Journal of Neuroscience Nursing:
Then & Now
Emotional Intervention Strategies for Dementia‐Related Behavior: A Theory Synthesis
Yao, Lan; Algase, Donna
Questions or comments about this article may be directed to Lan Yao, PhD RN, at email@example.com. She is an assistant research scientist at the University of Michigan School of Nursing, Ann Arbor, MI.
Donna Algase, PhD RN FAAN FGSA, is a Josephine M. Sana collegiate professor of nursing at the University of Michigan School of Nursing, Ann Arbor, MI.
Behavioral disturbances of elders with dementia are prevalent. Yet the science guiding development and testing of effective intervention strategies is limited by rudimentary and often‐conflicting theories. Using a theory‐synthesis approach conducted within the perspective of the need‐driven dementia‐compromised behavior model, this article presents the locomoting responses to environment in elders with dementia (LRE‐EWD) model. This new model, based on empirical and theoretical evidence, integrates the role of emotion with that of cognition in explicating a person‐environment dynamic supporting wandering and other dementia‐related disturbances. Included is evidence of the theory's testability and elaboration of its implications. The LRE‐EWD model resolves conflicting views and evidence from current research on environmental interventions for behavior disturbances and opens new avenues to advance this field of study and practice.
Behavioral issues such as wandering are widely acknowledged as among the most distressing aspects of cognitive impairment. A majority of elders with dementia (EWD) eventually experience behavior disturbances. Ninety percent of nursing home residents were shown to have at least one behavioral problem, and roughly 50% have four or more behavioral problems (Tariot, Porsteinsson, Teri, & Weiner, 1996).
While cognitive changes contribute to the genesis of dementia‐related behavior disturbances, the progressive and irreversible nature of dementia has made cognition appear a poor target for intervention. Rather, scientists and clinicians have focused on environmental modification as an important strategy to address behavior. Current studies offer insufficient evidence as to how environment affects wandering and other dementia‐related behaviors. This article describes development of a theory to address this gap.
Conceptualizing dementia‐related behaviors as needs‐driven is considered a breakthrough in dementia‐related behavior studies (Donaldson, 2000). The need‐driven dementia‐compromised behavior (NDB) model (Algase et al., 1996) introduced a value‐neutral term—NDB—suggesting an etiology centered on the person with the behavior. The model encompasses three categories of NDBs: physical aggression, repetitive vocalization, and wandering. Potential etiologies for NDBs are grouped as background factors (those placing patients at risk for exhibiting NDBs) or proximal factors (those triggering NDB occurrences). The model posits that effects of proximal factors (psychophysiological needs and aspects of the physical and social environment) on NDBs are mediated by background factors (neurocognitive deficits and preserved strength of the person's traits and basic abilities), underscoring the importance of both sets of factors in developing intervention strategies. Further theoretical and empirical work is needed to test specific mechanisms by which environment affects NDBs.
Derived from the NDB model, a model of locomoting responses to environment in elders with dementia (LRE‐EWD) is constructed through a theory synthesis approach. Models are constructed to address gaps in the field and to generate insights on how environment affects wandering and other NDBs. These insights can lead to prediction of and intervention for these behaviors. Critical issues of interest include mechanisms by which environment fosters manifestation of NDBs, particularly wandering, in long‐term‐care (LTC) settings and ways to reconcile conflicts in current environmental intervention models.
Theory Development Approach
Theory synthesis was chosen as the model construction approach because it affords a way to build theory from empirical evidence. Walker and Avant (2005) proposed a synthesis method consisting of three steps: specify focal concepts, identify factors related to focal concepts and relationships among them, and organize concepts and statements into an integrated representation of the phenomena of interest.
