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Negative Noise and Alzheimer's

Negative Noise

John Picker in his book "Victorian Soundscapes" Oxford University (2003) discussed noise. "The words noise and annoyance have similar origins: noise, after all annoys. That may even be a good definition. Noise annoys because it doesn't fit: it jars, disrupts, upsets. And it upsets because it can't be understood. There is no way to place noise in a preexisting sonic order, no way to relate it to other sounds that have meaning and sense. Harmony joins sounds; noise merely accumulates them." Picker's clever definition of noise also suggests why noise is a source of agitation to the Alzheimer's victim.

"Guidelines for Dignity" published in July 1992 after a three year study directed by the Alzheimer's Association noted: "Noise – Noise is distracting for residents. Reducing background noise provides a quiet surrounding, facilitates hearing and reduces agitation. It is important to note that noise sets the emotional tone of the environment and is controllable."

Matthew Rizzo, UI Professor of Neurology in a 1999 study of Alzheimer's tells us that "The Alzheimer's patients were abnormally sensitive to the presence of background noise." His tests of motion perception by Alzheimer's victims indicated that more than twice the motion signal was needed when there was background noise as compared to a control group.

World Alzheimer's Congress, July 14th 2000 – Presentations by Geri Hall, PhD, University of Iowa Center on Aging, and Cornelia Beck, RN, PhD, University of Arkansas School of Medical Sciences – "The best way to manage agitation is through environmental and atmosphere changes rather than medications....Modify the environment to reduce known stressors (...loud noises.) Responses to overwhelming or misleading stimuli: Excessive, noise, commotion or people can trigger agitation behavior...simplified approach to managing agitation behaviors can be summed up as "Modify the environment...studies show that playing calming music...can lead to a decrease in agitation. When used during meals soothing music can increase food consumption, when used during bathing, relaxing or favorite music can make it easier to give a bath. Experiment with relaxing, soothing classical, religious or period (..1920's or Big Band) music."

 

"Designing a Care Facility" (Alzheimer's and Dementia residents.) was published by the Alzheimer's Association in 2006. People with dementia have a decreased ability to deal with multiple and competing stimuli, and may be overwhelmed when there is too much activity in a setting. .....focus on minimizing those sources of stimulation that have a negative impact on residents...

Acoustic stimulation

1. Eliminate overhead public address (PA) systems.
2. Avoid playing music throughout the facility.
3. Minimize noise from necessary institutional support systems such as icemakers, carts and pill- crushers.
4. Enforce policies regarding care giving staff talking loudly to each other.
5. Regulate the amount of noise generated by group activities; activity rooms should have doors that can be closed or left open.
6. Utilize sound absorbing materials in public area.
7. Equip a few bedrooms with extra soundproofing for residents with disruptive vocalizations.
8. Use pleasing sounds as cues (bird songs as residents are rising, or singing show tunes or hymns before meals).

 

The British Alzheimer's Society Fact Sheet No. 509 (2008) discusses triggers for aggressive behavior: "They feel bewildered or anxious because there is too much noise, too many people around, or a change in a familiar routine."

The negative effect of noise on the Alzheimer's victim has been recognized for a long time by Alz-heimer's medical experts and professionals.

 

The current Alzheimer' Association's "Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes" (September 2006) Phase 1 and Phase 2 and the later Phase 3 End of Life Care (August 2007) is replete with admonitions against negative noise stimulation.

  1. "Distractions during meals should be limited by avoiding mealtime interruptions and by reducing unnecessary noise..."
  2. "Pleasant music and multiple opportunities to eat and drink, and also minimizes negative stimuli such as loud overhead paging and glare."
  3. "Hold an activity in a quiet room free of distractions or noise."
  4. "Environmental irritants – Excessive sound,... stimuli.."
  5. "Altering the environment for comfort, such as providing a calm environment, soft music..."
  6. "use a signal, such as a flower, to put on the door of the person who is actively dying to alert staff to be extra quiet in that area..."

 

 Minnesota Medicine, March 2008 containes two articles on health care environments and both discuss how negative noise will cancel out effect of creating "healing environnments."  

