Hello, damienmonarchs-ga!
First of all, I commend you for the loving care you are giving your
father. I stand in awe of your devotion during this difficult time. He
is very fortunate to have such a caring and loving child.
I am also facing this scenario with my mother, although she still has
my father to help care for her. It is very difficult for him, however,
since he is 86 years old and in failing health himself. She needs
24-hour care, but is still adamant that she will not allow a caregiver
in the house to give my dad some relief. As far as she is concerned,
she can still take care of herself, which is contrary to reality!
I did not find much in the way of behavior modification for
repetitive speech in connection with dementia, but I did find one
alternative therapy that appears to have some solid research behind
it- Music.
Have you ever tried switching off the television and putting on soft
music at the times your father is most agitated? Although there is
differing evidence concerning whether music that is individualized to
the patient's prior tastes in life versus classical music works the
same or better, there are clear results that music does sooth
agitation, including repetitive speech.
Music
=====
Am J Occup Ther. 1994 Oct;48(10):883-9. "The effect of music on
repetitive disruptive vocalizations of persons with dementia." Casby
JA, Holm MB. California Children's Service, Health Department, San
Jose 95128.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7825703
OBJECTIVE. "This study examined the effect of classical music and
favorite music on the repetitive disruptive vocalizations of
long-term-care facility (LTCF) residents with dementia of the
Alzheimer's type (DAT). METHOD. Three subjects diagnosed with DAT who
had a history of repetitive disruptive vocalizations were selected for
the study. Three single-subject withdrawal designs (ABA, ACA, and
ABCA) were used to assess subjects' repetitive disruptive
vocalizations during each phase: no intervention (A); relaxing,
classical music (B); and favorite music (C). RESULTS. Classical music
and favorite music significantly decreased the number of vocalizations
in two of the three subjects. CONCLUSION. These findings support a
method that was effective in decreasing the disruptive vocalization
pattern common in those with DAT in the least restrictive manner, as
mandated by the Omnibus Budget Reconciliation Act of 1987."
=
"Music and other strategies to improve the care of agitated patients
with dementia. Interviews with experienced staff." Ragneskog H,
Kihlgren M. Scand J Caring Sci. 1997;11(3):176-82.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9349059&query_hl=7
"Many patients with dementia symptoms display forms of agitation such
as the repeating of words, restlessness and aggression. These forms of
behaviour may inflict strain on the co-patients and the caregivers. In
this study, 17 experienced formal caregivers from nursing homes and
collective residential units were interviewed about their experiences
of agitated patients with dementia and strategies to improve their
care. The questions were open except for specific questions about
sound, music, and opinions about pharmacological treatment. A calm
atmosphere and a slow pace emerged as important strategies to control
agitation. Fixed routines could develop this. The mixing of lucid and
agitated dementia patients appeared as a major problem, because some
lucid patients became angry when patients with dementia displayed
agitation. Irritability in one patient could trigger agitation in
other patients but was possible to stop at an early stage.
** Several responders had successfully used music to calm individual
agitated patients. Music seemed to be an underestimated nursing
intervention to control agitation in daily life, but uncontrolled
sound could cause agitation in the patients and stress in the nursing
staff."
==
The following article discusses nonpharmacologic interventions for
various behaviors in dementia. The two most applicable to your
father's situation are music therapy and possibly, severak minutes of
therepeutic massage. I have only excerpted the paragrahs relating to
music, but you can read about other interventions in the full article.
"Nonpharmacologic Interventions for Inappropriate Behaviors in
Dementia. A Review, Summary, and Critique." Jiska Cohen-Mansfield. Am
J Geriatr Psychiatry 9:361-381, November 2001
http://ajgp.psychiatryonline.org/cgi/content/full/9/4/361
"For the purpose of this article, inappropriate behaviors will be
defined as "inappropriate verbal, vocal, or motor activity that is not
judged by an outside observer to be an obvious outcome of the needs or
confusion of the individual."
