When geriatric patients suffer from dementias that restrict them from home settings and result in hospitalization, their behaviors are often out of control. At such times, patients are frequently admitted to hospital units with specific complaints about agitation, extreme confusion, and assaultive behavior. Such patients engage in hitting, spitting, kicking, and other methods of assault and are extremely resistive to nursing care. It becomes the task of hospital staff to work toward decreasing patients' assaultiveness and increasing their willingness to allow nursing staff to provide care. Brushing teeth, washing the face, and changing clothes all become extremely difficult; it may require up to five staff members to accomplish these tasks. Combativeness is one of the most difficult problem behaviors occurring in this population. Jorm1 and Reed and Cummings2 have documented the varieties of problematic behaviors occurring in Alzheimer's patients.
Agitation and loss of purposeful and meaningful activity represent a second major problem area. If mobility is restricted as a result of unsteadiness, patients may be forced to sit in their chairs for extended periods. Through these hours, patients may frequently yell out and even attempt to grab or hit at patients or staff who walk by. Others stare blankly ahead, with no interaction with their environment. Kalicki described her perception that mental stimulation can be extremely therapeutic to Alzheimer's patients.3 Severa! other authors have also described the need of demented patients to interact with their environments in some way.1,4,5 If denied the opportunity tc relate to others, move, or explore objects in their environment, behavioral problems and deterioration ol abilities may occur.3
A variety of stimulus objects havd been used with this population. Francis and BaIy have described the use oí plush animals by demented patients.' Responses to music, touch, and objectil in Alzheimer's patients were describee by Norberg, Mellon, and Asplundt.7
In other settings with senior citizens] and nursing home residents, videe games have been used.810
The purpose of this study was td observe the demented patients' re sponses to a variety of toys and stimulus objects, and to determine the relative amount of interest displayed in sue! objects.
Patients in the study were diagnosed as having Alzheimer's disease or alcohol-related dementia and have displaced either assaultiveness or extreme agitation, which made it impossible for them to remain in less restrictive environments such as nursing homes. Patients studied included five male Alzheimer's patients (aged 66 to 88 years, mean age 74) and four male patients diagnosed with dementia secondary to alcohol abuse (aged 74 to 83 years, mean age 78). All subjects were patients within a geropsychiatric medical unit in a state psychiatric hospital.
Ten separate stimulus items were provided to patients over the course of a 2-week period (two 5-day work weeks). The entire procedure was repeated approximately 3 months later with the Alzheimer's patients; three out of the four alcohol demented patients had been discharged making it impossible to repeat the procedure with these patients. The objects included a set of keys; three small metal cars; a fabric book; a plush dog; a dressed doll; two versions of a transformer toy, one simple and developed for ages 1 to 3 (transformer 1) and the second more complicated and designed for school-age children (transformer 2); and three versions of the busy box, a plastic toy designed for infants and young children. Busy boxes 1 and 2 were rectangular and flat, busy box 3 was a cube form on a swiveling base. Each patient was presented with a different object each day for a 10-minute period; the objects were presented randomly. During the 10-minute presentation period, the amount of time that the patient actively interacted with the toy was observed, timed, and noted. It was also noted when the patient simply sat and held the toy. When a patient closed his eyes within the first 3 minutes of the 10minute period, the evaluator removed the toy and returned it at a later time.
Patients exhibited substantial interest in the toys and stimulus objects provided. Turning knobs and dials and holding and manipulating metal and mechanical items tended to hold their attention best.
Figures 1 and 2 illustrate the patterns of interest shown by two Alzheimer's patients. Figure 1 shows patient A's pattern of interest to the stimulus objects. Patient A's preferences were relatively persistent; he displayed substantial interest in simple mechanical tasks. Thus, transformer 1 and busy boxes 1 and 2 received substantial interest, varying between 310 to 600 seconds of the total 600 second play. Far less interest was displayed in the fabric book, busy box 3, and transformer 2. The lack of interest in the fabric book may be explained by the absence of movable or mechanical parts. The complexity of transformer 2 may have interfered with play. Busy box 3 rotates on a base, and patient A did not discover this, therefore there were decreased opportunities to play with this object.
