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Running head: Diversional Activities for Hospitalized Patients with Dementia

Evidence Based Practice


Diversional Activities for Hospitalized Patients with Dementia
Western Washington University
Kami Alexander RN, Lindsey Helms RN, Hannah Mckenzie RN, and Christan Mulder RN
March 7, 2016

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Abstract

Purpose: The purpose of this literature review is to examine the impact of diversional activities
on unwanted behaviors in hospitalized patients with dementia.
Background: Patients with dementia are admitted to hospitals frequently, and are at an increased
risk of adverse events such as falls and functional decline, leading to longer stays. Current
standards of care for hospitalized dementia patients include pharmacological interventions,
restraints, and 1:1 patient care attendants (PCA). The current standards of care are not adequately
meeting the needs of this patient population.
Methods: A literature review was conducted using previously published studies including
sixteen mostly qualitative articles. The database CINAHL was utilized for research purposes.
Key words searched include: Diversional activities, dementia, and activity therapy.
Results: There is little research to support the use of diversional activities in hospitalized
dementia patients. Research yielded three common themes including doll therapy, purposeful
activity and the use of music.
Implications: The use of diversional activities are appropriate when indicated, and are shown to
be effective in decreasing occurrences of unwanted behaviors in patients with dementia.
Education is critical in order to increase use of diversional activities within the hospital setting.
Staff must have the proper education and training in order to facilitate use of the activities.

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Introduction

There is growing concern for older adults requiring hospitalization within an acute care
setting. Research shows that the acute care setting is not the best environment for older adult
patients, especially when they have a diagnosis of dementia (Weitzel et al., 2011). Although less
than ideal, hospitalization may be required when advancing age begins to take a toll on body
functions.
It is estimated that about a quarter of hospitalized patients over the age of 75 have a
diagnosis of dementia, and this number is expected to double over the next 30 years (Weitzel et
al., 2011). When these patients are hospitalized there is an increased risk of adverse events such
as delirium, falls, poorly managed pain, and overall unmet needs (Weitzel et al., 2011).
Additionally, Sampson et al., (2014) notes that patients with dementia are at increased risk for
functional decline while hospitalized which can lead to a longer length of stay. Research
suggests that being in an unfamiliar environment is distressing to a patient with dementia, and
leads to increased confusion, delirium, agitation, and aggression (Sampson et al., 2014). The
issue is compounded by staff lacking specialized training, and a hospital environment that is
unprepared to meet the needs of dementia patients. Weitzel et al., (2011) believe that all staff
working in facilities providing care for dementia patients need to learn how to interact
effectively. Pharmacological therapy is often used as an intervention for unwanted behaviors in
hospitalized patients with dementia (Bradas & Mion, 2011). However, currently there are no
medications The US Food and Drug Administration has approved for treating agitation in
dementia patients. Antipsychotics and anxiolytics are frequently used to combat these behaviors,
and are associated with adverse side effects including over sedation or prolonged sedation,
tardive dyskinesia, and dizziness that often contributes to falls (Bradas & Mion, 2011).

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For years extended care facilities and specialized dementia care units have been
incorporating the use of diversional activities for patients with dementia. Given the increasing
number of patients with dementia requiring care in an acute setting, diversional activities have
potential to be an effective within solution. This research utilization paper will examine the
effects of diversional activities, and create evidence-based recommendations for the hospitalized
patient with a co-occurring diagnosis of dementia displaying unwanted behaviors. Specifically,
research was conducted with the goal of examining how diversional activities impact patients
stay in comparison to current standards of care. For the purpose of this research utilization paper,
the term diversional activities is defined as an activity designed to divert an individuals attention
away from a current feeling or activity to a new activity (Fitzmimmons, Barba, & Stump, 2015).
Three common themes are present in the literature, which include the use of doll therapy,
purposeful activity, and music therapy to combat unwanted behaviors. Purposeful activities are
individualized to each patient, and can be defined as an activity that gives the patient a sense of
purpose in their daily life (Roach & Drummond, 2014). Current standards of care for the purpose
of this paper will include 1:1 patient care attendants (PCA), pharmacological therapy, and the use
of restraints.
Methods
A literature review was conducted using previously published studies including, sixteen
mostly qualitative articles found on the database CINAHL. The specific goal of the research is to
examine how diversional activities impact length of hospital stay compared to current standards
of care for hospitalized patients with dementia. The research gathered has been compared to a
pilot program currently taking place at PeaceHealth St. Joseph Medical Center (SJMC) on the
Medical Care Unit (MCU). This pilot program pairs diversional activities based on patients

