Printer Friendly

The effectiveness of multistrategies on disruptive vocalization of people with dementia in institutions: a multicentered observational study.

ABSTRACT

The aim of this study was to evaluate the effectiveness of the daily interventions used by the nurses on disruptive vocalization (DV). DV includes all types of disturbing or unacceptable vocal expression: repetitive vocalization, verbal or nonverbal utterances, presented as inappropriate language, repeated and insistent demands, repeated calling out, shouting, complaining, or moaning that does not pertain to their circumstances or environment. A convenience sample of five nursing homes from the north of Italy, in the Friuli Venezia Giulia region, was included in the study. A randomized selection of 87 daily shifts was selected. Institutionalized patients with dementia, but with no associated psychiatric disorders, were eligible. Nurses involved in the study added patients progressively. Nurses involved were asked to keep diaries to record strategies and durations for each episode of DV encountered during the allotted shift. In the total amount of observation time (36,540 minutes), 23.6% (8,653 minutes) of nursing care time involved working with and managing DV patients. The nurses recorded an average of 6.5 (302/46) vocalizations on morning shifts and 7.3 (302/41) during afternoon shifts, with an average duration of about a quarter of an hour each. Managing DV with multistrategies reduces the duration of the DV episode and increases the perceived effectiveness of management.

**********

Disruptive vocalization (DV) is common in patients with dementia (White, Kaas, & Richie, 1996). The term disruptive vocalization includes all types of disturbing or unacceptable vocal expression: repetitive vocalization, verbal or nonverbal noises, presented as inappropriate language, repeated and insistent demands, repeated calling out, shouting, complaining, or moaning that does not pertain to their circumstances or environment (McMinn & Draper, 2005). Ryan, Tainsh, Kolodny, Lendrum, and Fisher (1998) and Algase, Beck, and Kolanowaski (1996) described DV as behavior comparable with other types of agitation typical of patients with dementia.

According to Lai (1999), there is still little known about the prevalence of DV, its manifestation, or its causes in between 11% and 36% of the patients with dementia. Hallberg, Luker, Norberg, Johnsson, and Eriksson (1990) and Hallberg, Norberg, and Eriksson (1990) conducted a study on 74 geriatric patients, 37 of whom demonstrated repetitive vocalization (the other 37 were a control group), adopting continuous semistructured observation from 7.00 a.m. to 10.00 p.m. For 71% of the total observation time (15 hours), the patients were left alone, and the rest of the time was dedicated to resting and nursing care such as personal hygiene and feeding. From their observation, the lack of stimulation that plays a major part in the daily lives of patients with dementia may be a cause of DV. McMinn and Draper (2005) also maintained that repetitive vocalization is associated with being left alone and to the lack of a social network and reduced participation in activities.

Matteau, Landreville, Lappante, and Laplante (2003) described vocalization as a way to communicate unfulfilled needs (physical, psychological, or social) and discomfort. Hunger, pain, insomnia, sadness, the difficulty of forming relationships with other patients, noise, and not being comfortable with the temperature of the environment are all factors that may be a cause of DV. These are also valid in the physical context, determining comfort or discomfort levels.

The effectiveness of management strategies of DV has also been given little attention in literature. Lindgren and Hallberg (1992) presented evidence that the number of vocalizations decreases following individual nursing intervention attempting to prevent social isolation, lack of sensory stimulus, disorientation, discomfort, and pain. More recently, Roth, Stevens, Burgio, and Burgio (2002) documented the effectiveness of strategies used to reduce DV in 66 elderly people in nursing homes. Data were collected before and after a course update on "comprehensive behavior" focused on helping nurses to understand patients' calls for help and for the patient to feel he or she has been understood. Cohen-Mansfield and Werner (1997), on the other hand, showed that managing pain or discomfort with medication reduces the amount of DV. Importantly, the same authors, in 1998, observed that talking to the patients about their past, hobbies, their family, and the weather reduced DV.

Despite the debate, there is little evidence to support the effectiveness of methods used to manage DV (Scottish Intercollegiate Guidelines Network, 2006) other than the associated impact on the patient or on the other patients (e.g., those sharing the same room), on the family, and on the nursing staff (Cohen-Mansfield, Werner, Watson, & Pasis, 1995). Whall, Gillis, Yankou, Booth, and Belel-Bates (1992) documented that, for 147 nurses working in facilities for older persons, DV was the hardest behavioral expression to manage, second only to physical aggression. DV causes emotional tensions, feelings of impotency and frustration, distancing from the patient (McMinn & Draper, 2005), burnout, and stress (Draper et al., 2000). The aim of this study was to evaluate the effectiveness of the daily interventions used by the nurses.

