Journal of Gerontology: PSYCHOLOGICAL SCIENCES1996, Vol. 5IB. No. 1.P3-P14

Copyright 1996 by The Gerontological Society of America

Observed Affect in Nursing Home ResidentsWith Alzheimer's Disease

M. Powell Lawton, Kimberly Van Haitsma, and Jennifer Klapper

Polisher Research Institute, Philadelphia Geriatric Center.

A method for assessing affect states among older people with Alzheimer's disease was developed for use in a studydesigned to evaluate a special care unit for such residents of a nursing home. The 6-item Philadelphia GeriatricCenter Affect Rating Scale was designed for the use of research and other staff in assessing positive affect (pleasure,interest, contentment) and negative affect (sadness, worry/anxiety, and anger) by direct observation of facialexpression, body movement, and other cues that do not depend on self-report, among 253 demented and 43nondemented residents. Each affect scale was highly reliable, expressed in estimated portions of a 10-minuteobservation period when the affect expression occurred. Validity estimates were affirmative in showing discriminantcorrelations between the positive states and various independent measures of social and other outwardly engagedbehavior and between negative states and other measures of depression, anger, anxiety, and withdrawal. Limitedsupport for the two-factor dimensionality of the affect ratings was obtained, although positive and negative affectwere correlated, rather than independent. Some hope is offered that the preferences and aversions of Alzheimerpatients may be better understood by observations of their emotional behaviors and that such methods may lead to abetter ability to judge institutional quality.

ONE'S MOST immediate impression of a person withAlzheimer's disease (AD) or a similar disorder is likely

to be conveyed by the massive inroads on overall compe-tence made by the brain damage resulting from these condi-tions. Personality, everyday needs, interests, emotional at-tachments, and all else related to the positive goals ofordinary human existence become leveled and dwarfed by

the psychopathology. However, closer contact with ADpatients reveals significant individual differences in residualfunctions and preferences. Research interest in quality of life(QOL) for AD patients, and especially the concern ex-pressed in the reforms embedded in the Omnibus Reconcilia-tion Act of 1987, recognize to some degree the need torestore the breadth of our conceptions of AD patients asindividuals.

This research investigated manifestations of affect innursing home residents suffering from Alzheimer's disease.Affect is an important aspect of personality and deservesstudy in its own right. Affect is also a potentially importantavenue toward understanding the likes and dislikes of a classof patients who are limited in their ability to introspect andreport on their internal states. If affect states can be dis-cerned in patients with dementing illness, this informationmay guide us in designing programs, treatments, and envi-ronmental features to enhance their quality of life. Thisreport describes the qualities of an instrument designed tomeasure observed affect expression in Alzheimer patients.The reliability with which trained observers made suchratings was tested.

The affect measure was used to determine whether theextent to which apparent affect expressions were observed inresidents with dementing illness was different from theextent to which they were observed in nondemented resi-dents. Because such illnesses have massive effects on otheraspects of the person, it is possible that even if affective

function persists, its frequency could be affected by thedementia. Although such analyses have not been performedfor dementia, research suggests that brain pathology mightdecrease positive and increase negative affect (Tucker &Williamson, 1984).

Building on earlier research, the interrelationships of thepositive and negative affect terms were determined in orderto test the consistency of the two-factor structure of affect asposited by Watson and Tellegen (1985) and others. That is,positive affects should be related to one another but not tonegative affects; the negative affects, in turn, would displayan analogous pattern. Such a structure should result inseparate independent positive and negative affect factors.

The validities of the affect ratings were tested by deter-mining their relationships to independently measured as-pects of the residents that might be thought to have a logicalassociation with affect, such as personality ratings, clinicalratings by staff members, and, in one specific hypothesizedinstance, cognitive performance.

Comprehending EmotionThe background for the present study was research in the

general psychology of emotion. Two facets of emotion arethe ability to recognize and comprehend emotion in others(decoding) and the experience and display of emotion (en-coding). Little research has explored these issues in Alzhei-mer's disease and related conditions. One relevant study wasthat of Albert, Cohen, and Koff (1991), who studied theability of AD patients to decode emotion from the facialexpressions of others. They found that AD patients wereindeed less accurate than cognitively intact patients. How-ever, once the effect of cognitive functioning was accountedfor statistically, they concluded that the deficit was explain-able in terms of the cognitive deficit rather than by anyresidual noncognitive deficit in emotion processing. Zandi,

P3

P4 LAWTON ET AL.

Cooper, and Garrison (1992) presented demented and non-demented subjects with tasks of naming emotions expressedin photographs, matching emotion terms with photographs,and producing facial expressions of emotions from verbalemotion names. AD subjects had deficits in all tasks, con-firming the contribution of cognitive deficit to emotiondecoding. They also concluded that the decoding problemwas associated with impaired memory search processesbecause impaired subjects performed better in matchingwords to pictured emotions than in the free naming task.They also found that encoding emotion from verbal labelswas less well performed in dementia patients than in normalpersons. In the case of deeply demented people, on the otherhand, experimental exposure to presumably positive andnegative situations evoked only basic reactions to the stimu-lation, rather than the differentiated responses characteristicof the primary emotions (Asplund, Norberg, Adolfsson, &Waxman, 1991).

Expressing EmotionOne limitation in exploring the experience of emotion in

demented people is their diminished ability to articulate theirfeelings verbally. This is especially true as dementia pro-gresses in its severity; staff and family need increasingly tobase their "reading" of the patient's emotions on nonverbalcommunications. Persons with dementia may express theiremotions through facial expressions, body movements, pos-ture, gestures, and nonword vocalizations (Bartol, 1979;Mace, 1989). Caregivers are left with the task of attemptingto assess the subjective state of the patient via direct observa-tion. Assessment of emotion through the direct observationof facial expression has received a great deal of attention innondemented populations, especially in the work of Ekman,Friesen, and Tompkins (1971) and Izard (1977). Theseinvestigators have developed elaborate rating systems toidentify emotional states such as happiness, fear, anger,disgust, contempt, interest, sadness, and surprise by observ-ing the musculature of specific regions of the face (Ekman &Friesen, 1978). Malatesta and colleagues (Malatesta, Fiore,& Messina, 1987; Malatesta, Izard, Culver, & Nicolich,1987) and Levinson, Carstensen, Friesen, and Ekman(1991) have successfully applied such methods to the studyof emotion in normal elders.

Recent research has begun to examine expressions ofemotion in people with dementing illness. In a clinicallyoriented study, Hurley, Volicer, Hanrahan, Houde, andVolicer (1992) developed a scale assessing expressions ofdiscomfort in AD patients, rated by an observer. This scaleis limited to negative emotional states as indicated by sadand fearful facial expressions, by language, and negativevocalizations. Initial work with this scale indicated promis-ing reliability and validity.

