June 2, 2026
Beyond Bingo and TV: Meaningful Activity Tools and Techniques in Assisted Living
By Joanne Kaldy
About three-quarters of assisted living community residents have cognitive impairment.1 While activities can provide joy and meaning for these individuals, studies show that residents with dementia spend most of their waking hours being sedentary.2 A session at PALTmed’s PALTC26 Annual Conference, Implementing Meaningful Activity Approaches for Residents with Dementia in Assisted Living, offered tips and insights on a unique and promising way to engage this population mentally, physically, and socially.
What Is a Meaningful Activity?
“Meaningful activity is person-centered and matches the activity with the ability and interests of residents in ways that bring meaning and value to the person,” said Sarah Holmes, PhD, MSW, assistant professor at the University of Maryland School of Nursing, adding that it makes a valuable contribution within the community.
“When someone is doing something that engages with their personal interests, it gives them purpose, joy, and meaning,” said Dr. Holmes. She identified five characteristics of meaningful activity: it’s enjoyable, tailored to individualized abilities and preferences, related to personally relevant goals, engaging, and related to an aspect of the person’s identity.
While meaningful activity has shown promise and positive impacts, Dr. Holmes noted that there are barriers to implementing such engagement. These include behavioral/ neuropsychiatric symptoms, comorbidities, pain, sensory impairment, and lack of motivation. She observed, “Many residents with dementia also have behavioral symptoms such as agitation, aggression, or resistance to care, and this can make caring for this population particularly challenging. They have a lot of complex care needs. On top of that, we know that they spend the majority of their time being sedentary.” She added, “For residents with dementia, we know that as their cognitive abilities decline, they have difficulty interacting with others and could have challenges communicating. They also may lack the self-initiative to engage in activities that they previously had enjoyed.”
At the same time, there are environmental and policy barriers, such as poor lighting, noise, and sights and sounds that cause visual overload; rough walking surfaces and/or poor quality of seating; and policies that are relevant (such as limiting access to outdoor areas or ineffective procedures for evaluating resident preferences).
There are also staff barriers to meaningful activity engagement. These include lack of education and training related to dementia care, communication approaches that cause misunderstanding or missed connections, and work demands that leave limited time for supporting engagement. Dr. Holmes noted, “Staff often lack the education and training specifically focused on dementia care and really understanding the best practices around communicating with residents living with dementia using nonverbal approaches and creating positive interactions.”
The MAC-4-AL Tool
The good news is that there are tools to support staff’s efforts and help ensure that residents are connected with activities they enjoy, can engage in, and benefit from. The Meaningful Activity for Assisted Living (MAC-4-AL) is a theoretically based four-step approach:3
- Step I: Development of a stakeholder team, community goal setting, and environmental and policy assessments
- Step II: Staff education
- Step III: Evaluation of resident preferences and goals
- Step IV: Mentoring and motivating residents and staff
MAC-4-AL is based on two key theories: The Social Ecological Model, which emphasizes the influence of intrapersonal, interpersonal, and environmental and policy factors on engagement in meaningful activity; and the Social Cognitive Theory, which guides interpersonal interactions between staff and residents to facilitate change.
This intervention is implemented by a research interventionist who works closely with a community champion and stakeholder team monthly. The community champion is key, said Sorah Levy, PhD(c),MSN, RN, RACT-CT, RAC-CTA, a PhD candidate at the University of Maryland School of Nursing, as they help to provide on-site support to encourage and motivate resident engagement in meaningful activity. This individual can be appointed by community leadership, self-appointed, or nominated by peers. As this responsibility shouldn’t just fall on one person, she said, it is important to identify alternative or co-champions. She added, “I think the best champions we’ve had were people who were not necessarily leaders by role or title but those who are into the idea of meaningful activity – someone who embraces the idea, champions it, and works with the stakeholder team.”
Ms. Levy explained that the stakeholder team includes team leaders, activity staff, nursing staff, and direct care workers. The intervention begins with a stakeholder meeting that introduces everyone to the participatory process and their responsibilities. It also establishes goals for the community. “Brainstorming is done to identify and overcome community challenges and barriers associated with implementing meaningful activity approaches,” she said.
A 12-Month Process
Like many positive changes, MAC-4-AL doesn’t happen overnight. A 12-month process involves:
- Month 1: Introduce the program, evaluate the community environment and policies, identify champion(s), build teams, and set goals
- Month 2: Conduct staff education and begin work with community champions, staff, and residents to implement the program
- Months 3-6: Establish resident preferences and goals for meaningful activity. This involves translating goals into practice, ongoing education reinforcement, completing the Meaningful Engagement Tool to evaluate resident preferences and establish goals, and providing resident and staff encouragement and positive reinforcement
- Months 7-12. Mentoring and motivating. This includes continued reinforcement and encouragement, ongoing education, and integrating MAC-4-AL and meaningful activity into the workflow in a sustainable way.
By following this timeline, Ms. Levy said, the community can continue to use the tool and sustain meaningful activity efforts over time. Best practices for implementing MAC-4-AL, she offered, include a multidisciplinary team of community collaborators on the stakeholder team, ongoing staff education to prevent gaps or halt momentum when there is staff turnover, and open communication with the direct care staff, families, and residents alike. She stressed, “MAC-4-AL is not specific to any one discipline, such as activities or nursing, and works best when it is a community-wide program.”
