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1 CRITICALLY APPRAISED PAPER (CAP) Park, H., Chun, Y., & Gang, M. S. (2015). Effects of the Patient-Centered Environment Program on behavioral and emotional problems in home-dwelling patients with dementia. Journal of Gerontological Nursing, 41(12), CLINICAL BOTTOM LINE The Patient-Centered Environment Program (PCEP) incorporates the use of visual, auditory, olfactory, and tactile stimuli in the room of a person with dementia. The PCEP was developed and administered according to the patient s preference. The present study revealed that PCEP may yield a decrease in agitation and pain among home-dwelling people with dementia. The authors found limited compelling evidence, however, regarding the effectiveness of PCEP in facilitating participation in activities of daily living (ADLs), sleep, and cognition and in decreasing stress among people with dementia. This lack of evidence suggests that PCEP should be used as a sole intervention only with caution. Therefore, occupational therapists should explore other evidence-based environmental-modification interventions to use in combination with or in place of PCEP when the outcomes of interest are ADLs, sleep, stress, or cognition. It must also be noted that PCEP requires that a person with dementia express his or her preferences; thus, it might not be readily applicable to a person with dementia who cannot do so. Such a challenge may be the case for people who are in the later stages of dementia. Moreover, the study had a limited sample size, and the type of setting was specific to participants home; thus, results must not be readily generalized to the wider dementia population or to application in other care settings. Occupational therapists may make informed decisions in light of this study for patients with dementia who exhibit agitation and pain and who can express their choices. For example, occupational therapists may incorporate PCEP into their assessment by asking the patient s preferences regarding various stimuli. The occupational therapist may include the results in the patient s occupational profile and consider them in treatment planning. Consequently, occupational therapy may suggest modifications in the home environment of the patient that 1

2 might decrease agitation and pain. RESEARCH OBJECTIVE(S) Investigate the effects of the PCEP on agitation, cognition, stress, pain, sleep, and ADLs on home-dwelling patients with dementia DESIGN TYPE AND LEVEL OF EVIDENCE Level III: Pre- and posttest design PARTICIPANT SELECTION How were participants recruited and selected to participate? The participants were recruited from two health centers in South Korea. The authors did not specify the method of recruitment. Inclusion criteria: Participants needed to be 60 years or older; be diagnosed with dementia; live at home; show agitation more than once a week, on the basis of the Cohen Mansfield Agitation Inventory; have a family member who could discuss patient information; and be able to describe a preferred environment. Exclusion criteria: No exclusion criteria were mentioned in the study. PARTICIPANT CHARACTERISTICS N= 9 #/ % Male: 2/22% #/ % Female: 7/78% Ethnicity: Not reported Disease/disability diagnosis: Dementia (7 participants had Alzheimer s disease, and 2 were specified as other) INTERVENTION AND CONTROL GROUPS 2

3 Group 1: Intervention group Brief description of the intervention The principal investigator developed a questionnaire that examined the patient s preferences on the following aspects of his or her environment: visual area light, wall color, pictures (e.g., of flowers or family); auditory area music, nature, birds, water sounds; olfactory area aromas, ventilation, flowers; tactile area rubber clay, beads for stringing, origami, oil, fur, round stones, grain; On the basis of the patient s responses to the questionnaire, the investigator developed a PCEP (i.e., preferred environment setup) specific to a patient. The intervention was administered according to the patient s time preference. For the visual area, most participants opted to see flowers, landscapes, and family portraits. For the auditory area, participants chose to listen to teuroteu music and gospel music. For the olfactory area, most participants preferred aromas such as lavender, chamomile, or rose. For the tactile area, most participants liked kneading rubber clay. How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? 9 participants The patient s personal room The principal investigator and two research assistants Twice per week, 30 minutes per session 16 sessions over 8 weeks INTERVENTION BIASES (Check yes or no, and include a brief explanation) Contamination: The study only included one group. Co-intervention: Seven of the participants were not receiving medication related to dementia, but 2 of the participants were receiving Aricept. In light of this, some of the 3

