Journal of Gerontological Nursing

Feature Article 

Effects of the Patient-Centered Environment Program on Behavioral and Emotional Problems in Home-Dwelling Patients With Dementia

Heeok Park, PhD, RN; Youngmi Chun, PhD, RN; Min Suk Gang

Abstract

The current pilot study examined the effects of the Patient-Centered Environment Program (PCEP) on agitation, cognition, stress, pain, sleep, and activities of daily living for home-dwelling patients with dementia. Nine individuals participated in the study. The PCEP included visual, auditory, olfactory, and tactile areas based on participants' preferences. PCEP sessions were held for 30 minutes twice per week and a total of 16 sessions were performed at participants' homes. Findings showed that agitation and pain improved with the PCEP (t = 2.91, p < 0.02; t = 4.51, p < 0.002, respectively). Findings suggested that a better study design, repeated with a reasonable sample size, must be considered for participants' health statuses to meet the PCEP contents. [Journal of Gerontological Nursing, 41(12), 40–48.]

Abstract

The current pilot study examined the effects of the Patient-Centered Environment Program (PCEP) on agitation, cognition, stress, pain, sleep, and activities of daily living for home-dwelling patients with dementia. Nine individuals participated in the study. The PCEP included visual, auditory, olfactory, and tactile areas based on participants' preferences. PCEP sessions were held for 30 minutes twice per week and a total of 16 sessions were performed at participants' homes. Findings showed that agitation and pain improved with the PCEP (t = 2.91, p < 0.02; t = 4.51, p < 0.002, respectively). Findings suggested that a better study design, repeated with a reasonable sample size, must be considered for participants' health statuses to meet the PCEP contents. [Journal of Gerontological Nursing, 41(12), 40–48.]

The number of individuals with dementia in South Korea has doubled since 2000 and most stay in their homes until admitted to hospitals or nursing homes as a result of serious symptoms (Han, 2004; Ministry of Health and Welfare, 2012). More than 50% of home-dwelling individuals with dementia show agitation, which results in increased medication use and hospital admission and decreased social interaction and quality of life (Cerejeira, Lagarto, & Mukaetova-Ladinska, 2012; Léger et al., 2002). Although agitation is one of the most serious problems in home-dwelling individuals with dementia, patients and their families are not shown how to manage the condition (Kim & Park, 2012). For this reason, families are stressed and determined to send their loved ones to hospitals or nursing homes (Cho & Kim, 2010; Huang, Shyu, Chen, & Hsu, 2009).

Many medications, including antipsychotic agents, are often used to control agitation; however, these medications cause undesirable effects, such as drowsiness, tardive dyskinesia, cerebrovascular events, and extrapyramidal symptoms (Ballard, Waite, & Birks, 2006; Drouillard, Mithani, & Chan, 2013). To decrease these undesirable effects, nonpharmacological approaches (e.g., light therapy, music therapy, aromatherapy, or snoezelen) should comprise the first line of treatment (Kong, Evans, & Guevara, 2009; Livingston et al., 2014; van Weert, van Dulmen, Spreeuwenberg, Ribbe, & Bensing, 2005).

Snoezelen, a multi-stimuli environment program, is defined as an approach that actively stimulates the senses using light, sound, smell, and taste, and requires incorporation of personal preferences and patient-centered contents (Kok, Peter, & Choufour, 2000). Patient-centered dementia care has been suggested as an effective intervention to control agitation (Brooker, 2007; Hobson, 2008; Rokstad et al., 2013; Sjögren, Lindkvist, Sandman, Zingmark, & Edvardsson, 2013) and includes four essential elements: (a) valuing individuals with dementia, (b) individualized care, (c) understanding the world from the patient's perspective, and (d) providing a social environment that supports the needs of the patient (Brooker, 2007; Rokstad et al., 2013). Several studies using snoezelen have been performed to control agitation in patients with dementia and showed positive effects. However, these studies have reported some limitations, such as focusing on nursing home settings only, researchers' designed programs, and group-based approaches (Baillon et al., 2004; Collier & Truman, 2008; Hwang & Kam, 2010; van Weert et al., 2005). In addition, these studies were limited in respect to the fact that they could not test correlated factors of agitation (e.g., stress, pain, sleep) at the same time.