"Inappropriate behaviors have been divided into four main subtypes: 1)
physically aggressive behaviors, such as hitting, kicking or biting;
2) physically nonaggressive behaviors, such as pacing or
inappropriately handling objects; 3) verbally nonaggressive agitation,
such as *** constant repetition of sentences or requests; **** and
4) verbal aggression, such as cursing or screaming. In the past,
inappropriate behaviors have been handled with psychotropic drugs or
physical restraints, or ignored. Research and clinical observations
have questioned these practices, leading to the OBRA '87 mandate to
reduce physical and chemical restraints. In response to these
developments, a plethora of nonpharmacologic interventions have been
initiated. However, our understanding of these interventions, their
effects, and their feasibility is limited."
** "The largest number of articles was found in the area of sensory
enhancement, especially for the provision of music for either
stimulation or relaxation."
"Behavioral interventions had the second-highest number of papers;
however, this is the only category where the majority of the articles
are case studies or include only small sample sizes."
** "Several studies reported a reduction in verbal agitation or
agitation in general while patients listened to music on a tape or a
CD player. In about half of these studies, the music was
individualized to match the person's preferences, whereas other
studies used soft or classical music. The effect of music was reported
to occur primarily during the listening sessions, and to be reduced
after the conclusion of the session."
"The best support for the notion that intervention needs to be
individualized to the person's past preferences comes from a study
conducted by Gerdner. She found that music based on participants' past
preferences had a greater beneficial impact on behavior than
non-individualized music."
==
"Individualized music played for agitated patients with dementia:
analysis of video-recorded sessions." Ragneskog H, Asplund K, Kihlgren
M, Norberg A. Int J Nurs Pract. 2001 Jun;7(3):146-55.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11811810&query_hl=7
"Many nursing home patients with dementia suffer from symptoms of
agitation (e.g. anxiety, shouting, irritability). This study
investigated whether individualized music could be used as a nursing
intervention to reduce such symptoms in four patients with severe
dementia. The patients were video-recorded during four sessions in
four periods, including a control period without music, two periods
where individualized music was played, and one period where classical
music was played. The recordings were analysed by systematic
observations and the Facial Action Coding System. Two patients became
calmer during some of the individualized music sessions; one patient
remained sitting in her armchair longer, and the other patient stopped
shouting. For the two patients who were most affected by dementia, the
noticeable effect of music was minimal. If the nursing staff succeed
in discovering the music preferences of an individual, individualized
music may be an effective nursing intervention to mitigate anxiety and
agitation for some patients."
==
Singing by the caregiver has also shown to stimulate increased
awareness and communication and sooth aggression in the dementia
patient.
"Influence of caregiver singing and background music on posture,
movement, and sensory awareness in dementia care." Gotell E, Brown S,
Ekman SL. Int Psychogeriatr. 2003 Dec;15(4):411-30.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15000420&query_hl=2
===
The following article touches on behavioral techniques to reduce or
change learned behavior in dementia. At the time of the writing, the
research was still a "work in progress" so no definitive conclusions
are outlined.
From "EVALUATION OF A BEHAVIOURALTREATMENT PROGRAM FOR DEMENTIA."
Colleen Doyle, PhDSenior Research Fellow. October, 1992
http://www.buseco.monash.edu.au/centres/che/pubs/wp24.pdf
"The trial is concentrating on one problem behaviour associated with
dementia, that is, excessive noise-making. This can include continuous
seeking out attention of carers, running commentary, stereotyped
excessive noises such as whistling etc. This type of behaviour is
common, can be very distressing to carers, and, more pragmatically, is
suited to the experimental paradigm and will not place the research
nurse/observer in any danger. The hypothesis being addressed is that
excessive noise-making behaviour is contingent on the social or
physical environment of the patient. We are testing this hypothesis by
borrowing some standard techniques from behaviour modification.
"Cohen-Mansfield et al (1990) reported two studies of noise-making in
nursing home residents. They found that five demented residents called
out most during the evening, on weekends and most when they were
alone, followed by when they were being touched. Music seemed to
influence calling out, since residents calmed down when music was
played, suggesting that music therapy may be an effective management
technique.
"A study by Hussian & Hill (1980) is the only systematic observational
study that I have been able to find of the effect of the environment
on the behaviour of severely demented elderly. They made naturalistic
observations of four long-term care patients. They found that barring
limb restraints and gags, the only thing that interrupted ongoing
behaviour was application of distractive auditory, visual or tactile
stimulus. When this noncontingent, external stimulus was removed, the
self-stimulatory behaviour returned after several seconds."
