Activities Related: August 2025

Monday, August 4, 2025

When We Think That We Understand More Than We Actually Do

Bob attends a group activity. His Activity History shows he used to participate in somewhat similar activities when independent. His MDS Sec. F states that he thinks similar activities are “very important,” and his Care Plan shows that we would schedule activities related to this one and be sure to invite him. He decides to participate. Therefore, we can pat ourselves on the back that our data predicted his behavior successfully. CMS will see that our Activity Care Plan is on target and be happy with us. You, the Administrator, will be glad you can count on us to get it right.

But Nassim Taleb in his book, “The Black Swan,” would probably say we and CMS are all suffering from “retrospective distortion.” Taleb made a fortune by not following the predictions of his fellow Wall Street colleagues. He says that when we interpret something after the fact, we might think we understand it better than we actually do. In my own experience, if we don’t observe a resident actually doing an activity, we cannot predict whether they ever will, no matter what the History or MDS says. It’s much more random and unpredictable than people think.

I knew a resident once who never willingly left her bed. She stated that she was not interested in any activities other than watching her TV while lying down. Yet, by the time I left that job, she was choosing to attend group activities, proactively asking about what was coming up next so she could be in her wheelchair and ready. As an Activity Professional, I would like to take credit for this transformation. I did spend a fair amount of time with her, building relationship and all that good stuff. But, at the end of the day, I know it was kind of random. The right person with the right prompt on the right day at the right moment for the right activity that just happened to click the right way with the right follow-up, etc. Any of those things not being “right” and progress would probably have stopped dead in its tracks. Predictable? Hardly.

And that works both ways. Sometimes the History and the MDS show the resident should be interested in participating in something – but they don’t and won’t. Now, we’re the bad guys and must spend valuable time re-analyzing the situation and trying to justify the refusals or come up with a fix so CMS won’t tag us. And that’s assuming that a wary AP hasn’t learned to avoid the problem by hedging their Care Plans behind generalized objectives and approaches, ones that would be hard not to achieve.

So, where do we get the idea that we can predict behavior? We know that our values/choices change with location, emotional state, age, health, abilities, social groups, and many other factors. Hello. All of these things are majorly changing by the time someone moves into a SNF. So, any data we collect from them, especially in the first week, is not going to be reliable for predicting anything.

Taleb suggests we’re being delusional, like people with Parkinson’s, who when given additional dopamine sometimes see patterns in completely random data. He describes a fellow who sued his doctor because he developed a gambling addiction following the prescribed dopamine treatment. After all, he felt it led him to bet on numbers because he actually believed he saw reliable patterns in them. Taleb writes,

“Note that a “history” is just a series of numbers through time. The numbers can represent degrees of wealth, fitness, weight, anything … we are explanation-seeking animals who tend to think that everything has an identifiable cause and grab the most apparent one as the explanation.” (119)

At each facility where I’ve worked, there has been a core group of residents who could fairly reliably be trotted out for a fairly wide range of activities. They were reliable in the sense of boots-on-the-ground observation of behavior, not interviews. There are also some activities that tend to appeal to many folks in general. Musical entertainment and food come to mind. This information does not come from individual interviews, but from experience with people. In my ideal world, CMS would encourage us to spend more quality time with our residents instead of using that time pretending we and they know what’s going on in our residents’ individual decision-making processes. Why? Because person-centered (or person-directed) care should be more about spending quality time than generating unreliable data.

Taleb, N. N. (2007). The Black Swan. New York: Random House.

No Scents Forgetting

Shortly after finishing my article on wayfinding, I read another book, this time about the sense of smell. I assumed they weren’t particularly related. Wrong. Jonas Olofsson, author of The Forgotten Sense: The New Science of Smell – and the Extraordinary Power of the Nose, picked up the trail after I left off. (Sorry, but smell science lends itself to puns.) He thinks the nose is underrated.

That’s one of the things that they’ve been testing. How accurate is the human nose? Way more than we’ve all been told! Of some 20 animal species that had been tested, human noses were more sensitive to odor molecules than most other animals.

“Humans were more sensitive than other animals to the vast majority of odor molecules. Human versus rat: 31 to 10. Human versus mouse: 36 to 35. Human versus vampire bat: 14 to 1. Human versus spider monkey: 58 to 23. The only animal that was clearly better than humans was the dog, which is more sensitive to 10 out of 15 odor molecules.” (17)

They even had people down on all fours following scent trails in the grass. You actually could try this at home, I guess. Just don’t snort the dirt up your nose … and make sure you have an alibi in case the neighbors see you!

