Aging & Mental Health, January 2005; 9(1): 16–24

ORIGINAL ARTICLE

Vocally disruptive behaviour in dementia: Development

of an evidence based practice guideline

B. MCMINN1 & B. DRAPER2

1
Centre for Mental Health Studies, Newcastle, NSW, 2Academic Department for Old Age Psychiatry,
University of New South Wales, NSW, Australia

(Received 14th August 2003; accepted 18th April 2004)

Abstract
Vocally Disruptive Behaviour (VDB) is a term that includes screaming, abusive language, moaning, perseveration, and
repetitive and inappropriate requests. It is one of the most challenging behaviours for nursing home staff, caregivers for
people with dementia, and other nursing home residents. As with other behavioural disturbances, multiple causal factors
have been identified in the literature and individual cases may have a number of interacting factors. There is a lack of
consensus about how to treat VDB. Systematic treatment studies are few and there is a lack of empirical data supporting the
effectiveness of specific interventions commonly used in clinical practice. This hinders clinicians and may result in the use of
inappropriate treatments. Our aim was to systematically review the literature in order to develop a practice guideline for the
assessment and management of VDB. The review will examine the typology, risk factors and management of VDB.

Introduction agitation (Burgio et al., 1996; Cohen-Mansfield,

Werner & Marx, 1990).
Vocally Disruptive Behaviour (VDB) is a term that Vocally Disruptive Behaviour is a broad term
includes both verbal and non-verbal vocal activity encompassing a range of sounds and behaviours.
that causes disruption to others. The behaviour As with other behavioural disturbances multiple
includes screaming, abusive language, moaning, causal factors have been identified in the literature
perseveration, and repetitive and inappropriate and individual cases may have a number of interact-
requests (Burgio, Scilley, Hardin, Hsu & Yancey, ing factors (Meares & Draper, 1999). Categorisation
1996; Cariaga, Burgio, Flynn & Martin, 1991; of VDB by vocalisation type or other associated
Hallberg & Edberg, 1993; Ryan, Tainsh, Kolodny, factors may be useful for prognostic and treatment
Lendrum & Fisher, 1988). There is no benchmark purposes (Sloane et al., 1999). There is a lack of
definition for VDB, nevertheless, the construct of consensus about how to treat VDB. Systematic
‘disruptive vocalisation’ remains helpful, in that it treatment studies are few and there is a lack of
describes vocalisations that are out of the ordinary empirical data supporting the effectiveness of specific
and creating stress within the environment and as a interventions commonly used in clinical practice.
result, justifies intervention. This hinders clinicians and may result in the use of
Vocally Disruptive Behaviour occurs in 11–30% of inappropriate treatments. Our aim is to system-
nursing home residents (Cariaga et al., 1991; Cohen- atically review the literature in order to develop a
Mansfield & Marx, 1990; Cohen-Mansfield & practice guideline for the assessment and manage-
Werner, 1997a; Ryan et al., 1988; Sloane, Davidson, ment of VDB. The review will examine the typology,
Knight, Tangen & Mitchell, 1999; Zimmer, Watson risk factors and management of VDB.
& Treat, 1984). It is one of the most challenging
behaviours for caregivers and nursing home staff,
Method
causing severe emotional strain with feelings of
powerlessness, frustration, anxiety, anger, and a Searches were undertaken through Medline,
distancing from the patient (Draper et al., 2000; CINAHL, PsycInfo and Embase databases using
Everitt, Fields, Soumeria & Avorn, 1991; Hallberg the following terms and grammatical variants:
& Norberg, 1990a; Whall, 1992). For other nursing screaming, noisemaking, vocal disruption, disruptive
home residents, VDB can trigger anxiety and vocalisation, vocally disruptive behaviour, vocal

Correspondence: Bryan McMinn, Clinical Nurse Consultant, Centre for Mental Health Studies, PO Box 833, Newcastle,
NSW 2300, Australia. Tel: þ 61 2492 46755. Fax: þ 61 2492 46768. E-mail: [email protected]
ISSN 1360-7863 print/ISSN 1364-6915 online/05/01001–9 ß 2005 Taylor & Francis Group Ltd
DOI: 10.1080/13607860512331334068
 Vocally disruptive behaviour in dementia 17

activity and verbal agitation. This was supplemented Behaviour Mapping Instrument. Later they devel-
by secondary references within articles obtained and oped the Typology of Vocalisations (TOV) (Cohen-
with key author searches. Searches were finalised in Mansfield & Werner, 1997b). Inter-rater reliability of
June 2003. Over one hundred articles were obtained the typology and validation against the classification
and reviewed, 85 of these related to the typology, by Ryan et al. (1988) of verbal and vocal disruptive
risk factors or management of VDB. Information behaviours were reported. The TOV was developed
was critically examined for inclusion in a Practice specifically to assist in deciphering the meaning of
Guideline. the VDB and to correlate VDB attributes with
treatment effectiveness (Cohen-Mansfield & Werner,
1997b, p. 1087). It provides the structure for
assessing the vocalisations as part of the Practice
Typology of VDB
Guidelines (see Figure 1).
There have been five major studies that have
examined the typology of VDB. Most of these
Risk factors for VDB
attempt to describe the sounds and/or attribute
meanings (Cariaga et al., 1991; Cohen-Mansfield & There are many studies that have reported associa-
Werner, 1994; Hallberg & Edberg, 1993; Ryan et al., tions between VDB and a broad range of variables.
1988). Cohen-Mansfield & Werner (1994) initially Lai (1999) proposed a framework of four groups of
developed a descriptive typology in the Screaming theories of causation of VDB. She described two

