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Question Answered step-by-step Hello, I need some help finding possible functions of Aaron… Hello, I need some help finding possible functions of Aaron Copland’s five purposes of film music in this short clip of the movie silence of the lambs. https://www.youtube.com/watch?v=s3nIw30hn4U&t=1s1. creating a convincing atmosphere of time and place2. underlining psychological refinements-3. serving as a kind of neutral background filler4. building a sense of continuity5. Underpinning the theatrical build-up of a scene and rounding it off with a sense of finality.Thank you. Arts & Humanities Writing Creative Writing GNED 1401 Share QuestionEmailCopy link Comments (0)

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Question Answered step-by-step Use the articles below to answer the following questions. Article... Use the articles below to answer the following questions. Article Link: https://www.sciencedirect.com/science/article/abs/pii/S0020748917302250?via%3DihubArticleWaszynski, C. M., Milner, K. A., Staff, I., & Molony, S. L. (2018). Using simulated family     presence to decrease agitation in older hospitalized delirious patients: A randomized        controlled trial. International Journal of Nursing Studies, 77, 154-161.         Use the articles above to answer the following questions.Questions Question 11 ptsWhat was the population of interest for this study?Group of answer choices Family members of hospitalized patients Hospitalized patients Staff responsible for assessing hospitalied patients' behavior Persons with agitation or delirium  Question 21 ptsWhich components of a randomized controlled trial are present in this research study? (Select all that apply.)Group of answer choices Randomization Intervention Researcher blinding 80% power Control group Repeated measures Statistical significance  Question 31 ptsWhat aspects of the study enhance the internal validity? (Select all that apply.)Group of answer choices Comparison group Random assignment to groups Low attrition rate Representative sample Blinding of the outcomes assessor Single assessor of patient behavior before and after intervention  Question 41 ptsWhat is a unique contribution to nursing science emanating from this study?Group of answer choices This appears to be the first published study to have examined the use of simulated family presence in hospitalized patients with delirium. The study demonstrates that the cost for creating a family video is minimal compared to the cost of treating a hospitalized patient experiencing agitation. The authors determined that simulated family precence may be used in place of pharmacologic agents to manage hospitalized patients with delirium. This is the first study to suggest that person-centered therapy may be useful in the treatment of hospitalized patients with delirium.  Question 51 ptsWhich of the following are limitation of this study? (Select all that apply.)Group of answer choices The study sample was mostly older persons over 50 years of age, reducing generalizability. One member of the research team was in the room at each measurement point, which may have provided participants with a wanted presence at the bedside. Due to the participants' agitated state, researchers were unable to determine the cause of the agitation nor whether the intervention was properly addressing the cause. The presence of continuous observers in participants' hospital rooms could have made participants' agitation better or worse. Purchase of DVD players and recording equipment necessary to implement the intervention may be onerous for hospitals.    Below is the article  Contents lists available at ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/locate/ijns Using simulated family presence to decrease agitation in older hospitalized delirious patients: A randomized controlled trial Christine M. Waszynskia,⁎ , Kerry A. Milnerb , Ilene Staffc , Sheila L. Molonyd a Department of Geriatric Medicine and Department of Nursing, Hartford Hospital, 80 Seymour Street, Hartford, CT 06012, USA b College of Nursing, Sacred Heart University, 5151 Park Ave, Fairfield, CT 06825, USA c Department of Research, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA d School of Nursing, Quinnipiac University, 275 Mt Carmel Ave, Hamden, CT 06518, USA ARTICLE INFO Keywords: Agitation Hospitalized patient Hyperactive delirium Mixed delirium Nature video Nonpharmacological intervention Simulated family presence Video messages ABSTRACT Background: Simulated family presence has been shown to be an effective nonpharmacological intervention to reduce agitation in persons with dementia in nursing homes. Hyperactive or mixed delirium is a common and serious complication experienced by hospitalized patients, a key feature of which is agitation. Effective nonpharmacological interventions to manage delirium are needed. Objectives: To examine the effect of simulated family presence through pre-recorded video messages on the agitation level of hospitalized, delirious, acutely agitated patients. Design: Single site randomized control trial, 3 groups × 4 time points mixed factorial design conducted from July 2015 to March 2016. Setting: Acute care level one trauma center in an inner city of the state of Connecticut, USA. Participants: Hospitalized patients experiencing hyperactive or mixed delirium and receiving continuous observation were consecutively enrolled (n = 126), with 111 participants completing the study. Most were older, male, Caucasian, spouseless, with a pre-existing dementia. Methods: Participants were randomized to one of the following study arms: view a one minute family video message, view a one minute nature video, or usual care. Participants in experimental groups also received usual care. The Agitated Behavior Scale was used to measure the level of