October 1, 2000 |

Alzheimer’s Care: A Family Affair

As I drive to my interview about the Snoezelen* approach to therapy for nursing home residents with Alzheimer's-practicing my pronunciation of the word Snoezelen (a bit like "snyooze-uh-lin") and dodging tractor-trailers on the interstate-I wonder what sort of facility I will encounter. Will it be all "spit and polish," with efficient staff scurrying around (eyes lowered, no time to smile, hurrying frantically to "get all the work done")? Or will it be a warm, inviting place where I'd be happy for someone I love to live?
I am welcomed at the front door by Duchess, O'Brien Memorial Health Care Center's unofficial greeter and official "house dog." The well-fed miniature collie belongs to the facility's accountant, whom she accompanies to work every day so she can hang out with residents, staff and guests.
O'Brien Memorial's secretary sees me there, patting Duchess, and asks if I need help. Almost at the same time a nurse peeks out of an office, smiles and asks if I'm being taken care of. As I wait a moment for Francine Kroner, the activities director and person who got the Snoezelen ball rolling at O'Brien Memorial HCC, I observe the goings-on in the lobby and hallway. There are hugs. And smiles. And kind words. And people stopping by to visit-people who look relaxed and glad to be *The word Snoezelen is derived from the Dutch words for "to snooze" and "to sniff." FlagHouse, Inc., is the sole U.S. distributor of the SNOEZELEN« concept and equipment.
At right: Activities Director Francine Kroner (left)
strolls through the courtyard with Josephine Nelson.

