Journal of Gerontological Nursing

Diagnosis: Dementia 

Diversional and Physical Nonpharmacological Interventions for Behavioral and Psychological Symptoms of Dementia

Suzanne Fitzsimmons, MSN, ARNP, GNP-BC, CRT; Beth Barba, PhD, RN, FAAN; Maria Stump, MSN

Abstract

This article is the last of a four-part series addressing the use of non-pharmacological interventions for older adults with behavioral and psychological symptoms of dementia (BPSD). These types of interventions are used to prevent, lessen, or eliminate BPSD, thereby reducing patient reliance on psychoactive medications. These interventions are easy to use, cost-effective, and simple to implement. The Centers for Medicare & Medicaid Services’ psychoactive medication reduction initiative encourages all staff to use nonpharmacological interventions to manage BPSD. As with any attempt to handle BPSD, health care professionals and staff need a tool-box of interventions, as what works one day may not work the next and what works with one older adult may not work with another. This article describes the categories of diversional and physical nonpharmalogical interventions, presents the evidence supporting their use, and provides information on effective implementation. [Journal of Gerontological Nursing, 41(2), 8–17.]

Ms. Fitzsimmons is Research Associate, Dr. Barba is Professor, and Ms. Stump is Doctoral Student, School of Nursing, University of North Carolina at Greensboro, Greensboro, North Carolina.

Dr. Barba and Ms. Stump have disclosed no potential conflicts of interest, financial or otherwise. Ms. Fitzsimmons is the author of and receives royalties for her book Brain Fitness.

Address correspondence to Suzanne Fitzsimmons, MSN, ARNP, GNP-BC, CRT, Research Associate, School of Nursing, University of North Carolina at Greensboro, 108 McIver House, PO Box 26170, Greensboro, NC 27402-6170; e-mail: S.Fitzsi@uncg.edu.

Posted Online: December 23, 2014

Abstract

This article is the last of a four-part series addressing the use of non-pharmacological interventions for older adults with behavioral and psychological symptoms of dementia (BPSD). These types of interventions are used to prevent, lessen, or eliminate BPSD, thereby reducing patient reliance on psychoactive medications. These interventions are easy to use, cost-effective, and simple to implement. The Centers for Medicare & Medicaid Services’ psychoactive medication reduction initiative encourages all staff to use nonpharmacological interventions to manage BPSD. As with any attempt to handle BPSD, health care professionals and staff need a tool-box of interventions, as what works one day may not work the next and what works with one older adult may not work with another. This article describes the categories of diversional and physical nonpharmalogical interventions, presents the evidence supporting their use, and provides information on effective implementation. [Journal of Gerontological Nursing, 41(2), 8–17.]

Ms. Fitzsimmons is Research Associate, Dr. Barba is Professor, and Ms. Stump is Doctoral Student, School of Nursing, University of North Carolina at Greensboro, Greensboro, North Carolina.

Dr. Barba and Ms. Stump have disclosed no potential conflicts of interest, financial or otherwise. Ms. Fitzsimmons is the author of and receives royalties for her book Brain Fitness.

Address correspondence to Suzanne Fitzsimmons, MSN, ARNP, GNP-BC, CRT, Research Associate, School of Nursing, University of North Carolina at Greensboro, 108 McIver House, PO Box 26170, Greensboro, NC 27402-6170; e-mail: S.Fitzsi@uncg.edu.

Posted Online: December 23, 2014

Statistics continually warn of the expected increase in the number of older adults over the next several decades. Individuals 65 and older numbered 43.1 million in 2012, a rise of 7.6 million (21%) since 2002 (U.S. Department of Health and Human Services [USDHHS], 2013). However, this figure will increase to more than 72 million by the year 2030, thus resulting in older adults comprising 19% of the population (USDHHS, 2013).

With this increase in older adults comes an increase in individuals with Alzheimer’s disease and other dementias. Current statistics estimate that 5.2 million Americans have dementia, and this figure is projected to rise to 7.1 million by 2025 and 15 million by 2050 (Alzheimer’s Association, 2014). In looking at these rising numbers, it is safe to assume that an increase in the number of individuals with behavioral and psychological symptoms of dementia (BPSD) will occur as well. A systematic review that included approximately 10,000 older adults in nursing homes found that 82% of patients had at least one neuropsychiatric behavior, with agitation and apathy being the most common (Selbæk, Engedal, & Bergh, 2013). Unless a medical breakthrough occurs, approximately 6 million individuals with BPSD could exist in the United States by 2025, and a staggering 12 million individuals with BPSD could exist by 2050. These numbers speak to the urgency of finding effective nonpharmacological interventions to manage BPSD, such as physical and verbal agitation, anxiety, apathy, wandering, and others.

Although the Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic medications for behaviors in residents of long-term care facilities, psycho-tropic medications remain the first choice for controlling BPSD (Borisovskaya, Pascualy, & Borson, 2014). OBRA (1987) recognized that these medications are often used solely for the convenience of staff and that treatment with psychotropic medications is indicated only to maintain or improve functional status of older adults. With the proper training, resources, and support of administration, staff can be effective at managing challenging behaviors without medication. Addressing a behavior quickly not only saves staff time but may also prevent a behavior from escalating or affecting others.

The focus of the current article is on strategies that are diversional or physical in nature, and helpful tips on selecting an intervention are included. In addition, the research behind these nonpharmacological interventions and how to implement them, to understand why they occur, and to prevent, lessen, or eliminate a behavior are addressed. A recreational therapist can help in the process of adapting a nonpharmacological intervention (Table 1) specific to an older adult’s functioning and interests, as well as the behavior being targeted.

Summary of Diversional and Physical Nonpharmalogical Interventions

Table 1:

Summary of Diversional and Physical Nonpharmalogical Interventions

What Are Diversional Activities?

