simulated presence therapy: using selected memories to manage problem behaviors in alzheimer's...

Simulated Presence Therapy: Using Selected Memories To Manage Problem Behaviors Q �9 �9

In Alzhe lmer ' s Disease Patients

B y P A T R I C I A W O O D S / J A N E A S H L E Y

he incidence of behavior problems among patients with cognitive impairment, including those with dementia of the Alzheimer's type (DAT), is re-

markably and consistently high. Zimmer et alJ surveyed more than 1000 patients in 42 skilled nursing facilities and reported that 64% of the patients demonstrated significant behavior problems. Others have found similarly high or even higher percentages of behavioral problems among patients with dementia. Ryden 2 studied aggressive behavior among cognitively impaired patients in nursing homes and found some form of aggression present in 66% of the patients sampled. Cohen-Mansfield et al. 3 reported that 93% of 408 demented nursing home residents observed exhibited at least one episode of agitation per week.

Caregivers, whether they are family members or nursing staff, must deal with a number of disruptive behaviors on a daily basis. Problem behaviors present a difficult challenge to caregivers, and the successful management of such behaviors is important to the well-being of the elder, of family members, and of the nursing staff.

PATRICIA WOODS RN, MSN, is a clinical specialist at the V.A. Medical Center in West Roxbury, Massachusetts, and JANE ASH- LEY RN, PhD, is an associate professor at Boston College, in Chestnut Hill, Massachusetts. GER]ATR NURS 1995;16:9-14. Copyright �9 1995 by Mosby-Year Book, Inc. 0197-4572/95/$3.00 + 0 34/1/51628

Current trends in patient care strongly suggest moving away from the use of medications and restraints as treatment for behavior problems. Although the regulations of the Omnibus Budget Reconciliation Act have motivated nursing homes to implement physical and chemical re- straint-reduction programs, the guidelines do not address ways to manage behavior problems in nursing homes with already limited resources. Programs have focused on behavioral approaches to treat excess disabilities, 4 on staff education, 57 and on alternative strategies to restraints. 8, 9

Success{u/management o{ such

behaviors is important to the

well-being o{ the eider, o{ [amily

members1 and o{ the nursing stall. Management of nursing home residents with undesir-

able behaviors often takes the form of simple reassurance from staff. But personal attention and conversation is not consistently effective in reducing disruptive behaviors. Cariaga et al. 1~ found that only 52% of vocally disruptive residents responded to increased attention provided by the nursing staff.

One area for intervention that has received little attention is the potential influence family members may have

GERIATRIC NURSING Volume 16, Number 1 Woods and Ashley 9

TABLE 1. RESPONSE TO SPT BY CATEGORIES OF BEHAVIOR (N = 27)

Behavior type

No. of No. of Percent of residents residents residents

displaying posi t ive improved behavior response with SPT

Social Isolation 25 21 84 Agitation 18 14 78 Aggressive 2 1 50

on patients' behaviors. Molonebeach and ZariU ~ studied the behavior pattern of a patient with DAT over 24 con- secutive hours and found that reminiscence by a special family member was the only intervention that effectively calmed the severe agitation of their subject. The findings suggests that appropriate reminiscences given by an individual with a special relationship to the person may provide a calming effect.

Intervention

The intervention used in this study, simulated presence therapy (SPT), is based on the belief that the primary and most central source of stability for the patient with DAT is often an established caregiver, typically a family member. The presence of this caregiver may provide dra- matic comfort. The development of SPT was based on the hypothesis that it may be possible to replicate a caregiver's "presence" in such a manner as to bring comfort to the patient. SPT is a personalized audiotape composed of a family member's side of a telephone conversation and soundless spaces that correspond to the patient's side of the conversation. On the SPT audiotape, a caregiver "converses" about cherished memories, loved ones, family anecdotes, and other best loved experiences of the patient's life. SPT may create an environment of comfort for the patient because it introduces the people closest to the patient and is animated by selected memories of the best loved experiences of the patient's life, which may remain stored in the patient's remote memory.

The SPT audio-tape is applied using headphones and a lightweight auto-reverse cassette player inserted into a hip pack. Headphones are used to exclude ambient noise, and the hip pack maximizes patient mobility and safety during use of SPT. (SPT is a patented product of SIM- PRES Incorporated, Boston, Mass.) The SPT telephonic audiotape recording module allows one to make an audiotape of the caller's side of the conversation while si- multaneously recording both sides of the conversation between the caller and the elder.

