The number of individuals living with dementia, including Alzheimer’s disease (AD), has profound personal, social, environmental, health care, and economic implications for the American population. It is estimated that one in eight (approximately 13%) individuals 65 and older and nearly one half of those 85 and older have AD (Centers for Disease Control and Prevention [CDC], 2011). For older adults newly admitted to a nursing home, the prevalence of dementia is 48% to 55%, whereas the prevalence rates for agitation in older adults with dementia vary from an overall rate of 55% to a range of 70% to 95%, depending on setting (Launer, 2011; Spira & Edelstein, 2006). Furthermore, $203 billion were spent in 2013 on health, long-term, and hospice care for individuals with AD and other dementias (Alzheimer’s Association, 2011, 2014), and this figure does not include the cost associated with the approximately 15 million American caregivers involved in the care of those with AD (CDC, 2011).
Agitation is a frequent and disturbing behavior for many patients with dementia: it not only places the older adult at risk for physical injury, but it also contributes to caregiver stress. Cohen-Mansfield (2008) identified the following four categories of agitation behaviors in individuals with dementia: (a) physically nonaggressive (e.g., pacing, restlessness, inappropriate eating and dressing); (b) physically aggressive (e.g., hitting, throwing things, hurting oneself or others); (c) verbally nonaggressive (e.g., attention-seeking behaviors, repetitive questions); and (d) verbally aggressive (e.g., screaming, cursing). Frequency of aggressive behaviors and disruptiveness were found to be highly correlated (Cohen-Mansfield, 2008). Untreated behavioral symptoms can decrease quality of life, accelerate dementia progression, and increase caregiver burden, thus hastening early nursing home placement (Gitlin, Kales, & Lyketsos, 2012).
Nursing staff are responsible for managing behavioral problems and agitation 24 hours per day in hospitalized patients. Two general types of pharmacological treatments for agitation exist: anxiolytic agents and antipsychotic medications administered on a regular or as-needed basis (PRN). Serious problems and side effects, including sedation, increased confusion, falls, anticholinergic and cardiac side effects, and even death, are associated with the use of these medications, which are not approved by the U.S. Food and Drug Administration. Reuben et al. (2013) recommended considering the use of nonpharmacological approaches before using these medications. Nonpharmacological interventions have the benefit of reducing the frequency and severity of agitation, while minimizing risk from adverse drug effects. Although nonpharmacological interventions are recommended as the first-line management for patients with dementia exhibiting behavioral problems (Sadowsky & Galvin, 2012), the practice of first prescribing numerous medications for agitation is not uncommon.
Nonpharmacological interventions for neuropsychiatric symptoms in dementia are divided into three general categories (Ayalon, Gum, Feliciano, & Areán, 2006). The first category, unmet needs interventions, is based on the theory that neuropsychiatric symptoms are an expression of unmet needs of the patient with dementia. Agitation and other neuropsychiatric symptoms represent a communication problem and are specific to the individual patient. To relieve unmet needs, the health care provider assesses the patient’s individual needs and intervenes to prevent potential neuropsychiatric symptoms. An example of an unmet need may be the need to toilet, whereas the corresponding physically, non-aggressive behavior exhibited may be pacing.
The second category, learning and behavioral interventions, is based on the theory that neuropsychiatric symptoms are positively learned and reinforced. These interventions are designed to change the frequency and/or duration of neuropsychiatric symptom behaviors. Repeatedly yelling “nurse” is an example of a learned, verbally nonaggressive behavior.
The third category, environmental vulnerability and reduced threshold interventions, targets a mismatch between environment and coping ability. For example, the patient with dementia, in a loud, crowded lounge area, may suddenly strike at staff, which is a physically aggressive behavior representing an inappropriate response to the environment.
