Procedural Memory and Emotional Attachment in Alzheimer Disease: Implications for Meaningful and Engaging Activities

David E. Vance, PhD MGS MS BS; Barbara S. Moore, DSN RN NHA; Tom Struzick, MSW/ACSW LCSW MEd


J Neurosci Nurs. 2008;40(2):96-102. 

In This Article

Abstract and Introduction

With an increasing number of older adults being diagnosed with Alzheimer disease, the need to find meaningful and enjoyable activities in which they can successfully engage is important for providing good quality of life while preventing behavioral difficulties that often accompany this diagnosis. Dementia-related neuropsychological impairments hinder engagement in a variety of enjoyable activities. For many older adults with Alzheimer disease who have been involved in a religious tradition, well-rehearsed rituals and emotionally salient behaviors can be employed well into the later stages of this disease. An approach called procedural and emotional religious activity therapy, or PERAT, can provide enjoyable and meaningful activities that may reduce agitation and increase quality of life for patients as well as for caregivers. Knowledge about the neuropsychology of procedural and emotional memory is needed to understand how PERAT works.

According to Lawton (2001), there are 11 universal human needs, one of which is meaningful activity. Given the neuropsychological impairment of adults with Alzheimer disease (AD), caregivers have difficulty finding stimulating, meaningful activities that will hold the attention of adults with this condition. Kovach and Magliocco (1998) found that adults in institutional settings with late-stage dementia participated in activities for 10 or fewer minutes daily. Caregivers assisted adults with activities 37.5% of the time. Many activities can be too mentally challenging, involve objects that look like children's toys (which may be insulting to those who are in the earlier stages of the disease), or have no inherent or intrinsic purpose or goal. As a result, many adults with AD spend time in unfulfilling ways (Burnside, 1986).

Approximately 4 million adults in the United States have been diagnosed with AD (Samanta, Wilson, Santhi, Kumar, & Suresh, 2006). Within the next two decades, the number of adults diagnosed with AD will increase to approximately 15–20 million (Brookmeyer, Gray, & Kawas, 1998). This increase will represent an enormous strain on families, healthcare and social service providers, and the nurses who care for patients with AD. Agitation and other behavioral problems often accompany an AD diagnosis (Vance et al., 2003), which increases this strain. It is imperative that healthcare researchers find effective means to help address behavioral problems for those with AD and their caregivers. By providing emotionally engaging, stimulating, and, most of all, meaningful activities for adults with AD, agitation and accompanying behavioral problems may be abated, improving quality of life for patients and their caregivers (Cotter, Stevens, Vance, & Burgio, 2000; Gruetzner, 1988; Mace & Rabins, 1991; Madori, 2007; Vance & Johns, 2002; Vance & Porter, 2000).

This article provides a neuropsychological framework for an activity intervention to help mitigate some of the behavioral disturbances accompanying AD while providing meaningful and engaging activities for patients from a religious tradition. This intervention is called procedural and emotional religious activity therapy, or PERAT (Vance, 2004). PERAT can be used by recreational therapists, nurses, and allied health professionals who work with older adults with AD (U.S. Department of Labor, Bureau of Labor Statistics, 2006).

PERAT seeks to match the cognitive ability of the adult with the cognitive demands of an emotionally salient, meaningful activity (in this case, a religious or spiritual activity). In this article, PERAT will be examined within the context of the neurological stages of AD. The procedural and declarative memory declines associated with AD are elaborated upon in relation to activity therapy in general. The role and resiliency of repetitive religious activities in regard to the neuropsychological losses of AD will relate to procedural memory and emotional attachments. PERAT is described in detail, examples are provided, and implications for nursing practice and research are posited.


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