Resident Function & Life Enjoyment
Interventions for Psychosocial Functioning
(click on author's name for summary or abstract)
Overview: The intervention literature relating to the category of the psychosocial well-being of residents is relatively extensive, although some topics have received considerably greater attention than others. For example, interventions addressing psychosocial issues that can manifest with problematic behaviors (e.g., agitation and depression) are comparatively well-studied, while those focusing on the purely socioemotional needs of residents (e.g., spirituality or satisfaction) have been little studied. For the purposes of this review, the interventions have been grouped according to modality rather than to the outcome they address. Thus, music-based interventions are grouped into a single subcategory, although their outcome measures range from agitation to exercise participation to overall well-being. Thirteen subcategories of psychosocial interventions were identified; these include environmental changes; person-centered/individualized care; exercise/physical activity; staff training/expertise; activities; psychological therapy; sensory stimulation; community integration; pet therapy/animal assisted therapy; music therapy; art therapy; aromatherapy; and a small miscellaneous category.
Environmental changes: Articles relating to improving the resident's psychosocial well-being by altering the facility environment fall into two main groups. The first focuses on providing better cues to promote independent behavior and decrease dependent or unwanted behaviors. For example, environmental cues and external memory aids are used to improve mealtime behaviors (Nolan & Matthews, 2004), room finding skill (Nolan et al., 2001) and way finding (McGilton et al., 2003). In the second group, misleading cues are intended to diminish dangerous behaviors; e.g., installing cloth barriers (Dickenson, 1998; Feliciano, 2004) and altering floor patterns (Hewawasam, 1996) to curb wandering and exiting behaviors. More studies examining physical design changes are described in the category "Resident Living Space."
Person-centered/individualized treatments/case management: All of the articles in this subcategory are aimed at reducing behavioral and psychological symptoms of dementia (BPSD) or depression. The two interventions described as 'resident-centered' focus on agitation during showering (Sloane et al., 2004) and to improve sleep and general levels of agitation (Matthews, 1996). Individualized treatments are employed to reduce agitation by decreasing stimulation (Lawton, 1998), reduce aggression during bathing (Hoeffer, 1997), and reduce depression by improving social interaction (Rosen, 1997). A case management approach was used by two studies to address BPSD. The first offers multidisciplinary treatments provided by staff and mental health professionals (Opie et al., 2002) and the second includes medication review, activities and educational rounds (Rovner, 1996). Finally, one study involved case management by a geropsychatric nurse specialist plus individualized attention provided by trained volunteers to reduce depression (McCurren et al., 1999).
Activities: This category includes studies investigating the effects of traditional and nontraditional activities programming and exercise on psychosocial wellbeing. The activities-based studies include snoezelen care (Baillon et al., 2004; Cox et al., 2004; Minner et al., 2004; Van Weert et al., 2005), gardening (Brown et al., 2004), Montessori-based activities (Orsulic-Jeras et al., 2000), reminiscence-based activity (Politis et al., 2004) and ADL focused activities (Beck et al., 2002). The exercise approaches include studies of walking to reduce aggression among physically active residents with dementia (Holmberg, 1997), increasing physical activity levels to improve sleep and reduce agitation (Alessi et al., 1999; Landi et al., 2004), and musical exercise to increase physical and cognitive function (Hagen et al., 2003).
Staff training or expertise: A handful of studies examined the effects of providing staff training to improve various care outcomes, including wandering (Cohen-Mansfield et al., 1997), nonverbal communication (Magai et al., 2002), agitation during self-care routines (Roth et al., 2002), behavioral management (Burgio et al., 2002), the resident's sleep environment (e.g., reduce noise and waking) (Alessi et al, 1999), and detecting depression (Wood et al., 2002) and other psychiatric needs (Proctor et al., 1999). Two common concerns about the efficacy of purely educational approaches have been the level of retention of information by staff over time and the integration of the information into actual care routines. Some of the above mentioned studies examine the delayed effects of the training in terms of staff retention and application of information and/or resident care outcomes (Burgio et al., 2002; Cohen-Mansfield et al., 1997; Magai et al., 2002; Wood et al., 2002). Finally, one study compared training methodology by providing training in depression and dementia via lectures and computer-based interactive video (Rosen et al., 2002).
Psychological therapy: Uniformity is seen within the subcategory of studies examining the effects of psychotherapy on resident psychosocial well-being in that each examines either a life review or reminiscence approach. Specifically, reminiscence is used to promote self-esteem and socialization (Tabourne, 1995; Wang, 2004), treat depression (Bass & Greger, 1996; Haight et al., 1998; Jones, 2003), improve well-being (Lai et al., 2004) and reduce agitation (Baillon, 2004) among residents with dementia. One study examines the longitudinal effect of reminiscence therapy over three years on depression, life satisfaction and self-esteem (Haight et al., 2000).
