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## Complete Summary

#### GUIDELINE TITLE

Non-pharmacologic management of agitated behaviors in persons with
Alzheimer disease and other chronic dementing illnesses.

#### BIBLIOGRAPHIC SOURCE(S)

McGonigal-Kenney ML, Schutte DL. Non-pharmacologic management of
agitated behaviors in persons with Alzheimer disease and other chronic
dementing conditions. Iowa City (IA): University of Iowa Gerontological
Nursing Interventions Research Center, Research Dissemination Core;
2004. 54 p. \[132 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Gerontological Nursing
Interventions Research Center (University of Iowa), Research Development
and Dissemination Core. Alzheimer\'s disease and chronic dementing
illnesses. Iowa City (IA): University of Iowa; 1996. 65 p.
(Research-based protocol; no. 1996).

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Dementia

-   Alzheimer disease

-   Other chronic dementing illnesses (e.g., Pick\'s disease, Huntington
    disease, and Parkinson disease)

#### GUIDELINE CATEGORY

Management

#### CLINICAL SPECIALTY

Geriatrics\
Neurology\
Nursing\
Psychiatry

#### INTENDED USERS

Advanced Practice Nurses\
Nurses

#### GUIDELINE OBJECTIVE(S)

To discuss evidence-based non-pharmacologic interventions designed to
decrease the frequency of agitated behaviors, thereby supporting
functional ability and enhancing quality of life for persons
experiencing Alzheimer Disease (AD) and other chronic dementing
conditions

#### TARGET POPULATION

Institutionalized patients with Alzheimer disease or chronic dementing
illnesses

#### INTERVENTIONS AND PRACTICES CONSIDERED

-   Patient screening using Mini-Mental State Examination

-   Assessment of patterns of agitated behavior using Cohen-Mansfield
    Agitation Inventory

-   General communication techniques including verbal and non-verbal
    techniques

-   Sensory enhancement/relaxation, such as massage and touch
    interventions, individualized music, white noise, sensory
    stimulation

-   Social contact including individualized social contact, pet therapy,
    one-to-one interaction, simulated interactions/family videos

-   Behavior therapy including differential reinforcement and stimulus
    control

-   Structured activities, such as recreational activities, outdoor
    walks, physical activities

-   Environmental interventions including access to wandering areas,
    natural/enhanced environment, reduced stimulation, light therapy

#### MAJOR OUTCOMES CONSIDERED

-   Functional ability

-   Quality of life for persons with dementia and their caregivers

-   Frequency and severity of agitated behaviors

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches using the
following sources: Medline, Cumulative Index to the Nursing and Allied
Health Literature (CINAHL).

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

The grading schema used to make recommendations in this evidence-based
practice protocol is as follows:

A.  Evidence from well-designed meta-analysis

B.  Evidence from well-designed controlled trials, both randomized and
    nonrandomized, with results that consistently support a specific
    action (e.g., assessment, intervention, or treatment)

C.  Evidence from observational studies (e.g., correlational descriptive
    studies) or controlled trials with inconsistent results

D.  Evidence from expert opinion or multiple case reports

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This protocol was reviewed by experts knowledgeable of research on
non-pharmacological management of agitated behaviors in persons with
Alzheimer\'s disease and development of guidelines. The reviewers
suggested additional evidence for selected actions, inclusion of
additional practice recommendations and changes in the protocol
presentation to enhance its clinical utility.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The grades of evidence (A-D) are defined at the end of the \"Major
Recommendations\" field.

**General Strategies to Assess, Monitor, and Prevent Agitated
Behaviors**

**Assessing Patterns of Agitated Behaviors**

The first step in managing agitation is to assess and record patterns of
behavior (Cohen-Mansfield, 2000; Hall, 1988; Hall, 1994; Hall &
Buckwalter, 1991; Teri & Logsdon, 2000) (*Evidence Grade = D*). One goal
of this assessment is to identify the underlying cause, or triggers, for
the agitated behaviors. The following questions may assist caregivers in
determining if patterns exist:

-   What specifically occurred?

-   When does the behavior occur?

-   Where does the behavior occur?

-   Who was present before or when the behavior occurred?

-   Was there an obvious antecedent to the behavior?

-   Is there an identifiable underlying unmet need or trigger?

**Avoiding Triggers for Agitated Behaviors**

Once triggers for agitated behaviors are identified, caregivers can take
steps to reduce the frequency of these triggers, avoid the triggers, or
minimize the impact of the trigger (Cohen-Mansfield, 2000; Hall, 1988;
Hall, 1994; Hall & Buckwalter, 1991; Teri & Logsdon, 1991) (*Evidence
Grade = D*). These steps may include meeting underlying needs or
avoiding known triggers, such as physical restraints.

I.  *Meet Physiological Needs*

> If a physiological need is identified as a trigger for the agitated
> behaviors, intervene to meet the resident\'s need (Cohen-Mansfield,
> 1996; Cohen-Mansfield & Werner, 1995; Ragneskog et al., 1998)
> (*Evidence Grade = C*). For example:

-   Offer food and/or fluids.

-   Treat pain and discomfort (Douzjian et al., 1998) (*Evidence Grade =
    C*).

-   Maintain bowel and bladder continence.

-   Offer extra clothing or remove extra clothing.

-   Support sensory reception.

    a.  Evaluate hearing and arrange for necessary assistive device
        (Palmer et al., 1999) (*Evidence Grade = C*).

    b.  Evaluate vision deficits and provide adequate lighting and/or
        corrective devices.

II. *Evaluate and Monitor Physical Restraint Use*

> Physical restraint use may trigger agitated behaviors. Therefore,
> restraint-reduction programs may be effective interventions for
> decreasing all types of agitated behaviors. Initiating such a program
> entails an educational component as well as an array of alternative
> interventions tailored to fit the resident\'s individual needs (Werner
> et al., 1994) (*Evidence Grade = C*).