The first article "Therapeutic Responses to Natural Envirnoments -  Using Gardens to Improve Health Care" by Dr. Stephen Mitrione. Of particular interest was a the following discussion - "Natural environments have also been shown to be effective in long-term care facilities, particularly among patients with dementia. Violent behavior by residents with demential decreased when they had access to secure outdoor envirnoments." In a suggested outline of desing guidlines for such garden or envirnoment the following caution appears: "Minimize intrusive stimuli. Noise, odors, and bright light can cancel out the benefits of a garden. Thus it is important to place the garden away from these negatiave stimuli or to mitigate their presence in order for the garden to be effective."

The second article "Creating Optimal Healing Envirnoments in a Health Care Setting" by T. Zborowsky, R.. Ph.D., and M Kreitzer, Ph.D., R.N. discusses the design of a hospital with features that will promote healing by reducing stress and anxiety. The article is replete with references to the necessity of eliminating negative noise. The following is noted: "Thus, a noisy, confusing hospital room might leave a patient not only feeling worried, sad, or helpless but also might raise his or her blood pressure and heart reate and increse muscle tension. In addition, hormones relesed in response to stress could suppress the patient's immune system, causing wounds to heal more slowly." ..."Florence Nightingale spoke of the importance of natural light, fresh air, and quiet for healing..." "Much of this research has shown that the conventional way hospitals have been designed with their bland clolor shcemes, hallways that echo, cramped patient rooms, and loud, overhead paging systems, contributres to stress....can effect the productivity of staff."..."choose the music they want to listen to"..."Recent studies have shown that excessive noise, glare, and poor air quality can create stess...good design can dampen noise from paging systems, equipment, alarms, room-mates, and staff, making hospitalization less stressful and more restful for patients."..."Less Noise. Hospitals are attempting to both reduce the sources of noise (for example, by elininating overhead paging) and imporve soundproofing with sound absorbing ceilings and carpeting in order to reduce stress. Carpet alone can reduce ambient noise by up to 70%. Architencts are also attempting to reduce noise when designing a facilitiy's infrastructure by wrapping ducts, providing higher levels of soundproofing in the walls, and building walls to the deck of the floor above. Designerss are also paying attention to the location of pneumatic tube stations and ice makers, both of which can be sources of noise 24 hours a day."..."They also need smaller, quiet places where individuals can go off by themselves to find peace."

 

There are no dissenters to the idea/theory that noise has a negative affect on Alzheimer's and other dementia residents and patients. In spite of this universal agreement by professionals in the field that negative noise stimulation has an adverse effect on Alzheimer's patients and victims, there is an apparent disconnect. There is a disconnect with the application of this information to the Assisted Living and Nursing Home facilities that specialize in care of Alzheimer's and other dementia residents. The reasons for such disconnect are many and varied. Cost factors, convenience and expediency, ignorance and apathy are all at work in this end result.

In fact many such facilities come close to being places of "Bedlam" that would mimic the medieval English Royal Mental Hospital of the same name. The term "Bedlam" has come to be associated with unreasonably loud noise. A history of the institution tells us "Visitors were permitted to bring long sticks with which to poke and enrage the inmates." "The noise was so hideous, so great that they are more able to drive a man that hath his wits rather out of them." When I think of the number of Alzheimer's victims that were most probably and inappropriately a part of the residents at this institution, my mind is engulfed in sadness.

Agitation and Fear

We have certainly made progress since that dark time in history. We have eliminated the "sticks," increased the level of care and reduced the overall intensity of the noise. However, noise is still a major problem in nursing homes and is still is with us on a daily basis.

I recall a recent conversation with a nurse who told me that she could never recall working at a nursing home that did not have a noise problem. She further advised that for this reason she would never allow her own mother to be a resident in a nursing home.

I also recall the look of aghast one day when I suggested to an in house education director that signs saying "quiet" should be posted on the premises. It appears that nursing home staff members after a time become so hardened by the daily drumbeat of negative noise that they tend to tune it out and are no longer aware of it.

What is needed by nursing home staff members and administrators is the prayerful attitude of one of the Pastors (Harley) at my Redeemer Lutheran Church. "Lord let me be willing to be willing."

Sources of negative noise range from loud talking and shouting by nursing and medical staff members as well as family visitors who are ignorant of the negative effects of such noise. It may also result from inappropriate loud music, TV or radios. It frequently also results from loud negative vocalization by other residents. Sometimes it may result from noisy equipment operations.