agitation prior to, during, immediately following, and 30 min following the intervention. Results: Both the family video and nature video groups displayed a significant change in median agitation scores over the four time periods (p < 0.001), whereas the control group did not. The family video group had significantly lower median agitation scores during the intervention period (p < 0.001) and a significantly greater proportion (94%) of participants experiencing a reduction in agitation from the pre-intervention to during intervention (p < 0.001) than those viewing the nature video (70%) or those in usual care only (30%). The median agitation scores for the three groups were not significantly different at either of the post intervention time measurements. When comparing the proportion of participants experiencing a reduction in agitation from baseline to post intervention, there remained a statistically significant difference (p = 0.001) between family video(60%) and usual care (35.1%) immediately following the intervention Conclusion: This work provides preliminary support for the use of family video messaging as a nonpharmacological intervention that may decrease agitation in selected hospitalized delirious patients. Further studies are necessary to determine the efficacy of the intervention as part of a multi-component intervention as well as among younger delirious patients without baseline dementia. What is already known about the topic? • Delirium is recognized as a global issue, affecting many hospitalized patients and putting them at risk for adverse short and long term outcomes. • Exploration of the use of nonpharmacological interventions to prevent and manage delirium has been encouraged. • Family presence has been found to be of benefit to hospitalized http://dx.doi.org/10.1016/j.ijnurstu.2017.09.018 Received 5 March 2017; Received in revised form 26 August 2017; Accepted 29 September 2017 ⁎  International Journal of Nursing Studies 77 (2018) 154-161 0020-7489/ © 2017 Elsevier Ltd. All rights reserved. T delirious patients. • There is a dated body of literature supporting simulated family presence to decrease agitation in nursing home residents with dementia, but this has not been studied in hospitalized patients with hyperactive or mixed delirium. What this paper adds • The findings of this study support the use of family video messaging as an effective patient centered and nonpharmacological, intervention to decrease agitation in older hospitalized patients experiencing hyperactive or mixed delirium. • This novel work can lay the ground work for more research using family simulated presence for patients with or at risk for delirium as an intervention to decrease harm and other negative consequences. 1. Introduction Delirium is a serious medical problem affecting one in five hospitalized patients (Ryan et al., 2013) with rates in the ICU setting exceeding 75% (Balas et al., 2007; Ely et al., 2004). Once thought to be an inevitable, transient, and innocuous phenomenon, there is evidence linking in-hospital delirium to negative clinical outcomes both during hospitalization and after discharge. These include increased risk for death during and up to two years following hospitalization, iatrogenic complications, increased length of stay in hospital and in extended care facilities, and hospital readmission (Dasgupta and Brymer, 2014; Dharmarajan et al., 2016; Kiely et al., 2008; Inouye, 2006; Salluh et al., 2015; Witlox et al., 2010). Recent work has focused on the persistent and, in some cases, permanent cognitive failure associated with prolonged in hospital delirium episodes (Cole et al., 2009; Girard et al., 2010; Kat et al., 2008; Van den Boogaard et al., 2012) as well as an association with delirium and the development of dementia in the future (Davis et al., 2012). Persons with dementia have a high risk of developing delirium during a hospitalization, which worsens the trajectory of their cognitive decline (Inouye, 2006). Behaviors displayed by patients experiencing hyperactive or mixed delirium can be challenging and distressing to the patient, family, and staff. These behaviors include restlessness, agitation, combativeness, loud speech, anger, persistent thoughts, and wandering, which often lead to the patient resisting care (Kable et al., 2012; Meagher et al., 2000). Patient safety can be threatened when restlessness leads to treatment disruption, resistance to care, and unsupervised mobilization. Pharmacological therapy is often ordered to decrease agitation. However, these medications can lead to adverse reactions including oversedation, falls, dysphagia, pneumonia, or paradoxically to increased agitation (De Jong et al., 2013; Knol et al., 2008; Muench and Hamer, 2010; Pautex et al., 2008; Ucok and Gaebel, 2008). A recent systematic review and meta-analysis confirmed a lack of evidence to support the use of antipsychotics for the prevention or treatment of delirium (Neufeld et al., 2016). Physical restraints used to restrict the patient's ability to disrupt treatments or move freely may increase agitation and risk of injury (Mohr et al., 2003). Continuous observers placed with agitated patients to prevent falls and treatment disruption are often unsuccessful and are not cost effective (Boswell et al., 2001; Harding, 2010). Patients with hyperactive or mixed delirium may experience distress in the moment, as demonstrated by their agitated and restless behavior, but also as a persistent or lingering suffering in the form of post delirium distress or Post Traumatic Stress Disorder (Partridge et al., 2013). There are few effective options available to nurses to relieve the patient's distress that do not  additional negative consequences for the patient. Nurses can feel frustrated and torn by their perceived duty to keep their delirious patient safe while also attending