Journal of Gerontology: MEDICAL SCIENCES
1997, Vol. 52A, No. 6, M369-M377
Copyright 1997 by The Cerontological Society of America
Management of Verbally Disruptive Behaviors
in Nursing Home Residents
Jiska Cohen-Mansfield1 and Perla Werner2
'Research Institute of the Hebrew Home of Greater Washington, and Psychiatry Department, Georgetown University.
2
Haifa University, Haifa, Israel.
Background. Verbally disruptive behaviors (VDB) are verbal or vocal behaviors that are inappropriate to the circumstances in which they are manifested. These behaviors are a source of concern because they disturb persons around
the older person and may be an indicator of distress.
Methods. Three interventions were tried and compared to a control no-intervention phase. The interventions were:
(1) Presentation of a videotape of a family member talking to the older person, (2) in vivo social interaction, and (3)
use of music.
Results. Thirty-two nursing home residents suffering from dementia and manifesting VDB were observed before,
during, and after the interventions, and the duration of VDB was recorded. The behaviors decreased by 56% during the
social interaction, 46% during the videotape, 31% during the music, and 16% during the no-intervention.
Conclusions. The effects of the interventions were clinically and statistically significant, indicating the importance
of providing stimulating activities and a richer environment to cognitively impaired nursing home residents.
V
ERBALLY disruptive behaviors (VDB) refer to verbal
or vocal behaviors that are either repetitive, disruptive, or inappropriate to the circumstances in which they
are manifested (1). VDB are common among elderly persons suffering from Alzheimer's disease (2-5), although
estimates of the prevalence of these behaviors vary. In institutional settings, prevalence rates for noisiness or disruptive verbal behaviors range between 10% and 30% (6-10).
The differences in prevalence rates probably stem from
lack of a consistent definition for the operationalization of
VDB. According to Cariaga et al. (11), disruptive vocalizations include screaming, abusive language, moaning, and
repetitious verbalizations. Cohen-Mansfield et al. (12)
defined screaming as shouting and howling. Christie and
Ferguson (13) defined vocally disruptive behaviors as loud,
repetitive verbal utterances. A possible classification for
VDB was suggested by Ryan et al. (14) based on a survey
of 400 residents by 122 nursing staff, including: (a) noisemaking that appears purposeless and perseverative; (b)
noise-making that is a response to the environment; (c)
noise-making that elicits a response from the environment;
(d) "chatterbox" noise-making; (e) noise-making due to
deafness; and (f) other noise-making.
Several studies examined the relationships between characteristics of institutionalized elderly persons and VDB.
Verbally disruptive behaviors tended to be exhibited by
nursing home residents who were female (15,16), more
functionally impaired (9,12,15), had more sleep disturbances (9,16), and who were more cognitively impaired
than other residents (9,12,15).
Other studies examined the temporal and environmental
correlates that may identify antecedents and possible triggering events for the behaviors. Cariaga et al. (9), based on
interviews with nursing staff members, found that VDB
occurred most frequently upon awakening in the morning,
followed by times before bathing or eating. Using an observational approach, Cohen-Mansfield et al. (12) found that
verbal agitation occurred most often when the resident was
alone, in his/her own room, in the evening and at night.
Verbally agitated behaviors increased when residents were
physically restrained and when they were involved in activities of daily living (ADLs), especially toileting and
bathing (12). Burgio et al. (17), in a computer-assisted realtime observational study of 11 nursing home residents who
manifested VDB, found that no activity was recorded during 87% of the observations.
Whereas existing research varies in the prevalence rates
reported for verbally agitated behaviors, in the definitions
used to describe these behaviors and in the characteristics
of elderly patients manifesting them, there is wide consensus regarding the disruptiveness of these behaviors and the
need to find effective interventions to manage them. Available studies dealing with the management of VDB present
two types of approaches: the first approach is based on staff
reports on how they manage those behaviors, and the second approach is based on case studies. The first approach
was undertaken by Cariaga et al. (9), who interviewed
nursing aides regarding the strategies they used to manage
disruptive vocalizations for 76 nursing home residents. The
most frequently cited intervention was attention and conversation (used with 91% of these residents), followed by
verbal reprimands (78%), psychotropic medications,
(67%), touching (59%), ignoring (43%), seclusion (34%),
repositioning (32%), and positive reinforcement for periods
of no disruptive vocalization (17%). Somewhat different
results were reported by Rogers et al. (18). They reported
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COHEN-MANSFIELD AND WERNER
that 15 different interventions were used to control the behaviors of 19 residents who were vocally disruptive. Nurse
interventions such as talking to patients, touching, or repositioning were used most frequently. Whereas repositioning
was considered effective in 89% of the residents with
whom it was used, the remaining nurse interventions were
considered effective for less than half of the residents with
whom they were used. Pharmacological interventions, including psychoactive drugs, were used less often, and perceived to be effective in about 88% of the cases in which
they were used. Generally, across both studies, none of the
available interventions was considered very effective by staff.
