Whall PhD RN Margaret E Black PhD RN Carla J Groh PhD RN Dawn J Yankou PhD RN Barbara J Kupferschmid MSN RN Norman L Foster MD Abstract Introduction Agitated aggressive behavior in late stage dementia occurs in 30 to 50 percent of patients This beha ID: 54798
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TheeffectofnaturalenvironmentsuponagitationandaggressioninlatestagedementiapatientsAnnL.Whall,PhD,RNMargaretE.Black,PhD,RNCarlaJ.Groh,PhD,RNDawnJ.Yankou,PhD,RNBarbaraJ.Kupferschmid,MSN,RNNormanL.Foster,MDAbstractIntroductionAgitatedaggressivebehaviorinlatestagedementiaoccursin30to50percentofpatients.Thisbehavioroftenresultsintheuseofchemicalandphysicalrestraints(whichhaveahighdegreeofuntowardsideeffects)andcaregiverburnout.Interventionsforagitat-edaggressivebehaviorareneededthatdonothavethesesideeffects,whicharereadilyavailableinnursinghomesandareeffectiveandacceptabletocaregivers.Environmentalpsychologistshaveproposedthatnatur-alelementswithintheenvironmentdecreaseagitationinthenondementedaswellasthedementedSincetheshowerbathisoftenatimeofgreatagitationindemen-tiapatients,naturalelementswereusedtomodifycareduringtheshowerbath(n=31).Therewasasignificantdecreaseinmeandifferencescoresfrombaselinetotreatmentsoneandtwo,withthetreatmentgroupdemonstratinganoveralldeclineinagitatedaggressivebehaviorAdditionalrandomizedtrialsoftheeffectsofnaturalenvironmentsuponagitationandaggressionindementiaareneeded.AnnL.Whall,PhD,RN,SchoolofNursing,UniversityofMichigan,AnnArbor,Michigan.MargaretE.Black,PhD,RN,SchoolofNursing,McMasterUniversity,Hamilton,Ontario,Canada.CarlaJ.Groh,PhD,RN,CollegeofHealthProfessions,UniversityofDetroitMercy,Detroit,Michigan.DawnJ.Yankou,PhD,RN,FacultyofHealthSciences,UniversityofWesternOntario,London,Ontario,Canada.BarbaraJ.Kupferschmid,MSN,RN,SchoolofNursing,UniversityofMichigan,AnnArbor,Michigan.NormanL.Foster,MD,SchoolofMedicine,UniversityofMichigan,AnnArbor,Michigan.216Thisstudyexaminedtheeffectofnaturalenviron-mentsuponagitatedandaggressivebehaviorinlatestagedementiapatients.Agitatedaggressivebehaviorinlatestagedementiaisoneofthemostdifficultaspectsofcare.1-3AccordingtotheNationalNursingHomesSurvey,themajority(30-50percent)ofpatientswithAlzheimer'sdiseaseexhibitagitated/aggressivebehav-iorduringlatestagedementia.4Cliniciansinnursinghomesoftenusetwomethodstoaddressagitated/aggressivebehavior-psychotrop-icmedicationsandphysicalrestraints.5Theseinter-ventions,however,areoftenproblematicinthem-selves.6-7Pharmacologicinterventions,forexample,cancausepermanentdamagesuchastardivedyskine-siaandtheneurolepticmalignantsyndrome.Likewise,theuseofphysicalrestraintsreducesquali-tyoflifeandhasledtofallsandotherinjuries.In1987,theNursingHomeReformActplacedrestric-tionsonbothphysicalandchemicalrestraintsfornursinghomeresidents,makingthesearchforothertreatmentsforagitationmorecritical.8Thisstudywasbasedonfindingsfromenvironmen-talpsychology,whichidentifiesthatmodificationsintheenvironmenttoincludemultiplenatureexperiencesmayhaveacalmingandrestorativeeffectuponper-sonswithcompromisedcognitiveabilities.9'10Kaplan,forexample,positsthatremembranceofthingspast(e.g.,animals,plants)whicharelaiddowninearlymemorymayresultinclarityandthuspleasureforthedemented.WhetherthesefindingsarerelatedtothoseonimplicitmemoryinAlzheimer'sdiseaseisasyetunclear.11However,apositivepriorresponseofAmericanJournalofAlzheimer'sDiseaseSeptember/October1997 