Meaningful Engagement Assessment: All About “Me”
Providing meaningful engagement is not a one-size-fits-all initiative, stressed Elizabeth Galik, PhD, CRNP, FAAN, FAANP, professor at the University of Maryland School of Nursing. She noted that the traditional activities of bingo, puzzles, and TV-watching are just not going to cut it. She said, “I’m not a bingo person, so [if I go into an assisted living community at some point] they are going to have to find different activities for me and different ways to interact with me.” The mismatch between resident preferences and activities offered, she observed, can lead to decreased participation and ultimately disengagement.
The Meaningful Engagement Assessment can help communities ensure that residents are offered and involved in activities that resonate with them throughout their stay in the community. It includes three components:
- Background: About Me. This provides background information that is helpful in getting to know the resident’s personal history and preferences.
- What Is Meaningful to Me? This is designed to identify what is meaningful to the resident and may involve personal examples. For instance, the team member says, “I feel accomplished when I complete a task on my to-do list, such as folding the laundry or walking the dog. What are things you do that help you feel accomplished?”
- Making It Happen! This involves using the information completed in the previous sections to identify ways to create meaningful moments for the resident.
This assessment can provide insights into how to engage residents on many levels. For instance, Dr. Galik mentioned that her mother’s name is Francis, but she hates being called that and goes by Fran. “Just having that little bit of information makes a difference in terms of getting her attention. Finding out where a person grew up, what they did, what special relationships they had with family or pets are all little ways that gets the person’s attention, as well as determining what is meaningful for them,” she said.
As with the MAC-4-AL and any innovation or change, staff education is key. Dr. Galik suggested, “Provide training for staff that includes a brief overview of the benefits of meaningful activity, motivational techniques to help encourage resident engagement, and instructions for completing the tool.” Think-Pair-Share, a learning strategy that promotes individual thought, peer discussions, and sharing ideas and insights to enhance understanding, may help staff become more comfortable with completing the tool.4
Motivating Caregivers and Residents
“Self-efficacy is great for motivating both staff and residents. Basically, this theory quite simply says the more you believe in your ability to execute a course of action, the more likely you're going to do it,” said Barbara Resnick, PhD, CRNP, FAAN, FAANP, professor at the University of Maryland School of Nursing. For example, she said, “Many of you went to exercise this morning because you believe you can do 30 minutes on the treadmill.” The other component of self-efficacy, she offered, is outcome expectations and the belief that if you do something, it's going to be beneficial. She said, “Your staff needs to believe that meaningful activity is beneficial to the residents and that it would also be beneficial to them, or it's not happening. The way we strengthen beliefs about performance and about outcome expectations is verbally encouraging. Actually performing the behavior — that's how you learn you can do it.”
While resident satisfaction and safety are always the goal, it will be important to manage unpleasant outcomes. To this end, Dr. Resnick said, the team needs to acknowledge, anticipate, prevent, and/or eliminate issues that can interfere with engagement. These include pain, fatigue, shortness of breath and fear of falling or getting hurt.
Caring and consistency are key, Dr. Resnick stressed. This means giving love and attention, meeting residents where they are (“becoming them”), serving as a calming force, and demonstrating trust, patience, humor, and play. She said, “We talk a lot about this as a team. When we go into communities and work to implement these programs, we give love and attention to the staff… When we think about residents, it's really thinking about getting into their heads and understanding what it feels like for them.”
“Nothing, probably, is as important as never giving up. Somebody may not engage in that meaningful activity the first time, but don’t stop trying,” said Dr. Resnick. “We tend to try new things one time, but sometimes it takes longer. We need to recognize that.” She observed, “It is critically important to help both the residents and the staff set goals around meaningful activity programs.” This may mean reigniting old favorites or introducing new ones.
The recordings for PALTC26 are now available. Go here for more information.
References
1. Samus QM, Onyike CU, Johnston D, et al. 12-month incidence, prevalence, persistence, and treatment of mental disorders among individuals recently admitted to assisted living facilities in Maryland. Psychogeriatr. 2013;25(5):721-731. doi:10.1017/S1041610212002244
2. Leung KCW, Sum KWR, Yang YJ. Patterns of sedentary behavior among older adults in care facilities: A scoping review. Int J Envir Res Public Health. 2021;18(5):2710. doi:10.3390/ijerph18052710
3. Holmes S, Scherr S, O’Brien E, et al. Testing the feasibility and preliminary efficacy of meaningful activity for managing behavioral symptoms of distress (MAC-4-BSD) intervention for residents with dementia in assisted living: Protocol description. Research in Nursing & Health. 2024;47(6):599-607. http://doi.org/10.1002/nur.22415
4. Guenther AR, Abbott CM. Think-Pair-Share: Promoting equitable participation and in-depth discussion. PRiMER 2024;8:7. Doi: 10.22454/PRiMER.2024.444143
Joanne Kaldy is a freelance writer living in New Orleans, LA.