But we don’t usually navigate on all fours. So, what does smell have to do with wayfinding? For starters, smells are linked to memories. And memories are part of narratives that we have in our brains.

“It is now well established that smells have a unique capacity to evoke memories of childhood. But that is not all. Olfactory memories are also different in other ways. They evoke a sense of “going back in time” in a way that no other sensory experience does. Smells can make you relive the time you helped your grandfather tar the rowing boat, the time you stepped out of the airplane on your first vacation to the Mediterranean or the wedding where you got to be a bridesmaid with your own bouquet of flowers. You remember the details, relive the moods. Smell memories are also more emotional than other memories.” (71)

Wayfinding and memory are both processed by the same part of the brain, the hippocampus. So, it is no surprise then that memory and wayfinding are both affected by dementia, which often affects the hippocampus early on in Alzheimer’s Disease. The hippocampus is part of the medial temporal lobe (MTL).

“We now know that the disease often starts in the regions of the medial temporal lobe and lower frontal lobe, both of which process smells. These regions also control memory storage, so the loss of smell combined with memory loss is particularly ominous.” (145)

Our narrative sense of our own history, our map of the past, is tied to our sense of smell. But what if that sense of smell becomes degraded? Alzheimer’s is known for affecting the sense of smell, but so is COVID. Ah, now you’re listening, because you might be one of many younger people who lost their sense of smell due to the pandemic. Sometimes it comes back on its own, but sometimes there are lingering problems. Is there anything that we can be doing for ourselves or our residents?

We’ve all seen the brain exercises using picture cards which the player must name from memory. Olofsson’s group came up with a smell-based memory game. They had players use it for 40 days, and saw clear improvements in smell detection. But they also saw improvement in the ability to identify things visually – even though that was not part of the game.

“But the most interesting result was found when we tested the memory games themselves, both visual and olfactory. Those who had played the regular visual memory game became very good at it after the training program. The same applied to those who had played the smell game … and they also got better at the visual memory game! However, those who played the regular picture memory game did not improve at all on the smell game or any other smell task. So by replacing images with smells, we were able to promote improvements in several different tasks.” (149)

What is his advice? Get the most bang for your brain-training buck. Don’t just use visual games, but use ones like smell training that target more than one skill.

“One area of the cortex of the parietal lobe may have even grown slightly thicker in those who trained with smells and learned to get better at both olfactory and visual tasks. This area is known to help us with spatial understanding, navigating [emphasis mine] and remembering where things are located in our environment. Training the ability to remember where the matching odor pairs were placed would now make this brain area more connected to the frontal lobe, which decides our movement patterns.” (150)

There are commercially available scent games on the market or you can Google Jonas Olofsson to watch some of his YouTube videos for more information.

Olofsson, J. (2025 translation). The Forgotten Sense. New York: Mariner Books.

Do You Know About the Senior Games?

Here’s why I like them.

To this Activity Professional, the Senior Games are the best thing since buttered bread. For seven years, I had the thrill of helping my residents prepare for and participate in their local county Games. I was there to see the pride on their faces; they knew they were representing their fellow residents in a competitive venue in the outside community. How cool is that? We’re not talking about staging a cute in-house thing. Those are needed and fun, but would you compare a high school gym class game to a varsity tournament? Me neither.

There are lots of competitions to choose from: Sports, Performing Arts, Visual/Heritage Arts, Literary Arts. All the competitions are divided into age groups. The folks in their 80’s are not competing against the ones in their 60’s. If someone in their 90’s needs to walk instead of run part of their 400m race, people still cheer wildly. I won’t go into too much detail – you can find more on the websites – but here are some examples that my residents entered, many of which won gold medals:

Literary Arts – We recorded some residents telling those great stories they have from back in the day, typed the stories up and popped them in folders.

Heritage Arts – Residents submitted knitted or crocheted projects they had made.

Visual Arts – Residents submitted photos printed from their phones, or hand-crafted paper flower displays.

Performing Arts – Our resident choir performed live in front of an audience of hundreds.

Sports – Putt-putt golf, corn hole, softball throw, fun walk.