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remaining cognitive ability and the presenting behaviors, with staff training, in an effort to
reduce patient length of stay and increase caregiver and patient satisfaction.
Synthesis of the Literature
Doll Therapy
A literature review conducted by Sue Hahn (2015) cites doll therapy as an alternative
intervention for patients with dementia. It is described as, a dynamic intervention between the
older adult, the doll, and other people to achieve benefits including improved communication,
social connectedness, calming effects and a reduction in socially inappropriate behaviors,
(Hahn, 2015, pg. 17). Although this intervention does have positive outcomes with some
patients, professionals have criticized it in the past for jeopardizing the dignity of older adults by
making them seem like infants. Criticism of doll therapy includes leading the patient to believe
that the doll is a real baby. While this might seem cruel or unethical, Hahn (2015) believes that
the benefits outweigh the risks. If the use of doll therapy with dementia patients prevents
physical abuse and emotional outbursts then perhaps one can conclude that the patients dignity
is maintained (Hahn, 2015).
The positive outcomes of doll therapy include a reduction in signs of anxiety, agitation,
and the need for attachment; and in one study over two-thirds of the staff reported improvement
in residents well-being after the implementation of doll therapy (Hahn, 2015). As with many
diversional activities, doll therapy is utilized in extended care settings, and has been written
about for many years. However, it lacks a good body of systematic research to support evidenced
based practice. Hanh (2015) suggests that despite having an inadequate body of research to
support the use of doll therapy, it will not inflict harm on patients. It is recommended to carefully

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evaluate patients when implementing this therapy, and let the patient guide the use of dolls to
maintain their respect and dignity (Hahn, 2015).
Purposeful Activity
In addition to doll therapy there is a variety of literature suggesting that hospitalized
patients with dementia need some kind of purposeful and stimulating activity. One pilot study
looked at how the implementation of specific Simple Pleasures interventions affected the use of
medications and restraints (Wierman, Wadland, Walters, Kuhn & Farrington, 2011). Simple
Pleasures is a set of interventions normally practiced in the nursing home setting, where patients
are evaluated based on their remaining cognitive abilities and engaged from a tactile perspective.
In this pilot study, researchers gathered information about patients from their nursing home or
previous living situation, as well as family if they were available. The patients were assessed in
regards to hearing, vision and cognition. Upon completion of the assessments, interventions were
implemented to target specific behaviors. For example, a patient who expressed agitation by
pulling at medical devices would be given an activity apron or sensory vest. Patients who
displayed behaviors such as rummaging and wandering would be given a treasure chest of sorts.
In the nursing home setting Simple Pleasures has been shown to improve patient and family
satisfaction and decrease agitated behaviors. The participants were evaluated by a geriatric
specialist at regular intervals to assess the effectiveness of the interventions. Although the
research was unable to produce statistically significant results, the staff participating in the study
expressed positivity in regards to having a better understanding of caring for dementia patients.
There were also trends in the research that showed a decrease in agitation after the
implementation of the intervention. Despite the fact that the results of the study were statistically
insignificant, the hospital that piloted the study disseminated the results and implemented the

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interventions facility wide. Once again, this intervention was implemented because it had no
adverse effects on patients and appeared to improve patients symptoms of anxiety and agitation
(Wierman et al., 2011).
Other research suggests that patients with dementia appear to experience improved
outcomes from involvement in meaningful activity (Benbow, 2014). The authors describe
meaningful activity as activity that creates feelings of enjoyment, a sense of belonging, and
personal autonomy. The activities necessary to stimulate these feelings will be different for each
patient. Some recommendations made include opportunities to release energy such as folding
laundry or kneading dough. Other activities noted in the paper include task-oriented chores that
instill a sense of purpose, such as stamping envelopes or cleaning. Although this literature review
study is focused on residents in extended care facilities, the results can easily translate to acute
care facilities. For example, in regards to task related activities, positive effects seen are
engagement in an activity for an extended period of time. Many residents found the most
engagement with simple one on one social interaction (Benbow, 2014).
Delirium is a common complication in hospitalized patients, leading to further cognitive
decline, increased morbidity and mortality, and can often hinder placement in a long term care
facility if the effects of delirium cause unwanted behaviors (Palmer et al., 2014). Delirium may
take longer to resolve then the medical illness that precipitated the hospital admission.
Purposeful activity plays an important role in patients with dementia who also have delirium. By
providing patients with simulation and diversional activities it enables their mind to become task
focused, and often time the negative behaviors subside (Palmer et al., 2014).

