Narratives of Care ProvidersConcerning Picking Behavior amongInstitutionalized Dementia Sufferers

Karin Johansson, RNT, MSc,Karin Zingmark, RN, Med. Licentiate, and Astrid Norberg, RN, PhD

Geriatric Nursing Volume 20, Number 1 29

Dementia sufferers often exhibit so-called “behavioraldisturbances,” behavior that seems inappropriate to thesituation, is dangerous for the dementia sufferer or oth-ers, or is embarrassing.1 Kirby and Lawlor2 discussedthe evidence for a neurochemical basis for behavioral

disturbances. The fact that neurologic changes are associated with be-havioral disturbances does not mean that experience or meaning donot lie behind the behavior or that the disturbing behavior cannot beaffected by human interaction. Kihlgren et al.3 found that dementiasufferers in an intervention ward, compared with those in a controlward, disclosed previously hidden competence when interacting withsupportive care providers. Beck and Heacock4 contended that behav-ioral disturbance has meaning. By focusing only on a patient’s disori-ented responses, care providers neglect the meaning inherent in thebehavior.

PICKING BEHAVIORPrevious research has described behavioral disturbances, such as

agitation,5 vocally disruptive behavior,6 and wandering.7 The behav-ioral disturbance expressed in repetitious picking at objects (picking)has been neglected in the literature. Sometimes the behavior is in-cluded in the concepts “inappropriate motor activity,”8 “purposelessbehavior,”9 “destroying property,”10 “physical aggression toward ob-jects,”11 or “pottering.”7 Hope12 included picking behavior in the con-cept of wandering, checking everyday matters, and ineffectively

CE Article

Abstract: To illuminate the meaning ofpicking behavior in institutionalizedpeople with dementia, the narratives of15 care providers were interpretedusing a method inspired by Ricoeur’sphenomenologic hermeneutics. Thecare providers saw the behavior as aform of meaningful communication.The behavior was described as occur-ring in combination with wandering andin connection with restlessness andstress related to fatigue, difficulty com-municating, and lack of occupation.The behavior also was seen as an at-tempt to engage in meaningful activi-ties. Some care providers reported thatthe picking behavior caused themstrain, whereas others reported a morepositive reaction because the behaviormade the ward more alive. Most careproviders perceived the meaning of thepicking behavior relative to the demen-tia sufferer’s previous life and said theyreacted by diverting, allowing, or un-derstanding the picking.

(Geriatr Nurs 1999;20:29-33)

Instructions to CE enrollees:The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page 28.

On completion of this article, the reader should be able to:1. Discuss the various meanings caregivers place on dementia behaviors2. Describe the picking behaviors as they relate to dementia3. Identify causative factors that may precipitate picking behaviors

30 Geriatric Nursing Volume 20, Number 1

performing household tasks. Picking also may be relatedto the phenomena of hiding things10 and emptying draw-ers or closets.11

Picking behavior is defined in this study as pickingat, rearranging, carrying about, tearing, and rollingthings. The aim of this study was to illuminate the mean-ing of picking behavior as narrated by care providers ofinstitutionalized people with dementia.

METHODSubjects. In two towns in northern Sweden, the

nursing managers at nursing homes and group dwellingsin a selected area were asked about people with demen-tia in their facilities who exhibited picking behavior. Thecare providers selected for the study (eight nurses’ aidesand seven licensed practical nurses; one man and 14

women) had been work-ing in nursing for 2.5 to30 years (median = 15years).

Interviews. Personalinterviews lasting 20 to60 minutes were re-corded. The care pro-viders were asked tonarrate experiences in-volving dementia suffer-ers who exhibited pick-ing behavior (ie, pickingat objects, rearrangingthings, carrying thingsabout, tearing thingsapart, rolling things).Questions were askedconcerning the peopleexhibiting the behavior,other so-called behav-ioral disturbances exhib-ited by the same people,their ability to communi-cate verbally and non-verbally, situations inwhich the behavior oc-curred, the interviewees’reactions to the behav-ior, and their ideas aboutthe reasons behind thebehavior.

Analysis. The inter-view text was interpretedby a method developedat the Department ofAdvanced Nursing atUmeå University in Swe-den and the Unit ofNursing Science at theUniversity of Tromsö in

Norway. This method, inspired by Ricoeur’s phenome-nologic hermeneutic philosophical method,13 focuses oninterpreting phenomena as they appear and has beenused previously (eg, Pejlert et al.14).

First the interviews were read jointly, one by one, toacquire a sense of the whole of each text (naive read-ing). The researchers then guessed about the meaning ofthe text. Next, the first author divided the text of eachinterview into meaning units, such as part of a sentenceor one or more sentences related by their content. Thecontent of each meaning unit was condensed and coded,and the codes were compared (structural analysis) andbrought together into texts describing individual de-mentia sufferers.

