The effects of environmental barriers on the attention span of Alzheimer's disease patients Kevan H. Namazi, PhD Beth DiNatale Johnson, MA

Abstract Anecdotal evidence indicates that Alzheimer's disease patients often appear confused and unable to concentrate, and that this may be related to attention span. This study utilizes barriers ofthree differentheights to test how visual and auditory distracters affect the ability to concentrate on a given task. Residents were given art projects with adult themes and were observed for number of distractions. The results indicate that both low and high barriers are more effective than no barriers in screening out extraneous visual and auditory distractions. Of equal or greater importance is thefinding that residents in the early and middle stages of the disease averaged 16 minutes offocused attention in a 20minute trial. Introduction Alzheimer's disease (AD) is a progressive and debilitating neurological illness that afflicts nearly four million adults in the United States.' Although the range ofdeficits produced by AD is beginning to be understood, it is not yet known which types of therapeutic interventions are most effective in the support of intact abilities. Kevan H. Namazi, PhD, is Director of Research, Corinne Dolan Alzheimer Center,

Chardon, Ohio. Beth DiNatale Johnson, MA, is Research Associate, Corinne Dolan Alzheimer Center, Chardon, Ohio.

The American Journal of Alzheimer's Care and Related Disorders & Research, January/February 1992

The short-term memory loss common to individuals with AD is often characterized by the deterioration of physical and cognitive abilities. As the literature indicates, the AD patient becomes increasingly unable to make sense of the environment, and he/she is more likely to appear confused or distracted.2 This increased distractibility has been associated with attention deficits;3 however, the relationship between the two has not been clearly established. This study uses removable barriers of varying heights to measure the ability of AD patients to attend to a specific task which requires concentration and examines the relationship between visual and auditory distracters in the environment. Although anecdotal evidence has been a useful descriptive tool,4 the aim of this project is to provide empirical evidence for specific environmental interventions which benefit individual patients with AD. A second goal is to address some of the methodological questions posed in prior studies by focusing on a single modification to see if it encourages independence and supports remaining cognitive skills. Literature review In the simplest of terms, attention is the ability of the mind to concentrate on a single object or thought. This includes the ability to limit or screen out extraneous external and internal

stimuli and to focus on information which is relevant to the individual.5 To understand how the study of attention is relevant to the distractibility as-

Early studies on selective attention supported an age related increase in distractibility based on physical changes in the brain ... sociated with AD, it may be helpful to review the four component parts of attention described by McDowd and Birren5 which include divided, switching, sustained, and selective attention. These categories allow attention to be conceptualized as the ability: * To perform two tasks simultaneously; * To monitor two sources alternately; * To maintain performance on a task; and * To filter information. Early studies on selective attention supported an age-related increase in distractibility based on physical changes in the brain, whereas more recent work suggests that sensory changes may be responsible.5

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Although it is clear that the role of attention, particularly the ability to discriminate relevant from irrelevant auditory and visual information, is significant, it is not understood how atten-

It is still uncertain how personality, chemicals, illness, life style, or the environment can influence attentional functioning in either the cognitively intact or the demented population. tion is affected by AD.6 Among investigators who concentrate on AD re-

search, Nebes and Brady7 conclude that both focused and divided attention abilities are relatively unimpaired in AD patients, while Stuart-Hamilton8 concludes that selective attention skills are hindered by extra visual information. Recent inquiries into Alzheimer's disease and attention have explored the neuropsychological aspects of cognitive impairment,9 or the descriptive changes in attentional behavior.l0 Other studies have focused on selective attention deficits," drug therapy,'2 comparative deficits in visual and spatial learning,'3 and auditory impairment. 4 However, most of these studies are theoretical in nature, somewhat abstract, and ignore the role of other pertinent variables. It is still uncertain how personality, chemicals, illness, life style, or the environment can influence attentional functioning in either the cognitively intact or the demented population. Modifications to the environment offer a different research approach for supportive care of the easily distracted AD patient. For example, Cleary's4 work suggests that reduced stimulation units can help decrease agitation and distractibility. She theorizes that