Aims

The aims of the study were as follows:

1. to describe the exposure by time of nurses working in nursing homes to dementia patients' DV and the types of DV during their daily shift work;

2. to describe the nurses' interventions used to manage DV in their daily practice;

3. to discover the effectiveness of these interventions during the DV episode and the nurses' perceptions of their effectiveness; and

4. to describe the determining factors for nurse intervention in DV.

Design

An observational multicentered study design was adopted. In the nursing homes included in the project, patients with dementia were recruited from the first time that DV was encountered for the entire length of the study (2 months). Nurses involved in the study kept a structured diary recording the strategies that they used for managing the observed DV and the duration of each episode.

Sampling

Context

A convenience sample of five nursing homes from the Friuli Venezia Giulia region (in the northeast of Italy) was included in the study (Table 1).

Nurses

Twenty-two nurses out of 39 of those working on the units were included in the study. The inclusion criteria were nurses who (a) gave their consent to be included in the study, (b) had done a specific course on the concepts of DV (first meeting) and on the methods for data collection (second meeting), and (c) had taken care of the same group of patients continuously for more than 80% of their shift. Exclusion criteria were, in particular, nurses involved in administrative or management roles or who were in charge of more than one ward or team and were therefore unable to give continuous care to the same group of patients.

Nurses included had graduated from a college of nursing or from the nursing science course at the university; three of them had a master's degree in geriatric nursing. They averaged 37.6 years old (range = 27-61 years, SD = 6.4 years), and they had worked in the nursing home for an average of 9.2 years (range = 0-33 years, SD = 7.7 years).

Shift Work

The study was done from July to October 2006. Daily shifts (mornings from 7:00 to 14:00 hours and afternoons from 14:00 to 21:00 hours) totaling 609 hours were observed. After having accepted the nurses and prepared them, the researchers selected their shifts to observe during the period considered for the study. A randomized selection of 87 daily shifts, from the 184 managed by the selected nurses during the period, was selected: 46 morning shifts and 41 afternoon shifts.

Patients

Institutionalized patients with dementia, but with no associated psychiatric disorders, were eligible. Nurses involved in the study added patients progressively. The inclusion criteria were patients with (a) a diagnosis of dementia, (b) one or more DV episodes during the randomized shift, and (c) care received by one of the nurses involved in the study. Patients were included progressively from the time they manifested DV behavior.

Thirty-nine patients (34 women and 5 men) were included in the study. They had an average age of 86.6 years (range = 71-97 years, SD = 6.1 years), and they had been institutionalized in the nursing home for an average of 3.3 years (range = 0-14 years, SD = 6.1 years). With reference to their medical records, these patients had an average score of 1.5 in the Mini Mental State Examination (MMSE; range = 0-14, SD = 3.4); 33 of them (89.1%) had an MMSE score of [less than or equal to] 2. Thirty (78%) patients had a Barthel's index score of [less than or equal to] 5.

Procedures Used for Data Collection First Phase

The preliminary phase involved the nurses doing a specific course with researchers to share the concept of DV of McMinn and Draper (2005) to standardize the recognition and documentation of DV. At the end of this course, organized in each nursing home where nurses involved in the study were working, researchers asked the nurses to keep a diary for 1 week to document the strategies they adopted for managing DV in their daily nursing practice. After this week, two researchers (A.P. and E.M.) collected the dairies and independently analyzed the strategies adopted by the nurses; according to the results of this analysis, researchers (A.P., E.M., R.P., and F.B.) decided to define three different DV interventions that nurses had used:

1. single strategy: when nurses used one or more of the following strategies to attend to the patient with DV:

a. speaking to or touching the patient (emotional intervention) and

b. managing a specific need: mobilization, hygiene, nutrition, hydration, or urinary or fecal elimination (physical intervention);

2. multiple strategies: when nurses cared for the patient with DV by combining emotional and physical intervention (e.g., by speaking with patients, touching them, and mobilizing them etc.) one or more times; and

3. pharmacological strategies: when nurses gave the DV patient analgesics, tranquillizers or sedatives.

Changes in the environment or acting as an intermediary between two inpatients were excluded in the list of the strategies because these strategies are congruent with the role of the nurses involved.

The researchers shared this categorization with the nurses involved in the study who suggested including a fourth category titled "no intervention." At times, the nurses did not do anything for DV patients either because they had no time or because of an excessive workload or when they had exhausted all other possible strategies.

Second Phase

The nurses involved were asked to keep a table in their diaries to record all the variables indicated in Table 2 for each episode of DV encountered during each randomized shift. This also included their age, nursing qualifications and experience, and the number of years of experience in nursing homes. They were told that they were free to choose the type of intervention they used for DV to describe their normal, daily nursing practice as well as possible.

The first five shifts worked by each nurse involved were considered as a pilot phase, after which they were given specific feedback on the accuracy of their diaries by the researcher who mentored them and observed the process during the pilot phase.

