«by Kyung Hee Lee A dissertation submitted in partial fulfillment Of the requirements for the degree of Doctor of Philosophy (Nursing) in The ...»
RELATIONSHIP OF EMOTION AND COGNITION TO WANDERING
BEHAVIORS OF PEOPLE WITH DEMENTIA
Kyung Hee Lee
A dissertation submitted in partial fulfillment
Of the requirements for the degree of
Doctor of Philosophy
in The University of Michigan
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
ACKNOWLEGEMENTSThis 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.
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.
TABLE OF CONTENTSDEDICATION
LIST OF TABLES
LIST OF FIGURES
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
Emotion in Dementia and Wandering Behavior
What Is Emotion?
Emotion of People with Dementia
Emotion and Wandering
Measurements of Emotion in Dementia
Cognition in Dementia
Cognition of People with Dementia
Cognition and Wandering
Emotion and Cognition in Dementia
Emotion, Cognition, and Behavior in Dementia
Need-Driven Dementia-Compromised Behavior (NDB) Model
Locomoting Responses to Environment in Elders with Dementia (LRE-EWD) Model
Proposed Theoretical Model
CHAPTER III: METHODS
Site and Sample
Procedure and Data Preparation
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
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
Recommendations for Future Studies
Implications for Nursing Practice
Definition of Wandering in literature
Summary of Measurement of Study Variables
Study Variables by Aim
Summary of Emotional Expression
Maximum Peak Time Period of PEE and NEE
Correlations among Six Emotional Expressions
Model Specifications of 2-Level HLM Poisson Regressions
Two-Level Poisson HLM for PEE
Two-Level Poisson HLM for NEE
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
NEE Pattern Difference by Resident Characteristics
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
Model Specifications of 2-Level HLM Poisson Regressions (Emotional Expression Only Model)
Two-Level Poisson HLM for Wandering Rates
Model Specifications of 2-Level HLM Poisson Regressions (Final Model)
Proposed Theoretical Model
Case Example of Hourly Distributions for PEE
Predicted and Observed PEE for Each Trajectory Group
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.