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CRITICALLY APPRAISED PAPER (CAP) WORKSHEET
General Instructions: Please insert your responses in the boxes provided, which will expand if
more room is needed. If information requested is NOT REPORTED in the article, use “NR” as
the response.
CITATION:
Swanson, E., Maas, M., & Buckwalter, K. (1994). Alzheimer’s residents cognitive and
functional measures. Clinical Nursing, 3, 27-41
FOCUSED QUESTION:
What is the effect of environmentally-based interventions on performance, affect, and behavior
(Montessori, Snoezelen, ESP, and Progressively-Lowered Stress Threshold) in both the home
and institutions?
PROBLEM STATEMENT (JUSTIFICATION OF THE NEED FOR THE STUDY)
1. Special care units have been identified as a needed intervention for residents with
Alzheimer’s disease in nursing homes.
2. Structured therapeutic environments improve the function of residents with Alzheimer’s
disease (AD)
3. There have been improvements in social interaction behaviors of AD residents on SCU’s
as opposed to non-SCU environments.
4. Early support for a positive effect of the SCU environment on residents’ cognitive and/or
functional abilities was generated from less rigorous, mostly single group studies without
controls.
5. Documentation of positive effects of SCU’s (special care unit) on residents’ cognitive
and functional abilities when standardized measures were used has been inconsistent.
State the problem the authors are investigating in this study.
What are the effects of the special care unit (SCU) on residents with Alzheimer’s disease who
lived on the SCU and on traditional (integrated) nursing home units?
RESEARCH OBJECTIVE(S)
List study objectives.
1. To evaluate the effects of the SCU intervention
2. To report data from a larger research project examinig the effects of a SCU
environment on residents with Alzheimer’s disease, their family members and staff
caregivers
3. To report comparisons of standardized assessments of cognitive and functional abilities
of residents on an SCU and on non-SCU’s.
AOTA Evidence-Based Literature Review Project CAP Worksheet.5-05
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Describe how the research objectives address the focused question.
This study looks the effects of an environmentally-based intervention, special care units, on
behavior, mood, and cognition.
DESIGN TYPE:
Non-equivalent groups, quasi-experimental design with 2 pretests and 2 posttests.
Level of Evidence:
Non-randomized control trial (with pretest and posttest) with 2 group. LEVEL II
Limitations (appropriateness of study design):
Was the study design type appropriate for the knowledge level about this topic? If no, explain.
Yes X
No
SAMPLE SELECTION
How were subjects selected to participate? Please describe
Inclusion Criteria
1. Dementia confirmed by a neuropsychological examination.
2. No history of major psychiatric illness or mental retardation.
3. A score of 3 to 6 on the Global Deterioration Scale (GDS) for Age Associated Decline
and AD (Reisberg, Ferris, deLeon, & Crook, 1982).
4. A score above 20 on the cognitive subscale and above 10 on the non-cognitive subscale
of the Alzheimer’s Diseases Assessment Scale (ADAS) (Rosen, Mohs, & Davis, 1984).
Exclusion Criteria
1. Resident was or became non-ambulatory
2. Resident was in the beginning or late stages of Alzheimer’s disease (Middle stages only)
Sample Selection Biases: If yes, explain.
Volunteers/Referrals
Yes X- All residents with irreversible dementia and those on the waiting list for
admission to the facility who met the study criteria were invited to participate.
No
Attention
Yes X- According to the others, the design does not control as well for variables other
than the SCU intervention that might explain any outcomes observed, but feel it is
superior to no systematic evaluation of the data.
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No
Others (list and explain):
SAMPLE CHARACTERISTICS
N=
% Dropouts NR
#/ (%) Male 20/90% #/ (%) Female 2/10%
Ethnicity Caucasian
Disease/disability diagnosis Middle stage of Alzheimer’s Disease
Check appropriate group:
<20/study 20–50/study 51–100/study 101–149/study 150–200/study
group group group group group
Sample Characteristics Bias: If no, explain.
If there is more than one study group, was there a similarity between the groups?
Yes X- All residents were in the middle stages of Alzheimer’s disease, were
ambulatory and had similar pretrial scores.
No
Were the reasons for the dropouts reported?
Yes X
No
INTERVENTION(S)—include only those interventions relevant to answering the evidence-
based question
Add groups if necessary
Group 1
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Brief Description A self-contained unit for ambulatory AD residents, designed to segregate
AD residents from non-demented residents, and to allow unrestricted safe
wandering on the unit. Sensory stimuli was controlled by keeping traffic
and noise at a minimum, by playing soothing music, and quiet, yet pleasant
décor of designs, textures and colors. Each staff member received 40
classroom hours and 40 supervised clinical practicum hours and was
assigned to the SCU unit and did not rotate on to other units
Setting Special Care Unit of a nursing home
Who Delivered? Registered Nurses, licensed practical nurses, nursing assistants, unit clerk,
activities therapist that did not rotate to other areas of the nursing home.