Ethical Considerations

Specific authorization was obtained from the nursing directors of the nursing homes included. Researchers assured participants' safety, dignity, and personal freedom during the entire research process. Each patient involved was given a number to ensure confidentiality and anonymity. Nurses involved in the study were asked to ensure that only the DV strategies usually done in their daily practice were reported without any changes. The nurses involved were informed about the aims of the study and had given their written consent to participate.

Data Analysis

Data entry and processing was done using the Statistical Package for the Social Sciences Version 12.00 for Windows. The chi-square test was used to compare proportions; the t test and analysis of variance (two-way) test were used to compare differences in the average between two or more groups of variables; Pearson's test was used to explore the correlation between continuous variables. The statistical level of significance accepted was defined as p < .05. To discover the determining factors associated with the most effective intervention on the duration of DV, the variables were processed with a multivariate analysis model, using regression logistics (95% confidence interval [CI]). The multivariate analysis model was adopted to explain determining factors, such as the relevance and the consequences of pharmacological intervention with sedatives for elderly people with dementia with associated DV.

Results

DV

There were 604 episodes of DV: 475 (78.6%) in patients with an MMSE [less than or equal to] 2 and 129 (21.4%) in patients with an MMSE >2. Moaning and making noises were more frequent in patients with an MMSE [less than or equal to] 2 (171, 85.5% vs. 29, 14.5%; [chi square] = 8.572; p = .02) who called out for a shorter period (M = 12.9 minutes, SD = 23.4 minutes vs. M = 19.4 minutes, SD = 23.3 minutes; t = -2.78; p = .006). Patients with an MMSE [less than or equal to] 2 called out more when in their rooms (318, 86.2%) than did those with an MMSE >2 (51, 13.8%). This difference is significant ([chi square] = 32.07, p = .00). Table 3 reports the details of the observed vocalization.

DV Causes

In the nurses' structured observation, the most common causes of DV are loneliness (185, 30.6%) and discomfort (144, 23.8%) related to, for example, incorrect posture or constipation; less frequently, it is caused by physical needs (78, 12.9%), physiopathological alterations determined by the dementia (72, 11.9%), pain (28, 4.6%), lack of visitors (11, 1.8%), or physical inactivity (10, 1.7%). The nurses were unable to hypothesize on the causes of 57 (9.4%) episodes of DV. These episodes of DV lasted 19.3 minutes, longer than the periods of DV observed where the nurses were able to name a cause (13.8 minutes). This difference is not statistically significant (t = 1.62, p = .105).

Interventions, Length of DV Episodes, and the Effectiveness as Perceived by Nurses

Table 4 shows the intervention strategies used by the nurses in their practice to manage DV, the effectiveness of these strategies on the duration of the episode, and its effectiveness as perceived by the nurses. The duration of DV episodes and their perceived effectiveness are inversely correlated (Pearson's test = -0.108, p = .01). The nurses perceived their intervention as being satisfactory in 344 (57%) episodes of DV but unsatisfactory on 260 occasions (43%). The effectiveness perceived in the management of DV by the dissatisfied nurses rated 5.4 on average (SD = 3.1), whereas those who were satisfied rated effectiveness at 7.9 on average (SD = 1.6). This difference is statistically significant (t = 12.38, p = .01). When the nurses use multiple strategies, they feel more satisfied (129/ 183, 70.5%) than when they use a single strategy (203/363, 55.9%) or use drug therapy (12/28, 42.8%). This difference is statistically significant ([chi square] = 32.23, p = .000; Table 4). The staff that use multiple strategies are more likely to feel satisfied than are those who only use a single strategy (odds ratio [OR] = 1.37, 95% CI = 1.02-1.83).

Multivariate Analysis

Multivariate analysis was used to show the factors associated with the choice to use multiple strategies, sedatives, or not doing anything in nursing care intervention with DV patients, and this is reported in Table 5.

Discussion

Context and Patients

There were many patients with dementia in the nursing homes included in the study (346), prevalence varying from less than a quarter (20.6%) of all inpatients to more than half (64.0%). This documents the relevance of the problem in Italian nursing homes and the need to support the nursing staff in managing these patients by improving educational opportunities, revising the nurse-to-patient ratio, and reducing the turnover of nursing aides, often supplied by an agency and, due to their lack of experience with these patients, requiring more supervision by nurses. In facing the facts of high prevalence and the heavy nursing care workload involved, as documented by McMinn and Draper (2005), the nurse-to-patient ratio (1:44) is very limited and varies from one center to the next (from 1:27 to 1:68). However, despite the large number of patients affected by dementia who could have been included in the study (346 in the homes involved), the nurses only included 39 of these because of the restrictive inclusion criteria defined in the study design.

