Service-Learning PaperObservations made at Garden House
Jennifer Mayer
Dr. Lisa Nicholson
FSN 315
5 June 2013
ABSTRACT
Due to the increasing lifespan in the United States, more elderly are living longer;
therefore increasing the chance they develop Alzheimer’s disease in their lifetime. Being one of
the most common brain disorders, it is crucial to understand the background and long-term care
options for patients with the progressive disease. With Alzheimer’s, it is common that their
increased physical limitations lead to decreased nutritional status—emphasizing the importance
of eating nutritionally dense foods and emphasizing the importance in helping the patient receive
adequate food intake.
There are many long term care options available for individuals with dementia such as
assisted living, or adult day centers, however if feasible, placing a loved one in a specialized
dementia care facility is preferable. Such facilities, like Garden House located in San Luis Obispo
County, note plate waste for adequate consumption of patients, have a secured home-like
atmosphere, and promote daily activities to keep the residents’ minds sharp.
Introduction
As the body follows the normal path of aging, there seems to be a common trend of
forgetfulness. Older adults begin to forget where they put their glasses or they don’t remember
things as well as they used to. However, for some older people, memory loss and confusion is a
sign of a serious problem within their central nervous system. The CNS is crucial for individuals
to be able to interact with others around them and perform activities of daily living, which can in
turn, affect the persons diet and nutritional status. One of the most common disorders that are
diagnosed when abnormal changes occur in the brain is Alzheimer’s disease.
Alzheimer’s Disease Overview
Alzheimer’s disease is an irreversible disease that slowly begins affecting the way a person
can carry out daily activities. While the mechanisms of brain damage are still uncertain in regards
to diagnosing Alzheimer’s, it is universally decided it is due to loss of function throughout nerve
cells. This nerve degeneration occurs by proteins found in the brain called beta-amyloid plaques,
“These toxic protein clumps induce deformed, twisted, and dead nerve fibers called
Neurofibrillary tangles and threads” (1). While these plaques can occur in all brain lobes, the most
common area affected is the hippocampus, which directly relates to one’s ability to learn and store
memories. As these tangles continue to form, more matter of the brain dies due to lack of nerve
conduction, demonstrating the slow progression of this disease (1).
Risk Factors and Prevention
Like many diseases, there are risk factors that are unavoidable such as age and genetics,
but with Alzheimer’s especially, such risk factors like environment and lifestyle are huge
contributors to the onset of this disease (1).
The main, and most well known risk factor is age. As one turns 65, each additional five
years doubles the risk of developing Alzheimer’s. Overall, the age group with the highest risk is
85 and older (2). These statistics are significant because as the lifespan in the United States
continues to increase, it increases the prevalence of Alzheimer’s as well.
Another inevitable risk factor is genetics, and due to increased research in the area, experts
are coming to realize the huge impact genetics has on Alzheimer’s. There are several genes
linked, however there is one gene, apolipoprotein E, which is the currently the most heavily
researched. “One of those genes, called apolipoprotein E (APOE), has three forms. One form,
APOE ε4, increases a person’s risk of getting the disease. It is present in about 25 to 30 percent of
the population” (2). While having this gene increases one’s risk, if one does have this gene, it
does not mean he/she will develop the disease.
Environment and lifestyle choices also greatly influence the onset of Alzheimer’s. In the
body, having high serum cholesterol or high blood pressure can aid in the development of
Alzheimer’s. Also low intake of folate (a vitamin commonly found in leafy greens), which is part
of essential methylation reactions that occur in neurotransmitters (2).
For preventative effects, it is thought the “Mediterranean diet may be protective against
mild cognitive impairment, which often precedes AD” (3). The emphasis on healthy fats found in
fish and by having all meals based on fruits and vegetables can contribute to lowering cholesterol
and provide good sources of folate. Mental stimulation is also critical in preventing the onset of
Alzheimer’s. Researchers have even found a walk a day helps keep the mind astute (3).
Symptoms
Around age 60, most symptoms begin to surface, and typically the first signs are memory
loss (1). The progression of Alzheimer’s is usually set on a spectrum, consisting of three stages:
mild, moderate to severe (2). True diagnosis for Alzheimer’s can only be made after death, when
an autopsy is performed and their brain tissue can be assessed (1).
Mild Alzheimer’s is characterized by problems such as poor judgment, repeating
questions, and having trouble handling money or paying bills. It is usually at this stage
Alzheimer’s is diagnosed. Continuing on the spectrum, Moderate Alzheimer’s is associated when
the individual has issues with recognizing family and friends, or has impulsive behavior. Finally,
what’s seen in severe cases is inability to communicate, difficulty swallowing, or groaning and
grunting (2,3).
