helping persons with mild or moderate alzheimer's disease recapture basic daily activities...

RESEARCH PAPER

Helping persons with mild or moderate Alzheimer’s disease recapturebasic daily activities through the use of an instruction strategy

GIULIO E. LANCIONI1, KATIA PINTO2, MARIA L. LA MARTIRE2, ALESSIA TOTA2,

VALERIA RIGANTE2, EMANUELA TATULLI2, ELISABETTA PANSINI2,

MAURO G. MINERVINI2, NIRBHAY N. SINGH3, MARK F. O’REILLY4,

JEFF SIGAFOOS5 & DORETTA OLIVA6

1University of Bari, Bari, Italy, 2Alzheimer Rehabilitation Centre Bisceglie, Italy, 3ONE Research Institute, Midlothian, VA,

USA,4University of Texas at Austin, TX, USA, 5University of Tasmania, Hobart, Australia, and 6Lega F. D’Oro Research

Centre, Osimo, Italy

Accepted January 2008

AbstractPurpose. The present three pilot studies assessed the effectiveness of verbal instructions, presented automatically throughsimple technology, in helping persons with mild-to-moderate Alzheimer’s disease recapture basic daily activities. Theactivities were morning bathroom routine, dressing, and table-setting.Method. The studies that focused on morning bathroom routine and on table-setting included three participants each,while the study that focused on dressing involved four participants. A non-concurrent multiple baseline design acrossparticipants was used for each study. The instructions and technology were available only during the intervention phases.Results. Data showed that the intervention strategy involving verbal instructions for the single activity steps presentedautomatically through technology was effective in helping all participants on each of the activities. The participants’ meanpercentages of correct steps across activities raised from 13 – 54 during the baseline periods to above 80 or 90 during theintervention periods.Conclusions. The results suggest that the intervention strategy reported may represent a suitable approach for helpingpersons with mild or moderate Alzheimer’s disease to recapture basic daily activities. New research should target otheractivities and check maintenance and generalization issues.

Keywords: Alzheimer’s disease, daily activities, verbal instructions, support technology

Introduction

Alzheimer’s disease is an age-related neurodegenera-

tive disorder, which is characterized by progressive loss

of memory, a deterioration of higher cognitive func-

tions, and the increasing difficulty/inability to perform

daily activities (i.e., self-help and occupational or

domestic activities) [1 – 6]. The growing awareness

about the spread of this disease and its greatly

negative implications at personal and social levels has

prompted a new emphasis on finding pharmacologi-

cal and behavioural strategies to confront it [6 – 10].

At present, the pharmacological approach relies

mainly on three types of intervention, that is, the use

of anti-oxidants (e.g., Vitamin E), the use of

acetylcholinesterase inhibitors (e.g., rivastigmine

and donepezil), and the use of the N-methyl-D-

aspartate receptor-antagonist, memantine [10 – 15].

The results seem to suggest that anti-oxidants can

slow down the progression of the disease but do not

improve the overall cognitive functioning of the

persons [11]. The other pharmacological interven-

tions may have beneficial effects on cognitive

functions and psychiatric symptoms but not neces-

sarily on performance of daily living skills [11,14].

Behavioural intervention can embrace a variety of

strategies including reality orientation therapy (in

which information such as the patient’s name, time,

Correspondence: G. E. Lancioni, Department of Psychology, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy. E-mail: [email protected]

Disability and Rehabilitation, 2009; 31(3): 211–219

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa Healthcare USA, Inc.

DOI: 10.1080/09638280801906438

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date, location, and current events are regularly

rehearsed), attention and memory drills (in which

the patients engage in repeated attention and

memory tasks), and face-name association tasks (in

which the pictures and names of relevant people are

regularly presented together to promote their match-

ing) [5,6,16 – 20]. These strategies are considered

essential to improve the overall cognitive/functional

condition of the person and thus are planned as a

countermeasure to the deterioration caused by the

disease. In spite of the large agreement on such a

countermeasure, two questions are apparent. First,

the overall effects of the interventions may not

necessarily be very strong. Second, such effects

may hardly influence the person’s performance

outside of the areas on which the intervention

focuses. More specifically, it may be difficult to

expect visible changes in activities of daily living as a

consequence of the aforementioned intervention

strategies [6,16,19 – 21].

Based on this realization, behavioural intervention

has also been directly aimed at promoting activities

of daily living such as dressing and washing. Such

intervention relied on computer-mediated prompt-

ing [4,22,23] or staff’s graduated prompting and

reinforcement [2,24 – 26]. Outcomes indicated im-

provements in the patients’ performance of those

skills. Such improvements, however, were not

necessarily striking in terms of overall independence

from staff and practical relevance, and could be

difficult (time-consuming) to achieve as well as

relatively unstable [2,25,26].