Frequency? 24-hours
Duration? 4 months prior and 4 months following the opening of the SCU
Group 2
Brief Description Demented residents integrated into the non-SCU traditional units.
Setting Traditional unit of a nursing home
Who Delivered? Registered Nurses, licensed practical nurses, nursing assistants, unit clerk,
activities therapist that did not rotate to other areas of the nursing home.
Frequency? 24-hours
Duration? 4 months prior and 4 months following the opening of the SCU
Intervention Biases: Explain, if needed.
Contamination
Yes NR
No
Co-intervention
Yes NR
No
Timing
Yes X- With the progression of Alzheimer’s disease and the length of the study was
conducted over 8 months on individuals in the middle stages.
No
Site
Yes NR
No
Use of different therapists to provide intervention
Yes
No X- same staff through the entire process
AOTA Evidence-Based Literature Review Project CAP Worksheet.5-05
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MEASURES AND OUTCOMES
Complete for each relevant measure when answering the evidence-based question:
Name of measure:
Alzheimer’s Disease Assessment Scale (ADAS)
Outcome(s) measured (what was measured?):
Assess the cognitive and non-cognitive functioning of residents with AD and evaluates the
severity of cognitive and non-cognitive behavioral dysfunctions.
Is the measure reliable (as reported in article)?
Yes X
No
Not reported
Is the measure valid (as reported in article)?
Yes X
No
Not reported
How frequently was the measure used for each group in the study?
The measure was given on bi-monthly bases prior to and following the opening of the SCU.
Post-SCU measures began in the 5 month to allow for the effects of relocation to the SCU to
dissipate.
Measurement Biases
Were the evaluators blinded to treatment status? If no, explain.
Yes
No X- The staff were not blind to the residents who were on traditional units versus
the special care unit.
Recall or memory bias If yes, explain.
Yes
No X
Others (list and explain):
Limitations (appropriateness of outcomes and measures) If no, explain.
Did the measures adequately measure the outcome(s)?
Yes X
No
AOTA Evidence-Based Literature Review Project CAP Worksheet.5-05
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Name of measure:
Global Deterioration Scale (GDS) for Age Associated Decline and AD
Outcome(s) measured (what was measured?):
Was used to measure cognitive status of individuals with AD
Is the measure reliable (as reported in article)?
Yes
No
Not reported X
Is the measure valid (as reported in article)?
Yes
No
Not reported X
How frequently was the measure used for each group in the study?
The measure was given on bi-monthly bases prior to and following the opening of the SCU.
Post-SCU measures began in the 5 month to allow for the effects of relocation to the SCU to
dissipate.
Measurement Biases
Were the evaluators blinded to treatment status? If no, explain.
Yes
No X- The staff was not blind to the residents who were on traditional units versus
the special care unit.
Recall or memory bias If yes, explain.
Yes
No X
Others (list and explain):
Limitations (appropriateness of outcomes and measures) If no, explain.
Did the measures adequately measure the outcome(s)?
Yes X
No
Name of measure:
Functional Abilities Checklist (FAC)
Outcome(s) measured (what was measured?):
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The FAC was used to assess behaviors relevant for residents with AD. The FAC includes five
subscales: self-care abilities, inappropriate behaviors, cognitive status, agitation, and sexual
behaviors.
Is the measure reliable (as reported in article)?
Yes
No
Not reported X
Is the measure valid (as reported in article)?
Yes X The
investigators
developed
the tool, and
compared it
with the
GRS to
determine
validity.
No
Not reported X
How frequently was the measure used for each group in the study?
The measure was given on bi-monthly bases prior to and following the opening of the SCU.
Post-SCU measures began in the 5 month to allow for the effects of relocation to the SCU to
dissipate.
Measurement Biases
Were the evaluators blinded to treatment status? If no, explain.
Yes
No X- The staff was not blind to the residents who were on traditional units versus
the special care unit.
Recall or memory bias If yes, explain.
Yes
No X
Others (list and explain):
Limitations (appropriateness of outcomes and measures) If no, explain.
Did the measures adequately measure the outcome(s)?
Yes X
No
AOTA Evidence-Based Literature Review Project CAP Worksheet.5-05
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Name of measure:
GRS (Definition not reported)
Outcome(s) measured (what was measured?):
The GRS is a standardized measure to assess 31 items of functional abilities such as grooming,
hygiene, toileting, bathing ,eating, sleeping, exercising, and interacting with others in the
environment.
Is the measure reliable (as reported in article)?
Yes
No
Not reported X
Is the measure valid (as reported in article)?
Yes
No
Not reported X
How frequently was the measure used for each group in the study?
The measure was given on bi-monthly bases prior to and following the opening of the SCU.
Post-SCU measures began in the 5 month to allow for the effects of relocation to the SCU to
dissipate.
Measurement Biases
Were the evaluators blinded to treatment status? If no, explain.
Yes
No X- The staff was not blind to the residents who were on traditional units versus
the special care unit.
Recall or memory bias If yes, explain.
Yes
No X
Others (list and explain):
Limitations (appropriateness of outcomes and measures) If no, explain.
