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Memory Matters in Assisted Living
Memory loss often signifies loss of independence, which is a growing concern for residents in assisted living (AL) facilities. The purpose of this exploratory study was to characterize the memory experiences and concerns of AL residents. Six residents voluntarily participated in 1-hour recorded interviews focusing on memory and guided by eight open-ended questions. Interviews were transcribed and analyzed using qualitative content analysis. Subjects reported varying degrees of memory loss they found frightening and frustrating, but also accepted the loss as a natural part of the aging process. Concerns focused primarily on inability to recall staff and resident names and activities, schedules, and appointments. Understanding memory experiences and concerns is important for nursing staff members who care for AL residents. Memory challenges identified by these residents were used to develop a memory intervention for older adults residents of this and other AL facilities. Improving cognitive skills may help AL residents maintain their functional abilities, enabling them to “age in place” in AL.
Learning and information retention are imperative to functioning successfully and performing activities of daily living. The images and impressions that are memories from one’s past act as a deterrent or support for future actions. Intact memory elevates a sense of independence and contributes to improved quality of life. As described by one group of researchers, “Forgetfulness is more than a simple loss of information and becomes real through its impact on skills and everyday meaningful know-how” (Imhof, Wallhagen, Mahrer-Imhof, & Monsch, 2006, p. 351).
Residents in assisted living (AL) facilities are at a pivotal point in their life. Although they need supportive care or supervision, they can maintain a certain level of independence. Consequently, AL is the fastest-growing residential care choice among older adults. Many AL residents fear a possible future move to a nursing home, however (Aud & Rantz, 2005; Williams & Warren, 2008, 2009). They have seen friends and family go through similar situations, and they value their independence and strive to maintain it for as long as possible. Gathering information about the memory experiences of this population may increase healthcare providers’ understanding of the limitations of those with memory impairment. Increased understanding of AL resident experiences and perceptions of memory loss may lead to nursing interventions that will increase the quality of supportive care received in AL facilities.
The causes, effects, and treatments of memory changes in the aging population are topics of increasing interest to researchers in the United States. Memory training research and commercial products now target older adults based on the premise that “use it or lose it” applies to both cognitive and physical abilities in aging. Older adults increasingly are concerned about their memory performance due to increased awareness of the risk for and prevalence of Alzheimer’s disease and other dementias. Normal age-associated reductions in short-term working memory and memory processing speed may be confused with signs of an early pathological cognitive disorder. Many older adults fear cognitive decline because it may lead to loss of self-concept or personhood. Memory loss and other cognitive loss also threaten self-care abilities and independent living, which universally are valued by older adults (Cutler & Hodgson, 1996; McDougall, 2000; Saczynski & Rebok, 2004).
Research has established a trajectory of performance decline on a variety of cognitive abilities including memory with aging (Schaie & Zanjani, 2006). By age 60, nearly all people demonstrate some measurable decline in cognitive performance. More significant impairments that affect daily functioning typically are present during the 70s. Memory self-efficacy, or the perception of one’s memory abilities, also declines with age and may negatively impact quality of life and participation in social activities that rely on memory. Memory lapses or “senior moments” are frustrating and embarrassing for older adults who do not want to be labeled as forgetful (Imhof et al., 2006). Memory decline has emotional and physical effects and may limit the ways in which a person functions in his or her daily routines that are essential to independent living (Imhof et al.; Willis et al., 2006).
Memory training interventions have been shown to significantly increase memory performance and memory self-efficacy (McDougall, 2002). Evidence supports the effectiveness of memory strategies, including mnemonic strategies, visualization, association, attention, and external memory aids for improving memory in older adults (Willis et al., 2006). Saczynski and Rebok (2004) demonstrated that memory decline can be slowed or reversed with the use of memory interventions that focus on modeling and practicing strategies specific to the tasks that require memory. Interventions have been successful in improving both the cognitive and emotional aspects of memory performance of older adults, but to this point research has focused on community-dwelling older adults. Limited research has tested cognitive interventions to improve memory and other cognitive functions in older adults who require supportive care in residential long-term care settings (McDougall, 2002; Williams, 2008). Older adults in AL have great potential to benefit from interventions that improve or maintain memory, and these interventions may enable them to continue living in AL in supported independence.
Purpose and Problem
The goal of this pilot study was to identify AL residents’ memory issues as a basis to develop an AL-specific training program to support memory. An additional goal was to identify variables that influence AL residents’ ability to remember. Based on the Health Belief Model (Becker, 1974), questions were designed to address memory loss perceptions of residents, barriers to remembering, resources residents used as memory supports, and actions residents would be willing to try to overcome barriers and improve their memory. Answers to these questions may provide insight into the challenges this population faces and will prove valuable for developing memory training interventions targeting the specific needs of AL residents.