The Two-Dimensional View of AffectA model of emotion that locates most specific affects

within a two-dimensional space is utilized in the researchreport here. Although there are clear methodological condi-tions under which the independence of the two factors islimited, and unresolved conceptual issues regarding their

independence, most research findings converge on thesedimensions as at least partially independent of one another(Russell, 1980). The names of these dimensions depend onboth the affect terms used to rate emotion and on thestatistical approach to factor specification. The major alter-native models specify these basic dimensions as either anactivation dimension and a bipolar pleasantness vs unpleas-antness dimension (Russell, 1980, using an unrotated factorsolution), or two bipolar dimensions of positive affect andnegative affect in a rotated solution (Watson & Tellegen,1985). The two-dimensional structure was replicated amongpeople of several ages and across older people of severaltypes, including very high-functioning community resi-dents, nursing home residents, and depressed elders (Law-ton, Kleban, Rajagopal, Dean, & Parmelee, 1992). Thelatter research was based, of course, on self-reported affectratings and included only a few mildly impaired subjectswith dementing illness. A need is thus seen to determinewhether the relationships among the affects as measured indementia are consistent with the two-factor structure, usingdirect observation rather than self-ratings.

The dual-channel hypothesis that relates positive andnegative affects differentially to their antecedents, was sug-gested in Bradburn's original research (1969) and in Law-ton's (1983) research with the aged. The dual-channel desig-nation originated in research showing that positive affect,but not negative affect, was related cross-sectionally toengagement in external events, such as socializing andengaging in recreational activities (Lawton, 1994). Con-versely, negative affect, but not positive affect, tended to berelated to inner phenomena. External engagement is behav-ior, cognition, or affect whose object lies outside the person;it is distinguished from internal engagement, where theorigin of the person's attention is some internal object, suchas a memory, a thought, or some internal stimulus such as aphysical symptom.

As in the case of the two-factor model of affect, the dual-channel model is relative, rather than absolute. Event-affectcongruence was demonstrated by Lawton, DeVoe, andParmelee (1995) in the stronger relationships between posi-tively valent events and positive affect, on the one hand, andbetween negatively valent events and negative affect, on theother, than those between the positive and negative members.The cross-relationships were not always zero, however. Infact, Lewinsohn, Biglan, and Zeiss (1976) demonstrated thatpositive experiences could be used therapeutically to reducedepression. It should also be noted that ratings of depressiondo not fall clearly into the negative affect factor as defined,for example, by Watson and Tellegen (1985) but into an areabetween negative affect and low positive affect (or deactiva-tion). Given these limitations on the absoluteness of the dual-channel structure, there is reason to hypothesize relative, butnot total, congruence between the valences of antecedentevents and affective consequences.

Hypotheses1. Affect states in dementing illness may be judged reli-

ably by trained observers.2. Although affects will be evidenced in dementing ill-

ness, the frequency of positive emotions will be less and the

AFFECT IN ALZHEIMER'S DISEASE P5

frequency of negative emotions greater than in people with-out dementia.

3. Among a small set of affect states, positive states willbe associated with other positive states but not with negativeaffects; negative affect states will be associated with othernegative affects but not with positive affects. As a set, theywill form two separate factors, as predicted by the two-factormodel of affect.

4. The validity of observed affect states will be estab-lished by a correlational pattern whereby the positive affectswill be related to "positive" personality traits and engage-ment in external activities; anger, sadness, and anxiety affectstates will be related to other indicators of these characteris-tics, and interest (which is hypothesized to have a strongercognitive component than the other affect states) will bepositively related to cognitive function.

5. One facet of the dual-channel model of the antecedentsof positive affect will be supported if participation in exter-nally engaging activities is associated with positive affectsbut not negative affects.

METHODThe data were gathered during the preintervention base-

line assessment period of an evaluation of a special care unit(SCU) for nursing home residents with dementing illness.Two 52-bed designated SCUs housed 104 of the 550 resi-dents in a large nonprofit nursing home, while 5 otherdiverse units also housed some demented residents, whowere recruited for a "scattered" comparison group.

Subjects

Residents with dementing illness. — There were 79 resi-dents assessed in one SCU and 77 in another, representingall residents who resided on the two SCUs long enough tocomplete the measures to be described (an additional 14subjects began the repeated affect measures to be describedlater, but died or were transferred before completing them).The baseline assessments extended over a period of 28months, during which time new residents of the two unitswere added to the original pool of 104 subjects as originalresidents died or were transferred. In the scatter units, 97residents with dementing illness were completed (with a lossof 7 who did not complete other baseline assessments). Allpotential subjects were judged minimally capable of com-prehending the consent information. Therefore, all subjectswere approached personally (as specified by the local IRB)for consent; all but one gave such consent. Family memberswere informed of the research but not requested to provideconsent.

The two physically identical SCUs were chosen becauseall subjects assigned there suffered from moderately severecognitive impairment. Clinical diagnoses for both the SCUsand scattered units were made by full-time medical staff andconsulting staff psychiatrists and clinical psychologists atformal staff conferences, based on both psychological test-ing and clinical interview. Definitive diagnoses according toADRDA-NINDS criteria (McKhann et al., 1984) were notavailable. However, their mean Global Deterioration Scalerating (GDS; Reisberg, Ferris, deLeon, & Crook, 1982) by

medical staff was 5.27 (SD = 1.11, range = 2-7) and theirmean Mattis Dementia Rating Scale (Mattis, 1976) scorewas 78.68 (SD = 30.63, range = 24-138). Although therewas considerable variability, the greater proportion of sub-jects were thus in the moderately severe range of cognitiveimpairment. Their mean age was 87.82 (SD = 5.83, range= 70-104). Their physical health was rated by physicianassistants using the Cumulative Illness Rating Scales (CIRS;Linn, Linn, & Gurel, 1968), which requires 5-point ratingsof each of 14 body systems. The mean overall score was26.9 (SD = 6.4, range = 12-60); the mean of 1.92 perbody system represents an overall "mild" burden of illness,but this was contributed to disproportionately by the patholo-gies of the neurological system. Activities of daily living(ADLs) as rated by nursing staff on the Minimum Data Set(MDS, Morris et al., 1990) indicated that the followingpercentages of residents were not fully independent on thebasic ADLs: Dressing 79%; personal hygiene 68%; toilet use62%; locomotion 44%; bed mobility 26%; eating 26%.

Residents without dementia. — A comparison group ofsubjects was selected from which to assess the rough fre-quency of the several emotion expressions among nonde-mented residents. Five care units that housed relativelyintact residents were selected for this purpose. Researchersattended the monthly residents council meeting in each areato describe the research; written descriptions of the proposedresearch were passed out to residents individually and postedin the care areas. The names of residents who attended themeeting were presented to the unit care coordinators, whothen designated those judged to be cognitively unimpaired.The resulting 43 residents thus represented a particularlyactive, alert, and well-functioning group of nursing homeresidents. None had a diagnosis of any of the dementingillnesses. It should be noted that the intent was to test grossdifferences in frequencies of observable affect states. Noattempt was made to sample either residents or situationssystematically or to estimate prevalence in an epidemiologi-cal sense.

Measuring Instruments: Core MeasuresThe data used for this report included core measures of

daily competence made by service-giving staff, families ofresidents, and research assistants. These measures werechosen for analysis in the present report to explore thenomological net of affect among demented nursing homeresidents, including assessment of the validity of the affectmeasures. Although all the core measures have been shownto possess acceptable psychometric characteristics, mostrepresent clinical ratings, often performed by nonprofes-sional staff. These limitations need to be kept in mind ininterpreting the results.