In South Korea, approximately 27% of home-dwelling older adults are diagnosed with dementia and 70% are cared for by their own families (Ministry of Health and Welfare, 2012). Therefore, snoezelen must be tried with home-dwelling individuals with dementia showing agitation. In addition, snoezelen must be provided for patients individually to meet their needs or preferences. Thus, there is a need to test the individualized Patient-Centered Environment Program (PCEP) on agitation and related factors. Therefore, the purpose of the current pilot study was to test the effects of the PCEP on agitation, stress, pain, activities of daily living, and sleep in home-dwelling older adults with dementia.

Method

Participants

A total of nine patients in D-city, South Korea participated in the current pilot study and were recruited from two health centers (i.e., six from D-health center and three from N-health center). Inclusion criteria were: 60 or older; diagnosed with dementia; living in own home; exhibiting agitation more than once per week according to the Cohen-Mansfield Agitation Inventory (CMAI; Cohen-Mansfield, 1986); having family able to provide patient information; and ability to express a preferred environment.

Instruments

Agitation. Agitation was measured using the CMAI (Cohen-Mansfield, 1986). The original CMAI includes 29 behaviors and each is classified by scores ranging from 1 = no agitation to 7 = agitation several times per hour; however, the score was modified for the current study, ranging from 0 = no agitation to 3 = severe agitation. In previous studies, validity of the CMAI has ranged from 0.64 to 0.95 and its reliability has been as high as 0.92 (Cohen-Mansfield, Marx, & Rosenthal, 1989; Ray, Taylor, Lichtenstein, & Meador, 1992).

Cognition. Cognition level was measured using the Korean Mini-Mental State Examination (K-MMSE; Kang, Na, & Hahn, 1997). The K-MMSE was standardized by the original MMSE (Folstein, Folstein, & McHugh, 1975). The K-MMSE includes seven areas: (a) time orientation (5 points), (b) place orientation (5 points), (c) registration (3 points), (d) attention and calculation (5 points), (e) recall (3 points), (f) language (8 points), and (g) drawing (1 point). Concurrent validity of the K-MMSE was 0.78.

Stress. Stress was measured using saliva cortisol levels. Participants washed their mouths 15 minutes before sampling. A total of 3 mL of saliva was collected in a conical tube, stored in a freezer, and sent to the lab of D hospital, K University. Saliva analysis was performed using a solid-phase radioimmunoassay technique; a special technician working in the lab analyzed the saliva levels. Coat-A-Count® Cortisol was used as a reagent and a gamma counter was used for measurement.

Pain. To measure pain levels, a modified Pain Assessment in the Dementing Elderly (PADE; Villanueva, Smith, Erickson, Lee, & Singer, 2005) was used. The original PADE comprises 24 items classified into three parts: (a) physical signs, (b) global assessment, and (c) functional activities. The original PADE was modified in the current study and included only the first part (i.e., physical signs) because the others were not appropriate to be measured for patients with dementia. The modified PADE was classified as scores ranging from 0 = no pain agitation to 3 = severe pain so that the total possible points ranged from 0 to 33. Validity and reliability of the original PADE were 0.296 to 0.421 and 0.24 to 0.98, respectively (Villanueva et al., 2005).

Sleep. Sleep was measured using the number of minutes slept per day (Lee, 2003), from bedtime at night to wake-up time in the morning, minus awakening minutes during the night.

Activities of Daily Living (ADL). ADL were measured using the Korean ADL (K-ADL) scale (Won, 2002). The K-ADL comprises seven items and is classified as scores ranging from 1 = completely independent to 3 = completely dependent so that possible points range from 7 to 21. Cronbach's alpha of the K-ADL was 0.95.

Patient-Centered Environment Program

In the need-driven behavior model (Algase et al., 1996), background and proximal factors cause need-driven behaviors (e.g., agitation) in individuals with dementia. Proximal factors include physiological and psychological need states, and physical and social environments. Based on the model, meeting patients' needs and respecting their preferences are encouraged to prevent agitation.

