reality orientation,
respondents continued to state that they felt that it was inappropriate to correct
a middle to end stage patient as to the day and date. Respondents were divided
25


FIGURE CAPTION
Figure 9. Children using Reality Orientation causes Violence
Children / Reality Orientation
Causes Violence
30;
Agree DisagrNo Op Agree DisagrNo Op Agree DisagrNo Op
Beginning Middle End
I Series 1
26


FIGURE CAPTION
Figure 10 Success of Intergenerational Programs
Success of Intergenerational Programs
27


(sixteen to fifteen) as to the use of reality orientation with beginning stage
patients (see figure eleven). These results are consistent with questions two and
seven.
Question Twelve: There were no definitive results in relation to
question twelve (see figure twelve). Respondents did not agree on if children
used reality orientation with Alzheimers Patients in any stage.
Question Thirteen: Most respondents stated that they had experience
working with Alzheimers Patients (see figure thirteen). Twenty nine stated
they had experience working with beginning stage patients, Thirty had
experience with middle stage patients, and twenty nine had experience with end
stage patients.
Question Fourteen: Respondents had multiple responses to this
question, despite the directions to circle one answer. Nine individuals (twenty
four percent) best identified themselves as a family member or friend of a
person diagnosed with Alzheimers Disease. Twenty Five individuals (sixty six
percent) identified themselves as professional caregivers and four (eleven
percent) identified themselves as educators/teachers (see figure fourteen).
The results of questions two, seven and eleven were combined to assess
the respondents overall opinion of the use of reality orientation (see figure
fifteen). The results were then separated out by the stages of disease
progression. Fifty eight percent of respondents agreed with the use of reality
orientation with beginning stage Alzheimers Disease patients (see figure
sixteen). Seventy two percent of respondents disagreed with the use of reality
28


FIGURE CAPTION
Figure 11. Reality Orientation 2
Reality Orientation 2
30 T
Beginning Middle End
Series 1
29


FIGURE CAPTION
Figure 12. Children Use Reality Orientation
Children Use Reality Orientation
16
Agree Disagr No Opi Agree Disagr No Opi Agree Disagr No Opi
Beginning Middle End
B Series 1
30


FIGURE CAPTION
Figure 13. Experience with Alzheimers Patients
Experience with Alzheimer's Patients
Beginning Middle End
Number of Agreements out of Possible
Hi Series 1 SH Series 2
31


FIGURE CAPTION
Figure 14. Categories of Respondents
Categories of Respondents
Professional Caregi\er (65.8%)
32


FIGURE CAPTION
Figure 15. Overall Reality Orientation
Overall Reality Orientation
Agree Disagr No Opi Agree Disagr No Opi Agree Disagr No Opi
Beginning Middle End
33


FIGURE CAPTION
Figure 16. Success of Reality Orientation, Beginning Stage
Success of Reality Orientation
Begininng Stages
34


orientation with middle stage Alzheimers Disease patients (see figure Figure
seventeen). Eighty three respondent disagreed with the use of Reality
Orientation with Alzheimers Patients in the end stages of the disease (see figure
eighteen). Respondents were divided as to the appropriateness of the use of
Reality orientation in the beginning stages of the disease, but were definitely
against the use of the reality orientation with Alzheimers patients as the disease
progressed.
Results from questions one, five, six, eight, and ten were combined to
evaluate the respondents overall opinion of intergenerational programs.
Eighty-seven percent of respondents reported that they felt that
intergenerational program with beginning stage Alzheimers Patients are
successful (see figure nineteen). Eighty three percent of individuals polled felt
that intergenerational programs with middle stage Alzheimers Disease patients
are successful (see figure twenty). Sixty seven percent reported that they believe
intergenerational programs are successful with end stage Alzheimers Patients
(see figure twenty one). It appears that respondents believe that
intergenerational programs are better received by beginning and middle stage
patients than those in the in stages of the disease process.
The overall results of the success of intergenerational programs was
compared with the success of reality orientation with the tendency of children
to use reality orientation were combined (see figure twenty two). No direct
correlation were found.
35