Depression was measured in two ways. Day-shift nursingassistants rated residents on the 8-item Depression factor ofthe Multidimensional Observation Scale for Elderly Subjects(MOSES; Helmes, Csapo, & Short, 1987). Nurses used theRaskin Depression Rating (Guy, 1976), which requestsratings on verbal reporting, depressed behavior, and second-ary symptoms of depression.

P6 LAWTON ET AL.

Agitation was indexed broadly by the Cohen-MansfieldAgitation Inventory (CMAI; Cohen-Mansfield, Marx, &Rosenthal, 1989), a 29-item inventory that inquires into theprevalence of pathological and disruptive behaviors. Forthese analyses, one subscale, Physical Aggression, was usedas a criterion for the ARS Anger rating. The total CMAIscore, minus the Physical Aggression items, to be referred toas agitation, was used as a behavioral indicator of anxiety.Anger was also assessed by nursing assistants on the MOSES6-item irritability factor (Helmes et al., 1987).

External engagement was originally conceptualized intwo ways, involvement with other people and involvementwith activities. In order to represent the concepts, nursingassistants rated residents on the 8-item Withdrawal factor ofthe MOSES (Helmes et al., 1987), which contains items inboth the social and the activity realms. They also providedratings on a Behavior Rating Scale, 4-point scales of plannedactivity, friendliness with other residents, and sociabilitywith staff. Another view of external engagement was ob-tained from activity therapists, who rated the latter threeengagement items plus rating frequency of participation in11 types of planned activities. The activity and sociabilityitems were combined separately for nursing assistants andactivity therapists for principal components analysis. Nurs-ing assistants' ratings on the 8 MOSES Withdrawal itemsand 3 Behavior Rating Scale items were subjected to aprincipal components factor analysis. For activity therapists,11 activity participation and 3 Behavior Rating Scale itemswere factor analyzed. For both of these analyses, a singlefirst component accounted for most of the variance. Thesocial and activities items were thus combined into differentsummed "sociability" composite scores for activity staff(14 items) and nursing assistants (11 items).

Personality. — The closest family member of record wastelephoned by the social worker and asked to complete apersonality inventory and to make a set of affect ratings. TheAdult Personality Rating Scale (APRS), a 44-item inventoryconstructed for an earlier research project on dementingillness (Kleban, Brody, & Lawton, 1971) was used tomeasure personality. The family member was asked to ratethe way their institutionalized relatives appear at the presenttime. An orthogonal principal components analysis of the 94responding relatives' ratings resulted in 4 factors (account-ing for 78% of the total variance). The factors were namedExtraversion, Hostility, Task Assertiveness, and Neuroti-cism. Because the "neurotic" dimension was representedby only three items, it is not included in the present analyses.Summed composite scores were created for these threedimensions. Results based on these factors are performedonly for the subset of 146 residents whose families providedvalid personality factor ratings.

The Dependent Variables: Affect Rating Scale (ARS)The affect measure was developed by using 6 of the 10

adjectives from the Philadelphia Geriatric Center Positiveand Negative Affect Rating Scales (Lawton et al., 1992).The number of affects used in this study was reduced from10 to 6 in order to lessen the burden on the observer. Theterms represented three positive states (pleasure, interest,

contentment) and three negative affects (sadness, anxiety,and anger). The rating form (Table 1) provides brief illustra-tions of cues by which each emotion expression may beidentified by an observer, and a 5-point rating to be madefollowing a 10-minute observation. The rating form beginswith the general instruction, "Over this 10-minute observa-tion period, rate the extent or duration of each affect state.The indications are named for illustrative purposes. Youmay use other indicators but if you do, please write them intothe defining block." The scales are the research observers'estimates of the amounts of time during the 10-minuteinterval in which each affect state was exhibited: Never, <16 sec, 15-59 sec, 1-5, and > 5 min, plus "can't tell"durations. The 5-point rating scales may be thought of asordinal ratings anchored roughly to time rather than cumula-tive real times denoted by on-off segments.

The same adjectives shown in Table 1 were used byactivity therapists and family members, but the instructionsrequested them to rate the frequency of each affect state overthe past 2 weeks: 1 = never, 2 = once per week, 3 = 2-6times per week, 4 = 1 - 2 times per day, 5 = 3+ times perday. Thus, in addition to using a totally different rating scale,these raters had considerably larger samples of time overwhich to accumulate their observations. The 2-week timespan also afforded a period of time during which aggregatedstates might begin to approximate traits (Epstein, 1983).

ProcedureThe core measures were performed over a period of about

4 weeks for each resident. Nursing assistants were trained

Table 1. Philadelphia Geriatric Center Affect Rating Scale

PleasureSigns: Smile, laugh, stroking, touching with "approach"manner, nodding, singing, arm or hand outreach, open-armgesture, eye crinkled

AngerSigns: Clench teeth, grimace, shout, curse, berate, push,physical aggression or implied aggression, like fist shaking,pursed lips, eyes narrowed, knit brows/lowered

Anxiety/FearSigns: Furrowed brow, motoric restlessness, repeated oragitated motions, facial expression of fear or worry, sigh,withdraw from other, tremor, tight facial muscles, callsrepetitively, hand wringing, leg jiggling, eyes wide

SadnessSigns: Cry, tears, moan, mouth turned down at corners,eyes/head down turned and face expressionless, wiping eyes,horse-shoe on forehead

InterestSigns: Eyes follow object, intent fixation on object or person,visual scanning, facial, motoric or verbal feedback to other,eye contact maintained, body or vocal response to music, wideangle subtended by gaze, turn body or move toward person orobject

Contentment (less intense than pleasure)Signs: Comfortable posture, sitting or lying down, smoothfacial muscles, lack of tension in limbs, neck, slow movements

AFFECT IN ALZHEIMER'S DISEASE P7

individually to make the depression, engagement, and agita-tion ratings by rating trial cases. Research assistants inter-viewed the nursing assistants individually about the residentin order to obtain these ratings. Physicians and physicianassistants received two formal training sessions conductedby a senior psychiatrist consultant on the GDS and by localstaff for the CIRS. Research assistants were trained inten-sively by senior clinical psychology staff to administer theMattis Scale. Activity therapists were trained by researchstaff to make the engagement ratings.

