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.

© Donna Stuart, ADC    June 29, 2025

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.

© Donna Stuart, ADC, MT   June 23, 2025

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?”

© Donna Stuart  March 7, 2025

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.

© Donna Stuart, ADC  12/3/2022

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.

© Donna Stuart, ADC     June 21, 2022

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.

©Donna Stuart, ADC August 17, 2020

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.

©Donna Stuart, ADC   October 22, 2019

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.

©Donna Stuart, ADC July 20, 2021

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

And Out Comes Happiness

There are some old songs from the time of the revolutionary war.  The victorious colonists took “Yankee Doodle” as their theme song, but when Cornwallis’ army was marched out of Yorktown in defeat, the fifes played “The World Turn’d Upside Down.”   This is how it goes:

If buttercups buzzed after the bee,

If boats were on land, churches on sea,

If ponies rode men and the grass ate the cows,

Then cats should be chased into holes by the mouse … (Luther 39-40)

You get the idea.  The underfunded, undertrained, outnumbered Americans had managed (with a great deal of help from France) to beat one of the best armies in the world.  It was devastating.

How many of you are feeling the same way about the COVID-19 quarantine situation?  Almost everything we were doing on purpose as activity professionals has become taboo or turned “upside down.”  Group socialization is good for the residents – no, it is dangerous.  Human touch is good for them – no, it is dangerous.  Getting out of their room is good for them – no, it is dangerous.  Singing together is good for them – no, it’s dangerous.  Visitors are good for them – no, they’re dangerous.  Assisting someone so they can be successful with a craft is good – no, you’re standing too close.  Loners are more susceptible to depression, etc. – no, they’re safer from the virus.  It seemed as though I could feel the gears in my brain screeching to a slow stop.

I could not get a picture in my brain of what the future of activities would be like.  What I could imagine looked pretty grim.  We started trying different things on the units, but it was not the same quality of life for my residents that I had been striving for these past years.  If we couldn’t provide quality of life, then what was the purpose of providing care?  Visions of the “bubble boy” came to mind.  Would it be possible for my residents to ever find happiness again, given the issues with the pandemic?

I obviously needed some outside input.  The Bible actually has a lot to say about happiness.  Useful stuff.  Some 2,700 related passages (Alcorn 19)!  I also began cruising the online TED talks.  Each TED talk is officially 18 minutes of presentation by an expert on a topic that expert is passionate about.  One of the first things I found was a 2004 talk about happiness entitled, The Surprising Science of Happiness, by Dan Gilbert.  He was describing the results of large-scale cognitive science experiments on how the brain functions.  2004 was before COVID-19.  It was even before the economic crash of 2008.  Would there be anything useful in it?

Gilbert states that the pre-frontal cortex of our brains has the ability to simulate experiences for us before we have them.  We call that imagination.  However well that works, he says the problem is that we are not so good at predicting how those simulations would affect us if they came true.  That is called the “impact bias” (TED, 2004).  He offers the example of imagining winning the lottery or else becoming a paraplegic and estimating which one would make you happier.  Well, duh, you say.  But the actual data from people who have experienced one or the other shows that neither set of individuals is particularly happier one year later.  Your prediction was, predictably, biased by lack of understanding of how your brain works.

So, what happened?  How could these two radically different scenarios result in a similar outcome?  Gilbert again explains that our brains have the tendency to change how we view our situation in a way that lets us feel better about it.  He says that we “synthesize” happiness with what he calls our “psychological immune system” (TED, 2004).  Whoa! Did he say something about an immune system?  Well, that certainly is timely.  And immunity to permanent devastation related to a bad situation sounds pretty useful.  How you look at something really does make a difference.  Actually, Gilbert says that except in certain types of cases, most outcomes even out after about 3 months!  The average natural happiness from what looks like a happy situation will tend to equal the average synthetic happiness from what used to look like a bad situation.

As a matter of fact, I think I have observed this very process at work in our building.  Two and a half months ago, the residents were not happy to be losing access to family visits, communal dining and group activities.  They became more upset as time went on.  Then I began noticing that there was more acceptance.  A new normal was setting in.  In fact, staff seems to be having more trouble adapting than the residents themselves.  A co-worker wondered if I was struggling because of the loss of control over my part of the activity program.  Well, yes, but hadn’t the residents also lost even more control over their own lives?  Gilbert might have an answer for this, too.  He describes other experiments that prove we synthesize happiness the best when we have no choices (TED, 2004).  Apparently, choices produce second-guessing which tends to rob us of happiness.  Staff is doing the second-guessing while the residents are busy adapting. 

