The aging of society is a global trend, and caring for older adults with dementia has become an urgent health issue. Alzheimer’s Disease International (2015) estimates that an average of one person every 3 seconds was diagnosed with dementia in 2015. The total cost of caring for patients with dementia is $8,180,000 USD annually. In 2011–2013, Sun and others (2014) used software-based random sampling in 19 Taiwanese counties and applied the latest guidelines on diagnosing dementia from the National Institute on Aging-Alzheimer’s Association in the United States to guide their investigation. They reported a prevalence of dementia of 9% in older adults aged 65 and older. Furthermore, the prevalence of dementia is increasing as the average age increases in Taiwan (Sun et al., 2014). The prevalence of dementia among residents of long-term care facilities is high, with 27% of the older adults with dementia residing in retirement centers, 62% in semiprofessional nursing homes, and 65% in professional nursing homes in Taiwan (Chen et al., 2007).
As this illness progresses, older adults with dementia often display negative emotions, memory problems, sleep disturbances, and agitated behaviors. Among these, agitated behavior is the most perplexing problem for family members and nursing staff to manage (Chang, Lin, Yeh, & Lin, 2010). Agitated behaviors may manifest in inappropriate language, noises, and gestures. Caregivers find it difficult to differentiate between actual needs and confused dysfunction. In certain cases, according to community standards, this agitated behavior is inappropriate (Cohen-Mansfield & Billig, 1986). Wu and Du (2001) interviewed 156 nursing home residents around southern Taiwan and found that 67% displayed agitated behaviors, with 26% displaying three or more types of agitated behaviors. In another study, 55% of the older adults with dementia displayed passive aggressive behaviors (Byoung, 2009). Passive aggressive behaviors refer to agitated behaviors that are attributed to or influenced by caregivers or situations. Common aggressive behaviors include wandering, abusive behavior, repetitive actions, wearing inappropriate clothing, shouting, biting or kicking, hiding or destroying items, sexual harassment, and self-abuse or abuse of others (Huang, Hsu, Li, & Chiu, 2011; Hwang, 2006; Lin, 2006). Factors that influence passive aggressive behaviors include disease-specific symptoms and the attitude of care providers or family caregivers such as compulsive and controlled behaviors or tone in the course of caretaking activities. In addition, the milieu of caring such as changing the living environment of care providers, noise, and sunset syndromes influence passive aggressive behaviors (Lee, Lee, & Ming, 2007; Xie & Yan, 2008).
Agitated behavior, if not controlled, reduces the quality of life of patients as well as increases the burdens of family caregivers and healthcare providers. Agitated behavior is affected by age, gender, level of cognitive impairment, chronic disease, medications, ability to perform tasks of daily living, physical restraints, and other factors (Ho, 2011).
The management of agitated behaviors may be divided into medication and nonmedication methods. However, medications often cause serious side effects such as extrapyramidal symptoms, falls, aspiration pneumonia, listlessness, or cognitive impairment (Akishita et al., 2011; Azumi, Ishizuka, Fujii, & Sasaki, 2011). As nonmedication treatment methods avoid the typical side effects of medications, these methods should be used in the initial stage of the intervention. Nonmedication treatment methods include behavior therapy, environmental therapy, and activity therapy. Music therapy is a form of activity therapy that may be used to control stimuli and noise in the environment. Music therapy creates an environment that may prevent and reduce anxiety and agitated behavior in the older adults with dementia (Ho, 2011; Sung, Chang, & Abbey, 2006).
Lee, Chen, and Wang (2010) revealed that low-frequency power, which represents cardiac autonomic modulations, and the ratio to high-frequency power, which reflects cardiac sympathetic modulations, were significantly greater in the noise intensity of 50–80 dBA among 16 healthy adults. Concurrently, they found the low-/high-frequency ratio to correlate significantly with the noise intensity. The authors suggested that the instant autonomic responses to white noise may be detected using power spectral analysis of heart rate variability and that the evoked responses may provide a sensitive measure of the real-time effect of noise on humans. However, few articles on the effects of white noise on aggressive behaviors in the older adults with dementia have been published. Therefore, the aim of this study was to investigate the effects of white noise on improving the agitated behavior, mental status, and activities of daily living of older adults with dementia.
The progression of dementia
On the basis of the diagnostic criteria of mental disease in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, one or more of the following cognitive dysfunctions may be used to diagnose dementia: cognitive impairment including overall attention, learning, memory, and executive function; language function; sensory function; and social interpersonal cognition (American Psychiatric Association, 2013). Dementia is generally divided into early, middle, and late phases. From the time of diagnosis of dementia to death, the average duration ranges from 8–10 years up to 15 years. In the early stage, patients experience a mild decline in cognitive function and remain able to care for themselves without significant changes in appearance. In the middle stage, moderate disorders of cognitive function, behavioral, and psychological symptoms become apparent, and assistance with activities of daily living becomes necessary. In the late stage, serious disability in cognitive function leads to total dependence on others for care (Woods, Aguirre, Spector, & Orrell, 2012).
