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Pathways to the Past
by Sandra Stimson ADC, CALA, CDP
Executive Director,
Alternative Solutions in Long Term Care
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ABOUT SANDRA

Sandra Stimson has
experience as a corporate
consultant, Corporate Trainer
and National Speaker. Her
experience is in long term
care, as Activity Director,
Director of Alzheimer's Units
and Assistant Administrator of a
550 bed long term care county
home.  She is Co-founder of
Pet Express Pet Therapy Club,
is a Life Replay Specialist.  
Sandra implements dementia
units nationwide.  Sandra has
written several books,
Volunteer Management
Essentials for Long Term Care
and Pet Express Pet Therapy
Program. Sandra has been a
facilitator for Alzheimer's
support groups and is the
Awards Chair for the NJ
Association of Activity
Professionals.  Sandra is the
Executive Director of
National
Council of Certified Dementia
Practitioners
http://www.nccdp.org  

Alternative Solutions in Long
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resident rights prints
Why Should I Conduct A Noise Study
on My Dementia Unit?
Sandra Stimson CALA ADC CDP CDCM
NCCDP Executive Director

“Florence Nightingale wrote about the importance of quiet for healing”
I was asked to consult for an assisted living facility that utilized a huge rotunda with
enormous vaulted ceilings for all the activity programs. There were six hallways that all
merged into the center of the rotunda.  The Administration was concerned that the
activities were ineffective.

On the morning of my first day, I documented my observations. There were three activity
programs being conducted at the same time for approx 100 residents. I observed staff
and visitors walking through this high traffic area.  The acoustics were so bad that the
noise literally bounced off the floor and struck my ears (it was painful).  Residents were
playing personal radios.  Staff, residents and visitors were talking loudly.  Music was
playing overhead.  Activity programs were loud as were overhead paging and squeaky
carts.  Clutter was everywhere and the over abundance of chairs added to the chaos. As
a result, it appeared the residents seemed agitated and frustrated which was evident in
behaviors such as crying, yelling, hitting and repetitive behaviors.  I was able to concur
that the activities were ineffective.  It never occurred to the administration that the reason
the activity programs were so ineffective was a direct result of the over crowed
conditions of the room, the clutter, the enormous size of the room, all kinds noises and
bad acoustics due to the vaulted ceilings.

Many recommendations were made. Although it meant making major changes and
costly improvements, the administration was willing to implement these changes
because it would greatly impact the resident’s quality of life. Three of the activity
programs were relocated to smaller quiet areas of the building. The lobby was used for
the “high functioning residents”.  A conference room was utilized for the dementia
population and the very low functioning utilized a sensory room. Because programs
were relocated, it meant there was a lot more transporting of the residents by the CNA’
s. The Nursing Assistants were asked to transport their residents to programs. For
nursing homes, F248 means Nursing Assistants should be transporting their residents
to programs. Traffic patterns were changed by placing a gazebo in the middle of the
room, so that no one walked through the middle of the rotunda. The ceiling was
lowered with special ceiling tiles to absorb sounds, extra chairs were removed, signs
were placed around the rotunda reminding staff and visitors to keep their voices low.  
Residents were asked to either play their music in their rooms or use earphones, or
use their radios outside on the patio. Overhead paging was eliminated, as well as the
overhead music was eliminated and the staff was in-serviced about the importance of
providing a calm and soothing environment. All of these changes were major changes
that affected the overall environment and provided a better quality of life. The facility
noticed an immediate improvement in resident behaviors and staff morale.   
   
As part of the yearly Quality Assurance program Dementia Unit Managers should
conduct a Noise Study once a year. Different   noises can affect behaviors and not
always in a positive way. A noise study will clearly indicate what changes need to be
made. Staff often times, become insensitive to noise because they hear it on a day to
day basis. Noise study forms are available at activitytherapy.com

A noise study should be conducted for a full week on all shifts in every area of the facility
that residents utilize. This includes dining rooms, day rooms, hallways, lobby, library,
outside court yard and possibly resident rooms. Each area that is targeted will have a
noise study conducted for 24 hours. You would be surprised how noisy a facility can be
at night.

The manager should document all the noises he / she sees and hears such as;  loud
ringing phones, echo, squeaky carts, overhead paging, overhead music, unanswered
call bells, staff speaking loudly, overcrowded dining rooms, ice machines, sounds at
parties & religious services,  dragging chairs across the floor, slamming doors,
activities that are noisy, clanking of dishes, scraping of silverware on dishes, TV and
Stereo volume, disruptive behaviors,  vacuum cleaners and floor polishers, etc.  A
comprehensive noise study also observes noises from the outside, loud highway
traffic, garbage trucks, dogs barking, etc.

