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.
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.
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 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
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.
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.
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 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 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).
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 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.
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.
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.