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

Application of PERAT

Figure 1 illustrates that cognitive abilities deteriorate at different rates during disease progression. Well-rehearsed religious and spiritual activities that do not rely heavily on explicit memory are more engaging. Likewise, the emotional salience of these activities as they are associated with peoples' faith, coupled with being resistant to neurological insults, helps ensure PERAT will be an effective approach for identifying activities for adults with all stages of dementia. It is important to keep in mind that such activities must be individualized, given the deeply personal nature of religious and spiritual life. The following guidelines are suggested for developing an individual plan for applying PERAT.

First and foremost, an assessment of the adult's religious and spiritual history is needed. This will require talking to patients, caregivers, and, if possible, the patients' family members. Second, an assessment of patients' cognitive status is needed to match religious and spiritual activities to cognitive levels. If patients are in the early stages of the disease, most activities will be appropriate. Activities requiring more procedural memory ability and less explicit memory ability are recommended for those in AD's middle-to-late stages.

Third, tasks must be selected for their procedural memory component and emotional salience. This requires knowledge about activities with which patients have emotional attachments. Fourth, materials for the activities must be obtained and usually can be acquired by family members. Materials must be items of intense emotional attachment such as religious books or icons. These things are tantamount to a spiritual "teddy bear" that can be calming for patients. When patients start to become agitated, for example, caregivers can hand them religious texts such as the Bible, the Koran, or the Dhampada and prompt them to thumb through them. Items such as family photographs and religious pictures that are strategically placed in the book can help to calm patients as they become engrossed in the activity. These environmental cues can be placed throughout patients' settings and offered as routine activities to provide comfort and support.

For Protestant patients, holding religious symbols such as the Bible, humming, or singing hymns may be appropriate. Protestant patients may place strong emphases on personal interpretations of scripture (Balmer, 1993; Nielsen et al., 1983), which can lead to an activity of reciting comforting scriptures (e.g., Psalm 23; The Beatitudes; 1 Corinthians 13; The Lord's Prayer). Such recitations may serve as especially appropriate activities during the early and middle stages of the disease.

For Catholic patients, many activities may be applicable, such as holding and reciting the Rosary, engaging in ritualistic prayer, or, as with Protestant patients, holding religious icons and singing songs. In fact, for those in the early stages of the disease, actions for a perpetual novena also may be appropriate by lighting a candle for a specific prayer request.

For Jewish patients, simple actions such as singing songs, reciting scripture (e.g., the Ten Commandments), holding sacred items (e.g., a Star of David or a yarmulke), or spinning a dreidel may be appropriate. For Muslim patients, holding religious items such as the Koran or facing toward Mecca to pray (e.g., Salah) are recommended.

For Buddhist patients, spinning a prayer wheel, making and managing a home shrine (e.g., Puja), or stringing prayer flags are activities that may be helpful. For Hindu patients, simple yoga exercises, chanting, or maintaining a shrine may be appropriate. The home shrine often is associated with offering incense, money, or food, and provides maintenance that may be meaningful and provide daily activity (Nielsen et al., 1983).

PERAT has been employed informally in service settings for patients with AD. In an AD daycare program, Jennings and Vance (2002) presented music appreciation classes to adults. Familiar music was selected to ensure participants would experience at least some recollection and be encouraged to participate. In fact, many of the songs had strong religious and patriotic themes. After participating in this activity, nursing assistants reported decreased agitation levels for these adults.

Khouzam and colleagues (1994) assessed nursing home residents on their religious affiliations, practices and rituals, and idiosyncratic beliefs. From this assessment, they focused on specific Bible verses that had strong emotional salience for each person. During a 6-week period, nursing staff were prompted to quote these verses to participants when they exhibited signs of agitation. By using this method, researchers found the overall incidents of agitation were significantly reduced.

Similarly, Carnes (2001) created a calm and relaxing spiritual environment for adults with dementia. This environment was designed to stimulate the senses through votive candles, spiritual music (e.g., chants, hymns, gospel music), and a wall hanging featuring a religious symbol (e.g., labyrinth). In this study, adults also were found to experience a decreased level of agitation. It appears the sensory cues of this environment may have evoked a reverence that, although it may not have been at a conscious level, inspired respect and peaceful feelings.

In four adult daycare centers in Israel, Abramowitz (1993) used morning prayers with cognitively impaired Jewish elders. Familiar prayers were recited for approximately 10–15 minutes each morning. During this time, the cantor read the prayers to the participants. Anecdotally, Abramowitz found participants received emotional satisfaction and security from this religious activity even though they may not have consciously recognized the prayers.

Several PERAT caveats should be addressed. First, this approach may not be applicable to adults who do not have a discernible religious tradition. Given the complexity of religious faith, some adults may have abandoned their faith; therefore, applying this approach could be counterproductive and cause agitation. It is for this reason that assessing patients' religious and spiritual histories remains important. Second, some adults may be particularly zealous and become overly excited by participating in religious and spiritual activities. If an older adult is listening to a tape of a sermon that has a hostile tone or disposition, for example, the adult may mirror that tone. Listening to a sermon that inspires holy indignation may result in an agitated or fearful state.

Finally, this approach may not be appropriate for all types of dementias. The approach is based on the cognitive and emotional processing of AD; however, PERAT may not be appropriate for adults with other forms of dementia. For example, Huntington disease specifically affects emotional processing (e.g., emotional prosody, verbally describing emotion; Baker, 1996; Speedic, Brake, Folstein, & Bowers, 1990); consequently, attachment to one's religious tradition may not be a motivating force in engaging in such activities.

PERAT represents a formalized way to incorporate patients' religious and spiritual backgrounds to meet the need for emotionally salient, engaging activities despite the cognitive declines associated with AD. Yet there are several obstacles that demand further research. First, PERAT should be compared with other activity paradigms (e.g., Montessori, sensory stimulation) in a clinical trial to determine the advantages and disadvantages of each paradigm (Vance, 2004). One paradigm may more effectively reduce agitation, but another may require more supervision by staff and caregivers.

Second, PERAT should be studied in several settings such as private homes, adult daycare centers, and nursing homes to determine the settings in which it is more feasible. Third, training materials for familial caregivers, nursing staff, and clergy should be developed. Training materials are essential for taking religious and spiritual assessments of participants; determining participants' cognitive abilities and the cognitive load of an activity; matching cognitive ability with an activity's cognitive load; and monitoring outcomes such as time engaged, agitation, and quality of life. Finally, because other forms of dementia (e.g., vascular, Parkinson, Lewy body, Huntington) have different patterns of cognitive decline, the PERAT approach must be examined in various dementia populations to determine whether it is applicable. Despite these obstacles, the literature supporting PERAT is promising for AD and related dementias.


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