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Music Therapy
Clair (2016) describes that music is a powerful tool for patients with dementia. Music has
been known to change moods and decrease agitation and anxiety in older adults with dementia.
Music triggers long term memories and can often evoke emotions both positive and negative.
Therefore, when using music therapy, it is important to observe the patient for signs of distress.
For some patients, certain music may remind them of a happy time during childhood, it can also
be associated with loss for others (Clair, 2016). The MCU at PeaceHealth SJMC is trialing the
use of Ipods as a diversional activity for patients with dementia. The Ipods are loaded with a
variety of music genres from different decades. As individuals progress into the later stages of
dementia and lose the majority of their remaining cognitive function, music from their childhood
appears to be the best option for engagement (Clair, 2016). A randomized controlled trial that
explored the effect of music on agitated behaviors and anxiety in older people with dementia
demonstrated that traditionally the symptoms of dementia have been managed through
pharmacological measures and the use of restraints (Cooke, Harrison, Moyle, Murfield, Shum,
2010). The study encourages researchers to search for alternative therapies and treatment; one
option being musical therapy (Cooke et al., 2010).
Barriers to Implementation and Gaps in Research
After reviewing the research it appears that one major barrier to the implementation of
diversional activities includes a lack of research specifically aimed at hospitalized patients. The
majority of research focuses on interventions intended for extended care facilities and special
care dementia units. However, given the fact that the population of hospitalized patients with
dementia is growing, there is a need for research to address the management of agitation and
other unwanted behaviors leading to negative outcomes. One reason for a lack of evidence is the

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difficulty in recruiting dementia patients for research studies (Park, 2015). Park (2015) explores
the fact that there is a lack of evidence about interventions aimed at specific stages of dementia,
making it difficult for providers to implement. Furthermore, there is no research addressing the
cost effectiveness of such interventions, and studies that do make suggestions about best practice
for dementia care do not report on costs (Park, 2015). Overall, there is a need for more and better
research surrounding diversional activities for dementia patients. Although studies show
conflicting levels of efficacy regarding implementation of diversional activities, the majority of
studies agree that it is worth a try to avoid the use of restraints and pharmacological
interventions.
The increased costs patients incur during lengthy hospital stays provide a motivating
factor for continued research in the study of diversional activities. A study done at Johns
Hopkins University showed that per capita hospital cost for patients with dementia was $17,542
compared to $13,552 for patients without dementia (Lyketsos, Sheppard & Rabins, 2000).
Studies focused on diversional activities show potential to decrease length of stay. However,
there is a lack of significant evidence that demonstrates the increased cost of caring for patients
with dementia.
Suggestions for Clinical Practice Change
A program launched to provide hospital staff members with continuing education to
address the growing concern of caring for patients with dementia yielded positive results
(Palmer, Lach, McGillick, Murphy-White, Carroll & Armstrong, 2014). The Dementia Friendly
Hospital Initiative (DFHI) was piloted in multiple phases with exercises and educational
activities for each group of participants. Five hospitals participated in the program with the
majority of those participants being Registered Nurses. After the program completion,

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participants were surveyed on how their attitude had changed in regards to caring for this
population, their confidence in providing care, and on new knowledge obtained. Overall
participants were pleased with the program and felt it provided them with powerful tools (Palmer
et al., 2014). The need for specialized dementia training is crucial. Nurses can be given all the
tools to provide safe and effective care but if they are not educated properly on utilizing tools
provided they often times are unsuccessful (Palmer et al., 2014). The number of hospitalized
patients with dementia is rising every year making it even more important that healthcare
workers are being properly trained and educated on caring for this special population of
patients.
At PeaceHealth SJMC the current standards of care include the use of PCA, restraints,
and pharmacological therapies, which are utilized as interventions at many hospitals around the
country. The current research suggests that the pilot program started on MCU is moving in the
right direction for best practice in dementia care. The pilot program includes a cabinet filled with
equipment used as a resource to create diversional activities. This cabinet was developed by a
nurse educator within the hospital who then created a class for caregivers that was specifically
focused on dementia care and how to utilize the cabinet activities depending on which stage of
dementia the patient is at. The caregivers on MCU including all nursing assistants and Registered
Nurses attended the class. Currently in the cabinet there are multiple items and activities that are
supported by the literature including dolls, Ipods with a variety of music from different genres,
and items that may be utilized to provide purposeful activity such as envelopes and paper, play
tools, and sewing items.
Suggestions for change include implementation of diversional activity cabinets on all
hospital units that care for this client population, and mandatory education including the

