With the improving quality of health care in this country, more of our citizens are living into their seventh, eighth, and ninth decades. As the life span increases, so do the number of health problems occurring in our aged population. Alzheimer's disease is one such problem. The most common of all dementing disorders, it claims 15% of the population of this country over age 65.1
Alzheimer's disease is a progressive disorder of the central nervous system with an average duration of eight years from onset to demise. The chronicity of the disease and the incapacitating symptoms of the patient place devastating financial, emotional, and physical burdens on families. Nocturnal wandering is one of the most trying problems for Alzheimer victims and their families. This problem has been described by caregivers as the least manageable problem they face when attempting inhome care for the person with Alzheimer's disease.
Elderly persons who wander at night present numerous safety problems and are a constant challenge to all who care for them. A safe, inexpensive, noninvasive intervention to manage night wandering would significantly ease the burdens of these caregivers.
The methods currently used to manage nocturnal wandering include chemical and/or physical restraints or simply letting the patient wander. These methods are rarely of much help, as there are inherent problems in their use. The use of sedatives by older people often increases confusion and enhances existing cognitive deficits.2
The use of physical restraints may result in severe physical and emotional problems for the patients. Skin abrasions, nerve injuries, cardiovascular, musculoskeletal, and metabolic disorders may occur, resulting from the enforced immobility.3 These physical problems create increased need for nursing care on a continuous basis (eg, repositioning, skin care, toileting, hydration needs). Physical restraints often levy additional time and energy on the already burdened caregiver.4 The increased agitation and confusion experienced by patients who can neither understand nor remember why they are being physically restrained, compounds their already confused state. This type of restraint also creates a loss of dignity, resulting in depression and despair, and increases the already overwhelming emotional problems for these patients. The only other alternative, letting the patient wander, is not always feasible, as many homes or institutions do not have a safe environment for this purpose.
This pilot research project was pursued to evaluate the use of "modified white noise" as a safer noninvasive method of decreasing nocturnal wandering. White noise is defined as any low intensity, slow, continuous, rhythmic, monotonous sound, for example, the whirl of a fan, or the hum of an air conditioner. The sound generator used in this study modifies basic white noise by using filters and oscillators and produces a variety of environmental sounds.
Night wandering is a major contributor to the fatigue of the caregiver. Mace and Rabins5 speculated that, over time, disturbance in the sleep of the caregiver precipitates institutional placement of the demented person. Sanford6 studied problems of families caring for demented patients in the home and found that caregivers felt lack of time for themselves and the sleep disturbance of the patient were the least tolerable aspects of care. Rabins et al7 collected longitudinal information about families caring for a member with dementia. These families indicated that chronic fatigue was their primary, most distressing problem.
Recent research on sleep patterns in the elderly using electroencephalographic (EEG) tracings8*10 indicates that the normal aging process is associated with decreased REM and increased non-REM sleep. With age, the total sleep time shortens, although time in bed increases or remains the same. The number of awakenings after sleep onset also increases. Prinz" studied older demented patients and found that most effects of normal aging are exaggerated in the demented patient. That is, there is a greater decrease in REM sleep and a greater increase in the number of awakenings per night. Prinz12 also found a direct correlation between decreased amount of REM sleep and decreased performance on cognitive testing.
Lowenstein's9 findings supported those of Prinz regarding a positive relationship between the severity of dementia and the amount of sleep disturbance. He hypothesized that a nocturnal, confusional state, phenomenologically similar to delirium, may result from neuronal damage. He also said that the person with dementia is unable to readjust to a disrupted sensory environment, ie, light/dark, sound/silence.
Since 1942, monotonous, repetitive stimulations have been known to induce a form of sleep having many of the physiological characteristics of normal sleep.13 It was not until the 1970s, however, that white noise, or sound conditioning, was first used in research as a means of generating this type of stimulation. Wolff and Matsumia14 explored the neurophysiological correlations of the effects of low intensity white noise on the infant. In their studies, they found a generalized shift in the sleep state such that REM sleep with white noise resembled an intermediate condition between REM and non-REM sleep without white noise. Non-REM sleep with white noise represented a more synchronous form of non-REM sleep.