So, yes, both faith and science tell us that our residents can find happiness in a quarantined world.  Some of us would say it’s a gift that God ‘hard-wired’ in.

©Donna Stuart, ADC   May 31, 2020

Alcorn, Randy. Happiness. Carol Stream, Illinois: Tyndale House Publishers, Inc., 2015.

Gilbert, Dan. (2004, February).  The Surprising Science of Happiness.  [Video File].  Retrieved from https://www.ted.com/talks/dan_gilbert_the_surprising_science_of_happiness

Luther, Frank. Americans and Their Songs. New York: Harper & Brothers Publishers, 1942.

Driven From Distraction

Part I

What kinds of problems do older people face?  Principle #1 of the Eden Alternative states that,  

“the three plagues of loneliness, helplessness, and boredom account for the bulk of suffering among our Elders.”

Do we think this only applies to the residents we see in the long-term care setting?  Jeri Sedlar and Rick Miners are thought leaders on retirement issues.  You might have seen them on The Today Show.  In their book, Don’t Retire Rewire! they discuss their 25 years-worth of experience interviewing and coaching people through the retirement process.  Their conclusion?  Loneliness, helplessness, and boredom are not just problems in the nursing home setting.

According to Sedlar and Miners, people face the potential of boredom at all different stages of life, but especially at retirement.  That can be due to poor planning and misconceptions about themselves and their own needs.  

“Boredom was one of the biggest complaints we heard in our research, and not just from Type A personalities or hard-charging executives” (24).

They also talk about people unexpectedly missing the camaraderie of the office and the sense of accomplishment they enjoyed at work. 

“In our experience working with clients, people underestimate the things they like about their work” (25).

Many of the clients they mention are in their 50s and early 60s.  The way I figure it, all my residents are in retirement.  It is just the location of their retirement that makes us look at it differently.  Most of us will live long enough to face retirement.  And everybody, it seems, needs to plan ahead to prevent boredom, loneliness and helplessness from taking over their lives.  Wake-up call, anyone?

The authors discuss the different opportunities people have to find meaning when transitioning away from their mid-life careers.  In today’s economy, many choose to continue some kind of work, even if it is not for pay.  Among all the options for post-retirement lifestyles,

                “… retirees repeatedly returned to the theme of wanting meaningful work.  There is no universal definition of meaningful, as each of us defines it in our own way.  They wanted to be engaged in activity that was meaningful, not just activity for activity’s sake” (24).

Again, the folks at the Eden Alternative agree, stating in Principle #6 that,

“Meaningless activity corrodes the human spirit. The opportunity to do things that we find meaningful is essential to human health.”

CMS takes a stab at defining “meaningful” with its Guidelines and Intent for §483.24(c)(1):

“Activities are meaningful when they reflect a person’s interests and lifestyle, are enjoyable to the person, help the person to feel useful, and provide a sense of belonging.”

“To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning).”

I have seen descriptions of some of the assessment tools available to recreation therapists.  These instruments claim reliability in measuring things that pertain to meaningfulness, things like attitude, interest, satisfaction and motivation for leisure activities.  I am curious about how they do that.

Sedlar and Miners tie what is “meaningful” to the satisfaction of what they call “drivers” or “personal motivators” (55).    Drivers represent the “psychic rewards” we get from any activity, whether working a job or socializing with friends.  It’s what we get out of a job besides money (59-60).

“You fulfill your drivers (which are internal) when you take part in activities (which are external)” (67).

Drivers are fairly subjective and the authors encourage their clients to personalize them.  CMS was actually naming drivers in §483.15(f)(1): enjoyment, making a difference (usefulness), and belonging.   The Eden Alternative talks of Domains of Well-Being, which were used as part of the CMS Intent statement and parallel many of the drivers listed by Sedlar and Miners.  For me, my main driver is probably accomplishments – I thrive on the part of the activity job that lets me design and carry out a variety of activities that actually succeed.  The duds, not so much.

I know I’ve found, by experimenting with my activity program, that you can work the drivers without necessarily re-creating past activities for people.  New or substantially tweaked activities might work just as well or better than activities directly based on past interests because there is not as much negative baggage associated with the lack of independence in performing them.  That is, if you’ve never done something before, there is no “past life/independent you” experience to compare it to.