SPT seeks to provide comfort to patients by altering their environment. The goal of SPT is to create an environment for the patient that includes the people and experiences best loved by the patient over the course of a lifetime. It is hypothesized that such an environment could decrease maladaptive behaviors.

Feasibility Study

Method. Two studies were conducted to provide preliminary data on the effectiveness of SPT in reducing problem behaviors. The purpose of the feasibility study was to determine what impact, if any, SPT intervention had on patients with DAT who manifested problem behaviors. Further, the feasibility study was used to identify criteria for the selection of patients who might benefit from this intervention and to establish protocols for application of the SPT.

Sample. The sample consisted of 27 cognitively impaired residents from four different nursing homes. Res- idents were selected for the study if they demonstrated a problem behavior as identified by the nursing staff and if they had a family member who was willing to participate in the study. Subjects were provided with explanations of the study; informed consent for residents' participation in the study was obtained from family members and legal guardians of the residents.

Of the 27 subjects selected to receive SPT, 24 were women. Age of the participants ranged from 76 years to 94 years. Administration of the Global Deterioration Scale revealed moderate to moderately severe cognitive impairment (a score of 4 or 5) for all subjects. 12

Procedure. Personalized SPT audiotapes were made for each subject according to a protocol that addressed two key components: audiotape content and characteris- tics of the tapemaker, or "caller."

Selection of audiotape content was based on identify- ing subject areas that were of interest to the patient. First, an asset inventory was completed by the subject's family member that identified the patient's most cherished memories and lifetime experiences. The family member was instructed to focus on remote memories that might be special to the patient (e.g., recalling childhood experiences). Areas of assessment include such things as best loved people, important life events, family anecdotes, favorite prayers, poems, hobbies, interests. The asset inventory was then reviewed with a family member by SPT staff to learn more about what the patient enjoys talking about during "live" visits and how the patient responds.

These topics were then presented to the subject and evaluated using the SPT Telephonic Recording Module, which records both sides of the conversation. A detailed editing step was essential to achieve a quality audiotape. Topics that had a positive effect were separated from those that elicited a negative or neutral effect. A "script" was developed for the telephone conversation. Specific guidelines included focusing on two or three themes re- peated in various ways, communicating phrases of affec- tion, and conveying a positive emotion through nuances of voice as well as content.

The tapemaker, who is usually a family member, is an important stimulus in presenting memories to the patient and requires careful selection that is accomplished through a series of steps. In these studies, all SPT audiotapes were made by a trained SPT communications ex- pert.

Each SPT tape is approximately l 5 minutes long. Au- diotapes were initially pretested with subjects to gauge

10 Woods and Ashley January/February 1995 GERIATRIC NURSING

their likely acceptance of SPT, as well as their acceptance of the audiocassette player and headphones.

Approximately three meetings were held with nursing staff for the purposes of information, planning, and training. Resident care conferences were held to develop an individualized plan regarding the application of SPT for each subject. SPT tapes were played for residents when they displayed a problem behavior identified in the care plan. Nursing staff recorded residents' responses to SPT in one of three categories: the problem behavior improved (i.e., the problem behavior either lessened or stopped); the problem behavior was unchanged; or the problem behavior worsened. Nurses' evaluations were impressionis- tic based on their observations of the resident before and during use of SPT. Researchers made weekly follow-up visits during the 1-month SPT trial.

Results. Three major types of problem behaviors were identified by the nursing staff: social isolation, agitation, and verbal or physical aggression. Social isolation included behavioral manifestations such as a blank facial expression and failure to engage in conversation and ac- tivities. It was the most common problem reported in the sample, with approximately 93% of subjects displaying signs of social isolation. Agitation, which included rest- less and pacing behaviors, was the second most common problem among the sample. It was identified in 67% of residents. Only 7% of the sample displayed aggressive behaviors, and none exhibited wandering behavior. The ma- jority of the sample (88%) displayed more than one type of problem behavior.

$PT appears most effective in

treating social isolation.

