The Pool Activity Level (PAL) Instrumental Tool4 is a framework designed to support persons living with dementia. Developed by Dr. Jackie Pool, PAL focuses on tailoring activities to match the cognitive and functional abilities of each person, fostering meaningful engagement.
This article discusses the benefits of PAL and how one can use it informally for persons living with dementia.
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What is Pool Activity Level Instrumental Tool (PAL)
The Pool Activity Level, or PAL in short, is an evidence-based tool for persons living with dementia. It was developed by Dr. Jackie Pool in 1999 to personalise activities for persons living with dementia.
PAL is widely used across the community care sector in Singapore 1, such as dementia day care centers and nursing homes. It helps community care providers tailor activities to enhance the well-being and quality of life for persons with dementia, but it can also be used by individuals caring for their loved ones with dementia to scale activities for daily living and recreation.
How is PAL Used?
Occupational therapists (OTs) often use the Pool Activity Level (PAL) Instrument to support persons living with dementia, by assessing their functional abilities and tailoring meaningful activities accordingly.
The following describes how one can use the PAL tool in practice:
Tips
One may observe whether a person can pick up a toothbrush and start brushing without being told, or if he needs help to get started.
2. Determine the PAL Level
There are four levels of PAL. To tailor the best activity for your loved one, you should know which level they fall under.
Level
Planned Level
Persons Living with Dementia Characteristics
Plan and carry out familiar tasks independently.
Examples (Getting Dressed)
Plans what to wear selects own clothing from cupboard; dresses in correct order.
Caregiver Role
Encourage autonomy with minimal guidance.
Exploratory Level
Can follow simple instructions and learn by doing.
Needs help to plan what to wear but recognises items and how to wear them.
Use hands-on, step-by-step prompts.
Sensory Level
Responds mainly to sensory stimuli (i.e music)
Needs help to plan, and with order of, dressing, but can carry out small tasks if someone directs each step.
Offer tactile, auditory or visual input.
Reflex Level
Reflexive, mostly involuntary responses (i.e massage)
Totally dependent on someone to plan, sequence and complete dressing; may move limbs to assist.
Focus on comfort, position, and routine.
How is PAL Used?
3. Activity Planning and Grading
Based on the person’s PAL level, one should:
- Ensure activities are something the person enjoys (cooking, painting etc).
- Design or adapt activities to match cognitive ability.
- Ensure activities are safe, engaging, and doable.
- Adjusts task complexity, environment, and instructions.
Tips
Example one:
For someone at the Exploratory Level, introduce a familiar baking task but break it down into single steps with demonstration.
Tips
Example two:
For a person at the Exploratory level, offer hand-over-hand assistance to get the person to water the plants at a garden.
Tips
Example three:
For a person at the Planned level, encourage full participation from planning to execution of a simple cooking task
i.e. cooking fried rice, providing verbal promptings when required.
4. Review and Reassessment
It is advisable to continually:
- monitor for changes in function or cognitive status;
- adjust the PAL level and revise activity plans as needed; and
- use PAL as a dynamic tool, not just a one-time assessment.
Tips
When someone who was at the Exploratory level is now unable to perform a painting task with guidance, consider getting the person to run his or her fingers over textured surfaces.
These simple actions provide a strong foundation of understanding persons living with dementia. One can also speak to an OT and care staff to better understand their loved one’s abilities.
Benefits of PAL for Persons living with Dementia
Research has supported the following areas where PAL can influence meaningful engagement and improve the quality of life (QoL) for persons living with dementia.
Promotes Person-Centered Care
Supports Cognitive Engagement
Activities designed at the appropriate PAL level help to stimulate the brain without overwhelming the person living with dementia. It helps to maintain cognitive function for as long as possible by promoting participation in structured, familiar, or sensory-rich tasks.
Improves Emotional and Psychological Well-being
Maintains Independence and Functional Skills
PAL preserves daily living skills. It empowers individuals to do as much as they can, with just the right level of support. It also encourages autonomy in personal care, mobility, and leisure where possible.
Even simple tasks like folding towels or sorting items can reinforce purpose and control for persons living with dementia.
Enhances Quality of Life Through Meaningful Activity
Activities under the PAL framework are emotionally and socially meaningful, tailored to personal preferences and history.3 PAL promotes occupational engagement based on the interest of the persons living with dementia. Individuals often display improved mood, better sleep, and more stable routines.
For example: A person living with dementia who was previously a teacher may find familiarity and engagement in grading papers or word searches compared to other activities.
Improves Safety
PAL helps therapists and caregivers identify risks based on cognitive level (e.g., poor problem-solving skills, impulsion). Activities and environments can be modified (e.g., simplifying tasks, removing hazards) to prevent injuries.
Supports Relationships and Communication
Track Progress or Decline
PAL can be re-administered over time to monitor changes in abilities. This supports timely adjustments to care plans and interventions.
Conclusion
The PAL tool is beneficial in enhancing the quality of life for persons living with dementia. Using a structured approach to understanding a person’s activity level, the PAL tool enables caregivers to tailor care that is meaningful and engaging. It contributes to a greater sense of well-being for persons with dementia.
- Agency for Integrated Care (2016). Dementia Care Competency Framework 2016. Agency for Integrated Care. https://www.aic.sg/wp-content/uploads/2023/06/Dementia-Competency-Framework-Assessment-Criteria.pdf
- Groenendaal, M., Smaling, H. J. A., Achterberg, W. P., & Caljouw, M. A. A. (2022). Maintaining meaningful activities for persons with dementia during transitions of care: A systematic review. Geriatric Nursing, 44, 176–183. https://doi.org/10.1016/j.gerinurse.2022.01.017
- Han, A., Radel, J., McDowd, J. M., & Sabata, D. (2015). Perspectives of people with dementia about meaningful activities: A synthesis. American Journal of Alzheimer’s Disease & Other Dementias®, 31(2), 115–123. https://doi.org/10.1177/1533317515598857
- Pool, J. (2012). The Pool Activity Level (PAL) Instrument. Jessica Kingsley publishers, London. https://www.dailysparkle.co.uk/wp-content/uploads/2022/04/PAL-Guide-for-Activity-Provision.pdf
- Wenborn, J., Challis, D., Pool, J., Burgess, J., Elliott, N., & Orrell, M. (2008). Assessing the validity and reliability of the Pool Activity Level (PAL) Checklist for use with older people with dementia. Aging & mental health, 12(2), 202–211. https://doi.org/10.1080/13607860801984375
