- Email: [email protected]
Vocalizations Among Cognitively Impaired Elders: What Is Your Patient Trying To Tell You?
Feature Article
Vocalizations Among Cognitively Impaired Elders What Is Your Patient Trying To Tell You? Diane S. Clavel, RN, MSN, GNP
Abstract: Unpleasant vocalizations are prevalent among cognitively impaired elders and often are considered disruptive and problematic by their families and caregivers. However, another way to perceive such challenging vocalizations is as a communication attempt by these patients to make their needs and feelings known. This article identifies possible meanings underlying these vocal behaviors and suggests strategies to help reduce their occurrence. (Geriatr Nurs 1999;20:90-3)
90
Geriatric Nursing Volume 20, Number 2
S
creams, curses, moans, groans, and verbal repetitiveness are some of the vocalizations among cognitively impaired elders that can thwart patient care efforts and precipitate feelings of frustration, failure, anger, and exhaustion in caregivers. In short, they are disruptive and can adversely affect the quality of life for families, caregivers, and even the patients themselves. Such common vocal behaviors, their underlying meanings, and strategies to help reduce their occurrence are presented in this article.
PREVALENCE Studies have explored some of the vocalizations peculiar to cognitively impaired elders and help discern their prevalence. A survey by Cohen-Mansfield et al.1 found 25% of 408 nursing home subjects screamed four times per week or more. Ryden et al.2 looked at 124 cognitively impaired nursing home residents and found that of the 86.3% who had some type of aggression, 47.6% were verbally aggressive. A study of residents from two nursing homes by Cariaga et al.3 identified 76 (11%) as vocally disruptive; another study by Ryan et al.4 identified 31% of 636 long-term care residents as noise-makers. Despite these statistical variances, challenging vocalizations among demented elders are clearly widespread and often perceived as disruptive.
REFRAMING VOCALIZATIONS However, what is considered “disruptive” is an individual perception, and with knowledge, such perceptions can be changed. Reframing vocal behavior positively as a communication effort is a first step toward effective management. Progressive dementia invariably is associated with deteriorating language and communication skills.5 Research by Bayles et al.6 found that the greatest deteri-
Table 1. Strategies to Enhance Communication with Cognitively Impaired Elders • Establish eye contact • Sit in close, comfortable proximity to your patient • Assume your patient is better able to understand speech than express it • Always talk respectfully to your patient • Slow your rate of speech; use simple words and short sentences • Give your patient time to respond to your questions • Adapt a nonthreatening manner: try a gentle touch, talk with a low, reassuring voice • Remain calm and in control
Geriatric Nursing Volume 20, Number 2
oration in people with Alzheimer’s disease occurred when they suffered moderate to severe impairments in cognition. For demented elders, the diminishing ability to find words and speak in sentences consisting of complete thoughts, coupled with the increasing difficulty for their caregivers to understand them, may precipitate or escalate vexing and seemingly meaningless vocalizations. Are such vocalizations meaningless? Some research suggests not. A study by Fuller et al. 7 found that the perceived roughness of voice, “jitter,” was a valid and reliable indicator of stressrelated anxiety. Additionally, research by Hallberg et al.8 suggests that interpreting the vocal activity of demented elders as either a language of feelings—usually strong and negative (eg, anxiety, frustration, fear) but sometimes positive (eg, gratitude, comfort)—or as a language to meet activity needs is possible.
Loud, busy, demanding environments may precipitate or intensify vocal outbursts in demented elders who cannot tolerate such sensory overload. Conversely, sensory deprivation (eg, auditory, visual, olfactory, tactile) also is stressful.
