In the final installation of the Pool Activity Level (PAL) Series, this article shares the best way to support and engage with your loved one living with dementia at the Sensory and Reflex Level using the Pool Activity Level (PAL) Tool.
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What is the Sensory and Reflex Level
The Sensory and Reflex Levels represent the most advanced stages of dementia within the Pool Activity Level (PAL) framework. Although they share a focus on comfort, sensory engagement, and emotional connection, the two levels are distinct — your loved one’s abilities, awareness, and the kind of support they need will differ depending on their Level.
| At the Sensory Level, a person can still respond to simple one-step prompts, briefly explore objects with guidance, and show emotional engagement through facial expressions or sounds. |
| At the Reflex Level, voluntary movement is minimal, communication is largely reflexive (e.g. blinking, changes in breathing, grasping), and care is centered on comfort and presence rather than activity. |
Understanding which level your loved one is at helps you choose the right approach. Care at this level is centered around comfort, safety, sensory regulation, and emotional connection, rather than active participation.
Use the cues below as a general guide:
Area | Sensory Level | Reflex Level |
|---|---|---|
Following Prompts | Responds to one-step prompts (“touch the scarf”) | Responds mainly through reflexes (blinking, grasping, breathing changes) |
Eating / feeding | May still feed themselves with hand-over-hand or hand-under-hand support | Requires full assistance with feeding, positioning, and personal care |
Communication | Uses single words or sounds to communicate | Communicates primarily through facial expressions or body tension |
For a more accurate assessment, the PAL Checklist should be completed in consultation with a healthcare professional.
How Caregivers can Support at the Sensory Level
The following shares how, as a caregiver, you can support your loved one at the Sensory Level:
- Encourage activities that involve touch, sound, movement, and rhythm.
- Keep tasks simple, familiar, and hands-on.
- Example: feeling the texture of fabrics, rolling dough, or splashing water.
- Show what to do, do not just tell them what to do.
- Use hand-under-hand guidance if needed, then step back to let them explore.
- Example: Guiding their hands to paint or place a puzzle piece.
- Provide clear starts and endings (e.g. “Let’s place these three blocks together”).
- Use one-step instructions, such as “Touch the ball,” “Feel the scarf”.
- Smile, make eye contact, and offer gentle encouragement, such as ‘‘That looks Lovely’’, “Let’s try that again”.
- Respond warmly to emotional expressions like smiling and nodding.
- Avoid correcting the task and focus on their engagement in the activity not the outcome.
- Create a safe, clutter-free space, and stimulating space.
- Offer objects they can explore safely like textured fabrics, large beads, tactile mats, and picture books.
- Remove hazardous items such as sharp scissors or knives, as they may not be able to distinguish safe materials from unsafe materials.
- Let them lead the pace, do not rush them during the activity.
- Watch for signs of boredom, fatigue, or distress, and gently shift the activity as needed.
- Use objects from their past: a favourite scarf, a soft blanket, a familiar song.
- Even if they don’t “remember” cognitively, the emotional recognition may remain.
How Caregivers can Support at the Reflex Level
The following shares how, as a caregiver, you can support your loved one at the Reflex Level:
- Ensure proper positioning to avoid pain or pressure sores (e.g., adjust cushions, support limbs).
- Monitor for facial expressions or body language that may signal discomfort (e.g, scrunched noses, clenched fists, etc).
- Keep the environment calm, quiet, and non-threatening. Remove clutter from tables and ensure the environment is not close to traffic.
- Offer soothing touch, such as hand-holding or gentle hand massage.
- Use pleasant scents (e.g., lavender, citrus) sparingly.
- Play soft, calming music or familiar voices nearby.
- Use soft lighting; avoid harsh or flickering lights.
- Gently brush hair, wipe face, or apply lotion using slow, rhythmic strokes.
- Speak in a calm, warm, familiar tone, even if they do not respond.
- Use soothing sounds, such as gentle singing, humming, or rhythmic tapping to their favourite songs.
- Place familiar objects in their hands (e.g., a favourite blanket or picture).
- Minimise background noise (TV, machinery, loud talking).
- Maintain a consistent care routine to reduce anxiety or overstimulation.
- Avoid sudden movements, like jerking or moving around quickly.
- Maintain eye contact and use facial expressions, such as smiling to convey care and safety.
- Spend more time engaging in touch and connection as they are more effective than words at this stage.
- Watch for eye movements, hand grasping, vocalisations, or changes in breathing as signs of response.
- Even small reactions are important indicators of connection or discomfort.
Goal at the Sensory and Reflex Level:
To ensure the individual feels safe, soothed, and connected through basic sensory experiences, even when they can no longer actively participate.
Activities for PLWD at the Sensory and Reflex Level
At the Sensory and Reflex Level of the Pool Activity Level (PAL), persons living with dementia are unable to initiate or participate in goal-directed activities.
The focus at this level should remain on comfort, emotional connection, and sensory stimulation.
Activities for the Sensory Level
Designed to stimulate touch and provide comfort:
- Handle sensory boxes (filled with rice, beans, buttons, or soft fabrics)
- Use touch-and-feel boards with various textures (fleece, Velcro, sandpaper, lace)
- Try rolling or squishing playdough
- Brush soft doll hair (e.g. Doll Therapy) or pet a plush toy
Great for emotional memory and engagement:
- Clapping or tapping to music (use simple rhythms)
- Shaking maracas or using hand drums
- Swaying or dancing to familiar songs
- Listening to soothing or familiar music
Encourage movement and success through rhythm and familiarity by:
- Stacking blocks or cups
- Sorting large colourful objects with guidance (e.g. by colour or shape)
- Folding washcloths or towels with support
Focus on the sensory process, not the final product:
- Participate in finger painting or using sponge brushes
- Participate in sticker pasting (large, easy-peel stickers)
Tap into preserved long-term memory by:
- Looking at photo books with large, familiar pictures, such as their old school days
- Holding and exploring familiar objects (e.g. a baby doll, an old scarf)
- Reminiscence cards with large images of food, holidays, or vintage items
Support regulation and physical comfort through:
- Simple chair-based exercises with music
- Guided hand massages with lotion or scented oils
- Tactile walking paths (barefoot on soft mats or textured pads)
Encourage connection and positive emotional experiences:
- Holding hands and singing
- One-on-one storytelling (even if they don’t respond verbally)
- Helping with a task together (e.g. “Can you hold this while I fold?”)
- Participating in a group activity with support (e.g. group drumming)
Activities for the Reflex Level
Gentle scents can evoke calm or emotional responses:
- Present lavender, rose, or citrus scents using essential oils on cotton pads
- Use familiar food aromas (e.g. coffee, cinnamon, peppermint) to stimulate memory
- Bring a scented flower or herb garden close to them (e.g. basil, rosemary)
Tip: Always check for aversions or allergies and avoid overpowering scents.
Comforting touch can help regulate and connect:
- Hand massages with warm lotion
- Soft fabric stimulation (e.g., silk, fleece, knit textures)
- Brush hair or stroke the arms rhythmically
- Place a blanket or soft shawl on their lap or shoulders
- Participate in activities like Namaste Care Programme
Sound can reach parts of the brain even when verbal ability is gone:
- Play familiar music or calming classical tunes
- Use soothing nature sounds (e.g., rainfall, birds, ocean waves)
- Sing softly or hum near them
- Read short, rhythmic poetry or religious or spiritual readings meaningful to them aloud
Appealing to their sense of sight can be grounding:
- Gently move a colourful mobile or light-reflecting item (e.g., a suncatcher) in their line of sight
- Show high-contrast, familiar photos (especially of loved ones or nature)
Tips:
- Go slow and observe for even the smallest responses (e.g. blinking, eye movement, sighing).
- Activities should be simple, soothing, and familiar.
- Always check in and stop or adjust the activity when your loved one shows signs of distress or withdrawal.
- Take note of mouthing risk when using items like playdough, beads, easy-peel stickers.
Conclusion
As a caregiver remember that being present is enough. You do not always need to fill the moment with activities, conversation, or stimulation. Sitting quietly beside your loved one, holding their hand, offering comfort, or simply sharing space together are meaningful forms of connection and care.
- Pool, J. (2012). The Pool Activity Level (PAL) Instrument for Occupational Profiling (4th ed.). Jessica Kingsley Publishers.