The interventions used in studies reporting case studies
include the following: Behavioral treatment, consisting of
contingent positive reinforcement for quiet time (usually,
attention, praise, and social contact), modified time out,
ignoring the behavior (13,19-21); social skills training program, which used instruction, modeling, role playing, and
feedback (22); relaxation with guided imagery (23). Other
forms of treatment used were: pharmacologic treatment,
using a combination of trazodon and tryptophan (24,25);
environmental enrichment, including increasing sensory
stimulation, with the use of music and touch (23-26); electroconvulsive therapy (27); and validation therapy (23).
Generally, case studies indicate strategies that may work,
but they do not indicate the rate of efficacy of the treatments or the ways in which treatments could be matched to
the person's characteristics or specific behaviors.
The type of intervention implemented should be based
on the theoretical approach used for understanding the
manifestation of VDB in persons suffering from dementia.
Several approaches have been discussed by different
researchers:
• VDB result from neurological changes and damage
associated with Alzheimer's disease or other dementias,
which cause disinhibition or directly activate screaming
(28,29).
• VDB are a natural response to pain and are exacerbated in persons who are unable to communicate, and
therefore try to communicate their suffering through
screaming. Pain is most frequently physical pain associated
with illness and disability, but it may also be associated
with mental pain, such as depression (12,24,30).
• VDB are an outcome of sensory deprivation and social
isolation. Demented persons in the nursing home suffer
from sensory deprivation stemming from their inability to
interact with their environment because of dementia, lack
of actual sensory stimulation in the sterile environment of
the nursing home, and decreased physical ability to process
sensory stimulation due to age and disease. The sensory
deprivation and social isolation, which may evoke underlying emotions of fear, loneliness, and boredom, result in
manifesting VDB. Several studies showed that providing
sensory stimulation to nursing home residents decreased
behavioral disturbances in general, and vocally disruptive
behaviors in particular (23,26,31).
• A VDB is an operant, reinforced by attention from
staff and other residents. Within the social vacuum of the
nursing home, any attention is a potent reinforcer. Birch-
more and Clague (26), in a description of a 70-year-old
blind woman, observed that the patient screamed more
when the nurses spoke to her.
Empirical studies support the second and third theories.
Specifically, our studies (7,12) found that screaming correlated with physical pain and depression (as perceived by
staff). Additionally, we found that the occurrence of
screaming is related to being alone and to a lack of structured activities, in agreement with the notion of sensory
deprivation and social isolation. No studies were found
directly related to the first theory, although several studies,
including ours, showed a link between screaming and
dementia. Therefore, the interventions assessed in this
study are based on the second and third approaches.
The aim of this study is, therefore, to assess the effectiveness of different interventions in a relatively large sample
of nursing home residents. The interventions assessed were:
(a) a thorough medical examination aimed at finding and
treating any underlying physiological reason for the manifestation of VDB; (b) the use of music; (c) the presentation
of a family-generated videotape; and (d) one-to-one social
interaction.
METHODS
Participants
Sixty-five nursing home residents who were identified by
nursing staff members as manifesting VDB at least several
times a day were approached by the research team, and
informed consent was requested. For those residents who
were unable to provide informed consent (as judged by a
staff member who was well acquainted with the participant), a close relative was contacted and asked to provide
consent. Additional information concerning the informed
consent procedure is available elsewhere (32). Five residents or their family caregivers refused to participate in the
study, yielding a consent rate of 92.3%.
Interventions
The four interventions assessed were selected on the
basis of the theoretical assumptions stated above:
Medical examination. — The medical examination was
performed by the participant's attending physician and concentrated on the identification of underlying causes for pain
or physical discomfort.
Exposure to music. — The aim of this intervention was
to provide auditory stimulation. The participants' relatives
provided information regarding their relatives' musical
preferences. Nine participants were exposed to classical
music, eight participants to Jewish music, four to big band
music, four to old popular music, two to opera, three to
show tunes, and two to country music. Half-hour audiotapes were prepared with the suggested music and were
played to the participants at their rooms.