to the needs of the other patients under their care (Dahlke and Phinney, 2008). The provision of an effective, practical, and low cost intervention to calm an agitated patient can be a significant contribution to delirium management. Nonpharmacological approaches to prevent and manage delirium have been reported in the literature. A systematic review found multicomponent nonpharmacological interventions as well as some singlecomponent interventions to be effective in the prevention but not treatment of delirium (Abraha et al., 2015). Clinical practice guidelines recommend a variety of nonpharmacological interventions for both the prevention and management of delirious patients, as they pose little harm and have the potential to offset the significant harm caused by the delirium (American Geriatric Society Expert Panel on Postoperative Delirium in Older Adults, 2015). Using a person-centered approach by incorporating familiar items, individualized preferred music, and family contact are examples of suggested nonpharmacological interventions for persons with delirium (Irwin et al., 2013). A recent literature review on family involvement with hospitalized delirious patients revealed only a few studies on this subject, examining several aspects of family participation. These included family education on delirium, delirium screening by family, and family caregiver interventions for the patient. The author reported that there were inconclusive findings to support that family involvement improves delirium outcomes, but acknowledged that family involvement should be studied further (Halloway, 2014). Family members can provide a sense of calm and familiarity to a delirious patient (House, 2000). Families should be encouraged to visit as much and as often as possible (Wass et al., 2008). Since most families cannot remain with the patient around the clock during a hospitalization, an intervention to simulate family presence was explored. Simulated presence therapy attempts to reproduce a family member's presence though a technological medium in order to bring comfort to the patient (Woods and Ashley, 1995). Pleasant memories and meaningful information is presented to the individual in a caring way by a close family member via an audio or video device. Simulated family presence (SFP) through the use of pre-recorded audio or videotapes has been shown to be an effective strategy to calm agitated persons with dementia in nursing facilities (Cohen-Mansfield and Werner, 1997; Lund et al., 1995; O'Connor et al., 2011). A systematic review and meta-analysis concluded that SFP significantly reduced agitation in persons with dementia (Zetteler, 2008). To date, there have been no studies evaluating the effect of SFP on persons displaying agitated behaviors related to delirium. Many older hospitalized patients who develop delirium during hospitalization have dementia at baseline (Inouye, 2006). Although delirium and dementia have different features, there are enough similarities and a strong association to justify a trail of SFP with delirious hospitalized patients displaying features consistent with the hyperactive or mixed subtype. Pilot work was conducted on five hospitalized patients experiencing hyperactive delirium. These individuals (age range 18-90) viewed a one minute pre-recorded family video message on a DVD player during an episode of agitation. The DVD was shown to each patient by the nursing staff who then gave feedback as to the effect of the intervention on the patient's behavior. In all five instances, nurses reported a decrease in agitation in response to viewing the family video message. Each family member approached was willing to participate in the video. Therefore, a randomized control trial was designed to examine the effect of family video messages on the agitation level of hospitalized, delirious, acutely agitated patients. This study tested the hypothesis that the viewing of a family video message by hospitalized delirious patients would decrease agitation. 2. Methods The Institutional Review Boards of both Hartford Healthcare and Sacred Heart University approved and monitored this study protocol. This work was carried out in accordance with The Code of Ethics of the World Medical Association for experiments involving human subjects. C.M. Waszynski et al. International Journal of Nursing Studies 77 (2018) 154-161 155 2.1. Setting The study was conducted in an 850 bed inner city level one trauma center in the state of Connecticut, USA. The clinical staff at this hospital performed delirium screening with the short version of the Confusion Assessment Method (Inouye et al., 1990) on all inpatients three times per day as part of routine care. Continuous observation by a patient care assistant was an intervention commonly used for patients exhibiting agitation related to hyperactive or mixed delirium. 2.2. Sample The study sample consisted of consecutive patients admitted to the hospital, age 18 years or older, who displayed hyperactive or mixed delirium as evidenced by a positive score on the Confusion Assessment Method (CAM) (Inouye et al., 1990) and a score > 0 on the Richmond Agitation Sedation Scale (RASS) (Sessler et al., 2002) documented in the record within 24 h of the record review. Additionally, the individual must have been under continuous observation at the time of enrollment and have been receiving visits from an English-speaking family member. Exclusion criteria included significant vision loss, severe hearing loss that did not improve with an amplification device, and hyperactive or mixed delirium thought to be due to substance withdrawal, terminal restlessness or a psychiatric disorder. A target sample size of 126 was calculated based upon previous pilot work by the author with the Agitated Behavior Scale (ABS) (Corrigan, 1989), the measurement tool chosen to