The Effects of Hand Massage on Stress and Agitation Among People with Dementia in a Hospital Setting: A Pilot Study.

Agitation in people with dementia is a growing concern as it causes distress for both patients and their nurses and may contribute to relational disorders. Previous studies involving patients with dementia living in long-term care facilities have reported decreased agitation following massage. The objective of this pilot study was to investigate the effect of hand massage on agitation and biological markers of stress in patients with dementia hospitalized in an acute geriatric psychiatry service. In this randomized controlled trial we included 40 agitated patients with dementia with an intervention group and a control group. The study is designed to test the effect of seven hand massages over three continuous weeks on agitation and levels of salivary cortisol (sC) and alpha-amylase (sAA). Compared to the control group, the intervention group exhibited larger increases in sC and sAA at week 1 from before to after the massage, but larger decreases at week 2 and 3, with a significant group effect for sAA at week 2. Agitation scores were not significantly different between the groups but tended to decrease more in the intervention group than the control group. This study provides first encouraging results suggesting that hand massage might have beneficial effects on stress and agitation in hospitalized patients with dementia. It also highlights the challenges associated with conducting such studies with this complex patient population. Further studies are needed to confirm these findings and the benefits of hand massage as part of routine care for patients with dementia.

[From constraint to containment through the nursing link]. / De la contention à la contenance par le lien soignant.

The implementation of a sufficiently strict, adapted care setting provides constructive support for a move away from isolation and restraint towards new spaces of freedom. The account of the evolutive management of a patient by a nursing team in Bourg-en-Bresse, presents possible therapeutic strategies.

Use of Tablet Devices in the Management of Agitation Among Inpatients with Dementia: An Open-Label Study.

OBJECTIVE: To investigate the feasibility, safety, and utility of tablet devices as novel nonpharmacologic tools in managing older psychiatric inpatients with agitation and dementia. METHODS: Thirty-six patients at a geriatric psychiatry inpatient unit were provided with tablets when agitated and used various apps on the tablet related to communication, games, music, web browser, and photography during their stay. Study staff documented the frequency, duration, and app usage history and rated the extent to which agitation improved after tablet use. RESULTS: All participants, regardless of dementia severity, were able to use apps and were rated by staff to have clinical benefit. Dementia severity was negatively associated with app complexity. Age was negatively associated with frequency and duration of tablet use. CONCLUSION: Tablet use as a nonpharmacologic intervention for agitation in older adults, including those with severe dementia, appears to be feasible, safe, and of potential utility.

Morphine versus clonidine for neonatal abstinence syndrome.

OBJECTIVE: The study goal was to determine whether clonidine treatment of neonatal abstinence syndrome (NAS) would result in a better neurobehavioral performance compared with morphine. METHODS: This pilot study prospectively enrolled infants ≥ 35 weeks' gestational age admitted for treatment of NAS. After informed consent was obtained, infants were randomized to receive morphine (0.4 mg/kg per day) or clonidine (5 µg/kg per day) divided into 8 doses. A 25% dose escalation every 24 hours was possible per protocol (maximum of 1 mg/kg per day for morphine and 12 µg/kg per day for clonidine). After control of symptoms, the dose was tapered by 10% every other day. Clinical staff monitored infants by using Finnegan scoring. Masked research staff administered the NICU Network Neurobehavioral Scale (NNNS) at 1 week and at 2 to 4 weeks after initiation of treatment and the Bayley Scales III, and Preschool Language Scale IV, at 1-year adjusted age. Analyses included descriptive statistics, repeated measures analysis of variance, and Wilcoxon tests. RESULTS: Infants treated with morphine (n = 15) versus clonidine (n = 16) did not differ in birth weight or age at treatment. Treatment duration was significantly longer for morphine (median 39 days) than for clonidine (median 28 days; P = .02). NNNS summary scores improved significantly with clonidine but not with morphine. On subsequent assessment, those receiving clonidine had lower height of arousal and excitability (P < .05). One-year motor, cognitive, and language scores did not differ between groups. CONCLUSIONS: Clonidine may be a favorable alternative to morphine as a single-drug therapy for NAS. A multicenter randomized trial is warranted.