The ARS ratings on demented residents were made byresearch assistants in association with direct observations ofongoing behavior entered into a hand-held event recorder.After each period of observation, the affect ratings were alsoentered into the programmed event recorder. The data weregathered by research assistants, who underwent a period oftraining in the use of the ARS. Training began with adidactic session during which senior staff discussed themeaning of emotion and the several manners in whichemotion is manifested. This session also included an intro-duction to the science of facial expressions as indicators ofemotion (Ekman et al., 1971). The training video tapes forthe Facial Action Coding system (FACS; Ekman & Friesen,1978) were used to illustrate some of the concepts behindthis process. It should be noted that the FACS itself was notused as the formal basis for the ARS ratings, but wasintroduced to sensitize the researchers to the use of facialexpressions. A manual was produced that elaborated on theindicators displayed in Table 1. It should be noted that verbalexpressions, voice, and all body motoric behaviors could beused as indicators. The training period proceeded over onemonth. Researchers discussed their experiences after theyhad spent several hours simply observing residents infor-mally and making their own ratings, in the presence of one ofthe authors (K.V.), who was available on the spot fordiscussion. At that point, each researcher was assigned aseries of observations with a senior staff member or anotherresearch assistant. An average of 35 to 40 such independenttwo-person ratings were performed, followed by discussionby the pair. Two cycles of formal comparisons of agreementrates were completed during the month, using results incorrective feedback. At the end of the month and before themain data were gathered, reliability was tested formally (seebelow). (The behavioral observations, called BehaviorStreams, were gathered in 10-minute segments; these dataare not reported in this article.) After each period of observa-tion, the affect ratings were entered into the programmedevent recorder. After training and informal training ratingsbut prior to the gathering of the ARS data to be described,pairs of research assistants observed the same subject on 243occasions.

A total of 16 10-minute Streams were collected over a 4-week period for each resident, sampling equally morning(10-12 noon), afternoon (1-3 p.m. and 3-5 p.m.), and earlyevening (7-8 p.m.) segments. A total of 224 subjects hadthe full complement of 16 Streams; an additional 20, whohad fewer than 8 because of deaths or transfers beforecompletion of the Streams, were not included among the 253dementia subjects reported on here. There were 29 subjectswho had 8-15 Streams; each of these residents' average

affect ratings was calculated for the reduced number ofStreams and used as data, resulting in an N of 253.

For the observations, the research assistants positionedthemselves to be as unobtrusive as possible while stillmaintaining a full view of the resident's face. As is usualwith naturalistic observation, despite the researchers' fre-quently being in full view of the resident, reactivity to theobserver was minimal by the time pilot work was completedand actual data collection had begun. Virtually all observa-tions were done within the confines of the subject's residen-tial unit, but the observer followed the resident wherever shewent. Toilets, bathrooms, treatment rooms, and closed bed-room doors were, however, off limits for observation.

The intact residents are quite mobile throughout the nurs-ing home, and thus ARS observations confined to theirresidential care unit would not be representative of their day.Therefore, the observers sought intact subjects in the resi-dential care unit, the central "mall" of the nursing home,the main dining room (not during meals but at off-mealriours), and in the waiting area of the nursing home medicalclinic. A quota, rather than a representative time-sampledgroup, of affect ratings was sought for nondemented resi-dents. Thus, a total of 143 ARS observations were obtainedfrom the 43 intact residents (a quota sample of 4 per residentwas sought, but achieved about half the time) to comparenormal with demented residents in terms of the frequencywith which the affect states were observed.

RESULTS

Table 2 shows the descriptive statistics for the measuresused in this report. Measures were available for most sub-jects on most measures. Only 239 were able to give scorableresponses on the Mattis, however. The APRS questionnaireswere returned by 146 family members. As can be seen, theinternal consistencies of most of the multi-item measureswere acceptable.

The results are presented so as to address each of theresearch questions. First, can emotion in dementia patientsbe reliably observed? Second, do residents with and withoutdementing illness differ in their frequency of display ofaffect states? Third, a test of the consistency of the resultswith the two-factor conception of affect was conducted.Fourth, is there evidence of validity in observers' ratings ofthe affect states of impaired elders? Fifth, the dual-channelview of affect was tested by determining whether peoplewho are more involved in engaging activities and socialbehavior exhibit more positive affects.

The Reliability of the Affect Rating ScaleTable 3 shows the reliabilities, frequencies, and mean

duration ratings. The first column of Table 3 shows thekappas for 243 two-observer ratings of each affect state forAD residents. These kappas are very high (.76 to .89) anddisplay few differences in reliability among the six states.

Table 3 also shows the frequencies of occurrence of eachaffect in directly observed behavior for the residents withdementia. The second column indicates the mean percentageof all 16 occasions in which each resident exhibited one ormore instances of each affect, i.e., the frequencies. The nexttwo columns show the mean affect ratings and their standard

P8 LAWTON ET AL.

Table 2. Means, Standard Deviations, and Ranges of Core Variables and Staff or Family Ratings

Reisberg Global Deterioration Scale (GDS)Mattis Dementia Rating Scale"Cumulative Illness Rating Scale (C1RS)Cohen-Mansfield Agitation Inventory (CMA1)

Agitation indexPhysical aggression index

Multiobservational Scale for Elderly Subjects (MOSES)DepressionIrritability

Sociability Rating — Activity staffSociability Rating — Nursing assistantsAdult Personality Rating Scale (APRS)

ExtraversionHostilityTask-centered assertiveness

n

239186234

253253

253253239253

146146146

No. ofitems

18714

236

86

1511

19139

Alpha

NA.91.68

.80

.62

.80

.83

.82

.80

.94

.90

.87

Mean

5.2773.6826.90

33.067.66

13.0912.3325.8830.62

51.7930.6819.79

SD

1.1130.636.37

10.733.40

4.734.646.457.85

16.3511.397.51

Range

2-714-13815-48

23.906-31

8-308-28

11-4316-49

19-8913-609-41

"High score denotes a large amount of the named characteristic, except for the Mattis, where high score denotes low impairment.

Table 3. Rater Reliabilities, Percentages of Streams With One or More Instance of Each Affect,and Means and Standard Deviations of Affect for Subjects With and Without Dementia

PleasureAngerAnxietySadnessInterestContent

Kappa

.80

.89

.78

.81

.86

.76

Subjects With Dementia

% Displaying

235

34118768

Mean

1.451.101.961.324.133.36

SD

.48

.18

.78

.48

.81

.88

Subjects Without Dementi*

% Displaying

450

25139797

Mean

1.811.001.471.204.574.69

i

SD

.74

.00

.58

.38

.62

.53

Univariate F

14 4***

NA14.6***2.06

11.31***90.22***

***p< .001.

deviations. It can be seen that the "hot" affects — anger,sadness, pleasure, and anxiety/fear — were relatively infre-quent, while contentment (68%) and interest (87%) wereobserved during the majority of the behavior streams.

Affect in Demented and Nondemented ResidentsTable 3 also shows the comparison between the mean

affect scores (i.e., estimated durations of each affect) ofdemented and nondemented residents. Pleasure, interest,and contentment were greater in cumulated duration amongnondemented residents, while anxiety was less. Anger wasnever observed among nondemented residents. Means werecompared with a multivariate analysis of variance (omittinganger because it lacked variance). The overall group differ-ence was highly significant (F = 24.68, df = 5,192, p <.001). The univariate tests showed significant differencesbetween the two groups on four of the five affect states, onlysadness displaying no difference in mean rating.

The Two-Factor Structure of AffectThe present results would be consistent with the two-

dimensional model of affect if the three positive states wererelated to one another but not to the negative states, and thethree negative states to one another but not to the positivestates.