======
I don't know how much the following article will apply to your
situation, but it does tend to reinforce the idea that stimulation, or
lack thereof, can have an affect on innappropriate vocalization in
dementia patients. (To be honest, I read it at least 3 times and am
still not sure what the conclusion is!!! :)
"FUNCTIONAL ASSESSMENT AND NONCONTINGENT REINFORCEMENT IN THE
TREATMENT OF DISRUPTIVE VOCALIZATION IN ELDERLY DEMENTIA PATIENTS."
Buchanan and Fischer, Journal of Applied Bahavior Analysis. Number 1
(Spring, 2002)
http://seab.envmed.rochester.edu/jaba/articles/2002/jaba-35-01-0099.pdf
===
Since repetitive speech seems to be a sign of fear or agitation, I am
wondering if your father's outburst occur primarily in front of the
television. Could it be that the stimulus of the television gets to be
too much for your father because he is unable to understand or
verbally respond to the information he is hearing? Perhaps switching
off the television and replacing the stimulus with soft music will
help to calm him. Just a thought.
One last reference that may prove helpful:
From "Management of Agitation Behavior," by Rich O'Boyle.
http://www.ec-online.net/Knowledge/Articles/agitation.htm
Understanding Agitation Behavior:
"Experts say that all types of behavior are forms of communication.
Your loved one is trying to tell you something even though the disease
has robbed them of other ways (i.e., talking) of telling you. Perhaps
your loved one is depressed or in pain and does not know how to
express it in words. Some experts believe that agitation behavior is
"the inability the deal with stress."
"For the caregiver, the key is to identify whether the behavior is
event-related (a visitor arrives, dinner is served), sudden
(unexpected outburst) or escalates ("catastrophic" spiral of tension
and outbursts). Organization by the caregiver will help a great deal
in beginning to combat these behaviors:
* Modify the environment to reduce known stressors (e.g., shadowy
lighting, mirrors, loud noises);
* Note patterns of behavior and subtle (and not so subtle) clues that
tension and anxiety are increasing (i.e., pacing, incoherent
vocalization);
* Dysfunctional behavior often increases at the end of the day as
stress builds and your loved one becomes tired.
* Certain stressors can trigger agitation behaviors. While this list
is not exclusive, it does provide the most common triggers and
suggestions for minimizing their occurrence. As the caregiver, you
have to use all of your senses to understand the environment and your
loved one?s behaviors. This is not easy stuff - and this is not
fool-proof. However, experimenting with these tools can go a very long
way!
* Fatigue
* Change of Environment, Routine or Caregiver
* Affective Responses to Perception of Loss: (Huh?) This means that
persons with Alzheimer?s Disease still have memories and perceptions
of activities that they used to enjoy. They miss being able to drive a
car, cook or care for children. Whether at home or in a facility, safe
activities should be substituted that satisfy your loved one.
Depression should be treated.
* Responses to Overwhelming or Misleading Stimuli: Excessive, noise,
commotion or people can trigger agitation behavior.
* Excessive Demand: Caregivers and families must accept that your
loved one has lost (and continues to lose) mental functions. No amount
of quizzing, reality orientation, "brain exercises," retraining or
pushing them to try harder will improve their mental capabilities.
Indeed, it can cause stress and a sense of futility. The best a
caregiver can do is provide positive support and understanding,
encourage independence and assist your loved one when they are unable
to perform a task.
(Read suggestions for What Can be Done...)
==
I hope these suggestions offer some helpful alternatives to
medication and prove fruitful.
Again, I am so thankful for the wonderful example you are displaying
in caring for your father at such a time of need. I do hope you have
some respite from time to time. Is there anyone you can call in to
help so that you have a few hours to yourself?
I wish you all the best as you continue through this struggle. My
best to you and your dad.
Sincerely,
umiat
Search Strategy
repetive speech with dementia
repetitive speech with dementia AND behavior modification
Noncontingent reinforcement in dementia
does noise increase agitation in dementia? |