Alzheimer'sdiseasepatientstoplantsandanimalsmayaccountforaportionoftheincreasedaffectduringthesenaturalexperiences.Thisstudyusedthenaturalelementsofbirdsongs,birdpictures,thesoundofbabblingbrooks,andfoodtoincreasethedementedperson'sexperienceofnaturalelementsduringnursingcare.Itwaspositedthatthisexperiencewouldresultinadecreaseinagitationandaggressionduringcareroutinessuchastheshowerbath.(Theshowerbathhasconsistentlybeenassociatedwithaggressivebehaviorinthedemented)."2Forthoseinsti-tutionalizedinlate-stagedementia,nursinghomesarenotrememberedexperiencesasevidencedbyrepeatedrequeststogohomeortoremovethestrangersfromtheirhome.Naturalelements,however,suchasthesoundsofbirdsandaccompanyingpictures,appeartoberemembered'andmayhearkenbacktoasafermorepleasanttimeintheirlives.NaturalelementsthusmaydrawuponsomeportionortypeofremainingmemoryinlatestageAlzheimer'sdisease.Inthisstudy,theresponseoflatestagedementiapatientstonaturalele-mentsduringacareprocedurewasexamined.UnderstandingoftheextenttowhichpatientswithAlzheimer'sdiseaseandotherpermanentdementiasmightrespondpositivelytoanenvironmentofnaturalelementswasunclear,however,asnursinghomepatientsarerarelyexposedtothesetypesofelements.Thispiloteffortsoughttodetermineifanincreaseinnaturalelementsduringanursingcareprocedure(shower-bath)woulddecreasethefrequencyofagitationandaggressivebehaviorinthesepatients.StudysubjectsFollowingapprovaloftheHumanSubjectsReviewCommittee,patients'relativesweresentlettersrequest-ingparticipationinthestudy.Elevenrelativesoutof79refusedparticipation(14percent)afterthestudywasdescribed;relativesrefusingparticipationweresupport-iveofthestudy,butmostfelttheirrelatives"hadbeenthroughenough."Uponwrittenapprovaloftherelative,patientswereexplainedthestudyinsimpleterms.Threeoutof35patientsrefusedassent(.08percent)afterrela-tive'sapprovalwasgrantedandalthoughitwasnotcer-tainthattheir"no,no,no"wasrelatedtothestudy,theirseemingdecisionwasrespected.Ofthethirty-onepatientswhoconstitutedthenon-probabilitysample,15wereinthenaturalexperiencegroupand16intheusualcaregroup.Allbutfourpatientswerewomen,andallwerediagnosedwithlate-stageAlzheimer'sdisease(AD)orADwithmulti-infarctdementia.Afterpermissionwasgiven,subjecteligibilitywasdeterminedusingthefollowingcriteria:AmericanJournalofAlzheimer'sDiseaseSeptember/October1997*AllhadarecentlyreconfirmeddiagnosesofADoramixtureofADwithmulti-infarctdementia;*SubjectsymptomswerecongruentwiththatofADormultiinfarctdementiaasfoundintheDiagnosticandStatisticalManualoftheAmericanPsychiatricAssociation(4thedition);*Agitatedaggressivebehaviorsuchashitting,kick-ingandbitingwasdisplayedbythesubjectsduringtheshower-bathatleasthalfthetime;*SubjectshadscoresoffiveorlessontheMiniMentalStatusExam;*Noneofthesubjectshadanacutehealthcondition;and*Duringtheconsecutivethreeshower-bathsthatwereobservedthefacilityagreedtomaintainanypsychotropicdrugsataconstantlevel.Inthataggressivebehaviorcontinuedinthesepatients,thepsychotropicdrugswerenothavinganobservableeffectuponthisbehavior.Allpatientsmeet-ingthestudyandhumansubjectscriteriawereacceptedintothestudy.Thesettingwasfivenursinghomesfromamongagroupof17fromwithinonenursinghomecorporation;allthehomeswerelocatedinasimilarworking-classareaofalargeUSMidwesterncityandallcareandtrainingprocedureswereuniformthroughoutthe17homes.ThemostfrequentformofpaymentforcarewasMedicaid.Inaddition,thenursinghomecorporationhadastablestaffwithseveralnurseaideswhohadbeenemployedforoveroneyear.Thislatterfeature(intheviewofthenursinghomeadministration)wasrelatedtoaideagreementtocooperatewithprojectssuchasresearch.Twooutofthefivehomesservedastreatmenthomesandthethreeoth-ersascomparisonhomes.Allfivehomeshadsimilarageandracialcharacteristicsofaidesandpatients.Nurseaidesateachhomewereselectedfromapoolofthosewhomettheaidecriteria:employmentforoveroneyearwithinthehomes,willingnesstogivethreeconsecutivemorningshower-bathstothesamepatients,andwillingnesstobeobservedalongwiththepatientsduringtheirshoweringofthesepatients.Themajorityofthenurseaideswhohadthestudyexplainedtothemagreedtoparticipate(15outof20),andthosewhorefusedmostoftenstatedtheywouldliketoparticipate,buthadschedulingorothersimilarproblems.Nurseaidesinboththetreatmentandcomparisonhomeshadreceivedtheroutinetrainingofthenursinghomecorpo-rationinshowercare;thistrainingconformedtothatrequiredbyfederalandstatelicensingagencies.Forthetreatmentgroup,theaidesgavetheusualcare217 atonebaselineshower-bathbeforetheyweretrainedinthenaturaltreatment.Thetreatmentgroupaides(n=10)werethentaughtinthreesessions(atotalofapproxi-matelyonehour)togivetheshowerwhileusingnaturalelements.Afterthebaseline,attwosubsequentbathsoneweekapart,treatmentgroupaidesgavethenaturaltreatmenttothesepatientsduringtheshowerbath.Theaideswereheldconstant(sameaidegavebathtosamepatient)acrossbothgroups.Thenumberofpatientseachaideworkedwithrangedfromonetoseven.Allaideswereblindtostudyhypotheses.Patientbehaviorduringallbathswasratedbyresearchassistantsexpertinratingagitationandaggres-sionusingtheCohen-MansfieldAgitationInventory(CMAI);theCMAIhasasubsetofaggressivequestionswithinthe29-iteminstrument.TheCMAIwasoriginal-lyconstructedfromclinicalobservationsofdementedpatientsbynurseswhocompletedtheCMAIfromret-rospectiverecallofacareevent.13'14Inthisinitialformataninter-raterreliabilityof.88wasreported.AlaterstudyusingtheretrospectiveformatCMAIwith408nursinghomeresidentsconfirmedinter-raterreliabili-tiesof.92,.92,.88,amongthreesetsofraters.13TheCohen-MansfieldAgitationInventorywasmod-ifiedbyWhall'5forusageasadirectobservationaltooltobeusedduringdistinctcareproceduressuchastheshower-bath.Theitemsremainedconstant,onlythefor-matwaschanged.Theinterraterreliabilityofthisnewformrangedfrom.72to.81inthethreeobservations.Theagreementofthismodifiedformwas.80withtheWardBehaviorInventory,anolder,moreestablishedinstrument.ThemodifiedformoftheCMAIwasusedinthisstudy.TreatmentThecomparisongroupreceivedtheusualcaredur-ingthethreeobservationswithexpertRAsratingpatientbehaviorusingtheCMAI.Thetreatmentgroupafterthebaseline,however,werebathedinashowerroomthatfeaturedrecordedsongsofbirds,soundsofbabblingbrooks,andthesoundsofothersmallanimalssuchasducks,kittens,chickens.Inaddition,largebrightpictures(capableofbeingseenbypersonswithpresbyopia,butnotwearingglasses)werecoordinatedwiththeaudiotapes.Athirdelementintheenviron-mentthatcontinuedthenaturalthemewastheofferingoffoodssuchasbananapuddingand/orsoda.Pre-interviewsofthenursinghomedieticianandstaffwereusedtoidentifypatientfoodpreferencescompatiblewithpatientdietaryrestrictions.Patientsinbothgroupsweregiventheusualshoweratbaselineorthefirstoccasion.TheirbehaviorwasrecordedbytheexpertRAsusingtheCMAI.Theaides,whowereassignedtousethenaturaltreatmentonthesecondandthirdoccasions,weretrainedtoaskthepatient,"Doyouhearabird?Whatkindofbirdisit?"Theaidewouldthenrefertoapictureofthebird,andsay,forexample,"Ithinkit'saduck.Canyouseetheduck?"Ifthepatientrespondedtothenaturalelement,thediscussioncontinuedofthatparticularnaturalele-mentuntilpatientattentionappearedtowane.Atthatpoint,anotherpictureorfoodwouldbeoffered."Hereissomebananapudding,"theaidewouldsayandasmallamountofpuddingwasplaceduponthelipofthepatientasthediscussionofthepuddingensued.Ifthepatientenjoyedthefood,morewouldbeofferedanddiscussionofthenaturalsightsandsoundsalsocontin-ued.Thetreatmentaidewastrainednottodiscussothertopicsotherthanthenaturalsights,soundsorfood.Inthisway,carewasfocuseduponnaturalelementswithintheenvironment(e.g.,birdsounds,pictures,andfoods)andnotupontheshowerprocedureitselforupontheagitatedaggressivebehaviorofthepatient.Besidesthequantificationofagitated,aggressivebehavior,datawerealsocollectedforvignettecasestudiesconcerningtheaffectofpatients.ResuItsThemeanlengthoftheshowerbathinbothgroupswassevento10minutes.Inordertodeterminewhetherthenaturalelementapproachdecreasedagitatedandaggressivebehaviorinthetreatmentgroup,threescoreswerecomparedontheCMAI,atthebaselinetotimeone(T1),atbaselinetotimetwo(T2),andfromTItoT2.T-testsforindependentsamplesconductedusedmeandif-ferencescores,comparedtreatmentandcontrolgroupsatthethreetimeperiods.Theresultssupportasignifi-cantdeclineinagitatedbehaviorfrombaselinetoTIandT2;agitationdecreasedsignificantlyinthetreat-mentgroupascomparedtothecomparisongroup.TherewasnotasignificantdifferencebetweenTIandT2astreatmentcontinued(seetable1).218AmericanJournalofAlzheimer'sDiseaseSeptember/October1997Table1.T-testsofmeandifferencescoresonagitationbetweentreatmentandcom-parisongroupMeanbaselinetoTI,-5.08;SD2.12;t=2.40,pMeanbaselinetoT2,-6.73;SD2.15;t=3.13,pMeanTItoT2,-1.98;SD1.55;t=-1.27,p ThesevenitemsontheCMAIthataddressedspecificaggressionsuchashittingalsowereexaminedseparatelyfromthetotalagitationscore.ThemeandifferencescoresontheseitemsalonewasbaselinetoTI,t=-.64,p=.53;baselinetoT2,t=-1.47,p.19.Thusphysicalaggres-sionasaseparateentityfromagitationdecreasedovertimeinthetreatmentgroup,butthedecreasedidnotreachsignificance.ItisthoughtthattheaggressionitemsontheCMAIaretoofewinnumbertocomplete-lycaptureaggressivebehaviorasseparatefromoverallagitation;infuturestudiestheRydenAggressionScale'6willbeusedalongwiththeCMAI.'5Inordertoassesswhetherthetworesearchassistants'observationswereconfoundedbyasystematicbias,acovariateanalysisoftheRAs'ratingswerealsomade.ItwasfoundthattheidentityoftheRAdoingtheratingdidnotcontributesignificantlytothechangeinscores,thusindicatingthattherewerenosystematicdifferencebetweentheRAraters.CasestudyreportsCasestudiesdescribetheaffectiveresponseofpatientstothenaturalenvironments.