Diversional activities are designed to turn an individual’s attention away from a current mood or activity to focus on another activity. BPSD often occur as a result of boredom or other factors described in the needs-driven, dementia-compromised behavior model (Kolanowski, 1999). This model postulates that BPSD are results of an inability to express unmet needs. The objective of diversional activities is to divert older adults’ attention to activities that calm them. These activities must be person-centered (i.e., based on the particular individual’s leisure interests and physical and cognitive functioning) (Zimmerman, Shier, & Saliba, 2014). A diversional activity can be passive, such as listening to guided imagery, or active, such as performing progressive muscle relaxation. Nurses should consider the behavior to be targeted when selecting a diversional activity; they should also select an activity based on (a) what is known about the individual’s interest and abilities, (b) what has worked in the past, and (c) whether the goal is to calm or alert the older adult. A successful diversional activity is one in which the individual enters the flow state (Csikszentmihalyi, 1990), which occurs when an activity absorbs an individual’s attention, thus causing a loss of the passage of time and an unawareness of surroundings. In essence, flow state is characterized by complete focus on what an individual does to the exclusion of everything else. In this case, a focus on the intervention thereby eliminating the behavior. To achieve this state, the activity should be pleasurable, not frustrating, and performed voluntarily.

Reading

Often, older adults with cognitive impairment require assistance to change their focus. Minimal research has been conducted on the benefits of reading to individuals with neurological conditions despite its age-old use to improve well-being (Davis, Billington, Carroll, Healey, & Kinderman, 2012; Latchem & Greenhalgh, 2014; Reiter, 1994).

Reading is a familiar activity and a good method of replacing negative thoughts with positive ones. Reading is also helpful for older adults with verbal nonaggressive behaviors, such as asking the same question over and over again or complaining. Researchers found a significant reduction in BPSD and identified (a) enjoyment; (b) meaningfulness; (c) sense of personal identity; and (d) the enhancement of listening, memory, and attention as positive outcomes (Billington, Carroll, Davis, Healey, & Kinderman, 2013). Upbeat and humorous readings have been found to be beneficial for those who have depression, apathy, or grief (Billington, Dowrick, Hamer, Robinson, & Williams, 2010). Often, an older adult enters a facility and is never provided or offered the opportunity to read again. Many individuals in the later stages of dementia can still read: they just need the information presented in a manageable format (Alzheimer’s Disease International, 2011). For reading to be successful, a choice of materials should be offered that are (a) related to the individual’s particular interests and (b) uncomplicated. Too many choices may be overwhelming; therefore, it is helpful to visually show patients the choices rather than list them verbally (Wexler, 2014). Large print and a quiet location are vital. Once the material is selected, nurses should ensure that the older adult is comfortable and in a relatively quiet location. The subject matter should not be complex, but children’s books should be avoided unless specifically requested. Some good examples of reading materials are fictional stories, poetry, spiritual and inspirational books, magazines, and the classics.

If older adults are going to read alone, nurses should ensure that (a) they have their glasses and the glasses are clean, (b) sufficient light exists, and (c) the light is not glaring into their eyes. They should ask if any older adults would like a beverage; if they do, nurses should ensure such beverages are within reach. Nurses should also determine if a sweater or anything else is needed. They should stay until the older adult has started reading and then ask if words can be seen clearly. Frustration may occur if the reading material is too difficult to understand or the font is too small, or if the older adult desires different material or wants more reading material after finishing. Books or magazines may have pages that are slick or thin and difficult to turn; they may also cause paper cuts.

Reading to older adults is advised for any older adult with alexia (i.e., difficulty in reading) (Woollams, Hoffman, Roberts, Lambon Ralph, & Patterson, 2014), expressive aphasia, or Parkinson’s disease dementia (Murray & Rutledge, 2014). When reading to older adults, nurses should allow enough time to complete the selected document. If reading to several older adults, nurses should create a small group so everyone can hear. They should use a calm, soothing voice, reading slowly to help the older adults understand what is being said and so it does not sound as if they are rushed to finish and leave.

Guided Imagery

Guided imagery is another method of placing positive thoughts in an individual’s mind. It is particularly useful for those with anxiety, stress, sleep problems, and even pain. It has been found to reduce anxiety and agitation in older adults with dementia (Buettner & Fitzsimmons, 2007; Fitzsimmons, 2006; Fitzsimmons, Sardina, & Buettner, 2014). Guided imagery involves listening to a story and imagining in one’s mind the place that is being described. Nurses should use or write a script based on the older adult’s interest; they should have a few scripts (Table 2) on hand, perhaps of a ride to a lake, the ocean, or a walk in the park. Scripts should be approximately 5 to 7 minutes long. Guided imagery can be performed in small groups or one-on-one. A quiet location with no overhead noise, radio, television, or foot traffic is important.

Guided Imagery Scripts

Table 2:

Guided Imagery Scripts

When performing guided imagery nurses should:

  • Help the older adults find a comfortable position in a chair or bed.
  • Ask the older adults to remove anything that is in their hands, such as a purse, cane, or walker, and close their eyes.
  • If using guided imagery for relaxation, turn the lights down, if possible, as it will help with calming.
  • Read the script slowly, pausing between sentences and using a calm, monotone, soft voice. Go slower and softer as the end nears.
  • Read the script slowly but with inflection and enthusiasm if reading to someone with apathy or depression to alert and engage the individual.
  • Keep alert for any participant who is falling asleep, slumping into an uncomfortable position, or falling onto the floor.

Older adults with reduced hearing should sit near the reader.

