LAUSR

Neuropsychiatric symptoms in dementia have detrimental consequences for patients and their families (Dyer et al., 2018; Feast et al., 2016). Apathy is one of themost prevalent symptoms in dementia, associated with adverse outcomes (Siafarikas et al., 2018). It is prevalent in 20–80% (depending on the study) of patients with dementia and is associated with increased disability, low quality of life, impaired interpersonal relationships, increased caregiver burden, and high mortality risk (Lanctot et al., 2017; Lyketsos et al., 2000; Mohammad et al., 2018; Vilalta-Franch et al., 2013). Finding ways to reduce apathy may provide relief to patients with dementia and help them in engaging in activities, decreasing isolation, and improving functioning. Despite the significance of reducing apathy in this population, evidence-based non-pharmacological interventions are sparse (Brodaty and Burns, 2012). In a review of non-pharmacological interventions for outcomes related to apathy, Brodaty et al found that potential elements of successful interventions include multisensory stimulation, creative activities, and special care programming (Brodaty and Burns, 2012). Because patients with dementia spent a significant amount of time within their “home” environment (either in their private residence or facility) and environmental factors affect their behavior, understanding the role of the environment and environmental stimulation is critical in developing non-pharmacological interventions for apathy in dementia. In this issue of International Psychogeriatrics, Jao et al. (2019) evaluated the association between environmental stimulation and apathy in nursing home residents with dementia. The authors evaluated 104 video observations of staff caregiver− resident interaction (63 unique caregiver− resident dyads) in 12 nursing homes; one or two baseline observations for each caregiver− resident dyad were examined from the Changing Talk randomized controlled trial. The videos focused on routine-care activities, including “bathing, eating, dressing, oral care, transferring, toileting,” and ranged in duration from one-half to 10 minutes. Different nursing students coded the videos; the raters had already achieved 90% interrater agreement on previous practice videos. Apathy was measured with the Apathy subscale of the Person-Environment Apathy Rating (PEAR)-Apathy scale (Jao et al., 2016), which was developed by the authors and demonstrated very good psychometric properties. Different verbal and non-verbal aspects of apathy were evaluated, including facial expression, eye contact, physical engagement, purposeful activity, verbal tone, and verbal expression. Environmental stimulation was assessed with the PEAR-Environment subscale, which included six items: stimulation clarity (i.e. stimulation is discernible and straightforward), stimulation strength (i.e. stimulation is strong and unique), stimulation specificity (i.e. stimulation is specifically delivered and tailored to the participant), interaction development (i.e. stimulation involves interaction with the participant), physical accessibility (i.e. stimulation is present at an accessible distance), and environmental feedback (i.e. stimulation intends to prompt or encourage the participant’s reaction). Residents of the nursing homes were primarily Caucasian females averaging 86 years old, with moderate to severe stage of dementia. Staff caregivers were also primarily Caucasian females averaging 36 years old and were registered nurses, certified nursing assistants, or certified medication aides, with wide range of clinical experience (1–46 years, average= 11 years). Results demonstrated that the overall quality of environmental stimulation was not associated with apathy, before or after controlling for resident characteristics. When individual environmental stimulation characteristics were examined, higher degree of environmental feedback was significantly associated with lower levels of apathy. None of the other individual items was significantly associated with apathy after controlling for resident characteristics, but higher stimulation specificity was significantly associated with lower levels of apathy only before controlling for resident characteristics. The results provide support that increased environmental feedback is associated with lower levels of apathy. The take-home message is that it is important for caregivers to pay attention to the two-way communication with patients in a nursing home environment, and even patients with advanced International Psychogeriatrics (2019), 31:8, 1077–1080 © International Psychogeriatric Association 2019