(Characteristicshavebeenchangedtoprotectidentities).Marthawasan80-year-oldlate-stageADpatientwhoseMMSEwaslessthanfiveonmultipleoccasions.Sheconsistentlydemonstratedagitatedandaggressivebehaviorduringtheshower-bath.ThecaregiversusingnaturalelementsmetMarthaatthebedsideandwithoutdiscussingtheshoweraskedherifshewouldlikebananapudding.Sheacceptedtheofferandshewastoldmorefoodwasavailabledownthehall.Attheshowerroomentrance,Marthabeganhangingontothedoorframetostopentry.Webeganthebirdsoundsandpic-turesandMarthabeganlookingaroundandallowedherwheelchairtoentertheshowerroom.Marthaacceptedmorefoodatthispointandwhenshewasaskedques-tionsaboutthebirdsongsandpictures,shetriedtospeak.Marthaallowedtheentireshowertobecomplet-edwithoutherusualscreaming/hitting/biting.Theshoweraidefoundherbehaviorverydifferentfromthatusuallydisplayed.DuringthefirsttreatmentMartha'saffectwentfromangrytoneutral,andthensheattempt-edsmiling.Atthelasttreatment,Marthatriedtospeakthebirdnamesandsmiledintermittently.Lucywasinherlate80s,alsodiagnosedwithAlzheimer'sdisease.Sheusedlanguageinfrequentlyanddisplayedagitationandaggression(hitting)whenherclothingwasremovedforbathingpurposes.HerMiniMentalStatusExamwasalsolessthanfiveonalloccasions.Thebirdcallsandsongswereplayedassheenteredtheshowerroomandshebegantobeundressed.Lucytriedtospeakwhenshewasasked,"Doyouhearabird?"Duringtheremainderoftheshower,shedis-playednoagitationoraggression.Duringthesecondnaturaltreatment,Lucylookedaroundandsmiledasshewaswheeledintotheshowerroomandforthefirsttimeinmanydaysshetriedtospeak.Shesmiledandsaidthewordbirdandlaterduckwhensheheardthebirdsoundsandsawthepictures.Whenanaideaskedherifshehadevercookedaduck,shesaidfat.Theaidesenjoyedhercommentastheylatersharedthatwhenonecooksaduck,muchfatisproduced.Lucydidnotdisplayagitat-edaggressivebehaviorthroughoutthesecondshowerandheraffectnoticeablyimproved.DiscussionTheuseofnaturalelementswithintheenvironment,suchasbirdcallsandpicturesinconjunctionwithothernaturalelementssuchasfood,wasassociatedwithdecreasedpatientagitationandaggressionandamorepositiveaffectiveresponse.Useofnaturalelementsdur-ingtheshowerbathtookanaveragetwominuteslongerthanusualcare,primarilybecauseofthefoodthatwasoffered.However,thistreatmentdoesnotappearcostlyassuchresourcesarereadilyavailableinmostnursinghomes.InadditiontheaidesinthetreatmentgroupenjoyedthenaturalexperienceandtheiraffectalsobecamemorepositiveintheopinionofthestudyRAs.Limitationsconcernthenon-randomizednatureofthestudyandresultantgeneralizabilityissues.Whethernaturalelementswillmakeasignificantdifferenceinagitation,aggression,andpatientaffectinrandomizedtrialsisyettobeaddressed,althoughcasestudyresultsaresupportiveofstudyfindings.Theuseofnaturalenvironmentstocombatagitationandaggressioninlatestagedementiapatientsduringcareroutinesisviewed,however,asapromisingapproachandonethatwarrantsfurthercontrolledinvestigations.AcknowledgmentFundingforthisprojectwasprovidedbytheNationalInstituteofNursingResearch,F33NR06911-01;TheUniversityofMichiganOfficeofVicePresidentforResearch;andtheNationalInstitutesofHealth,P50-AG0871(MADRC).References1.WhallA,GillisG,YankouD,BoothD,Beel-BatesC:Disruptivebehaviorinelderlynursinghomeresidents.JournalofGerontologicalNursing.1992;18(10):13-17.2.ZimmerJ,WatsonN,TreatA:Behavioralproblemsamongpatientsinskillednursingfacilities.AmericanJournalofPublicHealth.1984;74(10):1118-21.3.BurgioL,JonesL,ButlerF,Engle:Behaviorproblemsinanurbannursinghome.JournalofGerontologicalNursing.1988;14(1):31-34.AmericanJournalofAlzheimer'sDisease219September/October1997 4.NationalCenterforHealthStatistics(1989).Thenationalnursinghomesurvey,Series13,#97.Hyattsville,MD:DDHS,USPHS,#89-1758.5.NationalCitizensCoalitionforNursingHomeReform(1989).Untietheelderly:Symposiumco-sponsoredbytheUSSenateSpecialCommitteeonAging&KendallCorp.SilverSpring,MD:ManorHealthcareCorp.6.HelmsP:Efficacyofantipsychoticsinthetreatmentofthebehav-ioralcomplicationsofdementia.JournaloftheAmericanGeriatricsSociety.1985;137:1163-72.7.StumpfN,EvansL:Physicalrestraintofthehospitalizedelderly.NursingResearch.1988;37(3):132-37.8.USCongress(1987).NursingHomeReformAct.SubtitleC,OmnibusAct,PublicLaw100-203.9.KaplanR,KaplanS:Theexperienceofnature:Apsychologicalperspective.Cambridge:CambridgeUniversityPress,1989.10.KaplanS,KaplanR:Humanscape:Environmentsforpeople.AnnArbor,MI:Ulrichs,1982.22011.RandolphC,TierneyM,ChaseT:ImplicitmemoryinAlzheimer'sdisease.JournalofClinicalandExperimentalNeuropsychology.1995;17(3):343-51.12.SloaneP,RaderJ,BarrickA,HoefferB,DwyerS,McKenzieD,LavelleM,BuckwalterK,ArringtonL,PruittT:Bathingpersonswithdementia.TheGerontologist.1995;35(5):672-678.13.Cohen-MansfieldJ,MarxMS,RosenthalAS:Adescriptionofagitationinanursinghome.JournalofGerontology.1989;44(3):M77-84.14.Cohen-MansfieldJ,BilligN:Agitatedbehaviorsintheelderly.JournaloftheAmericanGeriatricsSociety.1986;34:711-721.15.ChrismanM,TabarD,WhallA,BoothD:Agitatedbehaviorincognitivelyimpairedelderly.JournalofGerontologicalNursing.1991;17(12):9-13.16.RydenM:Aggressivebehaviorinpersonswithdementiawholiveinthecommunity.Alzheimer'sDiseaseandRelatedDisorders.1988;2(4):342-355.AmericanJournalofAlzheimer'sDiseaseSeptember/October1997CallforlettersLetterstotheEditorwillbeconsideredforpublicationonmattersofcontentandlength.LettersregardingarticlespublishedinAmericanJournalofAlzheimersDiseaseorrelatedmattersarewelcome.Forbestconsideration,letterspertainingtoaspecificissueshouldbereceivedassoonafterpublica-tionaspossible.Alllettersshouldbetypewrittenanddouble-spaced;referencesshouldbelimitedtofivewhenpossible.Pleaseincludeyourfullname,position,andaddress.Mailcorrespondencetothefollowingaddress:LetterstotheEditorAmericanJournalofAlzheimersDisease470BostonPostRoadWeston,MA02193Fax:781-899-4900E-mail:alzheimersgpnpco.comWebsite:www.alzheimersjoumal.com