In light of these outcomes, one may argue that

regaining the performance of activities of daily living

by these persons may be easier if: (a) They are

allowed to use some form of instruction cues to guide

their performance, and (b) support technology is

applied to help them manage the aforementioned

cues efficiently and with limited or no effort [2,27].

The combination of these two elements could have

positive impact on the patients’ immediate and longer-

term performance and reduce the level of input

required from staff [28,29]. The aim of these three

pilot studies was in line with the aforementioned

reasoning. They assessed the effectiveness of verbal

instructions presented automatically through simple

technology in helping patients with mild-to-moderate

Alzheimer’s disease recapture basic activities of daily

living such as morning bathroom routine (Study I),

dressing (Study II), and table-setting (Study III).

Study I

Method

Participants. The participants, Roscoe, Stacey and

Flora, were 81, 79, and 86, years of age, respectively,

and were considered to function within the mild or

moderate range of the Alzheimer’s disease. Their

scores on the Mini Mental State Examination [30]

were 19, 22, and 10, respectively. They were

reported to be passive or erratic when asked to

perform basic activities of daily living, such as

morning toilet routine and dressing, as well as

occupational activities or house chores. However,

they seemed to possess (and control) the motor

schemes required for the single activity steps, and

prompting in the form of verbal instructions was

generally effective in guiding them through such

steps and ensuring their performance. They were

temporarily residing in an Alzheimer Rehabilitation

Centre, in which typical behavioural intervention

strategies such as reality orientation therapy were

implemented together with mild forms of movement

therapy. No specific pharmacological treatment was

available at the time of the study for the participants’

Alzheimer condition. The research was approved by

an ethics committee and received formal consent

from the participants’ families.

Setting, morning bathroom routine, data recording,

and reliability

The study was carried out in the participants’

bathroom, in the Alzheimer Rehabilitation Centre.

The morning bathroom routine consisted of 17

steps. Table I reports the list of steps and general

instructions that were available for them. The

instructions (recorded on tape by research assistants)

could show variations in the terminology and accent

used for the different participants and could also

include repetitions. For example, each instruction

could be uttered twice in close succession. Variations

and repetitions were to make the instructions more

suitable to the participants’ language characteristics

Table I. List of steps (and general instructions) for the bathroom

routine.

1. Sit on the toilet;

2. Take the soap;

3. Use the bidet;

4. Take the towel;

5. Dry yourself with towel;

6. Take the underpants;

7. Put on underpants;

8. Take toothbrush and dentures;

9. Go to wash dentures;

10. Take the soap;

11. Use soap over face and neck;

12. Take the towel;

13. Dry yourself;

14. Take new soap;

15. Wash your armpits;

16. Take the towel;

17. Dry your armpits.

212 G. E. Lancioni et al.

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and environmental background, which had been

previously assessed. The participants’ performance

of a step was recorded as ‘correct’ if it matched the

description of such step (and the instruction available

for it during the intervention) and occurred indepen-

dent of prompting by research assistants (see below).

Interrater reliability was checked in 25% of the

bathroom-routine trials. The mean percentages of

agreement (computed by dividing the number of

steps with agreement by the total number of steps and

multiplying by 100) for the single participants

exceeded 98.

Activity material and technology

The activity material involved a table with all the items

required for the bathroom routine. The technology

was comprised of a battery-powered, radio-frequency

photocell, light-reflecting paper, a modified Walkman

with the recording of the verbal instructions related to

the bathroom-routine steps (see Table I), and a

microprocessor-based electronic control unit. This

unit was fitted with specifically developed software

and included: (a) A radio-frequency receiver that

responded to the photocell inputs, and (b) a pro-

grammable command function that regulated the

Walkman and, thus, the presentation of the verbal

instructions. The photocell and light-reflecting paper

were arranged in front (at the opposite sides) of the

table with the items for the bathroom routine, so that

the person broke the photocell light beam every time

he/she reached for the items.

The bathroom routine activity started with the

control unit activating the Walkman and the first

instruction (i.e., sit on the toilet). After a pro-

grammed, long interval (e.g., 110 seconds), the

control unit activated the Walkman and the second

instruction occurred (i.e., take the soap). In taking

the soap, the person broke the photocell light beam.

