Alzheimer's disease (AD) is the most common form of dementia and is characterized by cognitive impairment, personality change, and behavioral disturbances. Patients with AD gradually lose their normal use of language and show an increase in levels of stress and frustration (Beck & Heacock, 1988; Hall & Buckwalter, 1987). This heightens the potential for non-cognitive, emotional, and behavioral disturbances such as anxiety, depression, delusions, and hallucinations, which affects 70% to 90% of patients with AD and can occur on a daily basis (Folstein & Bylsma, 1994; Teri et al., 1992). The Progressively Lowered Stress Threshold (PLST) model (Hall & Buckwaiter, 1987) presents the occurrence of non-cognitive problems such as anxiety and dysfunctional behaviors that can be triggered by internal or external situational stressors and can be minimized by maintaining a pleasant, calm, supportive, and caring environment (Hall, 1994; Hall & Buckwalter, 1987).
Some researchers have asserted the use of touch as a form of non-verbal communication alleviates anxiety in situations of stress by providing comfort, reassurance, and support to patients with AD (Bumside, 1979; Hollinger & Buschmann, 1993; Taft, Delaney, Seman, & Stameli 1993). Touching enables individuals to share their feelings, engage in non-verbal communication, and establish human relationships. This is demonstrated in the Touch model (Hollinger & Buschmann, 1993) and is an appropriate approach for individuals with AD as they maintain their emotions (Tappen, Williams, Fishman, & Touhy, 1999) and their sense of touch. However, in some cases, the individuals may become hypersensitive to touch, so care must be taken (Kovach, 2000). The combined use of the Touch model and the PLST model provides the basis for non-verbal communication to minimize situational stressors in patients with AD and decrease emotional and behavioral disturbances.
Conceptual models guide research by identifying the phenomena to be investigated, recommending methods with which to investigate the phenomena, and suggesting solutions to practical problems (Fawcett, 1995; Fawcett & Downs 1992). Although the conceptual models give some perspective to the goals and structure of nursing research and practice, they cannot be applied directly in empirical testing because of their generality and abstractness. Instead, the propositions of the conceptual model are tested indirectly through the empirical testing of theories derived from the model (Fawcett & Downs 1992; Walker & Avant, 1995).
Theory synthesis is useful to construct a theory to be tested and provides sophisticated representation of a phenomenon (Walker & Avant, 1995). In theory synthesis, all available information, concepts, and statements related to a phenomenon are pulled out and organized into a network. Theory synthesis, which is based on empirical evidence and enables a theorist to systematically assess relationships among factors pertinent to a topic of interest graphically, aids the process of highlighting areas in need of further research.
The following sections describe efforts to formulate a theory for future research and nursing practice using theory synthesis strategy developed by Walker and Avant (1995). This theory synthesis builds on a base of previous research findings pertaining to the phenomenon of interest for this study identified by two conceptual models, the PLST (Hall & Buckwalter, 1987) and the Touch (Hollinger & Buschmann, 1993) models. The terms theory and theoretical model will be used interchangeably because it is useful to use the term "theoretical model" for graphic expressions of theory and the term "theory" for the linguistic expressions of theory (Walker & Avant, 1995).
Anxiety and Dysfunctional Behaviors
Non-cognitive, emotional, and behavioral disturbances in patients with AD cluster together as a "behavioral symptom complex" and include psychotic symptoms such as delusional thinking, suspiciousness, and hallucinations as well as a number of other behavioral disturbances such as anxious behavior, agitation, violence, and verbal outbursts (Folstein & Bylsma, 1994; Reisberg et al., 1987). Although this behavioral symptom complex affects 70% to 90% of patients with AD, occurs on a daily basis, can impede care, and decreases the quality of life for both patients and caregivers, little is known about effective management (Teri et al., 1992).
The PLST model (Hall & Buckwalter, 1987), which was developed by relating the behavioral symptom complex to patients with AD, describes three main types of behavior presenting throughout the course of AD:
* Dysfunctional behaviors.
Normative behavior is generally a calm state. In patients with AD, normative behaviors diminish with the progression of the disease and are replaced by proportionately more anxious and dysfunctional behaviors due to a diminishing ability to cope with stress, which is called lowered stress threshold.
In a typical day, patients may demonstrate increased levels of stress and frustration due to fatigue, intolerance to multiple stimuli, perceptions of loss, and internal or external demands to achieve beyond their functional capacity. This heightens the potential for anxiety and dysfunctional behavior. Anxious behavior occurs when the patient feels stress. Although caregivers are unable to communicate effectively with patients who are socially inaccessible after catastrophic behavior occurs, they are usually able to communicate with patients when anxious behavior is about to begin and thus prevent or reduce the former behavior.