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heightened perceptual sensitivities and the resultant confusion hinder the ability ofthe Alzheimerpatientto focus his/her attention on a task. Another approach recommends increased stimulation to help maintain cognitive reserves.15 Although Izumil6 explores the qualitative relationship ofenvironmental space to perceptions and social relationships, he does not document his assertions with quantitative data. Finally, in a comparative study of special units for dementia patients, Ohta'7 concludes that the wide variability in settings, philosophies, environments, and therapeutic approaches precludes any significant examination of the relationship between unit characteristics and patient benefit.

For example, Ckary s work suggests that reduced stimulation units can help decrease agitation and distractibility. Clearly, the literature is contradictory and lacks empirical research on specific environmental modifications which support AD patients. There are no studies that measure the environmental conditions under which attentional behavior is either improved or diminished. Nor are there studies which relate specific environmental alterations to apparent attentional changes at various stages of dementia. Methodology This project was conducted at the Corinne Dolan Alzheimer Center (CDAC), a facility designed to support the needs of long term AD patients in the early and middle stages of the disease. A letter describing the nature and the duration of this study was sent to the family or guardian of each resident. Pertinent project information and tentative schedules were given to staff so

that trials could be incorporated into the residents' daily activity plans. Researchers used input from supervisory staff and program coordinators who are responsible for individual residents, along with residents' scores on various neuropsychological tests, to determine which residents would be

likely participants. Residents were encouraged, but not required, to participate in the project, so that some degree of self-selection was implicit in the study. Because each subject acted as his/her own control, the need for matching within this highly diverse population was eliminated. Residents were assessed at the University Hospitals of Cleveland Alzheimer's Center for probable AD, and for disease severity. Ascore on the Clinical Dementia Rating (CDR) scale" was assigned. The CDR scores ranged from one to three, with higher scores indicating greater impairment. One component of the CDR score (see the introductory article in this series, Namazi et al.,'9) is the Mini-Mental State Examination (MMSE)l evaluation. Preliminary screening excluded residents with visual disturbances (n=l) and those unlikely to cooperate (n=7). Although 15 subjects were initially included in this quasi-experimental project, three were unable

There are no studies that measure the environmental conditions under which attentional behavior is either improved or diminished. or unwilling to complete the entire series of trials. The remaining 12 participants included two men and 10 women whose ages ranged from 67 to 89 with a mean of 79.4 years. Length

The American Journal of Alzheimer's Care and Related Disorders & Research, January/February 1992

Figure 1. A sample art project completed by a resident In CDR=1 group.

Figure 2. A sample art project completed by a resident in CDR=2 group.

utilizing barriers, the subject was seated with his/her back towards a closed opening, and the observer was seated to the left. No attempt was made to control for auditory distractions. The

of residence in the CDAC varied from 131 to 287 days with a mean of 227.7 days. In order to test the effects ofenvironmental barriers on attention, projects were selected that required concentration, but which did not test intellectual ability. A series of nine-inch by 14-inch color-by-number art projects with adult themes was selected. Art projects were put into three categories according to the complexity of the design as perceived by research staff. As originally planmed, residents in the CDR=1 group were free to select from any of 10 art projects. Residents in CDR=2 group were limited to seven of these art projects which were less complex, while residents in CDR=3 group had a choice of two projects which were the simplest. The single participant in this category (CDR=3) was reluctant and unable to engage in the art project, and consequently, coin sorting was substituted as an activity. Forthe othereleven subjects with a CDR=l or 2, the choices of art projects remained the same as indicated above (see Figures 1-3).

