Nursing home residents with dementia often experience difficulty remembering appointments, dates, and scheduled events, such as mealtimes (Passini, Rainville, Marchand, & Joannette, 1995). Asking repetitive questions is common among individuals with dementia and often causes distress for staff as well as for the individual with dementia (Baumgarten, Becker, & Gauthier, 1990; Hwang, Tsai, Yang, Liu, & Lirng, 2000).
Environmental modifications to living areas that serve as orientation cues and external memory aids may increase functional independence in individuals with dementia (Namazi, Rosner, & Rechlin, 1991). Reese, Cherry, and Norris (1999) found community-dwelling older adults frequently used external memory aids or stimuli added to an existing environment to prompt desired behavior and compensate for memory deficits.
Similarly, external memory aids have been used to compensate for memory impairments in individuals with mild to moderate dementia or brain injuries (Wilson, 1995). Some examples include the use of lists to shop for groceries, calendars to remember dates and appointments, lists to remember the names of individuals or birthdays, and instruction cards acting as prompts to take medication properly; many of these memory aids also are used by individuals without memory deficits (Block & Morwiz, 1999; Reese et al., 1999; Sandler & Harris, 1992; Wilson, 1995).
Intervention strategies that facilitate residents' ability to act independently in their environment have been used for individuals with dementia of the Alzheimer's type. For example, one intervention designed to facilitate room finding for residents with dementia of the Alzheimer's type used signs and photographs of the residents as a younger adult (Nolan, Mathews, & Harrison, 2001). Prosthetic memory aids, or memory books, have been demonstrated to produce conversations and significant increases in statements of fact for patients with Alzheimer's disease (Bourgeois, 1990). An intervention that incorporated singing and a spaced retrieval procedure increased the ability of nursing home residents with dementia of the Alzheimer's type to name a familiar person in a picture (Carruth, 1997). Further such research focusing on specific interventions to improve the care of nursing home residents with dementia is needed (Beck, 2001).
The purpose of this study was to evaluate the effect of an environmental modification designed to provide residents of a special care unit with easy access to information about mealtimes. The study was designed after nursing staff expressed concern regarding the increased agitation and distress residents exhibited when asking repeated questions about mealtimes.
The study was conducted on a 40bed special care unit of a Midwestern residential nursing home. The special care unit was a locked unit that served older adults with dementia. The residents' rooms were located on two wings with one common dining room and a television and lounge area. The nurse's station was located at one end of the dining room. During the day, the unit was staffed by four certified nursing assistants and one nurse.
At the beginning of the study period, 35 residents met the criteria of being ambulatory or were in a wheelchair. All 35 participants met the American Psychiatric Association's criteria for dementia of the Alzheimer's type. Mean age was 87 years. There were 24 women and 11 men.
Observation sessions were conducted before mealtimes. In the morning, observations began at 6:00 a.m. and continued until breakfast was served (between 7:15 and 7:45 a.m.). Lunch observations began at 9:20 a.m. and continued until lunch was served (between 11:15 and 11:30 a.m.). Dinner observations began at 2:00 p.m. and continued until dinner was served (between 5:00 and 5:30 p.m.).
Observation sessions were conducted approximately 3 times per week between August 28, 2000 and February 8, 2001. No observation sessions were conducted for the 8 weeks between November 4, 2000 and January 7, 2001. A total of 48 observation sessions were conducted.
Questions or comments about eating, food, or other meal-related statements made by residents were noted. An observer sat in the dining room near the nurse's station and recorded all food and meal-related statements (e.g., regarding food, drinks, eating utensils, dining areas, kitchens, hunger) made by residents and noted the time the statement was made. Some examples of meal-related statements made by residents include:
* "When is lunch?"
* "I like water."
* "Can I have a bib?"
* "I wonder how much I pay for supper."
* "Do you like chicken?"
Recorded statements were then transferred to a time grid of 2-minute intervals.
Figure. Observations of residents' meal-related statements before breakfast (top), lunch (middle), and dinner (bottom) during the study period. The dashed vertical lines indicate a change in study phase.
A second observer independently recorded meal-related statements. The second observer recorded residents' statements simultaneously with the primary observer and used the same observation procedure.
Interobserver agreement was calculated from data collected by the primary and secondary observers' independently recorded meal-related statements. An agreement was scored when both observers recorded the same statement made by a resident and recorded the same time the statement was made. A disagreement was scored when the observers recorded different statements made by a resident or recorded the statement as being made at different times.
Percentage agreement was then calculated by subtracting the number of disagreements from the number of agreements and dividing the result by the total number of observations. Interobserver agreement was 100% during each of the reliability checks.
A large clock, measuring approximately 16 inches in diameter, was hung in the dining room. A largeprint sign that indicated the times for breakfast, lunch, and dinner was hung directly below the clock to facilitate the connection between time of day and mealtimes. The sign was constructed of poster-board and measured approximately 22 × 28 inches. The lettering on the sign was created on a personal computer and consisted of easy-to-read, large, heavy black type.
Although the nursing staff was aware the purpose of the clock and sign was to provide residents with easy access to information about mealtimes, the nursing staff was given no instructions or training. The rationale for not providing any instruction to the staff was to assess the effect of the intervention in the absence of any formal staff training. Therefore, the results of placing a clock and a sign may be more easily generalized to other settings.