Singing

The human brain is hard-wired to link music with long-term memory. Songs with a connection to important personal events can trigger the memory of lyrics. It is thought that music may calm chaotic brain activity and enable the listener to focus on the song and forget the behavior (Sacks, 2006). Care staff who sing to older adults with dementia have been shown to improve mood and reduce resistance to personal care (Götell, Brown, & Ekman, 2009; Hammar, Emami, Engström, & Götell, 2010). Music has been used with success to (a) relax older adults with anxiety or agitation, (b) alert those with apathy or depression, (c) reduce unmet needs, and (d) increase socialization and food intake (Götell et al., 2009; Millard & Smith, 1989).

To provide person-centered care, nurses must be aware of the songs that older adults enjoy. If singing to get a passive individual moving, songs should be upbeat. If an individual is agitated or anxious, nurses should sing a calming song.

For example, Mr. Jones does not want to get out of bed. The nurse’s aide offers her hands and starts singing “Take Me Out to the Ballgame.” The aide encourages Mr. Jones to sing along, while also helping him sit up, then stand, and then walk to the desired location. All of this is done while the aide continues to hold Mr. Jones’ hands and sing.

Nurses may sing to older adults, sing together with older adults, or encourage older adults to sing their favorite songs. They should make certain that someone’s singing does not disturb another older adult or that a particular song does not cause an individual to feel grief, depression, or irritation. A rousing song may cause an older adult to (a) be overstimulated and attempt to leave the vicinity or the unit or (b) become agitated. Nurses should ask residents and their family and friends what songs the residents’ like. If an individual or nurse does not know the words to a song, humming along to it is just as effective.

What Are Physical Interventions?

Physical interventions include activities that use small or large muscles. Significant evidence exists supporting the use of physical activities to reduce BPSD (Heyn, Abreu, & Ottenbacher, 2004). Physical functioning is inversely related to agitated behavior (Buettner, Lundegren, Lago, Farrell, & Smith, 1996); as strength, flexibility, and mobility improved, BPSD have been shown to decline. The more that older adults can do for themselves, the fewer unmet needs they perceive. Physical activities can be calming for someone who has anxiety or agitation or may be alerting for someone with apathy (Fitzsimmons et al., 2014).

Progressive Muscle Relaxation

Progressive muscle relaxation is a technique that involves tensing specific muscles and then relaxing them to release the tension built up in the body (Georgiev, Probst, De Hert, Genova, Tonkova, & Vancampfort, 2012). This technique is an effective activity for someone who has anxiety or is starting to become aggressive (Buettner & Fitzsimmons, 2007). Little research exists on the use of progressive muscle relaxation for individuals with dementia; however, research shows that it is effective in individuals with schizophrenia and anxiety (Georgiev et al., 2012) and for reducing anxiety for individuals undergoing chemotherapy (Lee, Bhattacharya, Sohn, & Verres, 2012). These findings are encouraging and support the use of this activity within other populations.

Nurses should position older adults so they are either sitting or lying down; however, some older adults may prefer to stand. Nurses should also remove any items in the older adults’ hands. If the older adults are standing, nurses should be observant for loss of balance. If more than one older adult is participating, nurses should ensure the older adults are far enough away from each other so as not to bump or hit their neighbors by accident. Nurses should demonstrate and instruct the exercises in front of the older adults so they can mimic the nurses.

After asking if the older adults would like to participate in the activity, nurses should inform them that they will be tensing and then relaxing their muscles to release tension. Each muscle will be tensed to the count of 7 and then relaxed. Older adults should be encouraged to feel the tension and stress leaving their bodies as they relax and tune out all other thoughts. Nurses should start with informing the older adults that they will start the technique at the head and then move down to the toes. Nurses should perform the exercises with the older adults.

The following is an example of a short version of the progressive muscle relaxation technique:

Raise your eyebrows…. 1,2,3,4,5,6,7…and relax.

Big smile…. 1,2,3,4,5,6,7…and relax.

Raise your head up high…. 1,2,3,4,5,6,7…and relax.

Shrug your shoulders…. 1,2,3,4,5,6,7…and relax.

Tense your arms and your bi-ceps…. 1,2,3,4,5,6,7…and relax.

Make a fist.… 1,2,3,4,5,6,7… and relax.

Tighten your stomach…. 1,2,3,4,5,6,7…and relax.

Tighten your thighs…. 1,2,3,4,5,6,7...and relax.

Tighten your butt…. 1,2,3,4,5,6,7…and relax.

Raise your toes and tighten your calves…. 1,2,3,4,5,6,7…and relax.

Curl your toes…. 1,2,3,4,5,6,7…and relax.

Nurses should perform the technique slowly, pausing between the muscle groups. For a longer version, include more muscle groups.

Sewing Cards

Simple Pleasures© Sewing cards is a simple handmade intervention that is useful for those with restless hands, as well as older adults who have fear or anxiety or are starting to become agitated. It can also be used with older adults with depression or apathy (Buettner, 1999; Fitzsimmons et al., 2014; Watson, 2005). The cards are made by volunteers and can even be made by residents of the facility. It is especially helpful to make them in an intergenerational program. If the sewing cards are used to decorate a room or unit, older adults may believe the activity is meaningful and that they are contributing to decorating the environment.

To make the cards, a poster board is cut into squares, and a picture is pasted in the middle. Holes are punched around the outside. Yarn is tied onto each corner for sewing. The ends of the yarn can be made stiff by dipping them into a combination of white glue and water; as a result, safety is ensured while ease of sewing is maintained. Nurses should provide a stack of sewing cards, demonstrate how they are sewn, and ask if the older adults wish to try. Older adults can sew the squares individually, or more than one can be sewn together to form a “quilt.” If the squares are made using letters, names can be formed. The instructions for making and using these cards, as well as 20 other Simple Pleasures items, can be found on the New York State website (access http://www.health.ny.gov/diseases/conditions/dementia/edge/interventions/simple/docs/patchwork_sewingcards.pdf).