Alzheimer’s and Nutritional Limitations
One of the main concerns with Alzheimer’s is weight loss, due to decreased ability to
perform activities of daily living (ADL), which have a ripple effect on dietary intake in
Alzheimer’s patients. The most obvious physical limitations are decreased ability to swallow,
hold utensils, or being unable to chew (2). In these circumstances weighted utensils can be used if
the patient has tremors, or if a patient has severe arthritis, then there are utensils with a thick
handle, called built-up utensils, that may be utilized. Also, there are two main methods to help a
person with Alzheimer’s eat effectively: guiding hands and caring hands. Guiding hands is when
the caretaker moves the patient’s hand to their mouth aiming to reestablish neural pathways; while
caring hands is when the patient has advanced into further stages of dementia and the caretaker
puts the patient’s hand on theirs while they feed them (4).
Other issues that could lead to diminished nutritional status are distractions while eating.
To lower distractions, the patient should be served a small meal at a table with few people around
them. Also, make the dining area room temperature with no music. If there are too many
distractions this could lead the patient to eating to slow or forgetting what he/she is doing, which
can lead to unwanted weight loss (4).
Long-Term Care Options for Alzheimer’s Patients
Depending on the status of the individual, a family can either decide to keep their loved
one at home, and use resources such as adult day centers or home health services. However, if the
patient has dementias to the point where it is too much stress on the family member or caretaker, a
residential care option may be favored. There are many housing options in communities such as
assisted living, specialized dementia care facilities and nursing homes, but for the purpose of this
paper, the focus will be on specialized dementia care facilities (5).
Specialized Dementia Care Facilities
These facilities are preferred when a patient needs more supervision than a classic assisted
living home. Specialized facilities have trained-staff and a very safe building, usually locked or
secured doors are standard. A lot of these facilities offer activity based-therapies to keep the mine
stimulated as much as possible—essential for patients with Alzheimer’s (5). However, there has
been speculation on the legitimacy of these facilities. Some experts wonder if they are just
marked up in price for the same care as an assisted living home, but with “added locked doors”
(6). However, the consensus from a variety of studies, it seems specialized dementia facilities
have lower patient hospitalization rate, less likelihood to use bed rails, and are more likely to use
toilet plans. However, it was also noted they rely more heavily on medications compared to
assisted living facilities (6). Overall, it seems to depend on the actual facility to determine if the
care is superior over assisted living.
Garden House—A Specialized Dementia Care Facility
Garden House is a “loving care facility set in the quiet seaside serenity of Morro Bay (7).”
Garden House portrays the image of a quaint home with all the safety features of a dementia
facility. To enter the premises, visitors have to ring the doorbell, and a staff member will enter a
code to let them in. However, to make the home seem more nostalgic, the residents are allowed to
bring their own furnishings, or even a small, well-mannered pet. The maximum occupancy is 15
residents; currently there are 12 women and 1 man. These residents are offered a variety of
activities such as pampering services, in-chair exercise and musical/art therapy. Their art therapy,
“‘Mneme Therapy’ uses painting patterning, singing, praise and story-telling in a unique
combination to create whole brain communication” (7). This therapy stimulates the brain to
remap pathways, creating amazing paintings by the patients.
As a volunteer, I helped mainly by assisting residents with severe Alzheimer’s eat meals.
After meals were finished, I would play catch and/or ring toss to contribute to their daily exercise.
On one day I was fortunate enough to sit-in and then participate in their weekly Music Therapy
sessions (see Appendix A). During the session, two music therapists come for an hour and sing
songs significant in their era, such as “Unforgettable” by Nat King Cole. Witnessing this
experience was fantastic. A patient that seemed unable to speak during meal times would start
singing the lyrics to all of the songs, and shed tears of joy—showing the impact music has on
memory. Overall, as a volunteer I helped the staff during meals and led exercise games.
Observations Made at Garden House
Meal Time Observations
First and foremost, the patients exhibited many signs of a classic Alzheimer’s patient
during mealtime. Each time I went to Garden House I sat at the same table, with four women who
had severe Alzheimer’s or tremors, and therefore needed aid with eating. The first visit I had, they
served oatmeal with banana, and a muffin. I served a woman named Julie (all names have been
changed). Julie has tremors and therefore uses weighted utensils to feed herself, on the days she
her tremors are low. As I was feeding Julie she kept putting her hand in her mouth, a sign that she
was having issues with her dentures. I called over an attendant and they fixed her dentures.
Immediately I could see a difference in Julie, as she ate faster and didn’t seem to have any pain.
The second session, I fed a woman named Jessica who has a severe case Alzheimer’s that rapidly
progressed in her early seventies. She is in a wheel chair and is unable to feed herself. That
morning bacon, eggs, toast, and fruit cocktail was served along side water and mango juice.
Jessica was very compliant when she ate, and didn’t do anything abnormal or difficult to deal
with. The only issue when feeding Jessica was her toast was too burnt, so after seeing a staff
member soak the toast in the fruit juice, I did the same and it went down much easier. For the third
session, I went during lunch. Meatloaf, mashed potatoes with gravy, and a vegetable mix were
served. I fed Olivia this time, a resident who has Severe Alzheimer’s, but depending on the food
item, she can sometimes feed herself. This meal was by far the most difficult to finish. Olivia had
a tendency to spit the meatloaf at the person next to her, bite on her fingers instead of focusing on
eating, and say no when I offered her bites of food. However, when I cut the meat loaf pieces
smaller she didn’t spit them out, and if I let her have a sip of water after a bite, she rarely shook
her head and kept on eating.