Exposure to a family-generated videotape. —This intervention was aimed at providing auditory and visual stimu-
TREATMENTS FOR VERBALLY DISRUPTIVE BEHAVIORS
M371
lation to the resident, as well as indirect interaction with a
loved one. The relatives of all the participants were asked to
prepare a videotape to be shown to the participants. Three
relatives refused and a fourth was hospitalized and unable
to prepare the videotape. For these participants, a research
assistant, a nursing assistant, and a volunteer prepared the
videotapes. Although family members received general
guidelines concerning the preparation of the videotapes,
the specific content and manner of conveying it were left
to them.
tiyeness as perceived by the research assistants involved in
the project. The least disruptive behavior, complaining, was
assigned a weight of 1; disruptive vocalizations received a
weight of 2; and shouting a weight of 4. An overall score
for VDB was derived by averaging these three behaviors.
Recordings were conducted for an hour a day (15 min
before intervention; 30 min during an intervention; and 15
mins after the intervention), and for 10 days for each of the
intervention phases (music, videotape, social interaction,
and no-intervention).
One-to-one social interaction. — The one-to-one social
interactions were performed by trained research assistants
and were aimed at providing direct stimulation through
interaction. A manual with guidelines for performing the
one-to-one interaction was prepared. It included general
information to be considered when approaching a nursing
home resident, such as: How to introduce yourself and how
to initiate an activity. An extensive list of possible activities
to engage the participants was also included. These activities were ordered by level of the demands an activity places
on the resident. The first activities required a more active
involvement from the resident than the last activities.
Research assistants were instructed to start every social
interaction with activities requiring more interaction (e.g.,
talking to the resident about themselves) and to continue
with the most passive activities (e.g., reading to them) if no
response or an adverse response was noted in the resident.
A "box of activities" (including games, pictures, balls,
books, etc.) was prepared. Examples of the alternative
activities provided are: (a) conversation: the research assistant was instructed in different general topics that may be
of interest to the resident, such as: personal information,
personal feelings, talk about specific holidays, favorite
food, favorite pet, etc.; (b) range of motion exercise, e.g.,
tossing a foam ball, hand and arm movement; (c) sensory
stimulation. A sensory kit including different fabrics,
school supplies, health aids, make-up, spices, soaps, etc.,
was available to be presented to the residents to stimulate
touch, sight, and smell; (d) manual activities, such as making a collage, a simple puzzle, clipping coupons. To avoid
confounding effects, music and television were turned off
while the social interaction was conducted.
Standardized observations. — The frequency of VDB
and the context in which screaming occurred were examined using the Screaming Behavioral Mapping Instrument
(SBMI), a behavior-mapping instrument specifically designed for this study. The SBMI includes nine types of
VDB: shouting, screaming, or howling; constant requests
for attention; repeating words; complaining or inappropriate verbalizations; cursing; verbal aggression; nonsense
talk; hallucinations (talk to or with someone the resident
seems to be perceiving, but is not there); and other disruptive verbal behaviors, such as groaning and singing. Each
manifestation of VDB was recorded as a check mark on the
SBMI. If manifested 5 or more times, a value of 6 (i.e.,
constant, C) or a value of 7 (i.e., extreme, E) was recorded.
Interobserver agreement (i.e., exact agreement) for 10 participants averaged 92.2%.
Instruments
Manifestation of VDB was the primary dependent variable. Three different methods were used to assess the VDB:
Tape recordings. — The duration of VDB was recorded
using a tape recorder that was located near the participant.
Following the recording, a trained research assistant coded
the output of the tape by listening to it through headphones
and using a computer program specifically developed for
coding video and audiotapes (33). An episode of a VDB
was considered ended if the resident was silent for 1 consecutive minute. Interrater agreement was calculated for 54
tapes by two independent coders and averaged 85% (range
= 56%-100%). Three types of VDB were coded: complaining, disruptive vocalizations, and shouting. The coded
behaviors were weighted according to their level of disrup-
Informant ratings. — Nursing staff members well
acquainted with the participants rated their VDB using
those items in the Cohen-Mansfield Agitation Inventory
(CMAI) that tap verbally disruptive behaviors (7). Each
item was rated on a 7-point scale of frequency (1 indicates
that the participant never engages in the specific behavior,
and 7 indicates that the participant manifests the behavior
on the average of several times an hour). The period to be
rated was the 2 weeks prior to the administration of the
CMAI, and information was collected at the end of each
intervention. Further details on the reliability of the CMAI
are provided elsewhere (34).
The duration and frequency of appropriate verbal behaviors were also assessed using the same methods described
for VDB. Appropriate verbal behaviors were any verbal
behavior considered appropriate to the circumstances and
place of the situation.
Background Information
Background information was collected regarding demographic data, cognitive and functional status, and medical
diagnoses. These data were collected before the implementation of the interventions.
Demographic variables. — This information was recorded from each resident's chart by the research assistants.
The following demographic items were obtained for each
participant: age, sex, marital status, and date of admission
to the nursing home.
