on progressive muscle relaxation (PMR), which we conceptualised as a motor ... progressive muscle relaxation would lead to a reduction of psychiatric and.
NEUROPSYCHOLOGICAL REHABILITATION, 1999, 9 (1), 31–44
Progressive Muscle Relaxation in the Management of Behaviour al Disturbance in Alzheimer’s Disease Julie Suhr, Steven Anderson, and Daniel Tranel Division of Behavioral Neurology and Cognitive Neuroscience, University of Iowa College of Medicine, Athens, USA Behavioural disturbances such as anxiety, irritability, and agitation are common in Alzheimer’s disease (AD) and make a substantial contribution to the disability of the disease. These symptoms often are treated with psychotropic medication, which can lead to undesired or even dangerous side effects, such as sedation and increased risk for falls. Development of effective nonpharmacological treatments for behavioural disturbance is a desirable component of care for patients with AD, and the goal of the present study was to develop such a treatment. We focused on progressive muscle relaxation (PMR), which we conceptualised as a motor memory skill that AD patients likely would be able to learn, given their relatively preserved procedural learning abilities. It was hypothesised that training in progressive muscle relaxation would lead to a reduction of psychiatric and behavioural difficulties in AD patients, and possibly, to improved performance on cognitive screening measures. Thirty-four patients and their caregivers were randomly assigned to progressive muscle relaxation or a control treatment. Results showed that patients who learned progressive muscle relaxation showed a significant decrease in psychiatric and behavioural disturbance, as well as improved performances on measures of memory and verbal fluency, from baseline to 2-month follow-up testing. The findings support the notion that PMR is an effective technique for managing psychiatric and behavioural disturbance in AD patients with mild to moderate dementia.
Although many clinicians and researchers have focused their attention on the cognitive symptoms of Alzheimer’s disease (AD), behavioural disturbances are also common. In the first descriptions of his dementing patients, Alzheimer stressed the prominence of behavioural disturbance as a characteristic feature
Requests for reprints should be sent to Julie Suhr, Department of Psychology, Ohio University, Athens, OH 45701, USA. This research was sponsored in part by a National Research and Service Award training grant from the National Institute of Aging (AG 00214). We thank two anonymous reviewers for their excellent reviews of an earlier version of this manuscript.
Ó 1999 Psychology Press Ltd
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of the disease (Alzheimer, 1977). Common behavioural symptoms of AD include paranoid delusions, visual hallucinations, dysthymia and depression, anxiety, irritability, aggression, sleep disturbance, agitation, wandering, repetitious behaviour, and hiding things (Burns, Jacoby, & Levy, 1990; Kumar, et al., 1988; Mega, Cummings, Fiorello, & Gornbein, 1996; Mendez, Martin, Smyth, & Whitehouse, 1990; Reisberg et al., 1987; Rubin, Morris, Storandt, & Berg, 1986). These behavioural symptoms are not confined to more severe forms of AD, but can be seen in the mildly demented (Rubin et al., 1986). Gilley and colleagues (1991) found only a weak association between most forms of behavioural disturbance and dementia severity, although others have found that the frequency and severity of behavioural disturbance increases with cognitive symptomatology (Swearer, Drachman, O’Donnell, & Mitchell, 1988; Teri, Larson, & Reifler, 1988). The behavioural symptoms of AD make a substantial contribution to the disability of the disease (Hall & Buckwalter, 1987; Kumar et al., 1988), and when combined with cognitive impairment, may produce even more overall functional impairment, necessitating changes in the caregiving situation. Problematic behaviours such as anxiety, irritability, aggression, and agitation can make home care difficult or impossible, and can place enormous physical and emotional burden on caregivers. Retrospective and prospective studies have found that AD patients with behavioural or psychiatric difficulties are more likely to be institutionalised than other patients with AD, while cognitive factors are less strongly related to institutionalisation, suggesting that treatment of behavioural and psychiatric symptoms of AD might delay or prevent institutionalisation (Chenoweth & Spencer, 1986; Cohen et al., 1993; Knopman, Kitto, Deinard, & Heiring, 1988; Morycz, 1985; O’Donnel et al., 1992; Steele, Rovner, Chase, & Folstein, 1990). Behavioural symptoms such as anxiety and agitation may also have an effect on the severity of the cognitive symptoms of AD. Research has shown that there is a range of hormonal responses for optimal memory, particularly among stress-related hormones such as epinephrine, and glucose, in which moderate levels enhance memory, whilst high levels impair memory (Gold & McCarty, 1995). It has been shown that administration of cortisol in healthy adult humans is related to impaired performance on declarative memory tasks, and that placing healthy adults in a stressful environment raises cortisol levels and creates a decline in memory performance (Kirschbaum, et al., 1996). Behavioural symptoms of AD are usually treated with psychotropic drugs (Mendez et al., 1990) However, medications typically used to manage behavioural problems are contraindicated in the elderly, and in dementia patients in particular, due to side effects such as drowsiness, ataxia, dizziness, central nervous system depressant effects (benzodiazepines), blurred vision, anticholinergic effects, confusion, cardiovascular effects, and tardive dyskinesia (neuroleptics) (Burlingame, 1993; Cummings & Victoroff, 1990; Gorman,