Problem behaviors improved with

SPT 91% of the time. Of the 27 subjects, 22 (81.5%) showed positive re-

sponses to SPT. A total of 20 subjects (74%) showed positive responses to the use of SPT regardless of the behavior problem being treated. Two subjects (7%) responded positively to SPT for the problem of social isolation but not for the problem of agitation. Only five subjects (18%) did not show any positive response to SPT.

There was a differential response to SPT associated with the type of behavior exhibited by the participants. Table 1 displays the SPT response rate broken down according to types of problem behaviors. Among the types of behavior problems noted, SPT appears to be most effective in treating social isolation (84% response). Im- provement in social isolation was evidenced by behavioral changes, including appropriate verbal response to the content of the audiotape, smiling, singing, and absence or reduction of purposeless body movements. Approxi- mately 78% of subjects with signs of agitation demonstrated improvement in the behavior manifestation of this problem with the use of SPT. Aggressive behavior was identified for only two residents in the sample. The effects

of SPT on these residents were equivocal: One resident with aggressive behavior became noticeably more calm with the application of SPT, but the behavior of the other resident did not improve.

In cases where subjects did not respond favorably to SPT (4 cases for the problem of social isolation, 4 cases for the problem of anxiety/agitation, and 1 case for the problem of aggression), subjects' behavior generally remained unchanged, rather than worsening. Only one par- ticipant was noted to have worse behavior, increased agitation, with SPT. This resident promptly returned to baseline with the removal of the audiotape. The results of this preliminary investigation were viewed as sufficiently promising to justify a more controlled pilot study.

Pilot Study

Method. A pretest-posttest quasi-experimental design was used to examine the effect of planned use of the SPT intervention on target behaviors among patients with DAT. Nine residents, from two units in a 120-bed nursing home, participated in the pilot study. Criteria for subject selection were derived from researchers' experience with the feasibility study. Subjects were selected for the study if they: (1) were diagnosed with dementia of the Alzheimer's type, (2) exhibited one or more problem behaviors as identified by the nursing home staff and confirmed by the researchers, (3) retained the capacity for verbal interaction, and (4) had a family member who was willing to participate in the project. Each subject was required to exhibit a recurring problem behavior that the nursing staff desired to minimize or eliminate. In this study the recurring behavior was termed a target behavior.

Of the nine participants, seven were women. Age of the subjects ranged from 71 years to 97 years, with a mean age of 82 years. Participants had resided in the nursing home from 2 months to 37 months, with an average length of residency of 21 months. All subjects were considered to have moderate cognitive impairment, as evidenced by scores of 4on the Global Deterioration Scale. Controlling for cognitive impairment was important because some studies report significant associations between level of cognitive impairment and frequency of certain behavior problems. 13-15 Informed consent was obtained as described in the feasibility study.

Procedure. SPT audiotapes were made for each resident using the protocol from the feasibility study. A target behavior and the time when the behavior was likely to occur were identified for each subject on the basis of chart review, discussion with the nursing staff, and observation of the subject. Each resident was scheduled to receive SPT twice a day, once in the morning and once in the afternoon or early evening. The exact time of SPT application varied with each subject according to the time when behavior problems were anticipated.

Nursing home staff documented a description of the resident's behavior before the application of SPT and again at the conclusion of SPT intervention. Observation of the subjects' behaviors before and after SPT were made on a standard target behavior form already in use


TABLE 2. TYPES AND FREQUENCIES OF BEHAVIOR (N = 9)

No. of clients

Observed exhibiting behavior Frequency Mean SD behavior

Physical 1 1.0 0.0 1 aggression

Verbal 142 35.5 20.4 4 aggression

Agitation 114 19.0 13.9 6 Social 168 21.0 15.0 8

isolation Total 425 47.2

TABLE 3. PAIRED T-TEST: BEHAVIOR BEFORE AND AFTER SPT (AVERAGE SCORES FOR 7

ADMINISTRATIONS)

Signif- Mean SD t-value df icance

Disruptive behavior (n = 8) Behavior 1.75 .46

before SPT Behavior 4.41 .95 -9.11 7 .001

after SPT Social isolation (n = 8)

Behavior 1.87 .35 before SPT

Behavior 3.89 .30 - 11.47 7 .001 after SPT

on the units. The target behavior form is used to document the outcomes of interventions used in managing difficult problem behaviors as part of a quality assurance program. The target behavior form provides space for caregivers to document the observed behavior (before intervention), the precipitating factors of the behavior, the intervention applied, and an observation of behavior following the intervention. Training sessions were conducted with all nursing home staff to familiarize them with SPT implementation guidelines, as well as with the documen- tation procedures.