**General Communication Approaches to Residents at Risk for Agitated
Behaviors**

A number of general communication techniques may be used to prevent or
manage agitated behaviors. Overall these techniques attempt to match the
health care provider and resident\'s conversation to the resident\'s
comprehension ability. These strategies also help the resident maintain
a sense of control to the extent that this is possible. These
communication approaches are important with all resident interactions,
including the specific interventions described in a subsequent section.

I.  *Verbal Communication Techniques*

> Use verbal communication techniques that are appropriate for persons
> with chronic dementing conditions. (Hall, 1988; Hall, 1994; Hall &
> Buckwalter, 1991) (*Evidence Grade = D*). For example:

-   Identify self with each interaction.

-   Slowly approach the resident from the front while telling them what
    you are going to do (Teri & Logsdon, 1991) (*Evidence Grade = D*).

-   Keep voice volume appropriate for distance and ability to hear.

-   Use a normal speech rhythm. Speaking too fast or in an irritated,
    excited manner may cause agitation.

-   Maintain an accepting, calm manner by using a reassuring and gentle
    tone of voice (Teri & Logsdon, 1991) (*Evidence Grade = D*).

-   Communicate face-to-face with simple, concrete, positive statements.
    For example, tell the resident what is wanted instead of what is not
    wanted (e.g., \"Please sit in the chair,\" instead of \"Don\'t pace
    in the hallway.\").

-   Distract the resident with questions about the problem and gradually
    turn their attention to a pleasant, unrelated subject. This may be
    accompanied by a change in activity, move to another room, or
    temporary leave from the situation (Teri & Logsdon, 1991) (*Evidence
    Grade = D*).

-   Give directions or ask questions slowly and one at a time. Attempt
    to match the provider\'s language complexity with the comprehension
    ability of the resident (Hart & Wells, 1997) (*Evidence Grade = C*).

-   Relate to the resident in a familiar way. Be knowledgeable about
    their occupation, family status, hobbies, and special interests.

-   Talk with, not at, the resident.

-   Be an active listener; allow for expression of feelings and share
    your understanding of their situation (e.g., \"You sound angry.\").

-   Avoid arguing or attempts at reasoning with the resident; such
    attempts tend to escalate agitation (Teri & Logsdon, 1991)
    (*Evidence Grade = D*).

-   Listen carefully to the resident\'s response; do not assume s/he
    understands what was said.

II. *Non-Verbal Communication Techniques*

> Use non-verbal communication techniques that are appropriate for
> persons with chronic dementing conditions. For example:

-   Supplement verbal communication with gestures or cues when possible.

-   Use non-threatening postures during interactions, such as standing
    or sitting at eye level rather than standing over the resident (Teri
    & Logsdon, 1991) (*Evidence Grade = D*).

-   Avoid sudden emphatic movements; use slow, deliberate gestures when
    appropriate.

-   Use touch judiciously, along with calm, soothing speech (Teri &
    Logsdon, 1991) (*Evidence Grade = D*). This approach helps to
    alleviate stress and anxiety, provide comfort and reassurance, and
    reinforce calm behavior (Kim & Buschmann, 1999) (*Evidence Grade =
    C*).

**Specific Interventions to Prevent and Manage Agitated Behaviors**

The following section includes a broad assortment of interventions to
manage agitated behaviors and is offered collectively as an alternative
to pharmacologic agents and restraint usage. Specific interventions are
categorized into six areas: sensory enhancement/relaxation, real or
simulated social contact, behavior therapy, structured activities,
environmental modifications, and staff development (Beck & Shue, 1994;
Cohen-Mansfield, 2001). Table 3 of the original guideline document
summarizes the specific interventions that fall within these broad
intervention categories.

**Sensory Enhancement/Relaxation**

Activities stimulating the senses and inducing relaxation have the
potential for reducing agitated behaviors among residents with Alzheimer
Disease (AD) and other chronic dementing conditions. The following
section describes interventions that attempt to stimulate the
resident\'s senses or induce relaxation, including massage and touch;
music therapy; white noise; and combination sensory stimulation
approaches.

I.  *Massage and Touch Intervention*

> Slow-stroke massage, hand massage, and therapeutic touch are specific
> interventions that have been tested in persons with chronic dementing
> conditions to decrease stress, enhance relaxation, and reduce agitated
> behaviors. Protocols for these techniques are described below.

A.  A Slow-Stroke Massage Protocol (Rowe & Alfred, 1999) (*Evidence
    Grade = C*):

    1.  Reduce noise from television, stereo, or any other extraneous
        noise.

    2.  Attempt to use the same location and time for each massage
        session.

    3.  Limit conversation to comments such as \"You are relaxing. Your
        neck, shoulders, and back feel warm, quiet, and relaxed.\"

    4.  Reduce your stress, because caregiver tension can be transferred
        to the resident. Therefore, before beginning the massage
        intervention, take 3 deep, slow breaths, pulling all of the
        tension in the body up and out with each breath. Imagine a
        bright ball of healing energy, bringing calmness that fills your
        body and finally flows from your fingers. Begin the massage when
        you feel relaxed. \[Note: Step 4 is to be completed by the
        person providing the massage intervention.\]

    5.  Seat the resident in a chair leaning over a table onto pillows.

    6.  Firmly grasp and knead the top of the resident\'s shoulders with
        both hands (2 minutes).

    7.  Place the first two fingers or thumbs of each hand on the second
        indentations at or just below the base of the resident\'s skull,
        making tiny circular movements on the upper neck (30 to 45
        seconds).

    8.  Place the palm of one hand at the base of their skull and make
        long, smooth strokes all of the way down the spine to the waist.
        The second hand follows the first at the base of the skull and
        strokes down the spine as the first hand returns to the base of
        the skull to start another stroke, and so forth. Strokes are
        continuous, sweeping movements down the spine with the effect of
        continuous contact (1 to 2 minutes).

    9.  Place hands on the sides of the resident\'s neck under the ears
        and stroke down and over the collarbones with the thumbs just
        over his/her shoulder blades. Repeat the motion several times
        (45 seconds).