DETECTIVE WORK: SO WHAT IS YOUR PATIENT TRYING TO TELL YOU? All behavior has meaning. Understanding the meaning behind vocal behaviors of demented elders requires strategies to enhance communication, as well as detective work on the part of caregivers. Table 1 outlines some of these strategies. Look for clues in the patient’s health history and physical assessment. Determine baseline behavior and the situations or context within which vocalizations occur. Especially important is to identify situations in which a patient seems quieter, more content. Attend to nonverbal cues (eg, facial expressions, posture, movements) that accompany vocalizations. Additionally, consider vocal tones and inflections. Is your demented elderly patient trying to communicate pain or discomfort that frequently accompanies an acute illness or a degenerative condition? Suspect pain if your
91
Table 2. Possible Meanings Underlying Challenging Vocal Behaviors of Demented Elders and Related Management Strategies Possible Underlying Meanings
Related Management Strategies
“I hurt!” (eg, from arthritis, fractures, pressure ulcers, degenerative joint disease, cancer)
• Observe for pain behaviors (eg, posture, facial expressions, and gait in conjunction with vocalizations) • Treat suspected pain judiciously with analgesics and nonpharmacologic measures (eg, repositioning, careful manipulation of patient during transfers and personal care, warm/cold packs, massage, relaxation)
“I’m tired.” (eg, sleep disturbances possibly related to altered sleep/wake cycle with day-night reversal, difficulty falling asleep, frequent night awakenings)
• Increase daytime activity and exercise to minimize daytime napping and promote nighttime sleep • Promote normal sleep patterns and biorhythms by strengthening natural environmental cues (eg, provide light exposure during the day, avoid bright, artificial lights at night); provide large calendars and clocks • Establish a bedtime routine • Reduce night awakenings: avoid excess fluids, diuretics, caffeine at bedtime; minimize loud noises; consolidate nighttime care activities (eg, changing, medications, treatments)
“I’m lonely.”
• Encourage social interactions between patients and their family, caregivers, and others • Increase time the patient spends in group settings to minimize time in isolation • Provide opportunity to interact with pets
“I need…” (eg, food, a drink, a blanket, to use the toilet, to be turned or repositioned)
• Anticipate needs (eg, assist patient to toilet soon after breakfast when the gastrocolic reflex is likely) • Keep patient comfort and safety in mind during care (eg, minimize body exposure to prevent hypothermia)
“I’m stressed.” (eg, inability to tolerate sensory overload)
• Promote rest and quiet time • Minimize “white noise” (eg, vacuum cleaner) and background noise (eg, televisions and radios) • Avoid harsh lighting and busy, abstract designs • Limit patient’s contacts with other agitated people • Reduce behavioral expectations of patient, minimize choices, promote a stable routine
“I’m bored.” (eg, lack of sensory stimulation)
• Maximize hearing and visual abilities (eg, keep external auditory canals free from cerumen plugs, ensure glasses and hearing aids are worn, provide reading material of large print, soften lighting to reduce glare) • Play soft, classical music for auditory stimulation • Offer structured diversions (eg, outdoor activities)
“What are you doing to me?” (eg, personal boundaries are invaded)
• Avoid startling patients by approaching them from the front • Always speak before touching the patient • Inform patients what you plan to do and why before you do it • Allow for flexibility in patient care
“I don’t feel well.” (eg, a urinary or upper respiratory tract infection, metabolic abnormality, fecal impaction)
• Identify etiology through patient history, examination, possible tests (eg, urinalysis, blood work, chest x-ray, neurologic testing) • Treat underlying causes
“I’m frustrated—I have no control.” (eg, loss of autonomy)
• When possible, allow patient to make own decisions • Maximize patient involvement during personal care (eg, offer patient a washcloth to assist with bathing) • Treat patients with dignity and respect (eg, dress or change patient in private)
“I’m lost.” (eg, memory impairment)
• Maintain familiar routines • Label the patient’s room, bathroom, drawers, and possessions with large name signs • Promote a sense of belonging through displays of familiar personal items, such as old family pictures
“I feel strange.” (eg, side effects from medications that may include psychotropics, corticosteroids, beta-blockers, nonsteroidal antiinflammatories)
• Minimize overall number of medications; consider nondrug interventions when possible • Begin new medications one at a time; start with low doses, titrate slowly. Suspect drug reaction if patient’s behavior (eg, vocal) changes • Educate caregivers about patient medications
“I need to be loved!”
