The Best Friends Book of Alzheimer's Activities, Volume One By Virginia Bell, M.S.W., David Troxel, M.P.H., Robin Hamon, M.S.W., and Tonya Cox, M.S.W.

Excerpted from the Introduction and Ch. 8 (p.170) of The Best Friends Book of Alzheimer’s Activities, by Virginia Bell, M.S.W., David Troxel, M.P.H., Robyn Hamon, M.S.W., & Tonya Cox, M.S.W.

Copyright © 2004 by Health Professions Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Introduction: Activities and the Best Friends Approach to Alzheimer’s Care

A young man working as an activity director in an assisted living community in California recently spoke at a conference and expressed frustration about his work. “I follow the recipes in the activity books, I try to throw my own ideas in, I do all the arts and crafts stuff, but I’m in a rut. The programs are falling flat. I feel like I’m on the softball field, playing for my team, but always striking out!” The purpose of this book is to help individuals such as the young activity director rethink and retool their activity programs. It is possible to find the “sweet spot” and hit a home run when it comes to activities.

The Best Friends Book of Alzheimer’s Activities is written for family caregivers, staff, and volunteers looking for creative and meaningful ways to plan and implement activities for persons with Alzheimer’s disease and related dementias. The book is based on the Best Friends™ model of Alzheimer’s care, a model developed by Virginia Bell and David Troxel in 1996 that is now in use around the world. The philosophy of the Best Friends model, simply put, is that what persons with Alzheimer’s disease need most is a friend, a “best friend,” who will provide loving care, accept their illness, and learn what we call the “knack” of caregiving.

The Best Friends approach to Alzheimer’s care helps family and professional caregivers recast or rethink their own life and work with persons with dementia. It can turn the daily stress and challenges of caregiving into a more rewarding and successful experience. 

ABOUT THE BEST FRIENDS MODEL

The Best Friends model is based upon the following principles:

Understanding what it is like to have Alzheimer’s disease or related dementias — Best Friends understand that behaviors that seem strange or unreasonable become quite understandable when you know their origins. The Best Friends approach suggests that knowing the cause of a behavior allows you to give people what they need, when they need it, whether it’s reassurance, physical contact, or a comment or gesture that helps them “save face.”

Learning the basics of dementia — Best Friends do not need to become experts at research, but it is important to have a good understanding of the basics of Alzheimer’s disease and other related dementias. This helps staff members accept sometimes-puzzling behaviors. It also helps staff spot treatable illnesses or conditions that affect daily life and a person’s ability to participate in activities. This book is not written to discuss the diagnosis, treatment, and research issues surrounding dementia; we assume some basic knowledge. If you want more information about Alzheimer’s disease we encourage you to check out reputable web sites and some of the books and sources mentioned in the Resources section (see page 197).

Strength-based assessment — Best Friends focus on what a person can still do, instead of the things a person with dementia can no longer do. Does the person enjoy music, reading the newspaper, or taking walks? Don’t aim too low with your activity programming—this robs a person of dignity. If you aim too high, however, you’ll invite frustration and failure. 

Knowing the person’s life story well — Best Friends learn as much as they can about the life stories, traditions, and values of persons in their care. This instantly helps personalize an activity because you can link the activity to a past or present interest and ability of the participant. Readers will note that each activity discusses the life story and how it can be used to give the activity more value.

Effective communication — Best Friends communicate well and know the “dos” and “don’ts” of communication with persons with dementia. Practicing active listening, speaking clearly and with simple sentences, giving compliments, and asking opinions help us better connect to persons with dementia and build a successful activity program. Each activity in this book includes “conversation starters” that will be useful for caregivers looking for ways to get the most out of an activity. 

Recasting relationships — The Best Friends model encourages caregivers to rethink their relationship with persons in their care from “resident” or “client” to friend. Doing this allows relationships to form and makes possible activities that enrich the lives of everyone. Recasting relationships also works in home-based care settings, whether a paid worker or a family member is providing care.

For more information about the Best Friends model, we refer you to this book’s companion volumes, The Best Friends Approach to Alzheimer’s Care (Health Professions Press, 1996) or The Best Friends Staff: Building a Culture of Care in Alzheimer’s Programs (Health Professions Press, 2001). A book for family caregivers was published in 2002 called A Dignified Life (Health Communications, Inc., 2002).