    10. Place the thumb of each hand beside the spine, beginning at the
        shoulders. Walk the thumbs down the spine to the waist and up
        the spine to the neck. Repeat several times (1 minute).

    11. Knead the upper back and shoulders again (1 to 2 minutes).

    12. Finish by placing palms on each side of the neck. Make
        continuous, long, sweeping strokes down the neck, across each
        shoulder, and down the back near the spine. Repeat the entire
        pattern several times (1 minute). Each massage stroke is
        intended to bring relaxation, using slow and rhythmic strokes.
        The length of time for each stroke, as well as the time between
        strokes, should be the same.

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B.  A 5-Minute Hand Massage Protocol (Kilstoff & Chenoweth, 1998;
    Snyder, Egan, & Burns, \"Efficacy of hand massage,\" 1995; Snyder,
    Egan, & Burns, \"Interventions,\" 1995; Snyder & Olson, 1996)
    (*Evidence Grade = C*):

    1.  Assess the resident\'s hands for open wounds, redness,
        irritation, and other skin conditions. Do not massage any
        injured, reddened, or swollen portion of the hand.

    2.  Seat the resident comfortably, preferably in their room.

    3.  Explain the procedure using concrete, simple terms.

    4.  Apply a small amount of oil to the resident\'s hand.

    5.  Use the following stroke sequence on the back of the hand:
        effleurage, using moderate pressure (short/medium-length
        straight, rhythmic, gliding strokes which follow the fiber
        direction of the underlying muscle from wrist to fingertips);
        large half-circular stretching strokes from center to side of
        hand, using moderate pressure; small circular strokes (making
        little O\'s with thumb) over entire back of hand, using light
        pressure; and featherlike, straight strokes from wrist to
        fingertips, using very light pressure.

    6.  Use the following stroke sequence on the palmar surface:
        effleurage, using moderate pressure (short/medium-length
        straight, rhythmic, gliding strokes which follow fiber direction
        of underlying muscle from wrist to fingertips); petrissage
        (kneading, gently lifting and squeezing the skin); small
        circular strokes (making little O\'s with thumb) over the entire
        palm of the hand, using moderate pressure; and large
        half-circular stretching strokes from the center of the palm to
        the sides, using moderate pressure.

    7.  Gently palpate the resident\'s fingers from base to tip on the
        sides and top/bottom surfaces, using light pressure. Follow with
        circular range of motion exercises for each digit and gently
        squeeze each nail bed.

    8.  Conclude by laying the resident\'s hand on yours and cover it
        with your other hand. Gently draw the resident\'s hand toward
        you several times. Turn their hand over and gently draw the hand
        toward you several times.

    9.  Repeat steps 4 to 8 for the other hand.

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C.  A Ten-Minute Therapeutic Touch Protocol (Snyder et al.,
    \"Interventions,\" 1995; Woods & Dimond, 2002) (*Evidence Grade =
    C*). Please refer to the Web site for Nurse Healers-Professional
    Associates International at
    [www.therapeutic-touch.org](http://www.therapeutic-touch.org/) for
    further training information on therapeutic touch techniques:

    1.  Seat the resident comfortably, preferably in their room.

    2.  Explain the procedure using concrete, simple terms.

    3.  Center self. Centering requires the provider to quiet
        himself/herself, direct attention inward, and concentrate on the
        wholeness of the resident with dementia. The centered provider
        is able to direct energies and attention to the resident.

    4.  Place hands on the resident\'s shoulder area in middle of
        his/her back. Perform the following gentle movements: down and
        up back, up neck, behind ears, and rest one hand on the forehead
        while making contact with the back of the neck using other the
        hand.

    5.  Transmit calming energy throughout movements. When rebound
        energy is felt, use unruffling (sweep hands over the length of
        the resident\'s body in long, rhythmic strokes) to smooth out
        energy fields and remove areas of congestion, thereby
        distributing the energy across all body surfaces.

    6.  Conclude by resting hands on the resident\'s shoulders.

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II. *Individualized Music*

> A substantial body of evidence demonstrates the effectiveness of
> individualized music as an intervention for agitated behaviors among
> persons with chronic dementing conditions by stimulating remote memory
> and sensation (Casby & Holm, 1994; Clark, Lipe, & Bilbrey, 1998;
> Cohen-Mansfield & Werner, 1997; Gotell, Brown, & Ekman, 2000;
> Ragneskog et al., 2001; Snyder & Olson, 1996) (*Evidence Grade = B*).
> Refer to the \"Evidence-Based Practice Protocol: Individualized
> Music\" for the complete description of the intervention (Gerdner,
> 2001).

III. *White Noise*

> White noise, defined as any low intensity, slow, continuous, rhythmic,
> monotonous sound, may be used as an auditory stimulation intervention
> for decreasing agitated behaviors. The use of environmental white
> noise has shown potential as an effective treatment for reducing the
> frequency of verbal agitation in some persons with dementia (Burgio et
> al., 1996) (*Evidence Grade = C*), as well as other types of agitated,
> restless behaviors (Young, Muir-Nash, & Ninos, 1988) (*Evidence Grade
> = C*). Examples of environmental white noise and other types of white
> noise, respectively, include:

-   Audiotapes containing sounds of mountain streams and ocean waves

-   A whirling fan, humming air conditioner, or other type of
    environmental sound generator

IV. *Sensory Stimulation*

> Sensory stimulation activities involving music, touch, and smell may
> be implemented alone or in combination to enhance psychological
> well-being and induce relaxation, thus potentially reducing distress
> and decreasing the prevalence of agitated behaviors (Ballard et al.,
> 2002; Brooker et al., 1997; Holtkamp et al., 1997; Snyder & Olson,
> 1996; Witucki & Twibell, 1997) (*Evidence Grade = C*).

A.  A combination approach using massage/touch and auditory stimulation
    entails the following (Snyder & Olson, 1996) (*Evidence Grade = C*):

    -   Provide hand massage to each hand for approximately five minutes
        (please refer to the hand massage protocol under the
        \"Massage/Touch\" section).