Person with Dementia &

Vocally Disruptive Behaviour1

Assess caregiver’s Assess to determine aetiologies

emotional responses:-
anger/ frustration (See Figure 2)
distancing/ anxiety

Respite / support General interventions

education/ clinical (see Figure 3)
supervision

PLAN OF AETIOLOGY SPECIFIC INTERVENTIONS2

(Usually multiple and require an individualised care plan)

NEUROLOGICAL PHYSICAL/MENTAL DEPRIVATION OPERANT

Treat causes of SUFFERING Provide social contact LEARNING
acute confusion Treat depressed mood/ agitation –use family videos, Avoid excess
Review adverse Calming therapies (aroma/ music) individualised music, attention to
drug effects Relieve discomfort (positioning, toilet, conversation VDB
Treat delusions & mobility, food & drink) Facilitate meaningful
Reinforce
hallucinations Regular analgesia/ physical therapies activities
for pain adaptive or
Minimise sensory loss
Relieve fatigue (sleep hygiene/ rest through hearing/
quieter
periods) vision aids behaviours
Avoid restraints Use first language (if Behavioural
Reduce meaningless stimulus/ remove acquired language approach must
irritations (noise, temperature) lost) be consistent
Facilitate expressions of feelings Orienting cues in across all carers
(grief, frustration, helplessness) immediate
Identify and relieve specific environment
frustrations
Minimise perceived threats
(personal space/ dignity/
privacy/ safety)

1. Monitor response to planned

strategies
2. Consider medication strategies
No improvement (see Fig 4) Improvement

Reassess Refer to specialist service

Figure 1. Practice Guideline for Vocally Disruptive Behaviour in persons with dementia (Adapted from White et al. [1996]1, Lai [1999]2;
Cohen-Mansfield & Werner [1997]3).
18 B. McMinn & B. Draper

ASSESSMENT to determine AETIOLOGIES

1. Typology of Vocalisation3
Type of sound (loud talk, singing, chattering or mumbling, yelling, groaning,
howling, sighing)
Meaning/ reason/ content (pain, complaints, requests for attention,
hallucinations, ADL requests, environmental discomfort, self-stimulation,
cursing, verbal aggression, no discernible meaning-nonsense
Timing (constant, random, apparent pattern)
Level of disruptiveness

2. Assessment of Person Vocalising

Are there features of depression? Consider using the Cornell Scale for
Depression in Dementia
Are there features of anxiety or panic?
Are there features of psychosis (delusions, hallucinations)?
Prior psychiatric illness (history of losses, abuse, stress)
Physical examination – is the person in pain or suffering other types of
discomfort e.g. constipation, cramps

Figure 2. Assessment to determine aetiologies of VDB in persons with dementia.

1
GENERAL INTERVENTIONS

o Remain calm, unhurried approach

o Use warm reassuring voice
o Emphasise non-verbal communications and eye contact
o Explain procedures/ happenings
o Avoid expression of judgemental thoughts & feelings
o Reduce meaningless stimuli eg noise, TV, high traffic areas
o Relieve immediate discomforts
o Provide orientation cues
o Provide meaningful activity

Figure 3. General interventions for VDB in persons with dementia.

MEDICATION STRATEGIES

o Limited goals of therapy, consider as adjunctive

o Low starting doses with slow increases
o Regular doses not PRN
o Risperidone where there is associated aggression and/or psychosis
o SSRI antidepressants if mood or anxiety symptoms
o Avoid benzodiazepines

Figure 4. Medication strategies for VDB in persons with dementia.

as being derived from biomedical models and two et al., 1990; Draper et al., 2000; Hallberg &
from psychosocial theories. Norberg, 1990b) and physical dependency (Burgio
et al., 1994; Cariaga et al., 1991; Cohen-Mansfield
et al., 1990; Cohen-Mansfield & Werner, 1997b;
Neurological change
Draper et al., 2000; Hallberg & Norberg, 1990b;
As with most behavioural changes associated with Jackson et al., 1989; Sloane et al., 1999). Eustace
dementia, VDB occurs more commonly as cognitive and Kidd (2001) found that the presence of paranoid
impairment increases (Burgio et al., 1994; Cohen- and delusional ideation was significantly associated
Mansfield et al., 1990; Draper et al., 2000; Jackson with verbal aggression. Hallberg & Norberg (1990b)
et al., 1989; Sloane et al., 1999). Factors that are in a controlled study of functional impairment
associated with dementia severity may contribute and behavioural disturbances in VDB patients
to VDB. These include psychosis (Eustace & Kidd, found that VDB was significantly associated
2001; Hallberg & Norberg, 1990b), other disturbed with delusions and hallucinations. Serotonergic
behaviours (Cariaga et al., 1991; Cohen-Mansfield dysfunction has been hypothesised as underlying
 Vocally disruptive behaviour in dementia 19