quantify the primary outcome of agitation. The study was powered at 80% for a moderate effect size. A research randomizer program (Research Randomizer) performed permuted block randomization with 10 blocks of 12 and one block of 6, assigning participants to one of three groups with 42 participants per group. Group #1 received a family video message plus usual care (intervention), group #2 received a nature video plus usual care (attention control), and group #3 received no video plus usual care (control). Usual care included any care delivered to the patient to address an immediate care need that arose during the study period, such as assistance with toileting, repositioning for comfort or redirecting any unsafe behavior. The randomized group assignment was generated by the statistician and written on the inside of each folder marked with sequential case number by a research assistant. This assignment was not known to the primary investigator (PI) until after the participant had been consented and assigned the next case number in the sequence. The individual assessing the outcomes was blinded to the intervention. A second randomization table was generated by the statistician using a research randomizer program to determine the order in which each of the 4 time point recordings generated for each study participant would be shown to the outcome assessor. 2.3. Design This study was a single site randomized control trial. A mixed factorial design of three groups (family video, nature video and control group) by four time points (pre-intervention/baseline; during intervention; immediately post intervention; 30 min post intervention) was chosen. 2.4. Intervention The intervention of interest was a one minute family video message, a form of SFP, created and played for the participant at a time when agitation was present and the family was not. The message contained a personalized greeting delivered by one or more family members intended to provide a sense of calm and familiarity for the delirious participant. A one minute segment of a nature video containing images and sound of rain falling on colorful tropical plants or flowers was the attention control intervention. This was included in the study design in order to differentiate the effect of the content of the video from the presentation of a video. 2.5. Procedure The PI reviewed the list of patients receiving continuous observation on a daily basis and took steps to identify and recruit those meeting eligibility criteria. Since all potential participants were delirious and unable to give informed consent, a legally appointed representative if one existed, or next of kin was approached for consent by the PI. For the group enrolled and assigned to the family video, at least one family member was recruited and an arrangement was made between the PI and the family to meet at an agreed upon place and time, obtain written consent, and create the family video message. This took place in a quiet area located somewhere in the hospital. The family participants were shown a sample video on a DVD player and were then given a written guide to review for suggested topics to include in their family video. When ready, a one minute video was filmed. After enrollment, the PI assessed the participant for delirium with the 3D CAM (Marcantonio et al., 2014) and obtained verbal assent to implement the intervention during this hospitalization. Assent was obtained by asking the participant if the researcher could return later that day if and when the participant felt "out of sorts" to possibly show a video. The continuous observer was instructed to notify the PI by phone immediately if the participant displayed any behaviors listed on the ABS (Corrigan, 1989). When notified, the PI returned to the participant's room and unobtrusively filmed the agitated behavior for one minute. Immediately thereafter, the participant was administered the intervention by the PI. Any participant assigned to the family or nature video watched the video on a DVD player placed on the over bed table located two feet in front of the participant. Those in the control group received no video intervention. The participant's behavior was filmed for one minute during this intervention period by the PI. After one minute, the intervention (if being administered) was then stopped, and the PI filmed a third one minute segment of behavior. The door was then closed and a sign was posted stating that a procedure was in process and that the patient should not be disturbed until a certain time. In addition, the nurses were instructed to delay assessments and medications for the 30 min period, unless the continuous observer contacted the nurse for a change in patient status. During this time, the continuous observer kept a written record of the participant's behavior, any potentially contributing environmental stimuli, and any care delivered to the participant by the continuous observer in five minute intervals for the next 30 min, after which time the PI returned and filmed the participant's behavior for one final minute. All filming captured only the participant's face and upper torso to assure outcome assessor blinding to the type of intervention and the time period (pre, during, immediately post or 30 min post intervention). The outcome assessor was an expert in assessing agitated behaviors. To further reduce potential bias, this expert viewed each video without sound so as not to hear if the family video message or nature video was playing. This method was chosen over the use of headphones for every participant, as headphones may be a source of agitation. A written transcription of the participant's and continuous observer's verbalizations during each of the four filming segments was provided to the outcome assessor so that this information could be used to score the ABS. Costs associated with this intervention included a video camera, DVD discs and a DVD player. 