Step 1. Focal Concepts
Consistent with the overarching perspective of the NDB model, we used dementia‐related behaviors, particularly wandering, and environment as initial focal variables to serve as entry points into the research. Multiple efforts to delineate relationships between environmental factors and locomotion were found in clinical research and practice literature. Environmental factors associated with wandering and pacing have been noticed as stressors or irritants (Algase, 1999; Cohen‐Mansfield, Werner, & Marx, 1991; Rader, Doan, & Schwab, 1985). An understimulating (boring) environment also may contribute to wandering (Kolanowski, Richards, & Sullivan, 2002; Rader et al.). Agitated psychomotor behavior, including wandering, was found to be associated with personal factors (greater functional dependency, poorer mental status, greater psychotropic drug use) and psychosocial or milieu factors (in particular, the staff mix in nursing homes; Kolanowski, Hurwitz, Taylor, Evans, & Strumpf, 1994). Environmental conditions conducive to pacing were low noise, adequate lighting, non‐meal‐time hours, and open areas such as corridors (Cohen‐Mansfield et al.). Clinical observation shows that residents paced more between locked exits. In general, wandering seems to increase when the environment is unfamiliar (Cohen‐Mansfield & Werner, 1995; Cohen‐Mansfield et al.), the noise level is low (except for television or music), two to five people are present, and lighting and temperature are normal. One study shows that wandering decreases when people are alone (Cohen‐Mansfield & Werner), yet other evidence demonstrates wandering and dementia‐related behaviors occur most often when people are alone (Kolanowski et al., 2002; Snyder, Rupprecht, Pyrek, Brekhus, & Moss, 1978).
Environmental interventions for wandering and other dementia‐related behaviors include architectural design interventions and milieu therapy, especially in LTC settings. Outcomes following environmental interventions are encouraging. Environments with low stress or stimuli, special care units (SCUs), homelike and, more recently, transformed environments (e.g., Eden Alternative [EA]), and multisensory environments (e.g., Snoezelen®) have demonstrated therapeutic benefits.
Low Stress or Stimuli
Hall and Buckwalter's (1987) progressively lowered stress threshold (PLST) model describes the effect of cognitive decline in EWD as an increasing inability to cope with stress. Their suggested interventions include modifying and simplifying the environment to reduce internal and external stressors and prevent or alleviate dysfunctional NDBs.
Special Care Units
One of the many goals of SCUs is to decrease environmental stress in LTC settings for EWD. Organizational, social, and architectural systems consistently are cited for making SCU environments special (Kovach, Weisman, Chaudhury, & Calkins, 1997), but support features of these systems are poorly defined. Exit control, walking paths or gardens, and both private and public recreational areas appear important. The homelike feature of some SCUs came about as an alternative to low‐stress or low‐stimulation ambiance. A homelike setting (a setting with a residential character that serves to deinstitutionalize the nursing home environment) is not limited to an environment's physical features; it also includes experiences and interpersonal relationships (Calkins & Marsden, 2000; Zingmark, Sandman, & Norberg, 2002). Central characteristics of the homelike concept remain vague, however. Zeisel and colleagues (2003) summarized eight therapeutic features of SCUs: exit control, walking paths, personal places, social space, healing gardens, residential character, independence, and sensory comprehensibility. Despite their popularity, effects of SCUs for EWD are debatable (Day, Carreon, & Stump, 2000; Kovach, 2000; Zeisel et al.).
Enhanced environments for EWD present another theme in recent studies. The EA proposes an enlivening environment designed to decrease loneliness, helplessness, and boredom by developing healthy habitats through integration of gifts from Mother Nature—namely, plants, animals, and children— into the physical, personal, and social milieu. The EA's distinctive characteristics are companionship, variety, and spontaneity (Barba, Tesh, & Courts, 2002). Snoezelen, a form of multisensory stimulation therapy originating with the care of children and adults with profound learning, mental, and physical disabilities (Baker, Dowling, Wareing, Dawson, & Assey, 1997; Pinkney, 1997), is considered an environmental intervention because it introduces a variety of sensory‐stimulating materials and usually is delivered in a specially designed room. Snoezelen, other multisensory approaches, and sensory integration are being applied increasingly to elders with severe to very severe dementia, especially in Great Britain and other European countries (Chitsey, Haight, & Jones, 2002; Finnema, Droees, Ribbe, & Tilburg, 2000), because a reduction of some problem behaviors has been observed with their use. These approaches provide stimulation while placing fewer performance demands on EWD.