here, not people who look filled with dread at having to visit their loved one in "that place."
So far O'Brien Memorial is scoring high marks in the category of that "homelike" atmosphere we're all so fond of talking about.
Soon Kroner-Franni, as she is affectionately called by fellow staff members and residents-arrives. Another warm greeting from her, and we're off to the "Snoezelen room." I'm eager to hear more about this multisensory-stimulating therapy, developed in The Netherlands in the 1970s for calming mentally disturbed children and later extended to the care of individuals with Alzheimer's and other dementias. But I'm almost as fascinated by the ease with which I see staff interacting-with each other and the people they're caring for. It says something about O'Brien Memorial's administrators and staff that all the marketing brochures in the world can't convey: family.
Kroner shows me to the Snoezelen room, located in the facility's Alzheimer's unit, explaining that its purpose is to provide a calming atmosphere to those who enter it. For residents with Alzheimer's, Snoezelen has proven useful for helping reduce the agitation, confusion and combativeness that sometimes come with the disease. It has also been shown to reduce wandering and improve bathroom independence and willingness to eat.
I look around the room. Placed on a large table are colored, translucent plastic "ropes" containing strings of flashing lights. A softly illuminated aquarium takes up a large share of one wall, and lava lamps and other decorative lights-containing swirling bubbles and bouncing plastic fish and other eye-catching objects and patterns-sit on smaller tables. Sometimes aromatherapy scents fill the room and often soft nature sounds or music is playing. There's a rotating glass ball on the ceiling-a small version of the kind seen tossing bits of light around a ballroom. The window is covered with a black felt curtain with glow-in-the dark stars and planets attached. I'm thinking, have I been transported back to another time-say, the 1960s?
I'm not the first person to react this way initially. Kroner, who in 1998 won the RAP Innovative Award from the Resident Activity Personnel in Ohio organization for introducing Snoezelen therapy to O'Brien Memorial HCC that year, says that some individuals in a group of medical professionals from neighboring hospitals who came to see the Snoezelen room reacted by saying (with a hint of sarcasm), "What is this room, a flashback to the sixties? Where's the marijuana?" Kroner says, however, that before their visit was over, their tone became softer and more relaxed from being in the room, and they experienced firsthand the mellowing effects of Snoezelen. In fact, sometimes staff members come to sit in the room for that very reason, she says.
Residents receive one-on-one attention in the Snoezelen room and usually only one resident at a time visits the room. A resident is generally brought in by a staff member, who might talk softly with the resident or remain silent, depending upon what the resident needs and wants. Sitting together in the room provides an opportunity to massage a resident's skin with lotion, and this touching is also part of the therapy.
The room is open at all times so that residents can go there on their own throughout the day if they choose. Staff members supervise these impromptu visits, to make sure residents are safe and to observe their demeanor and behavior. A form is provided for these observations, so that the benefits of the therapy can be documented.
There is no set pattern of activity in Snoezelen therapy-no "wrong" way to experience it. It's meant to be a stress-free activity with no rules beyond keeping the experience safe. Kroner says each resident perceives the room differently, and it can be a new adventure each time.
For many residents, the highlight of the room is the fish tank. Watching the fish often prompts reminiscing-about going fishing or having pets or a day at the ocean. And residents love the lights. Many have been heard saying things like, "They're so pretty. They remind me of the stars at night." This, according to Kroner, from people who previously were unable to express themselves.
When asked how Snoezelen got started at O'Brien Memorial HCC, Kroner modestly emphasizes that she was just a small part of the impetus. "One morn
ng before work I saw a program on Snoezelen on MSNBC," she says. "The program showed a nonverbal resident who, during Snoezelen therapy, turned and called her daughter by name. It was the first time she'd spoken in a long while. I got so excited about what this therapy could do for our residents that I made some calls to get more information." One source of information was FlagHouse, Inc., the sole U.S. distributor of SNOEZELEN« therapy equipment and supplies. FlagHouse sent a videotape about the SNOEZELEN concept, and Kroner presented the information to O'Brien Memorial's administration.
Kroner says she got nothing but support from the administration and staff when she suggested they implement the program. "They will do anything that benefits the residents. Our administration gave us a room to use and had it painted and carpeted for us. We didn't have a lot of money for equipment, so we improvised a bit. We purchased some equipment from Flaghouse, but some items we were able to purchase from regular stores. One of the nurses made the curtain, and we attached the stars and planets on it and on the walls."
The Snoezelen philosophy fits right into the relaxed, family-oriented atmosphere of the facility. Residents are not coerced into participating but do so willingly, and when they do participate, they experience Snoezelen at their own pace and in their own way. "Some people like to just come into the room and sit quietly and stare at the lights," Kroner says. "One gentleman, who passed away recently, loved to come in and watch the fish in the aquarium. He had previously been prone to agitation, but he often fell asleep peacefully in his geri-chair in front of that aquarium, and he called this 'his room.'"
For other residents, the Snoezelen room provides something different to do. Velma, for example, a little slip of a lady with silver hair and a twinkle in her eye, joins us during my tour. Kroner tells me later that Velma comes in regularly to turn off all the lamps. "She thinks they're a fire hazard, although everything in this room is quite safe. The staff comes in and turns them back on, and Velma comes in and turns them off again," Kroner says with an affectionate laugh. "It's Velma's 'mission,' and she enjoys it."

"We supervise the use of this room carefully, and in two years no one has ever been hurt," she says. "Well, at least no residents," she adds with a laugh. to other advanced degrees and certifications.
"And there's no 'pecking order' here. Care planning is totally interdisciplinary. Dietary staff are key to the care of people with Alzheimer's, as are restorative nursing and activities and everyone else. In fact, some of the best information we get about residents comes from housekeeping and maintenance, who see them every day and notice things that even nursing might not. It's not unusual to see a dishwasher from the kitchen walking a resident to her room, or a member of the maintenance staff wheeling someone down the hall in a wheelchair. Everyone's here because they care about our residents."
"Everyone just pitches in without blinking," adds Kroner. "These residents are part of our family, so of course we all lend them a hand wherever we can."
As I'm leaving O'Brien Memorial Health Care Center, Duchess walks over and offers her head for a goodbye pat. "Franni" Kroner walks me to my car. She seems like an old friend. I hear children laughing in one of the courtyards outside the building, and I realize that my story, which started out to be about Alzheimer's care, is about much more. It's about caring-caring about and caring for people who happen to have Alzheimer's disease. The Snoezelen program is a plus, to be sure. But I have this funny feeling that even without Snoezelen, somehow the residents here would get exactly the care they need. It's that family thing again.

