The “Build A Birdhouse” kit is one of the most common hands-on activities in senior residential care settings. It’s one of the few tabletop tasks that appeals to men and their sense of useful productivity.
For someone in even the early stages of Alzheimer’s, this task requires extensive working memory, attention, and sequencing skills. It requires the ability to hold on to a thought long enough to complete the step. In unfamiliar projects like this, where repetition is an unlikely luxury, there is little chance that the Alzheimer’s patient could complete this activity without significant help. Due to the cognitive demands of constructional tasks, activities like the birdhouse kit are frequently completed by the caregiver, while the person with dementia looks on with a distant gaze.
Constructional tasks are fine for Alzheimer’s patients if the goal of the activity is just participation, and not execution. But then again, is there something better we could do?
I met Stan at an assisted living facility. He had moved in the year before after being diagnosed with Alzheimer’s and was no longer able to live in his house alone. Stan had always been fairly independent and socially appropriate, even though he wasn’t the most gregarious guy in the building. The staff had growing concerns about Stan’s declining mental status and worsening depression. His ability to care for himself and his general interest in his environment plummeted quickly over the course of a few months. Antidepressant medications had failed to make noticeable improvement in his mood or cognitive ability.
When I introduced myself Stan, he was withdrawn and aloof. He was generally indifferent to his own health status or concerned about his declining function. In asking Stan some questions about his past, he told me that he was an optometrist. Describing his career was the only subject that lit up his flat affect. Stan had some clear cut memory issues, impaired reasoning, and poor insight. But when he talked about optometry and related topics housed in his long term memory, his language skills and thought processes seemed to markedly improve.
I knew I had to get Stan engaged in something meaningful in order to get him moving again. I went to a local optometry shop where I obtained a large box full of broken glasses. I took the box to Stan and told him I needed his help.
Stan was immediately defensive, “I can’t fix those. I can’t even see the screws anymore.” Sensing his own limitations, Stan felt defeated before he even started.
“I don’t need you fix them,” I said. “I need you to break them apart. We are recycling the pieces to make new glasses for children who can’t afford them.”
Stan’s entire outlook on life shifted in that moment. We sat together for a while and popped out lenses and snapped off frames. We sorted the parts into two smaller boxes. When it was clear that Stan could handle this job without me, I thanked him profusely and told him I’d pick up the parts the next day.
Replenishing his box of broken glasses became our weekly routine.
There are lots of lessons in this story related to Stan’s depression and psychological dysfunction. But in terms of his cognitive ability to attend to a task, deconstruction was far more useful task than construction.
Just like little boys who like to tear things apart, there is a certain pleasure in the act of dismantling something that feels very purposeful. There is no pressure to “get it right”. I’ve asked my patients who can no longer string together the steps of assembling something to disassemble it- and the increase in attention and participation in that task improved dramatically.
Old electronics, watches, appliances- there is a limitless supply of broken stuff in the world that is just waiting to be torn apart. The same principle applies to taking lids off containers (“Can you open this for me?”), tearing up boxes, or taking the sheets off the bed.
Deconstruction is a great way to accomplish gross motor movement, effective use of the hands, and therapeutic chores without excessive cognitive demand. It is a principle that can be applied to people at all stages of cognitive decline.
Now let’s tear that birdhouse apart!