DV

The nurses' management of DV in daily practice in five nursing homes was reported in this study. The nurses' structured observations were carried out over a period of 609 hours, more than was recorded by Hallberg, Luker, et al. (1990) and Hallberg, Norberg, and Johnsson (1993) where 15 were observed, whereas fewer patients were included in a study by Roth et al. (2002) who observed 66.

In the total amount of observation time (36,540 minutes), 23.6% (8,653 minutes) of nursing care time involved working with and managing DV patients. The nurses recorded an average of 6.5 (302/46) vocalizations on morning shifts and 7.3 (302/41) vocalizations during afternoon shifts, with an average duration of about a quarter of an hour each, although 50% of the DV lasted about 10 minutes and only one patient called out continuously during the shift. These data highlight that each nurse included in the study was involved in DV management for about 100 minutes per shift (14.4 minutes for an average of seven times each shift) and illustrate an increased nursing workload and the risk of emotional exhaustion as documented by McMinn and Draper (2005). What has been documented is probably underestimated considering that the nursing staff involved in the recording of data manages an average of 44 patients. Regional laws provide a minimum of 1 healthcare worker per 15 patients, but for the most part, these are nursing aides (Regional Law No. 2089, 2006): For this reason, it would be interesting in the future to also involve the nursing aides who work with the nurses in management of nursing home patients and probably have more contact with the patients.

The types of DV observed are comparable with those documented by McMinn and Draper (2005), mainly occurring in the patient's room where there is more risk of isolation and inactivity (Hallberg, Luker, et al., 1990; Hallberg, Norberg, & Eriksson, 1990; Hallberg et al., 1993). The most common disturbances were calling out and moaning, but the latter is typical of patients with a worse MMSE score.

More than half of the vocalizations (316/602) were associated with movement, as documented by Ryan et al. (1998), and with a mimicking of facial expressions and is accompanied by aggressive or agitated behavior; even if not excessive, this lasts a long time. It is probable that the nurses feel more inclined to answer a call for assistance than episodes of DV where a patient is talking or mumbling to himself, aggressive or agitated, and consequently, they were more conscientious recording the length of time of the first call than the entire period of disturbance.

DV Causes

The causes of DV hypothesized by the nurses were similar to those documented by Matteau et al. (2003) even if they do not appear to be associated with environmental factors (such as temperature and noise) or difficult relationships with other inpatients. In the preliminary phase of the study as well, when the types of interventions used by the nurses to manage DV were listed, changes in the environment and acting as an intermediary between two inpatients were excluded as not being nursing duties.

Loneliness is the main cause (30.6%), as documented by Hallberg et al. (Hallberg, Luker, et al. 1990; Hallberg, Norberg, & Eriksson, 1990; Hallberg et al., 1993), because of the distance of family members; physical discomfort (23.6%) and pain (4.6%) are also common. The nurses had no idea what could have caused 57 episodes of DV: These episodes lasted longer probably because the nurses were unable to understand the cause and so could not plan effective intervention.

Interventions and Effectiveness

Four types of intervention were used: a single physical intervention (attending to hygiene and mobilizing or moving the patient), emotional intervention (touching and using reassuring words), administering medication or doing nothing, or using multistrategies related to physical dimensions (mobilizing or moving the patient and giving him or her something to drink) and emotional aspects (reassurance and touch). These latter strategies are similar to those documented by Hallberg et al. (Hallberg, Luker, et al., 1990; Hallberg, Norberg, & Erkisson, 1990), who reported a reduction in the frequency of verbalization when the patients are managed with interventions that are oriented to understanding their needs.

The outcomes selected to measure the effectiveness of the interventions are different from those documented by Boehm, Whall, Cosgrove, Locke, and Schlenk (1995) who measured the frequency of disruptive behaviors, and this was similar to that documented by Cohen-Mansfield and Werner (1997) who monitored the duration of the DV, relating this with three different modes of intervention. The duration of the DV episodes and the level of effectiveness perceived by the nurses were researched: In fact, when they perceived the strategies to be effective, the nurses were less likely to suffer from stress-related disorders or burnout (Chrisman, Tabar, Whall, & Booth, 1991; Draper et al., 2000; Nagaratnam, Patel, & Whelan, 2003). As documented also by McMinn and Draper (2005), DV can also create a distancing from the patient, an automatic response for the nurses to protect themselves from negative feelings of being incapable of handling the situation. What emerged from the study is that the nurses who used multiple strategies have 37% more probability of being satisfied with their work.