Several sensory interventions have been investigated to evaluate their ability to decrease agitation in older adults with dementia. One meta-analysis of three studies revealed statistically significant differences between the sensory intervention and treatment groups, with moderate beneficial effects of sensory interventions on agitation (Kong, Evans, & Guevara, 2009). Another meta-analysis by Brodaty and Arasaratnam (2012) demonstrated that nonpharmacological caregiver interventions can significantly reduce neuropsychiatric symptoms, with effects at least comparable to antipsychotic drug use. Some of the sensory interventions these studies have targeted include the sense of smell, hearing, and touch (Lin, Chan, Ng, & Lam, 2007; Sung, Chang, Lee, & Lee, 2006).
Nonpharmacological interventions are effective and easy to use, and they can be individualized to specific needs and have minimal (if any) side effects (Libin & Cohen-Mansfield, 2004; Woods, Craven, & Whitney, 2005). Davison, Hudgson, McCabe, George, and Buchanan (2007) studied psychogeriatric patients with medication-resistant behavioral problems. The frequency of verbally agitated and aggressive behaviors declined significantly using interventions individualized to both staff and patient (Davison et al., 2007). This study is encouraging because verbally aggressive behaviors are considered particularly resistant to treatment.
For the quality improvement (QI) pilot project presented in the current article, staff nurses on a geriatric-psychiatric unit identified the need for innovative, nonpharmacological therapeutic interventions to decrease mild to moderate agitation in patients with dementia. They then implemented these interventions to treat mild to moderate agitation before administering medication.
The project was approved as a QI project by the QI review committee of the institution where the project occurred.
The QI project took place at a 310-bed urban psychiatric hospital that is part of a large academic medical center. The psychiatric hospital has a national reputation for providing research- and evidence-based treatment to patients with psychiatric disorders.
Participants were inpatients on a geriatric-psychiatric unit with a diagnosis of dementia who demonstrated mild to moderate agitation, as defined by a total score of 1 or 2 on the Pittsburgh Agitation Scale (PAS) (Rosen et al., 1994). Common behaviors associated with mild to moderate agitation included:
- aberrant vocalizations (mild: low volume/not disruptive; moderate: louder than conversation/mildly disruptive);
- motor agitation (mild: pacing/moving at normal rate/purposeless movement; moderate: increased rate of movements/mildly intrusive);
- aggressiveness (mild: verbal threats; moderate: threatening gestures/no attempt to strike); and
- resisting care (mild: procrastination or avoidance; moderate: verbal/gesture of refusal).
Patients were excluded if they could not be physically transported to the multisensory room or if they had visited the room within the past 48 hours.
Thirteen geriatric-psychiatric in-patients ages 61 to 89 (meanage=79.5, SD = 8.6 years) were included in the project, including nine (69.2%) women and four (30.8%) men, all of whom were of Caucasian or non-Hispanic origin. The majority (85%) were educated at high school level or higher. Admission length ranged from 1 to 83 days, with an average of 34.8 days (SD = 29.7 days). Most patients (69.2%) had one or more prior admissions, and four (30.8%) had no comorbid psychiatric diagnoses (e.g., a dementia diagnosis only). The dementia diagnoses included AD (30.8%), early-onset AD (15.4%), Parkinson’s disease (7.7%), and not otherwise specified (38.5%). Patients had two to 10 non-psychiatric comorbidities (mean = 5.6, SD = 2.4).
These 13 patients accounted for 32 visits to the sensory room. Nineteen (59.4%) of the visits were made by patients who had visited the room previously. Eleven (57.9%) of those visits were for patients who had been there one time, and the remaining eight (42.1%) were by patients who had visited two to five times.
The PAS was used to rate agitation based on the observation of aberrant vocalizations, motor agitation, aggressiveness, and resistance to care. The scale has been shown to have good interrater reliability and validity (Rosen et al., 1994). In the current authors’ data, PAS items showed good reliability at each assessment (i.e., pre, post, and 1-hour post assessment; interclass correlation coefficients between 0.60 and 0.77). Each behavior is rated on a scale of 0 (absent) to 4 (highly present). A total PAS score was calculated as the sum of the four behavior ratings.