This started a programmed, brief interval (e.g., 6

seconds) at the end of which the control unit activated

the Walkman and consequently the next instruction

occurred (i.e., use the bidet). This instruction started

another long interval at the end of which the control

unit activated the Walkman with a new instruction

(i.e., take the towel). In taking the towel, the person

broke the photocell light beam and the process

continued like above for this step and the next steps

of the sequence. The intervals were programmed by

the research assistants based on previous observations

of the participants through the activity [31,32].

Experimental conditions

The study was carried out according to a non-

concurrent multiple baseline design across partici-

pants [33]. All participants started with a baseline

phase the length of which varied across them (see

below). Subsequently, intervention started. Verbal

and physical prompting by a research assistant would

occur if the participants remained passive or wan-

dered around for about 30 sec, or failed to perform a

step appropriately (during both Baseline and Inter-

vention), or failed to respond to an instruction for

10 – 20 sec (during Intervention). At the end of the

sequence, the research assistant expressed social

appreciation (i.e., two or three sentences underlining

the participants’ good effort).

Baseline. The baseline phase included 6, 7, and 12

bathroom-routine trials for the three participants,

respectively. During baseline, the participants

were to perform the bathroom routine without

the help of the technology and related verbal

instructions.

Intervention. This phase was preceded by familiariza-

tion (practice) with the technology and instructions

during two bathroom-routine trials. The intervention

phase per se included 27, 27, and 47 trials for the

three participants, respectively (i.e., based on their

availability). During each trial, the participants

performed all bathroom-routine steps with the help

of the technology, which presented the instructions

as described above.

Results

The three graphs of Figure 1 summarize the data for

Roscoe, Stacey, and Flora, respectively. During the

baseline period, the participants’ mean percentages

of steps carried out correctly varied between 16 and

54. During the intervention, all three participants

showed a rapid and solid increase in the number of

steps carried out correctly with overall mean

percentages exceeding 90. The Kolmogorov-

Smirnov test showed that the aforementioned

increases from the baseline to the intervention were

significant (p5 0.01) for all participants [34].

Study II

Method

Participants. The participants, Trudy, Sara, Roscoe,

and Cecile were 81, 79, 81, and 74 years of age,

respectively, and were considered to function within

the moderate range of the Alzheimer’s disease.

Roscoe had been involved in Study I while the other

participants had no previous study exposure. Their

scores on the Mini Mental State Examination [30]

were 15, 15, 19, and 14, respectively. The partici-

pants were reported by their families to have

problems in carrying out activities of daily living as

Alzheimer’s disease and daily activities 213

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well as occupational activities or house chores and

tended to be passive or erratic. However, verbal

instructions were generally effective in guiding them

through the activity steps and ensuring their perfor-

mance. Indeed, they seemed to possess (and control)

the motor schemes required for the activity steps.

They were temporarily residing in the Alzheimer

Rehabilitation Centre (and received the same beha-

vioural intervention strategies) mentioned in Study I.

Pharmacological treatment for the Alzheimer condi-

tion was available only for Trudy and consisted of

acetylcholinesterase inhibitors. The research was

approved by an ethics committee and received

formal consent from the participants’ families.

Setting, dressing activity, data recording, and reliability

The study was carried out in the participants’

bedrooms, in the Alzheimer Rehabilitation Centre.

The participants sat on a chair at the side of their

bed. The dressing activity consisted of 10 or 12 steps

for different participants. Table II reports a list of 12

steps and the instructions that were available for

them. Regarding the instructions, some variations in

terminology and accent as well as repetitions (e.g.,

two utterances of each instruction in close succes-

sion) could be programmed to suit the participants’

characteristics and environmental background,

which had been previously assessed (see Study I).

Recording of participants’ performance and inter-

rater reliability were as in Study I.


The material required for the dressing activity (see

the items mentioned in Table II) was displayed on

the participant’s bed except for the shoes that were

under the bed. The technology was the same as that

described in Study I, whereas the verbal instruc-

tions matched the dressing steps programmed for

the participants. The intervals between instructions

(similar to those used in Study I) were programmed

by the research assistants based on previous

observations of the participants through the dressing

activity (see Technology in Study I). The photocell

and light-reflecting paper were arranged at the side

of the participant’s bed so that he/she would

interrupt the light beam anytime he/she reached

for an item.



concurrent multiple baseline design across parti-

cipants [33]. All participants started with a base-

line phase followed by intervention. Baseline,

intervention and pre-intervention familiarization

conditions were comparable to those reported in

Study I.

Results

The four graphs of Figure 2 summarize the data for

Trudy, Sara, Roscoe, and Cecile, respectively.

Figure 1. The three graphs summarize the bathroom-routine data for Roscoe, Stacey, and Flora, respectively. Each data point represents the

percentage of correct steps performed during a bathroom-routine trial.