The most effective strategies for limiting the duration of DV were, in order, the use of multiple strategies, the administration of pain killers, and the management of physical needs, whereas only attending to the emotional needs of the patient did not appear to be as effective. When multiple strategies are used, the nurses seem to have a "considerably attentive" attitude toward the patients, attempting to understand their needs, having more ways to "provide for physical and psychological needs," "show concern," and "get to know the patient," the same four attributes mentioned in literature as the concepts of caring (Cutcliffe & McKenna, 2005). For these reasons, the multiple strategies adopted by the nurses to manage DV can be classified as caring interventions. Managing DV with caring strategies reduces the duration of the DV episode and increases the perceived effectiveness of management.

An excessive duration of DV managed with sedative drugs may occur because of the time it takes for the drug to take affect, whereas the limited effectiveness perceived by the nurses when using this type of therapy seems to express their frustration at not being able to find other suitable ways to look after this type of patient.

Determining Factors

The multivariate analysis results showed that in some situations nurses more often adopted multiple strategies in the management of DV. Considering the ORs and the p value, the following types of patients have more likelihood of being cared for using multiple strategies than the others:

1. those whose disturbance took the form of moaning or groaning,

2. those who stayed in their rooms,

3. those who had been institutionalized for more than

3 years,

4. those with an MMSE score >2, and

5. those who the nurses hypothesize are lonely.

Also, an older staff member is more likely to use multiple strategies (OR = 12.432, 95% CI = 2,885-53,600). In the context of the study, it becomes apparent that, over a period of years of experience nursing this type of patient, it has probably been more effective to use more strategies. These attitudes may have been determined by getting to know the patients very well, getting to know their preferences and values, and considering that they felt they had been admitted into the nursing home in a better state than they actually were and that the nurses understood them. However, patients who were verbally disruptive in the afternoon were more likely to be given sedatives, and this seemed to show that the nurses wanted to guarantee that they slept at night. Even the use of sedatives seems to depend on the experience of the nurses: Nurses with more than 9 years of experience are less likely to use sedatives than are younger nurses (OR = 0.184; 95% CI = 0.064-0.529). Factors associated with the absence of strategies did not show up.

The patients who need to be studied in future research because they are less often managed with actual caring strategies (and are therefore at risk of only receiving a single intervention to satisfy physical or emotional needs) are those with the worst MMSE ratings. These patients are totally alone, have less communicative ability, are more fragile, and are those where the cause of the DV is the most difficult to discover. In future research, it would be interesting to study the differences that emerged in this study between nurses who work with nursing home patients with more or less experience (more than 9 years or less) in that field.

Limitations

The study has numerous limitations: The observations of nursing care practice were those as reported by the nurses in five nursing homes. Too few nurses were asked to report the length of the episode of DV, and the documentation may contain errors due to imprecise reporting by the nurses involved, although reports are assumed to be distributed uniformly between the different strategies used.

Conclusions and Indications for Practice

The objectives for trained nurses and others who provide care to elderly people with dementia are to look for new ways and test strategies to prevent their isolation, to guarantee sensory stimulation, to improve their quality of life, and above all to maintain their dignity and maintain maximum comfort. Often, a combination of factors, the patient's problems with communication and cognitive deterioration, an excessive workload on the part of the staff, and their frustration with the ineffectiveness of interventions, results in the needs of the people with dementia remaining unexpressed. The nurses have difficulty interpreting and managing them because of their complexity.

DV is common in patients with dementia (between 11% and 36%). Despite the frequency, there is still little known about the management of DV and the related effectiveness of nursing care. DV causes emotional tensions, feelings of impotency and frustration, distancing from the patient, burnout, and stress both in the families and in the nursing staff.

Nurses manage from six to seven DV on each shift in the nursing home. From their point of view, the main cause is loneliness. The most effective strategies for limiting the duration of DV were, in order, the use of multiple strategies, the administration of antipain drugs, and the management of physical needs. The patients who were more compromised in their MMSE assessment had a major risk of isolation and receiving single strategy care that was not effective. The effectiveness of caring strategies seems to have a positive affect not only during the DV episode but also on the nurses and their satisfaction in managing difficult situations like DV.

References

Algase, D., Beck, C., & Kolanowaski, A. (1996). Need-driven dementia--compromised behaviour: An alternative view of disruptive behaviour. American Journal of Alzheimer's Disease, 11(1), 10-19.

Boehm, S., Whall, A. L., Cosgrove, K. L., Locke, J. D., & Schlenk, E. L. (1995). Behavioural analysis and nursing interventions for reducing disruptive behaviours of patients with dementia. Applied Nursing Research, 8(3), 118-122.

Chrisman, M., Tabar, D., Whall, A., & Booth, D. (1991). Agitated behaviour in the cognitively impaired elderly. Journal of Housing for the Elderly, 17(12), 9-13.

Cohen-Mansfield, J., & Werner, P. (1997). Management of verbally disruptive behaviours in nursing home residents. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 52(6), M369-M377.

