Emotional Intervention Strategies for Dementia-Related Behavior: A Theory Synthesis

Behavioral disturbances of elders with dementia are prevalent. Yet the science guiding development and testing of effective intervention strategies is limited by rudimentary and often-conflicting theories. Using a theory-synthesis approach conducted within the perspective of the need-driven dementia-compromised behavior model, this article presents the locomoting responses to environment in elders with dementia (LRE-EWD) model. This new model, based on empirical and theoretical evidence, integrates the role of emotion with that of cognition in explicating a person-environment dynamic supporting wandering and other dementia-related disturbances. Included is evidence of the theory’s testability and elaboration of its implications. The LRE-EWD model resolves conflicting views and evidence from current research on environmental interventions for behavior disturbances and opens new avenues to advance this field of study and practice. Questions or comments about this article may be directed to Lan Yao, PhD RN, at lyao@umich.edu. She is an assistant research scientist at the University of Michigan School of Nursing, Ann Arbor, MI. Donna Algase, PhD RN FAAN FGSA, is a Josephine M. Sana collegiate professor of nursing at the University of Michigan School of Nursing, Ann Arbor, MI. Copyright © 2008 American Association of Neuroscience Nurses 0047– 2606/08/4002/0106$5.00 Vol. 40 No. 2 April 2008 107 Theory Development Approach Theory synthesis was chosen as the model construction approach because it affords a way to build theory from empirical evidence. Walker and Avant (2005) proposed a synthesis method consisting of three steps: specify focal concepts, identify factors related to focal concepts and relationships among them, and organize concepts and statements into an integrated representation of the phenomena of interest. Step 1. Focal Concepts Consistent with the overarching perspective of the NDB model, we used dementia-related behaviors, particularly wandering, and environment as initial focal variables to serve as entry points into the research. Multiple efforts to delineate relationships between environmental factors and locomotion were found in clinical research and practice literature. Environmental factors associated with wandering and pacing have been noticed as stressors or irritants (Algase, 1999; Cohen-Mansfield, Werner, & Marx, 1991; Rader, Doan, & Schwab, 1985). An understimulating (boring) environment also may contribute to wandering (Kolanowski, Richards, & Sullivan, 2002; Rader et al.). Agitated psychomotor behavior, including wandering, was found to be associated with personal factors (greater functional dependency, poorer mental status, greater psychotropic drug use) and psychosocial or milieu factors (in particular, the staff mix in nursing homes; Kolanowski, Hurwitz, Taylor, Evans, & Strumpf, 1994). Environmental conditions conducive to pacing were low noise, adequate lighting, non-meal-time hours, and open areas such as corridors (Cohen-Mansfield et al.). Clinical observation shows that residents paced more between locked exits. In general, wandering seems to increase when the environment is unfamiliar (Cohen-Mansfield & Werner, 1995; Cohen-Mansfield et al.), the noise level is low (except for television or music), two to five people are present, and lighting and temperature are normal. One study shows that wandering decreases when people are alone (Cohen-Mansfield & Werner), yet other evidence demonstrates wandering and dementia-related behaviors occur most often when people are alone (Kolanowski et al., 2002; Snyder, Rupprecht, Pyrek, Brekhus, & Moss, 1978). Environmental interventions for wandering and other dementia-related behaviors include architectural design interventions and milieu therapy, especially in LTC settings. Outcomes following environmental interventions are encouraging. Environments with low stress or stimuli, special care units (SCUs), homelike and, more recently, transformed environments (e.g., Eden Alternative [EA]), and multisensory environments (e.g., Snoezelen®) have demonstrated therapeutic benefits. Low Stress or Stimuli Hall and Buckwalter’s (1987) progressively lowered stress threshold (PLST) model describes the effect of cognitive decline in EWD as an increasing inability to cope with stress. Their suggested interventions include modifying and simplifying the environment to reduce internal and external stressors and prevent or alleviate dysfunctional NDBs.