    -   Play musical tapes of religious hymns, easy listening classics,
        or new age music, depending upon family and/or staff indication
        of resident preference. The use of a Spinoza bear™, or similar
        product, may be used to further stimulate the senses. The
        Spinoza bear™ is a stuffed bear that contains a tape
        recorder/player and hugs the person when held.

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B.  Approaches using aromatherapy, either alone or in combination with
    other sensory stimulating activities, include the following:

    1.  Aromatherapy used alone (Ballard et al., 2002) (*Evidence Grade
        = C*)

        -   Prior to the intervention, provide the resident with a brief
            verbal description of what will happen. Combine *Melissa
            officinalis* (lemon balm) essential oil with an odorless
            base lotion.

        -   Apply mixture topically to the resident\'s face and both
            arms twice a day.

        -   Use approximately 0.16 to 0.17 g per dose for a total of 6
            doses per day.

        -   Gently apply the cream for 1 to 2 minutes.

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    2.  Aromatherapy, used alone or in combination with massage/touch
        (Brooker et al., 1997) (*Evidence Grade = C*)

        -   Prior to the intervention, provide the resident with a brief
            verbal description of what will happen. Seat the resident in
            a comfortable chair with an aroma fan placed at shoulder
            level.

        -   Spread enough pure lavender oil onto a palette to last for
            30 minutes.

        -   Switch fan on 10 minutes prior to the session.

        -   Hand and lower arm massage may be provided separately or
            simultaneously with the aromatherapy treatment.

        -   If the resident becomes intolerant of massage, holding their
            hand may be an alternative option for providing the touch
            stimulation.

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    3.  Aromatherapy used in combination with music and massage (Witucki
        & Twibell, 1997) (*Evidence Grade = C*):

        -   Use as part of the resident\'s regularly scheduled activity
            plan.

        -   Prior to the intervention, provide the resident with a brief
            description of what will happen.

        -   Play recorded music selections identified by families as
            enjoyable for the resident in the past.

        -   Hold and massage the resident\'s hand for five minutes
            (please refer to the hand massage protocol under the
            \"Massage/Touch\" section).

        -   Offer various odors individually (e.g., orange, cinnamon,
            coffee, chocolate, flowers) to the resident\'s nostrils for
            five minutes.

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C.  Another combination approach that has demonstrated a positive effect
    on decreasing agitated behaviors in some studies involves the
    utilization of a multisensory stimulation environment (Burns, Cox, &
    Plant, 2000; Chitsey, Haight, & Jones, 2002; Finnema et al., 2000;
    Holtkamp et al., 1997; Lancioni, Cuvo, & O\'Reilly, 2002) (*Evidence
    Grade = C*):

    -   Snoezelen® is an individual-oriented, multisensory,
        environmental intervention aimed at promoting a general feeling
        of restoration, trust, and refreshment among persons with
        developmental disabilities, such as AD and other chronic
        dementing conditions.

    -   The intervention focuses on the physical arrangement of space
        and stimuli as well as the functional role of the staff taking
        part in Snoezelen®.

    -   The intervention is achieved by combining soft music,
        aromatherapy, textured objects, favorite foods, and colored
        lighting.

**Social Contact: Real or Stimulated**

Several interventions strive to increase the frequency and quality of
social interaction for persons with chronic dementing conditions in
order to minimize sensory deprivation and social isolation, and thereby
to prevent or reduce the incidence of agitated behaviors. The following
section describes interventions that attempt to enhance social
interactions, including individualized social contact, pet therapy,
one-to-one social interactions, and simulated social interactions. Many
of these interventions can be delivered individually or in a group
format.

I.  *Individualized Social Contact*

> The goals of individualized social contact interventions are to
> provide pleasant activities that match the resident\'s interests and
> abilities, as well as activities that take advantage of the
> resident\'s strengths rather than deficits (Draper et al., 2000;
> Mitchell & Maercklein, 1996; Teri & Logsdon, 1991) (*Evidence Grade =
> C*). For example:

-   Attain the resident\'s history, including their occupation, hobbies,
    leisure activities, strengths, and weaknesses to help identify
    meaningful activities.

-   Determine the resident\'s original language; persons who are of a
    non-English-speaking background may benefit from an intervention
    program individualized according to their original language (Runci,
    Doyle, & Redman, 1999) (*Evidence Grade = C*).

-   Create interventions based on the resident\'s personal and social
    history. For example, a person whose occupation was a textile
    salesperson may participate in an activity of matching squares of
    fabric and discussing what might be made with each type of cloth.
    This provides an opportunity to reminisce, capitalize on current
    abilities, touch different textures, and interact with the health
    care provider. Other examples of meaningful activities include:

    a.  Potting or attending to flowers or plants

    b.  Appropriate cleaning tasks

    c.  Laundry tasks

    d.  Cooking (with appropriate supervision)

    e.  Self-expression (e.g., music, coloring or painting, drawing, and
        using clay)

    f.  Individual or group painting (start a picture and have each
        person add to it)

    g.  Reminiscence (the vocal or silent recall of events in a
        person\'s life and life review; reminiscence can occur alone,
        with another person, or as a group activity) (Woods et
        al., 1992) (*Evidence Grade = D*)

    h.  Life review (a form of structured reminiscing that helps persons
        formulate their life stories according to the hopes or goals
        that they\'ve set for themselves. This occurs through the
        process of reviewing, organizing, and evaluating the overall
        picture of one\'s life).

    i.  Card playing (persons with early AD can still play cards with
        subtle reminders; persons with moderate AD can play simple games
        such as War or Old Maid, perhaps using only half a deck of
        cards; persons with moderate to severe AD can match cards
        according to color or suit)

II. *Pet Therapy*

> Pet therapy, or the use of companion animals, produces positive
> effects for persons with AD and other chronic dementing conditions via
> several mechanisms. Resident interactions with therapy animals may
> increase socialization (Kongable, Buckwalter, & Stolley, 1989;
> Kongable, Stolley, & Buckwalter, 1990). (*Evidence Grade = C*), induce
> relaxation, provide distraction, and/or provide physical contact. Pet
> therapy also may serve as an effective intervention for reducing the
> frequency of agitated behaviors in institutionalized persons with AD
> and other chronic dementing conditions (Churchill et al., 1999; Fritz
> et al., 1995; Zisselman et al., 1995) (*Evidence Grade = C*). For
> example:

-   Churchill and colleagues (1999) demonstrated short-term exposure to
    a therapy dog ameliorated agitated behaviors, particularly during
    the commonly regarded period of agitation known as sundown syndrome.
    Animal therapy can increase socialization behaviors and may be used
    in conjunction with other calming interventions.