In the left-hand portion of Table 4 are shown the correla-tions among the AD residents' affects, using each subject's16-day mean as the variate (N = 243). The 3 positive affectsformed a clear cluster (intercorrelations of .41, .43, and.56). Pleasure was minimally correlated with anxiety andanger but slightly negatively correlated with sadness (-.22).Anxiety and sadness were clearly related (r = .49), butanger was unrelated to sadness and only slightly (r = .23) toanxiety. Anxiety and sadness were strongly negatively re-lated to contentment (-.48 and-.46). Of special note was thepattern of correlations involving interest. Although clearly amember of the "positive triad," interest was also positivelycorrelated with both anxiety and anger. Interest thus ap-peared to have displayed components of both positive moodtone and psychological activation, albeit negative activation.

Although there are good reasons for examining each of theaffect ratings separately, the most definitive test of theapplicability of the two-factor model to these particularaffect states as exhibited in AD would come from a con-firmatory factor analysis allowing the positive factor to becorrelated with the negative factor. This hypothesis wastested through use of the Analysis of Moment Structures(AMOS; Arbuckle, 1994), a maximum-likelihood programthat allows raw data to be entered directly rather than asmultiple matrices. This solution could not be attained, how-

AFFECT IN ALZHEIMER'S DISEASE P9

ever, because of a singular matrix on the negative affectfactor. The reason for this result became apparent when theratings were subsequently analyzed by the principal compo-nent method with Varimax rotation. The right-hand portionof Table 4 shows such exploratory factor loadings. Thesingularity was introduced by the fact that anxiety accountsfor by far the greatest amount of variance in negative affect;anger and depression are clearly members of this factor, buttheir low prevalence and general covariation with anxietymean that the latent variable would be almost completelyaccounted for by anxiety.

An alternative accounting for the structure of the affectratings is provided by the first principal (unrotated) compo-nent, whose loadings are shown in the rightmost column ofTable 4. This clearly bipolar factor did not include anger atall, but indicated the poles as but defined by Contentment(.91 loading) vs Sadness (-.67 loading). There is thus somesupport for both a single- and dual-factor affect structure.

A Validity of the Affect Rating ScaleThe discriminant and convergent validities of the ARS

were determined by calculating each AD resident's meanrating across 16 occasions for each affect and using theresulting 6 mean affect scores to correlate with the variety ofother indicators of the resident's current status. These bivari-ate analyses were performed because some hypotheses were

advanced regarding relationships between specific affectstates and selected criterion measures. In other cases, com-posites may be the best source of validity correlates. There-fore, separate composites based on the exploratory factoranalyses were composed to represent Positive Affect (plea-sure, interest, contentment). Anxiety and Depression (omit-ting Anger because of its relative independence from otherstates), and Total Affect (the 3 positive affects plus reverse-coded anxiety and depression, a high score representingpositive total affect). For easier comprehension, the correla-tions will be presented separately for staff and family ratingsof negative characteristics (Table 5) and positive characteris-tics (Table 6). For convenience, the family APRS factor ofhostility is grouped with negative characteristics in Table 5,and extraversion and task assertiveness with the positivecharacteristics in Table 6. A series of hypotheses (detailedbelow) were made regarding the expected pattern of signifi-cant and nonsignificant relationships. Tables 5 and 6 showthe disconfirmed hypotheses, whether the hypothesis calledfor a significant or a zero relationship, by values enclosed inparentheses. That is, parenthetical significant correlationsare those that were not predicted, and parenthetical nonsig-nificant correlations are those that had been predicted to besignificant. The large number of bivariate correlations com-puted ensures that many would be anticipated on the basis ofchance. Therefore one might well provide Bonferroni ad-

Table 4. Correlations Among Affect Rating Scale Items and Rotated Two-Factor Loadings

CorrelationsFactor

ILoadings

IIFirstPC

1. Pleasure2. Interest3. Contentment4. Anxiety5. Anger6. Sadness

—41*43*

-0600

-22*

—56*28*20*

-02

—^ 8 *

02-46*

—23*49* 02

718678002730

-10.32

-.49.91.40.71

.63

.99

.91-.55-.02-.67

Notes: N = 243. Decimals omitted. PC = Principal component.*p< .001.

Table 5. Correlations Between Behavior Stream Affect Ratings and Staff and Relative Ratings of Negative Characteristics

BehaviorStream Affect

AngerAnxietySadnessPleasureInterestContentmentPositive AffectAnxiety/DepressionAffect total

ARS

ActivityTherapists

32*31*37*NANANA

Relatives

25*31*32*NANANA

MOSESDepression

0020*25*

(-29)*00

-16-13

25*-22*

Raskin

-03(13)32*

(-23)*-05

(-20)*-19

23*-25*

CMAIAgitation

0032*

(17)-13

01(-22)*-14

30*-27*

CMAIPhysical

Aggression

24*1602

-0707

-00011206

MOSESIrritability

37*16

-02-10

08-02

001207

APRSHostility

24*07

-03-05

04010104

00

Notes: ARS = Affect Rating Scale; MOSES = Multidimensional Observation Scale for Elderly Subjects; CMAI = Cohen-Mansfield AgitationInventory; APRS = Adult Personality Rating Scale. Decimals omitted. Cell entries in parentheses indicate divergent correlations (significant unpredicted ornonsignificant predicted correlations), n = 237 except for APRS, where n = 145.

* p < .001.

P10 LAWTON ET AL.

Table 6. Correlations Between Behavior Stream Affect Ratings and Staff and Relative Ratings of Positive Characteristics

PleasureInterestContentmentAngerAnxietySadnessPositive AffectAnxiety/DepressionAffect Total

ARS»

ActivityTherapists

38*35*

(13)NANANA

Relatives

30*(12)(05)NANANA

Sociability"

ActivityTherapists

44*35*43*

-06-10-19

49*-15

47*

NursingAssistants

41*31*36*

-00-07-18

43*-13

38*

Extraversion

24*(08)24*

-13(-24)*-10

23*

(-21)*28*

APRS"

TaskAssertiveness

(14)(08)(17)03

-15-14(16)-17

21*

MattisDementia

Rating Scale'

1022*1505

-08-04

20*-07

18

Notes: ARS = Affect Rating Scale; APRS = Adult Personality Rating Scale. Decimals omitted. Cell entries in parentheses indicate divergent correlations(significant unpredicted or nonsignificant predicted correlations).

>n = 237 for ARS and Sociability; n = 145 for APRS; n = 186 for Mattis.*p< .001.

justments to redefine traditional significance levels. For thisfirst exploratory descriptive study, however, showing themost complete picture, one that shows all values significantat the/? < .001 level, seems appropriate. The overall patternof confirmations and disconfirmations will also be analyzed.