Nursing staff on the Integrated Adult and Aging Unit of the psychiatric hospital screened all patients diagnosed with dementia using the PAS over 2 weeks. Patients with mild to moderate agitation were escorted to the multisensory room. While in the room with a staff nurse, patients received nonpharmacological therapeutic interventions, including exposure to lavender aromatherapy, soothing music, and dimmed lighting for 15 to 30 minutes. Patients were then escorted to a quiet place on the unit and reassessed using the PAS immediately after the intervention and 1 hour later. PRN medications administered after the intervention to control agitation were also documented. Some patients used the multisensory room again if a period of 48 hours had elapsed since their last visit.
The multisensory room included components shown to be effective nonpharmacological interventions for decreasing agitation. The room measured approximately 12.5 × 9.5 feet and provided enough space to enter comfortably with a wheelchair. The room contained a comfortable, upholstered glider chair; artwork; and a one-wall mural of an outdoor wooded scene. A cabinet was built along one wall and contained the aromatherapy machine. A smaller cabinet that resembled an old-fashioned record player contained a compact disk player to provide soothing music. Lighting in the room was operated by a dimmer switch. Finally, to simulate a comfortable atmosphere, the furnishings were enhanced with a lacy doily, a fuzzy blanket, and a potted plant. When the door was closed, the room provided a quiet atmosphere, separate from the inpatient unit.
SPSS version 20.0 was used for all analyses. Repeated-measures analysis of variance was conducted for each subscale of the PAS and for the total PAS scores. Paired t tests were performed post-hoc to detect pairwise differences in the pre-, post-, and 1-hour post assessment measures for each score.
Patients received a total of 32 nonpharmacological, multisensory interventions. No significant differences were found between patients who had visited the room previously and those who had not experienced a pre-room visit PAS, post-room visit PAS, and 1-hour post-room visit PAS (all p > 0.05). A significant decrease occurred in PAS total scores over time from pre-room intervention to both post-room intervention and 1-hour post-room intervention (F = 95.3, p < 0.001; Figure 1).
Average Pittsburgh Agitation Scale total score (0 = absent to 4 = highly present).
Significant effects were found for all PAS subscales (i.e., aberrant vocalizations, motor agitation, and resistance to care), with the exception of the aggression subscale (Figure 2).
Pittsburgh Agitation Scale subscale scores.
Furthermore, pairwise post-hoc t tests showed a significant decline in PAS overall and subscale scores between pre- and postintervention. A significant decrease in the overall PAS score (3.10 versus 0.71), average agitation scores for vocalizations (0.87 versus 0.32), motor agitation (1.39 versus 0.26), and resistance to care (0.74 versus 0.06; all p < 0.001) demonstrates an immediate response by patients when exposed to the multisensory room experience. No significant decrease occurred in the aggressiveness subscale of the PAS between the pre-intervention and post-intervention assessments.
Between preintervention and 1-hour postintervention assessments, a significant decrease also occurred in aberrant vocalizations (0.87 versus 0.16), motor agitation (1.39 versus 0.29), resistance to care (0.74 versus 0.06), and overall PAS scores (3.10 versus 0.55; all p < 0.001), which indicates that the calming effect of the sensory room lasted past the immediate postintervention PAS assessment. Moreover, no significant differences occurred on any subscales or overall PAS scores between the postintervention and 1-hour postintervention PAS assessments (Table).
Pittsburgh Aggression Subscale and Total Scores (N = 32)
Finally, in additional support of the observed longer-term effects of exposure to the sensory room, a PRN medication was required within the 1-hour postintervention period for only one (3.2%) patient of the total of 32 multisensory room interventions.
In the QI pilot project of non-pharmacological therapeutic interventions on an inpatient geriatric-psychiatric unit that is presented in the current article, the multisensory room experience provided an immediate and long-term (i.e., up to 1 hour) decrease in some of the agitation symptoms observed in patients. The project’s findings compliment findings from other studies (Brodaty & Arasaratnam, 2012; Kong et al., 2009; Lin et al., 2007; Staal et al., 2007; van Weert, van Dulmen, Spreeuwenberg, Ribbe, & Bensing, 2005). Specifically, a decrease occurred in aberrant vocalizations, motor agitation, and resistance to care. However, a significant decrease did not occur in the aggression subscale of the PAS, perhaps because preintervention aggression scores were low even before the intervention was initiated.