-   Fritz and associates (1995) concluded that interaction with a
    companion animal may temper agitation and aggression by reducing
    episodes of anxiety, verbal aggression, and hyperactive behaviors.

-   Visit the Alliance for Psychosocial Nursing\'s Web site at
    [www.psychnurse.org](http://www.psychnurse.org/) for more
    information regarding the use of dogs for pet therapy.

III. *One-to-one Interaction*

> Engaging a resident in one-to-one social interaction may aid in the
> prevention and management of agitated behaviors (Beck et al., 1998;
> Cohen-Mansfield, 1996; Cohen-Mansfield & Werner, \"Determinants,\"
> 1998; Draper et al., 2000) (*Evidence Grade = C*). One-to-one
> activities involving more interaction appear to be most effective
> (Cohen-Mansfield & Werner, 1997) (*Evidence Grade = C*). In addition,
> this intervention strategy may be more effective for persons
> exhibiting verbally agitated behaviors who are less cognitively and
> less functionally impaired (Cohen-Mansfield & Werner,
> \"Determinants,\" 1998) (*Evidence Grade = C*). Examples of 1:1 social
> interaction include:

-   Provide direct stimulation, appropriately engaging the resident in
    activities of varying levels of demand. Examples of things to
    include in the activity are talking, singing, hands-on activity,
    exercising, touch, food, and theme bags. Theme bags contain items
    having to do with a particular topic to look at, discuss, and share
    memories about. A \"children\" theme bag may include toys, a yo-yo,
    a doll, watercolors, crayons, and a top, while a \"cooking\" theme
    bag may include dry pastas, measuring spoons, recipes, cookbooks,
    and spices.

-   Use the time spent with the resident while performing activities of
    daily living (ADLs) to maximize one-to-one social interaction. For
    example:

    a.  Engage the resident in range-of-motion exercises by tossing
        balls, moving hands and arms.

    b.  Encourage sensory stimulation by using textured items, make-up,
        spices, or soaps.

    c.  Provide manual activities such as clipping coupons (Note: use
        safety scissors) or putting puzzles together.

    d.  Use conversation to discuss personal information and/or
        feelings, specific holidays, favorite things, or other topics
        unrelated to specific daily tasks (e.g., positive remarks about
        the resident\'s appearance, family photos in person\'s room, and
        birds heard outside). Nursing staff can conduct one-way
        conversations to demonstrate the resident is valued even though
        they may be unable to respond appropriately in return (Chen et
        al., 2000) (*Evidence Grade = D*).

IV. *Simulated Interaction/Family Videos*

> Simulated social interaction interventions, also called simulated
> presence therapy (SMT), use media such as videotapes and/or audiotapes
> to simulate an interaction with a person who is important to the
> resident with dementia. SMT is based on the belief that the most
> central source of stability for the resident is a family member or
> surrogate, and the presence of this person provides the resident with
> comfort. Creating such a tape, therefore, seeks to replicate the
> relative\'s or surrogate\'s presence and induce the sense of comfort
> (Woods & Ashley, 1995) (*Evidence Grade = C*). Examples of simulated
> interaction include:

A.  Provide family-generated videotapes or interactive audiotapes to
    provide auditory and/or visual stimulation as well as indirect
    interaction with a relative (Camberg et al., 1999; Cohen-Mansfield,
    1996; Cohen-Mansfield & Werner, 1997; Cohen-Mansfield & Werner,
    \"Determinants,\" 1998; Woods & Ashley, 1995) (*Evidence Grade =
    C*). For example:

    -   Identify cherished memories and other best loved experiences
        from the resident\'s lifetime to ensure a personalized
        intervention. Videotapes characterized by expressions of love
        and issues related to past events rather than to current events
        tend to be more effective in reducing agitated behaviors,
        particularly verbally disruptive behaviors (Werner et al., 2000)
        (*Evidence Grade = C*).

    -   Introduce the memories to the resident in the format of a
        one-sided telephone conversation with a family member or
        surrogate, rich in selected memories and positive emotions,
        using a continuous play audio tape system. Incorporate soundless
        spaces to correspond to the resident\'s side of the
        conversation.

    -   The approximately 15-minute intervention may be used for
        extended periods of time since each repetition is viewed as a
        fresh, live telephone call.

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B.  Play Video Respite (VR)™ tapes to induce a calming effect and
    resolve conflictual situations that may lead to agitation (Hall &
    Hare, 1997; Lund et al., 1995). (*Evidence Grade = D*).

    -   This intervention simulates interaction via conversational,
        slow-paced, and simple messages.

    -   Messages contain positive themes to enhance self-esteem as well
        as people and experiences residents are most likely to have
        ingrained in their long-term memories.

    -   VR Tapes™ are generic in nature, but several may be selected
        based upon the resident\'s cultural background (e.g., \"Sharing
        Christmas Cheer,\" \"A Kibbitz with David,\" and \"Celebrating
        African American Culture\").

**Behavior Therapy**

Behavior therapy includes interventions that attempt to change the
frequency, intensity, duration, or location of a specific behavior or
set of behaviors by systematically varying antecedent stimuli and/or
consequential events. Behavior therapy, as a term, is often used
interchangeably with behavior management, behavioral interventions,
behavioral strategies, and behavior modification (Boehm et al., 1995)
(*Evidence Grade = C*). Specific categories of behavior therapy
interventions described in this protocol include differential
reinforcement and stimulus control.