Assessment of cognitive functioning. — Cognitive functioning was assessed using a modified version of the Brief
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COHEN-MANSFIELD AND WERNER
Cognitive Rating Scale (BCRS) (35). The BCRS is a caregivers' rating instrument which does not require the participant's ability to communicate. The BCRS is a 7-point scale,
with high score indicating cognitive deterioration. The BCRS
was administered by a trained research assistant to nursing
staff members well acquainted with the residents.
Diagnoses of major degenerative diseases of late life
were also assessed. These are: Dementia — probable
Alzheimer's disease (according to the criteria for clinical
diagnosis of probable Alzheimer's disease as stated in the
Report of the NINCDS-ADRDA Work Group (36): Dementia — with the presence of vascular disorder (e.g., multiinfarct dementia); Dementia — with a diagnosis of Parkinson's disease; and Dementia — unknown etiology (i.e.,
cognitive impairment in an alert person that fits none of the
categories above). These data were provided by the physician through the medical examination.
Functional assessment. — Assessment of degree of functional independence was obtained from nursing staff members who were asked to complete Lawton and Brody's
Physical Self Maintenance Scale (PSMS) (37) for which
good reliability and validity have been established (38).
Medical diagnoses. — Medical diagnoses were marked
on a medical assessment form by the attending physician.
Procedure and Design
The medical examination was the first stage of the project. All participants were examined by their attending
physician. The aim of the medical examination was to identify and treat any underlying physiological reason for the
manifestation of VDB. Therefore, physicians were requested to pay special attention to possible hidden sources
of pain or discomfort. If indicated, a medical intervention
was provided. In those cases, the participant was considered for inclusion in the rest of the study only if the manifestation of VDB continued after complete implementation
of the medical intervention.
Participants were assigned to four groups, each containing three intervention conditions and one "no-treatment"
condition. In each group, the order of treatments was alternated, so that by the end of the evaluation period all groups
were exposed to all the treatments and to the no-treatment
period. Each treatment continued for 2 consecutive weeks
and was followed by a "wash-out" week.
Because the aim of the study was to manage highly disruptive rather than transient behaviors, the interventions
were performed at the time of the day at which the resident
was most verbally disruptive (based on nurses' reports) and
were performed only if the participant was verbally disruptive. If the resident was quiet, research assistants were
instructed to wait 15 min, and to start performing the standardized observations only when the participant became
vocal. If the resident remained quiet for more than 15 min,
the observation for this day was not performed. Each intervention lasted for 30 consecutive minutes and was administered for 2 consecutive weeks. Participants were observed
for an hour: 15 min before the intervention, during the 30min intervention, and for 15 min after the intervention.
Each observation lasted 3 consecutive min; they were staggered along the hour, so that a total of nine 3-min observations were performed during the hour observation.
RESULTS
Sample Characteristics
Seven of the 60 participants for whom consent was
obtained died before any data were collected. Five of the
remaining 53 participants (9%) died before completing the
interventions, 11 (21%) became quiet, 3 (6%) refused to
continue their participation, and 2 (4%) were physically
restrained and excluded based on previous findings showing that the manifestation of VDB increased when nursing
home residents were physically restrained (39). For 6 of the
11 participants who ceased manifesting VDB before completing the study, the reasons for being quiet were ascertained: 3 participants became quiet after they received additional attention, either from nursing staff members at their
unit or from the research assistants' presence. Two additional participants became quiet after receiving a medical
intervention such as being moved to an orthopedic chair or
receiving an antibiotic for a respiratory infection. An additional participant was prescribed with haloperidol.
The remaining 32 participants (53.3%) completed all the
interventions; their demographic characteristics are presented in Table 1. The majority of the participants were
female and widowed. They had been in the nursing home
for an average of 4 years, and were considerably impaired
in their functional and cognitive status. Ninety-seven percent
were diagnosed as suffering from dementia: of these, 55%
Table 1. Summary of Demographic Characteristics,
Functional and Cognitive Status for 32 Participants
Gender*
Male
Female
6(18.8%)
26(81.3%)
Age (yr)f
86.8 ± 1.16
Single*:):
Married
Widowed
Single
Divorced
Separated
5(15.6%)
21 (65.6%)
3 (9.4%)
2 (6.3%)
1 (3.1%)
Length of stay in the nursing home (yrs)f
4.1 ±0.60
ADLt
4.0 ± 0.15
BCRSt
5.5 ± 0.23
Diagnosis of dementia
Probable Alzheimer's
Multi-infarct
Unknown etiology
No diagnosis
16(53.3%)
9 (30.0%)
4(13.3%)
1 (3.3%)
Notes: ADL (Activities of Daily Living): 1 = independent; 5 = completely dependent. BCRS (Brief Cognitive Rating Scale): 1 = cognitively
intact; 7 = total cognitive deterioration.
