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Behavioral Interventions to Facilitate Growth
Geriatric Long-Term Care continuing education MFT CEUs

Module #2
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Activities of Daily Living (ADL)

Questions 1-15 found on this page
CE Test | Table of Contents | Geriatric & Aging
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

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This is Learning Module #2. It provides you with the Seven Basic Techniques for Instruction to increase your residents' ADL Independence. If you'll recall from Module #1, ADLs are activities of daily living, such as bathing, showering, eating, and washing your face and hands.

In the previous Learning Module, we discussed why independence is so important. If you'll recall, we talked about how you would feel if you had hurt your arm, and could not brush your hair, and had to ask for assistance. Sad? Frustrated? Depressed? Then we talked about the fact that a resident in your assisted living facility may have those same feelings. He or she may also feel sad, frustrated, and depressed because he or she is feeling in a helpless, childlike role.

What if you were living in a world where you could not fail and you felt loved and cared about? Would you define that as heaven? Well, I may be going to an extreme to get your attention and to make a point about verbal and nonverbal prompting, but you can make that heaven for your residents by providing them with an environment of success.

This staff training module gives you seven basic techniques regarding the use of instruction in such a way that it fosters and encourages ADL independence, rather than dependence. The challenge for some caregivers, in fostering or encouraging a resident's independence, is feeling uncomfortable when standing by and watching a resident struggle with a button while dressing, or reaching his or her arm high enough to brush their hair. This is especially true if you are new to working in health care for the elderly. Initially it is much easier, and by far much quicker, for you to do this for your resident or tenant.

The Problem with "Doing for" Your Resident
But, what unfortunately occurs, is that the more you do for someone, the less they feel like they are capable of doing for themselves. By doing for your resident, rather than assisting them to do for themselves, you may start them on the slide or spiral into dependence. After a period of time, as the resident takes on a dependent mind set, their self-esteem and self-worth slips. They end up doing less and less. This is hardly an environment for success. The result may be that a resident who could brush her hair and wash her face is now stating that she cannot do these ADLs on her own, and is now asking for help. In the long run, what appears to save you time, or perhaps as a reaction to your discomfort in watching a resident struggle, ends up depriving them of their independence and the feelings of success and accomplishment. Don't we all need these feelings?

Question #1: Give two reasons to do an ADL for a resident, rather than assisting them in doing it for themselves. To select and enter your answer go to CE Test Question #1.

Question #2: When you do tasks for a resident, you deprive them of an opportunity to experience what? See above

Here's an example closer to home. Have you ever taken your child out for ice cream? Sure you have. Let's say that in the past, you've always bought the medium size cone for him or her. However, on this particular day without giving any reason, you decide to buy your child an extra large cone. Now you tell me, what do think your child is going to expect the next time you go out for ice cream? You guessed it, an extra large cone. The point to be made is, if there is no reason or instruction given, the more you do for someone the more they will expect you to do. It's that human nature.

If you were to have given an explanation or instructions about the reason before purchasing the cone, it is less likely that the expectation level would have been as great. Would your child be less likely to expect all future cones to be extra large if you would have said "Because you made an 'A' on the spelling test, this time I am going to do something special"? Thus, because of your explanation or instructions prior to the purchase, your child's expectation of your doing more each time will be much less. Agree?

Methods of Instruction
Now what do ice cream cones and your child have to do with the resident in your Assisted Living Facility (ALF)? Well, the point to be made is as follows. With your resident, you can provide instructions one of two ways. First of all, you can state your instructions so that the resident expects you to do more and more. Or second, you can state your instructions in a manner that encourages your resident to be doing as much as possible for themselves. By doing this, you are fostering an environment of success.

Seven ADL Instruction Techniques
Here are seven techniques for giving ADL instruction in order to encourage independence, merely by the manner in which you give your instruction to the resident.

1. Asking instead of Telling
Technique number one involves initiating the instructions to do an ADL with your resident. The initiation, or introduction of an ADL, poses a challenging question. When you approach your resident to do an ADL, like washing his or her face, do you ask a question such as, "Are you ready?" or do you tell the resident "It's time to wash your face"?