Setting Certain architectural features of the CDAC facilitate research by

The American Journal of Alzheimer's Care and Related Disorders & Research, January/February 1992

accommodating changes within the environment in the two mirror-image wings. Each wing has a separate kitchen and a central common space defined by movable railings. Supports within the floor enable staff to alter the position and height of interior partitions as needed. The common areas can be used for dining, socialization, and other structured activities (see Figure 4). Removable dividers between the central public areas and the surrounding circular corridor make it possible to examine the effects of different barrier heights on resident distractibility. Three barrier heights were tested: * Condition A - 78-inch barrier; * Condition B - 54-inch barrier, and * Condition C - no barrier. Condition A screened the subject so that no activity in the corridor was visible from a seated position. Condition B defined physical space, but did not exclude all visual distracters. Condition C provided neither spatial definition nor visual separation from the pathway, common area, or testing site. Portable screens made out of a neutral colored fabric were set up to create a defined testing area. During each trial

routine activities of other residents and staff continued in the common areas and along the pathway throughout the test trials. The trials were conducted over a period of four weeks. Barrier height was randomly assigned by specific day, time of day, wing location, and subject. Four trials were conducted at each barrier level so that each subject participated in 12 trials. The participants worked with a trained observer who noted each time the subject was distracted, the type of distraction, and the duration of the episode. Subjects were given initial instructions, but conversation with the observer during the trial was not encouraged. The observer also served as a model for the subject as he/she simultaneously worked on a similar but not identical project. Two subjects were tested during each 20 minute trial period. During each trial a monitor recorded all ongoing activities outside of the test site. This included potential outside visual stimuli and auditory stimuli measured in decibels. Figure 3. A sample art project completed by a resident In CDR=3 eroun.

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barrier), the average time was 1155

Figure 4. A central location for common area (within dark pathways) encourages flexible use.

seconds. Results indicate that residents were more distracted with no barrier than with either low or high barriers. In the no barrier condition there were 296

distractions, with outside audible (38 percent) and outside visible (39 percent) accounting for 77 percent of the total distractions. This is in sharp contrast to the high and low barrier conditions when distractions decreased by two-thirds or more. Exit from the test site occurred less than 3.4 percent

For purposes of this study, a distraction was defined as any resident behavior which interfered with his/her ability to attend to the task. An interruption of five seconds or less was not considered a distraction. This decision was based on the observation that simple acknowledgement of an external stimulus does not necessarily interfere with the ability to concentrate on a task. Likewise, conversation with the observer which was directly related to the task was also considered focused

No attempt was made to controlfor auditory distractions. attention. Distractions of more than five seconds were separated into the following seven categories: * Outside visible - a visible distraction originating outside of the test site. * Outside audible - an audible distraction originating outside of the designated area. * Outside talk- conversation initiated by someone outside the designated area which distracts the resident. * Resident talk (to outsider)conversation initiated by the resident to someone outside of

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of the time (see Table 1).

designated area, which distracts him/her from the task. * Resident talk (to observer) unrelated conversation initiated by resident which distracts from the task. * Resident leaves abrupt departure from the test site. * Internal- undetermined cause for distraction. Results The range of time spent working on the project was 85 to 1200 seconds with an average time of 1130 seconds (out of a possible 1200 seconds). Under the

Likewise, conversation with the observer which was directly related to the task was also considered focused attention.

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condition A (high barrier- 78

Under the low and high barrier conditions, there was a reduction in the overall number of auditory distractions despite the fact that no attempt was made to control for sound. Barriers which reduce visual stimuli appear to reduce the impact of auditory distractions. Although CDR scores were used in the planning stages of this study, the narrow range of one to three did not reflect adequate variability in the results. Therefore, MMSE20 scores,

inches),

the average amountof time spenton the project was 1164 seconds. Under condition B (low barrier- 54 inches), the average time decreased to 1146 seconds, while under condition C (no

Table 1. Barrier conditions and frequency of distractions.