Nonpharmacological interventions are available to nurses without a physician’s order. By including nonpharmacological interventions in the plan of care, nurses can use sensory interventions, which provide staff with choices based on individual patient assessments, the ability to evaluate effectiveness of the intervention for individual patients, and the flexibility to revise the plan as necessary. Magai, Cohen, and Gomberg (2002) reported that high caregiver-expressed emotion was a predictor for increased negative behaviors in patients with dementia. In addition, their study with nurses on a dementia care unit found that disruptive behaviors affect the nurse–patient relationship.
The QI pilot project presented in the current article included only a small convenience sample. Although data were collected on the number of prior visits to the sensory room, the time each patient spent in the room was not documented. The staff members who escorted patients were instructed to use the room for 15 to 30 minutes, depending on patient reaction. Researchers also did not document how long it took staff to actually escort patients to and from the room.
Nurses can individualize nursing care plans to use one or more sensory interventions without the worry of medication side effects and the added burden associated with initiating/discontinuing medication orders by a physician or nurse practitioner. Nursing staff may experience increased empowerment through the use of nonpharmacological interventions, which may result in improved nurse–patient relationships and decreased negative outcomes, including injury. For patients, these interventions promote less agitation, avoid medication side effects, and improve cooperation with care.
Nurses can also use these tools to teach caregivers and their families about the availability of medication alternatives for preventing or managing agitation in their loved ones, which can lead to positive family responses to care and the potential prevention of premature nursing home placement costs.
The project presented in the current article supports one of the CDC’s (2011) 10 priority actions for improving cognitive health. Interventions to decrease agitation ideally improve effective use of an individual’s maximum cognitive functioning. Untreated behavioral symptoms, including agitation, decreased quality of life, and increased caregiver burden, may hasten early nursing home placement (Gitlin et al., 2012). Future research could expand upon the current QI pilot project to include a larger sample and a cognitive assessment scale pre- and post-intervention.
- Alzheimer’s Association. (2011). 2011 Alzheimer’s disease: Facts and figures. Retrieved from http://www.alz.org/downloads/Facts_Figures_2011.pdf
- Alzheimer’s Association. (2014). 2014 Alzheimer’s disease: Facts and figures. Retrieved from http://www.alz.org/downloads/facts_figures_2014.pdf
- Ayalon, L., Gum, A.M., Feliciano, L. & Areán, P.A. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: A systematic review. Archives of Internal Medicine, 166, 2182–2188. doi:10.1001/archinte.166.20.2182 [CrossRef]
- Brodaty, H. & Arasaratnam, C. (2012). Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. American Journal of Psychiatry, 169, 946–953. doi:10.1176/appi.ajp.2012.11101529 [CrossRef]
- Centers for Disease Control and Prevention. (2011). The CDC healthy brain initiative: Progress 2006–2011. Retrieved from http://www.cdc.gov/aging/pdf/hbibook_508.pdf
- Cohen-Mansfield, J. (2008). Agitated behavior in persons with dementia: The relationship between type of behavior, its frequency, and its disruptiveness. Journal of Psychiatric Research, 43, 64–69. doi:10.1016/j.jpsychires.2008.02.003 [CrossRef]