To facilitate, or increase your resident's independence, ask your resident if he or she wants to do something, rather than tell them. Let's say that you have a resident in room 107, and her name is Clarice. Rather than telling Clarice, ask, "Clarice, are you ready for lunch?" or "Are you ready to wash you face?" Asking, of course, gives your resident a feeling of choice, dignity, and most of all independence.

Question #3: Doing what action gives your resident a choice? See above

These techniques seem a little too obvious; however, initiating instructions by the offering of choices is not as simple as it seems. What if your resident is in the early stages of Alzheimer's and is forgetful? Many residents learn to cover up their lack of understanding by answering "yes" to most questions they are asked.

A key point regarding questions is to ask yourself, "Is this resident alert enough to benefit from being offered a choice?" Many residents with Alzheimer's are more likely to experience success if he or she is told, "It's time to wash your face," rather than given a choice. Staff Training Module Four on Verbal Prompts will give some very detailed techniques regarding the use of questions.

Question #4: Under what condition is it sometimes better to tell your resident, rather than to ask, regarding ADLs? CE Test Question #2.

So how do you know exactly where to draw the line, whether to tell, or whether to ask? As a rule of thumb, to support resident independence, ask first. Then, if when you look into Clarice's eyes, they have a puzzled or vacant expression, or she hesitates to take action, shift gear and tell her, "It's time to wash your face."

Question #5: How can you decide if a resident should be told or asked about an ADL? Look at what three things? See above

2. Observing and Judging Alertness

Instructional technique number two deals with judging the alertness level of your resident. Here's an ambulation example. Let's say you have a resident, Mary. As you are ready to assist Mary with rising from her chair and walking to lunch, observe her eyes to check alertness at the time you are giving instructions. In looking at her eyes, notice two things. How wide open are her eyes? Secondly, do her eyes look focused? The warning here is, of course, fall prevention.

Here's how this works. Mary has been sitting, half dosing in the chair in her room. Sound familiar? First, before you assist her to rise, look at her eyes. Are they still only three-fourths of the way open, indicating that she may mentally still be in a fog? Secondly, as you ask her, "Are you ready to go to lunch?" do her eyes move in your direction? Does she have direct eye contact with you? As you know, all too often, residents who are shaky upon rising from a chair, are at risk for falls. This risk can be greatly decreased if you make it a habit to really look at your resident's eyes.

Question #6: In checking your resident's eyes for alertness notice what two things? See above

If your resident's eyes seem to indicate that she isn't at full alertness yet, talk to the resident for a few minutes until he or she seems to come to full alertness. Mary will be much more likely to be able to rise independently if she is fully awake and alert. She will be much less at risk for a fall.

Question #7: If the resident is not fully alert, what should you do? CE Test Question #3.

Question #8: As you introduce an ADL to your resident, especially when there is a risk for a fall, make sure he or she is what? See above

3. Give Step-by-Step Instructions
So far we have talked about introducing ADL instruction by the use of a question, versus being told. We have also discussed waiting to initiate the ADL instruction until the resident is as alert as possible. Instructional technique number three is to give step-by-step instructions. For example, as you know, the steps in washing a resident's face, who is unable to do so are as follows: drape a towel around her neck. Then, turn on the water adjusting the temperature and flow. With the wash cloth, wring out excess moisture. Put soap on the cloth and proceed to wash the resident's face from the inner to the outer periphery of the face, forehead, cheeks, and chin. Rinse. Then dry with a towel.

Let's say you have a resident, Alice, who has had a stroke which affected her left hand. To provide an environment of success, instead of doing all of the these steps and washing her face for her, here is what you do: You turn on the water. You adjust the flow and temperature. You wet the cloth and wring it out. Then, hand Alice the cloth in her right hand. You put the soap on the cloth for her.

Since Alice is slightly forgetful, you might then instruct her by saying, "Alice, wash your forehead. Good, now your right cheek, now your chin. Great job washing your face, that's good exercise for your hand and arm." Since Alice can only use her right hand, and has limited range of motion in her right arm, you wash her left cheek for her. You follow a similar procedure for rinsing and drying, with Alice taking part in these steps of the ADL.