Agitated behaviors and interventions
Agitation has been distinguished by factor analysis into four subfactors: (a) physically nonaggressive behavior such as restlessness, repetitive movements, and pacing; (b) physically aggressive behavior such as hitting, pushing, scratching, and other physically violent acts; (c) verbally nonaggressive behavior such as verbal demands and complaints; and (d) verbally aggressive behavior such as screaming and cursing. Kong, Evans, and Guevara (2009) confirmed in a systematic literature review that behavioral, environmental, and other nondrug interventions such as touch and perceptive interventions including aromatherapy, thermal bath, music, hand massage, social interaction, pet therapy activity, therapeutic recreation, environmental modification, light therapy, and behavior therapy have effectively improved agitated behavior in patients with dementia. Yang, Wu, Lin, and Lin (2007) examined the effects of acupressure on agitated behaviors. They showed that agitated behavior lessened after 6 weeks of the acupressure intervention. Lin et al. (2009) examined the effects of acupressure and Montessori on agitated behaviors, with results indicating that both interventions decreased agitated behaviors, aggressive behaviors, and physical nonaggressive behaviors; caregiving was made easier as reported by nurse aides. Burgio, Scilley, Hardin, Hsu, and Yancey (1996) applied an environmental white noise intervention on residents in nursing homes and found a 23% reduction in language agitated behaviors. Nurse aides reported that the most common verbal agitated behaviors among older adults with dementia were sighing, moaning, self-talking, screaming, shouting loudly, and crying out for help. Language agitated behavior occurs more frequently after bathing, mealtime, and awakening in the morning and at night before the older adults with dementia fall asleep.
White noise has a very fixed frequency and pitch. It sounds like rain, waves, or the noise of the fan. Using a fixed frequency and tone, with the repeated and continuous stimulation, white noise covers other external noises and eliminates excessive stimulation (De Niet, Tiemens, Kloos, & Hutschemaekers, 2009; Forquer & Johnson, 2007; López, Bracha, & Bracha, 2002). The white noise induces brain alpha waves, which stabilize the body and mind, and abates brain beta waves, which cause physical and mental agitation. White noise, similar to music, provides a smooth environment with less stimulation, inducing feelings of pleasure and relaxation (Shih & Su, 2007; Sung, Chang, Lee, & Lee, 2006). Kim, Lee, and Kim (2013) revealed that the older adults in their experimental group who used a computerized cognitive rehabilitation training system with white noise for 6 weeks showed a significant difference from the control group in terms of digit span (forward, backward) and an auditory continuous performance test. Tsai (2012) reported a significant effect of white noise on insomnia for the older adults living in long-term care facilities. The older adults in the experimental group with a 4-week white noise intervention at night reported significantly increased sleep quality, as measured using the Pittsburgh Sleep Quality Index. Kaneko et al. (2013) exposed six patients with dementia associated with schizophrenia to white noise one to two times per day for 1 hour during a 4-week period. After this intervention, all participants immediately appeared more comfortable and, in some cases, started to smile. Moreover, their scores for neuropsychiatric symptoms (Neuropsychiatric Inventory) decreased significantly. However, their scores on the Mini-Mental Status Examination (MMSE) and Barthel Index did not significantly improve. On the basis of their report, which included only six participants, this study was undertaken with a larger sample and an experimental design to investigate whether white noise, a simple, easy, and noninvasive intervention, promotes relaxation through sound stimulation and reduces agitated behaviors and MMSE scores in older adults with dementia.
A pretest/posttest experimental design with two groups was conducted to examine the effects of white noise on agitated behaviors in older adults with dementia.
Six dementia care centers with roughly the same number of years in operation were identified and approached to participate in this study. The care centers were located in central and southern Taiwan for the experimental group and in central Taiwan for the comparison group. Each group included patients in three dementia centers, respectively. The inclusion criteria were (a) individuals with dementia over the age of 65 years, (b) no hearing disorder (able to hear normal speech volume) and ability to communicate in Mandarin or Taiwanese, and (c) willingness to participate in this study and provide written consent (both the study participant and a family member). The participants in the experimental group were exposed to the white noise intervention for 20 minutes per day for 4 weeks. The participants in the comparison group received routine care only. The data collections for pretest and posttest were conducted before and 4 weeks after the end of the intervention, as shown in Figure 1.
After this study was approved by the institutional review board (IRB number 1021001), we began recruiting participants and collecting data. The administrators of the six dementia care centers were contacted initially by telephone and e-mail. Then, group explanations and discussions of the aims, procedures, and participant rights were conducted with the family members. The participant and a representative of his or her family signed the consent form.