AVERAGE SECONDS OF PLAY FOR ALZHEIMER'S PATIENTS*
Figure 2 shows patient B 's patterns of interest. Patient B was generally less vigorous in his play and exploration than patient A, but he did exhibit interest in specific objects. There was less consistency from one session to the next than was seen with patient A. Of interest is the fact that patient B's interest in busy boxes 1 and 2 increased from the first session to the second, whereas his interest in the transformers was not apparent during the second session. Whereas patient A showed some interest in the plush dog, patient B was content to hold it but did not explore or play with it. Neither patient A nor B found the fabric book very interesting, but both did show substantial interest at times in busy boxes 1 and 2 and transformer 1.
Figures 3 and 4 represent average seconds of play for five male Alzheimer's patients and four male alcohol-demented patients. In comparing these two populations of patients, it can be noted that the Alzheimer's patients showed more interest in the busy boxes. Although these figures indicate that, at times, patients chose to play with objects only 30 to 60 seconds out of the total 600 seconds in which the toy was available to them, this is significant in indicating that the patient chose to utilize the toy when given an opportunity to do so. Even play of 30 to 60 seconds duration represents a significant departure from the blank stare so typical of the demented patient. It should also be noted that patients frequently fell asleep with the toy still on the lap, which decreased the amount of time engaged in play.
In comparing responses to transformer 1 and transformer 2, it is apparent that patients preferred transformer 1. It is our view that transformer 2, a far more complicated version, was much too advanced for these demented patients. Optimal stimulus objects for this population are at the infant to preschool level. The knobs and moving parts of transformer 1 entertained patients for an extensive period of time. Knob and dial turning behavior was extremely repetitive with either transformer 1 or busy box 1 or 2.
Despite the fact that patients observed in this study displayed extremely impaired cognitive skills, they continued to engage in stimulusseeking and exploring behavior. These patients also displayed an appreciatior of many of the stimulus objects and toys that were originally designed for children. Children utilize such objects foi entertainment, to familiarize themselves with the environment, to practice with objects that they see adults using, and as a means of obtaining sprecific sensory stimulation and input as to how things in the environment work. Whereas the motivation of dementec patients may be different, their enjoyment of stimulus objects is similar. Foi many patients, such stimulus object! will provide entertainment for extensive periods. During such times, their interest often remains on the object, result ing in an increase in interaction with the environment along with a possible decrease in agitation and com bativeness.
In looking at patterns of interest, ont would anticipate that there would bt gender-specific patterns of interest individual patterns of interest, and pat terns of interest based on backgroune experiences, including occupation, ree reational pursuits, and mechanical abil ities. Providing toys that help the patient recall tasks performed durinj his more productive years may be verj therapeutic and serve to create pleasani memories and improved self-esteem.
Interest patterns displayed in this study often varied greatly from sessior to session. Thus, for the first session, ? patient might find a dial on a stimulus object and would spin that dial for ar extensive period. At the second session, the patient might not find that dia] and would not actively play with the object.
Whenever possible, the patient population was studied in the morning for interest in these objects. Of necessity stimulus objects could not be given tc patients who were sleeping. Values provided in Figures 1 to 4, indicating interest in each object, show a great deal of variability; at times, patients would take the item, play for a short period, and then fall asleep. Fluctuating levels of attention and arousal and medication changes sometimes impacted patients' behavior greatly, resulting in a general depression of activity with lethargy and sleepiness. Even if the object is interesting enough to elicit attention and exploration, the patient may still be unable to remain awake. It is the habit of a large percentage of these geriatric patients to take frequent naps. This tendency to nap is partially responsible for some of the variation between values.
There are natural cycles in a hospital environment; in addition, each individual has his own circadian rhythm, with tendencies to sleep at specific times. We find it intriguing that despite the fact that there are such great variations, along with substantial changes in the health status of patients, that we still consistently found so much patient interest in specific objects.
Patients greatly enjoyed small metal cars, attempting to stack and roll them on table trays. Keys were also a favorite; however, patients who were given such items needed to be monitored very closely, and it should be noted that patients used the keys and the cars in an inappropriate manner, often sucking and putting them in their mouths. Alzheimer's patients tended to mouth objects far more than did the alcoholdemented patients. Safety aspects of the stimulus objects must be taken into consideration. Objects posing potential dangers must not be provided. For example, small toys that may be ingested must be avoided as potential stimulus objects. In addition, consideration must be given to the fact that many patients may attempt to use a toy as a weapon; thus, objects that are pointed, sharp, or heavy, and that may be used to hurt others must be avoided.