•Frequency (%).
tMean (SEM).
JThe marital status of one participant was not known.
TREATMENTS FOR VERBALLY DISRUPTIVE BEHAVIORS
(n - 16) from probable Alzheimer's disease, 31% (n = 9)
from dementia with the presence of a cardiovascular disorder, and 14% (n = 4) from dementia of unknown etiology.
The demographic characteristics of the 32 participants
who completed all the interventions were compared to those
who did not. No statistically significant differences were
found in the age, gender, marital status, length of stay in the
nursing home, and physical and cognitive functioning
between the groups. However, when the characteristics of
only those participants who became quiet on their own prior
to completing the study were compared to those who completed all the interventions, we found that those who became
quiet and had BCRS data (n = 7) had a significantly higher
cognitive status than those who continued manifesting VDB
(3.8 and 5.5 on the BCRS respectively, tm = 2.8, p < .01).
VDB in Participants Who Completed All Interventions
According to nurses' assessments performed at baseline,
11 participants (34%) manifested VDB several times an
hour; 18 participants several times a day (56%); and 3 participants once or twice a day.
The frequency of VDB was examined using the SBMI. A
total of 11,520 3-min observations were made (including
observation before, during, and after the interventions). The
percentage of observations in which VDB occurred was
calculated. The most frequently observed types of VDB
were: complaining, screaming, and nonsense talk. However,
as can be seen in Table 2, when begun, VDB tended to be
manifested constantly.
Effectiveness of the Interventions
Medical examination. — Thirty participants were examined by their attending physician. Two participants, who
had a private physician, were not examined.
The participants presented an average of 4.4 medical
diagnoses (not including dementia or psychiatric diagnoses). The most common diagnoses were a musculoskeletal diagnosis (66.7% of the participants); a cardiovascular
diagnosis (63.3% of the participants); a gastrointestinal disease (50%), and a genitourinary diagnosis (46.7%). Other
diagnoses included neurological diseases (33.3%), endocrine
Table 2. Frequency of Verbally Disruptive Behavior (VDB)
Type of VDB
Shouting
Complaining
Nonsense talk
Repeating words
Other VDB
Requests for attention
Hallucinations
Cursing
Verbal aggression
All
Observations
(%)
Observations in which VDB
were observed to be
manifested on a constant
or extreme basis* (%)
35.4
42.1
32.1
28.6
20.5
14.2
11.2
1.2
1.1
66.3
81.8
82.0
84.0
79.8
74.9
77.2
28.2
44.2
*VDB were coded as constant or extreme if they were manifested five
times or more during the 3-min observation.
M373
disease (16.7%), and respiratory disease (13.3%). Twothirds (n = 20) had a psychiatric diagnosis: 20% suffered
from depression; many (43%) were characterized as suffering from a psychotic mood disorder, a delusional disorder,
paranoia, or psychotic episodes; two were diagnosed with
anxiety disorder, and one with schizophrenia. Two-thirds of
the participants (n = 20) received psychotropic medications:
13 participants (43.3%) received an antipsychotic drug, 7
participants (23.3%) received antidepressants, 6 participants (20%) received benzodiazepines, and 1 participant
received sedative-hypnotics. Nine participants (30%) received medication for pain.
As stated above, the medical examination concentrated on
the assessment of physiological reasons for pain. For 23 participants (76.7%), the physicians did not find any physiological signs of pain. For the remaining 7, 2 were rated as suffering from mild pain once a week, 4 as suffering from
discomforting pain several times a week, and 1 participant
was rated as suffering from distressful pain several times a
week. Five of these participants were among the 9 who
received medication for pain. The sources for the pain were
arthritis (3 participants), contracture (1 participant), pain on
the urethral carbuncle as consequence of a past vaginal
bleeding (1 participant), and migraine (1 participant). The
source of pain for one participant was unknown. Three of the
7 participants for whom some pain was reported were administered treatment after the medical examination: one was prescribed with Tylenol 500 mg, one was prescribed with iron
supplement, and one was referred to a physiatrist. Despite
the presence of some pain, the physicians reported that for
none of the participants were the VDB caused by the pain.
Effectiveness of the environmental interventions. —
Analyses to assess the effectiveness of the interventions
were performed based on three data sources: recorded tapes
(i.e., duration), standardized observations (i.e., frequency),
and nurses' assessments.
Repeated measures multivariate analyses of variance
(MANOVAs) were performed in order to assess the effectiveness of the interventions.
Audio tape data: Based on the coding of the tapes, the
effect of Time (before and during the intervention) was significant [F(l,124) = 137.1, p < .01], as well as the interaction between Time and Type of intervention [F(3,124) =
7.7, p < .01]. The mean duration of VDB for each phase
across Time is presented in Figure 1.