the behaviour (Greenwald, Marin & Silverman, Depression in Dementia found 75% of 22 subjects
1986). compared to 8% of controls scored above the
threshold for depression.
Sensory deprivation and social isolation
Institutional care can be illusory. Despite being Operant learning
surrounded by other residents, staff and visitors, Nursing staff may use the pejorative term ‘attention
some residents are liable to become isolated and seeking’ to describe some of residents with
deprived of social interaction unless appropriate VDB. Attention is a powerful reinforcement of
structured activities are provided. This is particularly VDB (Allen-Burge, Stevens & Burgio, 1999; Doyle,
the case in residents too disabled to organise their Zapparoni, O’Connor & Runci, 1997), though
own social interactions. Hallberg & Luker (1990) the aetiological factors previously described and
and Hallberg & Norberg (1990c) reported social other factors such as the effects of past experiences
isolation to be part of the institutionalised life of a (Cohen-Mansfield & Marx, 1990), premorbid per-
person with dementia. Vocally Disruptive Behaviour sonality (Holst & Hallberg, 1997) and possibly female
has been found to be associated with being left alone gender (Burgio et al., 2000; Eustace & Kidd, 2001;
(Burgio et al., 1994); poor quality of social networks Jackson et al., 1989) are likely to be necessary
(Cohen-Mansfield et al., 1990); sensory impairments precursors. The care styles used by nursing staff are
(Cariaga et al., 1991; Cohen-Mansfield & Marx, implicated (Hallberg, et al., 1990). Numerous short
1988; Sloane et al., 1999); and reduced participation interaction episodes contribute to over-stimulation
in activities (Draper et al., 2000). In another study, (Hallberg & Edberg, 1993). Buchanan & Fisher
residents with VDB received less activating care than (2002) found VDB to be reinforced by attention
controls and 71% of the observed time they were left or maintained by contingent attention in two case
to themselves, reduced to inactivity and solitude studies.
(Hallberg, Norberg & Eriksson, 1990). Hence the These four theories of causation should not be
data support the idea that under stimulation is an viewed independently. Hallberg & Norberg (1990b)
important factor, though the extent to which it is found that VDB was significantly associated with
causal is unclear. physical dependence as well as disorientation in the
ward compared with controls. They suggested that
Expression of discomfort or suffering VDB develops when environmental factors such
as sensory deprivation interact with the effects of
It is not surprising that residents may call out when the brain damage. In many cases there are multiple
in pain and discomfort (Cohen-Mansfield & Werner, causes of VDB and in individual residents, different
1995; Cohen-Mansfield & Werner, 1999). Hallberg causes may be applicable at different times (Meares
& Edberg (1993) found that verbal communication & Draper, 1999).
related to either need for someone, incompetence, Nelson (1995) proposed a model of environmental
protest, help, pain or despair/fear. Cohen-Mansfield factors integrating the effects of: (1) environmental
& Werner (1999) studied longitudinal predictors of stimuli exceeding individual stress threshold;
verbally non-aggressive inappropriate behaviours in (2) unmet basic needs in individuals with low
200 community-dwelling 60–97-year-olds attending deprivation tolerance and (3) psychological reactions
senior day care centres. Depressed affect and pain to perceived threats to the person. Together,
predicted the behaviours. Cariaga et al. (1991) Nelson’s (1995) environmental model and Lai’s
reported that complaint of pain or request for (1999) framework of aetiologies provide a structure
medication by vocally disruptive residents was more for the assessment of aetiology-specific approaches to
likely to be ignored than in non-disruptive controls. VDB for inclusion in the Practice Guideline.
Nelson (1995) identified low tolerance for mild
deprivation, thirst, hunger and room temperature as
sources of discomfort triggering VDB. The use of
physical restraints is also associated with VDB and Management of VDB
may be a source of discomfort (Sloane et al., 1999;
Assessment
Werner, Cohen-Mansfield, Bruan & Marx, 1989).
However there are inconsistent findings on the role Appropriate management of VDB is determined
of medical problems (Cariaga et al., 1991; Draper by an accurate assessment of possible causes that
et al., 2000; Sloane et al., 1999). Depression is will guide treatment decisions. The Typology of
another type of suffering that has frequently been Vocalisations (TOV) is an assessment tool that
found in residents with VDB (Cohen-Mansfield recognises the individuality of behaviour (Cohen-
et al., 1990; Dening, 1991; Dwyer & Byrne, Mansfield & Werner, 1997b). By allowing the
2000; Draper et al., 2000; Friedman, Gryfe, clinician to rate each person’s behaviour on four
Tal & Freedman, 1992). Draper et al., (2000), in dimensions it increases the chances that the aetiology
a controlled study using the Cornell Scale for of the behaviour can be determined and hence
20 B. McMinn & B. Draper

improves the likelihood that the management will assessing, treating or managing VDB and the lack
be appropriate. However, the lack of operational of treatment response of the neurological changes
definition means that clinical knowledge is needed causing disinhibition of language and expression
to inform judgements (Ballard, O’Brien, James & (Appell, Kertesz & Fisman, 1982; Hart, 1990).
Swann, 2001). Edberg & Sandgren (1995) found
that nurses became impatient and stressed by their
patients’ severe communication problems. Draper Psychotropic medication. A number of cross-
et al. (2000) similarly found that VDB was associated sectional studies have shown that VDB is associated
with emotional distress in the nursing staff. Reasons with the prescription of psychotropic medication,
for referral to specialist services were thought to (Cariaga et al., 1991; Draper et al., 2000; Sloane
relate more to the stress experienced by nursing et al., 1999; Sørensen, Foldspang, Gulmann &
home staff in managing VDB than to specific Munk-Jørgensen, 2001). Causality cannot be
attributes of the VDB itself. Assessment of care- imputed from such studies but they do indicate
giver’s reactions and levels of distress should be an that psychotropics often do not solve the problem
important element of a practice guideline. (Burgio, Butler & Engel, 1988; Cariaga et al., 1991;
Draper et al., 2000). There have been no controlled
studies of antidepressant use in VDB despite the
Treatment
frequent association with depression. Furthermore,
There is very limited evidence that any particular most case reports do not specify whether the subjects
intervention is effective in the treatment of VDB. meet any criteria for depression, though the diag-
Most reports are case studies that demonstrate the nosis of depression in severe dementia is often
uncontrolled effects of a specific therapy. However, difficult. Anecdotal clinical reports have frequently
many cases of VDB are highly idiosyncratic and need cited noisy, agitated behaviour as a possible feature
tailor-made approaches (Doyle et al., 1997; Meares of depression in severe dementia (Carlyle & Killick,
& Draper, 1999). In addition, VDB includes a range 1991; Draper, 1999; Greenwald et al., 1986).
of behaviours so it is likely that a range of therapies A summary of studies of psychiatric treatments
will be required. The work of Cohen-Mansfield specifically for vocally disruptive behaviour in
and Werner recognises this by the matching of people with dementia is provided in Table I. There
treatment strategies according to the type of VDB have been a number of controlled trials of the use
as determined by the Typology of Vocalisations of anti-psychotic medication in the treatment of
(Cohen-Mansfield & Werner, 1997b). Audits of behavioural disturbances associated with dementia,
actual clinical practice demonstrate how difficult it but none specifically target VDB (Brodaty et al.,
can be to manage VDB with the use of a large range 2003; De Deyn et al., 1999; Katz et al., 1999). The
of pharmacological and psychosocial strategies, most evidence regarding risperidone in the treatment of
of which were reported to have limited effectiveness VDB is very promising, though controlled studies
(Cariaga et al., 1991; Draper et al., 2003). Many that have it as a primary outcome measure are
nursing home residents with VDB have poor out- required. At this stage though, risperidone is the
comes of treatment. Draper et al. (2003) found that psychotropic with the strongest evidence of efficacy
only 33% of surviving subjects had significant in VDB, particularly when associated with psychotic
reductions in VDB after three months and an average or aggressive features. There are no studies that
of 13–14 interventions. Similarly Sloane et al. (1999) report the use of other atypical anti-psychotics, mood
found staff reported trying a variety of treatments stabilisers, benzodiazepines, other sedative/hypnotic
with all subjects, often with little success. These agents or hormonal agents in the specific treatment
findings reflect both the practical difficulties in of VDB.

