internatwnal Psychogeriah.ics,Vol.4 , No. 2,1992 Q 1992 Springer Publishing Company
Temporal Patterns of Agitated Nursing Home Residents Jiska Cohen-Mansfield, Marcia S. Marx, Perla Werner, and Laurence Freedman ABSTRACT. Twenty-fourhighly agitated,cognitively impairednursing home residents were studied in depth to determine whether they manifested temporal patterns of agitation. Results demonstrated that agitated behaviors were significantly associated with temporal factors. For instance, residents made more requests for attention during lunch than other time periods, and residents screamed most often during the night. Some agitated behaviors (e.g., aggression) were manifested more frequently in the evening than in the day, consistent with the notion of sundowning in the nursing home. Implications of temporal patterns of agitation for caregivers of severely cognitively impaired and agitated nursing home residents are discussed.
At present, nursing homes in the United States contain about 5% of the population age 65 and older, 10% of persons age 75 and older, and 22% of persons age 85 and older(NCHS, 1987). While the number of elderly persons who will ultimately enter nursing homes may not increase proportionally with the “graying” of the population, any increase in the number of aged persons who enter nursing homes is cause for concern. There may not be enough room or nursing staff in the facilities. Currently, nursing homes are understaffed, and nursing staff experience serious stress, low pay, and, in turn, high rates of turnover (Kasteler et al., 1979; Stryker, 1982; Wallace & Brubaker, 1982; Waxman et al., 1984). The problems faced by nursing home staff are compounded when residents manifest agitated behaviors. Agitation in the nursing home elderly can take the form of aggressive behaviors (e.g., hitting, cursing), physically nonaggressive behaviors (e.g., pacing, repetitious mannerisms, general restlessness), or verbal behaviors (e.g., constant requests for attention, complaining) (Cohen-Mansfield, From the Research Institute of the Hebrew Home of Greater Washington, Rockville, Maryland (J. Cohen-Mansfield, PhD; M.S. Marx, PhD; and P. Werner, MA); Center on Aging, Georgetown University School of Medicine, Washington, Dc (J. Cohen-Mansfield, PhD); and the Biometry Branch, Division of Cancer Prevention and Control, National Cancer Institute, Rockville, Maryland, U.S.A. (L. Freedman. MA). 197
198
J . Cohen-Mamfiiki et al.
Marx et al., 1989). In a study of 408 nursing home residents, Cohen-Mansfield, Marx, and colleagues (1989) found that during the day shift the average nursing home resident manifests about four different agitated behaviors at a frequency of at least once a week. An investigationof 50 residents of an intermediatecare facility (94% of whom had a major psychiatricdisorder,most often dementia) revealed that 76% manifested at least one behavior problem (Rovner et al., 1986). Chandler and Chandler(1988) reported the prevalenceof neuropsychiatricdisorders(most often, dementia syndrome) to be 94% in a group of 65 nursing home residents; the most common behavioral problems, agitation and aggression, affected 48% of their sample. In order to provide adequate care in nursing homes, we must come to understand behavior disturbances. One facet of this understanding is to learn whether manifestations of agitated behaviors by agitated nursing home residents are “time-locked” to particular periods during the 24-hour day. Temporal changes in agitation in highly agitated and severely cognitively impaired nursing home residents is the focus of the present study.
METHOD This was an observational study designed to identify temporal patterns of agitated behaviors. The data presented here are part of a large data set that examined situational and environmental correlates of agitation.
Study Participants A group of 24 residents of a 550-bed long-term-care facility participated in this study. These 24 residents were selected because of their high levels of agitation on the basis of information from nurses and results of data analysis of a previous large cross-sectional study of agitation. (In that study, the level of agitation was assessed using the Cohen-Mansfield Agitation Instrument; see Cohen-Mansfield, 1986; Cohen-Mansfield,Marx et al., 1989). All 24 residents suffered from severe cognitive impairment, which was assessed via the Brief Cognitive Rating Scale (BCRS; Reisberg et al., 1983). The mean BCRS score for the group of residents was 6, where 1 denotes normal functioning and 7 indicates total cognitive deterioration. As to other characteristics of the 24 residents. they were similar to the total nursing home population in age (mean age = 86.7 years; age range: 62-93 years), in gender (3 men, 21 women), and in length of stay in the nursing home (mean = 3.7 years; range: < 1-15 years). Regarding their abilityto perform activitiesof daily living (ADL: bathing, eating, toileting, grooming,dressing, and walking), daytime charge nurses rated each resident via the Rapid Disability Rating Scale-2 (RDRS2; Linn & Linn, 1985).The mean RDRS-2 SCOR for this groupof residents was 3.1, where 1 represents independence and 4 represents total dependence on others. As these residents suffered from severecognitive impairment, informed consent
Temporal Patterns of Agitation
199
for study participation was obtained from a close relative of each resident (see Cohen-Mansfield et al., 1988, for details of this procedure).
Instrument The Agitation Behavior Mapping Instrument (ABMI; Cohen-Mansfield,Werner et al., 1989) is a nonobtrusive assessment used for direct observation and recording of behaviors as they occur in the natural environment. Interobserver agreement rates for the behaviors on the ABMI averaged .93 (Cohen-Mansfield,Wemeret al., 1989). Previous research has indicated that agitated nursing home residents tend to manifest the following behaviors most frequently: picking at or throwing things, repetitious mannerisms, strange noises (includes screaming),constant requests for attention, strange movements, and pacing (Cohen-Mansfield,Werner et al., 1989). Given their frequency, these behaviors were the focus of the present study. In addition, aggressive behaviors (including biting, hitting, and cursing) were examined because of their disruptive and sometimes painful consequences. We also included a composite score of total agitation derived for each resident as the weighted total number of agitated behaviors manifested by that resident. The weightings were based on the disruptive effect of the agitated behavior manifested; that is, aggressive behaviors are maximally disruptive while repetitious mannerisms are not particularly disruptive to persons on the unit (see Cohen-Mansfield, Werner et al., 1989).