To summarize, environmental modification is recognized as a promising approach, and current strategies have shown success among EWD with behavioral disturbances. Theoretical conceptions or underpinnings for these interventions are indistinct or contradictory, however, limiting understanding of how, why, or when they work. For example, environmental transformation focuses on correcting negative effects of sensory deprivation due to loneliness, helplessness, and boredom among nursing home residents (Barba et al., 2002), while the PLST model attempts to reduce sensory stimulation (Hall & Buckwalter, 1987). Kovach (2000) suggested pacing activity to facilitate optimum sensoristasis in EWD. Preventing imbalance in sensoristasis is a desirable strategy, but understanding the impact of dementia on fundamental person‐environment processes appears important to effectively target NDB interventions. As Zeisel (2003) pointed out, “Many environments that could be designed for well‐being are conceived and implemented by traditional design teams focusing on regulations, function, and visual impact, rather than available environment‐behavior research and knowledge” (p. 84).
Step 2. Role of Emotions in Person‐Environment Interaction Theory
Results of Step 1 were congruent with the NDB model in pointing to person‐environment interaction as the basis of behavior disturbances in dementia. A broad literature search in psychology and neuroscience was undertaken to identify an applicable conceptualization of person‐environment dynamics.
Cognitive and Emotional Processing of Information
Person‐environment interaction is widely conceived in terms of information processing by environmental psychologists. Accordingly, environments constitute an external source of information for undergoing experiences and executing human action. Understanding how human brains process information, or how neuronal systems support cognition and emotion and translate mental states into complex behaviors, has been one of the most challenging frontiers of psychology and behavioral neuroscience.
Cognition refers to all mental activities associated with thinking, knowing, and remembering (Myers, 1995). Computer science provides a powerful analogy for studying how our brains represent and process environmental information. Yet research on human brain processes shows distinct differences in human and computer information processing.
In the 1960s, Abelson coined the term hot cognition to denote cognition that is emotionally laden. Kaplan and Kaplan (1982) further posited that most cognitions are emotionally bound to some degree. Having emotions means the way things are, were, or will be matters, unavoidably affecting one's physical and psychosocial well‐being. Zajonc (1980) asserted an individual's affective state has dramatic effects on the way in which a particular environment is represented and used.
Scholars now agree no meaningful thoughts, actions, or environmental encounters occur without affect. However, a number of psychologists view all neural activity as cognition in some sense—even emotions are cognitively mediated. For example, Lazarus (1982) claimed that even instantaneously felt emotions require some sort of quick cognitive appraisal of the situation. Although cognition is used loosely as a term in contemporary psychology, certain traditional paradigms of cognitive processes, such as problem solving, and certain traditional paradigms of noncognitive processes, such as reflexes (Griffith, 1997), prevail. A difference between emotion and cognition is that
many if not most emotions involve bodily responses, but no such relation exists between cognitions and actions. In the case of cognitivelydriven responses, the response is arbitrarily linked to cognition. This is partly why cognition is so powerful … [it] allows us to be flexible, to choose how we will respond in a certain situation. (LeDoux, 1996, p. 40)
People may have an emotional response to something they have no thoughts about in the everyday sense; that is, thoughts not sufficiently sophisticated to be regarded as cognition. This response, albeit unconscious, has an outward physical or behavioral component.
Although many have attempted to define emotion, the only common ground is the conclusion that emotion is not easy to define. From a review of various definitions proposed by more than 100 authors, Kleinginna and Kleinginna (1981) concluded there is limited agreement on the definition of emotion. They suggested a comprehensive definition:
Emotion is a complex set of interactions among subjective and objective factors, mediated by neural/hormonal systems, which can: (a) give rise to affective experiences such as feelings of arousal, pleasure/displeasure; (b) generate cognitive processes such as emotionally relevant perceptual effects, appraisals, labeling processes; (c) activate widespread physiological adjustments to the arousing conditions; and (d) lead to behavior that is often, but not always, expressive, goal directed, and adaptive. (p. 355)
Adolphs (1999) identified three components of emotion to better operationalize it in research: (a) emotional response, including endocrine, autonomic, and neuromodulatory components, as well as motor behavior; (b) evaluation or appraisal of a stimulus; for example, recognition of the emotional value of stimuli; and (c) conscious experiences of emotion. Several psychologists agree conscious feelings are only one part of emotional processes (Berridge & Winkielman, 2003; LeDoux, 1996).