• Provide human contact and purposeful touch • Acknowledge or verify patient’s feelings • Encourage alternate, nonverbal ways to express feelings, such as through music, painting, or drawing • Stress a sense of purpose in life, acknowledge achievements, reaffirm the patient is still needed
92
Geriatric Nursing Volume 20, Number 2
patient has a diagnosis known to evoke pain, particularly if movement (eg, during personal care activities) precipitates aggressive behaviors,2 including vocalizations. Is your elderly patient expressing fatigue or irritability from lack of sleep commonly associated with changes in circadian rhythm? Sleep disturbances have been found to be a significant factor in a number of study patients considered vocally disruptive.3 Notably, fewer hours of sleep9 and interruptions of sleep from external cues1 have correlated positively to screaming. Can you associate your patient’s vocal behavior with a time period, an event, or an activity? Loud, busy, demanding environments may precipitate or intensify vocal outbursts in demented elders who cannot tolerate such sensory overload. Conversely, sensory deprivation (eg, auditory, visual, olfactory, tactile) also is stressful. Do vocalizations represent a compensatory effort to provide self-stimulation,3,8 self-nurturing,10 orientation to surroundings,10 or diversion? Are unmet emotional or social needs provoking vocal agitation? This neglect may explain perplexing vocal behaviors by demented elders who have depressed affect,1,9 are left alone,1,8 have weak social support systems,1,9 and are inactive.8,9 Is your patient voicing frustration, anxiety, or alarm from the loss of self-care skills or from environments perceived as unfamiliar or threatening? Demented elders may vocally protest if they sense violation of their personal boundaries.2,11 The greatest of these outbursts may be related to personal care, including bathing,1,3 dressing,2 toileting,1,2,8 and situations involving meals 3 or touch.1,2 Inappropriate, extreme, or needless use of medications may underlie some behavioral changes, including vocal behaviors, of your elderly, cognitively impaired patient. Strategies to prevent, reduce, or eliminate the occurrences of challenging vocal behaviors of cognitively impaired elders can be devised if the meaning of the behavior is understood. Table 2 provides examples.
CONCLUSION Reframing the vocalizations of elderly patients with dementia from disruptive behavior to a communication attempt may be tedious and challenging and may require a trial and error approach to uncover hidden meanings. However, the potential payoffs are enormous. Foremost, patients’ needs are more likely to be identified and met. Second, persistent vocal efforts by elderly patients may abate as such communication attempts become unnecessary. Finally, the overall quality of life may be improved for all—including family members, caregivers, and importantly, cognitively impaired elders.
Geriatric Nursing Volume 20, Number 2
Summary of Pertinent Points 1. Vocalizations, such as screams, curses, moans, groans, and verbal repetitiveness, occur often among cognitively impaired elders. 2. To help prevent, reduce, or eliminate occurrences, reframe vocalizations from disruptive behavior to a communication effort instead and probe for the underlying meanings. 3. Management strategies can be devised when the underlying meanings of vocal behaviors are understood. These approaches can relate to physiological or psychosocial needs, health problems, sleep/circadian rhythm disturbances, violation of personal boundaries, environmental/sensory stress, autonomy issues, and adverse effects from medications.