If the stress level is allowed to continue or increase, dysfunctional or catastrophic behavior often results. Dysfunctional behavior, which may be characterized by psychotic symptoms such as increased aggression, agitation, and sundowning, results from an overwhelming influx of stimuli. The PLST model proposes normative behavior and maximum functional levels can be partially achieved by the environmental manipulation of external stimuli such as noise or crowding and minimize change. Because stimuli also can be internal, such as pain or hunger, more than just the environment needs to be considered.
Caregivers may intervene to reduce both external and internal stress by providing supportive care to prevent dysfunctional episodes. This care would include such interventions as adequate rest periods, decreased noise levels, decreased crowding, and increased comfort. As anxious behaviors occur, external and internal stimuli can be modified until the anxiety diminishes or disappears.
Figure 1 . A typical day for a patient with Alzheimer's disease using implementation of physical touch.
Touch and Its Outcome
Touch is experienced not only physically as sensation, but also affectively as emotion and behavior. Because the nervous system functions holistically, the interaction of touch affects the autonomic, reticular, and limbic systems, and thus profoundly affects the emotional drives (Huss, 1977).
Touch, which is physical contact between humans, can provide a soothing effect under conditions of stress. Holding someone's hand under conditions of stress is likely to give both individuals a feeling of greater security by reducing anxiety (Montagu, 1953). Pratt and Mason (1981) said that touch used during an episode of illness, fear, or anxiety provides the assurance that someone else is available and will help.
On the other hand, one must be careful because touch also can increase anxiety with punitive actions when interpreted as an invasion of personal space (Hunter, Grinnell, & Blanchard, 1978; Pastalan & Bourestom, 1975). This was discussed at length in previous studies that used expressive physical touch (Buschmann & HollingerSmith, 1994; Buschmann, HollingerSmith, & Peterson-Kokkas, 1999).
The Touch model (Hollinger & Buschmann, 1993) demonstrates physical touch between caregivers and patients, and influences improvement in their emotion, behavior, and function. Caregiver-patient interaction influences attitudes toward touch. Each individual in the caregiver-patient relationship is involved as a portion of an interaction field, rather than as a separate entity (Burgener, Jirovec, Murrell, & Barton, 1992).
In this process, both the caregiver and the patient affect each other. Attitudes toward touch defined as acceptance of touch in the model affect touch behaviors of both caregivers and patients. Two general forms of touch occurring during the caregiver-patient interaction are procedural and non-procedural touch.
Procedural touch is the physical contact occurring while a particular task is being performed (Hollinger & Buschmann, 1993; Watson, 1975). This type of touch also is called taskoriented touch or instrumental touch.
Non-procedural touch does not require a task component but rather is spontaneous and affective, such as holding a patient's hand while talking or placing an arm around the shoulder of another in a greeting or supportive gesture. This form of touch also refers to "expressive physical touch."
Using the Touch model, previous researchers (Buschmann & HollingerSmith, 1994; Buschmann et al., 1999) studied the relationship between perception of touch and depression in elderly individuals. Positive perception of touch significantly contributed to reducing depression (Buschmann & Hollinger-Smith, 1994). Buschmann et al. (1999) implemented the use of physical touch on both nondepressed and depressed elderly individuals and found physical touch significantly reduced depression in elderly individuals.
There is no empirical research applying the Touch model to patients with AD. Therefore, in relation to applying the model on patients with AD, it should be understood that while their cognition and language capabilities are impaired, older adults' sense of touch remains intact as does their emotional response to their environment.
Combining the PLST and Touch Models
The PLST model provides information about why anxious and dysfunctional behaviors of patients with AD occur and how normative behavior and maximum functional levels can be achieved. The Touch model provides information about physical touch as an intervention for patients in situations of stress and outcomes of touch intervention. Thus, the theory proposed here, touch behavior from the Touch model and environmental manipulation from the PLST model, may reduce the emotional disorders and dysfunctional behaviors of individuals with lowered stress threshold brought on by AD (Figure 1).
Patients with AD experience increased levels of stress due to internal and external stressors in daily living. Stressors can be (Hall & Buckwalter, 1987; Hall et al., 1995):
* Physical, such as pain and discomfort.
* Change of caregiver, environment, or routine.
* Multiple and competing stimuli.
* External demands that go beyond the cognitive abilities.
* Affective responses to perceived losses.
