Social aspect of activity stimuli is related to positive affect in persons with Alzheimer's disease
- Correspondence to Shannon E Jarrott
Department Human Development (0416), Virginia Tech, Blacksburg, VA 24061, USA;
Implications for nursing practice
■ Social stimuli, including simulated stimuli, generate the most positive affect among persons with moderate to severe dementia compared with various other types of stimuli.
■ Nursing home residents with Alzheimer's benefit from increased pleasure and interest during activities that involve social stimuli, particularly when it reflects their self-identity.
Implications for nursing research
■ There is a need to extend current findings by determining how to sustain mean levels of positive affect over extended periods during the day.
■ Techniques to effectively deliver social stimuli to small groups need further evaluation as most facilities cannot offer one-on-one programming.
■ Methods by which pleasure and interest are enhanced merit further research to clarify whether the content of activity programming or the means in which it is delivered explains participants' responses.
Dementia scholars continue to discuss the impact of long-term care facilities lacking appropriate stimuli, social interaction with staff and a corresponding absence of resident pleasure or interest. Cohen-Mansfield and colleagues explore important questions related to appropriate stimuli that can engage people with dementia. Using Lawton and Nahemow's environmental press model,1 the authors compare a variety of different types of stimuli to explore their impact on residents' affect.
Nursing home residents (n=193) with Alzheimer's were included in the study. Residents' affect2 was coded with handheld computers in five conditions: (a) no activity stimuli (baseline), (b) live social stimuli (eg, a live dog), (c) simulated social stimuli (eg, a baby doll), (d) manipulative stimuli (eg, an activity pillow) and (e) self-identity stimuli (ie, reflecting each participant's past identity). These stimuli were presented to each resident individually. Observers coded the duration of pleasure, interest, anxiety, anger and depression.
Levels of pleasure and interest were highest in response to self-identity stimuli. Categorising stimuli further, analyses revealed that pleasure and interest were greatest in response to live social stimuli, followed by simulated social stimuli and then non-social stimuli (eg, reading). Negative affect was rare and did not differ among stimuli categories. Considering Lawton and Nahemow's assertion that more impaired individuals exhibit the greatest response to environmental changes, the authors assessed differential responses among those with higher and lower cognitive scores. Participants with higher cognitive scores experienced a significantly greater increase in pleasure than those with lower scores in all but one stimuli category.
Social stimuli delivered to residents, even those with significant cognitive impairment, supports higher levels of pleasure and interest compared with affect expressed when stimuli are absent. Not surprisingly, but worth highlighting, stimuli that reflect participants' interests and earlier hobbies or roles supported the greatest levels of pleasure and interest among participants.
The current paper leaves some questions unanswered, pointing to a need for greater clarity and expansion in this line of inquiry. For example, readers would benefit from knowing if observations were gathered for the duration of an activity session or only during one portion. Because participants may take time to warm to an activity or may lose interest quickly,3 data gathered only at one point may not reflect the participant's response to the activity as a whole. While achievement of pleasure and interest are desirable, data on how programming influences activity would enhance readers' understanding of the role of different stimuli. Cohen-Mansfield and colleagues have studied programming's effect on agitation extensively4 and could further consider participants' response to activities by measuring behavioural engagement with stimuli. Finally, the authors' tests of activity programming appear to demonstrate efficacy but may not prove effective in the group setting. Thus, effectiveness trials are needed if practitioners are to utilise these findings in their practice.
Readers can appreciate the potential importance of stimuli content (ie, self-identity stimuli over musical stimuli), but participants' responses could also reflect the manner in which the stimuli were delivered.4 Differential responses might reflect facilitator qualities as much or more than stimuli content. As researchers work towards standardised recommendations, we must be able to recommend best practice as well as best stimuli. The strengths found in this study allow readers to concentrate on the next steps in the research – theory - practice feedback loop. The relatively large sample, use of a theoretical framework and standardised measure and computerised data collection technique address limitations commonly found in similar studies. With Cohen-Mansfield and colleagues' results, scholars can test these social categories of stimuli with attention to facilitation qualities that will enhance replication in one-on-one and group settings serving persons with dementia.