Table I. Summary of studies of psychiatric treatments specifically for vocally disruptive behaviour in people with dementia.

Authors Intervention(s) Study design Sample size Results reported

Ramadan & Naughton (1999) Paroxetine Case series 15 70% reduction at three months
Ramadan & Naughton (2000) Paroxetine Case series 15 Reduction in all S’s at one month;
67–71% reduction in five S’s at three months
Pollock et al. (1997) Ciatlopram Case series 14 Reduction in 10/, increase in four;
no mean reduction
Kim et al. (2000) Citalopram Case series 2 ‘Considerable’ reduction in one S.
80% reduction in one S.
Greenwald et al. (1986) Trazodone & l-tryptophan Single case 1 Cessation at 8 weeks
Hottin (1990) Trazodone & l-tryptophan Single case 1 ‘Successful’ (not defined)
Friedman et al. (1992) Doxepin Case series 6 Reduction in five S’s
Kopala & Honer (1997) Risperidone Case series 2 Reduction to <20% baseline
Friedman et al. (1992) Thioridazine, haloperidol Retrospective 11 No response
or perpheazine case audit
Carlyle & Killick (1991) ECT Case series 3 Rapid resolution in all S’s.
 Vocally disruptive behaviour in dementia 21

Other physical treatments. Carlyle & Killick (1991) and removal of an irritating catheter. Clearly the
reported three verbally agitated patients with severe relief of discomfort and suffering, whenever it can
dementia who improved dramatically with ECT, be detected should be an important step in the care
only one of whom appeared to be depressed. of persons with VDB.
An early study reported a single case of recurrent . Sensory deprivation and social isolation. There have
laryngeal nerve surgery after numerous behavioural been many varied efforts designed to overcome
and pharmacological interventions failed to quieten social isolation and consequent boredom and
an 84-year old man’s yelling (Gafner & Robertson, depression in nursing home residents. Some have
1987). There are also anecdotal reports of the been specifically trailed in residents with VDB.
effective use of morphine (Draper et al., 2003). The use of videotapes of family members has been
With pain an identified risk factor for VDB, it is examined in several studies (Cohen-Mansfield &
possibly more surprising that there haven’t been Werner, 1997a; Werner, Cohen-Mansfield,
more reports of the use of opioids. Fischer & Segal, 2000). Reductions were observed
to be greater when the tapes were playing and
when they were associated with affection and not
Psychosocial interventions Numerous psychosocial concerning current events. A number of case
interventions have been used to treat VDB. As with studies have reported effectiveness of music in
physical treatments, the types of intervention trailed reducing VDB (Cohen-Mansfield & Werner,
should be guided by the assessment and be included 1997a; Gerdner & Swanson, 1993; Casby & Holm,
in a care plan. Lindgren & Hallberg (1992) found 1994; Ragneskog & Asplund, 2001). Individual-
that VDB decreased when a nursing treatment plan ized music appears to have some effect in reducing
(focussed on reversing sensory deprivation, social VDB, particularly during the therapy sessions.
isolation, disorientation, altered capacity to express Burgio et al. (1996) used environmental ‘white
needs, reflux discomfort and pain) was followed. noise’ audiotapes. Results indicate a 23% reduc-
Effective leadership, regular supervision of and tion in verbal agitation with this individualized
support to the caregivers were felt to be necessary. treatment strategy. These results were obtained
Similarly, Edberg & Hallberg (2001) in a pilot study even though the audiotapes were used during only
found that individually planned care and systematic 51% of the observations. One limitation of
clinical supervision reduced the frequency of VDB this study was that selection took place in early
and affected nurses attitude and interpretation of phases to identify responders from non-responders
VDB. Roth, Stevens, Burgio & Burgio, (2002) found to the intervention. Only responders went onto
that comprehensive behaviour management and experimental phases, indicating a selection bias.
communication skills training of nursing assistants Cohen-Mansfield & Werner (1997a) reported a
lowered the incidence of agitated episodes including study of 32 nursing home residents with VDB who
VDB during personal care while Burgio et al. (2002) were observed before, during, and after in vivo
found that formal staff management by supervisory social interaction. Vocally Disruptive Behaviour
staff led to the maintenance of behaviour manage- was reduced by 56% during the social interaction
ment skills of nursing assistants and the reduction of and by 16% during the no-intervention phase. In
agitation (including VDB) of the nursing home a study of 41 verbally disruptive nursing home
residents. Using the integrative model of aetiologies residents, Cohen-Mansfield & Werner (1998)
described above, the evidence supporting non- found that talking to the resident about the weather
medical management interventions will be reviewed or about family and reading to the resident was
under the headings of expression of discomfort or more effective for residents who were less cogni-
suffering; sensory deprivation and social isolation; tively impaired. Talking about the past, the
and operant learning. resident’s hobbies, holidays, food, and family were
associated with decreases in VDB. Meaningful and
. Expression of discomfort or suffering. It seems self- personalised interaction and stimulation (conver-
evident that treatment of any discomfort or sation, music, family videotapes) have moderate
suffering should be fundamental in any care plan. evidence to support their implementation as part
Cohen-Mansfield & Werner (1997a) found that of individualised care plans. From the evidence
several subjects with VDB undertaking a thorough available, environmental white noise cannot be
physical examination became quiet after medical recommended as a first line intervention.
treatment of identified conditions. Cariaga et al. . Operant learning. Behaviour therapy is based
(1991) found repositioning to be helpful in on operant learning and assumes that the person
five of 24 residents with VDB. White et al. with dementia still has sufficient cognitive capac-
(1996) reported a case study where attending to ity to learn. Operant treatments of VDB are
discomfort from cold and using preferred foods potentially useful where there is an absence of
relieved VDB. Lindgren & Hallberg (1992) positive consequences (usually no interactions with
describe a single case study with multiple inter- staff) following appropriate behaviour (quietness)
ventions including range of movement exercises and the presence of positive consequences
22 B. McMinn & B. Draper