O'Brien Memorial Health Care Center is part of Windsor House, Inc., a family-owned and -operated regional chain of nine nursing facilities and two assisted living residences in Northeast Ohio and Northern Pennsylvania. The 158-bed facility has a 42-bed Alzheimer's unit and two skilled nursing units. NH

Francine Kroner, RAC/AAC is O'Brien Memorial Health Care Center's activities director. Joanne Markovich, MSN, RN, C, is its director of nursing. For more information, contact Rita Clemente at (330) 545-1550.

"We did have a close call with the fish when a resident decided to feed them some chocolate-covered raisins and sausage. The fish survived, and we've since gotten a locking lid for the aquarium."
Since the Snoezelen program
started more than two years
ago, the staff at O'Brien Memorial have discovered that it offers benefits well beyond what they'd expected, for example extending to the residents in O'Brien Memorial's two skilled nursing units. "We have a cart that someone from maintenance rigged up for us with power outlets, so we can take Snoezelen to the people who can't come to the therapy room," Kroner says. "We place 3 or 4 items from the Snoezelen room on the cart and wheel it to bedridden residents' rooms," she explains. The lamps and aromatherapy unit and other items plug into the cart, and the cart's cord is then plugged into the outlet in the resident's room.
"This is good stimulation for people who experience life lying in bed all day," Kroner explains. She says activities staff also fluff the residents' pillows, comb their hair, massage them with lotion, play tapes and read to them during their visits with the Snoezelen cart.
Another advantage of the Snoezelen room is that it gives families a quiet place to sit and visit with their loved ones. They say the atmosphere in the room is relaxing for them, too.
Some ambulatory residents from the skilled nursing units also come to enjoy the room or are brought by staff when they need its calming effect. Later in my visit, Director of Nursing Joanne Markovich tells me that there is one resident, for example, who exhibits the "sundowner's" syndrome and screams incessantly every evening. Staff members take him to the room when he becomes agitated, and within a half-hour he is calm and ready to sleep through the night.
The next stop on my tour is a visit with Joanne Markovich. As I enter her office, she fields phone calls, stops to hug a visitor who has popped in, listens attentively to a staff member who tells her about an order of pharmaceuticals that has arrived, gives him some instructions and then turns her attention to me. The pace is obviously hectic, but her demeanor is serene and friendly.
I ask her how the Snoezelen program fits into the facility's philosophy on Alzheimer's care. "We believe in preserving the best quality of life possible for our residents-regardless of their illness or their stage of dementia," she says. "We plan activities and areas of care based on where residents are in their own minds, and we try to identify and meet their needs where they are. Snoezelen helps keep their activity level up, which is desirable, and the movement and the smells and sounds help stimulate their long-term memory."
Markovich points out that since some residents with Alzheimer's disease can't express their needs, providing the best care takes caregivers who know them well enough to intuitively figure out what they need.