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During the baseline period (including 6, 9, 10, and

13 dressing trials for the four participants, respec-

tively), the participants’ mean percentages of steps

carried out correctly varied between 14 and 41.

During the intervention, all four participants showed

a rapid and solid increase in correct performance

with overall mean percentages ranging between 80

and 96. The Kolmogorov-Smirnov test showed that

the aforementioned increases from the baseline to

the intervention were significant (p5 0.01) for all

participants [34].

Study III

Method

Participants. The participants, Muriel, Paula, and

Sandy, were 73, 81, and 73 years of age, respectively,

and were considered to function within the moderate

range of the Alzheimer’s disease. Their scores on the

Mini Mental State Examination [30] were 14, 15,

and 15, respectively. Like the participants of Studies I

and II, the present participants: (a) Had problems in

carrying out activities but were able to follow verbal

instructions related to those activities satisfactorily,

and (b) were temporarily residing in an Alzheimer

Rehabilitation Centre in which they received typical

behavioural intervention strategies (see above).

Pharmacological treatment for the Alzheimer condi-

tion was available only for Paula and consisted of

acetylcholinesterase inhibitors. The research was

approved by an ethics committee and received formal

consent from the participants’ families.

Setting, table-setting activity, data recording, and

reliability

The study was carried out in a dining room, in the

Alzheimer Rehabilitation Centre. The table-setting

activity consisted of 12 or 14 steps for the different

Table II. List of steps (and general instructions) for the dressing

activity.

1. Take the socks/stockings;

2. Put on the socks/stockings;

3. Take the pants;

4. Put on the pants;

5. Take the vest;

6. Put on the vest;

7. Take the pullover;

8. Put on the pullover;

9. Take the glasses;

10. Put on the glasses;

11. Take the shoes;

12. Put on the shoes.

Figure 2. The four graphs summarize the dressing data for Trudy, Sara, Roscoe, and Cecile, respectively. Data points are plotted as in

Figure 1.


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participants. Table III reports a list of 14 steps and the

instructions that were available for them. Regarding

the instructions, some variations in terminology and

accent as well as repetitions (e.g., two utterances of

each instruction in close succession) could be

programmed to suit the participants’ characteristics

and environmental background, which had been

previously assessed (see Study I). Recording of

participants’ performance and interrater reliability

matched those of the previous studies.


The activity material included the table-setting

items displayed on a cupboard or on a serving car.

For Paula, the items contained a label with the

matching name written on it. This was done because

she seemed to benefit from such labels in identifying

the items. The technology was the same as that

described in Study I, whereas the verbal instructions

matched the table-setting steps programmed for the

participants. The intervals between instructions

(similar to those used in Study I) were programmed

by the research assistants based on previous observa-

tions of the participants through the table-setting

activity (see Technology in Study I). The photocell

and reflecting paper were arranged in front of the

cupboard or serving car so that the participant

would interrupt the light beam anytime she reached

for an item.



concurrent multiple baseline design across partici-

pants [33]. Baseline, intervention and pre-interven-

tion familiarization conditions were comparable to

those reported for Studies I and II.

Results

The three graphs of Figure 3 summarize the data for

Muriel, Paula, and Sandy, respectively. During the

baseline period (including 10, 13, and 15 table-

setting trials for the three participants, respectively),

the participants’ mean percentages of steps carried

Table III. List of steps (and general instructions) for the table-

setting activity.

1. Take the table cloth;

2. Put table cloth on table;

3. Take fork and knife;

4. Put fork and knife on table;

5. Take the glass;

6. Put glass on table;

7. Take the plate;

8. Put plate on table;

9. Take the bread;

10. Put bread on table;

11. Take the water;

12. Put water on table

13. Take the fruit;

14. Put fruit on table.

Figure 3. The three graphs summarize the table-setting data for Muriel, Paula, and Sandy, respectively. Data points are plotted as in Figure 1.


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out correctly varied between 13 and 49. During the

intervention, all three participants showed a notice-

able increase in correct performance with overall

mean percentages exceeding 80. The Kolmogorov-

Smirnov test showed that the aforementioned

increases from the baseline to the intervention were

significant (p5 0.01) for all participants [34].

General discussion

The data of the three pilot studies support the notion

that the use of verbal instructions and basic

technology to control their presentation can be quite

effective in helping persons with mild or moderate

levels of Alzheimer’s disease recapture relevant daily

activities [2,27,29]. The positive effects seemed to be

by and large rapid, that is, the participants generally

improved their performance within a brief period of

time and with only rather modest external guidance.