2.6. Measures Clinical and demographic participant characteristics were collected from the electronic health record at the time of enrollment just prior to the intervention. These included age, gender, race/ethnicity, pre-existing dementia, presumed etiology of delirium, admission diagnosis and family relationship to participant for those who received the family video message. Following the intervention, specific information C.M. Waszynski et al. International Journal of Nursing Studies 77 (2018) 154-161 156 regarding medication administered for the purpose of decreasing agitation was collected. The dose, route and time of selected medications that had been administered to the patient within 12 h preceding the observation and intervention were recorded. These medications included drugs within the pharmacological categories of neuroleptics/ psychotropics, sedative/hypnotics, benzodiazepines, anti-seizure, and sedating antidepressants. It was then determined whether or not the medications were peaking at the time of the intervention measurement period. Those participants receiving a medication peaking during the measurement period were considered to be under the effect of a sedating medication. A pharmacist prepared at the doctoral level approved of this rationale. A research assistant skilled in communication rated each family video message as positive, neutral, or negative based upon its content and delivery. Positive videos would include encouraging personalized statements with mention of feelings of affection delivered with a pleasant tone of voice and facial expression. Neutral videos would include a message with cliché phrases and little or no personalization delivered in a flat tone. Negative videos would feature any message whose content or delivery might be interpreted to increase stress or agitation in the viewer. The outcome assessor described in the previous section viewed each of the four one minute film clips of each of the participants and assigned a score between 14 and 56 to reflect the participant's degree of agitation using the ABS (Corrigan, 1989). The ABS consists of 14 behaviors which the examiner rates on a scale from 1 to 4, a score of 1 indicating no agitation and 4 indicating severe agitation. This valid and reliable tool has been used to measure agitation in persons with anoxic encephalopathy, traumatic brain injury, and dementia (Bogner et al., 2001). 2.7. Statistical methodology Nonparametric statistics were used as the distribution of both age and ABS scores violated the assumption of normality in spite of log transformation. As there is no mixed factorial nonparametric statistic, this necessitated the use of different analytical tests applied to explore longitudinal change in median ABS scores within each group (Friedman) and cross sectional differences among groups (Kruskal Wallis) and between groups (Wilcoxon Ranked Sum). A Pearson ChiSquare examined differences between and among the groups in regards to the proportion of participants experiencing a reduction in agitation from pre- intervention to during, immediately following and 30 min following the intervention. In order to avoid a Type 1 error, a Bonferroni correction was applied with significance level set at 0.0125 for the individual tests. All tests were run in SPSS v21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). 3. Results Of the 422 individuals screened for eligibility from July 2015 to March 2016, 136 were deemed eligible and after the responsible parties gave informed consent, 126 individuals were enrolled. The recruitment period ended March 2016 as target enrollment was reached. Following enrollment, fifteen of the 126 enrolled participants did not complete the intervention due to resolution of delirium (n = 3), lack of agitation (n = 5), continuous family presence (n = 2), discharge (n = 3), or death (n = 2). Therefore, 34 participants received the family video message plus usual care, 40 received the nature video plus usual care, and 37 received no video and only usual care. This is displayed in Fig. 1. There was no statistically significant difference in the clinical or demographic variables among those who were enrolled (n = 126), those who completed the intervention (n = 111), and those who did not (n = 15). Nor was there a statistically significant difference in the clinical or demographic variables among the 111 participants who completed the intervention based upon randomized group assignment. As described in Table 1, the median age of this sample receiving the intervention was 79 years and participants were predominantly male (53.2%), Caucasian (82.9%), spouseless (55%), had baseline dementia (60.4%), and were admitted for a medical reason (79.3%). Most participants received the intervention while on a general medical or surgical unit (78.4%) and were not under the effect of a sedating medication (79.3%). The etiology of the delirium was most often presumed to be from an internal source (73%), such as metabolic, infectious, fluid imbalance, vascular or other, rather than from an external source such as trauma or medication. This was determined from documentation in the medical record. None of the participants were determined to be exposed to potentially agitating environmental stimuli during the 30 min period between post intervention observations based upon the 5 min incremental documentation of the continuous observer. The continuous observers documented delivering any necessary care, such as responding to the patient's request for food, drink or toileting. Other entries included providing reassuring answers to questions asked or statements made by the patient, as well as reminders not to pull at medical apparatus if the patient was attempting to. A total of 56 family members participated in the