(interactions with staff) following inappropriate Beck & Vogelpohl, 1999). Meares & Draper (1999)
behaviour (VDB). Operant treatments (including concluded interventions might need to be introduced
differential reinforcement of incompatible behav- simultaneously rather than in succession and often
iour and time-out from positive reinforcement) require the combination of biopsychosocial strategies
have been found to be more acceptable than tailored to the individual case. A series of interven-
drug therapy to both nurses (Burgio, Hardin, tions should be planned on the assumption that each
Sinnott, Janosky & Hohman, 1995a) and elders case is idiosyncratic (Bird et al., 1998). Realistic
(Burgio et al., 1995b). Nursing staff also report goals for improvement should include the acceptance
that contingent attention and conversation are of a residual level of VDB as a reasonable outcome
effective in the short term though doubts exist (Meares & Draper, 1999).
about long term effectiveness (Cariaga et al., Coulson (2000) used focus groups of expert
1991). Doyle et al. (1997) reported a case series clinicians to develop a sequence of questions to
of 12 studying the efficacy of psychosocial inter- identify a probable cause or causes of VDB. White,
ventions in reducing the frequency of VDB. Kaas & Richie (1996) created a decision tree that
Contingent reinforcement of quiet behaviour and directs management including early assessment of
environmental stimulation tailored to individual caregiver responses and general instructions in
preferences resulted in a clear reduction in noise in regard to interaction and environment before con-
three subjects and no reduction in four. Bourgeois, sidering aetiology specific interventions. The result-
Burgio, Schulz, Beach & Palmer (1997) described ing tree provides a sound framework for a problem
using written cues by trained caregivers of home- solving approach to VDB. The guideline that we
dwelling spouses in a controlled trial. Caregivers present here in Figure 1 is built on the decision tree
were successful at decreasing patient repetitions created by White et al. (1996). It uses the aetiological
and the intervention effects lasted for 16 weeks or framework of causation of VDB proposed by Lai
longer. There are a number of case reports on the (1999), incorporates the TOV assessment tool
use of contingent positive reinforcement for quiet- developed by Cohen-Mansfield & Werner (1997b)
ness and modified time out and ignoring (Baltes & and includes the specific interventions identified in
Lascomb, 1975; Birchmore & Clague, 1983; our literature review as being effective.
Christie & Ferguson, 1988; Wanless & Culver,
1990). These have been summarised by Burgio
Conclusion
et al. (1996) as of ‘limited success’. Buchanan &
Fisher (2002) found a ‘modest reduction using There have been a number of recent advances in
relatively rich non-contingent reinforcement sche- knowledge of the aetiology, assessment and manage-
dules’ in two cases. They expressed the opinion ment of VDB. This review aims to provide a concise
that it would be impractical to maintain a fixed summary of the available literature specific to VDB
time schedule of reinforcement in the nursing and to make recommendations based on this sum-
home setting. In summary, because of the financial mary and personal impressions. Our proposed
constraints and staff shortages common in most guideline for the assessment and management of
aged care facilities, interventions must be both easy VDB takes into account these recent advances but
to use and inexpensive (Burgio & Bourgeois, 1992; recognises that the effectiveness of interventions is
Burgio, 1997). Non-contingent reinforcement often limited.
schedules (Buchanan & Fisher, 2002) might not
be practical in residential settings. Contingent
reinforcement for periods of quiet or adaptive References
communication can be recommended on the basis
of numerous case series, with the reservation that Allen-Burge, R., Stevens, A. B., & Burgio, L. D. (1999). Effective
the withdrawal of reinforcement of noisy behaviour behavioral interventions for decreasing dementia-related
challenging behavior in nursing homes. International Journal
is often inconsistently applied. Aversive strategies
of Geriatric Psychiatry, 14 (3), 213–228.
have no supportive evidence and present ethical Appell, J., Kertesz, A., & Fisman, M. (1982). A study of language
problems. Time out may in some cases contribute functioning in Alzheimer’s patients. Brain and Language, 17,
to social isolation that has been identified as an 73–91.
aetiology (Burgio et al., 1994) and therefore Ballard, C. G., O’Brien, J. T., James, I., & Swann, A. (2001).
Dementia: The Management of Behavioural and Psychological
cannot be recommended.
Symptoms. Oxford: Oxford University Press.
Baltes, M., & Lascomb, S. L. (1975). The nurse as a change agent.
International Journal of Nursing Studies, 12, 5–12.
Beck, C. K., & Vogelpohl, T. S. (1999). Problematic vocalisations
Guideline for management in institutionalized individuals with dementia. Journal of