Stress levels continue to build until the lowered stress threshold is exceeded. Patients then demonstrate anxious behavior immediately prior to exceeding their stress level and subsequently, dysfunctional behaviors occur (Hall & Buckwalter, 1987). Before patients with AD exceed their stress level, the application of physical touch may provide relaxation and reduce discomfort. In situations in which physical touch is provided, anxious behaviors may be modified, normative behaviors and maximum functional levels can be achieved, and dysfunctional behavior will not be exhibited.
VARIABLES RELATED TO FOCAL CONCEPTS AND THEIR RELATIONSHIPS
Walker and Avant (1995) suggested a careful literature review using the focal concepts during theory synthesis process. Through the review, variables related to the focal concepts and their relationships can be identified and incorporated into a theoretical model. During the review process, the following questions were asked:
* What are the research variables related to the focal concepts of touch and its outcome?
* What are the relationships among the variables?
* Is there any evidence that the use of physical touch on patients with AD significantly affects their anxiety and behavior?
The review was restricted to articles in nursing and health services published from 1970 through 2000. Sources for the review included ancestry (tracking relevant citations) and a Medline computer search using the key words of Alzheimer's disease or dementia, communication, anxiety, and behavioral disturbance.
Ten studies published between 1979 and 2000 were reviewed (Bartol, 1979; Burgener & Barton, 1991; Burgener et al, 1992; Burnside, 1979; Cleary, Clamon, Price, & Shullaw, 1988; Kim & Buschmann, 1999; Marx, Werner, & Cohen-Mansfield, 1989; Oh, 2000; Snyder, Egan, & Burns, 1995; Swanson, Maas, & Buckwalter, 1993). Swanson et al. (1993) measured verbal and non-verbal interaction between patients with AD and other individuals as an outcome variable, which is related to the concept of touch in the Touch model.
Review studies reported touch as part of therapeutic interventions, used as an independent variable. Interventions were grouped into physical touch, verbal communication, and non-verbal communication. However, specific information on the execution of the physical touch intervention usually was not provided. Review articles operationaUzed the outcome of touch in a variety of ways such as improvements in calm and functional behavior; social interaction; caregiver-patient interactions; and diminishment of anxiety, agitation, wandering, aggressive behavior, and catastrophic reaction.
Several studies reported physical touch, eye contact, smiling, and soft or acceptable verbalization reduced anxiety and dysfunctional behaviors in patients with AD (Bartol, 1979; Burgener & Barton, 1991; Burgener et al., 1992; Burnside, 1979; Cleary et al., 1988; Snyder et al., 1995; Swanson et al., 1993). However, the broad uses of the intervention (e.g., touch was measured as part of a therapeutic parameter or a special care plan) were problematic when interpreting the effectiveness of touch (Burnside, 1979; Cleary et al., 1988; Swanson et al., 1993).
Two studies that analyzed touch as part of an intervention found no statistically significant relationships between caregivers' touch and patients' behavior (Burgener & Barton, 1991; Burgener et al., 1992). Marx et al. (1989) reported inconsistent findings. They noted that although caregivers' touch and patients' agitated behaviors were significantly related, the sign of the relationship was positive. Because the authors did not differentiate the type of touch examined, confounding results may have occurred when analyzing expressive and task-oriented touch together.
A number of studies examined the relationship between touch and agitation. Snyder et al. (1995) used expressive physical touch and reported a negative relationship between expressive touch and frequency of agitation (i.e., implementation of expressive touch with patients with AD resulted in reduced agitation). Similarly, the use of expressive physical touch and verbalization reduced anxiety and dysfunctional behavior in patients with dementia in a study by Kim and Buschmann (1999). Oh (2000) reported hand massage used as a form of expressive physical touch in patients with dementia resulted in emotional and physical relaxation.
Operational Definitions and Description
Variables often concomitant with expressive physical touch behavior were verbal communication, vocalization, eye contact, smiling, affection, and hand massage. These variables were categorized as verbal communication (verbalization and vocalization), non-verbal communication (eye contact, smiling, and affection), and expressive physical touch (hand massage and spontaneous physical touch). Outcome variables were anxiety; agitation; aggressive behavior; wandering; catastrophic reaction; and adaptable, relaxed, calm, and cooperative behavior. The empirically based relationships among variables are summarized as:
Figure 2. Touch-Stress model. (Note: ET = expressive physical touch, VC = verbal communication, ANX = anxiety, and DFB = dysfunctional behavior.)
* Expressive physical touch and verbal communication are negatively correlated to anxiety, agitation, aggression, and wandering and positively correlated to calm, functional, and cooperative behavior.
* Non-verbal communication is negatively related to agitation and positively correlated to calm, functional, and cooperative behavior.