creation of 42 family video messages. Due to the attrition of eight participants assigned to the family video who did not complete the intervention, 34 videos were actually shown. The majority (76%) of the family members featured in the videos were adult children. The video messages were between 45 and 90 s in length and took approximately five minutes to create. The family participants quickly and easily constructed a family message in one attempt. The majority (85.7%) of the videos were rated as positive with an encouraging message delivered in a warm and caring way. The neutral messages contained non-personalized themes delivered without positive emotion. One video was rated as negative due to the family member asking questions of the viewer. The primary outcome measure of this study was agitation as measured by the ABS. Cronbach's alpha indicated moderate internal consistency with 0.723 The range of ABS scores in this study were 14-29. There were statistically significant (p < 0.001) changes in median ABS scores across the four time periods for both the family video message and nature video groups but not the usual care group (Fig. 2). The ABS baseline median scores for each of the three groups were not significantly different (p = 0.071). During the intervention period, a statistically significant (p < 0.001, d = 0.197) difference was found among the three groups with the family video group displaying the lowest median ABS scores. Further analysis demonstrated a statistically significant difference between the median ABS scores of the family video and nature groups (p = 0.002, d = 0.32) and between the median ABS scores of the family video and usual care groups (p < 0.001, d = 0.194) during the intervention period (Table 2). An additional analysis examined the proportion of participants in each intervention group that experienced a reduction in agitation during the intervention, one minute following and 30 min following the intervention compared to the pre-intervention/baseline period. There was a statistically significant difference among all three treatment groups (p < 0.001) in the baseline to during intervention time period comparison, with 94.1% of the family video group, 70% of the nature video group, and 29.7% of the usual care group experiencing a reduction in agitation. In addition, statistically significant differences were seen between the family video and nature video groups (p = 0.008), family video and usual care groups (p < 0.001), and nature video and usual care groups (p < 0.001) during this time period comparison. When comparing the proportion of participants experiencing a reduction in agitation from baseline to immediately following the intervention, there remained a statistically significant difference among all three treatment groups (p = 0.001), as well as between family video and usual care (p = 0.001). There were no statistically significant differences in the proportion of participants experiencing reduced agitation when comparing baseline to 30 min post-intervention (p = 0.043) (Fig. 3). C.M. Waszynski et al. International Journal of Nursing Studies 77 (2018) 154-161 157 No patient or family participants appeared to have suffered harm or adverse effects from participating in the study. No patient participant verbally or behaviorally indicated a desire to stop viewing the family or nature video, or to have the PI leave the area while responses were being recorded. Family members who participated in the creation of a family video message were eager to learn of its effectiveness. 4. Discussion This study explored the effectiveness of using SFP to decrease agitation in hospitalized patients experiencing hyperactive or mixed delirium. Although simulated presence therapy has been used successfully in persons with dementia in nursing homes to decrease agitation (Woods and Ashley, 1995; Cohen-Mansfield and Werner, 1997; Lund et al., 1995; O'Connor et al., 2011; Zetteler, 2008), there were no reports in the literature of its use with hospitalized delirious patients. This study demonstrated that persons with agitated delirium can respond positively to simulated presence therapy involving family. There were small but statistically significant findings to support the use of family video messaging to decrease agitation in hospitalized, hyperactive delirious. There was also evidence that a nature video performed better than no intervention, but not as well as a family video message to decrease agitation. These results suggest that delirious individuals can show interest in a family video stimulus. The greatest benefit occurred while the family video was playing and immediately following the video. It is unclear whether or not the temporary benefit was due to the features of delirium or to the single, short exposure to the stimulus. The post-intervention median agitation scores were not statistically significantly different among the family, nature, and usual care groups, although all three groups were less agitated at the 30 min post intervention times compared to baseline measurement. Fatigue or an inability to sustain high levels of agitation over an extended time may be a contributing factor and potential explanation for this finding. Of interest is that each of the video groups showed a smaller proportion of participants less agitated from baseline as the time from the exposure to the stimulus increased, where as it was the opposite for the control group. Baseline agitation scores reflected states of mild agitation. The Fig. 1. Enrollment. C.M. Waszynski et al. International Journal of Nursing Studies 77 (2018) 154-161 158 researcher encountered difficulty capturing the states of high level agitation on video due to time lapse between researcher notification and arrival at bedside, one minute recordings, and unprovoked clinical situations. In spite of the low ABS