Aims: Exploratory research was conducted on the use of a sensory integration technique known as the Wilbarger Protocol with dementia patients in a secured long-term care unit to learn about the impact this may have on agitated behavior.

Methods: Ten randomly selected research participants from a 28-bed secured unit participated in a single case design study that involved a thirty-day baseline phase and a thirty-day intervention phase. Staff completed daily charting related to frequency of behavior, intensity was measured with use of the Agitated Behavior Scale also completed once daily.

Results: There was not a noted statistical difference, based on calculation of effect size, between baseline phase and intervention phase in any of the participants in frequency or intensity of behavior. Observations during actual implementation and staff interviews post study indicated efficacy of the technique. However, this effect did not continue throughout the duration of the targeted shift time.

Conclusion: More studies need to be conducted related to incorporating sensory integration with people who have dementia-related agitated behavior. According to direct observation and staff interviews the technique was helpful for short periods of time but effects “wore off” in a matter of minutes. Within the parameters of this study there was no statistically significant difference between the documentation of participants that was completed during the baseline phase versus the intervention phase indicating that the technique as implemented was not overall effective in reducing agitated behavior for extended periods of time.

Keywords: Agitated behavior; Dementia; Sensory integration; Wilbarger Protocol

It has been found that up to 90% of people with dementia present with verbal or physical aggression [1,2]. It is important to note that the target of the aggressive acts is often also highly vulnerable. While there are a small number of residents who account for most negative interactions, there can be substantial impact from these acts of aggression [3,4]. For instance, Caspi [5] examined the circumstances surrounding the deaths of 105 resident-to-resident incidents connected to dementia in long-term care homes and earlier Franco and Messinger-Rapport [6] noted similar findings about 40 deaths that were directly linked to negative resident-to-resident interactions.

There are several theoretical approaches that caregivers have turned to in an effort to eliminate or alleviate the frequency, intensity, duration or persistence of behavioral symptoms of dementia such as Medication Management, Reality Orientation, Sensory Integration, Therapeutic Recreation, Behavior Therapy, and Palliative Care but these are not consistently effective. Many interventions that support these theoretical perspectives tend to integrate and overlap so it may seem difficult to distinguish which perspective is directing an aspect of care.

The Centers for Medicare & Medicaid Services [7] has established that long-term care facilities are to be given deficiencies if they fail to establish or implement a plan of care for non-pharmacological interventions for agitation and behavior. With this, the nursing home settings must employ one or more options listed above. One option is to employ interventions such as the Wilbarger Protocol, or more simply, brushing. The Wilbarger Protocol is a sensory integration treatment that is designed to provide tactile and proprioceptive stimulation. The original protocol, designed to treat sensory defensiveness in children with autism, consisted of application every two hours during all waking hours for a two-week period and titrated down to application on as needed basis. While this was the original design, the literature also notes that single applications are used within practice to ease discomfort prior to a stressful event [8]. The complete protocol usually takes 2-3 minutes to administer. It typically involves using a soft, plastic, sensory brush which is run over the individual's skin, applying pressure similar to that of a deep pressure massage. Brushing normally starts at the arms and works down to the feet. More sensitive areas such as the face, chest, or stomach area are never brushed as they are more likely to cause adverse reactions.

The research in application of brushing with people who have dementia is limited. What is known is that people with dementia do respond with a reduction in agitated behavior to sensory integration treatments [9-11]. The most effective way to implement this treatment is through mechanical stimulation of body tissues as this is noted to provide “major afferent input to the dorsal column” [12]. The dorsal column is the part of the spinal cord that receives tactile/proprioceptive sensory input and sends it to the brain [12]. Shalita et al. [13] notes that there are three ways to appeal to the tactile sensory threshold-thermal, thermal pain and mechanical. The Wilbarger Protocol is a method of providing mechanical stimulation that has been shown to modulate CNS arousal. In Kimball’s study, this was shown clearly with pre- and post-tests of salivary cortisol levels. Measurements of the amount of salivary cortisol present in research participants was noted either elevated or below normal levels prior to implementation of the treatment. A sample taken fifteen minutes post treatment showed decreases or increases towards a normal level [8]. Cortisol is the hormone that is secreted as a result of stressful stimuli, it is the cause for the arousal of the CNS or what is commonly referred to as the “fight or flight” response. Prolonged stages of elevated cortisol cause a decreased threshold for stimuli and a sense of hypervigilance which typically is relieved with habituation [14]. The fact that a simple and cost-effective mechanical stimulation treatment in the form of brushing is able to modulate cortisol and depress arousal of the sympathetic nervous system is encouraging news for people with dementia and their caregivers.