But it’s not just the novelty of your residents experiencing a new activity that gives it value.  A new activity needs to resonate with the residents’ drivers.  For instance, when my residents collaborated on painting wood pallet murals, it was a new activity for all of them.  Most had never attempted to paint a picture since leaving school, much less a large mural.   What drivers did that activity hit?  I was going to list them, but it turned out there were potentially over 32!  Not every participant had all or even most of these drivers, but there was a good chance of some connection with a few of them.  Another program that has worked for me is tying my resident choir into the local county Senior Games.  None of the resident choir members had sung competitively before.  Many had sung in a church choir, but most hadn’t performed in front of any other type of audience except church.  It was a big stretch for them and for our facility in pulling it off.  But the reading on the “meaningfulness meter” shot off the scale.   It was good.  Residents are still periodically wearing the gold medals they won last year, and will tell you how proud they are of them.  So we did it again this year.  And now the residents are talking about next year.  I tallied up 24 “drivers” that might be involved:  accomplishments, action, belonging, fulfillment, competition, creativity, experiences, fulfillment, outside/community opportunity, goals, identity, intellectual stimulation, lifelong learning, making a difference, passion, people, prestige, problem-solving, recognition, self-esteem, skills & talents, social, structure, value, and visibility.  Yeah.

I’m going to try to do another blog post on this topic in the near future.  I want to focus on the implications of drivers relating to individual care-planning and the residents who choose to isolate.

© Donna Stuart, ADC     July 5, 2019

https://www.edenalt.org

CMS Requirements of Participation for Long-Term Care Facilities §483.24(c)(1) (as provided by https://www.nccap.org/assets/docs/F-TAG%20679%20ACTIVITIES.pdf – because after several hours of searching, I sure couldn’t find it in a recognizable form on the CMS website, bless their hearts)

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

Undoing the MDS Project

“While you are in this facility, how important is it to you to …?”

“Very important.  Somewhat important.  Not very important.  Not important at all.  Important but can’t do or have no choice.”

I’d like to turn that question around …

“As an activity professional, how important is it to you to use up to date interview techniques that directly generate meaningful information about your residents?”

1. Very important (If I’m going to be held accountable for the numbers generated by the MDS, I want them to reflect reality.)
2. Somewhat important (I’m kind of tired of residents telling me things that are the opposite of what their activity choices will be.)
3. Not very important (Don’t know, don’t care.)
4. Not important at all (I truly don’t mind wasting a lot of time to satisfy the folks at the Center for Medicare/Medicaid Services.)
5. Important but can’t do or have no choice (The system is crippled, but nobody cares what I, a lowly AP, have to say about it.)

Back in the 1950s, a fledgling psychologist named Daniel Kahneman was given the job of evaluating the new soldiers in the Israeli army.  They had been using interviews, but the results were pretty meaningless.  They didn’t help predict how the soldiers would perform.  Sound familiar?  So, he designed a new type of interview.  Michael Lewis describes the situation in his book, The Undoing Project.

“He [Kahneman] told them to pose very specific questions, designed to determine not how a person thought of himself but how the person had actually behaved” (80).

Suddenly, they were generating more meaningful data, data that had predictive value.

In the 60s and onward, Amos Tversky joined Kahneman to study how people make decisions.  Again, Lewis describes their findings:

“When people make decisions, they are also making judgements about similarity, between some object in the real world and what they ideally want” (114).

Residents in long-term care are asked to make decisions about which activities to participate in.  At that point, they are making judgements about the activities offered compared to what they ideally might want.  But judgements about similarity, Lewis continues, are related to the features we choose to compare, like how noticeable they are, the context we see them in, and how our brains classify them.  For instance, a resident who likes music might chose to skip a group music event because “it’s for old people who have lost their minds.”  He knows that other seniors, ones with memory/health issues are likely to be there.  However, if his room is close enough to the event, he might hear the music and excitement, change his mind, and show up.  Or not.  Decision-making is highly subjective and can change at any moment.