Developing Knack

As you rethink or recast your relationship to the person with dementia, you will gradually develop what we call “the knack.” Knack is an old-fashioned word with a meaning that is relevant for quality Alzheimer’s care. It means “the art of doing difficult things with ease” or “clever tricks and strategies.” It is the goal or ultimate outcome of the Best Friends model. 

When you follow the activities in the book, you take an everyday activity and add extra value and pizzazz. You can turn a meal into an opportunity for sharing life stories, a walk into a time to explore nature, brushing teeth into an opportunity to tell a joke, and an art activity into one that touches the spirit. A benefit of this book is that a staff or family member who follows the suggestions listed with each activity will gradually learn tricks and strategies to employ in almost any setting! They will develop knack! 

In writing this book, we spent time talking with individuals who have early-stage Alzheimer’s disease (or a related dementia). They consistently said that they value creative activities as a tool for maintaining quality of life. Their voices echo through much of this book as does the authors’ optimism that there will someday be an effective treatment or cure for Alzheimer’s disease.

Activity Principles

Here are some principles of activity programming done the Best Friends way that form the foundation of this book. 

The Art Is Not in What Is Done, It’s in the Doing — The process of the activity is always more important than the result or end product. The activity involving handmade bird feeders (see page 79) is a good example. Enjoy the process of the activity. It doesn’t matter if the feeder fits together exactly or has a perfect paint job.

Activities Should Tap into Past Interests and Skills — Consider the unique life story each of us has when thinking about activities. The home-based activity around laundry (see page 173), for example, would be different for a person with dementia who did laundry the minute a shirt hit the floor versus someone who did not mind wearing the same shirt several times before washing it.

Activities Should Be Adult in Nature — Activities that are unnecessarily juvenile can provoke frustration, anger, or apathy. The person with dementia can sense when an activity is demeaning or obviously busy work. Some persons respond positively to dolls and children’s toys, but you should not use this as an excuse to keep all activities at this level. Good examples of adult activities appear throughout the book. 

Activities Should Recall a Person’s Work-Related Past — Work plays a major role in many of our lives and many of us have a need to be productive and valued. The activity revolving around money (see page 148) will have a different flavor depending on the past occupation of the person with dementia and whether he or she dealt with finance.

Activities Should Stimulate the Senses — Although some of the senses diminish with age, many remain strong. Most successful activities stimulate more than one sense. For example, the activity in this book involving making handmade paper (see page 70) stimulates the senses with the tearing of paper, the sloshing of the water, and the feel of the wet paper.

Doing Nothing Is Actually Doing Something — Enjoying quiet time together or just sitting on a park bench can be a delightful activity for persons with dementia. We do not always have to be structured—life actually consists of more unstructured times. The activity Sit Beside Me (see page 180) is an excellent example of this principle.

Activities Should Tap into Physical Skills — Persons with dementia often retain excellent physical skills, including the ability to exercise, hike, and maintain good hand–eye coordination. Pitching and Catching (see page 111) is an example of a simple activity that keeps a person fit and connected to others. 

Activities Are Often Initiated by Others — Persons with dementia typically lose the ability to initiate activities. We need to be there to help them get started. An example of this can be found in the activity Ink Paintings of Winter Trees (see page 50) in which it is important to set the activity up for the person, hand him or her the paint brush, and demonstrate how to begin painting.

Activities Should Be Voluntary — Most of us, including persons with dementia, are reluctant to do something we do not want to do. For practical and ethical reasons, a person’s involvement in activities should be voluntary. We can gently encourage but should not be too aggressive. A good example of this concept is Let’s Dance (see page 114). Dancing is a wonderful activity, and we can ask someone to dance but should respect his or her right to either participate or decline.

Intergenerational Activities Are Desirable — Persons with dementia can be inspired and touched by the unconditional acceptance and love of younger people. Many persons see young children and young adults as their own and respond to youthful exuberance. At the same time, children and young adults can be touched by the wisdom and affection shown by their elders. Sharing Life with Young Children (see page 83) gives ideas about how to create more intergenerational experiences in your activities. 

Things You Think Never Will Work Often Do — We do not believe in the concept of “failure free activities.” Who leads a failure-free life? If you even could, it would mean you never took chances or tried anything new. Throughout this book, we encourage taking chances and trying new things. Encouraging persons with dementia to volunteer (see page 88) is a good example of this concept in practice.

Personal Care Is an Activity — Personal care is often “where the rubber meets the road” for staff and family caregivers. Are caregivers successfully getting residents dressed and bathed, or is it a constant struggle? Do staff members have time to engage in activities when they’re barely keeping up with their workloads? We argue that personal care should be redefined as an activity because it adds dignity and actually helps the task get completed more quickly. Dressing and bathing (see pages 123 & 124) are examples of this new way to look at personal care.