Finally, the interviews were read through again,taking into account the authors’ initial understanding(eg, their theoretical knowledge and practical experi-ence of caring for dementia sufferers) and the results ofboth the naive reading and structural analysis.

INTERPRETATION AND FINDINGSNaive reading. The most prominent findings of the

naive reading were that the care providers thought thatsuch stressful situations as too many choices, over-whelming situations, and fatigue led to picking behavior.This behavior sometimes was combined with wandering,especially in connection with elimination needs. Thecare providers talked with concern and respect aboutdementia sufferers who exhibited picking behavior.

Structural analysis. The results of the structuralanalysis are shown in Table 1. Picking often was com-bined with wandering, carrying, and wrapping or hidingitems. The motivation for the behavior mentioned wasmainly stress and fatigue in patients who had poor ver-bal and lively nonverbal communication. Thirteen of the15 care providers found the behavior to be a meaningfulexpression of the dementia sufferer’s inner world. Theyfound the behavior constituted meaningful fragments ofcommon activities in the patient’s past, such as trying totidy up or tend to flowers. Care providers described howthey tried to understand the meaning of the behaviorand react accordingly: meet it with tact and respect, di-vert the patient’s attention, find appropriate activities,prevent the patient from being upset or hurt and othersfrom being hurt by the patient.

The results revealed similarities and differences be-tween dementia sufferers. The staff saw two types of de-mentia sufferers with picking behavior: restless people(subjects 1, 2, 4, 7, 10 through 15) and people engaged inimportant activities (subjects 3, 5, 6, 8, 9).

An interaction occurred between the interpretationof the dementia sufferer and the environment. The careproviders narrated situations in which the dementia suf-ferer began picking and wandering behavior in connec-tion with overwhelming demands, visual disturbancesand noisy surroundings, hearing problems, and lack ofstimulation. The dementia sufferers had difficulty mak-

Care providers

described how

they tried to

understand the

meaning of the

behavior and react

accordingly: meet

it with tact and

respect, divert the

patient’s attention,

find appropriate

activities, prevent

the patient from

being upset or hurt

and others from

being hurt by

the patient.

Geriatric Nursing Volume 20, Number 1 31

Subjects(#)

4

13

1

8

5

2

3

6

12

14

9

7

10

15

11

Pickingresembling

Scrubbing,laying coffeetable

Housekeeping

Tidying up

Pottering

Tending flowers, hidingobjects

Housekeeping

Cooking

Tending flowers

Moving things

Cleaning up,carrying

Carrying,wrapping,hoarding allkinds of things

Carrying

Damaging the furnishing

Carryingfurniture

Behaviorcombined

with

Wandering

Wandering,aggression

Escaping

Aggression

Conditions forpicking/identified

stressors

Overwhelming situations, noise

Fatigue, loneliness,lack of stimulation

Not recognizingthings, not know-ing how to act

Unoccupied

Unoccupied

Fatigue, stress (eg,too many choices,anxiety)

Fatigue, stress,elimination needs

Cooking situations

Fatigue, anxiety,elimination needs

Noise, hearingproblems

Stress (eg, toomany choices, discomfort)

Overwhelming situations, stress,anxiety

Overwhelming situations, noise

Noise, irritation, inactivity

Caregiver’sinterpretations

Longing forhome

Seeking stimulation

Calming down,wanting thingsneat and tidy

Commitment to others

Performing important tasks

Wanting thingsneat and tidy

Helping withhouseholdtasks

Seeking stimulation

Needingactivity, wanting to feel alive

Calming down

Needingactivity, caringfor others

Calming down

Reducingstress, seekingstimulation

Needingactivity

Channeling feelings

Caregiver’sfeelings about

picking

Irritated

Positive to actionon the ward

Positive feelings,makes the wardalive

Hopelessness, not finding things

Being used to thebehavior

Stressed, irritated when patient takesthings away

Positive as activation

Positive as activation

Pitying the patient

Disturbing to caregivers andother patients

Irritation, wantingto move the pa-tient from the ward

Wanting to knowthe reason for thebehavior

Liking the patient

Connection withprevious life

Trying to use thingsas before

Trying to be as industrious as before

Trying to do thingsas before

Having been a pottering kind ofperson

Trying to do thingsas before

Always having beenan active person taking part in socialactivities

Trying to do thingsas before

Having been ahandy person (eg,working with hishands, makingmusic)

Been a hard-work-ing person as a gar-dener and a motherto many children

Trying to do thingsas before

Probably used to be thrifty

Trying to do thingsas before

Behaving as if in her antique shop

Caregiver’s actions

Shows understand-ing (eg, avoid injuring, allow sleep-ing in staff room)