Negative characteristics. — Among all possible correla-tions between ARS ratings of anger, anxiety, and sadness,and the ratings by staff and relatives, the following selectivehypotheses were made:

a. Negative-affect ARS ratings from directly observedbehavior should be significantly correlated with past-2-weekratings of the same three affects by Activity Therapists (AT)and Relatives (Rel).

b. ARS Anger should be correlated with CMAI Aggres-sion, MOSES Irritability, and Family APRS Hostility.

c. ARS Anxiety should be related to MOSES and RaskinDepression and CMAI Agitation.

d. Sadness should be related to MOSES and RaskinDepression and CMAI Agitation.

e. The negative composite (anxiety and depression) aswell as the overall affect score, should be related to MOSESand Raskin Depression and CMAI Agitation.

f. All other pairwise correlations were implicitly hypoth-esized to be nonsignificant, particularly those involving thepositive affects (pleasure, interest, and contentment). Thereis, of course, some ambiguity in the constructs that might beexpected to correlate with one another. For example, knowl-edge of how affects have correlated in other research mightpredict that the various measures of depression or anxietyand anger might be related as they often are in life. Angerwas seen as different enough from depression and anxiety,however, to warrant the hypothesis of no correlation. Onthe other hand, anxiety and depression, having been perenni-ally difficult to separate in self-report measures, were ex-pected to be correlated with one another in the observationalmode. All other bivariate correlations were hypothesized tobe zero.

Results from the above hypotheses may be summarized,first, by noting the significant, though moderate-sized corre-

lations between observed ARS negative affects and ratingsof the same emotions by activity therapists and relatives (firsttwo columns of Table 5). Thirteen of the 15 hypothesizedsignificant relationships (including those involving theAnxiety-Depression composite and the Affect total) indi-cated in Table 5 were confirmed. Anxiety was not signifi-cantly related to Raskin Depression, while Sadness was notcorrelated with CMAI Agitation. None of the 15 zero-hypothesized relationships involving the negative affectswas significant. All 24 correlations between the 3 positiveaffects (plus the PA compositive) and the negative character-istics were hypothesized to be zero. Four were, in fact, sig-nificant, 3 of them converging on the clear conclusion thatresidents in whom 2 of the positive affects (Pleasure andContentment) were less frequently observed were consid-ered more depressed by staff. Those less contented were alsoconsidered more agitated by nursing assistants.

Positive characteristics. — Among these correlations, itwas expected that:

(a) observers' ratings of the 3 positive affects should berelated to the 2-week frequency ratings of the same affectsby activity therapists and relatives.

(b) Each of the positive affects should be related to all 4positive characteristics (Sociability ratings by activity thera-pist and nursing assistants and Extraversion and Task Asser-tiveness ratings by relatives).

(c) One affect state, interest, should be related to cogni-tive function as estimated by Mattis scores.

(d) None of the 3 negative affects should be related to anyof the 2 measures of sociability or the 2 positive personalitytraits.

The validity coefficients between observers and activitystaff raters were significant for Pleasure and Interest but notContentment; observed interest and contentment were notsignificantly related to relatives' 2-week ratings of thesestates, but Pleasure as observed and as rated by familymembers was significantly related.

As shown in Table 6, 9 of the 13 hypothesized concurrentcorrelations were confirmed. Observer-rated interest was

AFFECT IN ALZHEIMER'S DISEASE Pll

unrelated to family APRS ratings of Extraversion and TaskAssertiveness. Neither Pleasure nor Contentment was sig-nificantly correlated with Task Assertiveness. Of the corre-lations hypothesized not to differ from zero, 18 of the 20 didnot. The only unhypothesized correlation showed that resi-dents rated as more extraverted by family members were lessoften observed to be anxious and showed lower scores on theAnxiety-Depression composite.

The Dual-Channel HypothesisThe correlations relevant to the dual-channel hypothesis

are included among those shown in Table 6. All 3 positiveaffect terms were associated with both measures of externalengagement (Sociability), while all of the relationships be-tween negative affect and Sociability were zero.

DISCUSSION

The discussion will examine the implications of the find-ings with respect to each of the sets of hypotheses and thenconsider some larger issues of quality of life and quality ofinstitutional care.

The Reliability of Affect Ratings in DementiaThese data attest to the persistence of observable emotion

among demented nursing home residents. The two-observerreliability of the scales was excellent, which reinforces theconclusion regarding the sheer presence of affect in dementia.One may still wonder what the ratings measure. Althoughobservers estimated the time during which each state waspresent, are they really approximations of the time duringwhich each emotion was registered? Because strict on-offclockings on real time were not made for each state, the ARSmay well represent more global perceptions of complex cueclusters than cumulated time during which affects were ob-served. Even if true, this pattern of results still affirms theability of the ratings to denote the occurrence of specificemotions. Further research clearly is required on the microbe-havioral dynamics of emotion in this subject group andcontext, research where antecedents and contextual condi-tions could be more precisely determined and small behav-ioral units linked to concurrent emotions. Although emotionwas not their focus, the nursing home research of Baltes andcolleagues (e.g., Baltes & Zerbe, 1976), is a good example ofthe possibility of relating a microbehavioral antecedent to amicrobehavioral consequence.

Affect State Frequencies in Dementedand Nondemented Residents

Within the dementia group, it is clear that all 6 emotionswere present to some degree or another. The prevalences andmean time intervals shown in Table 2 show that interest andcontentment were most often observed. Although content-ment and interest appear in most affect lists (e.g., Diener &Emmons, 1984; Watson & Tellegen, 1985), they appear tobe less intense and intrinsically more extended in time thanthe other three; thus we suggest the terms "cold" for thesetwo states, as compared to the other "hot" emotions. Quali-tatively the raters expressed much uncertainty about identi-fying contentment. Sometimes they used it as a residualcategory, on occasions when there was no evidence for

negative feeling, or for the presence of hot emotions, orinappropriate or totally detached behavior. Despite this per-ceived ambiguity, the psychometric performance of thecontentment item was not poorer than that of the other fouraffects, except in the failure of activity therapists and familyraters to agree with research assistants.

The observed differences between affect state frequenciesof the affects in demented and nondemented residents repre-sent only a preliminary view. The recruitment of nonde-mented subjects was not random and the contexts in whichthe behaviors of the two groups were observed were nottotally matched. This first view does, however, suggest thatthe positive emotions were somewhat less frequent amongdemented people, and anxiety was more frequent. Angerwas rare in the demented group and totally absent in thissample of nondemented people. The absence of a differencein sadness could represent either truly equal frequency or,perhaps, greater difficulty in assessing sadness by observa-tion. In any case, more research is needed to determine truedifferential prevalence rates.

The Two-Dimensional Model of AffectBecause of the singularity of the matrix, confirmatory

factor analytic methods could not be used to test the differen-tial goodness of fit of a one- versus two-factor affect struc-ture. By comparison with most other research on emotionratings, the present results are unusual in producing a bipolarone-factor exploratory solution. The failure of the singlefactor to account for anger is a disadvantage. The two-factorsolution accounted for all affect states and produced a resultmuch more similar to that of other studies, in demonstratingclear positive affect and negative affect factors, which werealso correlated.

One can only speculate about the meaning of the single-factor results. It is possible that the widespread pathology ofdementing illness does cause a leveling or simplification ofthe structure of affect in the direction of a simple good vs baddimension. It is just as likely that observers impose suchsimplicity of structure on what they see in AD patients. Weare inclined to add the ARS instrument itself to the list offactors leading to simplification. The affect list is short andthe indicators and their definitions represent a first effort.Before drawing any conclusion regarding the structure ofaffect in Alzheimer's disease, it is obviously necessary toexpand the methods used to study affect in residents withdementing illness.