Of course, it’s not just for the residents. Anyone “50 years old or better” can participate. I’m talking to staff here – of a certain age. I’ve personally done badminton, 50m, 100m, power walk, acrylic painting, and instrumental music, as well as leading the resident choir group vocal music. Wouldn’t it be great for facility morale if the residents could see more of us rejecting ageism and identifying with them and our “50 or better” peers?

There are yearly Games held in 54 counties here in NC in the spring. Make sure you find out about the Local level or county Games. Your state will have them also. You have time to prepare if you start soon, but the deadlines for registration are coming up fast!

For more details google “Senior Games near me.”

Donna Stuart December 2024

In My Mind I’m Gone to …

Wayfinding. Memory. Is memory more than a Facebook reel from the past? Is wayfinding more than the ability to navigate across some terrain? M. R. O’Connor, in her book, Wayfinding, discusses the terms and how they are intertwined. In one sense, memory could be called a narrative of our wayfinding history, what happened in the context of when and where.

“When we move through space, we perceive the environment and direct our attention to its characteristics, collecting information or, as some would describe it, building internal representations or maps of space that are “placed” in our memory. Out of the stream of information generated by our movement we create origins, sequences, paths, routes and destinations that make up narratives with starting points, middles, and arrivals.” (p.6) (emphasis mine)

It turns out that wayfinding and memory are both processed by the same part of the brain, the hippocampus. So, it is no surprise then that memory and wayfinding are both affected by dementia, which often affects the hippocampus early on in Alzheimer’s Disease. Mr. Smith gets lost while driving to the nearby grocery store and ends up on the far side of town. Mrs. Smith keeps wandering the halls of her facility, looking for the door that will let her cross the parking lot to her house that she is sure is right next door.

The hippocampus can be developed through use. Taxi drivers in London famously have larger hippocampi than you or I because they rely on it to navigate the labyrinth of old streets. But the hippocampus can also suffer from the “use it or lose it” phenomenon. Does my relying on GPS to find my way around town lead to brain atrophy? Some brain experts feel that wayfinding practice is so important to cognitive health that they are limiting their personal reliance on GPS technology. They don’t want their own hippocampi to deteriorate through lack of use.

Human groups around the world had significantly different ways to wayfind before technology interrupted the process. Using them, they could reliably find their way across the desert, ocean, jungle or tundra. Most of their strategies involved focused attention on the environment around them. Interestingly, some therapy for Parkinson’s Disease uses focused attention on the external outcome of a desired action. It can lead to better motor control for them. Focused attention is more than just having someone tell you that “you are home, Mrs. Smith” or “you are in your own room” or whatever. It can be prompted, but it still has to have an internal source.

I was told that resident wandering/elopement is mostly about them looking for the comfort of a remembered home and family. I’ve also heard that in some disorders, like ADHD, the brain seeks extra stimulation, hence the fidgeting, or impulsive behavior. This book makes me wonder if another reason for wandering could be the brain trying to fill in missing stimuli from the present, the missing parts of a coherent narration of one’s life story.

When residents wander, we tend to rely on redirecting, thwarting, or even restricting their movements. What would it look like in the domain of Activities to intentionally work on helping residents develop focused attention, mindfulness even? Is it possible that focused attention as they move through their present environment could help improve memory? As James Taylor sang about his homesick thoughts, “In my mind I'm going to Carolina. Can't you see the sunshine, can't you just feel the moonshine?”

O'Connor, M. R. (2019). Wayfinding. New York: St. Martin's Press.

Taylor, J. (1968). Carolina in My Mind. London: Apple Records.

Willful Blindness and Person-Centered Care

You are a character in a YouTube video, dressed in some nautical uniform and aiming to toss a life preserver to someone floating in the sea. You quickly realize that the target is moving and that a thick fog is swirling around the two of you obscuring your vision and messing with your aim even more. What can you do?

In the current environment of activities/life enrichment, I know everything is all about person-centered care or person-directed care. Let’s just say I’m skeptical about how those terms are understood and used. If you’ve read my other articles, where I’ve reviewed books about the topic of Cognitive Science, you might know why.

Doesn’t setting Person-Centered/Directed Care as a goal assume that it’s possible? Yes, I know you have anecdotal evidence of some incredible response you got from some residents when you hit that sweet spot of interest and motivation and ability and other unknown factors that happened to help. What about the rest of the residents? It is so easy to find yourself trying to convince someone to participate in an activity that all your interviewing tells you they should really want to do. Oh, those happy bang-your-head-against-the-wall moments!

