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«by Kyung Hee Lee A dissertation submitted in partial fulfillment Of the requirements for the degree of Doctor of Philosophy (Nursing) in The ...»

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RELATIONSHIP OF EMOTION AND COGNITION TO WANDERING

BEHAVIORS OF PEOPLE WITH DEMENTIA

by

Kyung Hee Lee

A dissertation submitted in partial fulfillment

Of the requirements for the degree of

Doctor of Philosophy

(Nursing)

in The University of Michigan

2011

Doctoral Committee:

Emeritus Professor Donna L. Algase, Chair

Associate Professor Bruno J. Giordani

Clinical Associate Professor Laura M. Struble Professor Reg A. Williams To my parents ii    

ACKNOWLEGEMENTS

This dissertation could not be completed without support and encouragement of many people. First of all, I sincerely thank to my advisor and committee chair Dr. Algase, who is also a principal investigator of the parent study. Her guidance and encouragement enabled me to continue and complete this work. I am also thankful to my dissertation committee, Dr. Struble, Dr. Williams, and Dr. Giordani for their time and valuable suggestions which improved my dissertation.

I would like to express my gratitude to the School of Nursing, Rackham, and the Center for the Education of Women fellowship grants from the University of Michigan and P.E.O. International Peace Scholarship for funding my dissertation and doctoral education. I would not have been to finish my doctoral study without their financial support.

Several other consultants at the University of Michigan also helped me to finish my work. Kathy Welch from the Center for Statistical Consultation and Research assisted me in finding the most appropriate statistical methods for my data and reviewed my analyses; Cathy Antonakos, who is a research specialist from the Institute for Social Research, prepared data for my dissertation and answered my numerous data- related questions.

iii

             

  I also would like to acknowledge the support and encouragement I have received from my friends, classmates, colleagues, and staff. They have all inspired me to continue my study. In addition, special thanks go to professors from Yonsei University College of Nursing, especially Dr. Chung Yul Lee.

Finally, my deepest gratitude should go to my parents in Korea and my younger brother in Vietnam. Without their endless prayers, support, and encouragement, I could not finish my doctoral study.

iv

             

 

TABLE OF CONTENTS

DEDICATION

ACKNOWLEDGEMENTS

LIST OF TABLES

LIST OF FIGURES

Abstract

CHAPTER I: INTRODUCTION

The Problem and Background

Significance of Study

Purpose of Study

CHAPTER II: LITERATURE REVIEW

Wandering Behavior in People with Dementia

What Is Wandering

Prevalence of Wandering

Factors That May Influence Wandering Behavior

Summary

Emotion in Dementia and Wandering Behavior

What Is Emotion?

Emotion of People with Dementia

Emotion and Wandering

Measurements of Emotion in Dementia

Summary

–  –  –

Cognition in Dementia

Cognition of People with Dementia

Cognition and Wandering

Summary

Emotion and Cognition in Dementia

Emotion, Cognition, and Behavior in Dementia

Conceptual Framework

Need-Driven Dementia-Compromised Behavior (NDB) Model

Locomoting Responses to Environment in Elders with Dementia (LRE-EWD) Model

Proposed Theoretical Model

CHAPTER III: METHODS

Research Design

Site and Sample

Measures

Procedure and Data Preparation

Data Analysis

Human Subjects

CHAPTER IV: RESULTS

Sample Characteristics for Aim 1 and Aim 2

Aim 1: Explore Emotion in PWD during the Daytime

Description of Emotional Expression

Correlations among Emotional Expressions

Observable Emotional Expression by Resident Characteristics, Cognition, and Time of Day

Trajectory Groups in Observable Emotional Expression of PWD during the Daytime

vi

             

  Emotional Expression Pattern by Resident Characteristics

Aim 2: Examine the Relationship between Patterns of Emotion and wanderers among PWD

Positive Emotional Expression and Wanderer

Negative Emotional Expression and Wanderer

Aim 3: Examine the Relationship between Frequencies of Emotion and Wandering in PWD