The two-factor solution exemplifies the only partial inde-pendence of the two factors. The correlation between them(-. 19, p < .01) is accounted for by dual loadings of interest,contentment, and sadness. Interest loaded positively, ratherthan negatively, on the negative affect factor and was corre-lated with both anxiety and anger. Earlier research hadalready identified interest as being minimally related to thenegative affects among noncognitively impaired elders (Law-ton et al., 1992). A possible explanation for the positivecorrelation between interest and both anger and anxietyamong AD patients may be that a certain amount of physicalvigor and attentional capacity is required to show interest,anger, and anxiety. (Note also the positive correlation be-tween interest and cognitive functioning on the Mattis).

P12 LAWTON ET AL.

These unexpected positive correlations may thus be a func-tion of the continued presence of vigor among moderatelyimpaired residents, compared to the inevitable decline ofboth physical and affective functions among those withgreater cognitive decline. The "cost" of continued vigormay thus lie in the possibility that engagement can bringabout negative as well as positive interactions. This hypothe-sis is worth testing in confirmatory fashion across a largersample of AD subjects with a broader range of cognitivefunction, to determine whether this anomaly persists.

Contentment appears to express a relatively global"good" state and Sadness a global "bad" state, each ofthem showing an understandable negative "crossover" inaddition to their expected high loadings on positive affectand negative affect, respectively. Sadness, or depression, isnotably absent from the Positive and Negative Affect Scales(PANAS; Watson, Clark, & Tellegen, 1988). These authorsachieved a zero correlation between PA and NA by carefullychoosing affect terms to represent these two dimensions soas to eliminate items like depression, which represent bothlow activation and negative valence. As was argued in ourconstruction of the Philadelphia Geriatric Center PositiveAffect and Negative Affect Scales (Lawton et al., 1992),allowing such bridging affect terms to appear in a scalecaptures better the reality of the full range of emotions aswell as providing a measure of a centrally important feelingstate. In conclusion, although we are unable to provide astatistical basis for choosing between a one-factor and a two-factor model of affect states of AD patients measured in thisway, the presence of evidence in favor of differential corre-lates of positive and negative affects (see below) argues infavor of the usefulness of retaining two separate factors.

The Validity of the Affect Rating ScaleAlthough the summary factor-derived composites express

well the overall affect state valence of each person, in somecase differential hypotheses were formulated for individualaffect states. This section will discuss these bivariate results,then consider whether the composites afford as much infor-mation as the individual affect states, and then whether someaffect terms are so redundant as to be superfluous. Thevalidity estimates were of modest magnitude, but it is stillreassuring that despite the multiple sources of ambiguityinherent in assessing people with dementing illness, theimprecision of assessing emotion, and this study's frequentreliance on modestly trained nursing-staff raters for criterionratings, a preponderance of positive concurrent validitiesemerged. Good agreement with research assistants' ARSratings of the negative and positive affects by activity staffwas observed, while relatives showed excellent agreementwith the ARS on all the negative affects and on Pleasure.Family members clearly had smaller samples of recentbehaviors on which to base their ratings. They also had todepend on the written instructions for guidance in makingtheir ratings, compared to the focused training provided forresearch assistants and activity therapists. Therefore, thefact that family agreed significantly (though to a modestextent) with research assistant observers at all gives hope forthe possibility of improving the validity of family members'rating skills through training.

Among all hypothesized concurrent validity correlationsbetween ARS ratings and the scales completed by staff andfamilies (plus the one between interest and the resident's testscore on the Mattis), 22 of the total of 29 positive predictedrelationships (76%) occurred.

The pattern of divergent validity estimates is particularlyrelevant to the dual-channel conception of affect-behaviorrelationships, which will be discussed in greater detail later.These indicators of discriminant validity also showed anoverall confirmatory pattern (91% of those hypothesized tobe zero were not significant). Significant but unhypothesizedcorrelations showed that Pleasure and Contentment did, infact, occur less frequently among residents rated by staff asmore sad and anxious. Intuitively this pattern also seems tobe quite expectable; people who are considered sad andanxious surely ought to experience fewer positive states. Theanalysis of within-ARS correlations and factor structurerepeated this picture. The disconfirmation here, however, ispart and parcel of the theoretically based expectation thatthere should be two factors, discussed earlier with theconclusion that two factors of partial independence representthe most useful model. The unhypothesized negative corre-lations between Extraversion and both ARS Anxiety and theAnxiety-Depression composite also are best understood asanother illustration of the limits of independence betweennegative states and positive personality traits.

These results are also relevant to the question of theappropriate type of aggregation of affect terms to bestrepresent the emotional valence of the dementia resident.First, it is clear that, despite the statistically acceptablebipolar single affect factor, the gains consequent to keepingpositive terms separate from negative terms were very welldemonstrated. In few cases were the Total Affect Scorescorrelated more highly with criteria than were the separatePA and NA composites. Less clear is whether the 3-item PAcomposite and the Anxiety-Depression composite are asuseful or more useful than the single affect terms that com-pose the indices. Interest was, in fact, quite different inits pattern of intercorrelations from those associated withPleasure and Contentment. One thus can conclude thatAnger and Interest should be used as separate affect terms.The sizes of the PA composite and the Anxiety-Depressioncomposite correlations with other measures were never im-pressively higher than those for the single affects. Thereforethere is little reason to prefer the composites.

To summarize the indicators of validity, the overall taskwas one of asking whether the aggregate time-sampledratings made by research observers were picking up affectstates that were congruent with totally independent, moretime-extended estimates of personal characteristics fallingmore toward the trait portion of the state-trait continuum. Inthis task, the ARS performed in a pattern that was highlyconfirmatory, despite built-in limitations in the judgmentsby clinical staff which were the basis for most criterionmeasures; even the nonhypothesized relationships were un-derstandable. One thus concludes that it is worthwhile topursue affect ratings as a way of further comprehending theresident with dementia. It also seems profitable to explorehow to use affect ratings as a means for tapping the knowl-edge of relatives regarding people with dementing illness.

AFFECT IN ALZHEIMER'S DISEASE P13

The Dual-Channel Model of Affect and ActivityIn Lawton's original statement of this hypothesis (1983),

antecedents of both positive and negative outcomes wereused in the data set. The present study was cross-sectional,of course. The selectively positive correlations betweenpositive affect and staff ratings of sociability and the lack ofcorrelations between negative affects and sociability areconsistent with the dual-channel view. This research testedonly the engagement channel, however, and not the channelthat might relate negative affects to other factors. This resultis similar to many others in the literature that document theelasticity of positive feelings in response to socially engag-ing activity. The present results show only a correlationbetween the two. It remains to be demonstrated whetherdeliberately programmed interventions that feature the useof leisure-time activities can have such consequences. None-theless, the search for enhancement of positive quality of lifethrough engagement seems worthwhile. The present resultssuggest that negative affective states are less likely to be-come ameliorated by such engagement. Further tests of sucha possibility are clearly warranted, however, in light of thefindings noted earlier suggesting that positive experiencescan ameliorate depression. The cross-loadings of sadness onthe positive and negative factors may be interpreted assupport in the ability of sadness, but not anxiety, to beinfluenced by positive experiences. The other channel of thedual-channel hypothesis, not tested here, would suggest thatinterventions directed toward the self and other interiorphenomena would be more clearly capable of diminishingnegative affect than of enhancing positive affect.

