# Response Facilitation in Dementia Care: Exploring Engagement Through Social Contexts: A Qualitative Study in Dutch Nursing Homes

## TL;DR

Group activities in nursing homes help engage dementia residents more than individual ones, even when they don't visibly participate.

## Contribution

This study shows that group settings promote engagement through response facilitation, using both behavioral and physiological data.

## Key findings

- Group-based recreational activities lead to more behavioral and physiological signs of engagement in dementia residents.
- Observational and physiological data often differ, suggesting internal engagement even without visible participation.

## Abstract

What are the main findings?
Group-based recreational activities seem to provide the strongest conditions for response facilitation, leading to more behavioural and physiological signs of engagement among residents with dementia.Observational and physiological data frequently diverge, showing that residents may display cognitive or emotional engagement even when not outwardly participating.

Group-based recreational activities seem to provide the strongest conditions for response facilitation, leading to more behavioural and physiological signs of engagement among residents with dementia.

Observational and physiological data frequently diverge, showing that residents may display cognitive or emotional engagement even when not outwardly participating.

What is the implication of the main finding?
The heightened attention seen in group activities suggests a need to understand why these settings seem to be more effective and to translate their social, spatial, and facilitative elements into everyday care contexts to invite broader engagement.Reliance on behavioural observation alone may underestimate residents’ internal engagement; care practices and evaluations could incorporate multimodal indicators to better understand and support meaningful participation.

The heightened attention seen in group activities suggests a need to understand why these settings seem to be more effective and to translate their social, spatial, and facilitative elements into everyday care contexts to invite broader engagement.

Reliance on behavioural observation alone may underestimate residents’ internal engagement; care practices and evaluations could incorporate multimodal indicators to better understand and support meaningful participation.

Background/Objectives: Dementia-related cognitive impairments and staffing shortages in nursing homes challenge the possibilities for individually tailored recreational activities, raising the question of how the physical and social environment might be leveraged to stimulate engagement through response facilitation, a form of vicarious incentive motivation grounded in Social Cognitive Theory. This study examines in which social contexts observing others’ recreational activities can effectively engage residents with moderate to advanced dementia. Methods: A qualitative, scenario-based multiple case study was conducted in four nursing homes (n = 21), using fly-on-the-wall observations, narratives, and three experimentally embedded social contexts (individual, dyadic, group) around familiar leisure activities. Behavioural engagement, mood, and agitation were assessed with validated observational scales (e.g., OERS and MEDLO), complemented by wearable sensor data (HR/PR, HRV/PRV, SCL, and temperature) and video for contextualised interpretation. Results: Across scenarios, non-participating residents showed limited behavioural responses in individual and dyadic settings, while group activities more frequently elicited both observable engagement and physiological markers consistent with attention or cognitive engagement. Observational and physiological data frequently diverged, which may indicate cognitive or emotional engagement even when overt participation or affect remained minimal or appeared negative. Conclusions: Response facilitation appears most likely in structured group activities if supported by explicit social scaffolding, rather than in individual or dyadic constellations alone. Reliance on behavioural observation or environmental design in isolation risks underestimating engagement; multimodal, context-sensitive approaches are recommended to better harness social mechanisms for meaningful participation in dementia care. Future research should integrate contextual factors with physiological measurements and observations as well as further explore patterns of inactivity to distinguish disengagement from subtle forms of cognitive engagement.