It is extremely typical of Alzheimer's patients to explore their environments with their mouths; it is unclear as to whether they are able to distinguish between food items and non-food stimulus objects. Many objects find their way into the Alzheimer's patients' mouths.11 For example, keys, small cars, and plastic flowers have all been used by Alzheimer's patients with such strategies as mouthing, chewing, and sucking.
AVERAGE SECONDS OF PLAY FOR ALCOHOL DEMENTED PATIENTS*
In selecting optimal toys and stimulus objects for this population, consideration must be given to the amount of intervention that is required on me part of nursing staff. It is inappropriate to give a patient a small item that will be constantly thrown or dropped off the tray table to the floor. This represents a safety hazard for ambulating patients, and the nursing staff cannot be expected to repeatedly retrieve stimulus objects.
Our findings were consistent with those of Francis and BaIy in that many patients displayed an affinity for plush animals; dolls were also appreciated.6 Plush objects seemed to provide patients with an opportunity for tactile exploration, as well as an opportunity to function in a nurturing manner, even though the object is not alive. The manner in which patients interacted with the dolls and the plush dog was often with quiet holding; this interest is not reflected in the figures as this was not considered to be active play. There may be some benefits to using live puppies, dogs, and kittens; when we have had opportunities to provide these to our patients, there was much interest. However, it is not always reasonable or practical to offer live animals in a hospital environment.
The amount of interest in the fabric book was variable. The manner in which patients explored fabric books was very different from the manner in which they explored mechanical objects. They would often stroke the fabric book, but would not look at it. With the mechanical objects, a more intensive exploration was typical, with simultaneous visual and tactile exploration.
It is our impression that use of the plush toys, fabric book, and dolls meets a need for stimulus exploration and stimulation mat was slightly different from the need met by mechanical objects. The softness of the objects, the opportunity to cuddle a small object, and the tactile sensation all provide patients with gratifying stimulation, but it was calmer and the interaction was much more passive than the interactions with mechanical objects.
Concerns as to how patients and family members would view such toys did occur; these concerns related particularly to the possibility of viewing the toys as infantalizing or demeaning. To date, there have been no complaints or negative responses from family members. An attempt was made to inquire of these patients as to how they viewed such objects. Only one patient responded; he indicated that the object was a "game. " It has been our observation that other patients have regarded this as "work" and have carried a busy box around like a brief case. We have encouraged patients to view this as a game or work, both of which are acceptable adult pursuits.
Our general impression is that patients are more calm after engaging in such exploration, that they are more satisfied than they are with inactivity, and they display less boredom and agitation. Toy objects have also been used with these patients as distractions, particularly during assaultive episodes. Thus, when a patient has attempted to grab or hit another individual, an interesting stimulus object has been provided and the patient has often shifted his attention away from the potential victim. Such patients often clutch at others' hands with such a firm grip that the other individual cannot free himself. At such times, toy objects have been extremely useful . At the point that the patient shifts his attention to the toy object, the hand is generally freed in a natural manner. In many ways, this is not unlike a tactic used with young children; two young children may be fighting over a toy and another interesting toy is provided, causing an immediate end to the aggression.
In using stimulus and toy objects with the demented population, it seems necessary at times to "shape" these patients' behaviors by showing them specifically how objects work, using a calm and slow patient teaching technique. It is often necessary to teach elderly, demented individuals specifically how the objects work, and to initially elicit their attention. Although patients were not taught to use such objects in this study, subsequent observations led us to believe that it is helpful to demonstrate to the patient how the parts move and how the toy can be manipulated.
In the past, little attention has been directed toward the importance of stimulus aspects of the environment in the care of demented patients. By focusing efforts on improved design and environmental modulation of stimulation levels, a degree of control can be provided over patients' behaviors. Hiatt12 and Kiyak13 have both provided excellent reviews of the literature, clarifying the fact that subtle alterations in the environment have enormous impact on this population. Optimizing architectural design of nursing homes and hospitals, increasing use of recreational toys and tools to incorporate stimulation of all senses as well as providing nursing staff with ways to utilize stimulus objects as distractions merit further study. It is our hope that future studies will particularly focus on the areas of environmental control over agitation and stimulus enhancement to increase self-esteem and contentment.
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