Effects of Multisensory Stimulation on a Sample of Institutionalized Elderly People With Dementia Diagnosis: A Controlled Longitudinal Trial.

Long-term effects of multisensory stimulation were assessed using a "Snoezelen" room on older residents with dementia. Thirty patients were randomly assigned to 3 groups: multisensory stimulation environment (MSSE) group, individualized activities (activity) group, and control group. The MSSE and activity groups participated in two 30-minute weekly individualized intervention sessions over 16 weeks. Pre-, mid-, posttrial, and 8-week follow-up behavior, mood, cognitive, and functional impairment in basic activities of daily living were registered. Items included in the physically nonaggressive behavior factor improved significantly in post- versus pretrial in the MSSE group compared to the activity group, with no significant differences between MSSE and control groups. The MSSE and activity groups demonstrated behavior improvements and higher scores on the Cohen-Mansfield agitation inventory, verbal agitated behavior factor, and Neuropsychiatric Inventory-Nursing Home, with no significant differences between groups. The MSSE could have long-term positive effects on such neuropsychiatric symptoms in older people with dementia.

The management of agitation among inpatients in a brain injury rehabilitation unit.

OBJECTIVE: Agitation post-acquired brain injury (ABI) is common and should be appropriately managed to optimize the patients' rehabilitation progress. The objective of this study was to assess how agitation is managed in current practice on an ABI rehabilitation unit. METHODS: A retrospective chart audit was conducted of patients admitted to an ABI rehabilitation unit to assess current practices. All information pertaining to agitation was abstracted from the patients' medical chart (e.g. behavioural incidences, medication information and behavioural outcome measures). The Agitated Behavior Scale (ABS) was the only assessment tool regularly utilized and, therefore, its use was evaluated. RESULTS: A total of 102 patient charts were reviewed. Fifty-one patients received medication for agitated behaviour. The ABS was administered to 28 patients; a total of 124 ABS tests were completed for these patients. Twenty-one of the 28 individuals never scored outside the 'normal' range; however, medications were given to 50%. CONCLUSIONS: The ABS and similar behavioural tools allow for a patient's behavioural patterns to be monitored and care plans to be created and executed according to evidence-based practices. There is a need to educate on the proper use and interpretation of assessment tools in order to improve care.

Efficacy of musical interventions in dementia: evidence from a randomized controlled trial.

Although musical interventions have recently gained popularity as a non-pharmacological treatment in dementia, there is still insufficient evidence of their effectiveness. To investigate this issue, a single-center randomized controlled trial was conducted with forty-eight patients with Alzheimer's disease or mixed dementia to compare the effects of music versus cooking interventions in the emotional, cognitive, and behavioral domain, as well as on professional caregiver distress. Each intervention lasted four weeks (two one-hour sessions a week). Multi-component evaluations (with blind assessors) were conducted before, during, and after the interventions to assess their short and long-term effects (up to four weeks post interventions). Analyses revealed that both music and cooking interventions led to positive changes in the patients' emotional state and decreased the severity of their behavioral disorders, as well as reduced caregiver distress. However, no benefit on the cognitive status of the patients was seen. While results did not demonstrate a specific benefit of music on any of the considered measures, the present study suggests the efficacy of two pleasant non-pharmacological treatments in patients with moderate to severe dementia. Our findings highlight the potential of such interventions in improving the well-being of patients living in residential care, as well as reducing caregiver distress.

Music therapy for early cognitive rehabilitation post-childhood TBI: an intrinsic mixed methods case study.