Nursing homes are required per the state and federal regulations to provide a proper
environment and the level of noise in that environment must be evaluated and
corrected.  In Assisted Living and Adult Day care settings, even if you do not have
federal regulations or state regulations that address environment it is best practice to
provide a proper environment.   Have you ever heard a resident state when she is
discussing someone in the hallway who frequently yells, “This goes on all day long!”
Staff may become immune to it but are we to expect the residents to adjust to this? Isn’t
this a form of abuse?

Once you have conducted a noise study, the manager should meet with the team to see
which noises can be eliminated. For example, Loud phones can be replaced with
chimes, overhead paging can be eliminated and replaced with cell phones, pagers and
Walkie Talkies, staff talking loudly can be in-serviced, Volume on TV can be turned
down, Talk Radio can be replaced with Companion Radio, room call bells can be
answered immediately, and squeaky wheels can be oiled, soothing comfort measures
can be offered to residents who are verbal and repetitive. Comfort measures would be
unique to the individual but some suggestions are large lollipops (screen to be sure
they can swallow), life like dolls, rocking chairs (anti tip), soothing music, outside stroll,
etc.

It is very important that comprehensive interviews are conducted with family members
to determine which interventions worked in the home when someone is noted to be
verbally repetitive or yells, moans, grunts, curses, etc. At one facility I consulted with, the
newly admitted resident screamed day and night for a full week. The nursing staff tried
all kinds of interventions and nothing worked. At the end of the week, the staff met with
family and asked what they did at home to calm the resident. The family stated, “My
mom loves to watch wrestling and we left a video in her drawer.” Once this was left on
for the resident she was calm! There are great free interview tools with the New York
State Department of Health, called the EDGE project. The link is located on the NCCDP
web site and these are free resources.    

For the outside garden areas, check with your local government office to determine if
you are allowed to order a sign and place outside that says, “Quiet Area”.
The point of the study is to determine what noises can be eliminated to provide a
soothing environment.

How does noise impact residents? People with Dementia or Alzheimer’s disease can
be more sensitive to noise.  Combination of noises such as staff talking and music
playing can be overwhelming.  Noise affects people differently from a mild response to
an over exaggerated response or catastrophic reaction.  Their individual coping style
and personal tolerance to noise both will impact how noise will affect the resident.
Noise can be frustrating, confusing, scary, and can physically hurt. Some common
behaviors are yelling, crying, moaning, mumbling, repetitive behaviors, pacing, etc.
Equally confusing to the care giver is the resident’s perception of the noise. Especially,
if they cannot tell you how the noise is affecting them.  You have to be a really good
detective to observe what may be upsetting them.  Their behavior can be directly
influenced by the noise and their capacity to deal with over stimulation. Some may have
a threshold of a few minutes and others may become overwhelmed after an hour.  
Keep in mind that the staff and visitors coming and going can attribute to auditory
stimulation.

Someone with a hearing loss naturally works harder to hear and back ground noise
can add to frustration. It is important for those who wear hearing aides to check that the
batteries are working.  A whistling sound from the hearing aid is frustrating not only for
the person wearing the aid but for everyone around them.  You might arrange for a
hearing test to check for hearing loss or Tinnitus (ringing in the ears).

A person with dementia may have lost physical control in a situation and is unable to
make the noise go away. For example, maybe they are unable to ambulate away from
the noise, or explain to someone to lower their voice. Losing control can also lead to
frustration, agitation, increased pacing, out bursts, spitting, disrobing and masturbation
in public places, hallucination and delusions.

Noise and over stimulation attributed to noise can affect self esteem, confidence and
can lead to depression. Depression can lead to self isolation and fatalism. For those
residents who pace, the noise level may increase their pacing or attempts to “escape”
from the locked noisy unit.

One thing to remember is a lot of these noises you identify in your noise study may also
happen at night and may impact how the resident rest, sleep and just relax. Noise can
also mean that their roommate snores loudly, yells, verbal or repetitive outburst and or
has the TV or radio on loudly. If they do not obtain a good night sleep, this could impact
their behavior the next day. You might see fear and fatigue. Administration may need to
look at using more sound proof materials for resident’s rooms that are very verbal or
vocal.

For some, the noise might be perceived as a threat. You may observe reactions such
as fear, ringing of the palms, rocking, screaming or crying, etc.
Often times, we are quick to blame the behavior on their disease when in fact, the
facility environment, building design, facility layout and staff approaches or lack of
approach can directly impact their behavior.  Most of our seniors came from quiet
homes where none of the noises we directly attribute to a long term care setting were in
their homes. These noises are unfamiliar to them. For example, no one has call bells
and squeaky carts in their home.