To perform statistical testing, a content analysis of data from the target behavior forms was conducted. The Disruptive Behavior Rating Scale was used to classify problem behaviors into five categories: physical aggression, verbal aggression, agitation, wandering, and social isolation. 16 The scale was selected because the manual includes highly specific definitions for the different types of behavior problems. Once behaviors were classified, pretest and posttest scores were derived. Two rating scales were used, one for the severity of behaviors considered disruptive (e.g., aggression, agitation, and wandering) and one for the severity of behaviors of affect (e.g., social isolation). Scores on the disruptive scale ranged from "1," meaning "behavior problem evident with severe symptoms," to "5," meaning "behavior problem resolved, and subject displays signs of positive affect." Scores on the affect scale ranged from "1," signifying "extremely withdrawn, no responsive behavior," to "4," signifying "demonstrates clear signs of positive affect (i.e., engaging in conversation, smiling, and singing)."

Results

Over the course of the 2-month observation period, a total of 425 episodes of problem behaviors were documented. The problem behavior manifested most frequently and by the most number of residents (n = 8) was social isolation. This behavior accounted for 39% of the 425 observations. Verbal aggressiveness represented 33% of problem behaviors, although only four residents exhibited such behavior. Agitation, as defined by restlessness

and pacing, was noted in six subjects and accounted for 27% of observations. Physical aggression was extremely rare in this sample. Only one resident demonstrated physical aggression, and this behavior occurred only once during the observation period. No patients had problems with wandering.

As expected, all residents in the sample displayed at least one type of problem behavior and most subjects exhibited several types. An average of 47 episodes of problem behavior per resident were observed, with a range of 25 to 68 episodes per person. Table 2 shows the frequencies and means for various types of problem behaviors. Means were calculated on the number of residents displaying each specific type of behavior, rather than on the total sample. This was done to improve the adequacy of the mean as a summary statistic for problem behavior.

Antecedents of problem behavior were examined and revealed that in 44% of the 425 observations, events pre- ceding behavior problems were either unknown or were idiosyncratic to subjects. The most frequently identified precipitants of problem behaviors were leaving a subject alone in a room (26% of the observations), initiating morning care (23% of observations), and, to a lesser extent, the presence of noise (3%).

Problem behaviors improved with SPT 91% of the time (388 of the 425 observations). In 7% of the observations, behaviors either remained unchanged or worsened with the audiotape. SPT intervention was refused 2% of the time. All nine residents exhibited positive responses to SPT for at least some of their episodes of problem behavior. Individual response rates to SPT varied from 100% (i.e., every episode of problem behavior improved with SPT) to 68%. Only small differences separated the type of behavior problem manifested and its correspond- ing response rate to SPT. The single episode of physical aggression responded positively to SPT. Verbal aggression responded 91% of the time, agitation responded 96% of the time, and social isolation responded 89% of the time.

Table 3 displays the results of paired t-tests. Only eight subjects were included in each analyses because one subject experienced problems with disruptive behaviors only


and did not receive SPT for social isolation. A second par- ticipant exhibited problems with social isolation only and did not receive SPT for disruption.

The results show that residents' behavior was signifi- cantly improved following the use of SPT. Further, SPT was equally effective for improving behaviors among residents who displayed disruptive behavior and among those who displayed signs of isolation.

Of the 36 subjects in the combined feasibility and pilot studies, 31 (86%) experienced improvement in their behavior most of the time when SPT was applied. Not only did participants show improvement with use of SPT, but also nurses reported that usual interventions such as dis- traction, reassurance, or medications appeared to be less effective than SPT intervention. The nursing staff also felt that SPT audiotapes seemed to offer a period of enjoyment to residents, particularly to those residents who were withdrawn, that is not duplicated with other interventions. Behavioral cues of enjoyment included such things as conversing, smiling, laughing, and singing.