A qualitative content analysis of guided interviews focusing on memory experiences was used to uncover information about memory issues encountered by AL residents. Approval to conduct the study was obtained from the university institutional review board. AL facility personnel provided a letter of agreement indicating their willingness to allow the research team to conduct the study on site. Interviews were conducted to elicit responses from the resident participants. Interviews were guided by questions or prompts and audio was recorded.
Subjects were recruited from an AL facility that was home to 40 residents in northeastern Kansas. The facility had expressed interest in participating in nursing research to improve care for residents. The research team announced the research opportunity at a resident council meeting and later recruited residents who requested the staff have the research team contact them to explain the study opportunity.
Four of the six subjects who volunteered were women and two were men. Five identified themselves as Caucasian and one was African American. The participants ranged in age from 77 to 89 (M = 82) years old. The residents had lived in the AL facility for 9 months to 4 years (M = 1.5 years). One resident had a graduate degree, one had a high school diploma, and the others had post-high school educations. Residents each had between 4 and 10 medical diagnoses, including chronic medical conditions. The number of prescribed medications ranged from 8 to 14. Fifty percent of the subjects reported they had been diagnosed with a minor form of dementia, but dementia was not documented in their AL medical records, and their Mini-Mental State Examination scores ranged between 25 and 30. All participants were responsible for decision making regarding their care in AL; were able to summarize the goals, activities, and risks of the study; provide signed informed consent; and respond appropriately to the interview questions. Recruitment of subjects continued until completed interviews demonstrated data saturation.
The interviews took place in residents’ apartments. This provided a comfortable and private environment for the residents. This setting was chosen to aid in the elicitation of sensitive personal information about emotions triggered by memory loss.
Eight interview questions were developed based on current literature about memory loss and aging guided by the Health Belief Model. The questions were reviewed by a qualitative expert consultant (Warren & Williams, 2008). Minor modifications were made to the interview questions (Table 1). After extensive discussion and modeling of the interview questions and format, the investigators conducted the individual interviews.
The length of interviews ranged between 8 and 50 minutes, with the average interview length being 29 minutes. Each resident consented to be recorded during the interview process. Portable minidisc recorders were used during each interview. At the end of each interview, the research team member summarized the information given by the resident. Interviews continued until the investigators concluded that novel responses to the questions were exhausted (data saturation was achieved). Demographic data were obtained from the AL medical records of each participant.
The recordings were archived in digital audio Wav (Waveform audio format) files in a secure computer. Using the Transcript Builder program Version 1.9.1 (Thinking Publications, Greenville, SC), the interviews were transcribed verbatim to allow for further analysis.
Qualitative content analysis was used to evaluate the transcripts and involved a color-coded system that reflected the interview questions. Before analysis, both investigators (the authors of this paper) reviewed all transcripts to become familiar with the data and form an overall impression of the responses. Deductive analysis then was used, guided by the Health Belief Model and the interview questions (Elo & Kyngas, 2007; Hsieh & Shannon, 2005). The two investigators agreed on the categories for the analyses and jointly coded a partial transcript; this prompted discussion of the rationale for category assignment, clarification of the categories, and development and revision of written operational definitions.
Several training sessions were held. Each guided interview question was assigned a color. Each utterance (sentence) or group of utterances that fit each question category were color-coded (highlighted) according to the corresponding interview question color. We achieved 90% agreement on category assignment on a separately coded transcript. We resolved the coding discrepancies, and the first author continued to code the remaining interview transcripts.
To assure trustworthiness of data coding, both authors individually coded one-third of the total transcripts in the sample. Interrater agreement on coding was 90% for identifying topic content (interrater coding in qualitative research is an established method to demonstrate reliability). There is disagreement about the proportion of a sample that should be jointly coded, however. Some qualitative methodologists do not believe that intercoder reliability is warranted in true qualitative research in which the coder is considered an instrument to subjectively interpret data (Carey, 2009; Elo & Kyngas, 2007; Hsieh & Shannon, 2005).
After all of the initial color coding was complete, all information pertaining to each category was compiled. This compilation helped the researchers to identify trends and reach conclusions about the data correlating to each interview question.
Findings are summarized for each of the eight interview question categories (Table 1).
1. Do you feel that your memory is not as good as it used to be? All of the residents participating in the study said their memory was not as good as it used to be. Residents A, E, and F stated that their short-term memory function is lower than it used to be. Residents A and E attributed their loss of memory to medical conditions including visual impairments and stroke. Although residents A, B, D, and E admitted they experienced some level of memory loss, all participants emphasized their current ability to retain memory. Words and phrases such as “fortunate,” “made good time,” and “long-term memory is almost perfect” reflect this optimistic view of memory loss. Residents C and F revealed that their memory loss was a slow process, stating that it came on “gradually” and it “sneaks up on you.”