Types of Person‐Environment Relationships
Faletti (1984) and other scholars noticed two kinds of person‐environment relationships. Transaction denotes active or purposeful behavior designed to accomplish a given task or activity. In performing a task or activity, the transaction outcome is a joint product of the person and the environment. Interaction is less associated with purpose; a person simply is perceiving or reacting to the environment in some way. The major outcome of personenvironment interactions is aesthetic satisfaction or some affective response.
Actions versus reactions. Transactions and interactions, categorized as actions and reactions, also have been differentiated from evolutionary and neurological perspectives by other researchers. LeDoux (1996, 2000) contends a human brain has prepackaged protective responses most effective for our species and for the ancient environmental conditions under which they were selected. These emotional responses are automatic, undeliberate, or unconscious, occurring before the brain can decide what to do. Emotions are powerful motivations for future behaviors, while conscious awareness of our emotional state, or feelings, is only part of the process (Berridge & Winkielman, 2003; LeDoux, 1996; Zajonc, 1980, 2001). “Human and rat body respond much the same to their special triggers, but humans fear things that a rat could never conceptualize” (LeDoux, 1996, p. 134). Feelings tell us something is going on. Nevertheless, stimulus processing at the consciousness level can be stored implicitly and have important influence on later thought and behavior. Zajonc (2001) found affective responses are more pronounced when obtained under subliminal conditions and are sufficiently diffuse to elevate overall mood state.
Animals' ability to switch quickly from automatic reaction to willful control (action) is a tremendous extra evolutionary advantage (LeDoux, 1996). Planning ahead or taking willful control involves recognizing and learning the particular history of our interaction with the environment. This added cognitive power affords flexibility and buys greater protection strategy for animals. Only primates, especially humans, have gained this capability through evolution.
Panksepp (1998) favored the view that emotions are adaptations shaped by evolution and, in humans, are on a continuum with emotions in animals. Panksepp proposed that humans have genetically predetermined neural systems designed to respond unconditionally to environmental stimuli. During brain evolution, psychobehavioral tendencies to respond persistently to various environmental challenges have been coded as emotional neural circuits. Consequently, various external stimuli have the capacity to arouse specific emotional tendencies that exist within neural circuits of the brain and are independent of external influences. These instinctual processes may be difficult to observe in adult behavior, however, because they are no longer expressed directly and instead are filtered and modified by higher cognitive activity (Panksepp). Mature humans take more rational actions, and many instincts manifest only as subtle psychological tendencies. These instincts provide internal guidance for behavior and can be suppressed.
Coping Options for Environmental Stress
Coping with environmental stress involves a number of options (De Young, 1999). Humans can change their physical or social settings to create more supportive environments (e.g., smaller‐scaled settings, territories) in which they can manage the flow of information or stress‐inducing stimuli. People can endure stressful periods, incurring mental costs they deal with later in restorative settings (e.g., natural areas and areas offering privacy and solitude). They also can seek to interpret or make sense of situations to diffuse their stressful effects, often sharing these interpretations as a part of their culture.
Enduring and reinterpreting a stressful situation purposefully requires higher‐level cognitive controls, while locomoting is a more basic approach. Individuals actively seek external sources of stimulation or increase internal stimulation by moving about if environmental stimulation is not optimal (Zuckerman, 1983). Kaplan (1992) proposed that locomotion through the environment, as a survival strategy, precipitates the additional demand for navigating abilities.
