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COPYRIGHT 2008 American Association of Neuroscience Nurses
Abstract: 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.
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Behavioral issues such as wandering are widely acknowledged as among the most distressing aspects of cognitive impairment. A majority of elders with dementia (EWD) eventually experience behavior disturbances. Ninety percent of nursing home residents were shown to have at least one behavioral problem, and roughly 50% have four or more behavioral problems (Tariot, Porsteinsson, Teri, & Weiner, 1996).
While cognitive changes contribute to the genesis of dementia-related behavior disturbances, the progressive and irreversible nature of dementia has made cognition appear a poor target for intervention. Rather, scientists and clinicians have focused on environmental modification as an important strategy to address behavior. Current studies offer insufficient evidence as to how environment affects wandering and other dementia-related behaviors. This article describes development of a theory to address this gap.
Conceptualizing dementia-related behaviors as needs-driven is considered a breakthrough in dementia-related behavior studies (Donaldson, 2000). The need-driven dementia-compromised behavior (NDB) model (Algase et al., 1996) introduced a value-neutral term--NDB--suggesting an etiology centered on the person with the behavior. The model encompasses three categories of NDBs: physical aggression, repetitive vocalization, and wandering. Potential etiologies for NDBs are grouped as background factors (those placing patients at risk for exhibiting NDBs) or proximal factors (those triggering NDB occurrences). The model posits that effects of proximal factors (psychophysiological needs and aspects of the physical and social environment) on NDBs are mediated by background factors (neurocognitive deficits and preserved strength of the person's traits and basic abilities), underscoring the importance of both sets of factors in developing intervention strategies. Further theoretical and empirical work is needed to test specific mechanisms by which environment affects NDBs.
Derived from the NDB model, a model of locomoting responses to environment in elders with dementia (LRE-EWD) is constructed through a theory synthesis approach. Models are constructed to address gaps in the field and to generate insights on how environment affects wandering and other NDBs. These insights can lead to prediction of and intervention for these behaviors. Critical issues of interest include mechanisms by which environment fosters manifestation of NDBs, particularly wandering, in long-term-care (LTC) settings and ways to reconcile conflicts in current environmental intervention models.
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[R]) 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.
Special Care Units
One of the many goals of SCUs is to decrease environmental stress in LTC settings for EWD. Organizational, social, and architectural systems consistently are cited for making SCU environments special (Kovach, Weisman, Chaudhury, & Calkins, 1997), but support features of these systems are poorly defined. Exit control, walking paths or gardens, and both private and public recreational areas appear important. The homelike feature of some SCUs came about as an alternative to low-stress or low-stimulation ambiance. A homelike setting (a setting with a residential character that serves to deinstitutionalize the nursing home environment) is not limited to an environment's physical features; it also includes experiences and interpersonal relationships (Calkins & Marsden, 2000; Zingmark, Sandman, & Norberg, 2002). Central characteristics of the homelike concept remain vague, however. Zeisel and colleagues (2003) summarized eight therapeutic features of SCUs: exit control, walking paths, personal places, social space, healing gardens, residential character, independence, and sensory comprehensibility. Despite their popularity, effects of SCUs for EWD are debatable (Day, Carreon, & Stump, 2000; Kovach, 2000; Zeisel et al.).
Enhanced Environments
Enhanced environments for EWD present another theme in recent studies. The EA proposes an enlivening...
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