Lets the patienthelp with house-keeping

None, not upsettingthe patient by interfering

Shows understand-ing (eg, giving a boxwith objects forpicking)

Prevents other patients from beingupset by taking theirproperty back

None or diverts patient by lettingher take part inward activities

Understands, diverts patient’s attention, taking herto a room to sleep

Permissive actions,accepts withoutcomments

Diverts patient’sattention

Gives time, prevents patientfrom being hurt

Gets tired

Suggests relativesmove the patient toanother ward

Shows tact and respect

Leaves patient alonewith activities in aspecial room (eg, tostack cardboards,sweep room)

Understands, diverts

Table 1. Structural Analysis of Interviews about Picking and Wandering Behavior in Dementia Sufferers

Housekeeping

32 Geriatric Nursing Volume 20, Number 1

ing choices among too many alternatives. Fatigue, anxi-ety, idleness, need for some employment, loneliness,elimination needs, unresolved crises, and death anxietyare other explanations for the behavior.

INTERPRETED WHOLE AND REFLECTIONThe picking behavior was seen as a meaningful

expression of the dementia sufferer’s current feelingseven if they were expressed in a way relative to the pa-tients’ previous life. The care providers related the pick-ing behavior to the kind of person the dementia suffererwas before the onset of the disease. For example, a knowl-edge of previous life activities, interests, and copingstrategies affords the care providers insights into currentbehavior patterns and responses to stress.15 Wykle andMorris16 thought behavioral disturbances may be relatedto memory activation.

This study reports themeaning care providersgave to dementia suffer-ers’ picking behavior, butno data are available yetthat can validate their in-terpretations. However,because the outcome ofhuman interaction isbased on interpretationsof the meaning of eachother’s actions, the careproviders’ interpreta-tions will affect the de-mentia sufferers.17 Whenthe care provider treatsthe dementia sufferer asif her or his behavior ismeaningful, the self-es-teem of the sufferer israised.3 This respect willaffect the behavior andhopefully promote his orher experience of whole-ness and meaning.18

Labeling a certainbehavior as disturbingdepends not only on thebehavior exhibited butalso on the care pr-ovider’s level of toler-ance and ability tounderstand the behavioras meaningful.19 There-fore the narrative inter-views reported in thisarticle can provide ideasthat may be used as abasis for observations of

dementia sufferers and the effects of care providers’ in-terpretations.

REFERENCES

1. Yi ES, Abraham IL, Holroyd S. Alzheimer’s disease and nursing: new scien-tific and clinical insights. Nurs Clin North Am 1994;29:85-99.

2. Kirby M, Lawlor BA. Biologic markers and neurochemical correlates of agi-tation and psychosis in dementia. J Geriatr Psychiatry Neurol 1995;8(Suppl1):2-7.

3. Kihlgren M, Hallgren A, Norberg A, Karlsson I. Disclosure of basic strengthsand basic weaknesses in demented patients during morning care, beforeand after staff training: analysis of video-recordings by means of Eriksontheory of “eight stages of man.” Int J Aging Hum Dev 1996;43:219-33.

4. Beck C, Heacock P. Nursing interventions for patients with Alzheimer’s dis-ease. Nurs Clin North Am 1988;23:95-124.

5. Rapp MS, Flint AJ, Herrmann N, Proulx GB. Behavioural disturbances in thedemented elderly: phenomenology, pharmacotherapy, and behaviouralmanagement. Can J Psychiatry 1992;37:651-7.

6. Hallberg IR, Norberg A, Eriksson S. Functional impairment and behaviouraldisturbances in vocally disruptive patients in psychogeriatric wards com-pared with controls. Int J Geriatric Psychiatry 1990;5:53-61.

7. Hope T, Tilling KM, Gedling K, Keene JM, Cooper SD, Fairburn CG. Thestructure of wandering in dementia. Int J Geriatric Psychiatry 1994;9:149-55.

8. Bolger JP, Carpenter BD, Strauss ME. Behavior and affect in Alzheimer’s dis-ease. Clin Geriatr Med 1994;10:315-37.

9.Teri L,Truax P, Logsdon R, Uomoto J, Zarit S,Vitaliano PP.Assessment of be-havioral problems in dementia: the revised memory and behavior prob-lems checklist. Psychol Aging 1992;7:622-31.

10. Devanand DP, Brockington CD, Moody BJ, Brown RP, Mayeux R, EndicottJ, et al. Behavioral syndromes in Alzheimer’s disease. Int Psychogeriatr1992;4:161-84.

11. Baumgarten M, Becker R, Gauthier S. Validity and reliability of the demen-tia behavior disturbance scale. J Am Geriatr Soc 1990;38:221-6.