Let me ask some questions. First, do you have access to the “real” people you’re dealing with? That’s a trick question, of course, because there is no such thing. Research shows that we change and keep on changing, minute by minute as well as year by year, and that process doesn’t stop just because you’re 93 years old. Second, can you find out what people “really” want or think is “important” by asking them? Research shows that people don’t reliably know what they want and that their answers are basically meaningless as relates to future activity choices. Third, are you able to mitigate the effects of group dynamics, aka conformity or peer pressure? Our residents are group members, whether or not we or they recognize it, and the group has a big effect on what they will or won’t do. Fourth, are you able to control for outside forces, like pandemics, which can actually change how our residents perceive reality? Fifth, how many of our residents have the desire or ability to direct their own care, much less that of others? I’m picturing a carload of people trying to decide which restaurant to go to for dinner. The residents I’m thinking of who had ideas, usually had ideas that were not feasible – crafts none of their cohort could do, outings no one could manage.

I have had folks who used to sing, but won’t sing now. I have had folks tell me it’s important to be with groups of people but who stay in their rooms now. I have had folks tell the resident council that they want to watch movies in the activity room, but then don’t come. I have folks who have dropped out of group activities because someone who sits at the dining room table with them pooh-poohs the whole idea. I have had wonderful large-group participation where a few natural leaders among the residents made it their job to promote group participation.

In the professional setting, our local activity professional association can’t seem to convince our members that they have enough time to participate in workshops or networking events. These are people who paid the membership fee to an organization that has typically run several workshops a year. This buy-in would seem to indicate that they “want” workshops, feel workshops are “important,” and value being with the group. Right.

In Willful Blindness, by Margaret Heffernan, she discusses the case of the vice chairman of the CIA National Intelligence Council back in the ‘80s. He had predicted the collapse of the Soviet economy, but didn’t have the data to prove it; that is, until he set up a special office to watch for unusual things, data that wasn’t normally collected.

“One of the benefits of a sense of history is that it can alert us to trends, and sensitize us to weak signals; … When is the information you’re getting denied by the evidence you are not getting?” (237)

I used to teach microscope skills in my biology class and one of the skills that was hard to teach was that sometimes you’ve moved in too close. Sometimes you need to zoom out and look at the bigger picture. If I were teaching an activity certification class, I would tell my students to back off a little and make sure they were really familiar with the culture, age, social groupings and cognitive patterns their residents were and are affected by. I would tell them to make the assumption, if possible (I know there are plenty of exceptions), that the generalized trends of those groups might still apply to the residents’ activity choices. I would encourage them to be willing to push to create the environment where those trends are used to generate activities that can more predictably apply in general. And I would tell them to throw stuff at the wall and see what sticks.

Heffernan, M. (2011). Willful Blindness. New York: Walker Publishing Company, Inc.

What if It’s Not All Downhill?

Some researchers took brain scans of people whose eyes had been completely blindfolded for 5 days. What did they find? Those lab subjects’ brains were already re-wiring, processing touch sensations where they used to process visual stimulation. And their touch sensitivity had improved. We call this neuroplasticity.

In her book, Sentient, Jackie Higgins compiles research like this about the implications of the ability to sense our world. We all know about the 5 senses, vision, hearing, taste, smell, and touch, but there are more. Animal studies point back to human possibilities and now they’re talking about some 30 senses that you and I possess. That and consciousness and cognition. That and the potential for neuroplasticity, the idea that where and how sensory information is processed in our brains can change.

Those of you who saw the movie, Daredevil (2003), might remember the scene where the blind protagonist was able to “see” the girl when it began to rain. His brain was able to hear the change in sound patterns where the rain was deflected and translate that into an “image.” In real life, John Hull, a man who had lost all his vision, describes experiencing this very thing, “Rain has a way bringing out the contours of everything; it throws a colored blanket over previously invisible things.” (58) Sound was providing the spatial sense that his vision used to.

Higgins quotes Harvard neurologist Alvaro Pascual-Leone,

“Everything we think, feel, dream, every experience we have keeps modifying the brain. Rather than written in stone, our brain is dynamic and capable of rapid change.” (76) He wonders if the part of the brain we associate with vision “might more accurately be defined as the area of the brain best able to discriminate spatial relationships and that it will use any relevant sensory input.” (80)

So, my question is, does this apply to the cognitive losses of dementia? If the brain is able to co-opt processing regions to mitigate sensory loss, is that what it sometimes does for cognitive loss?