"The value of our familiarity with our residents and their needs is dramatically illustrated when a resident is admitted to a hospital for an acute illness," Markovich says. "To us that resident is a family member, but to the hospital staff, he is a stranger. It is imperative, therefore, that hospital nurses review the information we send about each resident admitted."
If that is not done, says Markovich, the following scenario might ensue: "A hospital nurse will say when we visit a resident, 'This man was so agitated that we had to restrain him.' Of course, they haven't put on his glasses. They haven't put in his false teeth and then wonder why he isn't eating. They haven't put in his hearing aid, so he can't hear what they're saying to him. And to top it all off he has Alzheimer's and is nonverbal, and he doesn't know where he is or remember how he got there. No wonder he's agitated.
"You have to think about what someone might need before addressing his or her behavior. Unwanted behavior is usually the consequence of an unexpressed or inexpressible need. If we take care of the needs, we can alleviate the behavior." Markovich adds, "We've been able to greatly reduce the use of chemical restraints since the Snoezelen program was started."
Markovich repeats the family theme I've observed and heard about throughout my visit. "Our staff stay here a long time, and they are loyal. There is definitely a family camaraderie, a sense that we're all in this to sink or swim together. And the administration values-and therefore employs-highly skilled people. Several of our staff are certified gerontological nurses in addition to other advanced degrees and certifications.
"And there's no 'pecking order' here. Care planning is totally interdisciplinary. Dietary staff are key to the care of people with Alzheimer's, as are restorative nursing and activities and everyone else. In fact, some of the best information we get about residents comes from housekeeping and maintenance, who see them every day and notice things that even nursing might not. It's not unusual to see a dishwasher from the kitchen walking a resident to her room, or a member of the maintenance staff wheeling someone down the hall in a wheelchair. Everyone's here because they care about our residents."
"Everyone just pitches in without blinking," adds Kroner. "These residents are part of our family, so of course we all lend them a hand wherever we can."
As I'm leaving O'Brien Memorial Health Care Center, Duchess walks over and offers her head for a goodbye pat. "Franni" Kroner walks me to my car. She seems like an old friend. I hear children laughing in one of the courtyards outside the building, and I realize that my story, which started out to be about Alzheimer's care, is about much more. It's about caring-caring about and caring for people who happen to have Alzheimer's disease. The Snoezelen program is a plus, to be sure. But I have this funny feeling that even without Snoezelen, somehow the residents here would get exactly the care they need. It's that family thing again.

A Culture of Caring

The culture at O'Brien Memorial HCC is why Snoezelen was so eagerly received by staff and administration, according to Activities Director Francine Kroner. If the therapy would help their "family" of residents, they would do whatever it took to get the program started.
That culture of family extends to the administration's treatment of staff, as well, which could explain why all the staff members I observe during my tour look happy and at ease. From time to time employees find lottery tickets stapled to their paychecks. Administrators sometimes cook and serve special meals for the staff.
Then there's the facility's "Tradition of Caring" program. Residents, families and visitors put names of staff members who go above and beyond their expected duties and responsibilities on special postcards. Names are drawn from the accumulated postcards, and at the facility's annual employee recognition dinner, three people are rewarded. The "prizes" are a limousine-chauffeured night out to dinner anywhere between Cleveland and Pittsburgh, a weekend getaway and a week's paid vacation in exotic places like Hawaii or London.
It's no wonder staff members stick around for years, providing the consistency and familiarity that are so needed in caring for people with Alzheimer's disease. Kroner has been at O'Brien Memorial HCC for 10 years, and some of the nurses have been there 18 to 20 years.
Being treated like family by their employers contributes to the staff's family philosophy of caring for residents, too. Kroner points out that staff get involved in many of the activities available to residents in the Alzheimer's unit at O'Brien Memorial HCC. They have a lifelike doll for which staff members buy baby clothing at thrift shops. The women residents with Alzheimer's enjoy dressing and cuddling the doll and folding its clothes. They also enjoy washing dishes or baking cookies in the kitchen, with one-on-one supervision, and folding washcloths. There's daily music therapy and a special music program every week, such as a roving accordian player who goes from room to room, or singalongs to tapes of old songs. One woman, who normally doesn't speak, can sing almost all the words.
Residents from the special Alzheimer's unit are taken off the unit as often as possible, to enjoy parties and entertainment programs with the other residents. And staff members bring in their children, infants, dogs, cats and even their pet rabbits for the residents to enjoy. The redisents light up when pets and and kids visit. Kroner reflects, "We have residents who forget their own names, but they never forget babies and children."

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Alzheimer’s Care: A Family Affair

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