As can be seen in Figure 1, the greatest decrease in VDB
was observed during the one-to-one social interaction,
followed by the exposure to the family-generated videotapes. Because the level of VDB during the 15 min before
the intervention was higher for the videotape intervention
than for the other treatments, we assessed the effectiveness
of the intervention also as the percentage of change
observed in the VDB during the intervention. Using this
method, the effectiveness of the interventions was assessed
by calculating the percentage of change observed in the
VDB during the 30-min intervention, relative to the 15 min
before the intervention. A computed A variable, assessing
the percentage of change during the intervention, was created as follows:
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COHEN-MANSFIELD AND WERNER
A = {[level of VDB manifested before intervention
(averaged per minute)] - [level of VDB manifested
during intervention (averaged per minute)] / [level of
VDB manifested before intervention (averaged per
minute)]} X 100
Therefore, the variable A is the percentage of change
observed in the VDB during the intervention relative to the
period before intervention. A can take on values ranging
from 100 to negative infinity. However, values smaller than
-100 were recoded as -100 as it usually involved VDB that
were manifested for a very short period of time. Therefore,
the recoded ) variable ranges from -100 (i.e., an increase of
100% in the VDB observed during the intervention as compared to before the intervention) to 100 (i.e., the VDB
observed before the intervention was eliminated during the
intervention, a decrease of 100%).
A repeated measures MANOVA was performed to assess
whether the change observed in the VDB related to the type
of intervention. The effect of intervention was significant
[F(3) = 45.5, p < .001], and all the interventions were sig-
before
during
Test Time
n-32
Figure 1. Level of verbally disruptive behaviors before and during different interventions.
nificantly better than the no-treatment. The behaviors
decreased by 56% during the social interaction, 46% during
the videotape, 31% during the music, and 16% during
the no-intervention. Post-hoc tests showed that each one of
the interventions was significantly different from the nointervention.
Observational data: An analysis of change in VDB during treatments as compared to before treatment was also
performed for frequency of the different types of VDB
included in the observational tool (i.e., in the SBMI), in
order to find whether nursing home residents manifesting a
specific type of VDB will benefit more from one intervention or another. The results of the repeated measures
MANOVAs for the change observed in each type of VDB
(using the formula described above) are summarized in
Table 3.
As can be seen in Table 3, the one-to-one social interaction appears to most effectively manage VDB that involve
requests for attention, and repeating words. The familygenerated videotapes appeared to be most effective for hallucinations. Although exposure to music was related to a
decrease of almost all VDB, its relationship to the type of
behavior exhibited is unclear and its efficacy was the lowest.
Nurses' assessments: At the end of each intervention,
nursing staff members were requested to assess the frequency of VDB manifested by the participants during the 2week intervention period. No statistically significant effects
were found in any of the verbally agitated behaviors.
We were also interested in examining at what point in the
one-hour observation does the level of VDB change. Therefore, the observations were divided into 20 3-minute segments: five 3-minute segments before the intervention, 10
during the half-hour intervention, and five after the intervention. The average duration of VDB for each 3-minute
segment was calculated.
As can be seen in Figure 2, the duration of VDB decreased considerably during the first 3 minutes of each
intervention (except for the no-treatment intervention) and
remained relatively stable during the half-hour intervention.
The decline was especially noticeable for the one-to-one
social interaction and the family-generated videotape.
Table 3. Change in VDB by Type of VDB and Type of Intervention Based on Observational Measures
Shouting"**
Complaining or inappropriate verbal'1**
Nonsense talk
Other VDB' 1 **
Repeating words 1 "**
Requests for attention"
Hallucinations1**
Social interaction (%)
Videotape (%)
Music (%)
Nothing (%)
Significance
66
46
25
43
70
94
49
50
45
39
39
58
46
56
34
33
32
48
48
33
40
17
18
21
15
26
31
21
F(3,318)= 11.8*
F(3,354)= 11.5*
n.s.
F(3,183) = 6.6f
F(3,294)=18.8*
F(3,90) = 29.3*
F(3,39) = 3.6'
*p < .05.
tp<.01.
{Significant difference between nothing and social interaction (p < .01).
§Significant difference between nothing and social interaction and videotape (p < .01).
HSignificant difference between nothing and social interaction, videotape, and music (p < .01).
^Significant difference between nothing and videotape (p < .01).
••Significant difference between nothing and music (p < .01).
TREATMENTS FOR VERBALLY DISRUPTIVE BEHAVIORS
M375
appropriate verbal behavior
1
2 3 4
BEFORE
5
1
2
3
4
6 6 7
DURING
8
9
10
1
2 3 4
AFTER
5
TEST TIMES
INTERVENTIONS
VIDEO
-*- INTERACTION
- * - MUSIC
intervention
NOTHING
music
interaction
- * ~ video
' nothing
Figure 2. Level of verbally disruptive behaviors by 3-minute intervals
before, during, and after interventions.