Crochet Squares

Crochet squares are an effective activity for calming those who crocheted, quilted, or sewed in the past but cannot continue this leisure activity because of physical or cognitive functioning. Crocheting can be used for those with restless hands, as well as with those who have fear or anxiety, wander, or are beginning to become agitated. Crochet squares can also be used with older adults who are depressed or apathetic (Buettner, 1999; Fitzsimmons et al., 2014; Watson, 2015).

Knowing older adults’ abilities and leisure preferences is important with this activity, as it can be frustrating for an individual if the task is too difficult. Crocheted squares, yarn, and long plastic needles are the only supplies needed. Nurses should ask staff, family members, senior groups, and other organizations to donate crocheted squares so an adequate supply with various colors exists.

The plastic needle is not sharp enough to break the skin, but nurses should use caution to ensure that the needle does not go into anyone’s mouth or eye. It is safer to tie the needle on the end of the yarn so when the older adults are finished, the needle does not drop on the floor, get lost, and become a hazard. The crocheted squares are similar to the sewing cards but require slightly more skill and better cognitive functioning. Nurses should demonstrate how to sew two squares together by lining the squares up edge to edge, and sewing them together with the yarn. When those two squares are sewn together, they can add a third one and so on.

Older adults may make presents for family members, such as a throw blanket or baby blanket. If these items are being made to donate to a hospital or day care center, or if they are made to give as gifts to friends or family members, the older adults may believe that the activity is meaningful and that they are contributing to society. Some older adults will be occupied simply by sorting the different squares.

Art

Art activities are beneficial for individuals with dementia (Noice, Noice, & Kramer, 2014; Rentz, 2002; Sterritt & Pokorny, 1994). Art activities may be used as a medium for self-expression and to reduce aggression or anger (Leslie, 2001; Rentz, 2002). Art is a useful method of expressing how an individual feels, especially for older adults who have difficulty explaining their feelings. Art materials are used as a form of nonverbal communication; however, art activities are not effective for those with low cognitive functioning or limited fine motor skills. Instead, those who are unable to draw can be shown pictures that depict calmness, relaxation, or perhaps stress to help them point out which is more meaningful to them. Art therapy can combat depression often felt by older adults and serves as a release for emotions. This technique can help older adults decrease their anxiety, agitation, and depression (Mimica & Kalinic, 2011). Art can also trigger memories from the past, and the ensuing artwork helps care staff learn something new about each client.

For those capable of drawing, nurses should provide white paper and colored pencils or fine tipped markers. Crayons should be avoided, as they may seem childlike. Nurses should always make a drawing along with older adults so they do not feel as though they are on display. Drawing along with older adults helps cue them as to what to do and helps prevent them from feeling self-conscious. If patients are having trouble starting, nurses can provide suggestions. Nurses should watch for frustration over not being able to draw well or deciding what to draw, and they should be alert to older adults putting pencils or markers in their mouths, poking themselves or others, or drawing on surfaces other than the paper.

To implement the activity, nurses should ask older adults to draw how they are feeling. The drawing can be of themselves or anything that reflects their feelings. If they are hesitant, nurses can ask if they would like to simply write words that describe how they feel, or they should have an art book on hand for older adults to look through to select a painting that reflects their mood. When finished, nurses should show the older adults what they drew and explain its meaning; then they should have the older adults show what they drew and explain their feelings behind the drawings. This interaction may incite a discussion of worries and expressions of emotions, frustrations, anger, or fears (Richeson et al., 2008).

Brain Fitness

The use of small balls from the Brain Fitness© program (Fitzsimmons, 2008) has statistically significant research support (Buettner, Fitzsimmons, Atav, & Sink, 2011). The sensory movement of the balls has been found to have a calming effect on older adults with agitation and anxiety and an alerting effect for those with depression or apathy. The intervention requires focus, concentration, and hand–eye coordination. It can be performed one-on-one or in a group. Two 1″ or smaller balls per individual are the only items needed, as well as a hard surface. If the older adults have a history of placing items in their mouths, nurses should use a tennis ball or a ball similar in size. If any balls are dropped on the ground, nurses must retrieve these so they do not become a fall hazard when on the floor.

It is important to note that if the older adults cannot follow the specific directions, nurses should not point this out; instead, they should simply allow the older adults to move the balls in whatever way they can. The following examples are just a few of the different movements that can be performed with the balls:

  • Take one ball and place it on the table. Then put the end of the index finger on it. Roll the ball under the finger, down to the palm, and up the middle finger. Continue with all fingers until the ball reaches the thumb (or pinkie) and then go in the other direction.
  • Do the same thing with the left hand.
  • Do the same thing with both hands at the same time.
  • Roll the balls around the palms.
  • Do the right hand with both eyes closed. Then do the left hand with both eyes closed.
  • For those with greater dexterity, demonstrate placing a ball on the back of one hand and covering it with the other hand. Roll the ball around the hands. Make this more difficult by doing this movement with eyes closed or in partners.

Drumming

Drumming is a form of music therapy that relies on the fundamental subcortical levels of the brain. It does not need a melody or require following a song; its basis is rhythm, which is a primal sense of life and movement. Drumming has shown that vibrotactile stimulation increases participation in individuals with severe dementia (Clair, Bernstein, & Johnson, 1995) and decreases withdrawal and social isolation (Clair & Bernstein, 1990; Clair, Bernstein, & Johnson, 1995; Roskam, 1992). Clinical research that indicates rhythm can reduce anxiety for those with dementia (Sung, Lee, Li, & Watson, 2012). Unlike other instruments, drumming is something almost anyone can do and requires no talent. Individuals with low cognition or those who are frail and weak can generally participate. It is effective for those who need to release frustration; it can be used as a calming or alerting activity and can reduce the level of medications required by certain residents (Drum Therapy, n.d.). Drumming also reduces anxiety and can be a release for pent up emotions (Bahrampour, 2013).

