Objective: Approximately 18 million persons in the world have dementia. Alzheimer's disease or related disorders (ADRD) are characterized by progressive cognitive impairment that is a key antecedent to agitation in 64-83% of individuals. As postulated in the progressively lowered stress threshold (PLST) model, agitation is attributed to a decrease in the person's ability to receive and process sensory stimuli, resulting in a progressive decline in the stress threshold and a heightened potential for anxiety. Persons with ADRD usually experience a relatively low level of stress in the early morning. Without intervention, stressors begin to accumulate throughout the day until the stress threshold is exceeded, usually by early afternoon (Hall & Buckwalter, 1987). The purpose of this study was to examine temporal patterning associated with agitation in ADRD residents in long-term care facilities (LTCFs) as proposed in the PLST model.
Design: Findings focus on baseline data from an experimental study that evaluated the effectiveness of a non-pharmacological intervention for management of agitation when implemented 30 minutes prior to the estimated peak level of agitation.
Materials and Methods: Thirty-nine subjects were recruited from 6 LTCFs. The sample included 30 women and 9 men (mean age 82 years) with severe cognitive impairment. During week one, certified nursing assistants (CNAs) monitored each subject’s level of agitation over a five day period using the Temporal Patterning Assessment of Agitation. The subject’s "peak level of agitation" was estimated to the nearest quarter-of-an-hour. The time selected for baseline observation was individually determined to precede this time by 30 minutes. A modified version of the Cohen-Mansfield Agitation Inventory was used to assess the frequency of agitation over a 60-minute period of time that incorporated the "peak level of agitation". Assessment occurred two days per week (Monday/Thursday or Tuesday/Friday) for 3 weeks. Supplemental anecdotal notes were used to document potential internal or external stressors that may have affected the subject's behavior.
Results: Calculation of least square means for the frequency of agitation during this 3 week period revealed a gradual increase in the frequency of agitation over the 60 minute period. Anecdotal notes provided a rich source of data that informed quantitative findings. These data were used to develop case studies that exemplify the complexity and variability among subjects in their display of agitation. Cases were selected to provide a cross representation with regard to factors identified in the model that contribute to stress: 1) fatigue; 2) change in routine; 3) overwhelming stimuli; 4) affective response to perceptions of loss, and 5) physical stressors (i.e., infection).
Conclusions: Based on the small sample, it appears that temporal patterning of agitation in persons with ADRD is often predictable based on application of the PLST model. Staff are encouraged to recognize the early signs of anxiety and explore the meaning underlying these behaviors to provide timely and appropriate intervention.
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