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Read, & Cummings, 1993). Cohen-Mansfield (1986) found that nursing home residents who were both agitated and demented received more medication and had a higher incidence of falls than the nonagitated demented. There is a strong association between benzodiazepine use and fall incidence in both communityand institutional-dwelling elderly (Neutel, Hirdes, Maxwell, & Patten, 1996; Sorock & Shimkin, 1988; Tinetti, Speechley, & Ginter, 1988). Thus, development of effective nonpharmacological management strategies for behavioural and psychiatric difficulties is an essential component of the care of AD patients, in order to improve their quality of life, to decrease the burden on the health care system and on their caregivers, and to minimise the use of psychotropic medications. Although there are numerous effective psychological techniques for the management of behavioural disturbance, studies of psychological or behavioural management of these symptoms in AD are limited. Welden and Yesavage (1982) showed that intensive relaxation training was beneficial to inpatients with AD or multi-infarct dementia. The failure to use behavioural or psychological interventions in demented populations appears to stem, at least in part, from the belief that the memory impairment of AD patients precludes their learning new skills or behavioural repertoires. One effective nonpharmacological treatment for anxiety in nondemented persons is progressive muscle relaxation (Borkovec & Costello, 1993). Progressive muscle relaxation (PMR) consists of the sequential tension and relaxation of various muscle groups throughout the body. PMR can be quickly learned by most individuals and can be used to attain a state of relaxation in 10 to 20 minutes. Relaxation training has proven beneficial to learning and recall for highly anxious people (Straughan & Dufort, 1969), and has also been successfully used to manage agitated behaviour in autistic children (Graziano & Kean, 1968). PMR has also been shown to be useful in the management of subjective anxiety complaints in nondemented elderly (Rickard, Scogin, & Keith, 1994; Scogin et al., 1992). Many relaxation techniques, including PMR and imaginal relaxation, have been used to address memory complaints in nondemented elderly (Brooks, Friedman, & Yesavage, 1993; Yesavage, Rose, & Spiegel, 1982) as well as those who may be developing cognitive impairment (Simons, 1980). In the present study, we conceptualised PMR as a skill that involves procedural memory processes, because it involves learning a motor sequence and conditioning of a motor response. Procedural memory relies on motor output for its expression and does not require that information be brought to mind for conscious interpretation. While patients with AD have impaired declarative memory, it has been demonstrated that their procedural memory skills are relatively preserved. Procedural memory studies in AD have focused on skills involving motor output (finger mazes, mirror tracing, rotor pursuit), as well as tasks that do not involve a motor component (mirror reading, visual
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reaction time) (Deweer et al., 1993, 1994; Eslinger & Damasio, 1986; Ferraro et al., 1993; Gabrieli et al., 1993; Grosse, Wilson, & Fox, 1991; Heindel et al., 1989; Huberman et al., 1994; Knopman, 1991; Knopman & Nissen, 1987). Tranel and colleagues (Tranel, Damasio, Damasio, & Brandt, 1994) have demonstrated that nondeclarative (procedural) learning does not require mesial and lateral temporal or basal forebrain structures, which are the areas heavily targeted by Alzheimer’s pathology (Hyman, Van Hoesen, Damasio, & Barnes, 1984). Thus, AD patients should be able to learn and retain PMR, given their relatively preserved nondeclarative memory skills. In the present study, we trained AD patients in PMR. We hypothesised that PMR would be beneficial to AD patients in the management of anxiety, agitation, and other behavioural difficulties. Further, given the role of stress on performance on memory tasks, we hypothesised that induction of a relaxation response may improve performance on cognitive tasks in patients with AD.
METHOD Participants Participants were 34 persons diagnosed with probable AD (McKhann et al., 1984). Twenty-four were recruited from patients referred to our laboratory for evaluation of dementia, and 10 were recruited through local AD support groups and newspaper advertisements. Persons were selected for participation if they (1) were diagnosed with probable AD, as above; (2) if they or their caregivers complained of behavioural disturbances that affected daily functioning; and (3) if they were living at home with a primary caregiver (usually the spouse). Both the Ad participant and their primary caregiver participated in the study.