Cohen-Mansfield, J., Werner, P., Watson, V., & Pasis, S. (1995). Agitation among elderly persons at adult day-care centres: The experience of relatives and staff members. International Psychogeriatrics, 7(3), 447-458.

Cutcliffe, J. R., & McKenna, H. P. (2005). The essential concepts of nursing. Philadelphia: Elselvier Churchill Livingstone.

Draper, B., Snowdon, J., Meares, S., Turner, J., Gonski, R, Mc Minn, B., et al. (2000). Case controlled study of nursing home residents referred for treatment of vocally disruptive behaviour. International Psychogeriatrics, 12 (3), 333-344.

Hallberg, I., Luker, H., Norberg, A., Johnsson, K., & Eriksson, S. (1990). Staff interaction with vocally disruptive demented patients compared with demented controls. Aging, 2(1), 163-171.

Hallberg, I., Norberg, A., & Eriksson, S. (1990). A comparison between the care of vocally disruptive patients and that of other residents in psycho geriatric wards. Journal of Advanced Nursing, 15(4), 410-416.

Hallberg, I., Norberg, A., & Johnsson, K. (1993). Verbal interaction during the lunch-meal break between caregivers and vocally disruptive demented patients. American Journal of Alzheimer's Care and Related Disorders' and Research, 8(3), 26-32.

Lai, C. (1999). Vocally disruptive behaviour in people with cognitive impairment: Current knowledge and future research directions. American Journal of Alzheimer's Disease, 14(3), 172-180.

Lindgren, C., & Hallberg, I. (1992). Diagnostic reasoning in the care of a vocally disruptive severely demented patient. Scandinavian Journal of Caring Sciences, 6(2), 97-103.

Matteau, E., Landreville, P., Lappante, L., & Laplante, C. (2003). Disruptive vocalisation: A means to communicate in dementia. American Journal of Alzheimer's Disease and Other Dementias, 18(3), 147-153.

McMinn, B., & Draper, B. (2005). Vocally disruptive behaviour in dementia. Development of an evidence based practice guideline. Aging and Mental Health, 9(1), 16-24.

Nagaratnam, N., Patel, I., & Whelan, C. (2003). Screaming, shrieking and muttering: The noise-makers amongst dementia patients. Archives of Gerontology and Geriatrics, 36(3), 247-258.

Regional Law No. 2089. (2006). Approvazione linee strategiche regionali in materia di tutela della salute e protezione sociale dell'anziano e di indirizzo per la nuova classificazione del sistema delle strutture residenziali per anziani.

Roth, D. L., Stevens, A. B., Burgio, L. D., & Burgio, K. L. (2002). Timed event sequential analysis of agitation in nursing home residents during personal care interactions with nursing assistants. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 57B(5), 461-468.

Ryan, D., Tainsh, S., Kolodny, V., Lendrum, B. L., & Fisher, R. H. (1998). Noise-making amongst the elderly in long term care. Gerontologist, 28(83), 369-363.

Scottish Intercollegiate Guidelines Network. (2006). Management of patients with dementia. Clinical guideline. Scotland, United Kingdom: National Heath Service, Quality Improvement.

Whall, A., Gillis, G., Yankou, D., Booth, D. E., & Belel-Bates, C. A. (1992). Disruptive behaviour in elderly nursing home residents. A survey of nursing staff. Journal of Housing for the Elderly, 18(10), 13-17.

White, M., Kaas, M., & Richie, M. (1996). Vocally disruptive behaviour. Journal of Housing for the Elderly, 22(11), 23-29.

Questions or comments about this article may be directed to Alvisa Palese, MSN BCN RN, at alvisa.palese@uniud.it. She is an associate professor in nursing sciences at the University of Udine, Udine, Italy.

Elisa Menegazzo, BCN RN, is a staff nurse at the University of Udine, Udine, Italy.

Francesca Baulino, BCN RN, is a staff nurse in the Specialist Surgical Department, Azienda Ospedaliero-Universitaria Udine, Udine, Italy.

Raffaella Pistrino, BCN RN, is a staff nurse at the Nursing Home, Istituto Geriatrico per Anziani, Udine, Italy.

Carla Papparotto, MSC BCN RN, is the director of nursing services, Nursing Home, Tarcento, Udine, Italy.
TABLE 1. Nursing Homes Included in the Study

Nursing Institutionalized With
Home Patients (n) Dementia (a) (n)

1 52 20
2 68 14
3 45 12
4 165 46
5 397 254
Total 727 346

Nursing With Nurse:Patient
Home Dementia (%) Ratio (24 hours)

1 38.5 1:52
2 20.6 1:68
3 26.7 1:45
4 28.0 1:27
5 64.0 1:28
Total 47.6 1:44

(a) Registered in the medical records.