We know that music and touch can engage the brains of folks with dementia. There are multiple interventions with documented results that Activity Professionals and Therapists use for this purpose: Drum Circle, music therapy, massage, Music & Memory®, dance, and MnemeTherapy® are a few.

I mention MnemeTherapy because I recently certified to practice it. MnemeTherapy® is an activities-based intervention. It works by engaging the person’s attention with movement, sensory and cognitive tasks, and then focusing that attention on the painting process. The directed painting process itself provides sensory stimulation through the tools and techniques used. On the surface, it provides a rewarding experience, but sometimes there’s more. Sometimes there is significant improvement in a client’s verbal skills, mobility, combativeness, spatial acuity and/or the ability to follow instructions. Why, and what is the mechanism for this improvement? How can we improve what we offer?

I would love to know what brain scans before and after MnemeTherapy, or any of our other interventions, might show. Can NAAP be the advocate to draw research projects to study activities?

©Donna Stuart, ADC, CMT November 19, 2024

Higgins, J. (2021, Reprint Edition 2022). Sentient. New York: Atria Books.

All This And Ukraine Too

It seems to me that we Activity Professionals have a unique vantage point on the condition of the world, quality of life, and human behavior in general. So, when I read about research in other fields, I get all excited about the obvious tie-ins to our work. A few months ago I wrote an article reviewing Jonathan Rauch’s “The Happiness Curve” as it relates to long-term care, especially critical staffing shortages. That article appeared in McKnight's Long-Term Care News this spring. However, I couldn’t fit everything from Rauch’s book that applies to activities into the first article.

My activities tie-in is a bit heretical. I think that the “person-centered” movement is all well and good, but implementing the results of the meta-analyses being done in the field of human behavior might benefit our residents just as much. And combining the two approaches even more. For example:

Self-isolation. Hopelessness. Ukraine.

Rauch himself was looking for tie-ins from research on happiness, how people rate their own satisfaction with life (aka happiness) and how it affects their activity choices. As he describes it, our collective sense of satisfaction follows a predictable curve related to the age of the people being interviewed. No surprise but satisfaction with life tends to bottom out in middle age, even in the presence of great personal career/financial success. Then, later in life, our perspective starts changing and things get better. It’s a world-wide phenomenon. He also points out that age seriously affects our experience of time. Seniors often don’t think they have enough “time” for our activity programs, because … after all … they are hoarding the limited number of moments they feel they have left. Again, no surprise to you folks. Again, it’s a phenomenon seen in many cultures around the world. Meta-analysis, not person-centered data collection.

But Rauch had more numbers up his sleeve. That middle-age angst eventually begins to dissipate with age. Here we see seniors, sicker, more disabled and suffering more pain, but also happier, more mellow in general than they were 20 years ago. You know what I’m talking about. If I picture myself in the medical condition so many of our residents enjoy, I would picture myself as completely miserable, not mellow. And what about that sense of time being too limited to allow for out-of-room activities? It’s not set in concrete. There are examples that show we might be able to enlarge seniors’ sense of time in general with the right input. Applied meta-analysis, not derived from the MDS or an activity history.

How do we change our residents’ perception of time? Younger people assume they have time for going places, doing things, and meeting people (besides close friends and family). I’m wondering if we can convince our residents that there is enough time to do things besides wait in their rooms for family to visit. I’m not sure what the optimum time frame would be. Tomorrow? The next scheduled event? Christmas? A staff pregnancy or wedding? I’m thinking that we need to find some way to involve more residents in the preparations for the future. However, if staying in the room is part of the problem, asking for their suggestions on out-of-room activities is probably a waste of time. Resident council is supposed to elicit participation in the planning process, but if someone is coming out for resident council, they aren’t really the target for this intervention. Applied meta-analysis based on current level of participation/attendance, not on self-reported MDS answers or activity history.

I’m not above involving family members. One resident has been refusing activities she used to participate in happily. She only leaves her room for meals now, and only if staff really coaxes. By chance, I saw her heading to her room after a meal. She was right at the point where it was actually closer in time and distance to go to bingo than to go back to her own room. She let me assist her to bingo. When it was done, I asked if she had had fun. “Oh, yes,” she said, smiling broadly, “I had a good time.” Then she went back to her room, back to self-isolating. I saw her son the other day. I told him I had a job for him – he needs to talk to his mom about the future whenever he can, to try and get her thinking about the future.