Gerontological Nursing, 25 (9), 17–26.
A number of authors have recommended multi-
Birchmore, T., & Clague, S. (1983). A behavioural approach to
ple approaches to the individual with disruptive reduce shouting. Nursing Times, 79 (16), 37–39.
behaviour in dementia (Bird et al., 1998) and Bird, M., Llewellyn-Jones, R., Smithers, H., Andrews, C.,
VDB (Meares & Draper, 1999; Liu et al., 2000; Cameron, I., Cottee, A., et al. (1998). Challenging behaviours
 Vocally disruptive behaviour in dementia 23
in dementia, a project at Hornsby-Ku-Ring-Gai Hospital. J. Grimley, et al. (Eds.) Dementia and Cognitive Impairments.
Australasian Journal of Ageing, 17, 10–15. New York: Springer.
Bourgeois, M. S., Burgio, L. D., Schulz, R., Beach, S., & Palmer, B. Cohen-Mansfield, J., & Werner, P. (1995). Environmental
(1997). Modifying repetitive verbalizations of community- influences on agitation, an integrative summary of an
dwelling patients with AD. Gerontologist, 37 (1), 30–39. observational study. The American Journal of Alzheimer’s Care
Brodaty, H., Ames, D., Snowdon, J., Woodward, M., Kirwan, J., and Related Disorders and Research, Jan/Feb, 32–39.
Clarnette, R., et al. (2003). A randomized placebo-controlled Cohen-Mansfield, J., & Werner, P. (1997a). Management of
trial of risperidone for the treatment of aggression, agitation verbally disruptive behaviors in nursing home residents. Journals
and psychosis of dementia. Journal of Clinical Psychiatry, 64, of Gerontology, Series A, Biological Sciences & Medical Sciences,
134–143. 52 (6), M369–M377.
Buchanan, J. A., & Fisher, J. E. (2002). Functional assessment and Cohen-Mansfield, J., & Werner, P. (1997b). Typology of
non-contingent reinforcement in the treatment of disruptive disruptive vocalizations in older persons suffering from
vocalization in elderly dementia patients. Journal of Applied dementia. International Journal of Geriatric Psychiatry, 12 (11),
Behavior Analysis, 35 (1), 99–103. 1079–1091.
Burgio, L. D. (1997). Behavioral assessment and treatment of Cohen-Mansfield, J., & Werner, P. (1998). Determinants of the
disruptive vocalization. Seminars in Clinical Neuropsychiatry, effectiveness of one-to-one social interactions for treating
2 (2), 123–131. verbally disruptive behaviors. Journal of Mental Health &
Burgio, L. D., & Bourgeois, M. (1992). Treating severe behavioral Aging, 4 (3), 323–334.
disorders in geriatric residential settings. Behavioral Residential Cohen-Mansfield, J., & Werner, P. (1999). Longitudinal
Treatment, 7 (2), 145–168. predictors of non-aggressive agitated behaviors in the
Burgio, L. D., Butler, F., & Engel, B. T. (1988). Nurses’ attitudes elderly. International Journal of Geriatric Psychiatry, 14 (10),
towards geriatric behavior problems in long-term care settings. 831–844.
Clinical Gerontologist, 7, 3–4. Cohen-Mansfield, J., Werner, P., & Marx, M. S. (1990).
Burgio, L. D., Butler, F. R., Roth, D. L., Hardin, J. M., Screaming in nursing home residents. Journal of the American
Hsu, C.-C., & Ung, K. (2000). Agitation in nursing home Geriatrics Society, 38 (7), 785–792.
residents. The role of gender and social context. International Coulson, J. S. (2000). SHHHH. An expert system for the
Psychogeriatrics, 12 (4), 495–511. management of clients with vocally disruptive behaviour in
Burgio, L. D., Hardin, J. M., Sinnott, J., Janosky, J., & Hohman, dementia. Educational Gerontology, 26, 401–408.
M. J. (1995a). Nurses’ acceptance of behavioral treatments De Deyn, P. P., Rabheru, K., Rasmussen, A., et al. (1999).
and pharmacotherapy for behavioral disturbances in older A randomised trial of risperidone, placebo and haloperidol for
adults. Applied Nursing Research, 8 (4), 174–181. behavioral symptoms of dementia. Neurology, 53, 946–955.
Burgio, L. D., Cotter, E. M., Stevens, A. B., Hardin, J. M., Dening, T. R. (1991). Screaming and shouting in dementia, a
Sinnott, J., & Hohman, M. J. (1995b). Elders’ acceptability neglected problem. Geriatric Medicine, Nov, 13–14.
ratings of behavioral treatments and pharmacotherapy for the Doyle, C., Zapparoni, T., O’Connor, D., & Runci, S. (1997).
management of geriatric behavioral disturbances. Gerontologist, Efficacy of psychosocial treatments for noisemaking in severe
35 (5), 630–636. dementia. International Psychogeriatrics, 9 (4), 405–422.
Burgio, L. D., Scilley, K., Hardin, J., Janosky, J. H., Bonino, P., Draper, B., Snowdon, J., Meares, S., Turner, J., Gonski, P.,
Slater, S. C., et al. (1994). Studying disruptive vocalization and McMinn, B., et al. (2000). Case-controlled study of nursing
contextual factors in the nursing home using computer-assisted home residents referred for treatment of vocally disruptive
real-time observation. Journal of Gerontology, Psychological behavior. International Psychogeriatrics, 12 (3), 333–344.
Sciences, 49 (5), P230–P239. Draper, B., Turner, J., McMinn, B., Gonski, P., McIntosh, H.,
Burgio, L., Scilley, K., Hardin, J. M., Hsu, C., & Yancey, J. Latham, L., et al. (2003). Outcome of treatment of vocally
