Experience of media presentations for the alleviation of agitation and emotional distress among dementia patients in a long-term nursing facility

Abstract

Although the cause and the cure for dementia remain unknown, it is clear that environmental factors can offer relief of cognitive impairment and encourage emotional stability. The purpose was to explore dementia patients’ experiences of a media presentation including images of nature. Combining a qualitative approach with quantitative data analysis, the project exposed 23 participants to slide show presentations of fascinating natural scenes over 4 weeks. The patients’ feelings and experiences of the media presentations were investigated using semistructured interviews and daily chart reviews in which weekly behavioral changes. The experience of natural scenes in dementia patients’ everyday atmosphere became a new and positive aspect of life at the long-term nursing facility, although the quantitative data did not significantly change during the project. This treatment could provide dementia patients with a nurturing relationship, making nature a supportive part of their everyday experience.

Keywords

agitation and emotional distress dementia media presentation nature scenic view

Background

Agitated and aggressive behaviors are commonly seen in older adults with dementia, especially in nursing home units for people with dementia (Pitkala, Laurila, Strandberg, & Tilvis, 2004; Zuidema, De Jonghe, Verhey, & Koopmans, 2007). Antipsychotic medications are often used to manage these agitated and aggressive behaviors (Sink, Holden, & Yaffe, 2005), although these medications have side effects (Ames, Ballard, & Cream, 2005). In contrast, nonpharmacological interventions can be used for almost all dementia patients without side effects. Several recent studies recommend that nonpharmacological interventions should be used before pharmacological intervention (Azermai et al., 2012; Gauthier et al., 2010; Shinfuku et al., 2011).

One nonpharmacological intervention concerns the use of video combining with music as an intervention. Hall and Hare (1997) utilized Video Respite™ that was a series of 10 videotapes specifically designed to recall the long-term memory of patients with dementia. There was significantly effective in increasing positive behaviors during the intervention although a 21-min Video Respite tape was not significantly effective in reducing agitation (Hall & Hare, 1997). Volandes et al. (2007) utilized video image to communicate information to advance care planning for advanced dementia. It suggested that use of video could improve verbal communication and enhance the ability of patients to imagine a hypothetical health state.

As a form of multisensory stimulation (Kaplan & Kaplan, 1989), nature has an abundant source. Access to nature in controlled settings is particularly beneficial for people with dementia (Cohen-Mansfield & Werner, 1998; Lovering, Cott, Wells, Schleifer-Taylor, & Wells, 2002). Use of natural elements could promote positive cognitions in patients. Several research studies have shown that having free access to an outdoor area might reduce some agitated emotions and behaviors in dementia residents (Neville, McMinn, & Cave, 2006). One study (Pinkney, 1994) used multisensory therapy in dementia care for relaxation, recreation, enjoyment, and sensory stimulation. Later, Detweiler, Murphy, Myers, and Kim (2008) showed that gardening could encourage autonomy and sensory stimulation for improving dementia patients’ quality of life. However, as the disease worsens to the point of institutionalization, providing patients with opportunities to experience nature without hindering their safety becomes complicated by environmental factors such as windowsill height, building orientation, and outdoor access. These obstacles complicate patient exposure to nature even though this therapy has been increasingly recognized as an important resource in the care of people with dementia (Bossen, 2010). Additionally, social barriers such as policy, risk, health, safety, and staffing issues hinder this therapy. Due to these barriers that limit physical exposure to nature, exploration of the indoor use of media presentations of natural scenes has been pursued as a beneficial method of exposing patients with dementia to experiences with nature. A lack of research exists on the effect of media presentations of natural scenes on the symptoms of dementia patients. The results of this study provide valuable insight into the care of people with dementia at long-term nursing facilities. This study could provide evidence of an effective therapy for dementia patients in their exposure to media presentations of natural scenes in their everyday lives at long-term nursing facilities. Within this philosophical framework, the focus of interest in this study was to explore the experience of media presentations of natural scenes in dementia patients’ everyday lives at a long-term nursing facility. Nursing records of agitated behaviors over the time period of the project were used to support qualitative results.