So, here we are still dealing with the pandemic. We used to joke about PTSD at work. It’s no joke anymore. Many staff bailed since our major outbreak in 2020. Those of us who are left cringe when the office calls. We’ll be standing in the hallway and someone’s cellphone will ring and we look up and make eye contact with each other. News that another staff member tested positive. It just doesn’t end. Rauch had no way to know that the “happiness curve” would take such a hit so soon after he wrote his book. That was 2018. In 2019, my niece, in her late 30’s, took her own life. In 2021, a nephew in his late 30’s gave up on the future and took his own life. Both were heading into what probably looked to them like an unending downward slope. The drop in life satisfaction beginning in the 30’s and bottoming out in the 40’s and early 50’s is a real thing, and obviously the pandemic is not helping. In fact, the pandemic is probably also skewing our sense of time. When the future of the world as we know it seems problematic, all our personal plans for the future seem less relevant. Rauch had already figured out that while individual counseling could help people struggling with hopelessness, our society could do a better job of warning people what to expect. Maybe we’d feel less stigmatized and more inclined to get the help we need to wait it out. Maybe if you’ve just rolled into a long-term care facility and you wish your family would just let you die … maybe it would help to know there is still happiness to be had. Potentially life-saving meta-analysis.

You’re wondering why I mentioned Ukraine. Well, as I’ve pointed out, Rauch has data to show that the “happiness curve” is universal. In almost every country there is a self-reported drop in life satisfaction in middle age. There is also a universal rise in life satisfaction in later years. The problem is Russia. Their curve bottoms out lower and rises later. They are less happy in general and unlike the US, where we very gradually begin getting happier in our 50s, the Russians are barely starting to get happier in their 80s or 90s.

“… the curve there does not turn until the average person is dead” (80).

Rauch, J. (2018). The Happiness Curve. New York: Thomas Dunne Books, St. Martin's Press.

Individually Grouped

I wrote an article a few years ago talking about the benefits for residents in long-term care who belong to a performing choir. Well, actually, it turns out that belonging to almost any group can bring positive results. And … oh, yeah … we aren’t doing groups right now. That’s too bad, because feeling included in a group does help prevent loneliness. Feeling included in a group can also lead to perseverance. That’s a claim that David DeSteno makes in his book, “Emotional Success” (133). Who cares about perseverance? Everybody is concerned about the loneliness pandemic, not the loss of perseverance. But as an activity professional, I can assure you that perseverance is a big issue in senior care quality of life. It takes perseverance to keep a life from imploding.

DeSteno points out that perseverance is future-oriented (69). It’s actually a measurable behavior calculated to improve the future as opposed to the short term. When our residents lose perseverance they no longer value the future enough to make it better. You know the quote, “Old age sure ain’t for sissies.” It takes perseverance to get out of bed. It takes real perseverance when you live in a long-term care facility. Where I used to work, the CNAs would shake their heads and say so and so is “in the bed.” Not a good sign.

Pride is another topic DeSteno deals with, the good kind of pride that leads to intrinsic motivation. When you do something that your group considers valuable, they will let you know. When you are aware of their approval, you feel pride in your efforts, and your sense of pride will motivate you to cultivate the skill that won the approval (118). The group wins and you win. We entered our resident choir in the county-wide senior games in 2018. They were competing in front of their active peers still out in the community. When our choir got a standing ovation, something good happened. The choir members were invested before, but practice became more serious. Some of them had become focused on being ready for the next year’s competition. Group inclusion and pride encouraged perseverance. The future was being valued.

But now, I can’t get my whole choir together to practice. Depending on the current quarantine restrictions, I could get a few people at a time … or not. Out in the world, I did see that some folks found a work-around. They were using multi-screen technology. They video-recorded individuals singing the same song and then put them together. Huge choirs of individually recorded voices. You’ve probably seen them on YouTube or Facebook. Could we do that in a small assisted living unit? The short answer is, “Yes.” We’re testing the “Acapella” computer app that lets us record 9 people individually on an iPad. Each track is added to the ones recorded before. When you’re done, you see and hear 9 people singing “together.”