2. Please tell me about the first time you noticed your memory was not as good as it used to be. None of the six residents could recall the first time they noticed their memory was not as good as it used to be.
3. Describe another situation when you could not remember something. All of the residents could describe a separate instance during which their memory failed them. Situations in which the residents’ memory failed them included trying to remember names of neighbors and staff, breakfast items, and crossword puzzle clues and answers; trying to follow multistep instructions and answer direct questions; and ¨misplacing items. Residents A and E reported difficulty with remembering and accomplishing multistep directions/tasks. During the interview, Resident A played an answering machine message that detailed a multistep process to reach the caller. This process seemed daunting to this resident, who stated, “Now I have to rem … the thing is I have to remember tomorrow and in the meantime I have to find out how to call her. And then I have to go through the process of calling her. So for me those are difficult things.”
4. How did this make you feel? All of the residents used negative terms to describe their feelings toward memory loss. Common language included the words frustrating, confusing, mad, nervous, embarrassing, worry, and lost. Other negative descriptions included fear, scary, strange, terrible, disbelief, hate, uncomfortable, and aggravating. Resident E felt “less than adequate,” as a result of memory loss. Resident A said that not being able to remember and function in certain situations can be “taxing.” Resident C recalled an example from a previous shopping experience: “It’s just scary. When you think, ‘Gosh I don’t remember what door I came out of or what store I was at’ and . . . it, it, uh, makes you think about a lot of things.” The decreased ability to remember can become dangerous. Recounting an experience that almost resulted in a traffic incident, Resident E felt it was scary “because not only are you a danger to others, you’re a danger to yourself.”
Although all of the residents held negative views toward memory loss, five of six reported they tried to maintain a positive attitude about their memory. Resident A said, “I don’t let it defeat me.” When encountering memory loss, Resident C tries to “pass it off” or make “a joke of it.” Resident B simply said “You can’t reverse the aging process.”
5. What kinds of things do you tend to forget? and 6. Are there particular situations that make it harder to remember? All six residents reported trouble remembering names. Resident E said, “I do have great difficulty remembering peoples’ names. I can remember the old, older people that I knew years ago. I can almost name all of them but I can’t…something happened.” The residents felt they had trouble remembering many types of items or situations. These included names (objects, people, places), placement of items, events and appointments, conversations, directions, date and time, tasks (multistep), addresses, telephone numbers, current events, and reading material (newspaper articles and books). Resident C emphasized a specific problem: “I can put things away where I think I know right where they are and they’re not there.” Most participants shared concerns about remembering telephone numbers and addresses. Resident E carried notes with the address and telephone number of the AL residence when going shopping or to appointments. “I carry two or three of ‘em in my pocket so I can always get home.”
The residents attributed their memory impairment to several factors. Resident A thought that visual impairment made it more difficult to remember. Residents B and D believed their hearing impairments hindered their ability to remember. Resident C said that crowded situations made it harder to remember because this resident “[didn’t] want to miss anything.” Resident F said that loud situations caused distraction that made it harder to remember.
7. Do you use any techniques to help you remember things? Resident A was the only participant who reported using self-testing techniques. Resident A would name each medication and its purpose before taking it. This resident stated, “I really had a little purpose in it. I was testing my own mind and I’m educating [the other residents] that these are valuable things that you take.” Resident A also participated in a group crossword puzzle exercise. Resident A said, “It’s, it’s good for my mind…I like to do this and I still get my share, I think.”
Many of the residents shared common techniques to help them remember, including written reminders, lists, calendars, routine placement of objects, connection and association, and repetition. Resident E used photo albums, journals, and other written records to help remember important events and dates. One resident said, “I have these stickers all over everything. If you were to ask me, ‘Well, what’s your phone number?’ I don’t know, but I’ll have to look it up. ‘Where do you stay?’ I don’t really know, but I’ll look it up.” These stickers were written notes placed on tables, telephones, and even carried in this resident’s pocket. Resident D explained why repetition helped preserve memory: “You have an easier time remembering somebody’s name that you, you know, see every day then you do somebody you haven’t seen for a while.”