I.  *Differential Reinforcement*

> Psychosocial management techniques that involve differential
> reinforcement of behavior can reduce agitated behaviors among persons
> with AD and other chronic dementing conditions. For example,
> contingent reinforcement of quiet behavior and environmental
> stimulation tailored to individual preferences and past history may
> reduce the frequency of noisemaking behaviors (Birchmore & Clague,
> 1983; Doyle et al., 1997) (*Evidence Grade = C*). In addition,
> differential reinforcement (the use of tangible reinforcers, such as
> food) and extinction (attention given in the absence of the behavior)
> also may reduce the frequency of wandering behaviors (Heard & Watson,
> 1999) (*Evidence Grade = C*).

A.  Identify and develop behavioral interventions through the following
    behavioral analysis technique (Boehm et al., 1995) (*Evidence Grade
    = C*):

    -   Observe, document, and analyze the resident\'s behavior using
        the following framework:

        a.  Antecedent events preceding and serving as the stimuli for
            agitated behaviors

        b.  Small steps of the behavior comprising the whole behavior

        c.  Consequences following the behavior

    -   Based on step #1, an effective behavioral plan may include the
        following:

        a.  Antecedents to prompt calm behavior may include eye contact,
            a calm interaction, slow movements, a constant flow of soft
            and gentle words of encouragement, explanations of what will
            be done, and a warm cloth applied to the skin.

        b.  Prompt calm, cooperative behavior by reinforcing with food
            or praise for each small step toward the desired behavior.

        c.  Compliments, soothing speech, praise, and/or food may serve
            as reinforcing consequences that support resident
            cooperation.

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B.  Employ the following types of interventions together (Doyle et
    al., 1997) (*Evidence Grade = C*):

    -   Reinforce quiet behavior positively, using rewards tailored to
        each individual such as a favorite food. Put noisy behavior on
        an extinction schedule by ignoring noise.

    -   Distract residents with music, conversation, touch, or a visual
        aid.

    -   Provide extra stimulation, such as music, tapes of familiar
        voices, olfactory stimulation using pleasant odors, tactile
        stimulation of different types of materials, and social
        interactions.

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C.  Differential reinforcement techniques can also be implemented during
    daily care routines to reduce agitated behavior (Lewin &
    Lundervold, 1987) (*Evidence Grade = C*). The behavioral
    rehabilitation intervention used by Rogers and colleagues (1999)
    (*Evidence Grade = C*) consists of the following activities:

    -   Skill elicitation, where retained ADL skills are identified and
        elicited

    -   Habit training, where retained skills are reinforced and
        solidified and further functional gains are facilitated

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II. *Stimulus Control*

> Stimulus control techniques are another category of behavior therapy
> that may reduce the incidence of agitated behaviors. Specifically,
> residents may be conditioned to associate a specific cue with
> information or a behavior in order to modify agitated behavior (Bird,
> Alexopoulos, & Adamowicz, 1995; Hanley, 1981) (*Evidence Grade = C*).
> For example:

-   Hussian (1988) used verbal and/or physical prompts given to the
    resident to attend to a variety of enhancing stimuli followed by
    exposure to the stimuli without prompting (*Evidence Grade = C*).

-   A stimulus control intervention aimed at limiting potentially
    hazardous ambulation, such as elopement or wandering, includes the
    following (Hussian, 1982; Hussian & Brown, 1987; Mayer &
    Darby, 1991) (*Evidence Grade = C*):

    a.  Using a grid configuration, place 3, 4, or 6 one and one-half
        inch strips of tape horizontally on the floor in front of the
        exit door, with the last strip of tape placed 3 feet from the
        end of the hallway. Alternatively, a full-length mirror placed
        approximately 30 cm in front of the main exit ward door may be
        used. Mark its position on the floor to make sure it remains in
        the same place. The mirror must be placed in a position where
        the exit door can still be easily opened. The goal is to provide
        supernormal, artificial stimuli with sufficiently simplified and
        magnified characteristics (i.e. size, shape, color)

    b.  Verbally prompt resident to look down at the grid pattern (or
        mirror).

    c.  Grid pattern (or mirror) serves as the stimulus preventing
        elopement.

**Structured Activities**

Structured activities include interventions that engage the resident in
structured physical activities to prevent boredom and decrease
agitation. The following section describes interventions that attempt to
engage the resident in recreational activities, outdoor walks, and
physical activities.

I.  *Recreational Activities*

> Recreational interventions (Aronstein, Olsen, & Schulman, 1996) and
> other structured activities programs (Sival et al., 1997) may be
> helpful in the management of agitated behaviors in residents with AD
> and other dementias (*Evidence Grade = C*). A specific example of a
> recreational activity intervention used to diffuse and divert agitated
> behaviors as well as to engage residents during idle time includes the
> following (Aronstein, Olsen, & Schulman, 1996):

-   Individualize recreational interventions according to the
    resident\'s interest and strengths.

-   Incorporate an array of tactile, auditory, sensory, and visual
    stimulation.

-   Provide a range of complexities to respond to the varying cognitive
    and motor skills of the resident. Recreational activity types
    include:

    a.  Nurturing (e.g., dolls, stuffed animals)

    b.  Tactiles (e.g., fabric books, squeeze balls)

    c.  Sound/music (e.g., xylophones, bells)

    d.  Sewing (e.g., fabric squares, lacing tiles)

    e.  Sorting/perception (e.g., wood sorter, puzzles)

    f.  Manipulatives (e.g., bead mazes, flexible cubes)

II. *Outdoor Walks*

> A walking program designed to meet the physical and social needs of
> residents with AD and other dementias may reduce agitated behaviors
> (Hall, 1988; Hall, 1994; Hall & Buckwalter, 1991) (*Evidence Grade =
> D*), including unsafe wandering (Holmberg, 1997) (*Evidence Grade =
> C*). A suggested program facilitating an outlet for physical energy
> and interpersonal interaction includes the following (Cohen-Mansfield
> & Werner, \"The effects of an enhanced environment,\" 1998) (*Evidence
> Grade = C*):

-   Provide group walks through public areas of the nursing home or
    outdoors as tolerated by the resident.