Ah, but this wasn’t done as a group. I figured it would be fun for the residents and their families to watch, but it would not produce the documented benefits of group activities. That was before I read “Emotional Success.” On page 150, DeSteno describes an experiment done by Gregory Walton and Geoffrey Cohen at Stanford. Their subjects worked alone. Some were told they were part of a group, though they had never met this group. Others were told they were working by themselves. The results showed that even just telling you that you are a member of a group and that you are helping the group achieve some goal is enough to make you persevere more at a task. And my assisted living residents have much more social connection than that. Our choir has a history. Yes, even singing “by themselves” can help them be motivated to persevere.

DeSteno, David. Emotional Success. New York: Houghton Mifflin Harcourt, 2018.

Walton, G. M., Cohen, G. L., Cwir, D., & Spencer, S. J. "Mere belonging: The power of social connections." Journal of Personality and Social Psychology (2012): 102(3), 513-532.

Driving Alone

In a previous blog, I reviewed the book, Don’t Retire/Rewire, by Jeri Sedlar and Rick Miners. Their descriptions of “drivers” aka personal motivators still resonates with me. They identify eighty-five drivers (Appendix C) and then narrow it down to 30 main ones on p. 61. Drivers are tied to the concept of what makes an activity meaningful. Activities that match our personal drivers will be more satisfying than activities that merely keep us busy. “Drivers are the key to satisfaction,” the authors state (56).

However, as this book describes, most of us are stinking bad at identifying our own drivers, much less figuring out how to fulfill them. Indeed, the authors have to put their clients through a multilayered regimen of self-analysis in order to elicit a list of personal drivers and their applications. These clients are typically alert, oriented, successful in life, and self-motivated. And they’re reaching out and paying a lot for this service. Why? Because without expert coaches, they can’t tell you what their drivers are or how to satisfy them.

No wonder we in LTC have trouble providing person-centered activity programs for actual persons. The MDS questionnaire and the average activity history form hardly measure up to the process that Sedlar and Miners use to help their clients assess themselves. Like their clients, many of our residents don’t really know what they want, so how can they tell us? We don’t have the data, or the tools to get the data, up front.

I am intrigued by residents who choose to isolate themselves. It seems like there are many factors that lead to that lifestyle, not just one pattern. For some it has more to do with physical limitations: vision, hearing, mobility, dexterity. For others, there may be more of an emotional/cognitive cause. I once had a resident who chose to sit and stare at the wall of her room because she felt she couldn’t hear well enough to participate in group activities. (Thankfully, she learned to go outside on the enclosed patio and enjoy the fresh air.) But I’ve been adjusting my thinking about these folks since reading this book. According to Sedlar and Miners, there are still drivers at work here, drivers that could help each person achieve greater quality of life. Ironically, some of the drivers are actually driving the self-isolating behavior. For instance, residents who insist on isolating are expressing power over their circumstances. Having a sense of “power” is a driver. We all know what powerlessness feels like. There are residents who realize they don’t understand what’s going on around them. Some of them want to sit in their recliner with the curtain drawn. They’ve figured it out – that’s how to have a sense of structure in their environment. Leaving that behind might make them feel too vulnerable. Being able to solve problems and needing a sense of structure are both drivers. Person-centered/directed care should lead to more drivers being identified and satisfied. I want to use my understanding of drivers to help reach more residents.

From 1:1 interviews, Sedlar and Miners found that ”the happy people had either intuitively known what their drivers were and fulfilled them with new activities after they retired, or they discovered how to satisfy them through trial and error” (60). But, of course, not everyone intuitively makes the best choices and not everyone is willing to try again when they fail. Many of their clients would say that they “flunked” retirement (3) because they initially chose activities that did not satisfy and left them feeling frustrated. A common example the authors cite is of clients who planned to spend all their time “having fun” when they retired: playing golf, relaxing, etc. It didn’t take them long to realize they were bored and wondered why retirement was not as enjoyable as they’d hoped. Our residents might have already experienced this type of failure before they came to us. Some of them still haven’t figured out how to choose or ask for activities that provide fulfillment. It is a short step from there to make the assumption that no activity can satisfy. Might as well stay in the room.

