Letter to the Editors: Nonpharmacologic Interventions for Verbal Agitation and Disruptive Vocalization

      Graphical abstract

      Dear Editors,
      It is always useful to remind practitioners that nonpharmacologic interventions are most effective for the treatment of neuropsychiatric symptoms of dementia, and the review in the recent issue of Caring (2020;21[2]:19) provides excellent guidance. However, the summary table appears to address only evidence from randomized controlled trials (RCTs) on treatment of verbal agitation, sometimes called disruptive vocalization, and it states there are “no effective interventions.” There are no RCT results for treatment of this condition because, fortunately, it is relatively rare. However, loud vocalization can cause significant disruption, affecting residents, staff, family members, and visitors. We would like to alert readers to two case studies describing an effective treatment for disruptive vocalization and suggest one simple, effective intervention.
      The first case was that of Evelyn, a woman who had lived in a facility for nine years (J Gerontol Nursing 2012;38:52–56). She was originally admitted after breaking her hip, and she was a pleasant person with only mild memory loss. However, as her cognitive impairment worsened, she became a very difficult person to care for. She began to resist all attempts to provide personal care, especially bathing. Evelyn spent most of her time in her wheelchair, speaking to her clenched fist. Her speech would become distraught as she described horrific situations that she remembered from her work as a police dispatcher. Several medications were attempted to wipe away terrible images she experienced in her job, but none of them were effective.
      The second case involved Agnes, who had moved into the facility several years before with her husband, who subsequently died (Ann Paliat Med 2017;6:405–407). The couple had no children, and Agnes never received any visitors. She would cry, “Help me, help me” incessantly, and sometimes, “My head hurts.” No consolation or offers of help were effective in stopping these vocalizations. Several medications were tried, but none were effective. Her vocalizations decreased somewhat only when somebody was sitting beside her. Because the other residents found Agnes’s cries upsetting, she was rarely brought to an activity. Most of the time Agnes was placed in front of a nurse’s station where she could be observed. She also did not like to be touched, and several aides were needed for her bath.
      Both facilities where Evelyn and Agnes lived established a new program for residents with advanced dementia called Namaste Care (Simard, The End-of-Life Namaste Program for People with Dementia, 2nd ed., Health Professions Press, 2013). This group activity program was designed for residents who were no longer benefitting from the usual activities because of progression of their dementia. In a Namaste Care room, a calm environment is maintained with relaxing music and pleasant scents permeating the air. An unhurried, loving touch approach to all interactions is provided by dedicated staff. Although Evelyn and Agnes were not considered ideal program participants because their vocalizations could disrupt the calm environment, the staff members had seen the beneficial effect of Namaste Care for other residents and were desperate to help Evelyn and Agnes as well.
      When Evelyn was brought to the Namaste Care room, she was offered some baby roses. To everyone’s surprise, Evelyn stopped talking, took the roses, and smelled them. After Evelyn offered the roses to the Namaste Carer, she yanked them back and hit herself in the face — then, surprisingly, she laughed, which she had not done in months. After Evelyn had continued her daily sessions in the Namaste Care room, she retreated less and less into her life as a police dispatcher and was mostly quiet except for conversations with staff members. At one point Evelyn asked for some books to look through; she wanted them to be wrapped in brown paper because she enjoyed the process of unwrapping them. Another day, she asked the staff member to buy her a teapot, which prompted stories about tea parties she had hosted in her younger days. Evelyn changed from a deeply disturbed woman who did not like to be touched into one who not only enjoyed being touched but occasionally offered to massage the arms of the staff. The staff proclaimed this change to be a true miracle!
      Another miracle occurred with Agnes — her behavior changed immediately after being brought to the Namaste Care room: she stopped crying out, “Help me!” The staff were very gentle with her, and they welcomed Agnes to the group. They transferred her from her wheelchair into a comfortable recliner, gently tucked a soft blanket around her, and offered her coffee with cream and sugar, her favorite drink. She would sip it silently, observing the other residents. In the last months of her life, Agnes continued her Namaste sessions. Comfortably seated in the Namaste room, she allowed staff to give her hand massages and fuss with her hair, and she almost never cried out. Agnes also stopped resisting care, possibly because the gentle touching she received in her Namaste Care sessions had made her less afraid during personal care. Agnes became the favorite resident of one staff member; when Agnes was dying, the staff member would return to the facility after her shift had ended to sit by Agnes’s bed and gently talk to her until she died.
      Another pleasant surprise happened with a resident who would constantly cry out, “I want to go home.” Again, there was no medication or consoling that would stop her vocalizations. When she was initially brought to the Namaste Care room, she continued to tell staff over and over that she wanted to go home. However, her cries stopped when she was offered — and she accepted — a lollypop. When she finished the lollypop, she would cry out again until she was given another lollypop. This simple intervention allowed her to become accustomed to the Namaste Care room, and she eventually stopped asking to go home, even without the lollipop intervention.
      Of course, these cases provide only a few examples of the amazing changes that have occurred when residents with verbal agitation and disruptive vocalization are brought into the Namaste Care program. Some residents who had rejected personal care before attending Namaste Care continued to accept touch after they left the program. Their time in the Namaste Care room provided a “trickle-down effect” to other personal care, which was a welcome change for the staff.
      Conflict of Interest: Ms. Simard published a book describing Namaste Care.