12. Hope RA, Fairburn CG, Christopher G. The nature of wandering in demen-tia: a community-based study. Int J Geriatric Psychiatry 1990;5:239-45.

13. Ricoeur P. Interpretation theory: discourse and the surplus of meaning. FortWorth (TX): Texas Christian University Press; 1976.

14. Pejlert A, Asplund K, Norberg A. Stories about living in a hospital ward asnarrated by schizophrenic patients. J Psychiatr Ment Health Nurs1995;2:269-77.

15. Harrison C. Personhood, dementia, and integrity of a life. Special issue: Thehumanities in gerontology. Can J Aging 1993;12:428-40.

16. Wykle ML, Morris DL. Nursing care in Alzheimer’s disease. Clin GeriatrMed 1994;10:351-65.

17. Laing RD. The politics of experience and bird of paradise. Middlesex,England: Penguin Books Ltd Harmondsworth; 1967. p. 15-38.

18. Kihlgren M, Hallgren A, Norberg A, Karlsson I. Integrity promoting care ofdemented patients: patterns of interaction during morning care. Int J AgingHum Dev 1994;39:303-19.

19. Hinchliffe AC, Hyman IL, Blizard B, Livingstone G. Behavioural complica-tions of dementia: can they be treated? Int J Geriatric Psychiatry1995;10:839-47.

Acknowledgments: The authors are indebted to theResearch Programme “Arts in Hospital and Care asCulture,” the County Council of Stockholm, and BodenUniversity College of Health Sciences for economic sup-port and to Ms. Pat Shrimpton for assistance with theEnglish language.

KARIN JOHANSSON, RNT, MSc, is a lecturer at the Department ofNursing at Umeå University and the Boden University College ofHealth Sciences in Sweden. KARIN ZINGMARK, RN, Med.Licentiate, is the chief nurse manager and ASTRID NORBERG, RN,PhD, is a professor and head of the Department of Nursing at UmeåUniversity.

Copyright © 1999 by Mosby, Inc.

0197-4572/99/$5.00 + 0 34/1/96074

When the care

provider treats

the dementia

sufferer as if her

or his behavior is

meaningful,

the self-esteem

of the sufferer

is raised. This

respect will affect

the behavior and

hopefully promote

his or her

experience of

wholeness

and meaning.

Geriatric Nursing Volume 20, Number 1 33

1. The care providers assigned meanings to certainpicking behaviors. For example, when the behaviorresembled housekeeping, the care providers inter-preted that as:A. Seeking stimulationB. Commitment to othersC. A longing for homeD. Calming measures

2. The study defines picking behaviors as carryingabout, tearing, rolling things, and:A. Eating with their fingersB. RearrangingC. Grasping for imaginary objectsD. Scratching or picking at their skin

3. Care providers thought all the following situationsled to picking behavior EXCEPT:A. FatigueB. Too many choicesC. Overwhelming situationsD. Repetitive tasks

4. Most care providers perceived the meaning of thepicking behavior as:A. Disruptive to othersB. An attempt to withdrawC. Relative to the dementia sufferer ’s life before in-

stitutionalizationD. Having no meaning based in reality

5. Other picking behaviors have been included in thefollowing concepts EXCEPT:A. Checking thingsB. Personal groomingC. Performing household tasksD. Wandering

6. The motivation for picking behaviors was identifiedas:A. Loneliness and frustrationB. Anger and resentmentC. Stress and fatigueD. Boredom and fragmentation

7. When care providers treat the behaviors of demen-tia sufferers as being meaningful, it can:A. Confuse the individualB. Validate inappropriate behaviorC. Intensify others’ reactionsD. Raise self-esteem

8. Knowledge of previous life activities and interestsoffers the care providers insight into:A. Social preferencesB. Current behavior patternsC. Degree of lonelinessD. Level of anxiety

9. Picking and wandering behaviors were associatedwith all the following EXCEPT:A. Checking thingsB. Personal groomingC. Performing household tasksD. Wandering

10. Care providers’ interpretation of commitment toothers is associated with the picking behavior thatresembles:A. Tidying upB. CarryingC. Moving thingsD. Pottering

11. Focusing on a patient’s disoriented response or be-havior can cause the care provider to:A. Reinforce the behaviorB. Disrupt the patient’s routineC. Neglect the behavior ’s meaningD. Intensify the stress level

12. The concept of wandering is associated with pick-ing behaviors, especially when connected with:A. Elimination needsB. Communication needsC. Nutritional needsD. Self-esteem needs

Test I.D. No.: G96074Contact hours: 1.0Processing fee: $9Passing score: 9 correct answers (75%)C

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