REFERENCES 1. Cohen-Mansfield J, Werner P, Marx MS. Screaming in nursing home residents. J Am Geriatr Soc 1990;38:785-92. 2. Ryden MB, Bossenmaier M, McLachlan C. Aggressive behavior in cognitively impaired nursing home residents. Res Nurs Health 1991;14:87-95. 3. Cariaga J, Burgio L, Flynn W, Martin D. A controlled study of disruptive vocalizations among geriatric residents in nursing homes. J Am Geriatr Soc 1991;39:501-7. 4. Ryan DP, Tainsh SMM, Kolodny V, Lendrum BL, Fisher RH. Noise-making among the elderly in long-term care. The Gerontologist 1988;28:369-71. 5. Kirshner HS, Bakar M. Syndromes of language dissolution in aging and dementia. Compr Ther 1995;21:519-23. 6. Bayles KA, Tomoeda CK, Trosset MW. Relation of linguistic communication abilities of Alzheimer’s patients to stage of disease. Brain and Language 1992;42:454-72. 7. Fuller BF, Horii Y, Conner DA. Validity and reliability of nonverbal voice measures as indicators of stressor-provoked anxiety. Res Nurs Health 1992;15:379-89. 8. Hallberg IR, Edberg A-K, Nordmark A, Johnsson K. Daytime vocal activity in institutionalized severely demented patients identified as vocally disruptive by nurses. Int J Geriatr Psychiatr 1993;8:155-64. 9. Cohen-Mansfield J, Marx MS. Relationship between depression and agitation in nursing home residents. Compr Gerontology 1988;2:141-6. 10. Zachow KM. Helen, can you hear me? J Gerontologic Nurs 1984;10:18-22. 11. Bridges-Parlet S, Knopman D, Thompson T. A descriptive study of physically aggressive behavior in dementia by direct observation. J Am Geriatr Soc 1994;42:192-7.
Acknowledgments: I wish to thank Muriel Ryden, PhD, RN, FAAN, long-term care professor at the University of Minnesota School of Nursing, and Beverly Nilsson, PhD, RN, department chairwoman of nursing at Augsburg College in Minneapolis, Minn., for their support in the preparation of this article. DIANE S. CLAVEL, RN, MSN, GNP, is a gerontologic nurse practitioner for Nursing Home Services in St. Paul, Minn. Copyright © 1999 by Mosby, Inc. 0197-4572/99/$8.00 + 0
34/1/97008
93
Vocalizations Among Cognitively Impaired Elders What Is Your Patient Trying To Tell You? Diane S. Clavel, RN, MSN, GNP
Abstract: Unpleasant vocalizations are prevalent among cognitively impaired elders and often are considered disruptive and problematic by their families and caregivers. However, another way to perceive such challenging vocalizations is as a communication attempt by these patients to make their needs and feelings known. This article identifies possible meanings underlying these vocal behaviors and suggests strategies to help reduce their occurrence. (Geriatr Nurs 1999;20:90-3)
90
Geriatric Nursing Volume 20, Number 2
S
creams, curses, moans, groans, and verbal repetitiveness are some of the vocalizations among cognitively impaired elders that can thwart patient care efforts and precipitate feelings of frustration, failure, anger, and exhaustion in caregivers. In short, they are disruptive and can adversely affect the quality of life for families, caregivers, and even the patients themselves. Such common vocal behaviors, their underlying meanings, and strategies to help reduce their occurrence are presented in this article.
PREVALENCE Studies have explored some of the vocalizations peculiar to cognitively impaired elders and help discern their prevalence. A survey by Cohen-Mansfield et al.1 found 25% of 408 nursing home subjects screamed four times per week or more. Ryden et al.2 looked at 124 cognitively impaired nursing home residents and found that of the 86.3% who had some type of aggression, 47.6% were verbally aggressive. A study of residents from two nursing homes by Cariaga et al.3 identified 76 (11%) as vocally disruptive; another study by Ryan et al.4 identified 31% of 636 long-term care residents as noise-makers. Despite these statistical variances, challenging vocalizations among demented elders are clearly widespread and often perceived as disruptive.