Methods

Type of study

A qualitative research design with supportive quantitative research was used to gather information on patients’ experience of media presentations of natural scenes at a long-term nursing facility. The semistructured interview guideline was created after discussion with three researchers specializing in park recreation and tourism (PRT), psychology, and nursing. Also, the daily nursing records were used for quantitative information. The total duration of the study was 6 weeks.

Sample of the study

Purposeful sampling was used based on the following criteria: (1) more than 18 years old; (2) a diagnosis of dementia based on the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 4th ed., American Psychiatric Association, 2000); (3) consent to participate in this study (from both the participant and the participant’s guardian). The included participants were residents at one long-term nursing facility in Salt Lake City between February and May 2012. Among the 45 participants contacted to be in the study, 28 participants and family members/caregivers were agreed to participate. Among 28 participants, one patient passed away during the study and three patients moved to other facilities. One participant refused to watch the video after the second video. Thus, 23 patients participated in this study. The average age was 61 years old (ranged from 46 to 83). There were 21 Caucasian participants (91%), 18 male participants (78%), and four college educated participants (17%) (Table 1).

Table 1.

Characteristics of study sample.

Characteristics		Value
Gender	Female	3 (13%)
	Male	18 (78%)
Age	Under 50	2 (8%)
	50–59	5 (22%)
	60–69	9 (39%)
	Over 70	4 (17%)
Race	Caucasian	21 (91%)
	Black African American	2 (8%)
	Hispanic	1 (4%)
Education	Less than high school completion	7 (30%)
	High school completing	2 (8%)
	Some college/Bachelor’s degree	6 (26%)
	Graduate degree (MS/PhD)	2 (8%)
Level of dementia	Mild	4 (17%)
	Moderate	10 (43%)
	Severe	6 (26%)
Years in facility	Less than 1 year	1 (4%)
	1–4 years	10 (43%)
	5–10 years	8 (35%)
	Over 10 years	1 (4%)

Data are given as number (percentage) unless otherwise indicated.

Data collection

Permission for this study was obtained from the Institutional Review Board (IRB). In order to recruit subjects, long-term nursing facilities in Salt Lake City were selected. The directors of the long-term nursing facilities were contacted by phone and in person, and the study procedures were explained. The first long-term nursing facility asked to participate in the project consented to allow us to collect data in their facility. Participants were to be randomly assigned to either an early interview group (interviewed 3 days after the final presentation) or a late interview group (interviewed 2–3 weeks after the final presentation). Participants were exposed to fascinating natural scenes in a recreation room for 7–10 min once a day, 3 days a week, for 4 weeks. Among 23 participants, 21 participants were exposed to the entire six-DVD set during the study and two participants were exposed to the five-DVD set during the study. These scenes of nature included landscapes of American national parks, flora, fauna, and waterscapes accompanied by soothing music. The slides were shown on a 40″ HD monitor in the recreation room. Research assistants guided participants into the room and stayed with them while the slides were being played. All conditions for the early and late interview groups were the same. At the end of the 2-week period, the participants completing all media presentations in the early interview group were interviewed within 3 days of the final presentation, while participants in the late interview group were interviewed within 2–3 weeks. The location for interviews, chosen by the participants, was either in their private room at the nursing home or in the room where we showed them the videos, whichever was the most comfortable and relaxing for them. Interviews lasted approximately 5–40 min each. During the interview process, the participants were encouraged to express their feelings and their experiences. Interviews were audiotaped with the participants’ permission and were transcribed verbatim shortly after the interview (see Appendix 1).

In addition, agitated behaviors reported in daily nursing records were used to support the qualitative data. The following seven events were counted during the study: (1) hit a resident, (2) hit a staff member, (3) yelled/screamed, (4) cursed/swore, (5) experienced agitation to the point of interference with care, (6) threw things, and (7) threw self on the floor. The patients’ baselines were measured 2 weeks before the experiment began, and a follow-up measurement was also conducted 2 weeks after the experiment was completed in order to assess long-term effects.