pre-intervention/baseline scores and subtle changes, the family video message was able to demonstrate a statistically significant decrease in agitation while it was being administered and for at least one minute after the stimulus was stopped. However, no conclusions can be made concerning more severe agitation states. The creation and use of family video messaging is potentially feasible, effective and affordable. This intervention could be implemented by an organization for less than $500 in equipment costs and minimal staff time to  and show the video message to the delirious patient. The costs of creating the family video intervention for this study included the purchase of a video camera, DVD player and DVDs. The onetime investment costs are the video camera ($250.00) and the portable DVD player ($60.00). The DVD disc must be purchased for each individual patient at a cost of $2.00 per disc. The staff time to film and burn the video is approximately 15 min. Filming could be done by any available hospital employee or volunteer willing to learn and participate in the process. The staff time to show the video is approximately 2 min if all equipment is at the bedside. An organization might purchase several portable DVD players if they plan to use this intervention on several patients simultaneously. Total estimated initial cost for a hospital would be under $500. Compared to the costs associated with continuous observation and pharmacological therapy for agitated patients, this is a cost effective intervention. Several limitations are noteworthy. The majorityof participants were over the age of 50 and had a pre-existing dementia. This limits the generalizability of the findings. However, the effectiveness of the intervention held true regardless of whether the participant did or did not have dementia. All participants were under the care of a continuous observer further limiting the generalizability. The presence of the continuous observer and the PI recording the participant's behavior could have influenced their response. It is also possible that the source of the agitation influenced the participant's response to the intervention. If the agitation was due to pain, fear, hunger or need for toileting, the intervention may not have satisfied the patient's need. If the agitation was related to boredom or fear, the family video message may have been more effective. The response of the participants deemed to be under the effect of a sedating medication at the time of the study intervention (20.7%) may have been influenced by the pharmacological substance. 5. Conclusion This research suggests that family video messaging can decrease agitation in selected hospitalized patients with hyperactive or mixed delirium. This work lays the foundation for future studies to explore the impact of SFP on the potential reduction of restraints and sedatives, response to SFP provided more often and for a longer duration, and the potential to use SFP to prevent delirium in hospitalized patients at high risk for this condition. This research also suggests that a nature video may also be an alternative nonpharmacological intervention to decrease agitation in older hospitalized patients with hyperactive or mixed delirium if and when the creation or viewing of a family video message is not possible. This line of research fills an important gap in the literature on nonpharmacological person-centered delirium interventions involving family. If the results are replicated, it can make a significant contribution to delirium management as part of a multi-component Table 1 Demographic and Clinical Characteristics by Treatment Group. Characteristic Total (n = 111) n (%) Family video (n = 34) n (%) Nature video (n = 40) n (%) Usual care (n = 37) n (%) p Female 52 (46.8) 17 (50) 19 (47.5) 16 (43.2) p = 0.846 Marital Status With spouse 50 (45.0) 16 (47.1) 20 (50.0) 14 (37.8) p = 0.541 No spouse 61 (55.0) 18 (52.9) 20 (50.0) 23 (62.2) Ethnicity Caucasian 92 (82.9) 28 (82.4) 33 (82.5) 31 (83.8) a AfricanAmerican 5 (4.5) 2 (5.9) 2 (5.0) 1 (2.7) Latino 10 (9.0) 4(11.8) 3 (7.5) 3 (8.1) Asian 4 (3.6) 0 (0) 2 (5.0) 2 (5.4) Dementia comorbidity 67 (60.4) 19 (55.9) 24 (60.0) 24 (64.9) p = 0.740 Delirium Etiology Internal source 81 (73.0) 21 (61.8) 31 (77.5) 29 (78.4) p = 0.209 External source 30 (27.0) 13 (38.2) 9 (22.5) 8 (21.6) Admission diagnosis Medical 88 (79.3) 28 (82.4) 31 (77.5) 29 (78.4) p = 0.865 Surgical 23 (20.7) 6 (17.6) 9 (22.5) 8 (21.6) Level of Care ICU/SD 24 (21.6) 11 (32.4) 8 (20.0) 5 (13.5) p = 0.149 Med/surg 87 (78.4) 23 (67.6) 32 (80.0) 32 (86.5) Medically Sedated 23 (20.7) 6 (17.6) 11 (27.5) 6 (16.2) p = 0.412 Age Median 79.0 78.0 81.0 81.0 p = 0.569 Min-max 19-99 50-97 18-99 52-99 IQR 15.0 7.0 18.0 18.5 a Frequencies too small for statistical analysis. Fig. 2. Median Agitation Behavioral Scale (ABS) scores for each of the three groups (family video, nature video, usual care) at each time point (pre-intervention, during intervention, immediately post-intervention, 30 min post-intervention.) Potential range of ABS score = 14-56. C.M. Waszynski et al. International Journal of Nursing Studies 77 (2018) 154-161 159 approach. Acknowledgments Flora Drapeau served as the outcome assessor, reviewing and scoring every recorded participant response on the ABS tool. Jeanne Kessler reviewed every family video message for content. Michael Powell assisted with video transcription and data entry. Michael Ballintyn educated the PI on the use of the video equipment and process of burning DVDs. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This study was not registered.  