To summarize, although a cognitively intact person has a broad range of coping strategies when environmental challenges present, reaction is the initial automatic body response and action is the secondary deliberate response. The capacities required to react to and act upon environmental challenges are different. Reacting is an instinctual emotional process, but acting requires the melding of cognitive and emotional functions. If applying the affectdominance proposition in dementia‐environment interaction, this perspective would hold that EWD, particularly those with severe dementia, react emotionally in their environmental encounters.
Neurological Theories of Emotional Responses
Neuroscience neglected to study emotion for decades because it was perceived as a subjective topic (LeDoux, 2000). Recent neuroscience studies suggest human brains have as many instinctual operating systems (universal emotional reactions resulting from evolution) as other mammals. These systems extensively interact in strong and weak ways with higher and lower brain functions (Panksepp, 1998). Whereas emotion is universal, the cognitive accompaniments of a given emotion can vary greatly with factors such as age, experience, and culture. Therefore, the quality and complexity of conscious experience changes throughout an individual's life as emotions become associated with cognition, or as affective‐cognitive structures are formed. Researchers (LeDoux, 1996; Panksepp; Zajonc, 1980) have asserted that affective processes are more fundamentally tied or closer to bodily experiences than cognitive processes and they are channeled independently, more rapidly, and via different brain pathways than cognition.
Motor behavior is one of the most important emotional responses. Approaching versus withdrawing is fundamental in terms of action plans associated with all basic emotions (Ekman, 1992). Some emotion theorists, including Davidson (1993), suggested emotions are psychological processes organized around approach and withdrawal tendencies. Positive emotions such as joy, interest, and happiness facilitate approach behaviors, and negative emotions such as fear, disgust, and sadness evoke withdrawal behaviors. Mounting empirical evidence affirms that all emotional systems vary in the intensity of approach‐avoidance and affective‐arousal gradients they generate (Panksepp, 1998).
Concluding that emotional systems are evolutionary tools to promote psychobehavioral coherence, Panksepp (1998) chose four simple vernacular terms (seeking, fear, rage, panic) to discuss the affective life of mammals. Accordingly, seeking can be explained as the appetitive motivational system that encourages animals to search for all resources, including food, water, warmth, and the like. When fully aroused, seeking behavior helps fill the mind with interest and motivates organisms to move their bodies effortlessly in search of things they need, crave, and desire.
The neural basis of basic motor plans that animals exhibit, as well as primitive emotions such as seeking, some aspects of fear, aggression, and sexuality, are elaborated in basal ganglia (Panksepp, 1998), the deepest and most ancient layer in MacLean's triune brain. The next layer, the limbic system or visceral brain, sophisticates basic reptilian emotions (Panksepp). It also contains newer programs related to social emotions. The outer layer surrounding these ancient subcortical regions is the neocortex. The neocortex can be influenced by emotions and influences them through various appraisal processes, but is not the fundamental neural substrate for generating emotions. Higher brain areas involved in seeking are the amygdala, nucleus accumbens, and frontal cortex, which mediate planning and foresight in both humans and animals (Panksepp). Also refer to Berridge and Winkielman's (2003) description of brain substrates for unconscious and conscious emotional process.
The neurotransmitter involved in the system of seeking and core processes in emotion is dopamine (Berridge & Winkielman, 2003; Panksepp, 1998). Dopamine emanated from the ventral tegmental area projects to the limbic (e.g., amygdala, nucleus accumbens) and frontal areas of the cortex, while dopamine emanated from the substantia nigra area projects to the basal ganglia (Morris, 1996). The seeking system is sensitized by three things (Panksepp): regulatory imbalance, yielding general arousal and persistent forward locomotion; external stimuli; and cues associated with incentives. Stimuli that have innate strong interaction with the seeking system are unconditional incentives; for example, they are intrinsically relevant for survival and are intrinsically associated biologically with environmental events (Panksepp).