OBJECTIVE: The primary aim of this case study was to explore the behavioural changes of a paediatric patient in post-traumatic amnesia (PTA) during a music therapy session. A secondary objective was to measure the effect of the music therapy intervention on agitation. METHOD: Video data from pre, during and post-music therapy sessions were collected and analysed using video micro-analysis and the Agitated Behaviour Scale. RESULTS: The participant displayed four discrete categories of behaviours: Neutral, Acceptance, Recruitment and Rejection. Further analysis revealed brief but consistent and repeated periods of awareness and responsiveness to the live singing of familiar songs, which were classified as Islands of Awareness. Song offered an Environment of Potential to maximise these periods of emerging consciousness. The quantitative data analysis yielded inconclusive results in determining if music therapy was effective in reducing agitation during and immediately post the music therapy sessions. CONCLUSION: The process of micro-analysis illuminated four discrete participant behaviours not apparent in the immediate clinical setting. The results of this case suggest that the use of familiar song as a music therapy intervention may harness early patient responsiveness to foster cognitive rehabilitation in the early acute phase post-TBI.

Risk factors associated with physical restraints in residential aged care facilities: a community-based epidemiological survey in Taiwan.

AIM: To identify the rate and risk factors of physical restraint in residential aged care facilities in Taiwan. BACKGROUND: In Taiwan, physical restraint is commonly used in aged care facilities to prevent accidents. Many are unaware of the associated risks. Restrained residents cannot move freely, increasing the risk of atrophy and leading to reduced physical functioning. DESIGN: A community-based epidemiological survey. METHODS: Data were collected from June-December 2007 across 178 residential aged care facilities with 5,173 residential beds in the target city of Taiwan. Twenty facilities were sampled using probability proportional to size by beds and accreditation ranking. In all, 256 primary caregivers (78 nurses and 178 care aides) and 847 residents completed the study questionnaires and tests. A multilevel analysis approach was used to identify individual- and facility-level risk factors for physical restraint and assess the variation in physical restraint at the individual- and facility-level. RESULTS: Of 847 residents, 62% (527) were restrained during the study period. The main reasons for restraint use were fall prevention and prevention of tube removal. Resident level risk factors for physical restraint included lower Barthel Index scores (more dependent) and an agreement allowing the use of physical restraint to avoid injury signed by a family member or social worker. A facility-level risk factor for physical restraint was younger primary caregivers. CONCLUSION: To reduce the incidence of physical restraint in residential aged care facilities in Taiwan, educational programmes should target primary caregivers and families in facilities.

Occurrence and severity of agitated behavior after severe traumatic brain injury.

PURPOSE: To investigate the occurrence and severity of agitation in patients after severe traumatic brain injury (TBI), to identify predictors of agitation and to study interrater reliability for a translated version of the Agitated Behavior Scale (ABS). DESIGN: Prospective observational study. From November 1, 2006, through October 2007, 46 consecutive patients with TBI were included in the early rehabilitation phase following neurosurgical intervention. Agitated behavior was assessed by the ABS, which was implemented in clinical practice. Logistic regression analysis identified predictors of agitated behavior and Intra Class Correlation was used to analyze reliability. FINDINGS: Agitated behavior occurred in 41% of patients, of whom one third exhibited severely agitated behavior. The interrater reliability between three nurses was good to excellent. CONCLUSIONS: Using ABS as a tool in care of patients with agitated behavior may be effective through working as a common language. CLINICAL RELEVANCE: We recommend the use of ABS as a routine assessment in early rehabilitation of patients with TBI.

Use of behavioural contracting to increase adherence with rehabilitation treatments on an inpatient brain injury unit: a case report.

BACKGROUND: This systematic, single-subject case study presents a 37-year old male with a severe traumatic brain injury who exhibited agitation and poor adherence with rehabilitation treatment on an inpatient traumatic brain injury unit. Attempts to address presumed awareness issues were unsuccessful. Medication trials also failed to produce an observable response in the patient's behaviour. CASE STUDY: A behavioural contract was presented by staff that specified positive behaviours the patient needed to demonstrate in order to reach his goal of being discharged from the hospital. Immediately, patient agitation ratings decreased and soon normalized. Statistical analysis of single subject times series data using the method of Nonoverlap of all Pairs results in a ratio of 0.875, indicating a moderate effect size for the intervention. CONCLUSIONS: The patient was able to comply with all requests and, with supports, was able to be safely discharged from the hospital ahead of schedule. Factors that could have contributed to this outcome and potential limitations are discussed.