Throughout all of these sessions, I kept a close eye on plate waste for each of the
individuals. As noted in Table 1, Garden House measures their plate waste on percentage of the
total meal. The majority of the residents I fed ate all of their meal, which is great because of the
difficulties that come with eating and Alzheimer’s. The only issue seemed to be their lower liquid
consumption.
Table 1. Plate Waste Observations of Residents at Garden House During Varied Meal Times
Resident Name
Meal Time Type of Food Served
Type of Liquid Served
% Plate Waste
% Liquid Consumed
Julie Breakfast Oatmeal, ½ banana, muffin
Coffee, water, Apple Juice
100% 100%
Jessica Breakfast 1 egg, ½ slice toast, 1 strip bacon, fruit cocktail
Mango juice, water
90% (failed to finish burnt
toast)
60% (failed to finish most of
juice)
Olivia Lunch Meatloaf, mashed potatoes with gravy, and veggie mix.
Water, hot tea 90% (due to spit out
meatloaf)
80% (didn’t finish her tea)
Extra Activity-Making Cookies
On my final day I brought in sugar cookies for the residents to decorate. The only time I
could complete this activity was after lunch, so as expected a lot of the residents were too tired to
make them. I got a total of six residents to decorate (see Appendix B). One woman named Rachel
was very embarrassed throughout the process because she felt hers weren’t beautiful enough. Out
of all six, only one person ate the cookies (4 of them), simply because she said she was “hungry
and they looked good.” Another resident, Joanna, thought we were decorating them for children
and ended up decorating 14 of the cookies. Out of all the patients, none of them had issues
holding the plastic knives to spread the frosting, however one patient had an issue screwing off the
sprinkles lid.
Evaluation of Experience at Garden House
Before coming to Garden House, I was fairly nervous that I would be walking into a circus
with patients running around everywhere, etc. However, I have come to realize that just like most
elderly, the majority of patients with dementias are compassionate and kind-hearted, just a victim
of a terrible disease. While sometimes forgetful, a lot of the patients seemed as if they didn’t have
dementia, they merely needed to be placed into an Assisted Living Facility.
It was also eye opening to experience working with Alzheimer’s patients first hand,
compared to only learning about it in lecture. I was able to witness a patient get her dentures
fixed, then immediately notice a difference in her eating behavior. I was also able to use weighted
utensils first-hand, which was a unique experience. The most shocking thing for me to experience
compared to solely hearing about it in lecture was the patience it takes to be a caregiver. Meal
times alone take an hour, in addition to getting everyone ready to eat. Also, it was interesting to
me that the severe patients really only drink during meal times. With this observation, I would
recommend to the agency to try and give patients who are unable to talk a glass of water
throughout the day, rather than only at meal times to prevent dehydration.
Another observation I made that seemed to go against what was discussed in class is the
topic of distractions. When I first arrived, they had me put placemats on the tables, which were
bright pictures of cats with balloons. While cute, it seemed that these placemats could be
distracting during meal times. Also, the bibs used seemed very child like; so another
recommendation would to switch them out for “scarves,” making eating with them seem less
degrading and replace the placemats to simpler one.
Overall, having never worked with the elderly before in any agency, or other environment
alike, it was very beneficial to experience this to aid in my decision of working in geriatric
nutrition in the future.
APPENDIX
Appendix A: Residents enjoying Music Therapy
Appendix B: Residents decorating cookies
REFERENCES
1) Cohen, Elwood. Alzheimer’s Disease: Prevention, Intervention, and Treatment. Los Angeles: Health Press; 1999
2) Alzheimer’s Disease Education and Referral Center. National Institute on Aging. Website. http://www.nia.nih.gov/alzheimers. Accessed April 27, 2013.
3) Bernstein M, Schmidt Luggen A. Nutrition for the Older Adult. 1st ed. Massachusetts: Jones and Bartlett Publishers; 2010
4) Rasmussen, Helen. Alzheimer’s DINE guide. http://www.caringtoday.com/deal-with/alzheimers-the-dine-guide. Accessed May 28, 2013.
5) Alzheimer’s: Considering Options for Long-Term Care. Mayo Clinic.Website. http://www.mayoclinic.com/health/alzheimers/AZ00028. Accessed May 31, 2013
6) Studies Find Mixed Results from Dementia Units. New York Times. http://newoldage.blogs.nytimes.com/2013/05/10/dementia-care-units-may-improve-care-studies-suggest/. Accessed May 31, 2013
7) Garden House. Amazing Art Produced by Alzheimer’s Patients. Available: Garden House, Morro Bay