Studies on Emotions of Cognitively Impaired Persons
The question of whether awareness in dementia decreases is arguable (Clare & Wilson, 2006; Tappen, Williams, Fishman, & Touhy, 1999). Different trajectories for awareness were observed in Alzheimer disease (AD) patients (Clare & Wilson). It is possible demented elders still have awareness or subliminal awareness of self and their behaviors' meaning, but they only can express such in nonverbal ways (Appell, Kertesz, & Fisman, 1982; Kirshner, Webb, Kelly, & Wells, 1984; Morris, 1996). Research limited to verbal expression of feelings will have little practical significance for better targeted interventions.
Dementia characterized by neural degeneration of medial temporal lobe structures and diffuse cortical atrophy leaves subcortical structures relatively well preserved (Eldridge, Masterman, & Knowlton, 2002; Parks, Haxby & Grady, 1993). Empirical studies indicate cognitively impaired people retain affective capability to react to environmental stimuli regardless of whether these reactions lead to emotional memory enhancement effects (Hamann, Monarch, & Goldstein, 2000; Kazui et al., 2000; Kensinger, Brierley, Medford, Growdon, & Corkin, 2002; Moayeri, Cahill, Jin, & Potkin, 2000; Tappen & Barry, 1995). Neuroimaging data illustrate hypometabolism in higher‐level cortical regions, such as bilateral parietal lobes (Parks et al.), whereas primary sensory and motor cortices, the basal ganglia, the thalamus, and the cerebellum are unaffected (Mielke & Heiss, 1998; Parks et al.).
The selective deterioration of brain areas tends to be relatively stable in patients with AD through longitudinal observation (Parks et al., 1993). Basal ganglia may still receive neocortical input from primary sensory regions, but lack the normal inputs of higherlevel cortical processing (Eldridge et al., 2002). In AD, dopamine deficit is not usually observed. The dopaminergic cells of the ventral tegmental area, projecting to the limbic and frontal areas of the cortex, sometimes are reported depleted in AD, while the dopaminergic cells of the substantia nigra, projecting to the basal ganglia, are relatively unaffected (Morris, 1996). Because brain pathways processing emotions are relatively spared in dementias like AD, emotion may become the more operative and salient mode by which EWD relate to and process information from and about the environment, especially as dementia advances and the influence of cognition on emotion is weakened.
Until now, person‐environment processes in normal and demented brains were studied predominantly from a cognitive or thinking perspective (e.g., Kaplan & Kaplan, 1982). However, such cognitive models have been of limited value in illuminating the basis of disordered behaviors of EWD. The role of emotions in dementia‐environment dynamics should be added to complete our understanding.
Step 3. Integrated Representation of Concepts and Statements
In Step 3, the concepts of environment, wandering behavior, and emotional reactions and their relationships are aligned into a graphic representation and presented as a set. Literature review and examination of theoretical models of person‐environment dynamics revealed a new focal concept and emotion and led to the following relational statements.
A schematic presentation of a new model, LREEWD, is illustrated in Figure 1. Overall, the model indicates behavior is the outcome of cognitive and emotional processing of environmental information (relationship a). Bodily responses are mostly adaptive and have a primary relationship with emotions rather than cognition. Motor response is one type of emotional response and a fundamental issue associated with all basic emotions (relationship b). Emotional reactions result from instinctive perceptions (relationship c) and the primary reaction to the environment (relationship d). Cognition modifies or refines perception, emotional arousals, action impulse, and behaviors (relationship e). Emotion yields rigid and automatic responses, whereas cognition yields flexible and optimal responses.
Because brain pathways processing emotions are relatively spared in dementias like Alzheimer disease, emotion may become the more operative and salient mode by which elders with dementia relate to and process information from and about the environment.
This presentation focuses on locomotion as the behavior central to the model, recognizing that wandering is subsumed as a component of locomotion. The model depicts affect (emotion) and cognition as separate, interrelated systems. In an environmental encounter, stimuli are processed first (faster) via the affective system and do not depend on the cognitive system before yielding a global, generalized effect. Such effects relate to preferences and to approach‐avoidance of behavioral tendencies (Ulrich, 1983). Configurations of environmental stimuli that characterize ingrained preferences (or preferenda; Zajonc, 1980) often are too vague or global to be specifically identified features, but they are highly effective in eliciting affect.