Parsons and Verbeck15 examined sleep/wake patterns in 75 adults with mild head injuries using subjective and objective reports of behavioral characteristics of sleep. They found that sleep interruptions increased significantly both per week and per night. These authors speculated that permanent neuronal injury occurs and that this is the source of sleep disturbance. The demented patient in the middle to Eater stages of Alzheimer's disease exhibits global cognitive impairment and functional deficits indicative of neuronal cell damage.16 Given these changes, white noise could have an effect on the demented patient similar to that seen in the less mature central nervous system. White noise may also mask environ- T mental stimuli, causing disrupted sleep in the demented person.
A convenience sample of eight subjects was selected from a gerontological research inpatient hospital unit for a study on the effect of modified white noise on wandering behavior. Subjects were over 60 years old, drug free, diagnosed with Alzheimer's disease, and had a history of nocturnal wandering. They had no known concurrent problems that might contribute to nocturnal wandering.
Patients who were unable to hear the sound generator, persons with mobility problems where assistance was required, and patients with precipitate micturition were excluded from the study. The study included four males and four females ranging from 60 to 82 years old. The mean age was 70 years. All were classified in the moderately advanced (according to DMS III) stage of Alzheimer's disease.
A sound generator, the Marsonia 1200, was selected as the vehicle to deliver the modified white noise. This particular sound generator delivers a variety of environmental sounds: the roll of a slow surf, rate = 3/minute; the roll of a fast surf, rate = 9/minute; a waterfall or a rainfall. The roll of the slow surf was randomly selected as the intervention for this study.
SLEEP OBSERVATION TOOL
The study period consisted of 12 nights for each subject. The first four nights, Phase 1, were used as a period of acclimation to the hospital setting. Phase 2 consisted of nights five through eight, and Phase 3 was nights nine through 12 (see Figure 1).
The patients were randomized into two groups. The first group was provided with modified white noise during nights five through eight and group members were monitored as their own controls on nights nine through 12. The second group was monitored in the control environment on nights five through eight and was exposed to modified white noise on nights nine through 12.
The sound generator, located at the bedside, was turned on at the hour of sleep. The knobs were set on slow surf, medium bass tone control, and midrange volume. All knobs were taped to prevent patients from manipulating them. Subjects were observed every 30 minutes from 9 PM to 7 AM, by the nurse assigned to the patient. The behavioral observations were recorded on the sleep observation tool (see Figure 2).
Although the usual method of measuring sleep/wake cycles is through EEG tracings, this procedure was unavailable for this study. Therefore, the sleep/wake cycle was measured through the following behavioral observations. "Sleep" was defined as the nonawake state, eyes usually closed, respirations slow and regular, in bed or chair slumbering. "Awake" was defined as the nonsleep state, out-ofbed, active, and moving. "Resting" was defined as awake, not sleeping, quiet, nonrestless. "Restless" was defined as agitated, disoriented activity, aimless movement, tossing, turning, and moving about exclusive of regular position changes during sleep.
Each half-hour time increment was marked by one of the primary indicators (S^sleep, A=awake, R=resting) and a modifier, if appropriate (X=restless, BR=bathroom). For the purpose of this study, either A or A/X constituted wandering behavior.
Throughout the study, all 11 patients were housed in semiprivate rooms, but each was the only occupant of the room. The door was left ajar at night and the interior of the room was illuminated with a night-light. Nurses used flashlights for additional illumination when making rounds.
The data of this study were analyzed using repeated measures techniques. In this analysis, two effects - the treatment effect and the group effect - were measured.
Analysis of the data showed neither effect to be statistically significant for all patients. However, when each subject was evaluated individually, patient #6 became significantly less restless and agitated during the noise phase of the study. Patient #2 also demonstrated less restless, agitated behavior during the treatment phase.
This project was pursued to evaluate the use of modified white noise as a safe, noninvasive intervention to decrease nocturnal wandering in Alzheimer patients. Although the results were not statistically significant, data indicated that nocturnal, agitated restlessness did decrease in two of the eight patients during the treatment phase of the study. Considering the burden and distress nocturnal agitation and restlessness cause the patient, the patient's family, and the professional caregiver, any decrease in this behavior is advantageous.