Data analysis

Qualitative data analysis

NVIvo (Ver. 10) was used for qualitative data analysis. The qualitative data for the study were analyzed using the method devised by Mayring (2000). Content categories were inductively formulated, and their descriptions written down in a code manual (definition, examples, and rules for coding). Then, the passages of text were encoded using NVivo (Ver. 10) according to the code manual and assigned to content categories. Both inductive and deductive processes were used (Mayring, 2000) in the hopes of providing a more comprehensive picture of the use of media presentations of natural scenes in dementia patients’ everyday life at long-term nursing facilities. Content analyses not only analyzed the manifest content of the material, as the name suggests, but additionally coded text at differentiated levels; themes and main ideas were coded as “primary content,” while context information was coded as “latent content” (Mayring, 2000). Content was identified and coded according to the following criteria:

Positive verbalization: subject matter that is positively related to the media presentation of natural scenes by patients with dementia at the long-term nursing facility. The subject matter is mentioned directly or indirectly. In the latter case it can be definitely identified in the context, without being mentioned explicitly.

Negative verbalization: subject matter that is negatively related to the media presentation of natural scenes by patients with dementia at the long-term nursing facility. It is directly or indirectly mentioned. In the latter case it can be definitely identified in the context, without being mentioned explicitly.

Neutral verbalization: subject matter that is neutrally (neither positive nor negative) related to the media presentation of natural scenes by patients with dementia at the long-term nursing facility. It is directly or indirectly mentioned. In the latter case it can be definitely identified in the context, without being mentioned explicitly.

Mixed verbalization: content includes conflicting verbalization; the subject matter is positively expressed but immediately rejected in the following sentence.

Trustworthiness

Trustworthiness of the data was established by using the criteria of Lincoln and Guba (1985): credibility, transferability, dependability, and confirmability. Open-ended follow-up questions were used to verify participants’ responses, and participants were asked to validate findings to establish credibility during the interview, although some participants were cognitively impaired. The typed transcripts were carefully checked by listening to each tape again to ensure the accuracy of the transcripts. Using a few controlling conditions, variations in sampling analysis of a large volume of qualitative data established transferability. Dependability was validated using a peer review analyzing process. Three doctoral prepared researchers who specialize in psychology, nursing, and PRT completed the data analysis of the verbatim text alone and then cross-examined the analysis.

Quantitative data analysis

SAS (Ver. 9.3) was used for quantitative data analysis. Descriptive statistics were used to present the subjective outcome measures. A Multivariate analysis of variance (MANOVA) was used to test whether the daily events were significantly different from the baseline. The daily events recorded in daily nursing records were used to support the qualitative data. The following seven events were counted during the study: (1) hit a resident, (2) hit a staff member, (3) yelled/screamed, (4) cursed/swore, (5) experienced agitation to the point of interference with care, (6) threw things, and (7) threw self on the floor. The baseline was measured 2 weeks before the experiment began, and a follow-up measurement was also conducted 2 weeks after the experiment was completed in order to test for long-term effects.

Results

Qualitative findings

The 23 participants gave a total of 62 responses about the media presentation of natural scenes. There were 29 responses by the early interview group and 33 responses by the late interview group (Table 2). There was a significant difference in the number of neutral verbalizations identified in the interviews of the early and late interview group.

Table 2.

Content analysis of the interviews revealed four themes.

Themes	10 patients within 3 days after intervention	13 patients within 2–3 weeks after intervention
Positive	19	15
Negative	2	1
Neutral	4	15
Mixed	4	2

Positive themes

Positive themes included any subject matter which was expressed as positively related to the media presentation of natural scenes by patients with dementia at the long-term nursing facility. Most of positive themes were related to feelings of enthusiasm for or fascination with the media presentations of natural scenes. The participants drew the experience as a common positive experience, which could have positive emotional and physical consequences for them. They felt that the presentation was interesting and engaging.

I like them. Really enthused me. Looking for plants he can grow … Rotten bastards …. Plants … Immaterial, food. Stay away from drugs … .

Another world … . Human being … like people. Animals, surrounding. Animals are free. Like I was in it …. Felt like a king of nature …

One participant expressed that he felt like a king of nature and …. another world. This can be considered enthusiasm or fascination. It can also be considered a “being away” effect. This may indicate something other than the patient feeling physically distant from where he or she currently is; it may mean a temporary relief from stress or a temporary shift to a more positive mood state.

Other positive themes were related to the relaxation effect. One participant expressed how much he enjoyed the media presentation of natural scenes and that it helped him to relax. This effect may include experiencing mental quiet or the state of being free from anxiety. It can initiate a process of healing.