TABLE 2. Variables

1. Type of vocalization
 a. Moaning or groaning
 b. Call for help
 c. Expressing needs (e.g., "I'm thirsty")
 d. Repeated nonsense
 e. Screaming or yelling
 f. Speaking or muttering to himself or herself
 g. Singing
2. Place where DV occurs: bedroom, sitting room,
 dining room, corridor, or garden
3. Cause of DV according to the nurses: pain, loneliness,
 discomfort (e.g., position), or physical needs
4. Behavior associated with DV: physical movement,
 mimicking expressions, physical or mimicking
 movement, crying, or no mimicking or physical
 movement.
5. The patient's emotional state according to the nurses
 a. Agitated, aggressive, or angry
 b. Sad, upset, or depressed
 c. Normal
6. Strategies adopted by the nurses to attend to DV
 a. Single strategy
 b. Multiple strategies
 c. Pharmacological strategies
 d. None
7. Effectiveness of intervention
 a. Quantitative: on the duration of vocalization in
 minutes from the moment it starts to its cessation
 b. Qualitative:
 The effectiveness of the intervention as perceived
 by the nurse (numerical rating scale from 0
 [not effective] to 10 [maximum effectiveness])

 The impact on the nurse following the
 management of each episode of DV: satisfied
 or not satisfied

Note. DV = disruptive vocalization.

TABLE 3. Type, Duration, Context, and Characteristics of DV

 n %

DV 604 100.0
 Morning (7:00-13:59) 302 50.0
 Afternoon (14:00-20:59) 302 50.0
Duration
 Randomized shifts 87 100
 Total duration of DV -- --
 Average duration of DV -- --
 25% 169 28.1
 50% 574 97.3
 75% 594 98.6
Type of DV
 Call for help 271 44.9
 Moaning or groaning 200 33.1
 Nonsensical phrases 54 8.9
 Expressing needs 45 7.5
 Speaking or muttering to
 himself or herself 18 3.0
 Singing 11 1.8
 Screaming or yelling 5 0.8
Context
 Bedroom 369 61.1
 Sitting room 92 15.2
 Dining room 75 12.4
 Corridor 65 10.8
 Garden 3 0.5
Associated with
 Physical movement 281 46.5
 Mimicked expressions 127 21.0
 Physical or mimicking movement 35 5.8
 Crying 53 8.8
 No movement or other
 expression 108 17.9
Emotional content
 Agitated, aggressive, or angry 177 29.3
 Sad or depressed 154 25.4
 Normal 262 43.4

 Duration,
 M [+ or -] SD (minutes)

DV
 Morning (7:00-13:59) 12.9 [+ or -] 16.0
 Afternoon (14:00-20:59) 15.7 [+ or -] 29.1
Duration
 Randomized shifts 36,540 (609 hours)
 Total duration of DV 8,653 (144.21 hours)
 Average duration of DV 14.4 (1-420 [+ or -] 23.5 minutes)
 25% [less than or equal to] 5
 50% [less than or equal to] 10
 75% [less than or equal to] 15
Type of DV
 Call for help 16.0 [+ or -] 29.9
 Moaning or groaning 13.8 [+ or -] 20.5
 Nonsensical phrases 10.6 [+ or -] 7.6
 Expressing needs 12.0 [+ or -] 8.5
 Speaking or muttering to
 himself or herself 11.5 [+ or -] 5.4
 Singing 17.2 [+ or -] 6.4
 Screaming or yelling 11 [+ or -] 5.47
Context
 Bedroom 15.3 [+ or -] 26.2
 Sitting room 12.2 [+ or -] 10.5
 Dining room 11.3 [+ or -] 8.0
 Corridor 15.3 [+ or -] 31.5
 Garden 10 [+ or -] 5
Associated with
 Physical movement 16.4 [+ or -] 32.0
 Mimicked expressions 10.3 [+ or -] 7.9
 Physical or mimicking movement 16.9 [+ or -] 19.4
 Crying 11 .8 [+ or -] 9.0
 No movement or other
 expression 14.1 [+ or -] 12.3
Emotional content
 Agitated, aggressive, or angry 16.2 [+ or -] 18.2
 Sad or depressed 11.7 [+ or -] 6.4
 Normal 14.1 [+ or -] 31.2
 p

DV t = -1.46, p = .14
 Morning (7:00-13:59)
 Afternoon (14:00-20:59)
Duration --
 Randomized shifts
 Total duration of DV
 Average duration of DV
 25%
 50%
 75%
Type of DV F = 0.61, p = .72
 Call for help
 Moaning or groaning
 Nonsensical phrases
 Expressing needs
 Speaking or muttering to
 himself or herself
 Singing
 Screaming or yelling
Context F = 0.7, p = .58
 Bedroom
 Sitting room
 Dining room
 Corridor
 Garden
Associated with F = 1 .73, p = .14
 Physical movement
 Mimicked expressions
 Physical or mimicking movement
 Crying
 No movement or other
 expression
Emotional content F = 1 .54, p = .21
 Agitated, aggressive, or angry
 Sad or depressed
 Normal

Note. DV = disruptive vocalization.