-   Include time and places for residents to rest.

-   Escort residents to an outdoor garden using 1:1 supervision as an
    individualized approach to this activity.

III. *Physical Activities*

> Physical exercise decreases agitation behaviors by providing an outlet
> for anger and frustration as well as an alternative to repetitive,
> disruptive activities (Beck et al., 1992) (*Evidence Grade = D*). A
> sensorimotor program designed to improve strength and flexibility may
> effectively reduce agitated behaviors, as well as improve grip
> strength and flexibility among persons with AD and other chronic
> dementing conditions. For example:

A.  The Neurodevelopmental Sequencing Program (NDSP) is a type of
    sensorimotor program that uses a developmental approach to exercise
    and motor skills, and it includes the following (Buettner, 1995;
    Buettner et al., 1996):

    -   Specialized equipment to promote movement and success
        experiences

    -   Planned activities that match the functional abilities of the
        resident

    -   Programs planned around familiar themes (e.g., \"State Fair
        Days\" and \"Back to Nature\")

    -   Activities provided collaboratively by therapeutic recreation
        and nursing staff

    -   Activities performed using a group format. Therapy groups may be
        created by prescribing residents to different groups based on
        their cognitive and overall functioning.

    -   Programming/modalities provided may include the following:
        sensory air mat therapy; sensory stimulation box program;
        sensory special events; geriatric exercise/relaxation program;
        build your own games; sensory herb garden/adapted garden;
        sensory cooking program; the price is right cognitive therapy;
        special event prep program (gross motor arts); and wanderer\'s
        leisure lounge (area set up for independent leisure pursuits).

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B.  The Exercise/Movement Protocol for Alzheimer\'s Disease (TEMP-AD) is
    a program that provides opportunity for physical exercise, thereby
    decreasing agitated behavior (Namazi, Gwinnup, & Zadorozny, 1994).
    TEMP-AD consists of the following:

    -   A low-intensity exercise program conducted indoors

        a.  10-minute warm-up phase

        b.  20-minute light exercise/movement phase

        c.  10-minute cool-down phase

    -   Encouragement of active participation rather than perfection in
        executing routines

    -   Demonstration of movements to facilitate understanding of
        program routine

    -   Provision of verbal instructions to further cue residents\'
        participation

    -   Instruction on correct breathing techniques

    -   Stressed importance of stopping if resident feels discomfort or
        excessive fatigue

**Environmental Interventions**

Several environmental interventions exist that may decrease the
frequency of agitated behaviors by providing a home-like atmosphere,
reducing unnecessary stimulation, maintaining safety, protecting
autonomy and independence, and supporting normal sleep/wake cycles. The
following section describes interventions that attempt to decrease
agitation through environmental modifications, including wandering
areas, enhanced natural environments, reduced environmental stimulation,
and light therapy.

I.  *Wandering Areas*

> Interventions aimed at providing the freedom to go outdoors or have
> access to extra space for wandering may decrease the occurrence of
> agitated behaviors (Namazi & Johnson, 1992) (*Evidence Grade = C*),
> particularly verbal and physical aggression (McMinn & Hinton, 2000)
> (*Evidence Grade = C*). Such interventions include:

-   Unlocking exit doors leading to outdoor walking paths. Outdoor
    walking paths and courtyards need to be secured with fences or walls
    to prevent elopement.

-   Providing residents a release from mandatory confinement

-   For a complete description of interventions used to reduce problem
    wandering behavior, see the UIGN guideline \"Evidence-Based Practice
    Protocol: Wandering\" (Futrell & Mejillo, 2002).

II. *Natural/Enhanced Environments*

> Enhancing the resident\'s care environment by including natural
> elements or decorative objects may produce a positive effect on
> agitated behaviors.  For example:

A.  One environmental modification approach incorporates and focuses on
    natural elements within the care environment rather than on the care
    procedure or agitated behavior (Whall et al., 1997) (*Evidence Grade
    = C*):

    -   During the provision of care (e.g., bathing activities), do the
        following to draw upon the resident\'s early memory and induce a
        calming, restorative effect:

        a.  Play recorded bird songs, sounds of babbling brooks, and/or
            sounds of other animals.

        b.  Show large, bright pictures.

        c.  Allow the resident to taste a familiar food (e.g., pudding
            or soda).

        d.  Engage the resident in identifying the sound heard, picture
            seen, or food tasted.

        e.  If the resident responds to one or more of the natural
            elements, continue a discussion on the particular element.

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B.  Another environmental approach focuses on enhancing the resident\'s
    environment using decorative objects to create a nature-scene or a
    family-like scene (Cohen-Mansfield & Werner, \"The effects of an
    enhanced environment,\" 1998) (*Evidence Grade = C*).

    -   Decorate corridors, where residents who frequently pace spend
        much of their time.

    -   Include visual, auditory, and olfactory stimuli that are
        considered familiar to residents.

    -   Create a nature scene by including the following:

        a.  Display wall murals or posters of forests, valleys, and
            other colored vistas.

        b.  Add artificial plants and trees.

        c.  Play tape-recorded nature sounds (e.g., bird sounds).

        d.  Stimulate olfactory senses using an aroma diffuser machine
            (e.g., Aveda EPA-1000 may be used to replicate the smell of
            a forest).

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    -   Create a home or family-like scene by including the following:

        a.  Display enlarged black-and-white photos of family scenes
            from the early 1940s and 1950s.

        b.  Pictures of persons familiar to the general public (e.g.,
            President Kennedy) may also be posted.

        c.  Use artificial plants.

        d.  Play tape-recorded music.

        e.  Provide a citrus aroma to further stimulate the senses.

        f.  A home-like atmosphere may be further enhanced by adding an
            armchair or similar furniture piece next to a coffee table
            with books.