Procedure Over a three-month period, 1,000observations,on average, were obtained for each resident via the ABMI. Observationsof residents were scheduled using a stratified random time-sampling method. Each observation lasted for three consecutive minutes per hour (only one observation of each resident was scheduled per hour); all hours of the 24-hour day were sampled. However, only observations in which residents were awake are described in this paper. Further details of the procedure can be found in Cohen-Mansfield,Werner et al. (1989). During each observation, a research assistant recorded the number of times each resident manifested each of the individual agitated behaviors. The research assistant also recorded the following temporal conditions: time, date, and day of the week. We examined the frequency by which each resident manifested the individual agitated behaviors relative to the temporal conditions (e.g., time of day, day of the week) via separate analyses. In this way, we could determine whether frequencies of agitated behaviors varied as functions of the temporal conditions. The analysis employed was ANOVA (repeated measures), assuming the random effects model. That is, the temporal conditions were obviously finite and fixed, but subjects constituted a sample from a larger population of nursing home residents. This then implied that F statisticswere obtained by comparing the specificmean square for the temporal conditionterm with themean square of the interaction term. The significant main effects for each temporal condition are reported in the results section.
J . Cokn-Marqtlild et al.
200
RESULTS
Do Residents Manifest Temporal Patterns of Agitation? To determine whether residents manifested specific temporal patterns of agitation within each 24-hour day, the day was divided into eight time periods, reflecting the routine of the nursing home, and ANOVAs were performed. All interactions were statistically significant 0, c .Ol), indicating that time patterns of agitation varied among participants. Examination of the main effects revealed that manifestations of different agitated behaviors were differentially associated with specific time periods (see Table 1). Aggressive behaviors were displayed often during lunch and evening. Strange movements were manifested most often during the night. Residents picked at things most often during the night and least often during breakfast and late morning. Strange noises were noted most often during the night, followed by the evening time period. Pacing was observed throughout Time Periods 1-7, with a peak occurring during the early afternoon. Repetitious mannerisms were observed often during much of the day, peaking in the late morning; this behavior was manifested comparatively less often in the early afternoon through the evening. Constant requests for attention occurred most often during lunch, and least often at night. To determine whether a pattern of sundown syndrome would emerge from the data of the present study, “day” was operationalized as the hours from 6 AM to4:30 PM, and “evening” was operationalized as the hours from 4:31 PM to 11 PM. The results of the analysis revealed that all interactions were statistically significant
TABLE 1. Univariate F Scores and Mean Frequencies of Agitated Behaviors Manifested During the 8 Time Periods
~~
Aggressive behaviors Picking at things Strange noises Pacing Strange movements Repetitious mannerisms Constant requests for attention
0.05 0.91 1.07 1.04 0.54 2.73 1.62
0.08 0.33 0.79 1.04 0.17 2.57 1.56
0.11 0.49 0.67 1.89 0.22 3.20 2.01
*p < .05; **p < .01. Time I = Wake-up time (6:Ol ~ ~ - 7 : 3 0AM). Time 2 = Breakfast time (7:31 ~ ~ - 9 : 3 0AM). Time 3 = Late morning (9:31 ~ ~ - 1 1 : 3 0AM). Time 4 = Lunch (11:30 AM---1:30 PM). Time 5 = Early afternoon (1:31 ~ ~ - 4 3PM). 0 Time 6 = Dinner (4:31 ~ ~ - 7 : 3 0PM). Time 7 = Evening (7:31 PM-1 I:@ PM). Time 8 = Night (11:Ol PM--~:@ AM).
0.18 0.61 0.89 1.86 0.16 2.28 2.46
0.11 1.17 0.80 2.11 0.31 1.37 2.15
0.13 0.91 0.85 1.84 0.24 1.06 1.83
0.18 1.10 1.37 1.79 0.19 1.63 1.43
0.05 1.67 1.70 0.10 1.15 2.22 0.78
3.25** 5.40** 3.45** 5.08** 1.93 2.95** 2.45*
201
Temporal Patterns of Agitation
(p < .Ol), indicating that participants differed in the extent to which they experienced sundowning. As to the main effects, sundowning pattems (Le., more agitation during the “evening”) were seen for three behaviors. Strange noises, picking at things, and aggressivebehaviors were manifested more often during the “evening”hours (mean frequencies= 1.08,l .OO,0.14, respectively)than during the “day” hours (mean frequencies = 0.81, 0.65, 0.09, respectively) (F(,.,,, = 10.65, 5.09, 5.94, respectively; for strange noises p < .01, for the latter two behaviors p < .05). Although the test statistic was not significant, more pacing was observed during the “evening” hours than during the “day” hours. The other behaviorepetitious mannerisms,requests for attention, and strange movements-tended to occur more often during the “day” hous (the univariate F-scores were not significant). Separate examination of the data of each resident revealed that individual residents manifest consistent temporal pattems of agitation. As an example, the total number of agitated behaviors manifested during each day of the week by Resident A is shown as a function of time (see Figure 1). Each of the seven days, this resident manifested,on the average,the greatest amount of agitation during the late morning period (i.e., Time Period 3), with secondary peaks occumng around
MANIFESTATIONS OF AGITATED BEHAVIOR DAY OF WEEK AND TIME OF DAY RESIDENT A A G i T A T I 0 N
35 7 30 25 20 15 10 5 0 Wake-up
Breakfast
Late Morning
Lunch
Early After noon
Dinner
Evening
Night
TIME PERIOD
- SUNDAY THURSDAY
Figure 1.