Brushing has been applied in numerous populations that present with agitated behavior and has resulted in a significant decrease in disruptive behaviors [15]. It has been noted to improve outcomes in people with autism and other intellectual disabilities, adolescents with behavioral issues, Post-Traumatic Stress Disorder, Dissociative Disorder, Borderline Personality Disorder, Anxiety, Schizophrenia and Schizoaffective Disorder, and in patients with self-harming behaviors [16-19]. In fact, this intervention was developed for children with autism and has had multiple studies devoted to the topic, yet high quality evidence is limited [20]. The research in application of brushing with people who have dementia is even more limited. What is known is that people with dementia do respond with a reduction in agitated behavior to sensory integration treatments [9-11,21-25]. Heyn [26] also notes that people who participated in a multisensory exercise program had an improvement in mood and resting heart rate. It is evident that sensory interventions promote the well-being of people with dementia [27]. Given the fact that brushing appeals to the part of the brain that remains intact throughout progression of dementia, the success of this treatment with varied populations, the desirable response in people with dementia to other forms of sensory integration, and the push towards reduction in use of medication treatments, it is reasonable to hypothesize that use of the Wilbarger Protocol may serve as a practical treatment to reduce agitated behavior in people who have dementia. A review of the professional literature suggests this is the first study designed to examine the relationship between the Wilbarger Protocol and dementia patients. Thus, this study was designed to examine the effectiveness of using the Wilbarger Protocol in reducing the frequency and intensity of agitated behavior in people with dementia.

In order to investigate the efficacy of utilizing the Wilbarger Protocol in reducing agitated behavior a single case design was developed involving direct implementation with nursing home residents who have dementia and reside in a specialized memory care unit. The study was approved by the Institutional Review Board at the University of North Dakota on February 26th, 2016 and was also approved by the Administrator as well as the Medical Director of Valley Memorial Homes, a residential long-term care provider within a week of university approval.

Participants: The research participants consisted of ten residents of a secured memory care unit. Fourteen of twenty-eight resident names were randomly selected and ten ultimately participated. Two were male and eight were female. The average age was 86 years ranging from 73-93 years. All participants had a medically supported diagnosis of dementia with an average of 9.6 additional co-morbidities.

Measurements: Behavior was measured on a daily basis for 30 days prior to the intervention to establish a baseline and then daily during the 30-day intervention phase for a total of 60 days. Frequency of behavior was measured via daily nurse aide charting based on the items measured for the purposes of the Minimum Data Set (MDS) a federally standardized frequency measure of behavioral symptoms within a nursing home setting. Staff charted on a flow sheet throughout the day each time any of the following occurred: Repetitive Movements, Yelling/Screaming, Kicking/Hitting, Pushing, Grabbing, Pinching/Scratching/Spitting, Biting, Wandering, Abusive Language, Threatening Behavior, and Rejection of Care. For the purposes of this study flow sheet charting for the afternoon/evening shift that occurred from 2:00 PM to 10:00 PM was compiled. Intensity of behavior was measured via the Agitated Behavior Scale (ABS) which was filled out daily by the staff on the evening shift. The ABS consists of fourteen items rated on a Likert-type scale from 1 to 4 that has been noted to have good validity and reliability measures for institutionalized adults with dementia [7,28]. For measurement of the group one daily total was established each day for all ten participants. Scores for frequency measures could start at 0, which would indicate no documented behavioral issues on the shift for any of the ten participants up to an undetermined amount but the highest noted group number for a one-day interval was 28. Scores for intensity measures could start at 140, which would indicate no documented behavioral issues up to a maximum daily total of 560. Data was complete for the full sixty-day period.

Intervention: During the intervention phase the Wilbarger Protocol was applied by the principal investigator three times a day for thirty days consecutively. This was implemented on all 10 participants starting at approximately 1:30 in the afternoon until approximately 7:00 in the evening. This time of the day was selected because most agitated behavior in people with dementia occurs in the late afternoons and early evenings [6]. There was a space of 1.5 to 2.5 hours between each individual participant’s treatments and all treatments were completed by the principal investigator so as to control for any variation of technique.

Evaluation: Data was inputted into Excel spreadsheets. This program was used to calculate mean, standard deviation and effect sizes (Cohen’s d) for the baseline and intervention phases of each participant for both frequency measurements and intensity measurements. Effect size is noted by Allison, Silverstein, and Gorman to be an accurate index of magnitude of change and can also imply correlation therefore this was the method used to evaluate effectiveness of the intervention. In addition, Microsoft Excel was used to calculate the mean, standard deviation and effect size for the group data as a whole by summing daily cumulative scores and using each total as a data point.

