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