- Davison, T.E., Hudgson, C., McCabe, M.P., George, K. & Buchanan, G. (2007). An individualized psychosocial approach for “treatment resistant” behavioral symptoms of dementia among aged care residents. International Psychogeriatrics, 19, 859–873. doi:10.1017/S1041610206004224 [CrossRef]
- Gitlin, L.N., Kales, H.C. & Lyketsos, C.G. (2012). Nonpharmacologic management of behavioral symptoms in dementia. Journal of the American Medical Association, 308, 2020–2029. doi:10.1001/jama.2012.36918 [CrossRef]
- Kong, E.H., Evans, L.K. & Guevara, J.P. (2009). Nonpharmacological intervention for agitation in dementia: A systemic review and meta-analysis. Aging & Mental Health, 13, 512–520. doi:10.1080/13607860902774394 [CrossRef]
- Launer, L.J. (2011). Counting dementia: There is no one ‘best’ way. Alzheimer’s & Dementia, 7, 10–14. doi:10.1016/j.jalz.2010.11.003 [CrossRef]
- Libin, A. & Cohen-Mansfield, J. (2004). Therapeutic robocat for nursing home residents with dementia: Preliminary inquiry. American Journal of Alzheimer’s Disease and Other Dementias, 19, 111–116. doi:10.1177/153331750401900209 [CrossRef]
- Lin, P.W., Chan, W.C., Ng, B.F. & Lam, L.C. (2007). Efficacy of aromatherapy (Lavandula angustifolia) as an intervention for agitated behaviours in Chinese older persons with dementia: A crossover randomized trial. International Journal of Geriatric Psychiatry, 22, 405–410. doi:10.1002/gps.1688 [CrossRef]
- Magai, C., Cohen, C.I. & Gomberg, D. (2002). Impact of training dementia caregivers in sensitivity to nonverbal emotional signals. International Psychogeriatrics, 14, 25–38. doi:10.1017/S1041610202008256 [CrossRef]
- Reuben, D.B., Herr, K.A., Pacala, J.T., Pollock, B.G., Potter, J.F. & Semla, T.P. (Eds.) (2013). Dementia. In Geriatrics at your fingertips (15th ed.) (pp. 62–68). New York, NY: American Geriatrics Society.
- Rosen, J., Burgio, L, Kollar, M., Cain, M., Allison, M., Fogleman, M. & Zubenko, G.S. (1994). A user-friendly instrument for rating agitation in dementia patients. American Journal of Geriatric Psychiatry, 2, 52–59. doi:10.1097/00019442-199400210-00008 [CrossRef]
- Sadowsky, C.H. & Galvin, J.E. (2012). Guidelines for the management of cognitive and behavioral problems in dementia. Journal of the American Board of Family Medicine, 25, 350–366. doi:10.3122/jabfm.2012.03.100183 [CrossRef]
- Spira, A.P. & Edelstein, B.A. (2006). Behavioral interventions for agitation in older adults with dementia: An evaluative review. International Psychogeriatrics, 18, 195–225. doi:10.1017/S1041610205002747 [CrossRef]
- Staal, J.A., Sacks, A., Matheis, R., Collier, L., Calia, T., Hanif, H. & Kofman, E.S. (2007). The effects of Snoezelen (multi-sensory behavior therapy) and psychiatric care on the agitation, apathy, and activities of daily living in dementia patients on a short term geriatric psychiatric unit. International Journal of Psychiatry in Medicine, 37, 357–370. doi:10.2190/PM.37.4.a [CrossRef]
- Sung, H.C., Chang, S.M, Lee, W.L. & Lee, M.S. (2006). The effects of group music with movement intervention on agitated behaviours of institutionalized elders with dementia in Taiwan. Complementary Therapies in Medicine, 14, 113–119. doi:10.1016/j.ctim.2006.03.002 [CrossRef]
- van Weert, J.C., van Dulmen, A.M., Spreeuwenberg, P.M., Ribbe, M.W. & Bensing, J.M. (2005). Behavioral and mood effects of snoezelen integrated into 24-hour dementia care. Journal of the American Geriatrics Society, 53, 24–33. doi:10.1111/j.1532-5415.2005.53006.x [CrossRef]
- Woods, D.L., Craven, R.F. & Whitney, J. (2005). The effect of therapeutic touch on behavioral symptoms of persons with dementia. Alternative Therapies in Health and Medicine, 11, 66–74.
Pittsburgh Aggression Subscale and Total Scores (N = 32)
||Pre-Intervention Score (Mean [SD])
||Post-Intervention Score (Mean [SD])
||1-hour Post-Intervention Score (Mean [SD])
|Resistance to care