The measures used in this study included demographic characteristics and health-related issues, MMSE, Barthel Index, and Cohen-Mansfield Agitation Inventory (CMAI). Definitions of each measure are detailed hereinafter.
Demographic characteristics and health-related issues
This measure includes age, gender, educational level, MMSE, and Barthel Index (used to measure activity level, duration of residency, and restraint use).
Cohen-Mansfield Agitation Inventory
The CMAI was used to measure the frequency of agitated behavior incidents (Cohen-Mansfield, 1996). The scale has 29 questions using a 7-point scale, with 1 = never and 7 = several times an hour (Finkel, Lyons, & Anderson, 1992). Higher scores indicate more agitated behaviors. The participants were observed and recorded by trained research assistants during several observation periods during a 1-week period. Every participant was observed twice a day for 10 minutes for a total of 20 minutes. Yang et al. (2007) translated the original CMAI into Chinese and applied the inventory to assess 16 patients with dementia, with an interrater reliability of .99 and an intraclass correlation coefficient of .77.
Training phases for research assistants
Burgio et al. (1996) indicated that staff should receive training, especially with regard to managing agitated behaviors, before caring for patients with dementia. Therefore, the research assistants participated in two training sessions of 2 hours each. These sessions included learning how to identify dementia agitated behaviors; learning the definition, assessment protocol, and recording protocol for agitated behaviors; and learning the standard procedure for white noise intervention, with step-by-step instructions including volume control, the spacing of the portable audio equipment and the participants, and the explanation of the process to the participants. Intrarater reliability was measured at 98% before starting the observation and white noise intervention.
White Noise Intervention
White noise has a fixed frequency and pitch and includes the sounds of rain, sea waves, and electric fans. Expert advice was used in selecting the sounds used in this study. Most people are familiar with, and can recognize, sounds of waves, rain, wind, and flowing river water. White noise sounds were saved to a USB device, and a USB portable audio player was used to play white noise every afternoon for 20 minutes sometime between 4 and 5 p.m. for a period of 1 month.
The environment used for the white noise intervention was controlled by using the same nursing unit, which allowed the researchers to prevent distractions, disturbances, and external noise. White noise volume was kept between 55 and 70 dB, which is below the labor safety and sanitation hazard level of 85 dB as stipulated in Rule no. 300. Volume measurements of decibels were taken to comply with IEC 651 (International Electro Technical Commission) / Type 2 (model: TES-1350A, made in Taiwan) and to ensure measurement consistency. During the white noise intervention, if one of the participants could not control his or her emotions or behavior, he or she was allowed to leave the intervention to reduce the potential disturbance to other participants. The times and frequencies of the responses of participants to the white noise were recorded.
This study process consisted of a pilot study and a formal study, as described below.
One dementia care center was selected for the pilot study. The aims, process, and methods were explained to the administrators and to patients and their families by the researchers. Written consent forms were signed by patients and their families before data collection. Three older adults with dementia were selected for the pilot test to verify the process of observing, interviewing, and recording as well as to test the intervention.
Pretest and posttest
The pretest included an interview that was conducted using a structured questionnaire (demographic data and CMAI) and an observation that used structured guidelines and recording. Burgio et al. (1996) reported that agitated behavior is most likely to occur in the afternoon and at dawn. Therefore, 10-minute behavior observation periods were arranged between 2–5 and 6–8 p.m. (excluding dinner time) for a period of 7 days, with each participant observed for 2.3 hours. The data collected at posttest were the same as those collected at pretest.
The data were coded, double-checked, and analyzed using IBM SPSS Statistics Version 22 (IBM, Inc., Armonk, NY, USA). In addition to descriptive statistics, baseline measures between the two groups were compared where appropriate using t and Chi-square tests. Changes in the various outcome measures between the two groups over the duration of the study period were compared using analysis of covariance.
Demographic and Health Characteristics of Participants
In total, 63 participants were recruited from the six dementia care centers and participated in the pretest. There were 28 participants in the experimental group and 35 participants in the comparison group. Two participants (one in each group) were hospitalized during the posttest and did not participate in the posttest. The rate of participation in the white noise intervention was 88.4%. Chi-square and independent t tests were used to examine the demographic data and health characteristics of variations between the two groups. The use of restraints was significantly different (p < .05) between the experimental group (82.1%) and the comparison group (42.9%). There were no significant differences (p > .05; see Table 1) in other demographic characteristics and health characteristics between the two groups.
Comparison of the Effects of White Noise Intervention on Agitated Behaviors, Mental Status, and Activities of Daily Living Between the Two Groups
The research results showed that agitated behaviors decreased significantly in the experimental group (posttest = 40.07 ± 6.96 vs. pretest = 47.52 ± 9.35, t = 7.13, p < .001). In the comparison group, agitated behaviors decreased insignificantly (posttest = 42.26 ± 6.12 vs. pretest = 42.32 ± 5.84). The mental status and activities of daily living before and after the intervention did not change significantly between pretest and posttest in either group (see Table 2).