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specialized dementia class for all Peacehealth caregivers. Education is a critical component in
caring for patients with dementia. Despite the best intentions, without the appropriate training,
caregivers lack the skills necessary to safely and effectively work with this patient population.
This is especially critical when the role of a PCA is necessary, as a caregiver with the right tools
is likely to help implement diversional activities successfully to decrease unwanted behavior.
Often times the person providing direct care for this patient lacks the specialized education
necessary to manage the challenging behaviors. The literature indicates that education is key, and
it is recommended that all employees receive additional training; this should begin with all
PeaceHealth caregivers attending the Advanced Care of the Dementia Patient class.
Evaluation Plan
The development of a diversional activity evaluation tool can aid in the measurement of
patient and staff satisfaction, and strive to eliminate barriers to discharge. Due to the inability of
dementia patients to self-report, a tool to measure unwanted behaviors and success of
interventions would need to be objective so that it can be utilized by caregivers. The evaluation
tool needs to be used at consistent intervals to assess the effectiveness of the diversional activity.
When dementia patients are admitted to the hospital from their previous homes,
placement becomes increasingly challenging if the patient has required a PCA, pharmacological
interventions, or restraints to reduce unwanted behaviors, regardless of being medically clear. In
other words, the patients unwanted behaviors become a barrier to discharge. By measuring
length of stay past when the patient has been medically cleared, SJMC can evaluate the efficacy
of diversional activities and specialized staff training. However, when looking at length of stay,
outside factors must be taken into consideration. Frequently in Whatcom County, skilled nursing
facilities either do not have beds, or do not have the appropriate resources to accept a patient the

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day they are ready for discharge. By controlling for extraneous factors such as this, the effects of
diversional activities and increased staff training can be estimated with more precision. After
implementation of the pilot program at SJMC, evaluation could focus on the difference between
lengths of stay on MCU compared to other units where dementia patients reside for medical
stays.
A study done in Australia directly correlates dementia patients with increased length of
stay but also acknowledges extenuating factors such as marital status, gender, type of illness and
the severity of that illness (King, Jones & Brand, 2006). Another study in the UK found that
there is not a significant difference in length of stay between dementia patients in a unit with
staff who are specially trained versus a unit without specially trained staff (Clinical Digest,
2015). However, the patients level of happiness significantly increased along with family
member satisfaction. This experiment failed to mention criteria for discharge, which may be
significantly different for SJMC. The increased satisfaction levels between patients and families
in this study indicate that diversional activities are successful (Clinical Digest, 2015).
Prior to the implementation of the SJMC pilot program, a PCA, pharmacological
interventions, and restraints were used to reduce unwanted behaviors. SJMC should examine the
effectiveness of PCAs with special training versus those without. If PCAs with extended
dementia training reduce unwanted behaviors then it may demonstrate that the extra education is
effective. All of the evaluation tools would need to be standardized and implemented as a SJMC
policy.
Conclusion
Hospitalization in an unfamiliar and fast paced environment leads to confusion and
agitation in dementia patients. Current research suggests the use of diversional activities such as

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doll therapy, purposeful activity, and music therapy are helpful in reducing unwanted behaviors
in dementia patients. The pilot program at SJMC is taking steps towards alleviating the unwanted
behaviors that often accompany hospitalization. The program needs to create a standardized
evaluation tool to monitor the effectiveness of staff training and diversional activities with
dementia patients. An evaluation tool would help SJMC to assess the effectiveness of specific
diversional activities, and assess whether this program is having a positive impact on length of
stay.
When placed in an unfamiliar environment with multiple stressors patients with dementia
are likely to act out and display unwanted behaviors that may hinder the discharge process. There
are many ways to ease anxiety and create a less formidable environment for this patient
population. Although there is a lack of statistically significant evidence that supports the use of
diversional activities, research concludes that use of the activities appear to be clinically
significant in regards to patient safety. Continued research is necessary to find best practice
guidelines for dementia patients in acute care settings. As long as the research remains ethical
and does not place this vulnerable population at risk, caregivers should continue to trial and
document the use of diversional activities as interventions.

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