References Abraha, I., Trotta, F., Rimland, J., et al., 2015. Efficacy of non-pharmacological interventions to prevent and treat delirium in older patients: a systematic overview. The SENATOR project ONTOP series. PLoS One 10, 1-31. American Geriatric Society Expert Panel on Postoperative Delirium in Older Adults, 2015. American Geriatric Society abstracted clinical practice guideline for postoperative delirium in older adults. J. Am. Geriatr. Soc. 63, 142-150. Balas, M.C., Deutschman, C.S., Sullivan-Marx, E.M., et al., 2007. Delirium in older patients in surgical intensive care units. JNS 39, 147-154. Bogner, J.A., Corrigan, J.D., Fugate, L., et al., 2001. Role of agitation in prediction of outcomes after traumatic brain injury. Am. J. Phys. Med. Rehabil. 80, 636-644. Boswell, D.J., Ramsey, J., Smith, M.A., et al., 2001. The cost-effectiveness of a patientsitter program in an acute care hospital: a test of the impact of sitters on the incidence of falls and patient satisfaction. Qual. Manag. Health Care 10, 10-16. Cohen-Mansfield, J., Werner, P., 1997. Management of verbally disruptive behaviors in nursing home residents. J. Gerontol. 52A, 369-377. Cole, M., Ciampi, A., Belzile, E., et al., 2009. Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age Ageing 38, 19-26. Corrigan, J.D., 1989. Development of a scale for assessment of agitation following traumatic brain injury. J. Clin. Exp. Neuropsychol. 11, 261-277. Dahlke, S., Phinney, A., 2008. Caring for hospitalized older adults at risk for delirium. J. Gerontol. Nurs. 34, 41-47. Dasgupta, M., Brymer, C., 2014. Prognosis of delirium in hospitalized elderly: worse than we thought. Int. J. Geriatr. Psychiatry 29, 497-505. Davis, D., Muniz, G.T., Keage, H., et al., 2012. Delirium is a strong risk factor for dementia in the oldest old: a population-based cohort study. Brain 135, 2809-2816. De Jong, M., Van der Elst, M., Hartholt, K., 2013. Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Ther. Adv. Saf. 4, 147-154. Dharmarajan, K., Swami, S., Gou, R., et al., 2016. Pathway from delirium to death: potential in-hospital mediators of excess mortality. J. Am. Geriatr. Soc. http://dx.doi. org/10.1111/jgs.14743. (Accessed January 10, 2017). Ely, E.W., Shintani, A., Truman, B., et al., 2004. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291, 1753-1762. Girard, T.D., Jackson, J.C., Pandharipande, P.P., et al., 2010. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit. Care Med. 38, 1513-1520. Halloway, S., 2014. A family approach to delirium: a review of the literature. Aging Ment. Health 18, 129-139. Harding, A.D., 2010. Observation assistants: sitter effectiveness and industry measures. Nurs. Econ. 28, 330-336. House, R., 2000. Delirium and agitation. Curr. 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Knol, W., van Marum, R., Jansen, P., et al., 2008. Antipsychotic drug use and risk of pneumonia in elderly people. J. Am. Geriatr. Soc. 56, 661-666. Table 2 Comparison of ABS Scores across Groups over Time. Time period Family video median (min-max) Nature video median (min-max) Usual care median (min-max) Significance level Pre-intervention 16.0 (15-24) 17.0 (14-27) 16.0 (14-22) p = 0.071 During intervention 14.0 (14-18) 15.0 (14-26) 16.0 (14-24) p < 0.001 Immediate Post-intervention 14.0 (14-19) 16.0 (14-29) 16.0 (14-22) p = 0.158 30 min Post-intervention 15.0 (14-21) 15.0 (14-28) 15.0 (14-22) p = 0.971 ABS potential range of scores = 14-56. Fig. 3. Proportion (%) of participants in each group (family video, nature video, usual care) who show a reduction in ABS scores from pre-intervention to during the intervention, from pre-intervention to immediately following the intervention, and from pre-intervention to 30 min following the intervention. C.M. Waszynski et al. 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Antipsychotic medication for prevention and treatment of delirium in hospitalized adults: a systematic review and metaanalysis. J. Am. Geriatr. Soc. 64, 705-714. O'Connor, C.M., Smith, R., Nott, M.T., et al., 2011. Using video-simulated presence to reduce resistance to care and increase participation of adults with dementia. Am. J. Alzheimers Dis. Other Demen. 26, 317-325. Partridge, J.S., Martin, F.C., Harari, D., et al., 2013. The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this? Geriatr. Psychiatry 28, 804-812. Pautex, S., Herrmann, F., Zulian, G., 2008. Factors associated with falls in patients with cancer hospitalized for palliative care. J. Palliat. Med. 11, 878-884. Ryan, D., O'Regan, N., O'Caoimh, R., et al., 2013. Delirium in adult acute hospital population: predictors, prevalence and detection. BMJ Open 3, 1-9. Salluh, J., Wang, H., Schneider, E., et al., 2015. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ 350, 1-10. Sessler, C.N., Gosnell, M.S., Grap, M.J., et al., 2002. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am. J. Respir. Crit. Care Med. 166, 1338-1344. Ucok, A., Gaebel, W., 2008. Side effects of atypical antipsychotics: a brief overview. World Psychiatry 7, 58-62. Van den Boogaard, M., Schoonhoven, L., Evers, A.W., et al., 2012. Delirium in critically ill patients: impact on long term health related quality of life and cognitive functioning. Crit. Care Med. 40, 112-118. Wass, S., Webster, P., Nair, B., 2008. Delirium in the elderly: a review. Oman. Med. J. 23, 150-157. Witlox, J., Eurelings, L.S., De Jonghe, J.F., et al., 2010. Delirium in elderly patients and the risk of post discharge mortality, institutionalization and dementia: a meta-analysis. JAMA 304, 443-451. Woods, P., Ashley, J., 1995. Simulated presence therapy: using selected memories to manage problem behaviors in Alzheimer's disease patients. Geriatr. Nurs. 16, 9-14. Zetteler, J., 2008. Effectiveness of simulated presence therapy for individuals with dementia: a systematic review and meta-analysis. Aging Ment. Health 12, 779-785. C.M. Waszynski et al. International Journal of Nursing Studies 77 (2018) 154-161 161  Health Science Science Nursing BIO 155 Share QuestionEmailCopy link Comments (0)
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