Effects of White Noise Intervention on Agitated Behaviors, Mental Status, and Activities of Daily Living
The effects of the intervention on agitated behaviors, mental status, and activities of daily living were analyzed using analysis of covariance. Restraint status was listed as a covariate because this status was significantly different between the groups. A homogeneous test of variance (F = 1.25, p = .27) showed no significant difference. The 4-week intervention decreased the frequency of agitated behaviors (F = 3.85, p = .05). The degree of change in agitated behaviors was significantly different between the two groups (pretest scores minus posttest scores), with this change significantly higher in the experimental group (6.81 ± 1.12) than in the comparison group (0.04 ± 0.88) after 4-week white noise intervention in the experimental group.
The effects of the 4-week white noise intervention on the mental status of participants were examined. A homogeneous test of variance showed an insignificant difference (F = 2.67, p = .11). Although the intervention increased the score for mental status (F = 0.13, p = .725) in the experimental group, the change was not significant for either group (pretest scores minus posttest scores), and the change in mental status for the experimental group was insignificantly higher than for the comparison group at posttest.
In addition, the effects of the intervention on the activities of daily living for the participants were examined. A homogeneous test of variance found no significant difference (F = 1.32, p = .26). The intervention increased the scores for activities of daily living (F = 0.41, p = .53), indicating that these changes (pretest scores minus posttest scores) were insignificantly different between the two groups. Changes in the ability to perform activities of daily living in the experimental group were not significantly better than in the comparison group at posttest (see Table 3).
The 4-week white noise intervention effectively decreased agitated behaviors of the participants in the experimental group. These results are similar to those of Burgio et al. (1996), who used environmental white noise to reduce verbal agitated behaviors, and of Kaneko et al. (2013), who used white noise in six patients with schizophrenia-associated dementia in nursing homes. In addition, our review of participant responses identified that, although some participants did not respond to the intervention initially, these participants began tapping their feet rhythmically and moving their hands in a hand-dance fashion after multiple exposures to the intervention.
Although the intervention significantly lessened the agitated behaviors of the participants, it did not significantly improve cognitive function or their ability to perform tasks of daily living. These results are similar to those of Kaneko et al. (2013), who conducted a 1-hour white noise intervention for one to two times a day for a period of 4 weeks. However, as the frequency, intensity, and object properties of our intervention differ from those of Kaneko et al., further conclusions cannot be drawn.
The lack of improvement in terms of cognitive status and daily living may be explained by the different degrees of dementia and multiple chronic illnesses that were present in the participants. Greater assistance is necessary to improve the ability of severely disabled patients to perform activities of daily living. Because only a few articles have been published on the use and effectiveness of white noise intervention in treating agitated behaviors in older adults with dementia, additional studies that apply this type of intervention may prove beneficial. In addition to white noise therapy, reminiscence on the good old days or on old acquaintances, Chinese medicine therapies, pet therapy, gardening therapy, and cognitive therapy have been used to improve the aggressive behaviors of older adults with dementia. Further research may be conducted to compare the efficacy of the various abovementioned interventions in populations of older adults with dementia. The authors of this study will consider the future development of using single or combined intervention strategies to reduce levels of agitated behavior in older adults with dementia.
Conclusions and Suggestions
The 4-week white noise intervention achieved significantly positive results in terms of improving agitated behaviors in the experimental group. Although we identified minor improvements in MMSE and activities of daily living for this group, neither reached a level of significance. The results of the present research indicate that using white noise, which is a simple, convenient, and nonintrusive intervention, in the clinical care of older adults with dementia holds the potential to reduce agitated behaviors and improve quality of care.
Because of limited time, financial resources, and manpower, only six dementia care centers with 63 older adults participated in this study. Future studies should use larger sample sizes to improve the validity and generalizability of results. Furthermore, because random sampling was not used, the interference of other factors cannot be excluded. This may reduce the external validity of the findings, as a short-term effectiveness evaluation cannot predict long-term results.
White noise interventions may improve the agitated behaviors of older adults with dementia. The process and results of this study support the following recommendations: (a) expand future research to include other dementia care services and settings (such as dementia daycare centers) to examine the effects of the intervention on older adults across different care settings and (b) conduct research to examine the long-term effects of white noise interventions.
We express our sincerest thanks to all of the participants who provided the data for this study. We give special thanks to Nursing Supervisor Tsai Li-Jane and the Taiwan Nurses Association, which sponsored this research under Grant TWNA-1032009 in 2014. Thanks also to Mrs. Susan Wright for her support and editing.
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