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III. *Reduced Stimulation*

> Environmental modifications to reduce the level of sensory
> stimulation, minimize the resident\'s reliance on memory, and/or meet
> individual needs are associated with reductions in agitated behaviors
> (Cleary et al., 1988; Gold et al., 1991; Hall, Kirschling, & Todd,
> 1986; Leon & Ory, 1999; Meyer et al., 1992; Teri & Logsdon, 1991)
> (*Evidence Grade=C*).

-   The following strategies aim to create an environment that balances
    low stimuli with appropriate opportunities for social interaction:

    a.  Provide adequate and safe space for exploration and release of
        physical energy by moving tables and/or other furniture. If
        possible, enclosed wandering areas are beneficial.

    b.  Provide appropriate furniture and equipment to create a relaxed,
        home-like environment.

    c.  Provide soft yet adequate lighting to enhance a calming effect
        (Teri & Logsdon, 1991) (*Evidence Grade = D*).

    d.  Respect personal space and provide privacy to maintain
        self-esteem.

    e.  Provide environmental cues or modifications to minimize reliance
        on memory. Examples of environmental cues include arrows
        pointing to bathroom, signs that use pictures instead of words,
        nightlights, and Velcro fasteners instead of buttons.

    f.  Control noise levels; decrease intercom use and monitor TV
        and/or radio volume.

    g.  Monitor and limit noise-producing activities when appropriate.

IV. *Light Therapy*

> Agitated behavior in residents with AD or other chronic dementing
> conditions may worsen and increase at nighttime or near sunset, a
> phenomenon commonly referred to as sundown syndrome. Additionally,
> sleep patterns among the elderly and those with dementia may be
> disrupted, creating an irregular sleep-wake cycle that further
> contributes to the incidence of agitated behaviors. Interventions for
> decreasing agitation include light therapy according to the following
> protocols:

-   Increase the light intensity used during meal times to enhance
    visual stimulation; this may be further facilitated by setting the
    table to maximize visual contrast (e.g., the use of a white
    tablecloth with high contrast glasses and napkins) (Koss &
    Gilmore, 1998) (*Evidence Grade = C*).

-   Implement bright light (2500 to 5000 lux) therapy (Lovell,
    Ancoli-Israel, & Gevirtz, 1995; Lyketsos et al., 1999; Mishima et
    al., 1994; Thorpe et al., 2000) (*Evidence Grade = C*) according to
    the following guidelines:

    a.  Place a light box containing full-spectrum fluorescent lamps 1 m
        from the resident at a height within his/her visual field.

    b.  The resident should be in their most comfortable position.

    c.  Administer the intervention for approximately two hours in the
        morning.

    d.  The resident may enjoy another activity (e.g., watching
        television, eating) during the intervention while intermittently
        glancing at the light source.

**Definitions**:

**Evidence Grading**

A.  Evidence from well-designed meta-analysis

B.  Evidence from well-designed controlled trials, both randomized and
    nonrandomized, with results that consistently support a specific
    action (e.g., assessment, intervention, or treatment)

C.  Evidence from observational studies (e.g., correlational descriptive
    studies) or controlled trials with inconsistent results

D.  Evidence from expert opinion or multiple case reports

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=6221)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Improved quality of life for persons with dementia and their care
    providers.

-   Improved functional ability

-   Decreased frequency and severity of agitated behaviors

-   Reduced incidence of adverse occurrences related to chronic
    dementing illness.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This evidence-based practice protocol is a general guideline. Patient
care continues to require individualization based on patient needs and
requests.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The \"Evaluation of Process Factors and Resident Outcomes\" section and
the appendices of the original document contain a complete description
of implementation strategies.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Chart Documentation/Checklists/Forms\
Resources\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

McGonigal-Kenney ML, Schutte DL. Non-pharmacologic management of
agitated behaviors in persons with Alzheimer disease and other chronic
dementing conditions. Iowa City (IA): University of Iowa Gerontological
Nursing Interventions Research Center, Research Dissemination Core;
2004. 54 p. \[132 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2004)

#### GUIDELINE DEVELOPER(S)

University of Iowa Gerontological Nursing Interventions Research Center,
Research Translation and Dissemination Core - Academic Institution

#### SOURCE(S) OF FUNDING

Developed with the support provided by Grant #P30 NRO3979, National
Institute of Nursing Research, NIH

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Meghan L. McGonigal-Kenney, BSN, RN; Debra L. Schutte, PhD,
RN

*Series Editor*: Marita G. Titler, PhD, RN, FAAN

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Gerontological Nursing
Interventions Research Center (University of Iowa), Research Development
and Dissemination Core. Alzheimer\'s disease and chronic dementing
illnesses. Iowa City (IA): University of Iowa; 1996. 65 p.
(Research-based protocol; no. 1996).

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available from the University of Iowa Gerontological
Nursing Interventions Research Center, Research Dissemination Core, 4118
Westlawn, Iowa City, IA 52242. For more information, please see the
[University of Iowa Gerontological Nursing Interventions Research Center
Web
site](http://www.nursing.uiowa.edu/products_services/evidence_based.htm).

#### AVAILABILITY OF COMPANION DOCUMENTS

The original guideline document and its appendices include a variety of
implementation tools, including outcome and process indicators, staff
competency material, and other forms.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 30, 1999. The information
was verified by the guideline developer on June 23, 1999. This NGC
summary was updated by ECRI on February 4, 2005. The information was
verified by the guideline developer on March 4, 2005.

#### COPYRIGHT STATEMENT

This summary is based on content contained in the original guideline,
which is subject to terms as specified by the guideline developer. These
summaries may be downloaded from the NGC Web site and/or transferred to
an electronic storage and retrieval system solely for the personal use
of the individual downloading and transferring the material. Permission
for all other uses must be obtained from the guideline developer by
contacting the University of Iowa Gerontological Nursing Intervention
Research Core.

### DISCLAIMER

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