REFRAMING VOCALIZATIONS However, what is considered “disruptive” is an individual perception, and with knowledge, such perceptions can be changed. Reframing vocal behavior positively as a communication effort is a first step toward effective management. Progressive dementia invariably is associated with deteriorating language and communication skills.5 Research by Bayles et al.6 found that the greatest deteri-
Table 1. Strategies to Enhance Communication with Cognitively Impaired Elders • Establish eye contact • Sit in close, comfortable proximity to your patient • Assume your patient is better able to understand speech than express it • Always talk respectfully to your patient • Slow your rate of speech; use simple words and short sentences • Give your patient time to respond to your questions • Adapt a nonthreatening manner: try a gentle touch, talk with a low, reassuring voice • Remain calm and in control
Geriatric Nursing Volume 20, Number 2
oration in people with Alzheimer’s disease occurred when they suffered moderate to severe impairments in cognition. For demented elders, the diminishing ability to find words and speak in sentences consisting of complete thoughts, coupled with the increasing difficulty for their caregivers to understand them, may precipitate or escalate vexing and seemingly meaningless vocalizations. Are such vocalizations meaningless? Some research suggests not. A study by Fuller et al. 7 found that the perceived roughness of voice, “jitter,” was a valid and reliable indicator of stressrelated anxiety. Additionally, research by Hallberg et al.8 suggests that interpreting the vocal activity of demented elders as either a language of feelings—usually strong and negative (eg, anxiety, frustration, fear) but sometimes positive (eg, gratitude, comfort)—or as a language to meet activity needs is possible.
Loud, busy, demanding environments may precipitate or intensify vocal outbursts in demented elders who cannot tolerate such sensory overload. Conversely, sensory deprivation (eg, auditory, visual, olfactory, tactile) also is stressful.
DETECTIVE WORK: SO WHAT IS YOUR PATIENT TRYING TO TELL YOU? All behavior has meaning. Understanding the meaning behind vocal behaviors of demented elders requires strategies to enhance communication, as well as detective work on the part of caregivers. Table 1 outlines some of these strategies. Look for clues in the patient’s health history and physical assessment. Determine baseline behavior and the situations or context within which vocalizations occur. Especially important is to identify situations in which a patient seems quieter, more content. Attend to nonverbal cues (eg, facial expressions, posture, movements) that accompany vocalizations. Additionally, consider vocal tones and inflections. Is your demented elderly patient trying to communicate pain or discomfort that frequently accompanies an acute illness or a degenerative condition? Suspect pain if your
91
Table 2. Possible Meanings Underlying Challenging Vocal Behaviors of Demented Elders and Related Management Strategies Possible Underlying Meanings
Related Management Strategies
“I hurt!” (eg, from arthritis, fractures, pressure ulcers, degenerative joint disease, cancer)
• Observe for pain behaviors (eg, posture, facial expressions, and gait in conjunction with vocalizations) • Treat suspected pain judiciously with analgesics and nonpharmacologic measures (eg, repositioning, careful manipulation of patient during transfers and personal care, warm/cold packs, massage, relaxation)
“I’m tired.” (eg, sleep disturbances possibly related to altered sleep/wake cycle with day-night reversal, difficulty falling asleep, frequent night awakenings)
• Increase daytime activity and exercise to minimize daytime napping and promote nighttime sleep • Promote normal sleep patterns and biorhythms by strengthening natural environmental cues (eg, provide light exposure during the day, avoid bright, artificial lights at night); provide large calendars and clocks • Establish a bedtime routine • Reduce night awakenings: avoid excess fluids, diuretics, caffeine at bedtime; minimize loud noises; consolidate nighttime care activities (eg, changing, medications, treatments)
“I’m lonely.”