FIGURE CAPTION
Figure 17. Success of Reality Orientation, Middle Stage
Success of Reality Orientation
Middle Stage
36


FIGURE CAPTION
Figure 18. Success of Reality Orientation End Stage
Success of Reality Orientation
End Stage
No Opinion (6.5%) Agree (9.7%)
Disagree (83.9%)
37


FIGURE CAPTION
Figure 19. Success of Intergenerational Programs, Beginning Stage
Success of intergenerational Programs
Beginning Stage
38


FIGURE CAPTION
Figure 20. Success of Intergenerational Programs, Middle Stage Figure Caption
Success of Intergenerational Programs
Middle Stage
39


FIGURE CAPTION
Figure 21. Success of Intergenerational Programs, End Stage
Success of Intergenerational Programs
End Stage
40


FIGURE CAPTION
Figure 22. Reality Orientation versus Childrens use of Reality Orientation
compared with Success of Intergenerational Programs.
R.O. vs. Children'as Use of R.O.
Success of Intergenerational Programs
41


CHAPTER 7
DISCUSSION
In comparing expected with actual results the following were identified
As expected, methods of interaction utilized by adults and children did
vary.
Methods of interaction did vary by stage of Alzheimers disease.
Reality orientation was determined to be the preferred method of
interaction the early stages of Alzheimers disease.
Reminisce Therapy was not found to be the preferred method of interaction
in any stage, although it was predicted to be the preferred method of
interaction in the middle stage of disease progression.
Validation was found to be the preferred method of interaction in both
middle and end stage progression. The preference of validation in the
middle stage was not predicted.
Intergenerational programs were viewed as positive. There was some
unexpected hesitation about intergenerational programming in the end
stage of disease progression. Although this was not expected, it is
understandable, as society has preconceived fears about exposing
children to issues involving death.
Reality Orientation appears to continue to be an accepted methodology
of interaction skills only with individuals in the early stage of Alzheimers
disease. It is perceived that it is important for individuals to remain oriented as
42


long as they are able to do so without demonstrating a lot of distress. This
would correlate with Revee & Ivisons (1985) theory that self respect and self
esteem are based upon the individuals ability to predict and comprehend
reality. This also collaborates with intergenerational programming in that
Alzheimers patients tend to be comfortable with children reorienting them as
well. Although it is difficult to determine whether or not reality orientation is
the methodology most commonly used by children, it is not a negative factor
against the successes of intergenerational programs.
It is interesting to note that results did not yield in favor of reminisce
therapy in with patients in any stage of Alzheimers disease. This does correlate
with how children interact with confused elders in that reminisce therapy is not
something hat comes naturally and does have to be taught. That would rule
out its use by children as they are not taught how to respond like professional
caregivers are. This does not mean that this methodology can not be utilized to
effectively communicate with confused individuals. It does however rule it out
as a key factor in intergenerational interactions.
Validation is viewed as the preferred method of inteinteraction with
middle and end stage Alzheimers patients. Validation is taught to professional
caregiver, but it can come naturally to children. Children are taught to agree
with their elders and not to argue. They may use this method of interaction
skills without be aware of it. There does appear to be strong correlation with
belief of success in intergenerational programming and success of validation
therapy.
43


Intergenerational programs with Alzheimers patients are
popularly viewed as successful. They appear to be enjoyed by all participants
involved. The Alzheimers patients tend to be more accepting of being
corrected by children and tend to be more comfortable during these types of
interactions than they are with adults. Children involved in these programs do
not fear the elderly. These results mirror the response found in many other
studies and argue in favor of continue research in the are of why
intergenerational programs are successful.
Success of intergenerational programming may need to be looked at
more specifically in relation to the separate stages. It appears that reality
orientation and intergenerational programming are successful with early stage
Alzheimers patients and that Validation and intergenerational programming
are successful with middle stage patients. Interactions with end stage patients
tends to be looked at more precariously and would not be recommended to be
looked at initially for implication for further study.
Based upon the results of this survey in comparison with current
literature it would be prudent for research to continue into this arena with two
objectives.
To encourage and enhance the development of intergenerational programs
with Alzheimers disease patients. Although initially the rationale behind the
success of these programs may not be readily apparent. It is perceived that they
have a positive influenced on the lives of those involved. The more research
that is completed that advocates these types of programs the more companies
that will be inclined to facilitate intergenerational programs. At this time
44