Evaluation meetings held with nursing staff and family members at the conclusion of the studies provided further evidence of the effectiveness of SPT. In one case, a resident who had required 18 doses of buspirone hydrochlo- ride (BuSpar) in the 2 months before initiation of SPT, received only two doses during the 2 months of SPT intervention. A second resident required haloperidol (Hal- dol) every night for episodes of screaming. When an SPT audiotape was used for 1 hour every evening, the need for calming medications was eliminated.

The nurse managers and nursing directors in the nursing homes believed the use of SPT--especially in residents who were the most disruptive--reduced stress and burden among the nursing staff. One administrator re- ferred to the positive effect of SPT as providing a "re- spite" to the staff from the continual need to intervene for problem behaviors.

The acceptance of SPT has been high among those patients who have a verbal interactive capacity. Residents accepted the audiotapes repeatedly and often for extended periods. Six of the participants who responded well initially to SPT have continued with the therapy up to 9 months with continued positive results. In four cases, SPT tapes have been used daily for over 2 years.

Family members were particularly pleased that SPT intervention was personalized to their loved one. Each of the families had an opportunity to view their loved one's response to the SPT audiotapes. All of the families indi- cated that residents' responses to SPT were comparable to those of live visits, and in some cases residents' responses were even more animated. Some family members expressed relief in knowing the tape was used. In one ex- ample, family on extended travel requested that the nursing staff use the SPT tape routinely while they were away. In another case, a daughter expressed relief that the SPT audiotape had a calming effect on her mother who was constantly swearing and making derogatory re- marks to the nursing home staff. All families expressed a desire to continue the regular use of SPT audiotapes once the studies had ended.

Discussion

Interpretation of the studies is limited by the small sample sizes, lack of adequate controls, and the anecdotal nature of data collection. Further, the unblinded basis of observations could bias results in favor of positive results. Although the results of the studies must be considered preliminary, they are encouraging.

SPT shows some success in interrupting problem behaviors among patients with DAT. In addition, SPT appears to exert a positive benefit on patients' affect. There are several possible explanations for the apparent effectiveness of SPT. First, the SPT audiotape is personalized. Individualizing care is a primary goal of nursing intervention, and it is an approach that is likely to generate positive outcomes. 17"19 In one study that examined t h e communication patterns of caregivers and cognitively impaired elders, researchers found that, despite the dementing process, elders displayed individuality and expressed a desire to remain connected with others. 19 The researchers suggest caregivers recognize and respond to the elders' need for individuality. The need for individualized intervention may be particularly important to patients with DAT because the development and progression of the disease is often described as being idiosyncratic. 2~

SPT may be used repeatedly

because the deficit in recent

memory associated with DA T may

allow the audiotape to be

perceived as a new experience

each time. SPT uses selected memories to create an environment

of comfort for the patient with DAT. The use of memory and reminiscence as a nursing intervention has been used successfully with elderly persons to evoke pleasure and to achieve therapeutic goals. 21 SPT builds on the strengths of cognitively impaired elders because it relies on their remote memory, which is more likely to be retained than is their recent memory. It appears that SPT produces an op- timal type of environment for cognitively impaired elders. The selected memories of SPT seem to provide enough stimulation to evoke the elder's interest, involvement, and pleasure. Yet, the lack of a negative response to SPT suggests that the audiotape does not overstimulate the lis- tener. Interestingly, SPT may be used repeatedly because the deficit in recent memory associated with DAT may allow the audiotape to be perceived by the elder as a new experience each time.

SPT intervention may also be effective because it draws on--and perhaps enhances--the bonds between cognitively impaired elders and their loved ones. With SPT intervention, family members contribute to the care


of the elder by helping to identify treasured memories and by making the personalized audiotape. It is important to recognize the strong bond that often exists between the elder and family caregivers. 22, 23 York and Cal- syn 24 interviewed families of nursing home residents with DAT and found that families expressed a strong desire to become more involved in their relative's care and to become more knowledgeable about how to make their visits more enjoyable. There is evidence that family involvement in the care of nursing home residents is beneficial to the patient, as well as to the family and to the nursing staff. 25

Elders--particularly those who suffer dementia--need the positive contact that arises from social interactions with family and with caregivers. SPT may be an effective adjunct to these relationships. SPT may help soothe a resident's distress and provide positive social stimulation when family and caregivers are unavailable.