Drumming can be performed in a small group or one-on-one to prevent or reduce a behavior. It is not a good idea to use this technique when someone is physically agitated, as it may increase the agitation. The noise of the drumming may agitate some, so nurses should ensure that the activity is performed in a closed-off area. A drum stick can be used as a weapon, so nurses should watch for any growing agitation among the drummers or others nearby. For those who are frequently agitated, nurses should consider providing a drum for them to bang out their frustration in a separate room with supervision.

The only equipment needed is a drum and stick for each older adult, or they can use their hands on the drum. If no actual drums exist, older adults can “drum” on their legs or other body parts. Nurses do not need to buy large fancy drums; small hand drums with mallets are readily available at reasonable prices and can be pulled out and used quickly to prevent BPSD. Nurses may wish to teach a few hand signals, especially if they are drumming with more than one older adult; however, most individuals will respond automatically. The following are some basic drumming hand signals:

  • Stop drumming: Both arms out to sides in a quick motion.
  • Drum softer: Arms out to sides, lower arms down slowly, palms down.
  • Drum louder: Arms out to sides, raise arms up, palms up.
  • Drum slower: One arm and index finger up, making slow circular movement.
  • Drum faster: One arm and index finger up, making fast circular movement.
  • Drumming solo: Point to individual who will drum.

The New York State Department of Health funded research on drumming; an instructional DVD and booklet are available on the website (access http://www.health.ny.gov/diseases/conditions/dementia/edge/interventions/bethabraham/index. htm). Some of the drumming activities from the New York State project follow. Nurses should use the ones that seem most appropriate to the older adult and his or her behavior and/or situation. It is a good idea to start and end with a slow heart beat rhythm.

Heart Beat. This activity is a simple beat that follows the sound of the heartbeat. Start the beat and encourage the others to join in. Do not talk during the session. Do the following for at least 1 minute.

  • Thump-thump…pause.
  • Thump-thump…pause.
  • Thump-thump…pause.

Continue for 1 minute, then signal stop.

Naming. This activity involves saying an individual’s name on the drum. Help as needed until participants catch on.

  • The nurse performs a drum solo…1,2,3,4 (while saying “My name is Sue”).
  • The older adults say back “Your name is Sue,” while drumming each word.
  • Everyone drums back “Your name is Sue” three or four times.
  • The nurse points to one individual and asks him or her to drum his or her name.
  • The others respond as above.
  • This activity continues until everyone has had their names drummed.

Rhythm Group Dynamics. Start a rhythm and have participants add their own beats to it. Then use hand signals to have them play loud, soft, fast, and slow, and signal them to stop. This activity can be performed in any sequence. Ask one of the participants to lead the group, doing the starting beat and signals.

Ending. Redo the heartbeat activity as mentioned previously. Add the word “goodbye” to the beat, getting quieter and quieter, if desired.

Dance

Physical programs, such as dancing, can also reduce depression, apathy, and agitation (Guzmán-García, Mukaetova-Ladinska, & James, 2013; Nyström & Lauritzen, 2005; Palo-Bengtsson & Ekman, 1997; Palo-Bengtsson & Ekman, 2002; Palo-Bengtsson, Winblad, & Ekman, 1998). Dancing can help with improving balance, gait, and mobility, as well as reducing falls. Increasing physical function in older adults with dementia reduces the need for the care staff to help with activities of daily living, which can reduce frustration and agitation in older adults.

The conga is a simple dance that almost everyone knows how to do. The use of a conga line or other dance music is a fun way to get older adults into the dining room or other locations. It can also be used one-on-one with reluctant older adults who need personal care. The conga can be danced by those who can ambulate independently, need assistance, or use walkers, canes, or wheelchairs. No music is needed; nurses can simply sing the rhythm. Staff should be interspersed among residents to ensure safety.

Nurses should ensure that older adults have nonskid shoes and any assistive devices they use to ambulate. Care staff should help those who need assistance, are unsteady, or are at risk of falling. They should ask if older adults like to dance, hold out their hands, start the melody, and begin dancing forward. The steps are: right foot forward, left foot forward, right foot out to the side, left forward, right forward, left foot out to the side.

Summary

Nonpharmacological interventions are not used merely to maintain compliance with state regulations. They can and should be used to reduce or eliminate the use of psychoactive medications. Decreasing or eliminating the use of psy-choactive medications reduces the risks of increased confusion, falls, stroke, and death. The list of physical side effects is endless. However, what about the social, emotional, and personality side effects, as well as the losses that come with the use of these powerful medications? With chemical calming comes sedation and, often, an inability to participate in life in a meaningful way. These medications result in a loss of energy, and individuals lose their spark and essential personalities. This loss of personhood causes loss of relationships, as well as the loss of a sense of identity. Managing BPSD without medications may be challenging, but in most cases, it is not impossible. Nurses need a tool box of techniques to avoid the use of medications. Nonpharmacological interventions have little or no side effects other than enjoyment.

Let’s bring back the spark in our patients as they live out their remaining years. Let’s hear family members say, “It’s good to have Dad back.” Nurses can help do this by using and training others about the use of non-pharmacological interventions.