Frequencies of Observable Emotional Expression and Wandering Rates.....101 Effects of Emotional Expression Frequencies, Cognitive Impairment, Time of Day, and Resident Characteristics and Wandering Rates

CHAPTER V: DISCUSSION

Discussion of Findings

Emotional Expressions in PWD

Trajectory Groups in Observable Emotional Expression of PWD................111 Emotional Expression and Wandering

Methods

Limitations

Recommendations for Future Studies

Implications for Nursing Practice

APPENDIX

REFERENCES

–  –  –

Table 2.1.

Definition of Wandering in literature





Table 3.1.

Summary of Measurement of Study Variables

Table 3.2.

Study Variables by Aim

Table 4.1.

Residents’ Characteristics

Table 4.2.

Summary of Emotional Expression

Table 4.3.

Maximum Peak Time Period of PEE and NEE

Table 4.4.

Correlations among Six Emotional Expressions

Table 4.5.

Model Specifications of 2-Level HLM Poisson Regressions

Table 4.6.

Two-Level Poisson HLM for PEE

Table 4.7.

Two-Level Poisson HLM for NEE

Table 4.8.

Using BIC to Select a Model Having the Optimal Number of Groups............94 Table 4.9. Parameter Estimates for Group Trajectories and Group Membership.............95 Table 4.10. PEE Pattern Difference by Resident Characteristics

Table 4.11.

NEE Pattern Difference by Resident Characteristics

Table 4.12.

PEE Pattern Difference between Wanderers and Non-wanderers................100 Table 4.13. NEE Pattern Difference between Wanderers and Non-wanderers...............100 Table 4.14. Descriptive Statistics of Level-1 and Level-2 Variables

Table 4.15.

Model Specifications of 2-Level HLM Poisson Regressions (Emotional Expression Only Model)

Table 4.16.

Two-Level Poisson HLM for Wandering Rates

Table 4.17.

Model Specifications of 2-Level HLM Poisson Regressions (Final Model)

–  –  –

Figure 2.1.

LRE-EWD Model

Figure 2.2.

Proposed Theoretical Model

Figure 4.1.

Case Example of Hourly Distributions for PEE

Figure 4.2.

Predicted and Observed PEE for Each Trajectory Group

Figure 4.3.

Predicted and Observed NEE for Each Trajectory Group

–  –  –

Chair: Donna L. Algase Wandering is one of the most frequently encountered dementia-related behavioral disturbances and has been associated with negative consequences such as higher morbidity and mortality. In terms of relating factors of wandering, it has become increasingly clear that a close relationship exists between emotion, cognition, and behavior. However, little research has focused on the influence of emotion on wandering of people with dementia (PWD). The purpose of this study was to explore the relationship of emotion and cognition to wandering behaviors of PWD. This study applied a secondary data analysis utilizing a parent study that used a cross-sectional design with repeated measure nested within subjects. A total of 115 PWD in 17 nursing homes and six assisted living facilities in Michigan and Pennsylvania were included.

Subjects were randomly assigned to six 20 minute observation periods,

–  –  –

conducted on two non-consecutive days; their behaviors were videotaped. Poisson hierarchical linear modeling (HLM) was utilized to determine factors associated with wandering. Positive emotional expression increased wandering rates whereas negative emotional expression and higher MMSE score decreased wandering rates after controlling for other predictors (i.e., age, education, gender, and time of day). Therefore, both positive/negative emotional expression and cognition influence wandering; a tailored intervention that addresses both emotional and cognitive functioning may be required to improve wandering behaviors of PWD.