Simulated presence therapy requires a thorough investigation to determine the sustained effectiveness of this intervention in managing problem behaviors in nursing home residents with dementing disorders. Moreover, it is important to examine the implications of SPT for the family and the caregiver. Managing behavioral problems is one of the most difficult tasks for families and caregivers. It is important that nonpharmacologic approaches to behavior problems be developed and tested. SPT shows promise as such an intervention. �9

We thank the staff and families at the Newton and Wellesley Alzhe- imer Center, Resthaven Nursing Home, St. Teresa's Manor, and Villa Crest Retirement Community for their support of this project.

REFERENCES

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2. Ryden MB. Aggressive behavior in persons with dementia who live in the community. Alzheimer Dis Assoc Disord 1988;2:342-55.

3. Cohen-Mansfield J, Werner P, Marx M. Screaming in nursing home residents. J Am Geriatr Soc 1990;38:785-92.

4. Rabins PV. Behavior problems in the demented. In: Light E, Lebowitz BD, eds. Alzheimer's disease treatment and family stress: directions for research. Rockville, Maryland: US Department of Human Services, 1989:322-39.

5. Ray WA, Taylor JA, Meador KG, et al. Reducing antipsychotic drug use in nursing homes: a controlled trial of provider elimination. Arch Intern Med 1993;153:713-21.

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7. Strumpf NE, Evans LK. Alternatives to physical restraints. J Gerontol Nuts 1992;18:4.

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9. Kallman S, Denine-Flynn M, Blackburn D. Comfort, safety, and indepen- dence: restraints release and its challenges. GERIATR NtJRS 1992;13:143-8.

10. Cariaga J, Burgio L, Flynn W, Martin D. A controlled study of disruptive vo- calizations among geriatric residents in nursing homes. J Am Geriatr Soc 1991;39:501-7.

11. Molonebeach EE, Zarit SH. Current research issues in caregiving to the elderly. Int J Aging Hum Dev 1991;32:103-14.

12. Reisberg B, Ferris SH, DeLeon M J, Crook T. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry 1982;139:1136-9.

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21. Haight B, Burnside I. Reminiscence and life review: explaining the differences. Arch Psychiatr Nuts 1993;7:91-8.

22. Smith K, Bengston V. Positive consequences of institutionalizations: solidar- ity between elderly parents and their middle-aged children. Gerontologist 1979;4:438-47.

23. Brody EM. The role of the family in nursing homes. In: Harper MS, Lebowitz BD, eds. Mental illness in nursing homes: agenda for research. Washington: US Government Printing Office, 1986:159-79.

24. York J, Calsyn R. Family involvement in nursing homes. Gerontologist 1977;17:500-5.

25. Hansen SS, Patterson MA, Wilson RW. Family involvement on a dementia unit: the resident enrichment and activity program. Gerontologist 1988;28:508-10.

Continued from page 8.

the tools prior to the start of data gathering. During the practice sessions, questions were answered and feedback was provided by the CNSs.

With regard to time of day of cognitive ratings, as Souder, Wiseman, and O'Sullivan correctly point out, the symptoms of delirium are cyclical in nature. In our study, because of staffing constraints, cognitive ratings were conducted only on the day shift, that is, between 7 AM and 3 PM (the staff nurses and CNSs conducting this study did so in addition to their usual daily job responsibilities). It is possible, therefore, that some cases of delirium, symp- tomatic only during the evening or night hours (i.e., "sun- downing") may have been missed.

We very much appreciate the careful review and feedback on our study by Drs. Souder, Wiseman, O'Sullivan.

STEPHANIE A. LUSIS, RN, MSN, CS BEVERLY HYDO, RN, MSN LILLIAN CLARK, RN, MSN

REFERENCES

1. Lusis SA, Hydo B, Clark L Nursing assessment of mental status in the elderly. GERIATR NURS 1993;14:255-9.

2. Souder E, Wiseman EJ, O'Sullivan P. Mental status in elders [Letter]. GERr- ATR NURS 1994;15:186-7.

3. Nagley SJ. Prevention of confusion in hospitalized elderly persons [Unpub- lished doctoral dissertation]. Case Western Reserve University, Cleveland, 1984.

4. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975;23:433-4l.


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