(1996). Environmental ‘white noise’, an intervention for disruptive behaviour in nursing home residents. Australasian
verbally agitated nursing home residents. Journals of Journal of Ageing, 22 (2), 81–85.
Gerontology, Series B, Psychological Sciences & Social Sciences, Draper, B. (1999). The diagnosis and treatment of depression in
51 (6), 364–373. dementia. Psychiatric Services, 50, 1151–1153.
Burgio, L. D., Stevens, A. B., Burgio, K. L., Roth, D. L., Paul, P., Dwyer, M., & Byrne, G. J. (2000). Disruptive vocalization and
& Gerstle, J. (2002). Teaching and maintaining behavior depression in older nursing home residents. International
management skills in the nursing home. Gerontologist, 42 (4), Psychogeriatrics, 12 (4), 463–471.
487–496. Edberg, A., & Hallberg, I. R. (2001). Actions seen as demanding
Cariaga, J., Burgio, L. D., Flynn, W., & Martin, D. (1991). in patients with severe dementia during one year of intervention.
A controlled study of disruptive vocalizations among geriatric Comparison with controls. International Journal of Nursing
residents in nursing homes. Journal of the American Geriatrics Studies, 38, 271–285.
Society, 39 (5), 501–507. Edberg, A., & Sandgren, A. N. (1995). Initiating and terminating
Carlyle, W., & Killick, L. (1991). ECT: an effective treatment in verbal interaction between nurses and severely demented
the screaming demented patient. Journal of the American patients regarded as vocally disruptive. Journal of Psychiatric &
Geriatrics Society, 39 (6), 637. Mental Health Nursing, 2 (3), 159–167.
Casby, J. A., & Holm, M. B. (1994). The effect of music on Eustace, A., & Kidd, N. (2001). Verbal aggression in
repetitive disruptive vocalizations of persons with dementia. Alzheimer’s disease, Clinical, functional and neuropsycholo-
American Journal of Occupational Therapy, 48 (10), 883–889. gical correlates. International Journal of Geriatric Psychiatry, 16
Christie, M., & Ferguson G. (1988). Can’t anyone stop that (9), 858–861.
screaming? Canadian Nurse, 84 (9), 30–32. Everitt, D. E., Fields, D. R., Soumeria, S. S., & Avorn, J. (1991).
Cohen-Mansfield, J., & Marx, M. S. (1988). Relationship between Resident behavior and staff distress in the nursing home. Journal
depression and agitation in nursing home residents. of the American Geriatrics Society, 39 (8), 792–798.
Comprehensive Gerontology, 2, 141–146. Friedman, R., Gryfe, C. I., Tal, D. T., & Freedman, M. (1992).
Cohen-Mansfield, J., & Marx, M. S. (1990). Do past experiences The noisy elderly patient, prevalence, assessment and response
predict agitation in nursing home residents? International to the anti-depressant Doxepin. Journal of Geriatric Psychiatry
Journal of Human Development, 28 (4), 285–294. and Neurology, 4, 187–191.
Cohen-Mansfield, J., & Werner, P. (1994). Verbally disruptive Gafner, G., & Robertson, G. S. (1987). Surgery to quieten the
behaviours in elderly persons—A review. In B. J. Vellas, yelling of a demented old man. Journal of Medical Ethics, 13,
J. L. Albarede, P. J. Garry, L. J. Fitten, A. J. Campbell, 195–200. (Cited in Dening, T. R. (1991). Screaming and
24 B. McMinn & B. Draper
shouting in dementia, a neglected problem. Geriatric Medicine, home resident with dementia. Annals of Long Term Care, Clinical
Nov, 13–14). Care and Aging, 8 (5), 66–70.
Gerdner, L. A., & Swanson, E. A. (1993). Effects of individualized Meares, S., & Draper, B. (1999). Treatment of vocally disruptive
music on confused and agitated elderly patients. Archives of behaviour of multifactorial aetiology. International Journal of
Psychiatric Nursing, 7 (5), 284–291. Geriatric Psychiatry, 14 (4), 285–290.
Greenwald, B. S, Marin, D. B., & Silverman, S. M. (1986). Nelson, J. (1995). The influence of environmental factors in
Serotonergic treatment of screaming and banging in dementia. incidents of disruptive behavior. Journal of Gerontological
Lancet, 2, 1464–1465. Nursing, 21 (5), 19–24.
Hallberg, I. R., & Edberg, A. K. (1993). Daytime vocal activity in Plesk, P. E., & Greenhalgh, T. (2001). The challenge of
institutionalised severely demented patients identified as vocally complexity in healthcare. British Medical Journal, 323, 625–628.
disruptive by nurses. International Journal of Geriatric Psychiatry, Pollock, B. G., Mulsant, B. H., Sweet, R., Burgio, L., Kirshner,
8 (2), 155–164. M. A., Shuster, K., et al. (1997). An open pilot study of
Hallberg, I. R., & Luker, K. A. (1990). Staff interaction citalopram for behavioural disturbances in dementia, plasma
with vocally disruptive demented patients compared with levels and real time observations. American Journal of Geriatric
demented controls. Aging Clinical & Experimental Research, Psychiatry, 5 (1), 70–78.
2 (2), 163–171. Ragneskog, H. R. N., & Asplund, K. R. N. D. (2001).
Hallberg, I. R., & Norberg, A. (1990a). Staffs’ interpretation of the Individualized music played for agitated patients with dementia.
experience behind vocally disruptive behavior in severely Analysis of video-recorded sessions. International Journal of
demented patients and their feelings about it, an explorative Nursing Practice, 7 (3), 146–155.