DAY OF WEEK +
----
MONDAY FRIDAY
--*.- TUESDAY
--
SAT U R DAY
-
WEDNESDAY
I
J . Cohen-Mansfieldet al.
202
the early afternoon or dinner time. Maximum agitation occurred on Sunday and minimum agitation on Friday. Patterns of total agitation for a different resident are shown in Figure 2. This resident manifested large amounts of agitation during breakfast or late morning on Monday, Tuesday, Wednesday, Thursday, and Sunday. On Friday and Saturday, this resident exhibited large amounts of agitation during the lunch hours; a secondary peak of agitation was observed during the dinner time period. The results in Figures 1 and 2 are examples, included to show that manifestations of agitation are specific to the agitated resident. For Resident A, the temporal pattern of agitation was consistent within the 24-hour day, regardless of the day of the week. Resident B had a weekday temporal pattern of agitation differing from that for weekend days. Highly individualized temporal patterns of agitation were seen for the other residents under study.
Is Agitation Influenced by Either the Day of the Week or Holidays? ANOVAs were performed to determine whether the agitated behaviors were
manifested equally often during each of the seven days of the week. Significant main effects emerged only for pacing and strange noises (see Table 2). Residents manifested strange noises most often on Sunday, followed by Saturday; strange MANIFESTATIONS OF AGITATED BEHAVIOR DAY OF WEEK AND TIME OF DAY RESIDENT B
A
50
I
40
G
T 30 A T 20 I 10
0
.N-
0 Wake-up Breakfast
Late Morning
Lunch
Early Afternoon
Dinner
Evening
Night
TIME PERIOD
- SUNDAY THURSDAY
Figure 2.
DAY OF WEEK +
MONDAY FRIDAY
* -A-
TUESDAY SATURDAY
+
WEDNESDAY
203
Temporal Patterns of Agitatwn
noises occurred least often on Mondays. Pacing was frequently observed on Sunday, Monday, and Tuesday; pacing occurred least often on Thursday (see Table 2). ANOVAs were performed to determine whether manifestations of agitated behaviors were associated with the occurrence of holidays (Table 3). The interaction of subjects with holidays was significant, however, for strange noises only. As to main effects, residents manifested measurably more repetitious mannerisms and pacing during holidays (in comparison to other days). Although not significant, the other behaviors showed the same trend.
DISCUSSION The findings strongly indicate that agitation is affected by temporal patterns and that this relationship is complex. In examining the data of each resident separately, temporal patterns of agitation were found to be specificto the agitated resident. Yet, TABLE 2. Univariate F Scores and Mean Frequencies of Pacing and Strange Noises for the 7 Days of the Week
Monday Tuesday Wednesday Thursday Friday Saturday Sunday F(6.138)
Pacing (mean)
Strange Noises (mean)
1.74 1.73 1.58 1.35 I .4l 1.55 1.75 2.43*
0.81 0.87 0.90 0.90 1.03 1.15 1.19 3.31*
* p < .05.
TABLE 3. Univariate F Scores and Mean Frequencies of Agitated Behaviors Manifested During Holidays Versus Other Days
Aggressive behaviors Picking at things Strange noises Pacing Strange movements Repetitious mannerisms Constant requests for attention
Holidays (mean)
Other Days (mean)
F( 1 2 3 )
0.10 0.98 1.32 1.55 0.48 1.82 2.13
0.09 0.79 0.92 1.37 0.33 1.79 1.68
3.04 1.35 2.04 4.43* 0.30 5.33* 0.65
204
J . Cohen-Mansfreidet al.
in examining the data for the group of 24 agitated residents it was found that some temporal patterns of agitation were consistentacross residents. Specifically,strange noises were manifested most often during the night, followed by the evening time period. Constant requests for attention were manifested commonly during lunch. Pacing, on the other hand, was observed during all hours of the 24-hour day. We believe these temporal patterns of agitation are related to aspects of the environment of the agitated individual. For instance, it is conceivable that residents make more requests for attention during lunch because staff are available to help them during this time period. Additionally, residents may scream more at night because they are alone in their rooms, but not yet asleep. In other words, agitated behaviors may be “time-locked” to daily schedules. This explanation is plausible, since nursing home routines offer little flexibility, with typical days including specifically prescribed hours for meals, bathing, medications, activities, and sleep. We propose that agitated residentsmanifest agitated behaviors comparatively more often during certain time periods as a reaction to the regimentation of their daily schedules. Of course, it is also possible that temporal patterns of agitation may have a neurochemical basis or may be linked to a physiological mechanism, such as circadian rhythms, or both. This notion is reinforced by the finding of individualized patterns of agitation. Some agitated behaviors (i.e., strange noises, aggressive behaviors, and picking at things) were manifested significantly more often during the evening hours than during the day hours---findings that support the occurrence of sundowning in the nursing home. In 1987,Evans found an increase in restless and verbal behaviors in the late afternoon in 11 out of 89 nursing home residents; in addition, sundowners had more severe cognitive impairment with organic involvement than did residents who were considered to be nonsundowners. Cohen-Mansfield, Ma=, and colleagues (1989), in a study of 408 nursing home residents, compared levels of agitation during the day with levels during the evening shifts. For each behavior they found about 14% of the residents under study manifested more agitation during the evening and 17% of the residents manifested more agitation during the day shift. Another finding of the present study is that residents manifested strange noises more often on weekends than on other weekdays. (The same finding was reported earlier by Werner et al., 1989, for a subset of this sample who frequently scream.) It is conceivable that these agitated residents made more strange noises on the weekend days because they were unoccupied (i.e., no structured activities, fewer staff). We also found that another agitated behavior, pacing, was frequently manifested on Sunday, Monday, and Tuesday, and occurred least often on Thursday. In another study of these residents, we reported that physical restraints were applied more often on Thursday than on the other six days of the week (see CohenMansfield et al., 1990). It is possiblethat residents paced less onThursdays because they were physically restrained and thus were unable to perform this behavior. Although there is some variation in the manifestation of agitation by day of the week, there seems to be a consistency of temporal patterns within the day across