Apparently intervention by the State Departments of Health is needed in order to solve this problem. There needs to be a focus on "Noise" by the Health Departments at the time of their survey's of the operations of Assisted Living and Nursing Homes. Appropriate citations need to be issued for negative noise problems with subsequent follow up for corrective action. My personal efforts with the MN Department of Health has thus far been totally futile!

The dimension to this problem is apparent when one considers that in 2006 it was estimated that 69% of all nursing home residents had some degree of cognitive impairment including 27% who had mild cognitive impairment and 42% who had moderate to severe cognitive impairment. In June 2007, 46.4 percent of all nursing home residents had a diagnosis of Alzheimer's or another dementia in their nursing home record. (Alzheimer's Association 2008.)

 

I wonder how many drugs could be eliminated and a better life provided if we would/could just provide a calm, quiet and soothing atmosphere that does not provoke agitation, fear or anxiety?

 

                                              (Blelow right photo is June at the Wellstead in November 6, 2005 .) June at the Wellstead November 2005

 Notes on June: I recall an incident during the first year that June was in a facility (Wellstead - 2005) and was still able to express herself. I remember mentioning to June when a resident was shouting, "He is really loud. " June's response was "Yes, and it goes on all the time!" I remember the feeling of guilt, shame and helplessness in that I had taken part in subjecting her to this form of abuse on a daily basis. Later (2006-2007) as her power of speech left her, I could still see her visibly startled by a jerk of her body when a resident would suddenly shout out loudly. Unfortunately, June is now (2008) so deep in the shadows of Alzheimer's that she normally shows no visible response to such daily negative noise. However, I cannot believe that this noise is not continuing to impact her in a negative way. It is of even greater concern to me now that I know that June can no longer understand why she is being subjected to this abusive noise. Her world is now one that is puzzling, strange and without recognizable friends or relatives. No wonder she sits with her eyes closed most of the time, drawing a curtain on a world she does not understand and where she feels she is a stranger.

A Typical Daily Incident: Sunday in late July 2008 - Noon time. An altercation between two residents. One resident who has a history of frequent loud shouts of "Hey" was doing so several times in a period of twenty minutes. Another resident who did not like the shouting, was in turn shouting back at the first abusive resident. This resident in turn became abusive by his manner of response. This resident was responding with a loud and a foul abusive mouth. This went on for five (5) response cycles. The staff seemed oblivious to it all. Staff is not trained to be responsive so it was apparently ignored. Neither of the residents could be blamed for their actions as in both cases it was the voice of Alzheimer's speaking. The effect on other residents must be significant. The affect on June who does not understand saddens me.

My efforts to do something about noise in nursing homes by working through the State Department of Health has been one of my most obvious failures!

 

Reader's Comments 

Marie Christine  - Mexico City, Mexico - (7 August 2012):  "Negative noise is bad for ALL beings, affected by alzheimer or not. I wish people could understand that very simple fact..."

Dianne Cogar  - Springfield, Ohio - (8 August 2012): "Stan, this problem is not just in Nursing homes. I have found health care professionals working in doctors offices, dental offices , clinics and more talking loudly and in excess with laughter, or chewing gum cracking bubbles , and having...out of hand social time with patients in the waiting rooms where there are people that are tense and in worry being there in the first place. There's a time and place for everything. I agree that a happy face makes for a calmer place...but please, keep the unnecessary Negative noise down... professionals chewing "gum", especially where it could be heard, should not be allowed around patients. It's absolutely annoying!!! And anyone "in the work force" using a cell phone as a social media should not be permitted as well! Don't even get me started!"

Lynette Richards  - Hindhead, United Kingdom - (9 August 2012): "In nursing homes there is often negative noise made by residents in mental distress. My relative was almost mute but his neighbour shouted "help" constantly...The man who shouted help all day was left alone to shout because no-one thought they could help him. But getting back to the point of your thread, my relative also had to endure the noise of resident's buzzers (alarms) that seemed to be going off constantly - I think his room was near the central control point. It was like bedlam in that particular home."

  

June's Passing 

June passed away from the complications of Alzheimer's disease on 23 October 2008 after a long and exhausting struggle of nearly eleven (11) years. 

June's funeral notice as printed in the Minneapolis Star Tribune following her death in October 2008 can be found on the top blue navigation strip under the label "In Memoriam" and on the drop down menu or click on below link:

"June K. (Rolstad) Berg - In Memoriam".