Nature video makes me relax,. peaceful, relaxing. The place that never seen before. I am not finished … camera shot, I would like to visit the spot where camera man was located.

It is better than before, just pretty much happier.

A reminding effect was shown in some participants’ expressions. This effect stunted their cognitive decline. Some participants were reminded of places and family members after watching the media presentation of natural scenes. The familiarity of natural scenes played an important role in reminding patients of people, events, and places significant to their lives. “Reminding different places that I’ve been. Home sick. I’ve been to place to building home republishing home … ” “My mom used to like flowers. Kind of nature. I’ve been Grand Canyon. I’ve been all of the places, rock climbing. … ” Although the media presentation of natural scenes did not provide stimulation from a first-hand experience of nature, it played an even more important role stimulating patients’ desire to connect with nature. “I like to see sky … . Can I have more pictures about clouds or sky for the next?.” The other positive theme was reflection on their lives. The reflection effect could be defined as people thinking about themselves, their futures, and what has been most important to them in their lives. “When I leave here, I am looking more forward to independent where I end up. I don’t want to be … past several year is not really good … Better my left years … ”

In fact, reflection was the highest cognitive benefit of experiencing the media presentation. It helped participants to clear their minds of the cognitive noise that remains from the demands of their everyday lives at the long-term nursing facility. Reflection provided participants with an opportunity to think about immediate issues/problems and to reflect on their lives, even their goals and their futures.

Neutral themes

Regardless of the positive or negative impacts of the media presentation of natural scenes on their lives, some participants were not interested in engaging or being involved with it. Those participants felt that the media presentation of natural scenes did not matter to their situation or their lives. “Nothing to feel … it’s just a picture. … . Nothing to think about … analyzed it, liked it … . Wanted to show kids? Man destroys the flowers he sells… .” About 30% of participants couldn’t remember anything about the media presentation (seven out of 23 participants, two from the early interview group, and five from the late interview group). This may have been caused by severe cognitive decline. “The what?? I don’t remember … ” “No.?? what was that? ”

Negative themes

Primarily, negative themes were expressed in the following ways: “I didn’t like videos.” “No.” “I don’t.” Participants were asked to answer why they had negative perceptions of media presentation of natural scenes. They felt that it didn’t make any changes to their lives. The experience of the media presentation was explained as a feeling of disconnection to their real life. “A video is just a video … ” “I just like them but not sure if they really changed anything” “No change in watching wildlife.” The experience of the media presentation of natural scenes was seen as a limited contribution to their everyday lives. They may have hoped it would change their lives, but they adopted an inappropriate approach to the change. Their lives may be changed at some later point.

Mixed themes

Some participants expressed ambivalence, relating negative and positive themes, “Didn’t like videos. Has seen of past. it before. Reminded Hiking, fishing. Good memories … . Just.” Watching the presentation helped to remind them of forgotten aspects of their lives and to stimulate their memories although they did not feel the effects during the media presentation. Some patients may have had experiences that did not reach a point of cognitive recognition.

Quantitative findings

Daily nursing records were used to support the qualitative data. The following seven events were counted during the study: (1) hit a resident, (2) hit a staff member, (3) yelled/screamed, (4) cursed/swore, (5) experienced agitation to the point of interference with care, (6) threw things, and (7) threw self on the floor. Related to hitting a resident, there were significant effects over time (p = 0.09) and the interaction between levels of dementia (mild, moderate, and severe) and time (p = 0.08), based on the Wilks’ Lambda statistics. However, there were no other significant effects over time and the interaction between level of dementia and time (hitting staff—time (p = 0.58), interaction between time and level of dementia (p = 0.66); yell/scream—time (p = 0.34), interaction between time and level of dementia (p = 0.35); curse/swear—time (p = 0.58), interaction between time and level of dementia (p = 0.33); agitation to the point that it interfered with care—time (p = 0.52), interaction between time and level of dementia (p = 0.70); throw self on floor—time (p = 0.55), interaction between time and level of dementia (p = 0.63)) (Table 3).

Table 3.

The effects of media presentations of natural scenes over time.