study. International Journal of Aging & Human Development, Ramadan, F. H., & Naughton, B. J. (1999). Paroxetine for verbal
31 (4), 295–305. agitation. Annals of Long Term Care, 7 (7), 282–286.
Hallberg, I. R., & Norberg, A. (1990b). Functional impairment Ramadan, F. H., & Naughton, B. J. (2000). Treatment of verbal
and behavioural disturbances in vocally disruptive patients in agitation with a selective serotonin reuptake inhibitor. Journal of
psychogeriatric wards compared with controls. International Geriatric Psychiatry & Neurology, 13 (2), 56–59.
Journal of Geriatric Psychiatry, 5 (1), 53–61. Roth, D. L., Stevens, A. B., Burgio, L. D., & Burgio, K. L.
Hallberg, I. R., & Norberg, A. (1990c). Verbal interaction during (2002). Timed event sequential analysis of agitation in nursing
the lunch-meal between caregivers and vocally disruptive home residents during personal care interactions with nursing
demented patients. The American Journal or Alzheimer’s Care assistants. Journal of Gerontology, Psychological Sciences, 57B (5),
and Related Disorders and Research, May/June, 26–32. P461–P468.
Hallberg, I. R., & Norberg, A., & Eriksson, S. (1990). A Ryan, D. P., Tainsh, S. M., Kolodny, V., Lendrum, B. L., &
comparison between the care of vocally disruptive patients Fisher, R. H. (1988). Noise-making amongst the elderly in
and that of other residents at psychogeriatric wards. Journal of long-term care. Gerontologist, 28 (3), 369–371.
Advanced Nursing, 15 (4), 410–416. Sloane, P. D., Davidson, S. Buckwalter, K., Lindsey, B. A.,
Hart, S. B. (1990). Language and dementia, a review. Psychological Ayers, S., Lenker, V., et al. (1997). Management of the patient
Medicine, 18, 99–112. with disruptive vocalization. Gerontologist, 37 (5), 675–682.
Holst, G., & Hallberg, I. R. (1997). The relationship of vocally Sloane, P. D., Davidson, S., Knight, N., Tangen, C., & Mitchell,
disruptive behavior and previous personality in severely C. M. (1999). Severe disruptive vocalizers. Journal of the
demented institutionalised patients. Archives of Psychiatric American Geriatrics Society, 47 (4), 439–445.
Nursing, 11 (3), 147–154. Sørensen, L., Foldspang, A., Gulmann, N. C., & Munk-
Hottin, P. (1990). Pharmacotherapy to control agitation in Jørgensen, P. (2001). Determinants for the use of psychotropics
patients with cognitive deficits. Canadian Journal of Psychiatry, among nursing home residents. International Journal of Geriatric
25, 270–272. Psychiatry, 16, 147–154.
Jackson, M. E., Drugovich, M. L., Fretwell, M. D., Spector, Wanless, W., & Culver, S. (1990). Behavior modification in a
W. D., Sternberg, J., & Rosenstein, R. B. (1989). Prevalence demented nursing home patient. Journal of the American
and correlates of disruptive behaviour in the nursing home. Geriatric Society, 38 (8), A18.
Journal of Aging and Health, 1 (3), 349–369. Werner, P., Cohen-Mansfield, J., Bruan, J., & Marx, M. (1989).
Katz, I. R., Jeste, D. V., Mintzer, J. E. et al., for the Risperidone Physical restraints and agitation in nursing home residents.
Study Group. (1999). Comparison of risperidone and placebo Journal of the American Geriatric Society, 37, 1122–1126.
for psychosis and behavioral disturbances associated with Werner, P., Cohen-Mansfield, J., Fischer, J., & Segal, G. (2000).
dementia, a randomized double-blind trial. Journal of Clinical Characterization of family-generated videotapes for the manage-
Psychiatry, 60, 107–115. ment of verbally disruptive behaviors. Journal of Applied
Kim, K. Y., Bader, G. M., & Jones, E. (2000). Citalopram for Gerontology, 19 (1), 42–57.
verbal agitation in patients with dementia. Journal of Geriatric Werner, P., & Cohen-Mansfield, J. (1999). Auditory perceptions
Psychiatry & Neurology, 13 (2), 53–55. of vocalizations manifested by verbally agitated nursing home
Kopala, L. C., & Honer, W. G. (1997). The use of risperidone residents. Aging & Mental Health, 3 (1), 50–53.
in severely demented patients with persistent vocalizations. Whall, A. L., Gillis, G. L., Yankou, D., Booth, D. E., & Beel-
International Journal of Geriatric Psychiatry, 12 (1), 73–77. Bates, C. A. (1992). Disruptive behaviour in elderly nursing
Lai, C. K. Y. (1999). Vocally disruptive behaviors in people home residents, a survey of nursing home staff. Journal of
with cognitive impairment, current knowledge and future Gerontological Nursing, 18 (10), 13–17.
research directions. American Journal of Alzheimer’s Disease, White, M. K., Kaas, M. J., & Richie, M. F. (1996). Vocally
14 (3), 172–180. disruptive behavior. Journal of Gerontological Nursing, 22 (11),
Lindgren, C., & Hallberg, I. R. (1992). Diagnostic reasoning 23–29.
in the care of a vocally disruptive severely demented patient. Zimmer, J. G., Watson, N. N., & Treat, A. (1984). Behavioral
Scandinavian Journal of Caring Sciences, 6 (2), 97–103. problems among patients in skilled nursing facilities. American
Liu, D. M., Raji, M. M., Twersky, J., & Riggs, A. (2000). Case Journal of Public Health, 74 (10), 1118–1121.
report. Disruptive vocalization due to gout in an elderly nursing