The principal investigator's (H.P.) research team reviewed previous studies regarding patients' preferred environment, including visual, auditory, olfactory, and tactile areas. The research team developed the first draft of the PCEP as follows: (a) visual area = light, wall color, pictures (e.g., flowers, family); (b) auditory area = music, nature, birds, water sounds; (c) olfactory area = aromas, ventilation, flowers; and (d) tactile area = rubber clay, stringing beads, origami, oil, fur, round stones, grain. Based on findings of the questionnaires asking patients' preferences with respect to the four areas, the PCEP was individually developed to meet individual preferences.

The program was provided at patients' homes for 30 minutes twice per week, with a total of 16 sessions. The time frame of 30 minutes was chosen due to patients' short attention spans (Gerdner & Schoenfelder, 2010), and a total of 16 sessions for 8 weeks was chosen because interventions of more than 8 weeks had resulted in positive effects on agitation in previous studies (Park & Pringle Specht, 2009). The program was provided at a time patients preferred (i.e., if a patient preferred to have the program at 2 p.m. on Tuesday and Friday due to personal reasons, the program was provided at those times). The program was performed by the principal investigator and two research assistants in patients' personal rooms because they stayed in their rooms for most of the day. The principal investigator trained the research assistants regarding the importance and contents of the PCEP. The research assistants were RNs having >5 years' experience of caring for older adults with dementia in a hospital.

Data Collection

The current study was approved by the Institutional Review Board at D hospital of K university. Following approval, data collection began. The principal investigator and research assistants visited two health centers and presented the purpose of the study to the director and visiting nurses. First, the principal investigator and visiting nurses contacted home-dwelling patients with dementia and their families by phone to introduce the purpose of the study. Subsequently, they visited patients' homes to present the study at a convenient time. After the presentation, informed consent was obtained if patients and their families agreed to participate.

Following enrollment, the principal investigator and research assistants assessed patients' demographic data, preferred environment, agitation, cognition, stress, pain, ADL, and sleep at the first visit. Based on answers given by patients and their families regarding environmental preference, the PCEP was developed individually.

Agitation and pain levels were measured for the first 30 minutes prior to the PCEP and the following 30 minutes after the PCEP for the 16 sessions. The number of minutes that patients slept daily were measured using a daily sleep log during the last night prior to the PCEP and during the night on the day of the PCEP. Levels of cognition, stress, and ADL were measured at baseline and the final session. Measurements were performed by the principal investigator and research assistants.

Data Analysis

Data analyses were performed using SPSS version 20.0 and included: (a) descriptive statistics to describe participant characteristics; and (b) Student's t tests and repeated measures analysis of variance to compare differences in agitation, cognition, stress, pain, ADL, and sleep.

Results

Participant and Family Caregiver Characteristics

Participant characteristics are presented in Table 1. The majority of participants were older than 75 (n = 6), female (n = 7), Christian or Catholic (n = 5), married (n = 7), and had no more than an elementary-level education (n = 5). Most participants lived with their spouse (n = 6) and had a monthly income of <$1,000 (N = 9). Most participants had the Alzheimer's type of dementia (n = 7), were diagnosed more than 2 years prior (n = 7), were not taking any kind of medication related to dementia (n = 7), and had a spouse as their primary family caregiver (n = 6).

Participant Characteristics (N = 9)

Table 1:

Participant Characteristics (N = 9)

Family caregiver characteristics are presented in Table 2. Only characteristics of eight family caregivers were included because the ninth caregiver refused to answer the caregiver questionnaire despite wanting the research team to provide PCEP to the patient. The majority of family caregivers were older than 75 (n = 6), male (n = 5), of no religion (n = 5), married (n = 8), had a high school education or higher (n = 5), had no job (n = 8), and had a monthly income of <$1,000 (n = 7). Most family caregivers were healthy (n = 6), cared for the patient for more than 18 hours per day (n = 6), had cared for the patient for 12 to 72 months, and had no education related to dementia care (n = 7).