Figure 3. Level of appropriate verbally behavior before, during, and
after each intervention.
However, the VDB resumed immediately after the interventions to a level similar to that of no intervention.
The duration of the VDB during the no-treatment intervention remained relatively constant during the one-hour
observation.
In addition to the effectiveness of the intervention on
VDB, the usefulness of the interventions can be assessed by
their effect on the manifestation of appropriate behavior.
In order to explore this subject, a repeated measures
MANOVA was performed.
As can be seen in Figure 3, the duration of appropriate
verbal behaviors increased significantly during the one-toone social interaction and during the videotape [F(6,248) =
25.57, p<. 01].
by nursing staff members to participate in our study became
quiet after medical treatment and even before the relatives
were approached for consent to participate in the study. For
example, nursing staff members requested to include Ms. L.
in our study as she yelled constantly, every day. After a regular examination performed by her physician, it was found
that Ms. L. suffered from intense back pain, and her VDB
disappeared after she was treated for her condition and
before she was recruited for the study. Future studies
should rely on multiple sources of information (such as
information from nursing staff members as well as family
caregivers) about the pain of the residents in order to provide a more reliable assessment of pain and the opportunity
to identify more clearly physical conditions that may trigger VDB.
The environmental interventions assessed were found to
be clinically and statistically significant. The VDB decreased by as much as 56% during the time of the intervention. Interventions involving interaction (either face-to-face
or through the videotape) were the most effective ones,
although all interventions were significantly better than the
no-treatment intervention. The narrow difference in the
effectiveness of the one-to-one social interaction and the
family-generated videotape deserves some attention. Because the one-to-one social interaction requires the constant
presence of a person interacting with the participant, its
cost is much higher than that of the other interventions.
Indeed, exposure to music and to the videotape are interventions that can be implemented repeatedly without
investing high costs or staff members' time.
The effectiveness of the music intervention was considerably lower than the effectiveness of the other two interventions, although still considerably better than "no treatment."
Several reasons may account for these results. First,
although we tried to match the music played during the
intervention to the preferences of the participants, we only
received information about categories of music. Gerdner
and Swanson (48), in a recent study describing the effects
of individualized music on five agitated elderly persons,
stress the importance of requesting information about specific song titles and performers. Additionally, these authors
DISCUSSION
The manifestation of VDB is one of the most disruptive
problems in the nursing home. These behaviors disturb persons in the proximity of the older person, may be indicative
of distress in the elderly person, and present a confusing
and complex problem for caregivers. Trying to find simple
and inexpensive treatments for the management of these
behaviors is of utmost importance. The aim of this study
was to assess the effectiveness of a medical intervention
and of three simple environmental interventions for the
management of VDB. The environmental interventions
were selected on the assumption that VDB are the result of
understimulation and sensory deprivation; they included
music, the use of family-generated videotapes, and one-toone social interaction. Although several researchers described studies using social and sensory stimulation (such
as music, exercise, and touch), these were either limited to
description of case studies or small samples (26,40-42) or
not specific to VDB (43-45).
The fact that the medical intervention did not identify
many participants whose verbally disruptive behaviors were
caused by pain or any other physical reason does not diminish the importance of this intervention. First, it is well
known that the assessment of pain in cognitively impaired
elderly persons is very difficult (46,47). Secondly, our
experience showed that several residents who were referred
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COHEN-MANSFIELD AND WERNER
found that the effect of music was higher for those residents
for whom music played a significant role in their lives.
Future studies should include all this information in order
to maximize the effects of this intervention.
As for the effectiveness of the different interventions relative to specific types of VDB, we found the one-to-one
social interaction to be most effective in managing VDB
that involve requests for attention, and repeating words.
Possibly, these behaviors are a manifestation of feelings of
loneliness, boredom, or fear, feelings that decrease with
the involvement with the social interaction. The familygenerated videotapes appeared to be most effective for hallucinations. We can hypothesize that residents manifesting
these types of behaviors may be able to decrease their VDB
when they can see a familiar face, talking to them about
well-known topics, and many times in their own mother
tongue. The videotape may orient them back to reality or
may divert their attention out of the hallucinations.
Although exposure to music was related to a decrease of
almost all VDB, its relationship to the type of behavior
exhibited is unclear and its efficacy was the lowest. With
the small number of participants manifesting any specific
type of VDB, these findings should be considered preliminary, and they require further investigation.