People intuitively compare the past and present, and the comparisons can be pretty depressing. You could even call it a survival response, to avoid putting yourself into a situation that might generate thoughts like comparisons. To residents struggling just to survive in a facility when their health, competence and autonomy are compromised, the added threat of depressing comparisons is just that – a threat. You can’t exactly recreate a past activity, done by a healthy and independent individual, for a sick and/or dependent person. Putt-putt in the activity room will never be the same as the foursome on the golf course. For some, it would be a pleasant tie-in to a past hobby. For others, it would be a depressing reminder of lost strength. I am always recruiting for our resident choir. Some of the holdouts are the ones who used to have the best voices. “I can’t sing anymore,” they’ll say. I’m thinking that drivers like the identity, prestige, and recognition as a good singer are lacking, and with them the motivation to risk joining the choir.

So, self-isolating, or refusing activities linked to past pursuits, might both be related to attempts to fulfill drivers like the need for authority, identity, power, structure, problem-solving, and self-esteem. That would be why they are so hard to counter. We talk of sensory or cognitive stimulation, but it sounds like we need to provide enough stimulation to satisfy drivers as well. I know CMS wants assessments and care plans done quickly, but figuring out drivers will take more time. It will take multiple small successes of trial and error. It will also take a trust relationship. We’re talking about risk-taking and a change in mindset. And most of us don’t like either one.

Sedlar, Jeri and Rick Miners. Don't Retire Rewire! 3rd Ed. New York: Alpha Books Penguin Random House LLC, 2018.

Godzilla vs. King Kong

King Kong and Godzilla faced off above the city skyline. With his teeth, Godzilla rips a hunk from the skyscraper, flinging it in Kong’s direction. Kong bats it away, sending it spinning down onto the city streets below where mere humans, trapped in the drama, scurry helplessly. It’s been like that.

Keeping up with the news stories on the pandemic the past year and a half, you may have noticed there seemed to be two major threads. I’m not talking about “it’s the end of the world” vs. “it’s all a myth.” I’m talking about the droplet vs. aerosol transmission controversy, asking the question, how does the virus pass from one person to the next? Does it primarily pass via particles that quickly fall to the ground or to a nearby surface, or can it linger in the air, potentially travelling longer distances before infecting someone?

The CDC and WHO mostly represent the medical profession and the research generated by the medical profession. They have their turf. But there are other relevant professions out there, physics, engineering, etc., and those whose work span multiple disciplines. When one group doesn’t acknowledge the other, it’s more than just a turf war. It could be tens of thousands of seniors dying. It could be the seniors we loved and cared for who died.

Public health policy, coming from the CDC and WHO, camped on a historical view of the droplet transmission side with its hand washing and six foot social distancing. They only tended to consider aerosol transmission during certain specific medical procedures, such as intubation. But there were impressive studies showing that aerosol transmission was happening in other more normal settings. This is a serious difference. A life and death difference. Hand washing and a mere six foot distance wouldn’t be enough to prevent aerosol transmission. Ventilation has to be addressed. Maybe that’s why when COVID got into our facility, we were helpless to stop it. Our building was not designed to prevent aerosol transmission. While we were washing our hands, wearing non-N95 surgical masks and nagging the residents not to sit near each other, was the virus wafting slowly down the hallways behind us?

Wired magazine published an article by Megan Molteni, entitled The 60-Year-Old Scientific Screwup That Helped Covid Kill, on May 13, 2021. She documented some of the back and forth drama that was taking place over our heads. According to Molteni, the medical profession had taken some numbers that applied to tuberculosis and coal mine dust and, for the 60 years up until now, applied them incorrectly to almost all respiratory germs. Look up all the places where 5µ had been named as the particle size cutoff point for aerosols. Anything bigger was assumed to only travel through the air in droplet form. Now substitute the 100µ size that might actually go aerosol. Quite a difference. Unfortunately, the 5µ mistake had become so entrenched that it was like heresy to the medical profession to challenge it.

It was April 3, 2020, when a group of scientists arranged a Zoom meeting to formally challenge the WHO about droplet transmission. It was March of this year, when the the WHO issued ventilation guidelines. In June, the the CDC issued theirs. Both finally acknowledged that the other sciences might be right, that aerosol transmission might be a culprit in the spread of COVID outside of the intensive care unit. So, the question is at what point did the threads merge to produce coherent policy that would help us protect our residents? Answer: they haven’t yet. The vaccines arrived before Kong got on the same side as Godzilla.

https://www.wired.com/story/the-teeny-tiny-scientific-screwup-that-helped-covid-kill