school districts are beginning to form intergenerational programs and more
research may encourage the involvement of more Alzheimers patients. These
individuals continue to be marginalized by society and if they can be
re-mainstreamed by having them interact with children, all of society would
benefit.
New approaches for caregivers to be able to communicate effectively with
Alzheimers patients may be able to be derived from close examination of
intergenerational programs. It appears at this time that reality orientation is
most successful in the beginning stages of the disease process with validation
being use in the middle to end stages. This may be only the surface
explanations and by further examining intergenerational interactions other key
techniques have the potential to be developed.
This studys results may have been effected by one or more confounds.
The initial number of expected respondents did not mirror the completed
sample size. Thirty one respondents can give an accurate picture of viewpoints,
but increased survey participation would have possibly varied results.
Respondents were all associated with one institution. Many of these
individuals have received formal or informal training by this institution which
would have a large impact on their individual belief systems.
45


APPENDIX A
STAGES OF ALZHEIMERS DISEASE
46


STAGES OF SYMPTOM PROGRESSION
IN ALZHEIMERS DISEASE
Symptoms of Alzheimers disease generally progress in a recognizable pattern.
These stages provide a framework for understanding the disease. It is important
to remember that hey are not uniform in every person and the stages often
overlap.
First Stage 2-4 years up to and including diagnosis:
Symptoms
Recent memory loss
Progressive forgetfulness; difficulty with routine chores
Confusion about directions, decisions, and money management
Loss of spontaneity and initiative
Repetitive actions and statements
Mood / personality and judgement changes
Disorientation of time and place
Examples
Forgets if bills are paid
losses things and / or forgets they are lost
Arrives at wrong time or place
Constantly checks calendar
Forgets frequently called numbers
Second Stage 2-10 years after diagnosis (longest stage):
Symptoms
Increasing memory loss, confusion and shorter attention span
Difficulty recognizing close friends and / or family
Wandering
Restlessness, especially in late afternoon and evening
Occasional muscle twitching or jerking
Difficulty organizing thoughts or logical thinking
May see or hear things that are not there (hallucination)
Needs full time supervision
47


Examples
Sleeps often awakens frequently at night and may get up and wander
Perceptual / motor problems, difficulty getting into a chair, setting the table
Cant read signs, write name, add or subtract
Suspicious may accuse spouse of hiding things or infidelity (paranoia)
Loss of impulse control -may undress at inappropriate times or places
Huge appetite for junk food forgets when last meal was eaten
Third Stage 1-3 years
Symptoms
Unable to recognize family members or self in mirror
Loss of weight even with proper diet; eventually becomes emaciated
Capacity for self care diminished
Oral communication disappears, eventually becoming mute
Tries to put everything in mouth; compultion for touching
Bowel and Bladder incontinence
May experience difficulty with swallowing, skin infections or seizures
Examples
Looks in mirror and talks to own image
Needs total care with bathing, dressing, eating, and toiling
May groan or scream or make grunting noises
Sleeps more, becomes comatose, eventually dies
48


APPENDIX B
SURVEY AND CONSENT
49


1. Individuals diagnosed with Alzheimers disease appear uncomfortable
when interacting with children.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
2. It is important for an person diagnosed with Alzheimers disease to be
aware of the day and the date.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
3. Mr. Jones asks you when his wife will be here to pick him up (his wife
has been dead for fifteen years), you respond by asking him to tell you about
his wife (never commenting on the fact that she is no longer living).
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
4. Your goal in asking him to tell you about his wife is to ha ve him
remember that she is no longer living.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
50