A noisy unit directly impacts staff in negative ways such as stress, high turnover, staff
burnout and an increase in injury and falls. Because a noisy unit affects patients
differently, you may have patients with increased pacing, verbal outburst, chattering,
repetitive words and phrases, crying out, screaming and muttering which only
compounds the noisy unit.  This in turn adds to a stressful work environment.  
Providing a soothing, calm and quiet environment may help to decrease medications
and use of restraints. “Given the adverse effects of physical and pharmacologic
restraints and OBRA restrictions, it is prudent to investigate alternate methods of
managing disruptive behaviors.” A soothing environment is a nonpharmalogical
approach to behavior management.  One suggestion to provide a soothing
environment, once you have made changes to your unit are white noise (fans) while in
their rooms to promote rest & may also decrease agitation.

Consumers are very smart and informed shoppers when investigating a long term care
setting. Many check lists that are available on Caregiver web sites specifically ask
“What is the Noise Level.” It makes sense to make changes to your unit especially if it
means losing a customer because your unit is too noisy.
Tips to providing a soothing environment by Stanton O Berg
  • Eliminate overhead public address (PA) systems.
  • Avoid playing music throughout the facility.
  • Minimize noise from necessary institutional support systems such as
    icemakers, carts and pill- crushers.
  • Enforce policies regarding care giving staff talking loudly to each other.
  • Regulate the amount of noise generated by group activities; activity rooms
    should have doors that can be closed or left open.
  • Utilize sound absorbing materials in public area.
  • Equip a few bedrooms with extra soundproofing for residents with disruptive
    vocalizations.
  • Use pleasing sounds as cues (bird songs as residents are rising, or singing
    show tunes or hymns before meals).
  • Other ideas to consider from Stanton O Berg article are;
  • Distractions during meals should be limited by avoiding mealtime interruptions
    and by reducing unnecessary noise..."
  • "Pleasant music and multiple opportunities to eat and drink, and also minimizes
    negative stimuli such as loud overhead paging and glare."
  • "Environmental irritants – Excessive sound,... stimuli.."
  • "Altering the environment for comfort, such as providing a calm environment, soft
    music..."
  • "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..."

Additionally, develop individualized approaches and care plans to decrease agitation
that is unique for each resident where noise is impacting them in a negative way,
comfort items such as life like dolls, rocking chairs (anti tip), large glassed aviaries and
aquariums, soothing angel music, sound machines, waterfalls and ponds outside,
body pillows with the perfume of the loved one, Build A Bear with a family member pre
recorded message, sensory rooms, chapel, soothing music, dimming the lights, etc.
Be careful with the type of music programs you plan and entertainment you use.
Eliminate noisy music programs such as each resident provided with a different
instrument. Instead replace with everyone using Bells, or drums. But provide all
residents with the same instrument. You might not want to have the Bag Piper come to
the dementia unit because it is so loud but instead use a guitarist to play to St. Patrick
Day songs. You also might want to look at player pianos.     

Plan calming and soothing activities late in the day such as reminisce & relaxation  
programs, guided imagery, short stories, individualized projects, religious programs,
pet therapy, deep breathing and stretching exercises, relaxation videos, white noise
(fans), etc . Replace TV programs with soothing relaxation and reminisce videos. TV
programs and commercials send too many messages too fast and this only adds to
the resident frustration. Provide soothing music not upbeat tempos at the end of day. An
example might be Angel music.  Other suggestions are massages, Aroma therapy, pet
therapy, soft stuffed animal. Build a bear offers family opportunity to record a soothing
message. Body pillows with the cologne or perfume of their loved one, when in bed.  
Allow rest between activities and remove person to a quiet area if they do become
agitated or better yet, take the resident outside or for a walk. Encourage visitors and
family members to also utilize the outside court yards for visits.   

Administration can decide that noise pollution is an important issue that does have a
major impact on residents’ quality of life and take the necessary steps to control noise
pollution.  The alternative is to ignore it, become apathetic and continue to allow it to
negatively impact the quality of life for the residents and the work environment of the
staff.  Action on the part of administration may involve financial resources, hard work
and creativity but in the end, a soothing environment will pay off in many ways. A positive
work environment for the staff means longevity and a decrease in stress levels and
apathy. The benefits for the residents are a decrease in negative behaviors, emotional
outbursts, decrease in weight loss, falls and decrease in medications and use of
restraints.

“Harmony Joins Sounds; Noise merely accumulates them.” John Pickler
Resources to Consider

White Noise CDS
http://www.purewhitenoise.com/s-51-alzheimers-dementia.aspx

Reference Articles:

Reference Books:

Creating Successful Dementia Care Settings Volumes 1-4 available at activitytherapy.
com