Daily events	Effects over time	Interaction between levels of dementia and time
Hit a resident	p = 0.09	p = 0.08
Hit a staff member	p = 0.58	p = 0.66
Yelled/screamed	p = 0.34	p = 0.35
Cursed/swore	p = 0.58	p = 0.33
Experienced agitation to the point of interference with care	p = 0.52	p = 0.70
Threw self on the floor	p = 0.55	p = 0.66

Discussion

This study showed that the experience of natural scenes in dementia patients’ everyday atmosphere became a new and positive aspect of life at the long-term nursing facility, although the quantitative data were not significantly changed during the project except in one resident who exhibited a hitting behavior. Most of the participants indicated that the experience had positive emotional and physical consequences for them. They felt that it was interesting and engaging. They explained experience as something that made them happy, peaceful, and calm, reminding them of their youth/earlier life.

According to Cohen-Mansfield, Libin, and Marx (2007), providing appropriate activities for dementia patients not only engages them but also reduces negative behaviors. Similarly, Well and Evans’ study (2003) reported that exposure to nature has therapeutic functions for patients with mental health issues, and that exposure to nature itself provides the important benefit of maintaining healthy behaviors along with mental health. The use of natural environments can have positive effects not only on people with dementia, but it can have a positive therapeutic impact on older people as regards their general health and quality of life (Kaplan, 1973; Kaplan & Kaplan, 1990; Miligan, Gatrell, & Bingley, 2004). The images of nature on the slides can be used as a restorative environment. One of the central functions of restorative experiences is to reduce mental fatigue and eventually to attain a state of mental respite and calmness. Certain natural settings feature specific elements that improve opportunities for restoration (Korpela, Hartig, Kaiser, & Futher, 2001). Scopellititi and Giuliani (2004) also found that a restorative experience allowed people to regain a condition of psychophysical well-being and effectiveness in daily life. Similarly, this study found that the media presentation of natural scenes helped to restore dementia patients’ minds from the mental fatigue of their lives and contributed to the stimulation of their memories (through reminding effects). In fact, the media presentation of natural scenes included the concept of “restorative experiences” or “restorative effects.” According to Kaplan and Kaplan (1989), the results of “restorative experiences” include the removal of mental noise, recovery from mental fatigue, and the enhanced ability to reflect on important issues. Similarly, in this study, some participants expressed their reflections on their lives. It helped them to clear their mind of cognitive noise that remained from the demands of their everyday lives at long-term nursing facilities and gave them the opportunity to think about more immediate issues/problems in their lives.

Although the experience of nature helped to restore participants’ minds from the mental fatigue of their lives, contributing to an improvement in anxiety and agitation, the experiences may not have been enough to change their negative behaviors (e.g. hit residents, hit staff, yell/scream, etc.) at the long-term nursing facility. Many felt that it didn’t make any changes in their lives. The experience was explained by some as a feeling of disconnection from their real lives. This may be due to the lack of direct interactive activity between the participants and natural elements. Viewing natural scenery on the screen is not a physically interactive activity in the same way as walking in a park is, although it can be considered as an experience of nature (Kaplan & Kaplan, 1989). Berman, Jonides, and Kaplan (2008) also reported that people are better able to perform tasks that depend on directed-attention ability after having a direct interaction with natural environments. There remains no doubt that the direct interaction between a human being and natural elements would be more beneficial than watching a media presentation. For instance, Raske’s study (2010) found that the presence of a garden had positive effects on residents’ quality of life at a nursing home. Comparing gardening and viewing natural scenery, gardening has greater effects than viewing natural scenery. However in some cases, direct interaction with nature is complicated or impossible. Changing the existing physical environment of a long-term nursing facility may be very difficult and expensive, even though access to nature is often an essential aspect of a person’s cultural heritage. Access to nature is currently underused as a therapeutic resource for people with dementia. The media presentation of natural scenes is one of the most cost-effective methods of connecting with nature. Also Hall and Hare (1997) supported that the video may be used as an intervention which will increase positive social behaviors among cognitively impaired patients. Video technology could provide long-term care residents with a virtual experience of nature. Memory loss was a distressing part of this study. About 30% of the participants could not remember anything about the media presentation, whether they were in the early or late interview group. A comparison of the early interview group and the late interview group showed no significant difference in the number of the positive and neutral themes (including no memory of the media presentation). Also a comparison of the level of dementia showed no significant difference in the number of the positive (p = 0.10) and neutral themes (p = 0.24). This could have been due to severe cognitive decline.