An ABAB reversal design across mealtimes was used to determine whether the intervention changed the frequency of residents' requests for food or meal-related statements before mealtimes. The experimental design consisted of four phases (Kazdin, 1982):
* Phase A: initial baseline data were collected before breakfast, lunch, and dinner during a 5-week period with no environmental changes.
* Intervention phase B: the clock and sign were hung on the wall while observations of food-related or mealrelated statements were continued for 6 weeks.
* Repetition of phase A: the clock and sign were removed to return the environment to the baseline condition while data collection continued for 1 week.
* Replication of phase B: the clock and sign were returned to the wall while data collection continued for 4 weeks.
The number of observations for each condition was not predetermined beyond a minimum number of two observations per phase. Because of the nature of the intervention (clock and sign on the wall) and practical considerations, after a change in experimental conditions was made for one mealtime, the change remained in effect for all meals.
The Figure shows the effects of the environmental intervention on resident demands and questions about food before breakfast, lunch, and dinner times.
Before breakfast, residents' demands and questions about food were observed during 18% of the initial baseline observation intervals. These comments decreased to 6% of the observation intervals during the initial intervention condition when the sign and clock were posted in the dining area. After the sign and clock were removed, residents' comments increased to 29% in the reversal condition. However, when the environmental intervention was reinstated, meal-related comments and questions decreased to 5% of the observation intervals (Figure).
Before lunch, residents' demands and questions about food were observed during 5% of the initial baseline observation intervals. These comments decreased to 3% of the observation intervals during the initial intervention condition when the sign and clock were posted in the dining area. After the sign and clock were removed, residents' comments increased to 13% in the reversal condition. However, when the environmental intervention was reinstated, meal-related comments and questions decreased to 9% of the observation intervals (Figure).
Before dinner, residents' demands and questions about food were observed during 8% of the initial baseline observation intervals. These comments decreased to 1% of the observation intervals during the initial intervention condition when the sign and clock were posted in the dining area. After the sign and clock were removed, residents' comments increased to 18% in the reversal condition. However, when the environmental intervention was reinstated, meal-related comments and questions decreased to 9% of the observation intervals (Figure).
While the data within each experimental condition showed some variability, similar effects of the treatment were replicated across all three mealtimes and following the reversal condition within each mealtime. Overall decreases of 74%, 17%, and 63% from the baseline to the intervention phases were observed before breakfast, lunch, and dinner, respectively.
A within-participants MANOVA, with baseline phases (Al and A2) as the factor and intervention phases (Bl and B2) as the dependent variable, showed statistically significant differences for the intervention both before breakfast (Wilks's Λ = .35, F(1,5) = 9.34, p = .028, multivariate ηp 2 = 6.51) and before dinner (Wilks's Λ= .59, F(1, 6) = 4.19, p = .087, multivariate ηp 2 = .411). The dependent variable for the before lunch condition was not significant (Wilks's Λ = .99, F(1,9) = .11, p = .747, multivariate ηp 2 = .012).
The simple, low-cost intervention of placing a large clock and a largeprint sign that identified mealtimes in the dining area decreased residents' repetitive statements and questions regarding food and mealtimes. During the intervention phases, residents often were observed reading the sign aloud and pointing out the sign and clock to other residents.
While there is nothing fundamentally wrong with residents' asking questions related to food or mealtimes, observations revealed a repetitive pattern in meal-related questions. Nursing staff appeared to become frustrated with the residents' repetitive questions. Further, nursing staff responses to these statements ordinarily generated further questions on the part of the residents - all of which had similar answers that the residents might have forgotten in the next moment. It may be frustrating for residents to not know from one moment to the next when they will be able to eat.
Although frustration was not directly measured in the study, the researchers observed that residents exhibited furrowed brows, clenched hands, and increased agitation when they asked meal-related questions. Associations between orbitofrontal cortex lésions, memory problems, and frustration (often escalating to aggressive behavior) have been reported in the traumatic brain injury literature (Eslinger, Grattan, & Geder, 1995; Greve et al, 2002). The neurofibrillary tangles associated with dementia of the Alzheimer's type are lesions that can be located in the orbitofrontal cortex (Chu, Trane!, Damasio, & Van Hoesen, 1997; Van Hoesen, Parvizi, & Chu, 2000). Therefore, it stands to reason that the frustration exhibited in these patients may be linked to orbitofrontal cortex lesions in patients with dementia of the Alzheimer's type.
The nursing staff also reported this intervention alleviated residents' agitation before mealtimes. However, it is also possible that the staff's interpretation of a decrease in resident agitation was based on their own relief at not being questioned as frequently about meals.
Three months after the last data collection period of the study, the clock and sign remained mounted on the wall in the dining room. The nursing assistants reported they had replaced the clock battery and reinforced the holes in the sign so that it would remain on the wall. They stated they felt the sign was worth keeping because they believed it helped reduce residents' pre-mealtime confusion and agitation.
In addition to decreasing resident agitation, this type of environmental intervention also may reduce the nursing staff's expressions of exasperation with residents* behavior. Staff may be more willing to talk with or help residents when the staff are not constantly confronted with repetitive meal-related questions. The nursing staff at this special care unit informally reported they thought the residents were not asking as many repeated questions about mealtimes. Thus, the nursing staff were more likely to answer other questions in a friendlier tone of voice.
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