Tversky and Kahneman also realized that people make decisions based on the potential loss or gain they associate with the decision.  But to use potential loss vs. potential gain you have to start at some “reference point” of how you value where you are right now.  The problem is that the reference point can also vary.  It is basically a “state of mind” (275).  I don’t know about you, but my state of mind changes all the time.  I have good days and bad days, good moments and bad moments.  I remember skipping a good friend’s wedding back in the days when I was single.  It was only at the last minute that the prospect of sitting through a lively Polish wedding reception with no date suddenly sounded like a more of a downer than I wished to risk.

In the 1980s, I was in graduate school studying sociolinguistics.  We were trying to find out which language people would tend to use, and for what reasons, in societies that were multilingual.  Some languages enjoy higher prestige.  Some languages provide more credibility on the street. “Do not base your data on self-reported language preferences,” my professors told me.  Instead, we read about ingenious work-arounds that linguists use to ferret out when, where and why people choose to use one language instead of another.  I have interviewed people who claimed to always use a certain higher status language.  Only when pressed did they admit to using a lower status language for some situations.  Self-reported language use is more about self-image, than fact.  I suspect that the self-reported importance of religious participation also often falls into this category.  It’s a normative, a “what should be”, rather than what is.

Even major league baseball and basketball have learned to upgrade the metrics they study.  These teams compete during games, but they also compete to sign the best players.  Lewis documented how the 2002 Oakland Athletics baseball team competed successfully against teams with much more money to hire new talent.  They found that the normal statistics that scouts had been using failed to predict future performance.  The Oakland A’s knew what to look for and could get those players more cheaply because the big teams were overlooking them.  I wonder what metrics we could come up with that would more accurately predict future activity participation. And what if what is important to US, and what WE prefer, is more relevant to their participation than any data we could get from the residents themselves?

Do our residents maximize their utility?  Short answer – no.  “Maximizing utility” means that people will reliably attempt to get the most value for their expenditure, the most bang for their buck.  In the case of activity programming, it could mean the most happiness for the expenditure of time and energy.  Kahneman saw that economists lagged behind the psychologists because the economists

“…assumed that you could simply measure what people wanted from what they chose.  But what if what you want changes with the context in which the options are offered to you?” (278)

Just because someone used to enjoy doing something independently doesn’t guarantee they will want to do it with our “facilitation,” or in the nursing home environment at all.  Ever.

Lewis summarizes Kahneman’s conclusion about maximizing utility.

“…people’s anticipation of happiness differed from the happiness they experienced, and … both differed from the happiness they remembered.

… If happiness was so malleable, it made a mockery of economic models that were premised on the idea that people maximized their utility.  What, exactly, was to be maximized?” (351).

In 2001, Kahneman, the psychologist, won the Nobel Prize in …economics!

Scientists, psychologists, linguists, statisticians, sports analysts, and economists, have found that people in general are systematically irrational in their thinking processes and choices.  We don’t really know why we do what we do.  Making irrational choices is not an aberration.  It is normal.

Fast forward to 2018, and CMS still has us ask our residents to self-report on their activity preferences in the absence of any observable behaviors.  That is the MDS 3.0.  Then we are expected to relate that to the activity decisions the residents will actually make.  That is the activity care plan.  Then we are held accountable for any pattern of discrepancies between the MDS 3.0 and the residents’ actual behavior.  That generates a CAA and potentially a flag.

I know it’s possible to make lemonade out of a lemon and use the MDS interview to also generate a certain amount of activity history.  But that doesn’t make up for the amount of time and energy that CMS wants us to waste on the quest for that precious #1 – 5 that we have to try to coax from the residents.  There are better ways to get an activity history.  There are better ways to develop care plans.  And there are better ways to help activity professionals and residents develop good activity programs.  My activity director gave me a chuckle and a quote for this paper when she wrote to me that, “I am blessed to have you on our ALF actively engaging those folks into things THEY never knew THEY wanted!”

What am I saying?  Activity professionals are made to use methodology that is as much as 60 years out of date.  We are held to bad science that academics who study human behavior have spent whole careers discrediting.  There is a big difference in why our residents do things as opposed to why they think they do them.  Study after study has shown that nobody is a rational decision-maker.  So, who at CMS still thinks that you generate meaningful numbers by asking our residents “how important” something is?  And how long are we going to go along with it?

©Donna Stuart, ADC        January 21, 2018, 2019

Lewis, Michael. The Undoing Project. New York: W. W. Norton & Company, Inc., 2017.

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Archive-Draft-of-the-MDS-30-Nursing-Home-Comprehensive-NC-Version-1140.pdf