Barrier Conditions No

Distraction Outside visible Outside audible Outsider talks to resident Resident talks to outsider Resident talks to observer Internal Resident leaves Total

High

Low

N

percent

N

percent

N

percent

115 112

38.9 37.8 6.1 3.4 9.5 3.4

15 42 4 3 27 7 2 100

15 42 4 3 27 7 2 100

4 36 3

4.6 41.4 3.4

1 32 8 3 87

36.8 9.2 3.4 100

18 10 28 10 3 296

100

The American Journal of Alzheimer's Care and Related Disorders & Research, January/February 199 2

For individuals in group 1, which contained the least impaired residents, the mean time-on-task increased nearly 30 seconds under both the low and high barrier conditions. Distraction time (time-off-task) was negligible. For residents in group 2, data show that barrier effectiveness is somewhat ambiguous. There was little difference between the no and low barrier conditions, and a substantial decrease

Table 2.Frequency and percentage of distractions under different conditions and by MMSE scores. No Group 1 Group 2 Group 3 Total *Missing data

N

percent

58 111 127 296

19.6 37.5 42.9 100.0

used and familiar to most professionals for evaluation of cognitive abilities, were used to determine if there were additional attentional differences. The residents were grouped into three subcategories based on MMSE scores. Group 1 included three residents with an MMSE score of 20. Group 2 included three residents with MMSE scores ranging from 14-16, and group 3 contained five individuals with MMSE scores of 10 or 11. The data on distractibility were cross tabulated with MMSE scores under each barrier condition.

Participants in this study exhibited remarkable ability to concentrate on the activity and sustain attention to the task throughout the test period. The results show that residents with lower MMSE scores (group 3) were more distracted than residents in the two other groups (see Table 2). As might be expected, under all three conditions, those residents in the more advanced stages of the disease had a higher incidence of distractions than those in the earlier stages. Under the no barrier condition, they were twice as likely

The American Journal of Alzheimer's Care and Related Disorders & Research, January/February 1992

Barrier Conditions Low N percent 9 25 65 99*

9.0 25.3 65.7 100.0

N

High percent

8 16 58 82*

9.8 19.5 70.7 100.0

to be distracted as the residents in group 1 (19.6 percent compared to 42.9 percent). An increase in the number of distractions, particularly in the category of "resident talks to observer," under the low and high barrier conditions, suggests that the observer-participant relationship may have been influenced by other psycho-social factors related to the privacy of the barrier. For the more highly functioning residents, both low and high barriers were effective in reducing the number of distractions and thereby increasing attention. For group 1 and 2, distractions were reduced by one-half under the low and high barrier conditions (X2=30.36, df= 4, P < .0001). A third finding of interest is related to the average amount of time spent on task. Contrary to anecdotal observations which report that reduced attention span is characteristic of AD patients, participants in this study exhibited remarkable ability to concentrate on the activity and sustain attention to the task throughout the test period (see Table 3).

For the more highly functioning residents, both low and high barriers were effective in reducing the number of distractions and thereby increasing

attention. in time on task for the high barrier condition. Group 3 residents showed little change between the no and high barrier conditions, and may even have been adversely affected by the low barrier condition. Discussion Because individuals with AD may be more sensitive to environmental stimuli,2' the normal activities on AD units, even low-stimulus units, might interfere with the ability to pay attention. It may be difficult for some AD residents to participate in directed group activities in large multi-purpose rooms where there are many distractions. Environments which

Table 3.Average time on task minus average time of distractions, n=1200 seconds

MMSE

No

Group 1 Group 2 Group 3

1169.8 1039.5 1033.8

Barrier Condition Low

1098.8 1136.8 714.3

High 1197.5 948.7 1120.2

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accommodate the physical and mental decline of the Alzheimer patient, but which do not actively compete with the retained abilities can be an appropriate part of the therapeutic support system.

