Nurses working with residents of nursing homes can be instrumental in encouraging them to participate in challenging and rewarding activities as long as these activities are within the range of the clients’ mental capacity. If an activity is beyond their ability, or if, because of diminished confidence in their memory, patients think certain activities are beyond their ability, they may become agitated, anxious and withdrawn. Some may develop fear, refusing to attempt even the otherwise manageable challenges of daily living.
The degree of confidence that a person has in the reliability of his or her memory is known as memory self-efficacy. An early study I did of healthy adult-education students between the ages of 55 and 83 revealed that memory self-efficacy decreases with age (1994). As we get older, we tend to lose confidence in our ability to remember. We forget a familiar name or face and think we’re “losing it,” We set out to do something, forget what it was, and wonder if we have just witnessed an early hint of dementia.
Dozens of studies have demonstrated, however, that older adults can experience memory improvement, and some of these memory-training investigations have had the added benefit of buttressing the participants’ confidence in their memory. Clearly, belief in one’s ability to remember may be as important as actual memory improvement. This is as true for nursing home residents as it is for other people in our communities.
Though the daily routine of nursing home residents is often determined for them, they nevertheless continue to think, feel, carry on conversations and participate: in varied activities that require memory. Unfortunately, as a study of 106 nursing home residents revealed, the longer individuals live in a nursing home, the less likely they are to adopt strategies to improve their everyday memory (McDougall, 1998).
Because individuals who lose confidence in their memory also experience heightened feelings of anxiety and inferiority, I decided to test an efficacy-based memory intervention called the Cognitive Behavioral Model of Everyday Memory. Based on the premise that mental frailty and cognitive vulnerability are influenced by modifiable risk factors such as physical and emotional health, by decreased memory self-efficacy and by metamemory (one’s perceptions, beliefs and knowledge about the functioning and development of memory mechanisms and contents), the four-week course seeks to improve memory performance through stress inoculation, promotion of health awareness and everyday use of memory strategies. By incorporating information on how memory changes as people age, the course also helps participants become more realistic about and less fearful of cognitive aging (McDougall, 1999).
To improve memory self-efficacy, the curriculum incorporates Bandura’s (1997) four sources of information that increase confidence in one’s ability to remember: 1) experiences that validate one’s ability; 2) seeing others like yourself doing what you wish to accomplish; 3) positive feedback from people you admire and respect; and 4) enjoyment of an activity. These are accomplished with group exercises that have no wrong answers, discussion of common beliefs about memory aging and everyday activities that are helpful with remembering.
Previously, Hispanic elders attending a senior center (McDougall, 1998 and assisted-living elders participated in the memory improvement course (McDougall, 2000). This latest test, to determine the ability of the intervention to improve or prevent further decline in memory performance and self-efficacy among nursing home residents, was conducted at a 175-bed county nursing home in Northeast Ohio. Cognitive function was assessed with the Mini-Mental State Exam, and all potential subjects were screened before participating. Anyone scoring below 15 was excluded. Memory performance was tested with the Rivermead Behavioral Memory Test and memory self-efficacy with the 50-item Memory Self-Efficacy Questionnaire. The Center of Epidemiological Studies scale (20 items) measured depression. Health-related quality of life was measured with the 36-item Medical Outcomes Study questionnaire.
Forty-five residents participated in the test, 30 in the experimental group and 15 in the control group. At pretest, the experimental group had lower cognitive function, memory self-efficacy and prospective memory scores than the control group. Eight memory classes were provided to the experimental group and the average number of classes attended was five.
It was difficult to recruit and retain adequate numbers of individuals. Overall class attendance by individuals in the experimental group was poor, with a dropout rate of 58 percent. Investigators were later informed that residents with memory problems were brought to the class. Forty-three percent were found to be depressed and 46 percent cognitively impaired.
Depression, a condition that occurs with significant frequency in nursing home residents negatively influences perception of both memory capacity and memory change; Residents who are depressed feel they have less capacity to remember and that their memory is declining (Ide, McDougall,& Wykle, 1999; McDougall. 1998). Residents with depression will have difficulty participating in rehabilitation programs, since their motivation and stamina will be compromised. Cognitive ability And depression are both significant predictors of ability to participate in daily living activities. If cognitive rehabilitation is to be successful, depression must be treated.
Although the investigators had lists of potential subjects who might have benefited from the intervention, the nursing home staff paid no attention to their suggestions. A possible explanation for the staff’s misunderstanding about recruitment requirements may have been related to the health of the participants. At pretest, although the experimental group had better physical health and vitality than the control group, they also had more cognitive impairment and depression. Without specific information about the affective and cognitive status of residents, the staff was unable to distinguish individuals who seemed physically robust from those with depression or marginal cognitive function.
In spite of recruitment and retention problems, the memory intervention was a success with the residents who did attend class. Although post-test data, available for 13 subjects in the experimental group, revealed no pre- to post-test differences in memory performance scores, immediate story-recall did significantly increase. Moreover, with regard to the primary objective of the intervention, the group did make significant gains in memory self-efficacy, thereby decreasing their propensity for increased anxiety and feelings of inferiority. Clearly, enrichment activities with real goals are beneficial to frail elders.
Nurses must continue to assist nursing home residents to remain as independent as possible. Confidence with memory is in a tenuous balance between the assets for maintaining function and the deficits that threaten it. Nurses can remind an individual of his or her present ability and thus reinforce that person’s confidence. When their confidence is strengthened, residents will desire to participate in enrichment activities and may benefit from the mental stimulation, thus preventing the losses that accrue over time from unresolved depression. In addition to confidence-building, nurses can help older adults stay calm, clear and capable by teaching them simple, enjoyable methods to manage anxiety and stress.
Acknowledgments
This study, funded by the American and Rehabilitation Nurses Foundation, was acknowledged in 1999 with the Springer Award in Geriatric/Gerontological Nursing.