This could be considered a greatly relevant achieve-

ment countering some of the main problems of these

persons (i.e., their increasing failure, frustration and

withdrawal) and simultaneously promoting their self-

determination, alertness, and social image

[24,28,35,36]. The same results could also be

considered highly valuable for family and caregivers

in general. Indeed, they can give these people: (a)

Some respite as to the level of direct assistance

required, (b) a new, more positive image of the

person they care for with the possibility of enhancing

their emotional ties with him or her, and (c)

encouraging expectations and consequent motiva-

tion to extend the intervention through other daily

activities [20,21,37 – 39].

In view of the results, a number of considerations

may be made. First, the generally rapid improvement

obtained by the participants suggests that they: (a)

Were fairly capable of understanding the instructions

used for the activity steps (although not necessarily

consistent/accurate in following them, as indicated

by their below 100% performance), and (b) pos-

sessed the motor schemes (and related executive

function) required for the single activity steps.

Essentially, the intervention strategy used in the

studies was effective with participants whose poor

performance prior to the intervention was probably

due to their lack of initiative, deteriorated operative

memory, and poor general planning [40,41]. This

clarification may be important in determining the

applicability of the intervention strategy and the basic

prerequisites it relies on.

Second, the fact that the studies (intervention

phases) were carried out while the participants were

receiving reality orientation and movement therapy

and occasionally also medication may prevent one

from claiming that the results were solely related to

the instruction cues and the technology controlling

them. All the same, the ongoing (background)

behavioural and pharmacological aspects could

hardly be considered of particular relevance. In fact,

they had been applied for weeks/months prior to the

studies with no apparent changes in activities of daily

living or occupational tasks (as indicated by the

baseline levels). Moreover, the changes that followed

the intervention were generally rapid to indicate a

clear relationship between the two [33,42,43].

Third, although only limited data are available,

one may argue that the applicability of the strategy

reported in the three studies can be high among

persons in the mild-to-moderate range of the

Alzheimer’s disease (i.e., persons who can follow

instructions and plan/perform responses accurately).

In fact, the instructions may be largely tailored to the

characteristics and cultural background of the

persons and thus made quite effective. The applic-

ability could also be promoted by the simplicity of

the technology used and the relatively low cost of it

(i.e., about $750) [29,44 – 46]. Its simplicity would

allow caregivers to arrange its use with minimal time

investment or procedural difficulties; its low cost

would allow most rehabilitation centres and families

to acquire it [47,48].

Fourth, the array of activities targeted in the

present studies was rather narrow. One could easily

imagine that the same intervention strategy and

technology could be easily adapted to other activities

such as putting dirty kitchen items into a dish washer

or taking clean kitchen items out of it, preparing

ingredients/tools for a snack (i.e., glasses, drinks, and

foods), and preparing ingredients for a fruit salad or a

cold dessert [49 – 51]. Extending the range of

activities programmed would offer more occasions

of constructive occupation to the person with

important implications on an individual and a

social/environmental level [21,28,37,42].

Fifth, the issues of performance maintenance and

generalization, which were not assessed in these

studies, require careful analysis. One may consider

maintenance a specific index of how important the

intervention is to enhance the person’s functioning

and slow down his or her expected deterioration

[4,6,14,24 – 26]. The maintenance issue could also

be linked to a variety of social-emotional aspects of

great relevance such as person’s dignity and mood,

staff and family’s relief and increased empathy

[2,26,52 – 54]. The generalization may, on the other

hand, represent an index of the applicability of the

intervention strategy. With regard to this latter

aspect, one can refer to the comments made above

both about the instructions and the technology

adopted for presenting them [44 – 48].

Sixth, new research in this area could consider

four aspects as critical. The first aspect could

concern the aforementioned issues of maintenance


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and generalization. The second aspect could concern

an extension in the range of activities considered for

intervention. The third aspect could concern an

analysis of the mood of the persons prior to the

intervention and during the intervention. The possi-

bility that persons obtain some benefit in this area

would be of great importance also in view of their

reported tendency to show depression and sadness

[5,55 – 58]. A fourth aspect could concern a social

validation assessment of the reported data on activity

and mood. Such validation could involve family

members and staff personnel as raters [59 – 61].

In conclusion, the present pilot studies have shown

the possibility of using simple intervention strategies

supported by technology for helping persons with

mild or moderate Alzheimer’s disease improve their

performance of daily activities. These data are still

preliminary for the reasons expressed above. None-

theless, they may constitute an important basis for

advancing rehabilitation intervention in this area and

exploring the four questions suggested for future

research.

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helping persons with mild or moderate alzheimer's disease recapture basic daily activities...

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