–  –  –

As the number of people living to the age of 65 and above has increased, so has the number of elderly with dementia. Thirty-nine million people age 65 and over lived in the United States in 2008, accounting for just over 13 percent of the total population (Federal Interagency Forum on Aging Related Statistics, 2011). The elderly population in 2030 is expected to be twice as large as it was in 2000, growing from 35 million to 71.5 million and representing nearly 20 percent of the total U. S. population (Federal Interagency Forum on Aging Related Statistics, 2011). In a recent report, it was revealed that over 5 million people age 65 and older suffer from Alzheimer’s disease and the prevalence of Alzheimer’s disease will grow as fast as the baby boomers age (Alzheimer’s association, 2010). The socio-economic burden of caring for people with dementia is growing alongside dementia’s increased prevalence, since dementia care is particularly timeconsuming and expensive. According to the Alzheimer’s Association (2010), costs for the care of people with dementia were $172 billion in 2010 and they will increase up to $1.08 trillion in 2050.

As dementia progresses, functional impairment and behavioral disturbances often emerge to accompany the significant cognitive impairment of dementia (Wooltorton, 1   2002). Behaviors such as agitation, wandering, and problematic vocalizations are related to caregiver burden, institutionalization, and care costs (Donaldson, Tarrier, & Burns, 1997; Lyketsos, et al., 2000; Martin, Ricci, Kotzan, Lang, & Menzin, 2000). A majority of patients experience behavior disturbance at some time during the course of dementia.

In a representative study, almost all nursing home residents presented at least one behavioral problem, and half showed four or more behavioral problems (Tariot, Teri, Porsteinsson, & Weiner, 1996).

Wandering, dementia-related locomotion behavior, is one of the most common behavioral disturbances. Although estimates of wandering vary widely, its prevalence among the community-residing elderly with dementia is reported to be as high as 50% (Teri, Larson, & Reifler, 1988). The Alzheimer’s Association estimates that up to 60% of persons with Alzheimer’s disease (AD) will wander at some point over the course of the disease (Alzheimer's Association, 2007). Wandering has also been associated with patient morbidity (Evans & Strumpf, 1989; Rheaume, Riley, & Volicer, 1988) and mortality (Moritz, Fox, Luscombe, & Kraemer, 1997) due to safety risks including elopements, falls, and injuries; it has also been reported to require costlier care (Lam, Sewell, Bell, & Katona, 1989). In order to design interventions for wanderers, an understanding of wandering behaviors is essential.

In terms of those factors related to wandering, it has become increasingly clear that a close relationship exists between emotion, cognition (i.e., mental processes involving in thinking such as memory, attention, perception, etc.), and behavior (Bucks & Radford, 2004). Emotion involves both conscious and unconscious mental response to be mediated by neural systems and to lead to behavior (Kleinginna & Koeinginna, 1981), which 2     includes emotional expression and emotional recognition. Positive or negative emotions are expressed via the face, voice tone, and body posture; emotional recognition is the ability to perceive emotion expressed by others. Based on current knowledge of brain function and connectivity, Pessoa (2008) stated “emotion and cognition not only strongly interact in the brain, but also are often integrated so that they jointly contribute to behavior” (p. 148).

From a theoretical standpoint, the Need-driven Dementia-compromised Behavior (NDB) Model explains how dementia-related behavior results from the interplay of background and proximal factors (Algase, et al., 1996). Background factors include neurological factors, cognitive factors, health status, and psychosocial factors; proximal factors include both physical and social environments and personal factors including emotions and physiological need states (Algase, et al., 1996). Cognitive factors and emotions, then, often critically influence wandering behaviors.

Therefore, this study sought (1) to explore emotion of people with dementia and (2) to examine the relationship of cognition and emotion to wandering behaviors of people with dementia (PWD).

–  –  –

Although the number of studies concerning PWD has increased, some gaps still remain. While most studies have focused on cognitive aspects of dementia, relatively few studies have shown the influence of emotional aspects of dementia (Bucks & Radford, 2004). In this section, the significance of this study is justified by the relative lack of 3

–  –  –

studies on emotion in dementia— particularly as compared to the number addressing cognition— as well as inconsistent results across existing studies.



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