Temporal Patterm of Agimion
205
weekdays, as seen in the figures. While we found clear evidence of temporal changes in agitation in severely agitated and cognitively impaired nursing home residents, we acknowledge that further research is needed to study this phenomenon in those who manifest agitation less frequently or less intensely. The finding that temporal patterns of agitation exist for agitated residents has important implications for professional caregivers. If caregivers know the time periods when agitated behaviors are most likely to occur (or increase) for residents on their units, they can plan ahead for these “agitated periods” by altering staffing patterns whenever possible and/or by implementing types of behavioral management (or intervention, particularly in the case of physically aggressive behaviors). Obviously, it is not realistic to expect caregivers to obtain systematic data of the kind used in this study, since they typically have neither the experience in observational research nor the extra time to devote to data collection. It is important for caregivers to pay attention to temporal patterns of agitation, however. It would be interesting to determine the extent to which caregivers are able to ascertain through natural observation the temporal patterns of agitation in elderly persons (rather than by means of systematic data collection); furthermore, increasing caregivers’ sensitivity to types of agitation and to the fact that temporal patterns do occur may increase their ability to identify these patterns. Obviously, examination of temporal patterns and interventions for agitation are appropriate only after nursing home caregiverslook for reversible causes of agitation, such as medication and environmentalsituations. Knowledge of temporal patterns of agitation also has important implications for future research. That is, if a researcher wants to evaluate the effectiveness of an intervention (e.g., music therapy, pharmacological trials), the effect of the intervention should be scheduled to coincide with the time period the residents under study manifest the most agitation.
REFERENCES Chandler, J. D., & Chandler,J. E. (1988). The prevalenceof neuropsychiatricdisorders in a nursing home population. Journal of Geriatric Psychiatry and Neurology, I, 71-76. Cohen-Mansfield,J. (1986). Agitated behaviors in the elderly:11. Preliminary results in the cognitive1y deteriorated.Journal of the American Geriatrics Society, 34,722-727. Cohen-Mansfield, J., Kerin, P., Pawlson. L. G., Lipson, S., & Holdridge, K. (1988). Informed consent for research in the nursing home: Processes and results. Gerontologist, 28,355-359. Cohen-Mansfield,J., Marx, M. S.. & Rosenthal, A. S. (1989). A description of agitationin a nursing home. Journal of Gerontology, 44, M77-MM. Cohen-Mansfield, J., Marx, M. S., & Werner, P. (1990). Patterns of restraint use with cognitively impaired residents on 3 units of a nursing home. (Monograph 49). Rockville, MD:Research Institute of the Hebrew Home of Greater Washington. Cohen-Mansfield, J., Werner, P., & Marx, M. S. (1989). An observational study of
J . Cohen-Mansfreld et al.
206
agitation in agitated nursing home residents. International Psychogeriatrics, I , 153-165.
Evans, L. K. (1987). Sundown syndrome in institutionalized elderly. Journal of the American Geriatrics Society, 35. 101-108. Kasteler, J. M., Ford, M. H., White, M. A,, & Carruth, M. L. (1979). Personnel turnover: A major problem for nursing homes. Nursing Homes, 28,20-25. Linn, M. W.. & Linn, B. S. (1985). The Rapid Disability Rating Scale-2. Journal of the American Geriatrics Society, 30,378-382. National Center for Health Statistics (1987). Health Statistics on Older Persons, United States, 1986. Vital Health Statistics, Series 3 (No. 25) (DHHS Pub. No. (PHS) 871409). Washington, DC: U.S. Government Printing Office. Reisberg, B., Schneck, M. K., Fems, S. H., Schwartz, G. E., & De Leon, M. J. (1983). The Brief Cognitive Rating Scale (BCRS): Findings in primary degenerative dementia (PDD). PsychopharmacologyBulletin, 19,47-50. Rower, B. W., Kafonek, S., Filipp, L., Lucas, M. J., & Folstein, M. F. (1986). Prevalence of mental illness in a community nursing home. American Journal of Psychiatry, 143. 1446-1449.
Stryker, R. (1982). The effect of managerial interventions on high personnel turnover in nursing homes. Journal of Long-term Care Administration.10,21-33. Wallace, R. W., & Brubaker, T. H. (1982). Biographical factors related to employment tenure: A study of nurses' aides in nursing homes. Journal of Long-term Care Administration, 10, 11-19. Waxman, H. M., Carner,E. A., & Berkenstock,G. (1984). Job turnoverand job satisfaction among nursing home aides. Gerontologist,24,503-509. Werner, P., Marx, M. S., & Cohen-Mansfield, J. (1989). Two studies of screaming in nursing home residents. Gerontologist (Special Issue), 29,69A. Acknowledgments. This research was supported by grant #1R01 MH40758 from the National Institute of Mental Health and by grant #RO1 AGO8675 from the National Institute on Aging.
OfSprints. Requests for offprints should be directed to Jiska Cohen-Mansfield, PhD, The Research Institute, The Hebrew Home of Greater Washington, 6121 Montrose Road, Rockville, M D 20852,U.S.A.