Nursing care of the brain injury patient on a locked neurobehavioral unit.

Behavioral problems after a brain injury can be extremely challenging for those working with brain injured people. Nursing staff must be familiar with commonly used post brain injury medications and their effects, behavioral management plans, appropriate use of restrictive devices, and verbal or physical crisis intervention techniques when necessary. Rehabilitation nurses caring for brain injured patients on a locked neurobehavioral unit must maintain continual training and specific competence in this environment to ensure patient and staff safety.

Citalopram for agitation in Alzheimer's disease: design and methods.

BACKGROUND: Agitation is one of the most common neuropsychiatric symptoms of Alzheimer's disease (AD), and is associated with serious adverse consequences for patients and caregivers. Evidence-supported treatment options for agitation are limited. The citalopram for agitation in Alzheimer's disease (CitAD) study was designed to evaluate the potential of citalopram to ameliorate these symptoms. METHODS: CitAD is a randomized, double-masked, placebo-controlled multicenter clinical trial, with two parallel treatment groups assigned in a 1:1 ratio and randomization stratified by clinical center. The study included eight recruiting clinical centers, a chair's office, and a coordinating center located in university settings in the United States and Canada. A total of 200 individuals having probable AD with clinically significant agitation and without major depression were recruited for this study. Patients were randomized to receive citalopram (target dose of 30 mg/d) or matching placebo. Caregivers of patients in both treatment groups received a structured psychosocial therapy. Agitation was compared between treatment groups using the NeuroBehavioral Rating Scale and the AD Cooperative Study- Clinical Global Impression of Change, which are the primary outcomes. Functional performance, cognition, caregiver distress, and rates of adverse and serious adverse events were also measured. CONCLUSION: The authors believe the design elements in CitAD are important features to be included in trials assessing the safety and efficacy of psychotropic medications for clinically significant agitation in AD.

A man with severe Alzheimer's disease stops wandering during a picture colouring activity.

OBJECTIVE: To assess the effects of a picture colouring activity on the wandering (and constructive engagement) of a man with severe Alzheimer's disease. METHOD: The colouring activity was compared with a music listening condition and a baseline/control condition. A choice phase involving the colouring activity and the music condition was also implemented. RESULTS: Wandering was constant during the baseline condition, but it was reduced to low or virtually 0% levels during the music condition and picture colouring activity. Moreover, the patient regularly selected the colouring activity (which also promoted constructive engagement) during the choice phase. CONCLUSION: Simple leisure activities, such as picture colouring, might help patients with Alzheimer's disease reduce wandering.

A randomized clinical trial of theory-based activities for the behavioral symptoms of dementia in nursing home residents.

OBJECTIVES: To test the main and interactive effects of activities derived from the Need-Driven Dementia-Compromised Behavior model for responding to behavioral symptoms in nursing home residents. DESIGN: Randomized double-blind clinical trial. SETTING: Nine community-based nursing homes. PARTICIPANTS: One hundred twenty-eight cognitively impaired residents randomly assigned to activities adjusted to functional level (FL) (n=32), personality style of interest (PSI) (n=33), functional level and personality style of interest (FL+PSI) (n=31), or active control (AC) (n=32). INTERVENTION: Three weeks of activities provided twice daily. MEASUREMENTS: Agitation, passivity, engagement, affect, and mood assessed from video recordings and real-time observations during baseline, intervention, random times outside of intervention, and 1 week after intervention. RESULTS: All treatments improved outcomes during intervention except mood, which worsened under AC. During intervention the PSI group demonstrated greater engagement, alertness, and attention than the other groups; the FL+PSI group demonstrated greater pleasure. During random times, engagement returned to baseline levels except in the FL group in which it decreased. There was also less agitation and passivity in groups with a component adjusted to PSI. One week after the intervention, mood, anxiety, and passivity improved over baseline; significantly less pleasure was displayed after withdrawal of treatment. CONCLUSION: The hypothesis that activities adjusted to FL+PSI would improve behavioral outcomes to a greater extent than partially adjusted or nonadjusted activities was partially supported. PSI is a critical component of individualized activity prescription.