Family Caregiver Characteristics (N = 9)a

Table 2:

Family Caregiver Characteristics (N = 9)

Participants' Patient-Centered Environment Program Preferences

The PCEP preference, including visual, auditory, olfactory, and tactile areas, of each participant at each session was investigated. For the visual area, most participants preferred looking at flower, landscape, or family pictures in the early sessions of the program, but refused to do so due to eye discomfort, needing eyeglasses, or wanting more focus on listening to music or talking with research assistants. For the auditory area, all participants except one preferred listening to teuroteu music (e.g., Na, Hoon-a; Lee, Mi-Ja; and Sim, Soo-Bong—the most famous pop singers in South Korea during participants' youth). The one participant who did not prefer to listen to teuroteu preferred listening to gospel music and enjoyed singing along with the research assistants. For the olfactory area, many participants preferred the aromas of lavender, chamomile, or rose; however, three participants refused to participate because they either did not like the scents or were unable to smell. For the tactile area, most participants preferred kneading rubber clay because it felt good to touch and easy to handle, and they could make anything they wanted. In early sessions, some female participants preferred stringing beads, but later rejected using them because they were too small and difficult to handle.

Changes in Agitation, Pain, Sleep, Cognition, Stress, and Activities of Daily Living

Changes in agitation, pain, and sleep are presented in Table 3. The mean level of agitation 30 minutes prior to the PCEP was 2.42 and decreased to 1.56 after 30 minutes with the PCEP. The difference in agitation level between before and after the PCEP was significant (t = 2.91, p < 0.02). The mean level of pain 30 minutes prior to the PCEP was 1.89 and decreased to 1.16 after 30 minutes with the PCEP. The difference in pain level between before and after the PCEP was significant (t = 4.51, p < 0.002). The number of hours slept during the night prior to the PCEP was 7.18 and increased to 7.31 during the night on the day of the PCEP; the difference in sleeping hours was not significant.

Changes in Agitation, Pain, and Sleep (N = 9)

Table 3:

Changes in Agitation, Pain, and Sleep (N = 9)

Changes in cognition, stress, and ADL are presented in Table 4. The mean levels of cognition, stress, and ADL at baseline were 12, 0.01, and 9.22, respectively, and changed to 13.33, 0.01, and 8.78, respectively, at the final session. The differences were not significant.

Changes in Cognition, Stress, and Activities of Daily Living Scores (N = 9)

Table 4:

Changes in Cognition, Stress, and Activities of Daily Living Scores (N = 9)

Discussion

The current study investigated the use of the PCEP for home-dwelling patients with dementia and measured its effect on agitation, cognition, pain, sleep, stress, and ADL. Results of the current study show that only agitation and pain were reduced with the PCEP.

Previous studies providing the PCEP for nursing home patients have shown similar effects on agitation (van Weert et al., 2005). An individual, 24-hour snoezelen program for nursing home patients was provided based on the taking of family history and stimulus preference screening, and showed a significant effect with respect to levels of aggressive and rebellious behavior (van Weert et al., 2005). Baker et al. (2001) also compared the effects of multisensory stimulation and activity on behavior, mood, and cognition, and reported that the multisensory stimulation group showed a significant improvement in behavior compared to the activity group. Rokstad et al. (2013) investigated the effect of person-centered dementia care on agitation and other neuropsychiatric symptoms in nursing home patients and showed reduced agitation levels in the person-centered dementia care group compared with the control group. These previous studies showed reduced levels of agitation; however, they were performed with nursing home patients with dementia.

In the current study, the PCEP (including visual, auditory, olfactory, and tactile areas based on participants' preferences at every session) was provided for home-dwelling individuals with dementia. The majority of participants preferred auditory, olfactory, and tactile areas, with the visual area (e.g., flower or family pictures) being the least preferred. Flower or family pictures were presented to participants and they enjoyed seeing the pictures and talking about something related to them during the first visit. However, on subsequent visits, participants refused to see the pictures due to eye discomfort, a preference of looking at real flowers, or needing reading glasses. For future studies, programs in the visual area must meet participants' eye health statuses and include more auditory, olfactory, and tactile areas.