It may be difficultfor some AD residents to participate in directed group activities in large multi-purpose rooms where there are many distractions. The results of this project suggest some interesting speculations and invite further study. It is still unclear how disease severity and sensory sensitivity to environmental stimuli are related to distractibility. For those who are least impaired, a barrier appears to decrease distractibility and may support attention span and increased concentration. Analysis of the specific types of distractions which occurred with group 2 indicates that the high barrier increased the frequency of "resident talks to observer" incidents. This interactive relationship suggests that other behavioral mechanisms may be at work that need to be investigated. It is still unclear why the mean distraction time for the most impaired group decreased by 25 percent under the low barrier condition. Further study with a larger sample size would be helpful in addressing this apparent anomaly in the data. Of perhaps greater significance is the finding that even with no barrier, residents were able to concentrate on a task for an average of 16 or more minutes during the 20-minute trial. As residents engaged in a meaningful and dignified activity, both focused and selective attentional behaviors were

exhibited. Quite clearly, this project suggests that the ability to concentrate

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and the attentional skills of the AD resident can be supported through activities that are interesting and individualized and can be further enhanced by barriers. This research supports Nebes and Brady's7 findings that both focused and divided attention abilities are relatively unimpaired in AD patients. The 78inch high barrier encouraged the residents in this study to concentrate on a task. The use of barriers produced a dramatic reduction in the frequency of visual distractions. The decrease in the number of audible distractions, even though there was no control for sound, suggests that modification of the en-

to investigate whether barriers are helpful in supporting activities of daily living or instrumental activities of daily living skills like eating, ...

making telephone calls, or doing light housework. vironment to control visual stimuli may also reduce the effects of auditory stimuli. These results support StuartHamilton's8 findings that the selective attention skills which filter visual stimuli may also have some effect on the ability to screen out auditory stimuli. The results suggest several other interesting research directions. First, on a practical level, staff members frequently try to encourage patients with AD to participate in small group activities. It would be interesting to see if the results reported under different barrier conditions and in the one-on-one test format of this project would also hold true for small group activities. A second approach might be to test

whether barriers are effective screen-

ing devices when several activities are occurring simultaneously in centralized areas. A third approach would be to investigate whether barriers are helpful in supporting activities of daily living or instrumental activities of daily living skills like eating, making telephone calls, or doing light housework. The use of barriers to define space within a large room appears to be helpful for people in the earlier stages of Alzheimer's disease. The residents were less distracted in an environment in which mild modifications reduced the impact of auditory and visual stimuli. It is still unclear how the nature of the task and these environmental modifications were related. Although the barriers reduced the number of distractions, the level of interest in the projects was also important. Residents were eager to participate in this project, and some verbalized their pleasure to

the observer. Activities which are interesting and yet offer the resident a dignified form of self expression may also be an important part of increased attention span. Inexpensive movable partitions may help increase attention span in closed AD units by reducing potential visual and auditory distractors. A flexible approach to environ-

The use of barriers to define space within a large room appears to be helpfulfor people in the earlier stages of Alzheimer's disease. mental control with barriers would allow the staff to mediate the demands of the environment based on patient needs and moods. Supervision of patients in public space or open lounge areas also has further implications for utilization of staff. With a minimum amount oftime,

The American Journal of Alzheimer's Care and Related Disorders & Research, January/February 1992

effort, or money, staff can create spaces where individuals and small groups with AD can concentrate on a specific task or activity more effectively. A low barrier appears to provide the AD patient with physical, social, and psychological boundaries that help support remaining abilities. A sig-

. . . the findings of this research suggest that flexible environmental barriers may help reduce episodes of distraction and support increased attentional behaviorforAD residents. nificant decrease in distractibility and improvement in attention span at the low barrier height suggests that for many Alzheimer patients, appropriate supervision and effective environmental support of intact abilities are not incompatible. Furthermore, barriers may also be effective for promoting small group interaction and for encouraging other types of activities. Barriers to screen out extraneous stimuli may also have implications for the caregiver at home. Portable screens, easily set up and taken down, may help support AD patients in a household where there is a high level of activity. Patients might be able to dress, eat, or attend to other tasks in an environment which shields them from intrusive stimuli. Once a task is completed, the screen could be removed so that the AD patient could once again be a part of the larger family setting. Individuals with Alzheimer's disease exhibit a variety of characteristic behaviors and may have changing sensory responses to stimuli in the environment. For this reason, no single