One limitation of the current study was the fact that the length of time it took the participants to view the entire six-DVD set was determined by the individual participants, not the researchers. Participants who did not wish to view the video on a particular day (or were sleeping, or could not be located, etc.) were not forced to participate that day. This resulted in a few individuals completing the DVD set in 2 weeks, while others took as long as 4. It was decided to extend the study from 2 to 4 weeks due to this issue and the need for participants to all receive the same dosage of the treatment in order for the data to be more meaningful. Future research should attempt to alleviate this issue, perhaps by playing the nature DVDs in the patients’ private rooms instead of a communal area or by arranging a more frequent viewing schedule.

Another limitation of this study was the lack of individualized or personalized intervention. Cohen, Marx, Thein, and Dakheel-Ali’s study showed that the personalized interaction required more involvement and cooperative responses by dementia patients (Cohen-Mansfield, Marx, Thein, & Dakheel-Ali, 2011). Similarly some participants in this study expressed their desire to view particular types of images. Personalizing the media presentations would improve health outcomes of patients viewing the natural scenes.

Also, the sample in this study was limited to dementia patients from one long-term nursing facility. Its results cannot be generalized to include other facilities or other settings. Additionally, the study did not compare the effects of the media presentation on people in varying stages of dementia. Further research should examine the effects of media presentations of natural scenes on patients in different stages of dementia.

The results of this study can provide valuable insights into the care of people with dementia as related to the use of media presentations of natural scenes. While there are clear barriers to providing dementia patients with adequate connections to nature without changing the physical design of their care facilities, the use of media presentations of natural scenes could offer similar benefits. As we know, the cause and the cure for dementia remain unknown. However, this study also supports Gibson and Chalfont’s study (2007), which shows that environments can offer support for people with cognitive impairment. The mandatory indoor confinement of dementia residents could increase verbal and physical agitation and use of psychotropic medications (McMinn & Hinton, 2000). We still have a choice to replace locked units with those incorporating access to natural settings. More studies are needed to examine the specific health-related outcomes of connection with nature as a therapy/intervention and how we might adequately offer this connection between nature and human beings, especially to people with dementia at long-term nursing facilities.

Conclusions

In summary, dementia patients’ experience of watching natural scenes seems to induce a calming effect, as well as provide them with a feeling of relaxation and a sense of tranquility. Regardless of whether the experience is direct or indirect, experiencing nature has been shown to be an interactive process in which people undergo restorative experiences. These experiences could provide long-term nursing facilities with a new method of building their patients’ relationships with nature, making it part of their everyday lives in an effort to support the health and happiness of people with dementia.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Acknowledgements

The authors would like to thank the participants for their participation and for sharing their experiences. We also thank Ms. Mija Kyung and other staff members in the nursing home for their cooperation and our research assistants, Paige Martinez, Nicholas Gailey, and Hairin KIm for their valuable assistance.

Joohyun Chung is an associate professor in the Department of Nursing, at Utah Valley University. Her clinical, teaching, and research interests include nursing informatics (especially for older adults), nursing education, and biostatistics.

Seong-In Choi is an assistant professor in the Department of Psychology and the Master of Science in Clinical Mental Health Counseling program at Westminster College in Salt Lake City, Utah. Her clinical, teaching, and research interests include multicultural and cross-cultural issues in mental health, anxiety and mood disorders, and psychological test and measurement.

Jun Kim is an assistant professor in the Department of Health Education and Recreation, Southern Illinois University Carbondale. More than 5 years his research interest has been exploring the relationship between psychological benefits and the beauty of nature and creating special program for the marginalized people to experience the beauty of nature with musical/natural sounds.

Appendix 1: Structured interview questions

Tell me about yourself

How are you feeling here (can you describe your feeling about life here)

How did you feel when you watching a video

Would you please describe the first time you watched the video?

What was the best experience you have watched among all videos?

What made that you feel like that?

What did you remind anything when you watching the video? What was that? Would you please tell us about what made this?

Tell me about any changes after watching the videos?

Please specify

Would you be willing to watch the video later?

Under what circumstances might you feel more enjoyed the video?

Where (in their own room, etc.), how often, how (screen size, music, some more routine program, etc.)

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