EFFECT OF TOUCH ON PATIENTS WITH ALZHEIMER'S DISEASE
Theory synthesis led to the formulation of the theoretical model, the Touch-Stress model (Figure 2), to guide future research and nursing practice interventions for emotional and behavioral problems in patients with AD. The components of the Touch-Stress model include touch intervention as a non-verbal communication, verbal communication, and outcome variables including anxiety and dysfunctional behavior. Sociocultural background variables are theory-driven factors influencing touch behavior and outcome variables. Expressive physical touch and verbal interventions directly affect anxiety and indirectly affect dysfunctional behavior in patients with AD. The relationship between intervention variables and outcome variables are negative.
Acceptance of Touch in Cognrtively Impaired Individuals
Individual cultural differences influence perception of touch and eventually touch behavior and outcome. Huss (1977) identified that individuals learn the boundaries of tactual communication culturally. In fact, previous studies (Hollinger & Buschmann, 1993; Buschmann et al, 1999) reponed individuals' preference for privacy was strongly related to their attitudes, perceptions, and responses to touch, including invasion of personal space. Therefore, individuals' acceptance of touch should be determined in both the research process and clinical practice.
There are two tools that determine the acceptance of touch by subjects: the Perception of Touch Scale (Hollinger & Buschmann, 1993) and the Privacy Preference Scale (Buschmann et al., 1999). However, these scales require that individuals be cognitively intact. Because these rating scales are inappropriate for cognitively impaired patients with AD, individuals' reactions to physical touch may be objectively observed. For example, if an individual shies away or pulls back, this reaction to physical touch may be interpreted as unacceptable.
Defining outcome variables to be measured and using a well-developed categorical system helps increase the validity of outcome measures. Noncognitive characteristics in AD, including anxiety and dysfunctional behaviors, have a wide range of definitions across studies. Researchers acknowledge the need to clarify which types of behavior are to be incorporated into the measurement domains under investigation (Patel & Hope, 1993; Teri et al., 1992; Welsh, Corrigan, & Scott, 1996). Use of psychometrically sound, clinically relevant measures, avoidance of global clinical impressions to evaluate change, and integration of comprehensive strategies of assessment enhances outcome measures in research (Teri et al., 1992).
In a data-based study, Kim and Buschmann (1999) collected actual outcome data. Anxiety, one of the outcome variables, was defined as a bodily reaction to stress as measured by the pulse rate. Dysfunctional behavior was defined as behavioral manifestations of psychotic phenomena brought on by dementia and included suspiciousness and delusional thinking, hallucinations, agitation, violence, and verbal outbursts. These were measured with the Empirical Behavioral Pathology in Alzheimer's Disease (E-BEHAVEAD) rating scale, which has been psychometrically tested (Auer, Monteiro, & Reisberg, 1996).
Observational methods were used when collecting data because participants' cognition, affected by AD, impairs their ability to provide appropriate responses to interview or questionnaire items. Observations were conducted indirectly by collecting reports of behaviors from interviews with caregivers; however, it should be noted that behavioral data obtained through caregiver reports may cause measurement bias (Auer et al., 1996). Reliability and validity of caregivers' subjective reports must be considered when they are being used in evaluation of participants' behaviors.
The aim of an intervention for emotional and behavioral problems in patients with AD is to provide supportive care for patients and their families, and to maintain the quality of life for both parties during the long-term course of the disease. According to Kim and Buschmann (1999), expressive physical touch with verbalization reduced anxiety and dysfunctional behavior in patients with AD. Physical touch used in patients with AD provided soothing effects under conditions of stress and reduced anxiety and dysfunctional behaviors brought on by AD.
The essence of nursing practice is care, competence, comfort, and compassion. In trying to provide high quality of life and care to individuals with dementia, their behavioral disturbances and catastrophic actions often prove troublesome. The Touch-Stress model for touch intervention in caring for patients with AD is both time efficient and cost effective in providing the best care and the highest quality of life. It provides the essence of nursing in preventing anxiety, fear, and confusion in cognitively impaired individuals. This theory is based on completed research for the Touch model, the PLST model, and the new proposed combined Touch-Stress model. This fulfills the aim of an intervention for emotional and behavioral problems in patients with AD in providing supportive care for patients and their families and to maintain quality of life during the long-term course of the disease.
The Touch-Stress model was formulated on the basis of combining two conceptual models and conducting a literature review through theory synthesis to provide a theoretical basis for nursing research and practice. With empirical validation, this model can contribute to theory development, serve to improve care for patients with AD suffering from emotional and behavioral disturbances, and increase quality of life for caregivers and families of patients with AD by providing supportive care to manipulate the environment surrounding patients with AD.
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