Preferenda of the environment will elicit an initial preference judgment through stimulation of one's visual, auditory, and sensory organs. Initial affect ratings produce arousal in the electrocortical and autonomic systems, motivating behaviors or tendencies that occur mostly automatically and unconsciously (LeDoux, 1996; Panksepp, 1998). They then trigger the cognitive system, where stimuli and the setting are evaluated for significance to well‐being via recognition, identification, and much more extensive information processing (Ulrich, 1983).
Cognitive evaluation of the actual or anticipated outcome of the encounter, which is influenced by experience (learned associations, expectations, memories), refines an initial affective response from which other emotions may be generated (Ulrich, 1983). To the extent that cognition modifies emotion, this will produce postcognitive arousals that may switch emotional reactions to cognitive actions; that is, to continue to carry out initial neurophysiological arousals and action impulse or to suppress or deny them. Since motor behaviors are basic adaptive animal behaviors motivated by different affective or arousal reactions to scenes (Davidson, 1993; Ekman, 1992; Panksepp, 1998), the cognitively impaired person will be mobilized for undertaking or sustaining locomotion if he or she is able to ambulate.
As a result of damage to brain function, some or all of the cognitive factors that normally function may not be able to be triggered (Hamann et al., 2000) to modify initial reaction in EWD. Cognitively impaired persons' initial responses may remain as dominant reactions in their environmental encounters. In fact, emotional responses elicited subliminally are more profound than responses triggered by a known source (Zajonc, 2001). In Figure 1, this process (relationship e) is signified by dashed arrows. As the stage of dementia progresses, the processes depicted by these dashed lines also progressively weaken.
All theoretical models require empirical validation because, in the context of research, the purpose of theory synthesis is to uncover the conceptual structure and linkage of existing knowledge about a phenomenon so the structural knowledge can be used to ensure operational adequacy of indicators and research procedures (Walker & Avant, 2005). To operate constructs in the LRE‐EWD model, theoretical substruction is applied to ensure the congruence between theoretical and operational systems in model testing. Substructing is a process that contrasts with constructing. Figure 2 shows the chart we developed to illustrate the substruction process of the LRE‐EWD model by applying Dulock and Holzemer's (1991) terminology. The chart is read from top to bottom, with terminologies listed at the top associated with higher level of abstraction. In Table 1, the relational statements between two constructs, concepts, empirical indicators, and scores are referred to as axiom, proposition, hypothesis, and measurements (Dulock & Holzemer). Axioms in Table 1 are based on propositions of the NDB model (Algase et al., 1996). Results of model testing, which can be found in a separate article (Yao & Algase, 2006), supported the theoretical position of the LRE‐EWD model.
This synthesized conceptual framework is an effort to model a mechanism mediating person‐environment dynamics in dementia. The framework is embedded in the interaction of background and proximal factors of the NDB model, and resulted from integration of various discrete information about dementia‐related behaviors, particularly wandering and environment. This way of using existing resources is a strength of theory synthesis (Walker & Avant, 2005).
This model has significant scientific implications. First, it provides an alternative to cognition alone in explaining person‐environment dynamics among EWD. The LRE‐EWD model asserts the role of emotional reactions, essentially precognitive, as initial responses to the environment. Further, it reconciles the current environmental therapy models by casting dementia‐environment dynamics at two levels: the immediate environment (as described by Hall & Buckwalter's  PLST model and possibly represented by Snoezelen) and the larger physical and social milieu (characterized by environmental transformation and global enhancement [e.g., the Eden Alternative]). Reconciliation of studies on environmental stressors and milieu therapy begins by first looking at how person‐environment interacts on a momentary basis rather than the larger perspective represented in milieu studies.