Sensory stimulation: The articles in the category examine various forms of stimulation to improve resident well-being, including auditory, tactile, visual, multisensory and passive movement. (Music and aromatherapy are discussed in separate categories below.) Within the auditory grouping, three studies examine the simulated presence of loved ones or positive personalized memories (Camberg et al., 1999; Cohen-Mansfield & Werner, 1997; Miller et al., 2001) on affect and agitation, and a third study examines the effects of white noise on agitation (Burgio et al., 1996). Tactile therapies included increasing positive physical touch during care (Butts, 2001), hand massage (Remington, 2002) and massage (Rowe & Alfred, 1999; Sansone and Schmitt, 2000). Visual stimulation was examined via bright light stimulation for depression (Sumaya et al., 2003) and sleep (Ancoli-Israel et al., 2003; Fetveit et al, 2003). Two studies provided multisensory stimulation including exercise, imaging and storytelling (Heyn, 2003) and snoezelen and garden rooms (Cox et al., 2004). Finally, a few studies create situations in which the resident passively experiences the sensation of movement, for example on a glider swing (Snyder et al., 2001) or by seating the resident in a wheelchair attached to the front of a bicycle ridden by a staff person (Beuttner & Fitzsimmons, 2002; Fitzsimmons, 2001).
Pet therapy/animal assisted therapy: Most studies examined the effect of cats and or dogs in persons with dementia on such outcomes as agitation (Churchill et al., 1999; McCabe et al., 2002; Richeson, 2003), social interactions, depression and blood pressure (Stasi et al., 2004), and loneliness (Banks & Banks, 2002). In an attempt to avoid some of the negative components of pet therapy, including resident's allergies and staff care time, two studies examine robotic pets (Libin & Cohen-Mansfield, 2004; Tamura et al., 2004) and compared a dog visit with a "happy person" visit (Kaiser et al., 2002). Finally, one study examines the short term and longitudinal effects of adding fish aquariums to the dining room on resident nutritional intake and weight gain (Edwards & Beck, 2002).
- A reader on the Pioneer Exchange compiled another reference list concerning pets in long-term care, with several 2005 references. Please leave a comment there if you know of other sources.
Music therapy: The effects of music therapy have been tested on a wide variety of outcomes. Four studies examined calming music for agitative and other disruptive behaviors in persons with dementia (Clark et al., 1998; Cohen-Mansfield & Werner, 1997; Gerdner, 2000; Remington, 2002). Other outcomes focused on residents with dementia include improving language function (Brotons & Kroger, 2000), food intake (Ragneskog et al., 1996), and physical and cognitive function (Hagen et al., 2003). Among residents generally, music has been tested for improving depressive symptoms (Ashida, 2000) and increasing levels of participation in exercise activities (Mathews et al., 2002).
Aromatherapy and art therapy: Four studies were identified that test the usefulness of aromatherapy. All address behavioral symptoms of dementia (Ballard et al., 2002; Smallwood et al., 2003, Snow et al., 2004), although one specifically examines the effects of aromatherapy on agitation during medication administration (Gray & Clair, 2002). One study examined the effects of weekly art therapy on positive affect and self-esteem (Rentz, 2002).
Reviews: Review articles that examine the intervention topics covered in the above subcategories are listed here and included in the annotated bibliography. For behavioral disturbances in dementia, Teri et al. (2002), Forbes (1998) and Grasel et al. (2003) review nonpharmacological treatments and Allen-Burge et al. (1999) review behavioral interventions. Lou (2001) reviews the use of music to decrease agitated behavior. Bartels et al (2003) review mental health services provided to nursing home residents. Marshal & Hutchinson (2001) review the use of activities for persons with dementia. Finnema et al. (2003) reviews emotion-oriented approaches (e.g., reminiscence, life review and validation therapies). Finally, Price et al. (2000) review research on subjective barriers to prevent wandering and Siders et al. (2004) is a comprehensive and up-to-date review of nonpharmacological interventions for wandering.
Miscellaneous: DeGuchi (2000) addresses the use of nighttime spa bathing to improve sleep and daytime behaviors. Miskelly (2004) looks at electronic tagging for wandering. Cohen et al. (1999) examines the effectiveness of natural helping networks (nondemented residents acting as 'buddies' to residents with dementia). Finally, Hamilton et al. (1999) describe a long-lasting intergenerational visitation program and offer materials to facilitate program replication.