Did the measures adequately measure the outcome(s)?
Yes X
No
Name of measure:
Individual Incident (IIR)
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Outcome(s) measured (what was measured?):
The IIR was developed by the investigators and was used to measure catastrophic and other
disruptive behaviors, and social interactions as indirect indicators of function.
Is the measure reliable (as reported in article)?
Yes
No
Not reported X
Is the measure valid (as reported in article)?
Yes
No
Not reported X
How frequently was the measure used for each group in the study?
The staff person assigned to care for the resident each 8-hour shift documented these behaviors
for half of the day randomly selected from each 2-months data collection period.
Measurement Biases
Were the evaluators blinded to treatment status? If no, explain.
Yes
No X- The staff was not blind to the residents who were on traditional units versus
the special care unit.
Recall or memory bias If yes, explain.
Yes
No X
Others (list and explain):
Limitations (appropriateness of outcomes and measures) If no, explain.
Did the measures adequately measure the outcome(s)?
Yes X
No
RESULTS
List results of outcomes relevant to answering the focused question
Include statistical significance where appropriate (p<0.05)
Include effect size if reported
AOTA Evidence-Based Literature Review Project CAP Worksheet.5-05
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Using repeated measures ANOVA, the cognitive, non-cognitive, and total scores on the
ADAS did not differ significantly between the SCU subjects and the non-SCU subjects.
The SCU group’s cognitive mean score increased from 56.67 to 59.69, and the non-SCU
group’s cognitive mean score increased from 45.38 to 52.88. Thus, both the SCU and
the non-SCU subjects demonstrated a decline in cognitive ability following the opening
of the SCU.
With regards to functional abilities, there were no significant differences between the
SCU and the non SCU groups or from pretest to posttest for either group in the FAC or
GRS total scores. Although not statistically significant, the general trend for both the
SCU and the non-SCU groups was a gradual decline in functional abilities.
Significant results were found, however, with the indirect (IIR) measures of function.
Catastrophic reactions decreased significantly for the SCU group when compared to the
non-SCU group after the implementation of the SCU. Among the SCU group,
interactions with staff increased from a pre-intervention mean of 108.1 to a post-
intervention mean of 391.9. During the same time period, the non-SCU group had a pre-
intervention mean of 158.3 compared to a post-intervention mean of 205.4. Among the
SCU group, “interactions with family” increased from pre-intervention mean of 3.9 to a
post-intervention mean of 10.00, while the non-SCU group increased from 6.33 (pre) to
9.44 (post) in the same time period.
Was this study adequately powered (large enough to show a difference)? If no, explain.
Yes X
No
Were appropriate analytic methods used? If no, explain.
Yes X
No
Were statistics appropriately reported (in written or table format)? If no, explain.
Yes X
No
CONCLUSIONS
State the authors’ conclusions that are applicable to answering the evidence-based question.
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The results of the study support the findings of other systematic studies of SCUs that have
found no significant effects on direct measures of the cognitive and functional abilities of
residents with AD when compared with the effects of care on traditional integrated nursing
home units. The authors explain that there are a number of possible explanations why changes
that may have occurred were not captured due to the tests used or the time allotted for the study.
The authors determined that catastrophic reactions and interactions may be more appropriate to
detect change within these residents. The authors feel that more attention may need to be given
to the development and testing of reliable and valid measures that are also more sensitive to the
effects of SCUs on the function of residents with AD. The authors stated that there continues to
be a need for studies of representative samples of SCUs in order to describe their characteristics
and develop a taxonomy of SCU types.
Were the conclusions appropriate for the Study Design (Level of Evidence)? If no, explain.
Yes X
No
Were the conclusions appropriate for the statistical results? If no, explain.
Yes X
No
Were the conclusions appropriate given the study limitation and biases? If no, explain.
Yes X
No
IMPLICATIONS FOR OCCUPATIONAL THERAPY
There are some significant implications for occupational therapy in the treatment of
individuals suffering from the middle stages of Alzheimer’s disease (AD) and the
implementation of special care units (SCU). In order to increase the profession of occupational
therapy, program development is crucial. The components that are included in a special care unit
(i.e. soft music, textures, colors and a quiet environment) are all useful in longitudinal treatment
of individuals with AD. An occupational therapist that is practicing in a long-term care facility
such as a nursing home could implement a special care unit in their facility. The benefits of a
special care unit as part of a larger unit within a nursing home have been documented in the
research study above. Occupational therapy needs to continue to be involved in the treatment of
individuals with Alzheimer’s disease. As the population of older adults continues to rise, so too,
will the incidence of AD. Occupational therapists need to equip themselves with the knowledge
that will promote their involvement in treatment.
The study above indicated that while subjects on the special care unit demonstrated better
behavior than their counterparts on traditional units, there were no statistical differences between
the two groups. Occupational therapists and students can contribute to the body of knowledge on
this subject area by performing evidence-based research. Additional studies are needed in order
to increase the efficacy of special care units for individuals with Alzheimer’s disease.
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