It goes without saying that it is faster and easier to wash Alice's entire face for her. But, recall my story about the ice cream cone and your child. The more you do for someone, the less they feel they can do for themselves. If you jump in and do, do, do, for Alice, she does less and less for herself. I am sure you, like I, have seen many residents slide downhill into more and more dependence with no real physical reason.

The key to remember with step-by-step instruction is, only do for a resident what they cannot do for themselves. However, in order to be able to do this, you need to be able to look at an ADL and break it down into steps like I did. Then, take each step and ask yourself, "What piece, or part of this ADL could the resident be doing themselves?"

Question #9: The key to remember with step-by-step instruction is only do what for a resident?
See above

4. Fading - Withdrawing Instruction
Instructional technique number four is called fading, and goes hand-in-hand with technique number three, step-by-step instruction. Fading refers to fading out, or withdrawing instruction or verbal prompts as soon as your resident is on the right track. Observe closely, and adjust your step-by-step instruction to your resident's ability level.

Give instruction only if the resident appears to be hesitant, and is unsure of what to do. The key to providing an environment of success with the fading technique is to watch what Alice does with her hands as she is washing her face. If upon getting soap on the cloth, she readily washes her forehead, cheeks, and chin, fade out, or in other words don't provide verbal prompting like, "Now your cheeks, now your other cheeks, now your chin." If you provide too much step-by-step instruction, depending upon Mary's alertness level, she may feel insulted, as if you are treating her like a child. Going to the extreme, if over-instruction is given on a consistent basis, she may become depressed and feel mentally incompetent.

Question #10: Fading refers to fading out, or withdrawing of instruction or verbal prompts, as soon as a resident is what? CE Test Question #4.

Question #11: The key to providing an environment of success with the fading technique is to watch what about your resident?
See above

Think about yourself for a moment. Have you ever had someone over explain something to you, as if you did not have a brain in your head? How did you feel? Angry? Frustrated? If they continued, did you start to doubt your own mental capacity? Well, the same is true for the resident. So for technique number four, it very important to fade out, or not use, verbal prompts or other forms of assistance if they are not needed.

Question #12: The excessive or inappropriate use of verbal prompts in step-by-step instruction can cause a resident to feel what? See above

5. Repeat, then Change
Instructional technique number five is called, "repeat, then change." Here's how it works. Let's say Alice appears to have repeated difficulty understanding a particular word or phrase in your ADL instructions. A rule of thumb is, after you have repeated the same phrase, such as, "Let's go to dinner" two or three times, you might find a different way of saying it. To provide an environment of success, state the first smaller step in the task. Say to Alice, "Stand up. Now it's time for dinner."

Here's an example that I'll bet that you can relate to. Have you ever asked for an explanation of a repair to your car, and it sounded like they were speaking a foreign language? When you asked for more information, they just repeated the same words that you didn't understand in the first place. Or, worse, they raised the volume of their voice, and repeated the same words. How did you feel? Helpless? Hopeless about understanding what is going on with your car repair? Perhaps misunderstood, and frustrated?

Unfortunately, if a resident has difficulty in understating what you are saying, instead of admitting it, they may just say they don't want to or cannot do something. The key to remember is, if you get a refusal, try presenting your resident with the first small step of the ADL.

Question #13: If you get a refusal to do an ADL, present your resident with what? CE Test Question #5.

6. Avoid Quick Topic Changes with Verbal Sign Posts
Instructional Technique six is to avoid quick changes in the topic. Many ALF residents who are becoming forgetful, or are in the early stages of Alzheimer's, have problems shifting gears to new topics quickly. That is, if you are talking about washing the resident's face, complete that topic before you talk about brushing his or her hair.

When you do make a topical switch, create a verbal sign post. The resident will be more able to follow your thought transition. By verbal sign post, I mean using a signal for the change in ADL topics by saying something like, "Let's brush your hair now." After that, proceed to explain the next step. As opposed to just moving to the next ADL with- out the transitional sign post.