While scientific research must look for a cause and a cure for this disease, nursing research must look to managing the nursing care problems these patients present. It is the current lack of knowledge concerning management of such problems as wandering, that has forced families to institutionalize the demented patient. The money, the physical and emotional energies saved by effective management of nursing care problems may delay institutionalization of hundreds of Alzheimer patients and enable subjects to live longer in the community with their families.
Due to the ever increasing prevalence of Aizheimer's disease in our society, more research into all aspects of its management is imperative. As wandering behavior has been identified by caregivers as one of the least manageable problems associated with this disorder, further research into management of wandering behavior should be pursued. Replications of this study using a larger population would facilitate a better understanding of individual differences and identity those subjects best suited for modified white noise intervention.
Our study was carried out in a selective research setting, with each patient staying in the hospital for approximately two weeks. In replicating this study, a more constant environment is recommended. Use of a long-term care facility would be preferable, as the subject already would be familiar with the environment and the staff. More ideal would be the adaptation of this study for home use.
In adapting this study for the home environment, consideration could be given to alternative methods of delivering modified white noise. Some examples of these alternatives would be the hum of an electric fan or air conditioner, an auto-reverse cassette tape player with an environmental sound tape. Due to commercials and newsbreaks, radio is not recommended as an alternative method of delivering modified white noise.
The data obtained from this study are encouraging. Further research, however, is needed before any conclusion can be formed concerning the effectiveness of modified white noise on wandering in Alzheimer patients. The results of this pilot project, while not conclusive, provide some hope for a breakthrough in the management of agitated nocturnal wandering.
- 1. Terry M: Aizheimer's disease, in David R, Robertson D (eds): Textbook of Neuropathologv. Baltimore, MD, Williams and Wilkins/1975, pp 824-842.
- 2. Fielo S, Rizzolo M: The effects of age on pharmacokinetics. Geriatric Nursing, November-December 1985, pp 332-237.
- 3. Gioiella E, Bevil C: Nursing Care of the Aging Client. Norwalk. CT, Appleton-Century-Crofts, 1985. pp 481-483.
- 4. Heim K: Wandering behavior. J Gerontol Mrs 1986; 12(ll):4-7.
- 5. Mace N, Rabins P: The Thirty-Six Hour Day: A Family Guide to Caring for Persons with Aizheimer's Disease. Baltimore, MD, Johns Hopkins University, 1981, p 93.
- 6. Sanford J: Tolerance of disability in elderly dependents by supporters at home: Its significance for hospital practice. British Journal of Medicine, 1975, pp 471-473.
- 7. Rabins P, Mace N, Lucas M: The impact of dementia on the family. JAMA 1982; 3:334-335.
- 8. Miles L, Dement W: Sleep and aging. Sleep 1980; 3:119-220.
- 9. Lowenstein R: Disturbances of sleep and cognitive functioning in patients with dementia. Journal of Neurobioiogy of Aging 1982; 3:371-377.
- 10. Research on sleep and dreams. National Institute of Mental Health, publication No. (ADM) 1976 76-244.
- 11. Prinz P: Sleep patterns in the healthy aged: Relationship with intellectual functioning. J Gerontol 1977; 32:435-451.
- 12. Prinz P, Peskind E, Vitaliend P: Changes in the sleep and waking EEC's of nondemented and demented elderly subjects. JAm Geriatr Soc 1982; 30:86-93.
- 13. Louvelle G, Morgen S: Physiological and motor response to a repetitive sound: A study in monotype. Journal of the Experimental Psychology 1942; 30:435-451.
- 14. Wolff P, Matsumia Y: The effect of white noise on the somatosensory evoked response in sleeping newborn infants. Electroencephalogr Clin Neurophysiol 1974; 3:269-274.
- 15. Parsons L, Verbeck D: Sleep-wake patterns following cerebral concussion. Nurs Res 1983; 31:5.
- 16. Bumside I: Nursing and the Aged, ed 2. New York, McGraw-Hill Ine, 1981, p 183.
SLEEP OBSERVATION TOOL