Assisting children with Attention Deficit Hyperactivity Disorder actively reduces limb hyperactive behavior with a Nintendo Wii Remote Controller through controlling environmental stimulation.

The latest studies have adopted software technology which turns the Wii Remote Controller into a high-performance limb action detector, we assessed whether two persons with multiple disabilities would be able to control an environmental stimulus through limb action. This study extends the functionality of the Wii Remote Controller to the correction of limb hyperactive behavior to assess whether two children with Attention Deficit Hyperactivity Disorder (ADHD) would be able to actively reduce their limb hyperactive behavior through controlling their favorite stimuli by turning them on/off using a Wii Remote Controller. An ABAB design, in which A represented the baseline and B represented intervention phases, was adopted in this study. Result showed that both participants significantly increased their time duration of maintaining a static limb posture (TDMSLP) to activate the control system in order to produce environmental stimulation in the intervention phases. Practical and developmental implications of the findings are discussed.

Reliability of the Perceive, Recall, Plan and Perform System of Task Analysis: a criterion-referenced assessment.

OBJECTIVE: To conduct preliminary examination of the rater and test-reliability of the Perceive, Recall, Plan and Perform (PRPP) System of Task Analysis, an ecological measure designed to assess task-embedded information processing capacity during occupational therapy assessment of confused and agitated adults following traumatic brain injury. METHODS: Occupational therapists observed and scored client performance using the PRPP System of Task Analysis. Correlational analysis and measures of agreement were performed to determine interrater and intrarater reliability. Test procedures were examined for reliability and internal consistency. RESULTS: Interrater and test reliability considered three factors: therapists, clients and tasks. A moderate level of interrater reliability was achieved between trained therapists (intraclass correlation coefficient (ICC) = 0.60). Test procedures were highly reliable (ICC = 0.88). Across two measurement occasions, therapists showed a tendency towards harder rating on the second test occasion (-4.5%; 95% confidence interval for: -10.67% → 3.17%). CONCLUSION: The findings of this study support the use of criterion-referenced tests in the area of occupational performance measurement. Occupational therapists achieved moderate interrater reliability when measuring the performance of adults with brain injury on various activities of daily living. Test procedures were found to be highly reliable in measuring the occupational performance of adults demonstrating confusion and agitation typical to the stage of post-traumatic amnesia following head injury.

Effective occupational therapy intervention with adults demonstrating agitation during post-traumatic amnesia.

OBJECTIVE: To investigate the effectiveness of occupational therapy (OT) with adults demonstrating agitation and post-traumatic amnesia (PTA) following brain injury. DESIGN: Single-system experimental design (ABAB) across subjects. METHODS: Eight subjects were recruited during acute rehabilitation. Current OT intervention was alternated with the experimental Perceive, Recall, Plan and Perform (PRPP) System approach over 4-weeks. Therapy was conducted daily. Information processing capacity during occupational tasks was measured using the PRPP System of Task Analysis. PTA status was monitored with the Westmead PTA Scale. EXPERIMENTAL INTERVENTION: The PRPP System is a dynamic assessment and intervention approach that directly links results of cognitive task analysis with strategies for intervention. PRPP Intervention adopts an information processing approach that simultaneously focuses on task training, strategy training and strategy application within occupational performance. RESULTS: Seven subjects significantly improved in their application of processing strategies during the PRPP Intervention in comparison to current OT Intervention phases. Large treatment effects favoured the PRPP Intervention. Subjects demonstrated improved information processing strategy use both prior to and following emergence from PTA. CONCLUSIONS: Occupational therapy intervention based upon the PRPP System of Task Analysis and Intervention improved subjects' ability to apply information processing strategies during occupational performance when compared to current intervention approaches.