Finally, the LRE‐EWD model contributes to the understanding of wandering behaviors and other NDBs. It offers an explanation for the sometimesconflicting views of wandering (harmful versus helpful, seeking versus leaving, attracting attention versus avoiding withdrawing) and for the increase in wandering with advancing cognitive impairment apart from its spatially disordered nature. Anxiety and related aggressive acts traditionally were regarded as an outcome of stress exceeding the cognitive capability of an elder with dementia; however, they could be emotional reactions to various situations. This position supports the behavioral constellation described by the NDB model, which parallels wandering and verbal and physical aggression as behaviors that are need‐driven. Knowledge generated through this study may contribute not only to the management of wandering behavior but also to the full array of NDBs.
Practical implications of the model point to a focus on emotions in structuring environmental therapies. The LRE‐EWD model builds on the immediate person‐environment interaction process, which in return contributes to the long‐run milieu therapy. Researchers and clinicians have strived to study the impact of social and physical environment on behaviors of EWD, yet an explicit understanding of supportive environmental models for patients with dementia—enhanced, transformed, restorative, low stimuli, special care, and therapeutic—remains largely a mystery. Kaplan and Kaplan (1982) proposed that humans prefer environments that make sense and encourage involvement. A supportive environment, from that stance, is one in which information for comprehension and for making choices is available. However, using the above argument, a supportive environment for this special population of cognitively impaired people will be one that has a pleasant ambiance first and foremost rather than elements that make sense to them because their initial emotional response will affect ongoing brain activities based on cognitive reserves. If the assumed emotional response concept is correct, an exemplary application for the long‐term nursing‐home environment is to place personal items associated with good memories in residents' rooms in place of items that are merely homelike or recreational. Pets also can be introduced into LTC environments if residents are fond of them. No single music, art, or recreational intervention will work for everyone (Gerdner, 2000). The fact that 4 of 31 subjects dropped out of Baker and colleagues' (1997) study because they disliked the Snoezelen environment may validate this assumption. Another example of the model's clinical implication is its guidance on daily nurse‐patient interactions. Recognizing patients' feelings and emotions, talking to them with a smiling face, and using words that validate and bring about warmth are emotion‐oriented interpersonal communication techniques that may serve as effective communication preludes for each nurse‐patient interaction.
In summary, the LRE‐EWD model recognizes that emotions are a conduit for controlling immediate dementia‐environment interactions as well as emotional‐cognitive interplays. From this viewpoint, positive emotions may be used as vehicles within which other types of clinical nursing interventions can be transported to help EWD.
The LRE‐EWD model depicts an apparent linear relationship among environment, emotional response, cognitive modification, action tendency, and behavior. In reality, however, connections among these concepts could be both multifaceted and dynamic. For example, instead of letting emotional reactions take the dominant position in the response chain, a weak or distorted cognitive evaluation may be elicited, compared with a cognitively intact individual. Under this circumstance, evaluation may be accompanied by memories and associations that, along with emerging emotions, add to the complexity of the observer's conscious experience. Emerging affect may in turn influence perceptual activities and cognition; therefore, some encounters will entail a complex, ongoing interplay of emotional and cognitive activities. Though we do not know enough about how emotion interacts with cognition in complicated situations, ensuring a positive affective reaction is always better than the opposite. Fredrickson (2001) found even fleeting positive emotions have long‐lasting benefits. She posited that experiencing positive emotions not only signals wellbeing and guides behavior at the moment, but also broadens the individual's momentary thought‐action repertoires. Therefore, managing the flow of information or environmental stressors and preserving, restoring, and creating a preferred environment that makes an individual's overall affective state more positive can be assumed to increase behavioral effectiveness and improve function and quality of life in elders with AD. Although solid evidence on the effectiveness of emotion‐based interventions is minimal (Finnema et al., 2000), further investigation in this direction is recommended. Finally, a synthesized theory is limited in its generalizability by the evidence upon which it is built (Walker & Avant, 2005). Additional research is required to strengthen the empirical validity of the constructed theoretical model.
Lan Yao, PhD RN, is funded by the American Academy of Nursing/John A. Hartford Foundation Building Academic Geriatric Nursing Capacity (BAGNC) Program.
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