References

  • Alzheimer’s Association. (2014). 2014 Alzheimer’s disease: Facts and figures. Retrieved from http://www.alz.org/downloads/facts_figures_2014.pdf
  • Alzheimer’s Disease International. (2011). Read with people with moderate to advanced dementia [Web log]. Retrieved from http://www.alz.co.uk/icaniwill/library/professional-carers/activities/reading
  • Bahrampour, T. (2013, June19). Seniors with dementia express themselves, connect with others in drumming circle. The Washington Post. Retrieved from http://www.washingtonpost.com/local/seniors-with-dementia-express-themselves-connect-with-others-in-drumming-circle/2013/06/19/a806f5f2-d842-11e2-a9f2-42ee3912ae0e_story.html
  • Billington, J., Carroll, J., Davis, P., Healey, C. & Kinderman, P. (2013). A literature-based intervention for older people living with dementia. Perspectives on Public Health, 133, 165–173. doi:10.1177/1757913912470052 [CrossRef]
  • Billington, J., Dowrick, C., Hamer, A., Robinson, J. & Williams, C. (2010). Liverpool Health Inequalities Research Institute: An investigation into the therapeutic benefits of reading in relation to depression and well-being. Retrieved from http://www.thereader.org.uk/media/72227/Therapeutic_benefits_of_reading_final_report_March_2011.pdf
  • Borisovskaya, A., Pascualy, M. & Borson, S. (2014). Cognitive and neuropsychiatric impairments in Alzheimer’s disease: Current treatment strategies. Current Psychiatry Reports, 16, 470. doi:10.1007/s11920-014-0470-z [CrossRef]
  • Buettner, L.L. (1999). Simple pleasures: A multilevel sensorimotor intervention for nursing home residents with dementia. American Journal of Alzheimer’s Disease & Other Dementias, 14, 41–52. doi:10.1177/153331759901400103 [CrossRef]
  • Buettner, L.L. & Fitzsimmons, S. (2007). Relaxation and dementia: An ideal program for reducing anxiety. Activities Directors Quarterly for Alzheimer’s & Other Dementia Patients, Spring, 41–45.
  • Buettner, L.L., Fitzsimmons, S., Atav, S. & Sink, K. (2011). Cognitive stimulation for apathy in probable early-stage Alzheimer’s (Article no. 480890). Journal of Aging Research, 2011. doi:10.4061/2011/480890 [CrossRef]
  • Buettner, L.L., Lundegren, H., Lago, D., Farrell, P. & Smith, R. (1996). Therapeutic recreation as an intervention for persons with dementia and agitation: An efficacy study. American Journal of Alzheimer’s Disease & Other Dementias, 11, 4–12. doi:10.1177/153331759601100503 [CrossRef]
  • Clair, A.A. & Bernstein, B. (1990). A comparison of singing, vibrotactile and nonvibrotactile instrumental playing responses in severely regressed persons with dementia of the Alzheimer’s type. Journal of Music Therapy, 27, 119–125. doi:10.1093/jmt/27.3.119 [CrossRef]
  • Clair, A.A., Bernstein, B. & Johnson, G. (1995). Rhythm playing characteristics in persons with severe dementia including those with Alzheimer’s type. Journal of Music Therapy, 32, 113–131. doi:10.1093/jmt/32.2.113 [CrossRef]
  • Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York, NY: Harper and Row.
  • Davis, P., Billington, J., Carroll, J., Healey, C. & Kinderman, P. (2012). A literature-based intervention for older people living with dementia: An evaluation report by the Centre for Research into Reading, Information and Linguistics Systems. Retrieved from http://www.thereader.org.uk/media/56538/a_literature_based_intervention_for_older_people_living_with_dementia.pdf
  • Drum Therapy. (n.d.). Aged care [Web page]. Retrieved from http://www.drumtherapy.com.au/aged-care-drumming
  • Fitzsimmons, S. (2006). Guided imagery for relaxation. Activities Director Quarterly for Alzheimer’s & Other Dementia Patients, Summer, 45–47.
  • Fitzsimmons, S. (2008). Brain fitness: An instructor’s manual of 150 exercises for people with low to high cognitive function. State College, PA: Venture.
  • Fitzsimmons, S., Sardina, A. & Buettner, L.L. (2014). Dementia practice guidelines for recreation therapists: Treatment of behavioral and psychosocial symptoms of dementia. Greensboro, NC: Author.
  • Georgiev, A., Probst, M., De Hert, M., Genova, V., Tonkova, A. & Vancampfort, D. (2012). Acute effects of progressive muscle relaxation on state anxiety and subjective well-being in chronic Bulgarian patients with schizophrenia. Psychiatric Danubina, 24, 367–372.
  • Götell, E., Brown, S. & Ekman, S.L. (2009). The influence of caregiver singing and background music on vocally expressed emotions and moods in dementia care: A qualitative analysis. International Journal of Nursing Studies, 46, 422–430. doi:10.1016/j.ijnurstu.2007.11.001 [CrossRef]
  • Guzmán-García, A., Mukaetova-Ladinska, E. & James, I. (2013). Introducing a Latin ballroom dance class to people with dementia living in care homes, benefits and concerns: A pilot study. Dementia, 12, 523–535. doi:10.1177/1471301211429753 [CrossRef]
  • Hammar, L.M., Emami, A., Engström, G. & Götell, E. (2010). Reactions of persons with dementia to caregivers singing in morning care situations. Open Nursing Journal, 5(4), 35–41. doi:10.2174/1874434601004010035 [CrossRef]