Temporal Patterns of Agitated Nursing Home Residents Jiska Cohen-Mansfield, Marcia S. Marx, Perla Werner, and Laurence Freedman ABSTRACT. Twenty-fourhighly agitated,cognitively impairednursing home residents were studied in depth to determine whether they manifested temporal patterns of agitation. Results demonstrated that agitated behaviors were significantly associated with temporal factors. For instance, residents made more requests for attention during lunch than other time periods, and residents screamed most often during the night. Some agitated behaviors (e.g., aggression) were manifested more frequently in the evening than in the day, consistent with the notion of sundowning in the nursing home. Implications of temporal patterns of agitation for caregivers of severely cognitively impaired and agitated nursing home residents are discussed.
At present, nursing homes in the United States contain about 5% of the population age 65 and older, 10% of persons age 75 and older, and 22% of persons age 85 and older(NCHS, 1987). While the number of elderly persons who will ultimately enter nursing homes may not increase proportionally with the “graying” of the population, any increase in the number of aged persons who enter nursing homes is cause for concern. There may not be enough room or nursing staff in the facilities. Currently, nursing homes are understaffed, and nursing staff experience serious stress, low pay, and, in turn, high rates of turnover (Kasteler et al., 1979; Stryker, 1982; Wallace & Brubaker, 1982; Waxman et al., 1984). The problems faced by nursing home staff are compounded when residents manifest agitated behaviors. Agitation in the nursing home elderly can take the form of aggressive behaviors (e.g., hitting, cursing), physically nonaggressive behaviors (e.g., pacing, repetitious mannerisms, general restlessness), or verbal behaviors (e.g., constant requests for attention, complaining) (Cohen-Mansfield, From the Research Institute of the Hebrew Home of Greater Washington, Rockville, Maryland (J. Cohen-Mansfield, PhD; M.S. Marx, PhD; and P. Werner, MA); Center on Aging, Georgetown University School of Medicine, Washington, Dc (J. Cohen-Mansfield, PhD); and the Biometry Branch, Division of Cancer Prevention and Control, National Cancer Institute, Rockville, Maryland, U.S.A. (L. Freedman. MA). 197
198
J . Cohen-Mamfiiki et al.
Marx et al., 1989). In a study of 408 nursing home residents, Cohen-Mansfield, Marx, and colleagues (1989) found that during the day shift the average nursing home resident manifests about four different agitated behaviors at a frequency of at least once a week. An investigationof 50 residents of an intermediatecare facility (94% of whom had a major psychiatricdisorder,most often dementia) revealed that 76% manifested at least one behavior problem (Rovner et al., 1986). Chandler and Chandler(1988) reported the prevalenceof neuropsychiatricdisorders(most often, dementia syndrome) to be 94% in a group of 65 nursing home residents; the most common behavioral problems, agitation and aggression, affected 48% of their sample. In order to provide adequate care in nursing homes, we must come to understand behavior disturbances. One facet of this understanding is to learn whether manifestations of agitated behaviors by agitated nursing home residents are “time-locked” to particular periods during the 24-hour day. Temporal changes in agitation in highly agitated and severely cognitively impaired nursing home residents is the focus of the present study.
METHOD This was an observational study designed to identify temporal patterns of agitated behaviors. The data presented here are part of a large data set that examined situational and environmental correlates of agitation.
Study Participants A group of 24 residents of a 550-bed long-term-care facility participated in this study. These 24 residents were selected because of their high levels of agitation on the basis of information from nurses and results of data analysis of a previous large cross-sectional study of agitation. (In that study, the level of agitation was assessed using the Cohen-Mansfield Agitation Instrument; see Cohen-Mansfield, 1986; Cohen-Mansfield,Marx et al., 1989). All 24 residents suffered from severe cognitive impairment, which was assessed via the Brief Cognitive Rating Scale (BCRS; Reisberg et al., 1983). The mean BCRS score for the group of residents was 6, where 1 denotes normal functioning and 7 indicates total cognitive deterioration. As to other characteristics of the 24 residents. they were similar to the total nursing home population in age (mean age = 86.7 years; age range: 62-93 years), in gender (3 men, 21 women), and in length of stay in the nursing home (mean = 3.7 years; range: < 1-15 years). Regarding their abilityto perform activitiesof daily living (ADL: bathing, eating, toileting, grooming,dressing, and walking), daytime charge nurses rated each resident via the Rapid Disability Rating Scale-2 (RDRS2; Linn & Linn, 1985).The mean RDRS-2 SCOR for this groupof residents was 3.1, where 1 represents independence and 4 represents total dependence on others. As these residents suffered from severecognitive impairment, informed consent
Temporal Patterns of Agitation
199
for study participation was obtained from a close relative of each resident (see Cohen-Mansfield et al., 1988, for details of this procedure).
Instrument The Agitation Behavior Mapping Instrument (ABMI; Cohen-Mansfield,Werner et al., 1989) is a nonobtrusive assessment used for direct observation and recording of behaviors as they occur in the natural environment. Interobserver agreement rates for the behaviors on the ABMI averaged .93 (Cohen-Mansfield,Wemeret al., 1989). Previous research has indicated that agitated nursing home residents tend to manifest the following behaviors most frequently: picking at or throwing things, repetitious mannerisms, strange noises (includes screaming),constant requests for attention, strange movements, and pacing (Cohen-Mansfield,Werner et al., 1989). Given their frequency, these behaviors were the focus of the present study. In addition, aggressive behaviors (including biting, hitting, and cursing) were examined because of their disruptive and sometimes painful consequences. We also included a composite score of total agitation derived for each resident as the weighted total number of agitated behaviors manifested by that resident. The weightings were based on the disruptive effect of the agitated behavior manifested; that is, aggressive behaviors are maximally disruptive while repetitious mannerisms are not particularly disruptive to persons on the unit (see Cohen-Mansfield, Werner et al., 1989).
Procedure Over a three-month period, 1,000observations,on average, were obtained for each resident via the ABMI. Observationsof residents were scheduled using a stratified random time-sampling method. Each observation lasted for three consecutive minutes per hour (only one observation of each resident was scheduled per hour); all hours of the 24-hour day were sampled. However, only observations in which residents were awake are described in this paper. Further details of the procedure can be found in Cohen-Mansfield,Werner et al. (1989). During each observation, a research assistant recorded the number of times each resident manifested each of the individual agitated behaviors. The research assistant also recorded the following temporal conditions: time, date, and day of the week. We examined the frequency by which each resident manifested the individual agitated behaviors relative to the temporal conditions (e.g., time of day, day of the week) via separate analyses. In this way, we could determine whether frequencies of agitated behaviors varied as functions of the temporal conditions. The analysis employed was ANOVA (repeated measures), assuming the random effects model. That is, the temporal conditions were obviously finite and fixed, but subjects constituted a sample from a larger population of nursing home residents. This then implied that F statisticswere obtained by comparing the specificmean square for the temporal conditionterm with themean square of the interaction term. The significant main effects for each temporal condition are reported in the results section.
J . Cokn-Marqtlild et al.
200
RESULTS
Do Residents Manifest Temporal Patterns of Agitation? To determine whether residents manifested specific temporal patterns of agitation within each 24-hour day, the day was divided into eight time periods, reflecting the routine of the nursing home, and ANOVAs were performed. All interactions were statistically significant 0, c .Ol), indicating that time patterns of agitation varied among participants. Examination of the main effects revealed that manifestations of different agitated behaviors were differentially associated with specific time periods (see Table 1). Aggressive behaviors were displayed often during lunch and evening. Strange movements were manifested most often during the night. Residents picked at things most often during the night and least often during breakfast and late morning. Strange noises were noted most often during the night, followed by the evening time period. Pacing was observed throughout Time Periods 1-7, with a peak occurring during the early afternoon. Repetitious mannerisms were observed often during much of the day, peaking in the late morning; this behavior was manifested comparatively less often in the early afternoon through the evening. Constant requests for attention occurred most often during lunch, and least often at night. To determine whether a pattern of sundown syndrome would emerge from the data of the present study, “day” was operationalized as the hours from 6 AM to4:30 PM, and “evening” was operationalized as the hours from 4:31 PM to 11 PM. The results of the analysis revealed that all interactions were statistically significant
TABLE 1. Univariate F Scores and Mean Frequencies of Agitated Behaviors Manifested During the 8 Time Periods
~~
Aggressive behaviors Picking at things Strange noises Pacing Strange movements Repetitious mannerisms Constant requests for attention
0.05 0.91 1.07 1.04 0.54 2.73 1.62
0.08 0.33 0.79 1.04 0.17 2.57 1.56
0.11 0.49 0.67 1.89 0.22 3.20 2.01
*p < .05; **p < .01. Time I = Wake-up time (6:Ol ~ ~ - 7 : 3 0AM). Time 2 = Breakfast time (7:31 ~ ~ - 9 : 3 0AM). Time 3 = Late morning (9:31 ~ ~ - 1 1 : 3 0AM). Time 4 = Lunch (11:30 AM---1:30 PM). Time 5 = Early afternoon (1:31 ~ ~ - 4 3PM). 0 Time 6 = Dinner (4:31 ~ ~ - 7 : 3 0PM). Time 7 = Evening (7:31 PM-1 I:@ PM). Time 8 = Night (11:Ol PM--~:@ AM).
0.18 0.61 0.89 1.86 0.16 2.28 2.46
0.11 1.17 0.80 2.11 0.31 1.37 2.15
0.13 0.91 0.85 1.84 0.24 1.06 1.83
0.18 1.10 1.37 1.79 0.19 1.63 1.43
0.05 1.67 1.70 0.10 1.15 2.22 0.78
3.25** 5.40** 3.45** 5.08** 1.93 2.95** 2.45*
201
Temporal Patterns of Agitation
(p < .Ol), indicating that participants differed in the extent to which they experienced sundowning. As to the main effects, sundowning pattems (Le., more agitation during the “evening”) were seen for three behaviors. Strange noises, picking at things, and aggressivebehaviors were manifested more often during the “evening”hours (mean frequencies= 1.08,l .OO,0.14, respectively)than during the “day” hours (mean frequencies = 0.81, 0.65, 0.09, respectively) (F(,.,,, = 10.65, 5.09, 5.94, respectively; for strange noises p < .01, for the latter two behaviors p < .05). Although the test statistic was not significant, more pacing was observed during the “evening” hours than during the “day” hours. The other behaviorepetitious mannerisms,requests for attention, and strange movements-tended to occur more often during the “day” hous (the univariate F-scores were not significant). Separate examination of the data of each resident revealed that individual residents manifest consistent temporal pattems of agitation. As an example, the total number of agitated behaviors manifested during each day of the week by Resident A is shown as a function of time (see Figure 1). Each of the seven days, this resident manifested,on the average,the greatest amount of agitation during the late morning period (i.e., Time Period 3), with secondary peaks occumng around
MANIFESTATIONS OF AGITATED BEHAVIOR DAY OF WEEK AND TIME OF DAY RESIDENT A A G i T A T I 0 N
35 7 30 25 20 15 10 5 0 Wake-up
Breakfast
Late Morning
Lunch
Early After noon
Dinner
Evening
Night
TIME PERIOD
- SUNDAY THURSDAY
Figure 1.
DAY OF WEEK +
----
MONDAY FRIDAY
--*.- TUESDAY
--
SAT U R DAY
-
WEDNESDAY
I
J . Cohen-Mansfieldet al.
202
the early afternoon or dinner time. Maximum agitation occurred on Sunday and minimum agitation on Friday. Patterns of total agitation for a different resident are shown in Figure 2. This resident manifested large amounts of agitation during breakfast or late morning on Monday, Tuesday, Wednesday, Thursday, and Sunday. On Friday and Saturday, this resident exhibited large amounts of agitation during the lunch hours; a secondary peak of agitation was observed during the dinner time period. The results in Figures 1 and 2 are examples, included to show that manifestations of agitation are specific to the agitated resident. For Resident A, the temporal pattern of agitation was consistent within the 24-hour day, regardless of the day of the week. Resident B had a weekday temporal pattern of agitation differing from that for weekend days. Highly individualized temporal patterns of agitation were seen for the other residents under study.
Is Agitation Influenced by Either the Day of the Week or Holidays? ANOVAs were performed to determine whether the agitated behaviors were
manifested equally often during each of the seven days of the week. Significant main effects emerged only for pacing and strange noises (see Table 2). Residents manifested strange noises most often on Sunday, followed by Saturday; strange MANIFESTATIONS OF AGITATED BEHAVIOR DAY OF WEEK AND TIME OF DAY RESIDENT B
A
50
I
40
G
T 30 A T 20 I 10
0
.N-
0 Wake-up Breakfast
Late Morning
Lunch
Early Afternoon
Dinner
Evening
Night
TIME PERIOD
- SUNDAY THURSDAY
Figure 2.
DAY OF WEEK +
MONDAY FRIDAY
* -A-
TUESDAY SATURDAY
+
WEDNESDAY
203
Temporal Patterns of Agitatwn
noises occurred least often on Mondays. Pacing was frequently observed on Sunday, Monday, and Tuesday; pacing occurred least often on Thursday (see Table 2). ANOVAs were performed to determine whether manifestations of agitated behaviors were associated with the occurrence of holidays (Table 3). The interaction of subjects with holidays was significant, however, for strange noises only. As to main effects, residents manifested measurably more repetitious mannerisms and pacing during holidays (in comparison to other days). Although not significant, the other behaviors showed the same trend.
DISCUSSION The findings strongly indicate that agitation is affected by temporal patterns and that this relationship is complex. In examining the data of each resident separately, temporal patterns of agitation were found to be specificto the agitated resident. Yet, TABLE 2. Univariate F Scores and Mean Frequencies of Pacing and Strange Noises for the 7 Days of the Week
Monday Tuesday Wednesday Thursday Friday Saturday Sunday F(6.138)
Pacing (mean)
Strange Noises (mean)
1.74 1.73 1.58 1.35 I .4l 1.55 1.75 2.43*
0.81 0.87 0.90 0.90 1.03 1.15 1.19 3.31*
* p < .05.
TABLE 3. Univariate F Scores and Mean Frequencies of Agitated Behaviors Manifested During Holidays Versus Other Days
Aggressive behaviors Picking at things Strange noises Pacing Strange movements Repetitious mannerisms Constant requests for attention
Holidays (mean)
Other Days (mean)
F( 1 2 3 )
0.10 0.98 1.32 1.55 0.48 1.82 2.13
0.09 0.79 0.92 1.37 0.33 1.79 1.68
3.04 1.35 2.04 4.43* 0.30 5.33* 0.65
204
J . Cohen-Mansfreidet al.
in examining the data for the group of 24 agitated residents it was found that some temporal patterns of agitation were consistentacross residents. Specifically,strange noises were manifested most often during the night, followed by the evening time period. Constant requests for attention were manifested commonly during lunch. Pacing, on the other hand, was observed during all hours of the 24-hour day. We believe these temporal patterns of agitation are related to aspects of the environment of the agitated individual. For instance, it is conceivable that residents make more requests for attention during lunch because staff are available to help them during this time period. Additionally, residents may scream more at night because they are alone in their rooms, but not yet asleep. In other words, agitated behaviors may be “time-locked” to daily schedules. This explanation is plausible, since nursing home routines offer little flexibility, with typical days including specifically prescribed hours for meals, bathing, medications, activities, and sleep. We propose that agitated residentsmanifest agitated behaviors comparatively more often during certain time periods as a reaction to the regimentation of their daily schedules. Of course, it is also possible that temporal patterns of agitation may have a neurochemical basis or may be linked to a physiological mechanism, such as circadian rhythms, or both. This notion is reinforced by the finding of individualized patterns of agitation. Some agitated behaviors (i.e., strange noises, aggressive behaviors, and picking at things) were manifested significantly more often during the evening hours than during the day hours---findings that support the occurrence of sundowning in the nursing home. In 1987,Evans found an increase in restless and verbal behaviors in the late afternoon in 11 out of 89 nursing home residents; in addition, sundowners had more severe cognitive impairment with organic involvement than did residents who were considered to be nonsundowners. Cohen-Mansfield, Ma=, and colleagues (1989), in a study of 408 nursing home residents, compared levels of agitation during the day with levels during the evening shifts. For each behavior they found about 14% of the residents under study manifested more agitation during the evening and 17% of the residents manifested more agitation during the day shift. Another finding of the present study is that residents manifested strange noises more often on weekends than on other weekdays. (The same finding was reported earlier by Werner et al., 1989, for a subset of this sample who frequently scream.) It is conceivable that these agitated residents made more strange noises on the weekend days because they were unoccupied (i.e., no structured activities, fewer staff). We also found that another agitated behavior, pacing, was frequently manifested on Sunday, Monday, and Tuesday, and occurred least often on Thursday. In another study of these residents, we reported that physical restraints were applied more often on Thursday than on the other six days of the week (see CohenMansfield et al., 1990). It is possiblethat residents paced less onThursdays because they were physically restrained and thus were unable to perform this behavior. Although there is some variation in the manifestation of agitation by day of the week, there seems to be a consistency of temporal patterns within the day across
Temporal Patterm of Agimion
205
weekdays, as seen in the figures. While we found clear evidence of temporal changes in agitation in severely agitated and cognitively impaired nursing home residents, we acknowledge that further research is needed to study this phenomenon in those who manifest agitation less frequently or less intensely. The finding that temporal patterns of agitation exist for agitated residents has important implications for professional caregivers. If caregivers know the time periods when agitated behaviors are most likely to occur (or increase) for residents on their units, they can plan ahead for these “agitated periods” by altering staffing patterns whenever possible and/or by implementing types of behavioral management (or intervention, particularly in the case of physically aggressive behaviors). Obviously, it is not realistic to expect caregivers to obtain systematic data of the kind used in this study, since they typically have neither the experience in observational research nor the extra time to devote to data collection. It is important for caregivers to pay attention to temporal patterns of agitation, however. It would be interesting to determine the extent to which caregivers are able to ascertain through natural observation the temporal patterns of agitation in elderly persons (rather than by means of systematic data collection); furthermore, increasing caregivers’ sensitivity to types of agitation and to the fact that temporal patterns do occur may increase their ability to identify these patterns. Obviously, examination of temporal patterns and interventions for agitation are appropriate only after nursing home caregiverslook for reversible causes of agitation, such as medication and environmentalsituations. Knowledge of temporal patterns of agitation also has important implications for future research. That is, if a researcher wants to evaluate the effectiveness of an intervention (e.g., music therapy, pharmacological trials), the effect of the intervention should be scheduled to coincide with the time period the residents under study manifest the most agitation.
REFERENCES Chandler, J. D., & Chandler,J. E. (1988). The prevalenceof neuropsychiatricdisorders in a nursing home population. Journal of Geriatric Psychiatry and Neurology, I, 71-76. Cohen-Mansfield,J. (1986). Agitated behaviors in the elderly:11. Preliminary results in the cognitive1y deteriorated.Journal of the American Geriatrics Society, 34,722-727. Cohen-Mansfield, J., Kerin, P., Pawlson. L. G., Lipson, S., & Holdridge, K. (1988). Informed consent for research in the nursing home: Processes and results. Gerontologist, 28,355-359. Cohen-Mansfield,J., Marx, M. S.. & Rosenthal, A. S. (1989). A description of agitationin a nursing home. Journal of Gerontology, 44, M77-MM. Cohen-Mansfield, J., Marx, M. S., & Werner, P. (1990). Patterns of restraint use with cognitively impaired residents on 3 units of a nursing home. (Monograph 49). Rockville, MD:Research Institute of the Hebrew Home of Greater Washington. Cohen-Mansfield, J., Werner, P., & Marx, M. S. (1989). An observational study of
J . Cohen-Mansfreld et al.
206
agitation in agitated nursing home residents. International Psychogeriatrics, I , 153-165.
Evans, L. K. (1987). Sundown syndrome in institutionalized elderly. Journal of the American Geriatrics Society, 35. 101-108. Kasteler, J. M., Ford, M. H., White, M. A,, & Carruth, M. L. (1979). Personnel turnover: A major problem for nursing homes. Nursing Homes, 28,20-25. Linn, M. W.. & Linn, B. S. (1985). The Rapid Disability Rating Scale-2. Journal of the American Geriatrics Society, 30,378-382. National Center for Health Statistics (1987). Health Statistics on Older Persons, United States, 1986. Vital Health Statistics, Series 3 (No. 25) (DHHS Pub. No. (PHS) 871409). Washington, DC: U.S. Government Printing Office. Reisberg, B., Schneck, M. K., Fems, S. H., Schwartz, G. E., & De Leon, M. J. (1983). The Brief Cognitive Rating Scale (BCRS): Findings in primary degenerative dementia (PDD). PsychopharmacologyBulletin, 19,47-50. Rower, B. W., Kafonek, S., Filipp, L., Lucas, M. J., & Folstein, M. F. (1986). Prevalence of mental illness in a community nursing home. American Journal of Psychiatry, 143. 1446-1449.
Stryker, R. (1982). The effect of managerial interventions on high personnel turnover in nursing homes. Journal of Long-term Care Administration.10,21-33. Wallace, R. W., & Brubaker, T. H. (1982). Biographical factors related to employment tenure: A study of nurses' aides in nursing homes. Journal of Long-term Care Administration, 10, 11-19. Waxman, H. M., Carner,E. A., & Berkenstock,G. (1984). Job turnoverand job satisfaction among nursing home aides. Gerontologist,24,503-509. Werner, P., Marx, M. S., & Cohen-Mansfield, J. (1989). Two studies of screaming in nursing home residents. Gerontologist (Special Issue), 29,69A. Acknowledgments. This research was supported by grant #1R01 MH40758 from the National Institute of Mental Health and by grant #RO1 AGO8675 from the National Institute on Aging.
OfSprints. Requests for offprints should be directed to Jiska Cohen-Mansfield, PhD, The Research Institute, The Hebrew Home of Greater Washington, 6121 Montrose Road, Rockville, M D 20852,U.S.A.