5. Intergenerational programs with Alzheimer's patients are disliked by the
children involved.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
6. Alzheimer's Patients have a tendency to be friendlier and more
cooperative with adults than they do with children.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
7. It is important for individuals with Alzheimer's disease to be informed of
current events.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
8. Children who have been involved in intergenerational programs with Alzheimers patients generally have a fear of the elderly.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
51


9. If a child corrects an person diagnosed with Alzheimer's disease by
telling them it is 1998 and not 1953 the Alzheimers patient will most
probably become angry and may become violent.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
10. Intergenerational programs with Alzheimers patients are generally successful.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
11. An Alzheimers patient should be corrected when confused to person, place, and time.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
12. Children are focused on reality and tend to correct Alzheimers patient when they appear disoriented.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
52


13. I have had experience working with Alzheimers patients.
Beginning Stage: Agree Disagree No Opinion
Middle Stage: Agree Disagree No Opinion
Latter Stage: Agree Disagree No Opinion
14. I best identify myself as: (circle one)
Family member/friend of a person diagnosed with Alzheimers Disease
Professional Caregiver
T eacher/Educator
Comments:
53


Consent Form For Research Survey Participation
Research Objectives
The objective of this study is to help to begin to create new approaches for
caregivers to utilize to successfully interact with Alzheimers patients. Interactions
between caregivers and demented individuals can be disruptive and painful for all
involved, if not carefully negotiated. Alzheimers patients have lost their ability to
comprehend abstract reasoning. The social constructed rules of what you can and
can not say or do in certain situations no longer exist for these individuals. This
can cause great amounts of stress on caregivers. Caregivers are always searching
for answers on how to handle even the simplest of situations without upsetting the
confused person or emotionally burdening themselves.
Alzheimers patients typically respond well to interactions with children.
Research has proven time and time again that intergenerational contact can create
positive interactions for Alzheimers patients. Is there something inherent in the
way that children act towards individuals that are confused? Can these methods of
interaction utilized by children, be taught to caregivers to help them improve the
quality of their interactions with Alzheimers patients? How do caregivers view
intergenerational interaction in comparison to their own methods of interaction? I
hope that this research study will be beneficial in providing some answers to help
improve the quality of interactions between Alzheimers patients and their
caregivers.
*Subjects participation will be limited only to the time required to complete the
survey.
*There are no known risks based upon participation with the exception of
1. Some participants may experience minor psychological discomfort when
answering questions. Please omit any question that you do not feel comfortable
answering.
2. If confidentiality were to be breached some participants may experience
social embarrassment and/or minor psychological distress as to others knowing
there beliefs related to the use of intergenerational programs with Alzheimers
patients.
*There are no known benefits from participating in this study.
*Please do not place your name on your completed survey to maintain
confidentiality.
Participation in this study is voluntary. After receiving the survey you may choose
not to complete and or return it.
54


*If you are interested in the results of this study please feel free to contact the
principle investigator at her place of employment: Jacquelyn Roschbach
(303)450-2700.
*If you have any questions regarding your participation in this study please contact
Office of Academic Affairs
CU Denver Building
Suite 700
(303)556-2550
Signature of Participant: ___________________________
Please keep the attached copy for your own records.
55


APPENDIX C
PROPOSAL FOR FURTHER STUDY
56


ABSTRACT
Interactions between elderly individuals diagnosed with and without
Alzheimers Disease and preschool aged children will be observed to determine
qualities of successful communication skills between the two groups. Research
has proven, that interactions between children and Alzheimers patients have
therapeutic effects. The successful interaction techniques observed will be
evaluated to see if they differ between confused and non-confused individuals.
These approaches will then be compared with the communication skills
currently taught to caregivers working with Alzheimers patients. The goal is to
improve the quality of interactions between Alzheimers patients and their
caregivers, based upon the successes of intergenerational programming. These
observations will occur in a pre-existing setting presenting no potential risks to
the individuals involved in the study.
57