• Encourage social interactions between patients and their family, caregivers, and others • Increase time the patient spends in group settings to minimize time in isolation • Provide opportunity to interact with pets
“I need…” (eg, food, a drink, a blanket, to use the toilet, to be turned or repositioned)
• Anticipate needs (eg, assist patient to toilet soon after breakfast when the gastrocolic reflex is likely) • Keep patient comfort and safety in mind during care (eg, minimize body exposure to prevent hypothermia)
“I’m stressed.” (eg, inability to tolerate sensory overload)
• Promote rest and quiet time • Minimize “white noise” (eg, vacuum cleaner) and background noise (eg, televisions and radios) • Avoid harsh lighting and busy, abstract designs • Limit patient’s contacts with other agitated people • Reduce behavioral expectations of patient, minimize choices, promote a stable routine
“I’m bored.” (eg, lack of sensory stimulation)
• Maximize hearing and visual abilities (eg, keep external auditory canals free from cerumen plugs, ensure glasses and hearing aids are worn, provide reading material of large print, soften lighting to reduce glare) • Play soft, classical music for auditory stimulation • Offer structured diversions (eg, outdoor activities)
“What are you doing to me?” (eg, personal boundaries are invaded)
• Avoid startling patients by approaching them from the front • Always speak before touching the patient • Inform patients what you plan to do and why before you do it • Allow for flexibility in patient care
“I don’t feel well.” (eg, a urinary or upper respiratory tract infection, metabolic abnormality, fecal impaction)
• Identify etiology through patient history, examination, possible tests (eg, urinalysis, blood work, chest x-ray, neurologic testing) • Treat underlying causes
“I’m frustrated—I have no control.” (eg, loss of autonomy)
• When possible, allow patient to make own decisions • Maximize patient involvement during personal care (eg, offer patient a washcloth to assist with bathing) • Treat patients with dignity and respect (eg, dress or change patient in private)
“I’m lost.” (eg, memory impairment)
• Maintain familiar routines • Label the patient’s room, bathroom, drawers, and possessions with large name signs • Promote a sense of belonging through displays of familiar personal items, such as old family pictures
“I feel strange.” (eg, side effects from medications that may include psychotropics, corticosteroids, beta-blockers, nonsteroidal antiinflammatories)
• Minimize overall number of medications; consider nondrug interventions when possible • Begin new medications one at a time; start with low doses, titrate slowly. Suspect drug reaction if patient’s behavior (eg, vocal) changes • Educate caregivers about patient medications
“I need to be loved!”
• Provide human contact and purposeful touch • Acknowledge or verify patient’s feelings • Encourage alternate, nonverbal ways to express feelings, such as through music, painting, or drawing • Stress a sense of purpose in life, acknowledge achievements, reaffirm the patient is still needed
92
Geriatric Nursing Volume 20, Number 2
patient has a diagnosis known to evoke pain, particularly if movement (eg, during personal care activities) precipitates aggressive behaviors,2 including vocalizations. Is your elderly patient expressing fatigue or irritability from lack of sleep commonly associated with changes in circadian rhythm? Sleep disturbances have been found to be a significant factor in a number of study patients considered vocally disruptive.3 Notably, fewer hours of sleep9 and interruptions of sleep from external cues1 have correlated positively to screaming. Can you associate your patient’s vocal behavior with a time period, an event, or an activity? Loud, busy, demanding environments may precipitate or intensify vocal outbursts in demented elders who cannot tolerate such sensory overload. Conversely, sensory deprivation (eg, auditory, visual, olfactory, tactile) also is stressful. Do vocalizations represent a compensatory effort to provide self-stimulation,3,8 self-nurturing,10 orientation to surroundings,10 or diversion? Are unmet emotional or social needs provoking vocal agitation? This neglect may explain perplexing vocal behaviors by demented elders who have depressed affect,1,9 are left alone,1,8 have weak social support systems,1,9 and are inactive.8,9 Is your patient voicing frustration, anxiety, or alarm from the loss of self-care skills or from environments perceived as unfamiliar or threatening? Demented elders may vocally protest if they sense violation of their personal boundaries.2,11 The greatest of these outbursts may be related to personal care, including bathing,1,3 dressing,2 toileting,1,2,8 and situations involving meals 3 or touch.1,2 Inappropriate, extreme, or needless use of medications may underlie some behavioral changes, including vocal behaviors, of your elderly, cognitively impaired patient. Strategies to prevent, reduce, or eliminate the occurrences of challenging vocal behaviors of cognitively impaired elders can be devised if the meaning of the behavior is understood. Table 2 provides examples.