  • Heyn, P., Abreu, B.C. & Ottenbacher, K.J. (2004). The effects of exercise training on elderly persons with cognitive impairment and dementia: A meta-analysis. Archives of Physical Medicine and Rehabilitation, 85, 1694–1704. doi:10.1016/j.apmr.2004.03.019 [CrossRef]
  • Kolanowski, A.M. (1999). An overview of the need-driven dementia-compromised behavior model. Journal of Gerontological Nursing, 25(9), 7–9. doi:10.3928/0098-9134-19990901-05 [CrossRef]
  • Latchem, J.M. & Greenhalgh, J. (2014). The role of reading on the health and well-being of people with neurological conditions: A systematic review. Aging and Mental Health, 18, 731–744. doi:10.1080/13607863.2013.875125 [CrossRef]
  • Lee, E.J., Bhattacharya, J., Sohn, C. & Verres, R. (2012). Monochord sounds and progressive muscle relaxation reduce anxiety and improve relaxation during chemotherapy: A pilot EEG study. Complementary Therapies in Medicine, 20, 409–416. doi:10.1016/j.ctim.2012.07.002 [CrossRef]
  • Leslie, H. (2001). Dementia and art. Nursing Older People, 13(7), 10–13.
  • Millard, K.A. & Smith, J.M. (1989). The influence of group singing therapy on the behavior of Alzheimer’s disease patients. Journal of Music Therapy, 26(2), 58–70. doi:10.1093/jmt/26.2.58 [CrossRef]
  • Mimica, N. & Kalinic, D. (2011). Art therapy may be beneficial for reducing stress-related behaviors in people with dementia—Case report. Psychiatric Danubina, 23, 125–128.
  • Murray, L.L. & Rutledge, S. (2014). Reading comprehension in Parkinson’s disease. American Journal of Speech-Language Pathology, 23, S246–S258. doi:10.1044/2014_AJSLP-13-0087 [CrossRef]
  • Noice, T., Noice, H. & Kramer, A.F. (2014). Participatory arts for older adults: A review of benefits and challenges. The Gerontologist, 54, 741–753. doi:10.1093/geront/gnt138 [CrossRef]
  • Nyström, K. & Lauritzen, S.O. (2005). Expressive bodies: Dementias persons’ communication in a dance therapy context. Health, 9, 297–317.
  • Omnibus Budget Reconciliation Act of 1987. (1987). Subtitle C, nursing home reform: PL100-203. Washington, DC: National Coalition for Nursing Home Reform.
  • Palo-Bengtsson, L. & Ekman, S.L. (1997). Social dancing in the care of persons with dementia in a nursing home setting: A phenomenological study. Scholarly Inquiry for Nursing Practice, 11, 101–123.
  • Palo-Bengtsson, L., Winblad, B. & Ekman, S.L. (1998). Social-dancing: A way to support intellectual, emotional and motor functions in persons with dementia. Journal of Psychiatric and Mental Health Nursing, 5, 545–554. doi:10.1046/j.1365-2850.1998.560545.x [CrossRef]
  • Reiter, S. (1994). Enhancing the quality of life for the frail elderly: Rx, the poetic prescription. The Journal of Long Term Home Health Care, 13, 12–19.
  • Rentz, C.A. (2002). Memories in the making: Outcome-based evaluation of an art program for individuals with dementing illnesses. American Journal of Alzheimer’s Disease & Other Dementias, 17, 175–181. doi:10.1177/153331750201700310 [CrossRef]
  • Richeson, N., Buettner, L., McKenzie, S., Burgener, S., Buckwalter, K., Beattie, E. & Yu, F. (2008). Evidence supporting expressive arts interventions for persons in early stage Alzheimer’s disease. Activities Directors’ Quarterly for Alzheimer’s & Other Dementia Patients, 9, 10–22.
  • Roskam, K.S. (1992). Feeling the sound: The influence of music on behavior. San Francisco, CA: San Francisco Press.
  • Sacks, O. (2006). The power of music. Brain, 129, 2528–2532. doi:10.1093/brain/awl234 [CrossRef]
  • Selbæk, G., Engedal, K. & Bergh, S. (2013). The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: A systematic review. Journal of the American Medical Directors Association, 14, 161–169. doi:10.1016/j.jamda.2012.09.027 [CrossRef]
  • Sterritt, P.F. & Pokorny, M.E. (1994). Art activities for patients with Alzheimer’s and related disorders. Geriatric Nursing, 15, 155–159. doi:10.1016/S0197-4572(09)90043-X [CrossRef]
  • Sung, H.C., Lee, W.L., Li, T.L. & Watson, R. (2012). A group music intervention using percussion instruments with familiar music to reduce anxiety and agitation of institutionalized older adults with dementia. International Journal of Geriatric Psychiatry, 27, 621–627. doi:10.1002/gps.2761 [CrossRef]
  • U.S. Department of Health and Human Services. (2013). A profile of older Americans: 2013. Retrieved from http://www.aoa.gov/Aging_Statistics/Profile/2013/docs/2013_Profile.pdf
  • Watson, N.M. (2005). Simple Pleasures: A new intervention transforms one long-term care facility. American Journal of Nursing, 105(7), 54–55. doi:10.1097/00000446-200507000-00030 [CrossRef]
  • Wexler, M. (2014). A poetry program for the very elderly—Narrative perspective on one therapeutic model. Journal of Poetry Therapy, 27, 35–46. doi:10.1080/08893675.2014.871811 [CrossRef]
  • Woollams, A.M., Hoffman, P., Roberts, D.J., Lambon Ralph, M.A. & Patterson, K.E. (2014). What lies beneath: A comparison of reading aloud in pure alexia and semantic dementia. Cognitive Neuropsychology, 31, 461–481. doi:10.1080/02643294.2014.882300 [CrossRef]
  • Zimmerman, S., Shier, V. & Saliba, D. (2014). Transforming nursing home culture: Evidence for practice and policy. The Gerontologist, 54(Suppl. 1), S1–S5. doi:10.1093/geront/gnt161 [CrossRef]