Setting up definite transitions or verbal sign posts are invaluable to someone with Alzheimer's disease, who has an interrupted thought process. Here is an overview of the problem. The damage Alzheimer's does to the brain has been described as being like a switchboard that is transferring calls to the wrong locations. The disease actually creates holes in the surface of the brain. For this reason, the key to remember here is, discuss one topic at a time. When you do move on to the next task, signal the change by stating, "Let's talk about..." and then state the ADL.

Question #14: Verbal sign posts signal a change in what?
See above

7. Single Word Instructions
Technique number seven, our last instructional technique is invaluable, especially with ambulation assistance. Use single word instructions. For example, for the resident who recently has started to use a cane, single word instruction will be of great assistance. You say, for example, "Step, cane, step, cane." Or in the case of a transfer, where a pivot onto the toilet is needed, you can assist the resident by providing one word instructions like "Stand, step, grab safety bar, turn, turn, turn, step back, sit."

As you know, resident alertness level may vary from one time of day to the next. So be prepared to give one word instructions to facilitate, maintain, and encourage your resident's ADL independence.

Question 15: Single word instructions are a great assistance especially in what?
See above

In summary, seven instructional techniques to provide an environment of ADL success are:
#1: When possible, "ask" your resident to do an ADL, do not "tell" them. Then, evaluate if the resident understands the question.
#2: When initiating instruction, observe your resident's eye openness and eye contact as an indicator of their alertness level before proceeding with further ADL instruction. This alertness check is especially important for fall prevention during transfers and ambulation.
#3: Think of your ADL instruction in terms of a series of individual steps. Give ADL instructions and assistance only for the steps that the resident requires assistance.
#4: Fade out instruction, if it is not needed. Get in the habit of evaluating a resident's ability each time you work with them. Look for ways to support and encourage their independence.
#5: As a rule of thumb, repeat an ADL request two to three times, like, "It's time for lunch." If your resident's lack of movement indicates that they do not understand, request the resident do the first small step in performing the ADL. For example, "Mrs. Jones stand up now. It's time for lunch."
#6: Use a verbal sign post to signal a change in topics.
#7: Use one word instructions to aid transfers, ambulation, and other ADLs. Words like stand, sit, turn, move, etc. help to prompt your resident's movements. Use a word, then evaluate the ones that make the ADL performance easiest for the resident.

In this staff training module, number two, you've just learned about seven basic techniques for giving instruction in oder to effectively increase your residents' ADL independence.

As stated at the beginning of this module, you need to have a working knowledge of the techniques just presented on instruction in order to take action to improve the quality of your residents' lives. That is what this Staff Training Module and entire series is all about, taking action. You now have what you need to be successful. You have just been provided with very concrete, specific examples of how to use instruction to increase your resident's ADL independence. The rest is up to you. In module three you will learn about the use of Demonstration. Remember take action!

Peer-Reviewed Journal Article References:
Avila, J., Flowers, A., Scott, T. M., Quilici, J., Apostolova, L. G., Woo, E., Ringman, J., & Razani, J. (2015). Daily activity abilities in MCI, Alzheimer’s disease, and healthy controls. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 28(4), 191–200.

Fleiner, T., Trost, A., Depiereux, R., Zijlstra, W., & Häussermann, P. (2015). Geriatric psychiatry in motion—Bringing physical exercise to geriatric psychiatry: A multi- and interdisciplinary program to promote physical activity among elderly psychiatric patients. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 28(4), 173–181.

Harris, J. A., Kwok, D. W. S., & Gottlieb, D. A. (2019). The partial reinforcement extinction effect depends on learning about nonreinforced trials rather than reinforcement rate. Journal of Experimental Psychology: Animal Learning and Cognition, 45(4), 485–501.

Matthews, K. M., Newcomb, E. T., Morgan, C. A., Chen, T., & Vanderburg, N. (2019). Effects of emulation training on activities of daily living and job-related skills. Behavior Analysis: Research and Practice, 19(4), 379–388.

Vanderburg, N. (2019). Effects of emulation training on activities of daily living and job-related skills. Behavior Analysis: Research and Practice, 19(4), 379–388.

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