CONCLUSION Reframing the vocalizations of elderly patients with dementia from disruptive behavior to a communication attempt may be tedious and challenging and may require a trial and error approach to uncover hidden meanings. However, the potential payoffs are enormous. Foremost, patients’ needs are more likely to be identified and met. Second, persistent vocal efforts by elderly patients may abate as such communication attempts become unnecessary. Finally, the overall quality of life may be improved for all—including family members, caregivers, and importantly, cognitively impaired elders.
Geriatric Nursing Volume 20, Number 2
Summary of Pertinent Points 1. Vocalizations, such as screams, curses, moans, groans, and verbal repetitiveness, occur often among cognitively impaired elders. 2. To help prevent, reduce, or eliminate occurrences, reframe vocalizations from disruptive behavior to a communication effort instead and probe for the underlying meanings. 3. Management strategies can be devised when the underlying meanings of vocal behaviors are understood. These approaches can relate to physiological or psychosocial needs, health problems, sleep/circadian rhythm disturbances, violation of personal boundaries, environmental/sensory stress, autonomy issues, and adverse effects from medications.
REFERENCES 1. Cohen-Mansfield J, Werner P, Marx MS. Screaming in nursing home residents. J Am Geriatr Soc 1990;38:785-92. 2. Ryden MB, Bossenmaier M, McLachlan C. Aggressive behavior in cognitively impaired nursing home residents. Res Nurs Health 1991;14:87-95. 3. Cariaga J, Burgio L, Flynn W, Martin D. A controlled study of disruptive vocalizations among geriatric residents in nursing homes. J Am Geriatr Soc 1991;39:501-7. 4. Ryan DP, Tainsh SMM, Kolodny V, Lendrum BL, Fisher RH. Noise-making among the elderly in long-term care. The Gerontologist 1988;28:369-71. 5. Kirshner HS, Bakar M. Syndromes of language dissolution in aging and dementia. Compr Ther 1995;21:519-23. 6. Bayles KA, Tomoeda CK, Trosset MW. Relation of linguistic communication abilities of Alzheimer’s patients to stage of disease. Brain and Language 1992;42:454-72. 7. Fuller BF, Horii Y, Conner DA. Validity and reliability of nonverbal voice measures as indicators of stressor-provoked anxiety. Res Nurs Health 1992;15:379-89. 8. Hallberg IR, Edberg A-K, Nordmark A, Johnsson K. Daytime vocal activity in institutionalized severely demented patients identified as vocally disruptive by nurses. Int J Geriatr Psychiatr 1993;8:155-64. 9. Cohen-Mansfield J, Marx MS. Relationship between depression and agitation in nursing home residents. Compr Gerontology 1988;2:141-6. 10. Zachow KM. Helen, can you hear me? J Gerontologic Nurs 1984;10:18-22. 11. Bridges-Parlet S, Knopman D, Thompson T. A descriptive study of physically aggressive behavior in dementia by direct observation. J Am Geriatr Soc 1994;42:192-7.
Acknowledgments: I wish to thank Muriel Ryden, PhD, RN, FAAN, long-term care professor at the University of Minnesota School of Nursing, and Beverly Nilsson, PhD, RN, department chairwoman of nursing at Augsburg College in Minneapolis, Minn., for their support in the preparation of this article. DIANE S. CLAVEL, RN, MSN, GNP, is a gerontologic nurse practitioner for Nursing Home Services in St. Paul, Minn. Copyright © 1999 by Mosby, Inc. 0197-4572/99/$8.00 + 0
34/1/97008
93