Procedure Pretraining Examination. Immediately prior to training, AD participants were given a brief cognitive screen consisting of the Benton Visual Retention Test (Sivan, 1992), Controlled Oral Word Association (Benton, Sivan, & Hamsher, 1994), and Category Fluency (Cerhan, Tranel, & Jones, 1994). These measures were selected because of their known sensitivity to cognitive change in dementia (Cerhan et al., 1994; Eslinger, Damasio, Benton, & Van Allen, 1985). The AD participant also completed a common self-report measure of anxiety, the Beck Anxiety Inventory (Beck, 1987). The caregiver completed checklist measures of problematic behaviour they observed in daily life, including the frequency portion of the Memory and Behavioral Problems Checklist (Zarit, Orr, & Zarit, 1985) and a measure of problematic behaviour in Ad created specifically for this study, the Behavior Rating in Alzheimer’s Disease. The Memory and Behavioral Problems Check-
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list was chosen after a review of numerous psychiatric and behaviour rating scales for dementia, based on its ease of administration, psychometric properties, and coverage of behavioural symptoms. The Behavior Rating in Alzheimer’s Disease questionnaire was created to evaluate comprehensively behavioural disturbances in AD, including symptoms that are not part of the Memory and Behavioral Problems Checklist, such as angry outburst, appearing nervous, complaining of anxiety symptoms, fidgeting with clothing or other objects, persistently following caregiver around, wandering, irritability, and difficulty speaking secondary to emotional distress. To establish test–retest reliability, the scale was administered twice (with a one week interval) to 15 caregivers of patients with AD (not part of the present sample). The two administrations were adequately correlated (r = .78, P < .01). The caregiver also completed ratings for dementia severity using the Dementia Severity Rating Scale (Clark & Ewbank, 1996). The clinician completed the Brief Psychiatric Rating Scale (Overall & Gorham, 1962) to assess psychiatric symptomatology in the person with AD.
Training. The AD participants, together with their caregivers, were than randomly assigned to one of two treatment conditions: progressive muscle relaxation, or a control treatment. PMR consisted of Ad participant and caregiver participation in once weekly sessions designed to teach basic the technique (see Appendix for specifics). The number of sessions required was individually tailored based on the needs of the patient, and the methods of tensing muscles were modified if medically necessary (such as arthritic hands). During sessions, both therapist and patient ratings of patient relaxation were recorded, using the Behavioral Relaxation Scale (Poppen, 1988). The patient and caregiver documented home practice of the PMR technique and progress in using the technique by using the Behavioral Relaxation Scale. The control treatment was matched in as many ways as possible to PMR, in terms of session structure, frequency of sessions, documentation of in-session relaxation, and home practice with Behavioral Relaxation Scale recordings. The control treatment utilised an imagery technique, individualised for each patient (see Appendix). Imaginal relaxation techniques are common, and have been shown to be just as effective as PMR for older persons with anxiety and for psychiatric inpatients (Rickard, Collier, McCoy, & Crist, 1993; Scogin et al., 1992). Initially, to keep the two techniques matched as much as possible, both groups were provided with written instructions for the use of their respective technique. However, there was a high drop out rate in the control group, prompting the use of a taped imagery technique in that group to facilitate participation. Post-training evaluation. All measures utilised in baseline testing were repeated after training was completed (two months post initiation of training).
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For the Visual Retention Test and Controlled Oral Word Association, alternate forms were used in follow-up testing.
Hypotheses Our specific hypotheses were as follows: 1. Neither group would show a significant change in basic level of dementia (Dementia Severity Rating Scale). from pre-training to post-training. 2. There would be a significant decrease in psychiatric symptomatology between pre-training and post-training for the PMR group, but not for the control group (demonstrated by lower scores on the Brief Psychiatric Rating Scale). We hypothesised that the self-report measure of anxiety (Beck Anxiety Inventory) would show no change, as studies suggest that dementia patients are unreliable in their report of their psychological and behavioural symptoms (Gotlieb, Gur, & Gur, 1988; Teri & Wagner, 1991). 3. There would be a significant decrease in behavioural symptomatology between pre-training and post-training for the PMR group, but not for the control group (demonstrated by lower scores on the Memory and Behavioral Problems Checklist and Behavior Rating in Alzheimer’s Disease scale). 4. There would be a significant improvement in cognitive performance for the PMR group at post-training (as reflected in increased number correct and decreased number of errors on the Visual Retention Test, and higher number of words provided on the Controlled Oral Word Association and Category Fluency tasks).
RESULTS Demographics There were 17 patient and caregiver pairs randomly assigned to each group. One of the pairs assigned to PMR and five of the pairs assigned to the control treatment dropped out. There were no differences in age or education between groups (age: PMR = 75.7 [7.2], control = 73.9 [6.6]; education: PMR = 14.9 [3.6], control = 15 [3.6]. There were no differences in performances on cognitive or behavioural tests at pre-training (see Tables 1 and 2). There were also no difference between the two groups in terms of number of medications being taken for treatment of psychiatric or behavioural symptoms (PMR = 0.4 [0.6], control = 0.6 [0.7]) or in percentage of patients in each group taking any 2 psychotropic medications (38%versus 42%, c