Summary of Diversional and Physical Nonpharmalogical Interventions

Nonpharmacological InterventionUse ForQuick Tip
ReadingAnxiety, apathy, depression, restlessness, wandering

Assess for reading preferences.

Use large print books.

Encourage self-reading, setting older adult up with glasses and lighting.

Leave favorite books in older adult’s room.

Guided imageryAgitation, anxiety, apathy, depression, fear, insomnia, restlessness, wandering

Use a calm, soft, monotone voice.

Avoid areas with any distractions.

If using to increase alertness, having more than one older adult listening is a plus, and use enthusiasm and inflection.

SingingAgitation, anxiety, apathy, depression, fear, restlessness, wandering

Select a song based on the individual’s preference and target behavior.

Think about the emotion the song will invoke in the older adult.

Good activity to help get an older adult up and moving, as it will shift his or her focus.

Progressive muscle relaxationAgitation, anxiety, apathy, depression, fear, restlessness, wanderingDo this activity slowly and make certain to inform older adult to feel the tension leaving his or her body during the release stage.
Simple Pleasures© sewing cardAnxiety, apathy, depression, restlessness, wanderingProvide an assortment of cards for the older adult to choice from. These cards are good items to be made in an inter-generational program.
Crochet squaresAnxiety, apathy, depression, restlessness, wanderingUse with higher functioning older adults with adequate fine motor skills.
ArtAgitation, anxiety, depression, restlessness, wanderingDo a sketch along with the older adult so he or she does not feel uncomfortable being watched.
Brain Fitness©Agitation, anxiety, apathy, depression, restlessness, wandering

Use small balls for patients who do not have pica. For those who have pica, use tennis balls.

Do not correct the older adult if he or she cannot do what is instructed.

DrummingAgitation, anxiety, apathy, depression, restlessness, wanderingDrumming should be performed in a separate room so as not to disturb other older adults.
DanceAgitation, anxiety, apathy, calming, depression, restlessness, wandering

Good activity to get an older adult from one area to another, as it will shift his or her focus.

Watch for unsteady gait.

Include those in wheelchairs.

Staff should be interspersed between older adults if forming a chain.

Guided Imagery Scripts

For Agitation or Anxiety

Instruction to participants: We are going to do an exercise that will help you to relax. It is called guided imagery. I will read you a story, and while I do, I want you to imagine in your mind the place I am describing. I will turn down the lights. Get comfortable in your seat, let go of anything in your hands, and close your eyes. (Read the story slowly, as to not sound rushed to finish.)
The story: You are riding in the front seat of a car. You are on your way to a house on a lake. You have been riding for several hours. The road bends. And turns. Close to the lake. Finally you arrive. The car stops. You climb out of the car. Smell a wonderful smell. Pine. You can see the lake through the trees by the shore. You walk down the dirt path to the lake. Small sticks and leaves crunch under your feet. The air is warm and slightly humid. The sun is shining through the branches. Such a warm wonderful feeling. So peaceful. So content. You get to the water’s edge. And sit on a rock warmed by the sun. The sun shining on the lake looks likes diamonds. Your arms, legs, and face feel the warm sun. The slight gentle breeze. Feels like a soft touch. You hear the lake. Gently lapping on the shore. You see a few small fish. Swimming slowly through the water. The lake is so clear. You can see to the bottom. Smooth sand and small stones. Of every color. You put your hand in and pick up a handful of sand. Within the sand are shiny beautiful smooth stones. You drop them back in the water. Removing your shoes. You place your feet in the water. It is warm here. Where the water is shallow. The water feels silky. Smooth. Thick like syrup. You hear a bird overhead calling. Then another from a distance replies. You spread out a blanket. And lie down. Soon the warm sun is beating on your back. Feeling soothing. And wonderful. Like a touch-less back rub. You hear the lake gently lapping. You smell the water. You smell the pine trees. Your body is feeling very light. Very relaxed. You drift. Into a light pleasant sleep. When finished, do not speak for 1 to 2 minutes. Then say “I hope you have found this to be relaxing.”

For Apathy or Depression

Write a guided imagery script based on the older adult’s past leisure interests and a happy memory. Read with enthusiasm and inflection. The following script is an example of one from a woman who loved to dance. The story may be followed by music. Try to get the older adult to tap his or her feet or clap his or hands, or ask the older adult to dance.
Instruction to participants: We are going to do an exercise that makes you feel more alert and happy. It is called guided imagery. I will read you a story, and while I do, I want you to imagine the place in your mind. Everyone get comfortable in your seats, let go of anything in your hands, and close your eyes.
The story: I can still hear and hum some of the wonderful music from the forties. Bing Crosby, Glen Miller, Frank Sinatra, Tommy Dorsey, and many others. The dance hall was always decorated so nicely with streamers and paper flowers. I would go with my friends almost every Saturday night. We take a lot of time finding the right dresses, shoes, and a purse to match. I do my hair up and put on some make-up, especially the red lipstick and rouge. I wonder which of the men will be there and if I will be asked to dance. At the dance hall the music is already playing, and many couples are out there doing the jitterbug. I preferred the fast dances, such as the Lindy and swing dances. One of my favorite songs was Boogie Woogie Bugle Boy by the Andrews Sisters. One time, a fellow twirled me over his shoulder during a swing dance. He was a great dancer. All of us girls would sit in chairs on one side of the dance floor, while the fellows sat on the other. We would watch a fellow get up and walk toward us and wonder who he was going to ask to dance. When a fellow asked us to dance, we would just have a ball. At the end of the evening a slow song would be played, a romantic one such as I’ve Got a Crush on You or I’m in the Mood for Love. I would waltz or foxtrot with my favorite fellow. A year later, my favorite fellow and I married and danced to The Twelfth of Never. And that’s a long, long time. The end.

10.3928/00989134-20141215-01

Sign up to receive

Journal E-contents