4 Timing of intervention: Site of intervention: participants received intervention other than the PCEP, which could have affected the outcome. The authors did not indicate whether the participants received nonpharmacologic intervention (e.g., therapy) other than the PCEP. The authors chose the 30-minute duration in light of patients limited attention span, and they decided on 16 PCEP sessions over an 8-week duration in alignment with prior studies. The authors did not, however, consider how the progressive nature of dementia might have affected the performance of the participants in the span of 8 weeks. The intervention was administered in the participants personal rooms. Use of different therapists to provide intervention: The principal investigator and two research assistants administered the intervention. The use of three researchers in administering the intervention might have resulted in an inherent bias. Baseline equality: Although the researchers indicated the characteristics of the participants (e.g., age, gender, diagnosis, duration of dementia), they did not indicate whether there was any equality in terms of the outcome of interest (e.g., ADL status). Thus, some of the participants might have had higher or lower scores since baseline, which might have affected the outcome scores. MEASURES AND OUTCOMES Measure 1: Cohen Mansfield Agitation Inventory Name/type of reliable (as reported in the article)? valid ( article)? Cohen Mansfield Agitation Inventory Agitation First 30 minutes prior to the PCEP, and 30 minutes after the PCEP was administered for the 16 sessions Measure 2: Korean Mini-Mental State Examination 4

5 Name/type of valid Korean Mini-Mental State Examination Cognition At baseline and the final session Measure 3: Modified Pain Assessment in the Dementing Elderly Name/type of valid Modified Pain Assessment in the Dementing Elderly Pain Measure 4: Korean ADL Name/type of valid Measure 5: Daily log First 30 minutes prior to the PCEP, and 30 minutes after the PCEP was administered for the 16 sessions Korean ADL ADLs At baseline and the final session 5

6 Name/type of valid Daily log Sleep The sleep log was completed every day. The first log was the night prior to PCEP, and the last log was the night on the day of the PCEP. Measure 6: Gamma counter Name/type of valid Gamma counter Stress At baseline and the final session MEASUREMENT BIASES Were the evaluators blind to treatment status? Was there recall or memory bias? The authors did not indicate that the assessors were blinded. The outcomes that were assessed inherently did not require recall from the participants. RESULTS Agitation 6

7 The mean level was 2.42 at pretest and decreased to 1.56 at posttest. The difference was significant (p <.02). Cognition The mean level was 12 at pretest and at posttest. The difference was not significant. ADLs The mean level was 9.22 at pretest and 8.78 at posttest. The difference was not significant. Pain The mean level was 1.89 at pre-test and decreased to 1.16 at posttest. The difference was significant (p <.002). Sleep The number of sleep hours was 7.18 before PCEP administration and increased to 7.31 after PCEP administration. The difference was not significant. Stress The stress level was 0.01 at pretest and 0.01 at posttest. Thus, there was no change. Was this study adequately powered (large enough to show a difference)? The sample size of the study was small. Were the analysis methods appropriate? Although the researchers did not indicate the basis for their choice of analysis method, the method seemed to be appropriate in light of the study objectives. Were statistics appropriately reported (in written or table format)? The statistics were written in text and in table format. Was participant dropout less than 20% in total sample and balanced between groups? YES NO No dropout w study. What are the overall study limitations? The study is limited by its small sample size. Moreover, the assessors were the investigators of the study and were not blinded, which could have resulted in an assessor bias. The researchers also did not indicate whether the participants showed baseline equality, which might have 7

8 affected the pretest and posttest scores. CONCLUSIONS PCEP caused improvement in the participants agitation and pain. This work is based on the evidence-based literature review completed by Janel Anne Belarmino, OTR/L, and Sarah Smith, DSc, OTR/L, faculty advisor, Creighton University. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: 8

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