TABLE 4. Effectiveness of Nursing Care Interventions Used to
Manage DV

Intervention n %

1. Single strategy
 a. Speaking with patient or
 physical touch 245 40.5
 b. Mobilization or hygiene or
 feeding 118 19.5
2. Multiple strategies 183 30.3
3. Pharmacological strategies
 a. Sedative or tranquillizer 18 3.0
 b. Analgesic 10 1.7
4. No intervention 30 5.0
Total 604 100.0

 Duration of DV, (a)
 Average Minutes
Intervention (95% CI)

1. Single strategy
 a. Speaking with patient or
 physical touch 15.13 (11.02-19.24)
 b. Mobilization or hygiene or
 feeding 13.12 (11.48-14.76)
2. Multiple strategies 11.49 (9.79-13.18)
3. Pharmacological strategies
 a. Sedative or tranquillizer 29.72 (12.17-47.27)
 b. Analgesic 12.10 (7.72-16.48)
4. No intervention 22.86 (15.79-29.93)
Total 14.37 (12.49-16.26)

 Effectiveness Perceived
 by Nurses, NRS
 0 Minimum-10 Maximum, (b)
Intervention Average (95% CI)

1. Single strategy
 a. Speaking with patient or
 physical touch 6.31 (5.99-6.64)
 b. Mobilization or hygiene or
 feeding 8.49 (8.12-8.86)
2. Multiple strategies 7.23 (6.94-7.52)
3. Pharmacological strategies
 a. Sedative or tranquillizer 6.89 (5.50-8.27)
 b. Analgesic 7.90 (7.04-8.76)
4. No intervention 2.47 (0.96-3.97)
Total 6.87 (6.65-7.09)

Note. DV = disruptive vocalization; CI = confidence interval.

(a) F = 2.994, p = .01. (b) F = 34.967, p = .00.

TABLE 5. Factors Determining the Choice of Intervention

Factors Associated With the Use
 Of Multiple Strategies OR 95% CI p

Afternoon versus morning shift 0.979 0.663-1.445 .915
Moaning versus other forms of DV 3.529 2.163-5.756 .020
Bedroom versus other places 1.621 1.043-2.518 .032
DV associated with movement
 versus none 0.937 0.605-1.450 .769
DV associated with aggression
 versus no aggression 0.798 0.184-3.455 .763
DV caused by loneliness versus
 other causes 2.305 1.442-3.685 .000
Patient's age [greater than or
 equal to] 86 years 1.403 0.880-2.238 .155
Institutionalized [greater than
 or equal to] 3 years 1.491 0.840-2.646 .173
MMSE [greater than or equal to] 2 10.421 3.593-30.229 .000
Female patients 1.010 0.544-1.874 .976
Relationship between nurse and
 patient [less than or equal
 to] 1:28 2.081 0.441-9.815 .354
Seniority of nursing staff member
[greater than or equal to]
 9 years experience 12.435 2.885-53.600 .001
Factors Associated With the
 Administration of Sedatives or
 Tranquillizers
Afternoon versus morning shift 4.448 1.31-15.11 .0017
Moaning versus other forms of DV 0.249 0.016-3.393 .326
Bedroom versus other places 0.740 0.232-2.362 .611
DV due to pain versus none 0.000 0.000- .998
DV associated with movement
 versus none 0.895 0.207-3.871 .882
DV associated with aggression
 versus no aggression 3.211 0.900-11.460 .072
Patient's age [greater than or
 equal to] 86 years 0.950 0.316-2.852 .927
Institutionalized [greater than
 or equal to] 3 years 0.259 0.018-3.645 .317
MMSE [greater than or equal to] 2 0.000 0.000- .995
Female patients 0.402 0.108-0.488 .172
Seniority of nursing staff member
 [greater than or equal to]
 9 years of experience 0.184 0.064-0.529 .002

Note. DV = disruptive vocalization; OR = odds ratio;
CI = confidence interval; MMSE = Mini Mental State Examination.
COPYRIGHT 2009 American Association of Neuroscience Nurses
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2009 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Palese, Alvisa; Menegazzo, Elisa; Baulino, Francesca; Pistrino, Raffaella; Papparotto, Carla
Publication:Journal of Neuroscience Nursing
Geographic Code:4EUIT
Date:Aug 1, 2009
Words:6591
Previous Article:Hemolytic uremic syndrome: a case review.
Next Article:Erratum.
Topics:

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters