Copyright 1996 by The Gerontological Society of America
Journal of Gerontology: PSYCHOLOGICAL SCIENCES
1996, Vol. 51B, No. 6, P364-P373
Environmental "White Noise": An Intervention for
Verbally Agitated Nursing Home Residents
Louis Burgio, Kay Scilley, J. Michael Hardin, C. Hsu, and Jeannie Yancey
University of Alabama at Birmingham.
This study presents preliminary data on the efficacy of two environmental "white noise" audiotapes for the treatment
of verbal agitation in severely demented nursing home residents. The researchers employed a computer-assisted realtime observational system to assess both the frequency of verbal agitation and the actual use of the intervention on the
nursing units (treatment fidelity). Intervention by nurse aides (NAs) on the unit was preceded by a researchercontrolled functional analysis phase that provided information regarding which of the two audiotapes would be most
effective for individual residents. Results indicate a 23% reduction in verbal agitation with this individualized
treatment strategy on the nursing units. These results were obtained even though treatment fidelity data showed that
the audiotapes were used during only 51% of the observations. The authors discuss the need for formal staff
management procedures for increasing staff compliance with treatment regimens.
agitation is a prevalent form of behavioral
VERBAL
disturbance, in nursing homes with 11% (Cariaga, Burgio, Flynn, & Martin, 1991) to 28% (Ryan, Tanish, Kolodny, Lendrum, & Fischer, 1988) of residents exhibiting
some form of this problem. As used by most researchers,
this term includes an array of vocal behaviors including
screaming, calling out, repetitive statements, and moaning.
Verbal agitation can be stressful to other residents and to
direct care staff. Over time, the occurrence of this and other
disruptive behaviors can adversely affect the morale of
nursing staff. This, in turn, can impact the quality of care
provided to all residents.
Historically, residents displaying clinically significant
verbal agitation have received pharmacotherapy, with psychotropic drugs used most frequently (Billig, CohenMansfield, & Lipson, 1991). Unfortunately, pharmacotherapy has been shown to be, at best, only moderately effective
(Devanand, Sackheim, & Mayeux, 1988; Sunderland &
Silver, 1988). In fact, a meta-analysis examining the efficacy
of pharmacotherapy with patients diagnosed with Alzheimer's disease, found that only 1 out of every 5 patients
responded favorably to this type of intervention (Schneider,
Pollock, & Lyness, 1990). Moreover, pharmacotherapy can
produce serious side effects, including, but not limited to,
memory impairment (Larson, Kukill, Buchner, & Reifler,
1987), sedation (Allen, 1986), and tardive dyskinesia
(Thompson, Moran, & Nies, 1983).
Recognizing these therapeutic limitations, the Health
Care Finance Administration (HCFA) passed guidelines
(OBRA-87) which restrict the conditions under which nursing homes may administer psychotropic medications (American Health Care Association, 1990). According to these
guidelines, residents displaying a behavioral disturbance
must also exhibit psychotic symptoms or be a danger to
themselves or others before neuroleptic medication can be
prescribed. As an alternative to medication, the guidelines
specifically recommend that nursing homes utilize behavioral interventions and staff training as an initial approach to
managing behavior problems.
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Behavioral and environmental interventions have shown
promise in ameliorating the behavioral complications of
dementia in nursing home residents (Burgio & Bourgeois,
1992). Preliminary data suggest that these interventions can
be used effectively to treat behavioral excesses such as
physical aggression (Vacarro, 1988, 1990) and wandering
(Hussian, 1981; Hussian & Brown, 1987); and behavioral
deficits in such areas as ambulation (Burgio, Burgio, Engel,
& Tice, 1986) and communication skills (Bourgeois, 1991).
Researchers have reported limited success in decreasing
verbal agitation using behavioral treatments such as differential reinforcement procedures (Birchmore & Clague,
1983), aversive conditioning and time-out (Matheson,
Mian, MacPherson, & Anthony, 1976), and positive reinforcement combined with a modified time-out procedure
(Baltes & Lascomb, 1975).
More recently, researchers have investigated auditory
stimulation as an intervention for verbal agitation. One
rationale offered for using this type of intervention is that
verbal agitation may be an attempt by some residents to
provide auditory stimulation in an environment that supplies
inadequate stimulation across all modalities. In one study,
an inexpensive amplification device was used to decrease
yelling in a hearing-impaired elderly nursing home resident
(Leverett, 1991). Researchers have also begun to examine
the effects of music on verbal agitation. Goddaer and Abraham (1994) used relaxing music during mealtime to decrease
verbal agitation in 29 nursing home residents. Gerdner and
Swanson (1993) also reported reductions in verbal agitation
when music therapy was used with five residents with
Alzheimer's disease. Interestingly, in the Gerdner and
Swanson study, observations taken during the hour directly
following the music intervention continued to show reduced
rates of verbal agitation. Finally, Casby and Holm (1994)
used classical and favorite music selections to decrease
disruptive vocalization in two of the three nursing home
residents they treated.
Unfortunately, the majority of intervention research with
older adults, including the aforementioned studies, have
ENVIRONMENTAL ' 'WHITE NOISE''
serious methodological weaknesses. To date, studies have
relied heavily on behavioral rating scales as their primary
outcome measure (Burgio, 1996). Although rating scales are
an excellent resource for gathering information on a rater's
current impression of resident behavioral status, they can be
insensitive to behavioral change because they are dependent
on an individual's ability to recall occurrences of behavior
over time (Bellack & Hersen, 1988). More sensitive behavioral data can be gathered through the use of direct observational techniques, with continuous (nonsampled) observation being the most sensitive procedure for recording low
rate behaviors (Mudford, Beale, & Singh, 1990).
Past studies have also tended to neglect the importance of
assessing treatment fidelity (Moncher & Prinz, 1991). Failure to reliably assess the correct application of interventions
can compromise the researcher's ability to draw conclusions
regarding treatment efficacy. Also, intervention researchers
must consider the practicality of implementing any intervention in a naturalistic setting with indigenous staff (e.g., nurse
aides) employed as the primary interventionists. Due to the
financial constraints and staff shortages that are commonplace in most nursing homes, interventions must be both
easy to use and inexpensive (Burgio & Bourgeois, 1992;
Burgio & Burgio, 1986).
Finally, nursing home intervention research has yet to
capitalize on the utility and explanatory power of a behavioral assessment technique termed functional analysis (Neef,
1994). Functional analysis involves the introduction of a
brief assessment phase prior to intervention in an effort to
generate information on the relationship between environmental events and the behavioral disturbance. Information
about this relationship can help inform the therapist about
potentially effective environmental interventions. During a
functional analysis, environmental stimuli are introduced
and withdrawn systematically, while any effects on the
behavioral disturbance are examined (Horner, 1994). This
assessment strategy has been used extensively in intervention research with developmentally disabled individuals to
identify potential individual treatment approaches prior to
intervention (Iwata, Dorsey, Slifer, Bauman, & Richman,
1994).
The purpose of the present study was to use precise, direct
observation assessment techniques to examine the efficacy
of an auditory stimulation intervention. Our choice of intervention was based on a serendipitous finding from our prior
research. In a pilot study examining the relationship between
verbal agitation and environmental contextual variables, our
results suggest that residents displayed briefer duration verbal agitation while they were with the nursing home hairdresser (Burgio et al., 1994).
Our field notes documented statements from the hairdresser that verbally agitated residents rarely displayed agitation while under a hairdryer. From this we hypothesized
that "white noise," produced by the hairdryer, might,
through some unknown mechanism, be related to the reduction in verbal agitation. In the present study, we tested this
hypothesis by using environmental "white noise"
audiotapes (gentle ocean and mountain stream). Recently,
environmental "white noise" has been combined with music therapy in the treatment of depression with elderly
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individuals living in the community (Hanser & Thompson,
1994). Researchers have not previously examined environmental ' 'white noise'' as an intervention for verbal agitation.
More specifically, this study examined the efficacy of
environmental "white noise" as an intervention for verbal
agitation in demented nursing home residents. A functional
analysis phase was initiated by research staff, and the resulting information was used by the researchers for planning
interventions on the nursing units. Using a computerassisted, real-time observational system, we sampled
whether the intervention was in use on the nursing units
(treatment fidelity) and measured precise rates of verbal
agitation under various conditions. Finally, we assessed the
social validity of the intervention (Wolf, 1978), as viewed
by the nurse aides (NAs).
METHOD
Setting and Participants
This study was conducted in two Birmingham area nursing homes. A census count at the beginning of the study
indicated Nursing Home 1, a county-run facility, had a total
of 306 residents residing within the facility; Nursing Home
2, a corporate owned, for-profit facility, had 232 residents.
The average nurse-to-resident ratios were similar in both
nursing homes. On the day shift, average ratios for NAs,
LPNS, and RNs were 1:8, 1:27, and 1:67, respectively.
Average staffing ratios for the evening shift were 1:12, 1:27,
1:156 for NAs, LPNS, and RNs, respectively. Neither
facility was unionized.
Fifteen of the 16 subjects entered into the study had
participated in an earlier observational study of verbal agitation. In the earlier study, the nursing staff referred residents
who were at least 65 years of age, were expected to remain in
the facility for at least 3 months, and exhibited verbal
agitation at least once a week; all subjects were judged by the
Medical Director to be in stable medical condition. Between
the two facilities, 213 residents met the entry criteria. Our
consent rate was 54%. Residents in this earlier study were
observed for an average of 2.52 hours. The average percentage of total observation time that the residents exhibited
verbal agitation was 35% (range = 7%-79%).
Prior to the start of the current study, the nursing staff
were asked to update the list of verbally agitated residents
using the same entry criteria used in the earlier observational
study. In an effort to maximize the likelihood of detecting
any reduction in verbal agitation due to the interventions, the
researchers chose to target only residents displaying severe
verbal agitation. To identify these residents, a group of unit
charge nurses from each facility was asked to identify the 8
residents displaying the most severe and highest frequency
verbal agitation. Also, in preparation for the audiotape
intervention, the researchers identified residents with hearing impairments based on medical record review and staff
report. Residents with severe hearing impairments were
excluded from the study.
Although 16 subjects entered the study, not all subjects
completed this four-phase study. Figure 1 shows the sequencing of the four phases (baseline, functional analysis,
staff training, and intervention). During functional analysis,
BURGIOETAL.
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Sequence of Study Phases
Staff Training
(2 days)
Intervention
(10 days)
Naturalistic
Observations
(10 sessions)
NO
OBSERVATIONAL
DATA
COLLECTED
- 1 5 min —
samples
Figure 1. Sequence and duration in days of the four study phases.
the researchers systematically introduced and withdrew the
audiotaped stimuli in a controlled setting to assess the effects
of these tapes on rates of verbal agitation. This information
was then used by the researchers for' 'prescribing" a specific
environmental sound tape for use on the nursing unit (see
below for a more detailed description).
Three of the 16 residents did not complete the functional
analysis phase and were dropped from the study. One of
these residents was excluded by the researchers because she
displayed a very low rate of verbal agitation during all trials
of the functional analysis phase, making it impossible to
acquire meaningful assessment data. One resident refused to
wear the tape player headphones, and a third resident died
prior to functional analysis.
The mean age of the 13 residents completing this functional analysis phase was 83.08 years (range = 67-99).
Twelve residents were women. Only one resident was reported by staff to have a marked hearing impairment; however, the researchers assumed some level of hearing impairment for the remaining 12 residents. We attempted to assess
the residents' cognitive and functional status with the MiniMental State Exam (MMSE; Folstein, Folstein, & McHugh,
1975) and the Barthel Self-Care Rating Scale (Sherwood,
Morris, Mor, & Gutkin, 1977). The range of possible scores
on the Barthel items is 1-4, with 4 denoting total assistance
on the care activity. One resident could not be assessed with
the MMSE because of severe agitation. The average MMSE
score for the 12 assessed residents was 1.66 (range = 0—
12), indicating severe cognitive impairment. Residents had a
mean Barthel item score of 3.44 (range = 1.38—4.0),
signifying that this group required near total assistance with
activities of daily living.
Medical record review showed that 12 of the 13 residents
had received a diagnosis of dementia, with 4 of these
diagnosed with probable Alzheimer's disease. The resident
without a dementia diagnosis presented with symptoms
strongly suggestive of dementia. Eight of the 13 residents
received psychotropic medications for agitation on a routine
basis, with 3 of the 8 residents also prescribed a psychotropic
on an "as needed" (PRN) dosage schedule. Only one
resident was recorded as having received a PRN psychotropic during the sampled times.
Of the 13 residents completing the functional analysis
phase, 9 residents displayed reliably lower verbal agitation
while exposed to an environmental "white noise" audiotape
as compared to the no-audiotape condition. These 9 subjects
were considered responders and only they were provided an
environmental "white noise" intervention on the nursing
unit. The mean age of these 9 residents was 83.89 (range =
67-99); 8 were women. The average MMSE and Barthel
scores for this group were 1.00 (range = 0-5) and 3.32
(range = 1.38-4.0), respectively. Eight residents had a
dementia diagnosis, with 2 diagnosed with probable Alzheimer's disease. Six of these 9 responders were prescribed
psychotropic medication on a routine basis, and 3 prescribed
psychotropic medication on a PRN basis.
The Cohen-Mansfield Agitation Inventory (CMAI;
Cohen-Mansfield, Marx, & Rosenthal, 1989) and the Survey of Disruptive Vocal Behavior (SDVB; Cariaga et al.,
1991) were administered to NAs to provide a more complete
description of the residents' behavioral disturbances. For the
13 residents completing the functional analysis phase, NAs
reported that the most common forms of verbal agitation
were (the number of residents displaying the behavior is in
parentheses): moans/groans (8), self-talk (7), screaming (6),
and calling out for assistance (6). The situations reported by
NAs where verbal agitation was most likely to occur were:
after grooming/bathroom use (5), during grooming/
bathroom use (4), during meals (4), upon awakening in the
morning (4), and before evening bedtime (4). Five residents
were reported to display verbal agitation constantly. On the
CMAI, NAs reported that all 13 residents displayed behavior
problems other than verbal agitation (e.g., physical aggression, wandering), with a mean of 3.1 additional problems.
Eight residents displayed 1 to 3 and 5 residents displayed 4 to
6 additional behavior problems.
Functional Analysis and Treatment Conditions
On-unit baseline. — Prior to exposure to the functional
analysis procedures, naturalistic observations were conducted with all subjects during a 10-day baseline phase on
the nursing units. Behavioral observations were conducted
during the 2-5 p.m. and 6-8 p.m. time periods (the dinner
period was excluded). Our prior research (Burgio et al.,
1994) suggested that verbal agitation was most likely to
occur during the late afternoon and early evening hours.
Each resident was observed for two continuous 15-minute
intervals during each of the 5 hourly blocks of time, for a
total of 2.5 hours of observation per resident during the
baseline phase.
Functional analysis. — Immediately following baseline
assessment, the 16 identified residents were exposed to a
functional assessment of the mountain stream and gentle
ocean audiotapes (13 residents completed the phase). These
audiotapes are part of an environmental sounds series and
were purchased from the Nature Company® (Berkeley, CA;
$9.95 each). Both of the tapes presented a type of environmental "white noise," although the sound profile on the two
audiotapes was different. The mountain stream audiotape
presented a continuous sound of water rushing over rocks in
a stream bed, whereas the gentle ocean audiotape presented
the sound of crashing waves interspersed with the more
ENVIRONMENTAL ' 'WHITE NOISE''
muffled sound of receding waves. Both sounds are considered by the manufacturer and the researchers to be soothing
and monotonous.
The audiotapes were played through a portable cassette
player with an auto-reverse function and were equipped with
headphones; (Gerrard® Personal AM/FM Cassette Stereo,
Model 5, $24.95). Over this 10-day phase, each resident was
targeted to receive a maximum of four trials (exposures) with
each of the two audiotapes (total of eight trials). Each trial
lasted 20 minutes, and consisted of four sequential 5-minute
segments wherein the therapist alternated "audiotape-on" and "audiotape-off" conditions. The order of
audiotape presentation was counterbalanced across trials to
control for potential order effects.
One requirement of functional analysis is that the subject
must either be naturally exhibiting the target behavior during
the assessment, or the behavior must be elicited by the
researcher so that the effects of the experimental stimuli can
be assessed. We preferred to not exercise the latter option;
thus, observers were required to be available during lengthy
periods of time on the units so that functional assessment
could be conducted in response to naturally occurring episodes of verbal agitation. Specifically, research staff made
observational "rounds" with participating residents recurrently from 11 a.m. to 5 p.m. (a high probability period for
agitation). Although this was the general observational procedure, some residents were agitated more reliably during
the morning hours, and these few residents were observed at
that time. Within a trial, observations and experimental
manipulations (i.e., audiotape on and off) were completed
by the same individual, although the role of experimenter/
observer was alternated among a Project Manager and two
research assistants.
Most of the 13 residents who completed the functional
analysis phase displayed verbal agitation at lower rates than
predicted by the charge nurses during the initial referral.
Consequently, regardless of our frequent availability on the
units for observations, only one resident received the complete set of eight trials; 5 residents received six trials; 5
received five trials; one received three trials, and one received two trials. A secondary reason for residents not
completing the maximum of 8 trials was refusal to wear the
headphones during a trial. Our data show that 14% of the
trials were refused by the residents; 8 out of 13 residents
(62%) refused at least one trial. Some resistance was expected by the researchers, and our intention was to oversample the functional analysis with eight trials. We believe that
sufficient functional analysis data were generated for all
residents, including the resident who received only two trials
(i.e., 40 min of continuous direct observation).
During this phase, the occurrence (i.e., percentage of
observations) per trial of verbal agitation during ' 'audiotapeoff" and "audiotape-on" conditions with each of the two
audiotapes was graphed for each resident. At the end of the
phase, the research team examined the residents' graphs and
classified residents as "responders" if verbal agitation occurred reliably less often during the "audiotape-on" conditions than during the "audiotape-off" conditions. Nine
residents were considered responders based on this criterion
and were entered into the intervention phase of the study.
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Residents were assigned to receive the audiotape (i.e., either
ocean or stream) that produced the largest decrease in verbal
agitation during functional analysis.
Staff training. — All NA training was conducted on the
nursing units. The Project Manager (PM) met with the NAs
in small groups, and occasionally one-on-one, to provide the
initial rationale and description of the intervention. The NAs
were told that we wanted to try a new intervention that might
help verbally agitated residents. The PM described the
audiotape intervention and explained that environmental
sounds could have a calming effect on these residents.
NAs were instructed how to use the tape player and the
appropriate procedures for placing the headphones on the
resident. A formal program was written for each resident, in
nontechnical language, that included a definition of the
resident's verbal agitation, a description of each step of the
intervention, and the proper volume setting for the resident.
The volume was set at the medium volume point of the tape
player for all residents except for the one resident with a
marked hearing impairment. For this resident, the volume
level was set slightly above medium volume. The NAs were
cautioned to check the volume level frequently to ensure that
the optimal volume was used.
They were told that the tape players would be available
between 2 p.m. and 8 p.m. NAs were provided with a list of
residents who were to receive the intervention on their unit.
They were asked to approach the residents during the targeted time and say that they would like them to listen to an
audiotape. If the resident did not resist, the NA was to place
the headphones on the resident as instructed. If the resident
resisted placement of the headphones, the NA was instructed
to try again at a later time. The audiotapes were to be used
"as much as possible" during this 6-hour period; however,
NAs were asked not to apply the intervention during personal care or group activities, mealtimes, when the resident
was sleeping, or when visitors were present. NAs were also
told to use the intervention in response to specific occurrences of verbal agitation during this 6-hour time period, if
the audiotape was not already in use.
During the 2-day training phase, research staff provided
on-the-job instruction and performance feedback to the
NAs. Data on verbal agitation were not collected during this
time.
Intervention on the unit. — A copy of the behavioral
program was placed on the resident's bedroom wall and in
the medical record. The researchers distributed the tape
players and audiotapes prior to 2 p.m., and collected them
for safe storage at 8 p.m. At the beginning of this time period
NAs were informed that the audiotapes were now available
for the assigned residents. When a tape player was not in use
during time periods between 2 p.m. and 8 p.m., it was kept
on top of the bedside table in the resident's room.
The observation schedule used during intervention was
identical to the baseline phase. Observations were scheduled
between 2-5 p.m. and 6-8 p.m., with specific times of
observation distributed randomly across residents. Observations were completed by the PM and two research assistants.
However, during these half-hourly observational rounds, the
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BURGIOETAL.
observers were allowed to prompt the NAs to use the
audiotape intervention if the headphones were not in place
and the resident was not engaged in any activity that conflicted with use of the intervention (e.g., group or care
activity). Research staff did not prompt the NAs systematically; prompting was estimated to have occurred one to two
times per shift. The NAs were aware that the project was
important to the nursing home administrative staff; however,
NAs' performance of the intervention was not tracked nor
were there any specific consequences for performance or
nonperformance of the intervention. A total of 22.8 hours of
observation was collected during the intervention phase.
Measures
Mini-Mental State Examination. — The MMSE (Folstein
et al., 1975) was administered to all participants within 2
weeks prior to the start of the baseline phase. The test-retest
and inter-evaluator reliabilities for the MMSE are .89 and
.83, respectively. Three research assistants were trained to
administer this measure by a neuropsychologist with expertise in geriatric cognitive assessment.
Barthel Self-Care Rating Scale. — The Barthel (Sherwood et al., 1977) is a 17-item assessment of activities of
daily living tailored specifically to inpatients in chronic care
settings. Sherwood et al. reported alpha reliabilities ranging
from .95 to .96 for this measure. An NA who was familiar
with the resident was asked to rate his/her ability to complete
self-care on activities that included feeding, dressing, hygiene, bathing, mobility, and toileting. Items are rated on a
4-point (1-4) Likert-type scale with higher numbers signifying greater dependence on staff. Two of the items, use of
prosthesis and wheelchair, are not applicable to all participants. Thus, a mean score for the applicable items was
generated for each subject. The Barthel was administered
during the baseline phase.
Cohen-Mansfield Agitation Inventory (CMAI). — This
measure consists of 29 behavior problems which were identified from the literature and NAs' perceptions. NAs rate
each specific agitated behavior on a 7-point frequency scale
with " 7 " indicating that the resident manifests the behavior
on an average of several times an hour. Inter-rater agreement
rates for each behavior on the CMAI averaged between .88
and .92 (Cohen-Mansfield et al., 1989).
Medication tracking form. — This form was developed by
the researchers to provide a structured format for recording
resident medications. Medication names, strength, number
of pills taken in the last 24 hours (or doses if liquid or
parenteral), and duration the resident has taken the medication are catalogued for each medication from the nursing
medicine administration records. This form was completed
at the end of the baseline, functional analysis, and intervention phases. The form is limited in its ability to track
administration of PRN medications in that only PRNs received by the resident within the 24-hour period preceding
the assessment are reported.
Survey of Disruptive Vocal Behavior (SDVB). — This
measure is a modification of a staff questionnaire used in our
earlier study of verbal agitation in the nursing home (Cariaga
et al., 1991). It was designed to gather information on verbal
agitation from the NA that was not obtainable from our
computer-assisted data collection system. The survey elicited staff's impressions of the type and severity of verbal
agitation, possible antecedent conditions, and interventions
that had been used previously with the residents.
Social validity item. — A social validity item was designed by researchers to assess the primary NA's impressions of the environmental "white noise" intervention. This
item was administered at the end of the intervention phase.
The resident's primary NA was asked: "Since we started
using the behavioral intervention, how would you describe
the resident's verbal agitation?" The NA rated the effectiveness of the intervention on a scale from 1 to 5, with 1
signifying that the resident was a lot worse, 5 a lot better, and
3 denoting no change.
Computer-assisted data collection system: hardware and
software. — Three Panasonic CF170 laptop computers were
used to collect observational data in this study. The computers have 80286 microprocessors, 20 megabyte hard
drives, and internal 3.5 floppy disc drives. The Portable
Computer Systems for Observational Research software
programs from Communitech International (DeKalb, IL)
were chosen for this project (Repp, Karsh, van Acker, Felce,
& Harman, 1989). These programs allowed researchers to
assign keys on the laptop computer to various behavioral and
environmental events. One set of keys was assigned to code
the resident's social environment, which included information on whether the resident was alone or in the presence of a
staff member. Another group of keys recorded one-to-one
verbal and tactual interaction; yet another group recorded
behavioral disturbance. During the intervention phase, two
keys recorded resident contact or no contact with the tape
player headphones. These keys provided a measure of treatment fidelity. Another pair of keys allowed researchers to
track the assessment conditions (i.e., "audiotape-on,"
"audiotape-off") during the functional analysis phase (a
detailed description of this computer-assisted observational
system can be found in Burgio et al. [1994]).
Detailed operational definitions were generated for all
codes. Verbal agitation was defined as screaming, cursing,
complaining, negativism, moaning, paranoid verbalization,
repeated requests for attention, repetitious words or sentences, singing outside of an organized activity, and self-talk
regardless of volume. Additional detail was provided on
each resident's idiosyncratic verbal agitation to assist observers in coding.
Interobserver reliability was assessed independently
among three observers during 13% (12.6 hours) of the total
observation time. Observer agreement was calculated using
Cohen's Kappa, which controls for chance agreement (Cohen, 1968). A computer program was written by the researchers to calculate Kappas through a second-by-second
comparison of the observational files. The Kappas for verbal
ENVIRONMENTAL ' 'WHITE NOISE''
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agitation and contact with headphones were .90 and .95,
respectively. All other Kappas were .70 or higher.
RESULTS
A total of 75.15 hours of observation was completed
across the study phases. Due to the complexity of the data
base, results were analyzed for only the most relevant
variables. Because the sample size was small and not randomly sampled, all data were analyzed using paired Mests
with a random sampling test procedure, or randomization
test, as it is commonly called. This is a permutation test that
allows the researcher to use standard test statistics even when
random sampling or other distribution assumptions have
been violated (Edgington, 1987).
In the randomization test, statistical significance is assessed by using a probability distribution generated by the
researcher instead of the standard significance tables most
commonly employed. The probability distribution is created
by repeatedly computing the test statistic, in this case a ttest, on all permutations of the experimental data. All the
permuted data /-values that are as large or larger than the tvalue obtained from the original data set are totaled and
divided by the total number of permuted data t-values calculated to produce the overall p-value. The " R T " software
program (Western Ecosystems, Inc., 1991) was employed to
analyze the data. Our data set allowed a total of 120 different
data permutations. As suggested by Edgington (1987),
5,000 random samples of the 120 different possible data
permutations were tested.
Examination of the functional analysis phase data for the
13 available subjects indicated a significant decrease in the
amount of verbal agitation exhibited when an environmental
"white noise" audiotape was on (M = 51.70%) compared
to when it was off (M = 57.61%, p < .001, see Figure 2).
Nine residents were considered responders to the intervention based on graphic analysis of "audiotape-on" and
"audiotape-off" conditions. Both responders and nonresponders were included in the analysis. When examined
separately, both the ocean (p — .002) and stream (p = .06)
audiotapes were associated with decreases in verbal agitation. All 13 subjects received both the ocean and stream
audiotapes. These results can be found in graphic form in
Figure 3.
Because of the small sample involved, informal comparisons were made between responders (n = 9) and nonresponders (n = 4) to the audiotape intervention. Results from the
CMAI show that nonresponders displayed fewer additional
nonverbal behavior problems than responders (M = 2.0 and
3.6, respectively). Results from the SDVB also suggest
differences between nonresponders and responders. Staff
reported that more nonresponders displayed moaning and
groaning (100%) and crying (75%) than responders (44%
and 11%, respectively). Also, more nonresponders (75%)
than responders (22%) were described as displaying constant
verbal agitation. Comparisons on these characteristics between ocean and stream audiotape responders were not
attempted either in the functional analysis or intervention
phases because of sample size limitations.
The percentage of verbal agitation during on-unit observations of responders (n = 9) was aggregated into an environ-
Audiotape Off
Audiotape On
Treatment Condition
Figure 2. Mean percentage of verbal agitation during the functional
analysis phase for combined environmental "white noise." All subjects
exposed to this phase (N = 13) were included in the analysis. The vertical
lines denote the standard error.
II
O 4J1
I!
OH
r?
Ocean Audiotape
Stream Audiotape
Treatment Condition
Figure 3. Mean percentage of verbal agitation during the functional
analysis phase analyzed by type of audiotape (N = 13 for both ocean and
stream audiotapes). All subjects exposed to this phase were included in the
analysis. The vertical lines denote the standard error.
mental "white noise" condition (5 residents received the
ocean tape and 4 residents received the stream tape). Results
show a statistically significant decrease in verbal agitation
from baseline (M = 50.02%) to intervention (M = 38.78%,
p = .001). These results can be found in graphic form in
Figure 4.
Treatment fidelity data indicate that residents were wearing headphones during 51% of the observations on the
nursing unit. Results from the social validity item were
aggregated over the 9 residents who received the intervention on the nursing unit. Their mean score on the item was
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BURGIOETAL.
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Intervention
Baseline
Study Phase
Figure 4. Mean percentage of verbal agitation during baseline and
intervention phases. Due to the small sample (n = 9), results for the two
audiotapes are presented in combination as environmental "white noise."
The vertical lines denote the standard error.
3.78. Thus, on average, NAs reported that the residents'
verbal agitation was somewhat better after the intervention.
DISCUSSION
The results of this preliminary study suggest that the use
of environmental "white noise" audiotapes may be an
effective treatment for reducing the frequency of verbal
agitation in demented nursing home residents. These residents were severely cognitively impaired (mean MMSE =
1.66) and required almost total assistance to complete activities of daily living. It has been hypothesized that patients
with this level of impairment are not good candidates for
environmental/behavioral treatments due to their purported
insensitivity to environmental stimuli. Moreover, these residents were severely agitated, with verbal agitation recorded
during more than 50% of the observation intervals. This
level of agitation was observed in spite of the majority of
residents (8 out of 13) receiving psychotropic medications
for agitation.
Using a highly precise and reliable direct observational
system, environmental "white noise" was associated with a
decrease in verbal agitation during both the researchercontrolled functional analysis phase and during the on-unit
nurse aide-managed intervention. During the functional
analysis phase we observed an 11 % mean decrease in verbal
agitation, with 9 of 13 subjects considered responders to the
intervention (a 69% response rate). This compares favorably
to the 20% response rate to pharmacotherapy reported by
Schneider et al. (1990). Data from the functional analysis
suggest that residents were responsive to both the ocean and
stream audiotapes. Although Figure 3 indicates somewhat
greater responsivity to the ocean audiotape, it would be
premature to form a conclusion regarding the comparative
efficacy of these two environmental sound audiotapes considering the small subject sample in this study.
The results also suggest that the functional analysis proce-
dure is an effective means of identifying geriatric patients
who are probable responders to environmental/behavioral
interventions. The procedure not only identified responders,
but also provided information on which of the two
audiotapes might be most effective for individual residents
when used on the nursing unit. By including only the 9
functional analysis responders for intervention on the units,
the percentage mean decrease in verbal agitation more than
doubled to 23%. This decrease in verbal agitation was
recorded even though our treatment fidelity data indicated
that residents were using the audiotapes during only 51% of
the observations. The social validity data suggest that this
decrease in verbal agitation was noticed by the NAs. Specifically, NAs reported that these 9 residents were "somewhat
better" due to the intervention.
In the nursing home, the practicability of environmental/
behavioral interventions is of critical importance. Our
choice of environmental "white noise" audiotapes was
based, in part, on the ease of obtaining these audiotapes and
the relative affordability of the intervention ($34.90 for the
audiotape and tape player, combined). In addition, the
purpose of employing a functional analysis to identify probable responders was to allow staff to devote their valuable
time only to the residents who were most likely to benefit
from their efforts. A similar strategy has been used by
Schnelle and colleagues to identify probable responders to a
prompted voiding procedure. Prompted voiding is a behavioral intervention used by NAs in the treatment of urinary
incontinence (Schnelle et al., 1989). Specifically, research
staff employ prompted voiding for incontinent residents
during a 3-day period. Nurse aides are asked to use prompted
voiding on the nursing units only for those residents who
were responsive to this prompted voiding pre-trial conducted
by research staff.
Although in our study the functional analysis was conducted by research staff, we believe that the procedure can
be more easily employed by nursing home staff. As described above, functional analysis requires that the intervention be applied while the resident is displaying disruptive
behavior. One option is to elicit the behavior problem; an
alternative is to apply the intervention while the behavior is
occurring naturally. To complete the latter option with
research staff, we were required to make frequent, researchstaff-intensive "rounds" in an attempt to "catch" the residents while they were displaying the target behavior. Still,
only 1 of 13 residents received the maximum number (8) of
functional analysis trials. Research has shown that NAs
spend over 50% of their time engaged in direct care activities
with residents (Burgio, Engel, Hawkins, McCormick, &
Scheve, 1990). This high rate of resident contact should
allow ample opportunities for the NAs to apply the intervention while the disruptive behavior is occurring, and to
conduct the brief (5-minute) observations of resident verbal
agitation with and without the audiotape.
In spite of the substantial workload of NAs, research has
shown that direct care staff in institutional settings are
capable of observing and recording resident behavior reliably (Burgio et al., 1992). We are not recommending at this
time that NAs use a computer-assisted data collection system
for observing resident behaviors. However, partial-interval
ENVIRONMENTAL ' 'WHITE NOISE''
time sampling (Kazdin, 1982) or even frequency recording
by NAs is feasible, particularly when only one behavior is
being observed.
Particularly noteworthy is the finding that residents were
observed using the audiotapes during only 51% of the
observational samples. It is likely that a better response to
the intervention would have been observed with more frequent use of the audiotape. This observed rate of use could
be related to resident resistance to the intervention (e.g.,
wearing the headphones), NA resistance to employing the
intervention, or both. Unfortunately, we did not collect
specific data on resident or staff resistance during the intervention phase. Nevertheless, the impression of the research
team is that resident resistance was a factor influencing
audiotape use on the nursing unit. It should be noted,
however, that residents who frequently resisted the intervention would have been excluded during the functional analysis phase (one resident was excluded for this reason).
It is our belief that NA noncompliance with the intervention protocol was a more potent factor affecting intervention
use. Schnelle, Newman, and Fogarty (1990) found that
using state-of-the-art instructional techniques and on-the-job
training was not adequate for maintaining NAs' use of a
prompted voiding procedure. In the current study, we attempted to invest the NAs in the study by emphasizing their
importance in making the intervention a success. We structured their assignments by providing explicit instructions
and written, individualized therapeutic programs. Finally,
we occasionally prompted the NAs verbally to use the
audiotape intervention.
Research has shown that staff compliance with therapeutic procedures can be improved through the use of more
formal staff management procedures (see Burgio & Burgio,
1990, and Burgio & Scilley, 1994, for reviews of this
literature). Total Quality Management (Schnelle, Ouslander, Osterweil, & Blumenthal, 1993) and Behavioral Supervision (Burgio & Burgio, 1990) are two staff management
systems that have been used in nursing homes. These systems are similar in that they both employ systematic staff
monitoring and performance feedback by the supervisor. In
addition, Behavioral Supervision uses simple incentives for
staff who reach performance criteria. Both systems have
been used effectively to increase NAs' use of prompted
voiding (Burgio, Engel, Hawkins, McCormick, Scheve, &
Jones, 1990; Schnelle et al., 1989). Our research group is
currently using Behavioral Supervision to increase NAs' use
of behavior management procedures in the nursing home
(Burgio et al., 1996). We believe that the procedure could
easily be adapted to increase staff's compliance with an
environmental "white noise" intervention.
There are a number of limitations to this preliminary
study. The results are based on a small sample of highly
agitated nursing home residents. Replication is needed on a
larger sample of residents with varying levels of agitation
(e.g., mild, moderate, and severe). Testing the intervention
on a larger sample would also allow investigation of resident
characteristics which may predict responsiveness to the
intervention. One potentially important resident characteristic is the presence of a hearing impairment. Although we
attempted to modulate the sound volume of the audiotape to
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each resident's hearing acuity, the information from the
medical record and staff report suggested that only 1 of the
13 residents suffered from a hearing impairment. Findings
from an audiologist's evaluation would provide more accurate information for individualized treatment plans. Also,
although the data show the effects of the intervention on the
rate of verbal agitation, we do not know if the intervention
affected the volume of vocal outbursts, or if certain types of
verbal agitation are more amenable to treatment than others.
For example, the very preliminary data from the NAcompleted SDVB suggest that the nonresponders in this
study were more likely to display constant verbal agitation,
consisting of moans/groans and crying. These types of
verbal agitation may have occurred in response to pain and/
or depression. Agitation associated with these factors may
be less responsive to environmental interventions.
It should be noted that the observers and NAs were not
blinded to the intervention. Researchers have acknowledged
the inherent difficulties of blinding individuals to the application of behavioral interventions (Teri et al., 1992). We
have argued elsewhere (Burgio et al., 1994) that real-time
observational recording systems are much less vulnerable to
rater bias than other types of measurement. Our system
involves frequent independent interobserver reliability assessments. The observational records are compared on a
second-by-second basis. Thus, if observers were biased, in
order to obtain high interobserver reliability scores they
would not only need to be biased in the same direction, the
bias would need to affect their ratings at the precise second
of recording. In other words, the bias would need to affect
the two observers in such a way that they would agree that a
certain behavior not only occurred, but that it occurred
during the same 1-second intervals. Although it is certainly
possible that bias affected the NAs' social validity ratings
reported in this study, it is unlikely that observer bias
affected the observational data, considering the excellent
Kappa reliabilities reported herein.
In conclusion, this study presents preliminary results
suggesting that environmental "white noise" audiotapes are
effective for decreasing verbal agitation in demented nursing
home residents. Although the intervention produced only a
23% reduction in this behavior on the nursing units, it should
be noted that verbal agitation has been reported to be a
notoriously intractable behavior problem. We have argued
that the effectiveness of the intervention could be improved
through the identification of patient characteristics associated with responsiveness, and the use of formal staff management procedures to increase staff's compliance with the
therapeutic protocol. Perhaps most importantly, this study
presents data suggesting that, contrary to common belief,
severely demented individuals can be responsive to
environmental/behavioral interventions.
ACKNOWLEDGMENTS
This study was supported through grants from the Retirement Research
Foundation (#91-74), the National Institute for Nursing Research
(R01NR02988), and a SERCA award (1K01AG00491) to L. Burgio from
the National Institute on Aging.
The authors thank the nurses, nurse aides, and administrative staff of
Jefferson County Nursing Home and Integrated Health Services at Briarcliff
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BURGIOETAL.
for their support and assistance. We acknowledge Eric Bodner for preparation of the figures.
Address correspondence and reprint requests to Dr. Louis Burgio, University of Alabama at Birmingham, Division of Gerontology/Geriatrics,
Community Health Services Building, Suite 219, 933 South 19th Street,
Birmingham, AL 35294-2041.
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Received January 26, 1996
Accepted June 5, 1996
ADVANCE DIRECTIVES
Videotapes in Spanish and Hmong
These videotapes may be used to educate non-English
speaking Hispanic or Hmong elderly about the Living
Will and Power of Attorney for Health Care. The
information is presented in a non-state specific manner.
Topics discussed include:
• The right to make one's own medical decisions
• Medical technology
• The concept of advance medical decision-making
• The Living Will
• The Power of Attorney for Health Care
English and Hmong or Spanish scripts are included.
Playing time: Spanish - 16 minutes; Hmong - 18 minutes
Format: VHS
Cost: $75 (Includes shipping and handling)
For more information, please contact:
Wisconsin Geriatric Education Center
Marquette University
P.O. Box 1881
Milwaukee, Wl 53201-1881
Phone: (414)288-3712
Toll-free: 1-800-799-7878
FAX: (414)288-1973
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