In the current study, the favorite tactile area was rubber clay or origami (rather than stringing beads). Female participants enjoyed stringing beads for the first 2 to 3 minutes, but subsequently complained due to eye discomfort and uncomfortable positions. Thus, for future studies, stringing beads needs to be reconsidered for patients with dementia. Participants preferred using rubber clay and origami because when they made something, they enjoyed telling certain stories related to them. For instance, one participant often made flowers using rubber clay and explained, “Nobody bought [me] pretty flowers when [I] was young” and “People always die, as flowers do.” Making something with rubber clay or origami made her feel good and brought back good memories. In addition, participants enjoyed kneading rubber clay because it felt soft to the touch. Previous studies have reported that touching has had positive effects on behavioral and psychological symptoms of dementia (Hulme, Wright, Crocker, Oluboyede, & House, 2010). Thus, using soft materials (e.g., rubber clay) is helpful to control agitation in patients with dementia.

Throughout the study period, the principal investigator and research assistants realized few programs exist for home-dwelling individuals with dementia in South Korea. Although the number of individuals with dementia has dramatically increased in South Korea, the majority stay in their homes (Han, 2004). Patients with dementia staying in nursing homes can participate in diverse programs, including music interventions, art therapy, and social activities; home-dwelling individuals with dementia have less chances to participate in such programs. In addition, only one of eight family caregivers in the current study had education experience related to dementia care. Providing education programs systematically, such as understanding the characteristics of dementia, managing patients' agitation, and providing social support or networking, is suggested for family caregivers.

In the current study, one participant had no close family or friends. Her son, daughter-in-law, and grandson spent no time with her. She was lonely and always waited at the door for the research assistants and program time. Thus, a program is urgently needed for home-dwelling older adults with dementia showing agitation and loneliness.

Limitations

The current pilot study used a quasi-experimental design; therefore, it is limited to general findings. Based on the findings, the intervention needs to be repeated with a greater and more reasonable number of participants. Replication of the study needs to consider participants' health statuses to meet the contents of the PCEP.

Implications for Geriatric Nurses

Geriatric nurses may apply the PCEP by modifying the environment based on patients' preferences and health statuses to improve agitation and pain.

Conclusion

The current pilot study showed that the PCEP improved agitation and pain in home-dwelling individuals with dementia. The PCEP included visual, auditory, olfactory, and tactile areas based on participants' preferences at every session. Findings warrant further investigation (using a better study design and reasonable sample size) to determine the effects of the PCEP. Further studies should include randomization and considerations of participants' health statuses.

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Participant Characteristics (N = 9)

Variable Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 Participant 7 Participant 8 Participant 9
Age (years) 79 80 86 81 75 77 75 79 67
Gender Female Female Female Male Female Female Female Male Female
Religion Other Christian Christian Catholic Other Christian None None Catholic
Marital status Married Married Widowed Married Married Married Married Married Divorced
Education Elementary Elementary University University None None None University Middle school
Living with someone Spouse Spouse Children Spouse Spouse Children Spouse Spouse Siblings
Monthly income <$1,000 <$1,000 <$1,000 <$1,000 <$1,000 <$1,000 <$1,000 <$1,000 <$1,000
Dementia type Alzheimer's Alzheimer's Alzheimer's Alzheimer's Alzheimer's Alzheimer's Other Alzheimer's Other
Duration of dementia diagnosis (years) 4 to <6 2 to <4 4 to <6 2 to <4 <2 <2 2 to <4 4 to <6 ≥6
Medication related to dementia None Aricept® None None Aricept® None None None None
Caregiver Spouse Spouse Daughter Spouse Spouse Daughter-in-law Spouse Spouse Daughter-in-law

Family Caregiver Characteristics (N = 9)a

Variable Caregiver 1 Caregiver 2 Caregiver 3 Caregiver 4 Caregiver 5 Caregiver 6 Caregiver 7 Caregiver 8
Age (years) 83 84 46 79 80 32 79 79
Gender Male Male Female Female Male Female Male Male
Religion Catholic None Christian Catholic None None None None
Marital status Married Married Married Married Married Married Married Married
Education Middle school High school University High school Middle school University Elementary University
Job None None None None None None None None
Monthly income <$1,000 <$1,000 <$1,000 <$1,000 <$1,000 $2,000 to $3,000 <$1,000 <$1,000
Health status Moderate Moderate Moderate Bad Moderate Good Bad Moderate
Duration of caring for patient (months) 60 48 54 42 12 13 36 72
Hours of care per day ≥18 ≥18 <4 ≥18 ≥18 <4 ≥18 ≥18
Education experience related to dementia care No No Yes No No No No No
Social support Day and night care Special cash paymentb Day and night care Special cash paymentb Special cash paymentb