PURPOSE AND BACKGROUND
Three main paradigms teach care givers how to communicate
therapeutically with Alzheimers patients: Reality Orientation Reminisce
Therapy, and Validation Therapy. Reality Orientation helps mentally ill
individuals cope with reality and become productive members of society. This
therapeutic intervention is met with criticism when used with Alzheimers
Patients as it is argued that are was no benefits in orienting an Alzheimers
Patient to reality. Reality Orientation causes additional stress and
re-integration into society is not necessarily a reasonable goal.
Reminiscence Therapy has the same primary goal as Reality
Orientation. The methodology varies in that the caregiver is encouraged to
discuss old memories with the confused person and gradually orient them to an
understanding of present day reality. For example, a caregiver would reminisce
with the Alzheimers Patient about their wedding day and their life with their
spouse with the objective of reminding them that are currently a widow.
Caregivers continue to argue with the goal of this model being orienting a
confused person to reality.
Naomi Feil created Validation Therapy for caregivers to focus on the
importance of the patients emotions and not their orientation to reality. She
argues that with memory loss, reality orientation is frightening and not
therapeutic. Validation Therapy continues to grow in acceptance and its use is
encouraged by the National Alzheimers Association.
58


Both theories encourage socialization between children and the elderly
as it provides a positive experience. This is perplexing, because children are
reality focused and tend to impose their reality on others around them. An
in-depth study of current approaches and communication utilized between
children and Alzheimers Patients will yield implications for a new therapeutic
model of interaction.
The objective of this study is to create new approaches for caregivers to
utilize to successfully interact with Alzheimers patients. Interactions between
caregivers and demented individuals can be disruptive and painful for all
involved, if not carefully negotiated. Alzheimers patients have lost their ability
to comprehend abstract reasoning. The social constructed rules of what you
can and can not say or do in certain situations no longer exist for these
individuals. This can cause great amounts of stress on caregivers. Caregivers
are always searching for answers on how to handle even the simplest of
situations without upsetting the confused person or emotionally burdening
themselves.
Alzheimers patients typically respond well to interactions with children.
Research has proven time and time again that intergenerational contact can
create positive interactions for Alzheimers patients. Is there something
inherent in the way that children act towards individuals that are confused?
Can these methods of interaction utilized by children, be taught to caregivers to
help them improve the quality of their interactions with Alzheimers patients?
By studying intergenerational interactions between children and Alzheimers'
59


patients I intend to identify five different approaches utilized by the children to
help negotiate difficult situations, and test their effectiveness when utilized by
adult caregivers. I hope that this research study will be beneficial in providing
some answers to help improve the quality of interactions between Alzheimers
patients and their caregivers.
60


DESCRIPTION OF SUBJECT POPULATION
The individuals involved in this study attend a pre-existing
intergenerational program, Eldercare in Denver, CO (please see attached
brochure). This program is designed to meet daycare needs for both the elderly
and young children. The two groups frequently interact with each other within
an therapeutic recreational model. Often programming includes arts and craft
projects that can be completed jointly, story hour in which the elderly read to
the children, or free time in which the two groups can interact freely. The
number of participants varies from session to session as both are given a choice
as to desired participation.
61


METHODOLOGY
All observations will take place during the regularly scheduled
programming of the Eldercare program. Activities observed will vary based
upon the sites pre-existing schedule. Observation periods will generally last one
hour as this is the maximum attention span expected for both groups involved.
Observations will be made using the participant observer model. Notes will be
taken during and post each observational setting. These notes will appear in
case study type formats.
62


DATA DISPOSITION
Documentation of observations will be completed manually and then
input into a computer for accessibility. No audio or videotaping will be used to
preserve participant identification. All names utilized in this study will be
pseudonyms to maintain confidentiality.
63


POTENTIAL RISKS AND BENEFITS
Observations will occur in a pre-existing program, therefor there are no
new benefits or risks to participants associated with this observation.
64


METHODS OF OBTAINING INFORMED CONSENT
Consent for participation in the program will have already been
obtained upon admission to the Eldercare program. The program frequently
allows volunteers and observers in to be a part of their setting. All individuals
who attend the program are notified of this policy upon admission.
65


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