Activities Can Be Short — Staff members often complain that they do not have enough time to do activities. We empathize with the plight of many staff whose days are consumed by personal care and other demands. Yet, Best Friends activities can be short and done throughout the day. As an example, in Chapter 1, one of the activities honors a person’s preferred name. 

Activities Are Everywhere — It is our hope that activities programs receive an adequate budget for supplies, but inspiration for activities can be found everywhere. Most of the activities in this book require minimal outlays of money to be successful. Creative staff members can also utilize everyday items and information from the library or Internet to make something out of nothing. See, for example, the creative activity around something as simple as beans (see page 37).

Activities Should Also Fill Religious and Spiritual Needs — Regardless of whether a person with dementia has a specific faith background, everyone has spiritual needs waiting to be fulfilled. Best Friends activities celebrate a person’s faith but also encourage staying in touch with the spirit through nature, music, and the arts. The activity Acknowledge Me (see page 5) exemplifies this with religious and spiritual components. 

HOW TO USE THIS BOOK

When we began working on this book, we asked activities staff what they needed most. Almost all said that they want idea books that they can turn to and “grab and go.” This book meets this need with 147 activities that can be used for 1 hour, 1 day, or even throughout a week as a “theme,” for example a week’s worth of activities can be planned around Summertime (see page 35). 

The Best Friends Book of Alzheimer’s Activities is aimed primarily at persons in the middle stages or course of Alzheimer’s disease or related dementias. These individuals generally cannot initiative activities on their own. They need a caregiver’s or staff member’s help to stay connected to activities, but once they begin they can successfully participate and receive much enjoyment from their participation. As noted later in the Introduction, we also offer suggestions throughout the book for persons with early and late dementia.

Although much of this book is aimed at staff members working in residential or day center settings, most of the activities can easily be adapted for home settings. Friends, family, and neighbors often look for activity ideas; this book will be an inspiration for them as well as paid staff. Volunteers, in any setting, will also find the book chock full of ideas to help create a meaningful volunteer activity.

Each Activity Page

We start every activity with a brief introduction or summary in a gray, shaded box that discusses the activity in general and makes some specific remarks about how the activity particularly benefits persons with dementia. Read this gray box first.

The Basics

This section contains the ingredients to pull together the activity. The ingredients might include people (e.g., you and the person with dementia), supplies needed for an arts activity (e.g., paint, paper, tools), or a caregiving technique (e.g., find a quiet place, make eye contact). Also in this section are Variations (another activity or list of activities based on a variation of a theme discussed on the page) and Planning Tips (general tips to help activities run smoothly).

The Best Friends Way  

This is where an everyday activity becomes an activity done with knack. We encourage staff members doing the activities to sample the ideas in this section so they can learn the process of converting everyday “humdrum” activities into ones with “flair.” We suggest many ways to do this; you will certainly come up with more on your own!

Life Story: We start every activity with notes on this fundamental part of the Best Friends model. To deliver quality care, we need to individualize care whenever possible. In an activity setting, this can include designing activities around a person’s past or present. It can also include acknowledging the life stories of individual members of a group, including their attitudes, values, traditions, and history.

Some of the following ingredients are also included in each activity:

The Arts: Activities are enriched when tied to the arts. This can include connecting an activity to a well-known painting, reading a poem aloud, playing classical music, or admiring a sculpture. Many of the activities also involve participating in the arts, something which can be done as actual artists or as armchair critics. 

Exercise: We take note of any opportunities for stretching, walking, or other physical activities that benefit the person and staff member engaged in the activity. It is so valuable to keep the body moving because exercise builds strength, relieves boredom, and helps use up nervous energy.

Music: Music should be woven into as many activities as possible as it remains a source of joy for many persons with dementia. Even after they have lost language skills, memories of old songs are often intact. We suggest songs to sing, most of which are well known. If you don’t know the lyrics, search the Internet for sites containing song lyrics or purchase songbooks. 

Humor: We sometimes forget just how enjoyable laughter can be. Whether the source of humor is a joke, a humorous anecdote, or even a timely smile or gesture, laughter is a beneficial addition to almost any activity.

Early Dementia: In this section, we note whether the activity or part of the activity may be particularly helpful for persons with early-stage dementia. Although definitions of the stages vary, for the purposes of this book it includes individuals who have awareness of their situation and who can initiate and do activities on their own or with minimal supervision.