The American Journal of Alzheimer's Care and Related Disorders & Research, January/February 1992

approach can be recommended to meet the needs of all AD patients. However, the findings of this research suggest that flexible environmental barriers may help reduce episodes of distraction and support increased attentional behavior for AD residents.L) References 1. Evans D: The East Boston study. Paper presented at the 6th International Conference of Alzheimer's Disease International, Mexico City, Mexico, 1990 2. Hussian RA: Severe behavior problems. Geropsychological assessment and treatment. Springer, New York, 1986 3. Gugel RN: Managing the problematic behaviors of the Alzheimer's victim. The American Journal of Alzheimer's Care and related disorders and research 1988;3:12-15 4. Cleary TA, Clamon C, Price M, Shullaw G: A reduced stimulation unit: effects on patients with Alzheimer's disease and related disorders. Gerontologist 1988;28:511-514 5. McDowd JM, BirrenJE: Aging and attentional processes. In JE Birren KW Schaie (eds.): Handbook of the psychology of aging, Academic Press, New York, 1990 6. Vitaliano PP, Breen AR, Albert MS et al: Memory, attention, and functional status in community-residing Alzheimer Type Dementia Patients and optimally healthy aged individuals. Journal of Gerontology 1984;39:58-64 7. Nebes R, Brady C: Focused and divided attention in Alzheimer's disease. Cortex 1989;25:305-315 8. Stuart-Hamilton I, Rabbitt P, Huddy A: The role of selective attention in the visuo-spatial memory of patients suffering from dementia of the Alzheimer type. Comparative Gerontology, 1988;2: 129-134 9. Caltagirone C, Carlesimo A, Nocentini U: Differential aspects of cognitive impairment in patients suffering from Parkinson's and Alzheimer's disease: a neuropsychological evaluation. Clinical Neurological 1989;44:107 10. Gugel RN: Managing the problematic behaviors of the Alzheimer's victim. The American Journal of Alzheimer's Care and Related Disorders & Research 1988;3:12-15 11. Freed DM, Corkin S, Growdon J, et al:

Association, Inc. Cleveland Chapter 1987 16. Izumi K: Perceptual factors in design of environment for mentally ill. Hospital and community psychiatry 1976;27:802-806 17. Ohta RJ, Ohta BM: Special units for Alzheimer's disease patients: A critical look. Gerontologist 1988;28:803-808 18. Hughes CP, Berg L, DanzigerWL, etal: Anew clinical scale for the staging of dementia. British Journal of Psychiatry 1982; 140:566-572 19. Namazi KH, Whitehouse PJ, Rechlin LR, et al: Environmental modifications in a specially designed unit for the care of patients with Alzheimer's disease. An overview and introduction. Am J Alz Care and Rel Disorders & Research, 1991;6:3-9 20. FolsteinMF, Folstein S E, McHugh PR: Minimental state; A critical method for grading the longtime state of patients for the clinician. Journal of Psychiatric Research 1975;12:189-198 21. LawtonMP,BrodyEM,Thrner-MasseyP:The relationships of environmental factors to changes in well-being, Gerontologist 1978;18: 133-137 Photos by Sharon R. Haynes

Acknowledgement This research was supported inpart by grant no. 14715 from The Robert Wood Johnson Foundation, and grant no. 87-584-64Rfrom The Cleveland Foundation.

Selective attention in Alzheimer's disease:

Characterizing cognitive subgroups of patients. Neuropsychologia 1989;27:325-339 12. Tecce JJ, Cattanach L, Boehner MB, Branconnier RJ, et al: Neuropsychological study of decline of attention and drug therapy of patients with Alzheimer's disease. Presse Medicale 1983;12: 3155-62 13. Cossa FM, Della, Spinner: Selective visual attention in Alzheimer's and Parkinson's patients: Memory and data-drive control. Neuropsychological 1989;27:887-892 14. Mohr T, Cox C, Williams J, et al: Impairment ofcentral auditory function in Alzheimer's disease. Journal of Clinical and Experimental Neuropsychology 1990;12:235-246 15. Alzheimer's Disease and Related Disorders

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