The effects of the interventions were found to be limited
to the time of the interventions. The manifestation of VDB
resumed almost immediately after the one-to-one social
interaction and after the videotape.
The time specificity of the effectiveness of the interventions is also reflected in the fact that, based on nursing staff
reports, no differences were found in the frequency of VDB.
We can assume that since staff members were not present at
the time of the intervention, they did not notice any decrease
in the manifestation of VDB as a result of the interventions.
However, this time-specific effect does not diminish the significance of our findings. First, nursing staff members caring
for verbally disruptive residents need tools for intervening
when the behaviors occur, even if the effects are not long
lasting. Additionally, utilization of these treatments may be
perceived by nursing staff members as providing them with
respite. Indeed, although no perceptions of effectiveness
were found based on nurses' ratings, the need that the nursing staff has for these treatments is reflected by the sharp
increase observed in their referral of participants. Secondly,
with the exception of the direct interaction, the interventions
used are simple and inexpensive and can be implemented
almost continuously. Staff members could be trained to
implement these interventions as needed. Additionally, the
one-to-one social interaction was found to have a rehabilitative effect as it increased the manifestation of verbally
appropriate behaviors in these very frail elderly residents.
These behaviors increased by 82% during the face-to-face
interaction. Indeed, two of the participants who were
thought to be completely unable to talk coherently started to
say some words after a couple of sessions.
Results of our study also highlight the characteristics of
verbally agitated nursing home residents. These residents
are generally frail and cognitively impaired. The medical
examination found that these residents suffered from multiple medical diagnoses and were heavily medicated, al-
though their verbal disruptiveness was not perceived to be
related to their physical status or to their pain feelings. Furthermore, as many as 20% of the participants died before
all of the data could be collected. This points to VDB as
possible indicators of high morbidity and of a risk of dying.
It is yet unclear whether these behaviors are to be interpreted as indicating the suffering associated with severe
disease, a possible fear of death, or realization of impending
death. Clinically, these possibilities need to be considered.
The most frequently observed VDB were complaining,
screaming, and nonsense talk (between 32% and 45% of the
observations). However, even those VDB that were observed
infrequently were manifested at a constant or extreme rate
during over half of their occurrences. For example, although
verbal aggression was observed only during 1% of the
observations, during 44% of the time in which it was manifested it occurred at a constant or extreme rate.
Results of our study stress the need to provide cognitively impaired residents with more stimulating activities
and with a richer environment, and indeed our results seem
to corroborate the hypothesis that VDB are in great part the
result of stimulus and social deprivation in the nursing
home environment. The finding that social interaction and
family interaction via videotape were superior to music
suggests that the social aspect of the intervention is of
importance beyond the impact of stimulation, although
alternative explanations are possible and should generate
further research (e.g., verbal stimuli with or without human
presence may be better stimuli than music for a majority of
this population). Still another explanation for our findings
is that rather than fulfilling the needs for stimulation and
social contact resulting from understimulation and loneliness in the nursing home, these interventions merely provide a distraction from "real causes," such as fears. It is difficult to distinguish between distraction and providing
needed stimulation in the nursing home, because the nursing home has been shown to provide minimum levels of
appropriate stimuli (such as structured activities, as compared to inappropriate stimuli, such as calls for staff members on the intercom). In any event, for persons included in
the study (i.e., those with severe cognitive impairment who
manifest high levels of VDB), no simple diversion or other
interventions have been identified by staff members during
routine care outside the study. Therefore the interventions,
despite their seeming simplicity, provide an important route
for managing these difficult behaviors.
The results underscore the importance of individualizing
interventions for residents suffering from dementia. For 12
participants, social interaction was the most effective intervention; for 4 residents, the family-generated videotape was
the most effective; and for 2 participants music worked
best. The other participants had two or more interventions
that were equally beneficial for them.
Future studies should explore the relationships between
residents' characteristics and the effectiveness of the interventions. These relationships may guide nursing staff members in matching the most beneficial intervention to each
resident.
In summary, results from this study, which we believe to
be the first to assess the effectiveness of interventions for
TREATMENTS FOR VERBALLY DISRUPTIVE BEHAVIORS
the management of VDB in a relatively large sample, show
that implementing simple environmental interventions can
have a significant impact on the well-being of verbally agitated nursing home residents.
ACKNOWLEDGMENTS
This study was supported by National Institute on Aging Grant R01 AG10642. The authors acknowledge the contributions of Gabriela Segal,
Katie Holdridge, Jodi Cummins, and Shannon Wheeler for their assistance
in the data collection.
Address correspondence to Dr. Jiska Cohen-Mansfield, Research Institute of the Hebrew Home of Greater Washington, 6121 Montrose Road,
Rockville, MD 20852.
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Received May 25, 1996
Accepted December 18, 1996