Late Dementia: We often forget to include persons with late dementia in our thinking about activities. Their ability to participate is limited but they still enjoy being in a joyful environment. Music and touch are particularly appropriate; involve them as much as possible.

Old Sayings: Experienced activities staff members know that reciting old sayings is a favorite thing to do with persons with dementia. Although so many memories fade, many persons with dementia can still complete old sayings, such as “You can lead a horse to water but . . . (you can’t make it drink).” Have fun recalling old sayings and discuss their meaning.

Old Skills:  Persons may recall learned motor skills or other skills they have practiced in their lives. We encourage activities that help persons practice these old skills, be it flipping a pancake, spinning a top, hammering a nail, or folding clothes. Successfully engaging in old skills builds a person’s self-esteem and confidence. 

Sensory: Persons with dementia benefit from activities that stimulate the five senses — touch, sound, taste, vision, and smell. Keeping this in mind can enrich many activities. For example, a simple baking activity is enhanced if the leader of the activity takes the time to encourage everyone to enjoy the smells of freshly baking bread and to do some tasting along the way. 

Spirituality: Best Friends activities touch on the spiritual — whether it be acknowledging and embracing a person’s religious faith or celebrating the person’s spiritual nature. Spirituality often expresses itself through the arts, through music, or through long-held life values such as helping others. Although not everyone is part of a religious faith, we believe everyone has a spirit that can be touched. 

Conversation: Each activity concludes with some conversation starters tied to the activity. Staff with knack don’t need help in this area. Yet many staff find it helpful to see ways to talk with persons with dementia about the activity. We hope that these conversation starters will inspire many more questions and comments to enrich any activity. 

An ounce of prevention...We assume that the staff have basic competencies and understand that supervision is important for almost all aspects of dementia care. Some activity pages note at the bottom any special precautions that need to be taken during the activity. Don’t let this comment dissuade you from trying an activity; just use common sense to ensure that an activity is safe. 

The Best Friends Book of Alzheimer’s Activities is a rich resource of activity ideas, but it is just a starting point. Get a small group together and bring out an easel and butcher-paper pad. Pick a chapter and work through the activities together. You’ll find that a group working together will easily double the number of ideas that we present on a single page. Talk about specific individuals in your program who would enjoy the activity. Make an implementation plan. Families can do similar work in home settings.

Chapter 8: In the Home

Sample Activity

Arranging Fresh Flowers

Everyone enjoys receiving a beautiful bouquet of flowers. It is pleasurable for a person with dementia to not only receive flowers, but to actually take part in creating the arrangement! This activity if familiar and has many different levels of accomplishments, making it effective throughout the disease.

The Basics

Choose a variety of fresh-cut flowers to make the arrangement colorful and varied. Take time to look at and smell the flowers. Talk about and name each kind of flower. Decide on a container. Discuss how the flowers should be arranged, how long the stems should be, and how to create the most beautiful flower arrangement. Invite the person to place the flowers in the container one by one.

Variations: Gathering the flowers can be a separate activity. Enjoy gardening and see catalogs. Force bulbs to flower in winter. Visit a farmer’s market and enjoy seeing all of the variety of flowers for sale direct from the growers.

The Best Friends Way

Life Story: Has the person had a long-held interest in flowers. Did he or she have a beautiful garden? Has the person ever visited England to see the beautiful gardens? Find out if the person has a favorite flower.

The Arts: Use some of the fresh-cut flowers to inspire a still-life drawing (see page 50), or for flower pounding (see page 66).

Humor: Joke about how men often give women flowers when they’re in trouble!

Early Dementia: Ask a person who enjoys arranging flowers to create floral arrangements for a church night supper or a family party.

Old Skills: Some persons have arranged flowers since they first picked a bunch of daisies as a child.

Sensory: Consider putting fresh herbs such as rosemary or mint into the arrangement. Have the person crush the herb with his or her fingertips and enjoy the aroma. 

Conversation: Give compliments, “I like the way you put the tall flowers in the middle. Now we can enjoy these short flowers that are so pretty.” Spend time admiring the arrangement, “It is so colorful and fragrant.” Reminisce with a brother, “When we were young you always bought flowers from the carts in the city? You always brought flowers to Mother.” Try to solve a problem together, “I wonder how the flowers get their beautiful colors.” Encourage, “You are doing a great job. I want you to continue.”