The calculated effect sizes indicated no statistically significant difference between baseline and intervention phases of this study for any of the participants or for the group as a whole. This would indicate that over the course of an evening shift, the Wilbarger Protocol did not impact levels of frequency or intensity in documented and measured agitated behavior.

Frequency: Group effect size for frequency was calculated at 0.25 indicating a moderate increase in documented and measured agitated behavior during the intervention phase. On Figure 1, the X axis reflects each day as a separate interval and the Y axis shows the cumulative behavioral symptoms documented on the flow sheet during the designated PM shift from all research participants over the course of 60 days. As it relates to individual effect sizes for frequency of agitated behavior effect sizes varied from -0.11 to 1.26. Two of the ten participants had a slight decrease (-0.08 and -0.11) while 6 reflected an increase (0.16, 0.11, 0.24, 0.07, 1.26, 0.16). Two of the participants had no change noted at all.

Figure 1: Group Frequency; X axis: day of the study; Y axis: average number of behavioral symptoms as measured by the minimum daily set.

Intensity:  Group effect size for intensity was also calculated at 0.25 indicating a moderate increase in documented and measured agitated behavior during the intervention phase.  On Figure 2, the X axis reflects each daily interval while the Y axis indicates cumulative daily score of the ABS among all participants. As it relates to individual effect sizes for intensity of agitated behavior effect sizes varied from -0.74 to 1.17.  Three of the ten participants had a slight decrease (-0.07, -0.18 and -0.26).  One had a statistically significant decrease (-0.74).  Six participants reflected an increase (0.03, 0.27, 0.29, 0.44, .87, 1.17).

Figure 2: Group Intensity; X axis: day of the study; Y axis: intensity of behavioral symptoms as measured by the Agitated Behavior Scale.

This project is the first of its kind as it relates to application of the Wilbarger Protocol in people with dementia. Although initial results appear discouraging, with adjustments to timing and participant selection, it appears this could be found to be a useful tool in reducing agitated behavior, caregiver and patient injuries, medication use and adverse events, and decrease in deficiencies for care facilities. Staff noted immediate and short-lived benefits for this protocol, however, this was not found to benefit participants throughout the full duration of an 8-hour shift. This is consistent with other findings related to implementation of sensory stimulation [9,29]. Going back to the concept of Sultana et al., [30] physioneurosis, it should be considered that agitated behavior is actually a startle response to stimuli due to a nearly constant state of arousal of the CNS. With this in mind, a study that involved training staff to implement the treatment a short time before a triggering event and measuring behavioral responses during the event may be a more accurate reflection of effectiveness. Many of the research participants had minimal to no agitated behavior noted during the baseline phase which made a reduction in agitated behavior nearly impossible. Random selection typically strengthens the ability to generalize results however random selection from a pool of people who have a history of pattern of agitated behavior may have shown better accuracy at reduction.

While this particular study did not reflect statistical significance, staff and the principal investigator observed significant benefits from use of the Wilbarger protocol. However, this research was designed as the culminating experience for the graduate program of the principal investigator so she was limited to the quantitative measures alone and these observations could not be further examined through a mixed methods design utilizing qualitative techniques. There appears to be promise in a 3-minute individualized intervention with a reusable 8-dollar brush and no adverse consequences versus currently existing interventions, however, a more effective mixed methods design of capturing and illustrating that promise needs to be utilized.

Despite promising efforts in medical research towards curing or preventing dementia, it is a reality of our society that is growing in prevalence every day as the overall population ages. The epidemic proportions of this projection could be globally catastrophic in the sense that there will be many people with limited cognitive capacity relying on reflexes and instincts while utilizing massive amounts of societal resources. Someday the technology will exist that can cure or prevent this pervasive disease however current providers need tools to care for the most problematic aspect of dementia-agitated behavior. The Wilbarger Protocol is a cost-effective intervention that could be easily implemented within long term care settings to reduce agitated behavior and the adverse consequences. This study, and more like it may be warranted and could ultimately allow for increased resources to be allocated towards the goal of curative or preventative treatment.

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Corresponding author: Dr. Randall Nedegaard, California State University, Fresno, USA.

Copyright: © 2021 All copyrights are reserved by Randall Nedegaard, published by Coalesce Research Group. This work is licensed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.