Changes in Agitation, Pain, and Sleep (N = 9)

Variable Timing Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Total t p
Agitation (mean, SD) 30 minutes prior to the PCEP 4 (1.86) 4.5 (0.73) 0.56 (1.03) 2.19 (1.91) 0.56 (0.89) 0.81 (0.83) 2.19 (1.33) 4.06 (1.39) 2.88 (1.71) 2.42 (1.55) 2.91 0.02*
30 minutes after the PCEP 1.88 (1.54) 2 (1.46) 0.38 (0.62) 0.94 (0.57) 0.13 (0.34) 0.44 (0.63) 2 (1.15) 3.81 (1.52) 2.44 (1.93) 1.56 (1.2)
Pain (mean, SD) 30 minutes prior to the PCEP 2.56 (1.26) 1.75 (0.58) 0.94 (0.68) 1.25 (1.13) 0.63 (0.81) 0.75 (0.68) 2.06 (1.73) 3 (1.15) 4.06 (2.59) 1.89 (1.15) 4.51 0.002**
30 minutes after the PCEP 1.06 (1.12) 0.38 (0.5) 0.56 (0.51) 0.5 (0.52) 0.13 (0.34) 0.06 (0.25) 2 (1.93) 2.69 (1.08) 3.06 (2.38) 1.16 (1.14)
Sleep (n = 6) (mean, SD)a Night prior to the PCEP 7.85 (0.75) 9.28 (0.24) 8 (0.23) 4.4 (0.78) 4.56 (1.31) 9 (0) 7.18 (2.16) −1.49 0.197
Night on the day of the PCEP 8.16 (0.72) 9.52 (0.45) 8.04 (0.06) 4.22 (0.9) 4.89 (1.23) 9 (0) 7.31 (2.21)

Changes in Cognition, Stress, and Activities of Daily Living Scores (N = 9)

Variable Timing Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Total Mean (SD) t p
Cognition Baseline 6 8 5 22 11 6 14 20 16 12 (6.34) −1.32 0.225
Final session 12 9 4 19 13 7 17 18 21 13.33 (5.85)
Stress (n = 6) Baseline 0.02 0.01 0.01 0.01 0.01 (0 .01) 1 0.391
Final session 0.01 0 0 0.01 0.01 0.01 0.01 (0)
Activities of daily living Baseline 8 11 20 7 7 9 7 7 7 9.22 (4.27) 0.94 0.377
Final session 10 8 19 7 7 7 7 7 7 8.78 (3.96)

Keypoints

Park, H., Chun, Y. & Gang, M.S. (2015). Effects of the Patient-Centered Environment Program on Behavioral and Emotional Problems in Home-Dwelling Patients With Dementia. Journal of Gerontological Nursing, 41(12), 40–48.

  1. Patient-Centered Environment Program (PCEP) sessions may include visual, auditory, olfactory, and tactile areas, depending on patients' preferences.

  2. The PCEP helps improve agitation and pain for home-dwelling patients with dementia.

  3. During PCEP sessions, home-dwelling patients with dementia in Korea preferred listening to teuroteu music and the aroma of lavender or chamomile, but had difficulties handling string beads.

Authors

Dr. Park is Assistant Professor, College of Nursing, and Mr. Gang is PhD Candidate, Keimyung University; and Dr. Chun is Assistant Professor, Department of Nursing, Taegu Science University, Daegu, Korea.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The study was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the South Korean Ministry of Education Science and Technology (2012R1A1A1040385). The authors acknowledge the individuals with dementia and their family members who participated in this study. The authors also thank S.Y. Km and S.H. Lee for helping with data collection.

Address correspondence to Heeok Park, PhD, RN, Assistant Professor, College of Nursing, Keimyung University, 1095 Dalgubeol-daero, Dalseo-Gu, Daegu, Korea 704-701; e-mail: hopark@kmu.ac.kr.

Received: May 20, 2015
Accepted: September 09, 2015

10.3928/00989134-20151111-02

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