Q. I am looking to design an extinguishing program for a psychogeriatric client to reduce yelling and calling out. I'm looking for a successful template for this type of program.

A. My literature search turned up very little in the way of specific behavioral programs for the geriatric or demented patient with yelling or so-called disruptive vocalizations (DV). All the literature emphasizes--and I would concur--that the clinician must do a very thorough neuropsychiatric and behavioral differential diagnostic evaluation, prior to designing a treatment strategy for these patients. For example, demented patients with DV may be unable to verbalize a variety of complaints, ranging from untreated pain to social isolation to a need for assistance with activities of daily living (see White et al, J Gerontol Nurs 1996;22:23-9).

A recent study by Dwyer et al (Int Psychogeriatr 2000; 12:463-71) found a correlation between DV and depressive symptoms, in a group of elderly nursing home patients. This would raise the obvious possibility of using antidepressant medication in that sub-group. Indeed, a variety of medication options might be worth considering, including low-dose atypical antipsychotics and anticonvulsant mood stabilizers. In terms of behavioral approaches, White et al recommend "...using gentle touch, creating a familiar, home-like environment, and using diversions during ADLs."

Davis [Nursing Times 1983; 43:26-27] reported on a method of reducing DV by combining (1) reinforcement of positive behaviors not compatible with DV with (2) removal of reinforcers for the DV. A good illustrative vignette is found in the chapter by Swanwick, in the book, Behavioral Complications in Alzheimer's Disease, edited by BA Lawlor, American Psychiatric Press, 1995. Swanwick describes a case of a 68-year-old man with Alzheimer's Disease, who constantly cried out for his wife, while an inpatient in a respite setting. Whenever he settled down, the nurse went to attend to another patient, and the calling would start up again. At that point, a behavioral program was initiated.

Only one member of the staff on each shift attended to the patient. That nurse sat or walked with him for ten minutes each half-hour, regardless of his behavior in the interim, and did not attend to him at any other time. Initially, he was more agitated; but the reinforcement of the crying out (attention) had been removed, and the stimulus for it (need for company) was diminished. In effect, the patient got his need for attention met on a regular basis, whether he called out or not. Music therapy was also introduced into this patient's care. For more specific approaches, see the paper by Allen-Burge et al, Int J Geriatr Psychiatry 1999;14:213-28; or, try contacting the authors at the University of Alabama, Tuscaloosa [raburge@sw.ua.edu]. Good luck.

October 2001

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