8. If you were able to participate in a memory training class would you do so? Why or why not? All of the participants expressed interest in participating in a memory training class. Resident A hoped to get “a little faster response on my part” from a class if it were offered. Resident C stated there was no particular reason for wanting to participate in a class, but noted potential advantages in being able to, “remember upcoming dates, you know, without having to write out a calendar or something like that.” Resident D said that gaining knowledge about techniques “that would refresh your memory” would be helpful and useful in his or her daily activities. Resident E said there was not a specific thing he or she would like to get out of the class; instead, the resident, “just hope[s] to remember more.”
Our ability to remember declines as we age. This decline often leaves older adults troubled by memory loss. All of the AL resident participants reported memory challenges and concerns. Our findings may not be generalizable to other older adult populations due to the unique responses of older adults in residential care settings (Warren & Williams, 2008). Although data saturation was achieved, the memory issues described by our convenience sample may not be representative of other older adults in AL residency. However, the information provided and consensus among our subjects provides a starting point with which to design a memory training intervention for AL populations.
All of the residents expressed difficulty remembering names, dates, and appointment times. Telephone numbers, past conversations, and addresses were other areas of concern. Although all of these participants experienced memory loss, they could compensate for their decreased ability to remember. Many residents used calendars, lists, and written notes as reminders throughout their day. One resident used self-testing methods to sharpen memory abilities. Others relied on written records, photo albums, special placement of objects, and association techniques to strengthen their ability to remember.
The interviews also revealed sensitive details about the emotional toll of memory loss. Words such as frustrating, confusing, nervous, and embarrassing were used when discussing the hardships of memory loss. Although all of the residents held negative views of their memory loss, five of the six participants expressed a positive outlook on their experiences with memory loss. Memory loss is a process that all older people will experience at some point in their lives. This study identified common themes regarding the ways in which memory loss is perceived and experienced by members of the AL population.
Implications for Nursing Practice
Nurses strive for excellence in helping patients to achieve optimal wellness. Understanding patient perspectives regarding health and mental health issues is vital to tailoring interventions that result in quality care. This study identified important aspects of the memory experiences of AL residents that may inform nursing practice. Nurses may assist residents by being sensitive to and supporting memory abilities. AL nursing staff may be able to provide care that is less reliant on highly functional memory ability and can reinforce residents’ previously successful memory strategies. For example, staff should consistently wear name tags, and using table place cards in the dining room may reduce memory demands for AL residents. Care can become more personalized as nursing staff and residents share memories. Staff also can learn to increase their knowledge about useful memory techniques and share this knowledge with residents during routine care or activities. Knowledgeable care providers can teach residents specific strategies to address their memory challenges. These techniques, when reinforced in the AL environment and shared with other residents, may increase independence and self-esteem. Improved memory self-efficacy may encourage AL resident participation in social and recreational activities. The ability to recall names is considered polite during many social activities, and this ability can enhance quality of life.
This study was conducted to develop a memory training program tailored for an AL resident population, adding to the few cognitive interventions specifically targeting older adults in AL (McDougall, 2000; Williams, 2008). The findings provided the background to develop a memory training program targeting AL residents. The Memory Exercises in Assisted Living (MEAL) intervention was pilot tested in a small sample of AL residents. The MEAL pilot study results are reported in a separate article (Williams, manuscript submitted for publication).
This study established that learning practical strategies to remember and recall names of other AL residents and staff (a need identified by all subjects in our study) is a priority for AL residents. Memory training for AL residents may take place in a formal program or informally during care activities. Teaching a variety of approaches to remember names may be required to meet the needs of diverse residents. Additional AL-specific memory topics should include recall of phone numbers, appointments, and schedules; the ability to locate objects around the apartment; and the efficient use of external memory aids (notes and lists). Group classes can spotlight residents who are willing to share their favorite memory strategy with others. Understanding the memory-encoding and recall process may increase an older adult’s perceived control of and confidence in their memory abilities. Negative attitudes, embarrassment, and fear about memory loss also must be addressed and confidentiality assured for participants. Educating older adults about normal reductions in memory (in contrast to pathological cognitive decline) may provide reassurance and promote successful adaptation.
All of the residents in this study expressed an interest and were receptive to the idea of possible improvement or maintenance of their current memory performance. Common memory loss experiences will dictate content that is meaningful and applicable to AL residents. Increasing the awareness of memory experiences will help nurses working with older adults in a variety of settings to optimize memory performance and improve quality of care.
This research was supported by the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) K-12 Award to Dr. Williams at Kansas University Medical Center School of Medicine, HD052027, P. Thomas PI.
About the Authors
Jenna Asha Malini Marchant, BS RN, is a staff nurse at Truman Medical Centers Hospital Hill, Kansas City, KS.
Kristine N. Williams, PhD RN, is an associate professor at the University of Kansas School of Nursing, Kansas City, KS. Addresss correspondence to her at firstname.lastname@example.org.
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