Quality of Institutional Life and Quality of CareAn ideal scenario would be to determine what an older AD

patient likes and dislikes, what soothes her and what stimu-lates her, and so on, through skilled observation of the typedescribed here. Observed pleasure should allow one todiscern a preference for some valued object; observed nega-tive feelings would suggest aversions. Individualized treat-ment could then be tailored to the needs of each resident, sothat the geographic location of the resident, the sensory andinterpersonal stimulus context, the one-to-one care transac-tions, and the planned and unplanned activities of the treat-ment environment could converge in a way that wouldmaximize positive emotion and minimize negative emotion.

The present report has moved the state of knowledge onestep toward such a goal, in demonstrating the "legibility" ofthe dementia patient's outward mien and the gross congru-ence between some indicators of context and apparent emo-tion. However, one must be cautious about the claims madefor the association between affective indicators and context.A major problem concerns the level of aggregation used inthe present report. That is, the person was the unit of analysisand the measure of emotion was the person's mean across 1610-minute periods. Thus, what has been demonstrated is thatpeople who smile, gaze with interest, and appear content arealso people who participate in activities, show higher levelsof activity, and are considered to be extraverts by familymembers. At this point, then, personality consistency hasbeen demonstrated in several of the traditional componentsof personality. Not yet tested is the degree to which single

individuals' emotions vary with the environmental, social,or treatment situation. This is the intraindividual level ofcovariation, an analytic task where interindividual differ-ences are no longer of concern. This is a very complexanalytic task, which is now under way in the analysis ofother data from this research project.

These results suggest that it is possible to define institu-tional quality through the use of observed emotion. Thepresent findings suggest that high activity and structuredsocial interaction level are associated with favorable residentaffects. It is tempting to suggest that more activity is theanswer. What is much more likely is that people vary both interms of their general sensitivity to context and their valenceof responsiveness to external and internal stimulation. Theintraindividual level of analysis may well identify peoplewhose day-to-day affect improves as engagement increases;it is also likely that some will become more anxious or angryas stimulation increases, and that still others will be impervi-ous to such influence. Basing intervention on these princi-ples will be the true bottom line of personalized treatmentquality. The quality indicator for an individual will be thecongruence between contexts and psychological well-being.On an institutional level, the quality indicator may, conceiv-ably, be an index of aggregated stimulation, but only ifpositive-reacting residents are most prevalent among thetotal resident population. A probable better indicator wouldbe an audit that can detect (a) the extent to which theinstitution makes an effort to match context with individualneed, and (b) the counted aggregates of positive and negativeaffect, which we hypothesize will reflect the outcomes ofexternal stimulation whether the person's preference is forhigh or low levels of stimulation. The use of affect ratings asquality indicators is a future possibility, but considerablymore research is needed before counted affects may be usedin quality control. Nonetheless, the present results give somehope that direct-care staff, and perhaps even Medicaid sur-veyors, might add this element to their ability to identifyhigh-quality care.

ACKNOWLEDGMENTS

This research was supported by National Institute on Aging Grant AG-10304, one of 10 cooperative research studies of special care units forAlzheimer's disease patients (Marcia Ory, Science Administrator). Theintervention was sponsored by the Harry Stern and Joseph AbramsonFamilies Center for the Study of Alzheimer's Disease. Special thanks aredue the staff of the Philadelphia Geriatric Center, especially the nursingassistants of Levin Building floors 3 and 4, and the research staff whopainstakingly gathered the data: Julia Corn, Heidi Melley, Charlene Riedel,and Robin Landow.

Address correspondence and requests for reprints to Dr. M. PowellLawton, Philadelphia Geriatric Center, 5301 Old York Road, Philadelphia,PA 19141.

REFERENCES

Albert, M. S., Cohen, C , & Koff, E. (1991). Perception of affect in patientswith dementia of the Alzheimer type. Archives of Neurology, 48,791-795.

Arbuckle, J. (1994). AMOS: Analysis of moment structures. Psychome-trika,59, 135-137.

Asplund, K., Norberg, A., Adolfsson, R., & Waxman, H. M. (1991).Facial expressions in severely demented patients: A stimulus-responsestudy of four patients with dementia of the Alzheimer type. Interna-tional Journal of Geriatric Psychiatry, 6, 599-606.

P14 LAWTONETAL.

Bakes, M. M., & Zerbe, M. B. (1976). Independence training in nursinghome residents. The Gerontologist, 16, 428-432.

Bartol, M. A. (1979). Nonverbal communications in patients with Alzhei-mers disease. Journal of Gerontological Nursing, 5, 21-31.

Bradburn, N. M. (1969). The structure of psychological well-being. Chi-cago: Aldine.

Cohen-Mansfield, J., Marx, M. S., & Rosenthal, A. S. (1989). A descrip-tion of agitation in a nursing home. Journal of Gerontology: MedicalSciences, 44, M77-M84.

Diener, E., & Emmons, R. (1984). The independence of positive andnegative affect. Journal of Personality and Social Psychology, 47,1105-1117.

Ekman, P., & Friesen, W. V. (1978). Facial action coding system. PaloAlto, CA: Consulting Psychologists Press.

Ekman, P., Friesen, W., & Tompkins, S. S. (1971). Facial affect scoringtechnique. Semiotica, 3, 37-58.

Epstein, S. (1983). Aggregation and beyond: Some basic issues on theprediction of behavior. Journal of Personality, 51, 360-392.

Guy, W. (1976). ECDEU assessment manual for psychopharmacology.Rockville, MD: U.S. Department of Health, Education and Welfare.

Helmes, E., Csapo, K. G., & Short, J. A. (1987). Standardization andvalidation of the Multidimensional Observation Scale for Elderly Sub-jects (MOSES). Journal of Gerontology, 42, 395-405.

Hurley, A. C , Volicer, B., Hanrahan, P. A., Houde, S., & Volicer, L.(1992). Assessment of discomfort in advanced Alzheimer patients.Research on Nursing and Health, 15, 369-377.

Izard, C. E. (1977). Human emotions. New York: Plenum.Kleban, M. H., Brody, E. M., & Lawton, M. P. (1971). Personality traits

in the mentally impaired aged and their relationship to improvements incurrent functioning. The Gerontologist, 11, 134-140.

Lawton, M. P. (1983). The dimensions of well-being. Experimental AgingResearch, 9, 65-72.

Lawton, M. P. (1994). Personality and affective-correlates of leisureactivity participation by older people. Journal of Leisure Research, 26,138-157.

Lawton, M. P., DeVoe, M. R., & Parmelee, P. (1995). The relationship ofevents and affect in the daily lives of an elderly population. Psychologyand Aging, 10, 469-477.

Lawton, M. P., Kleban, M. H., Rajagopal, D., Dean, J., & Parmelee, P.A. (1992). The factorial generality of brief positive and negative affectmeasures. Journal of Gerontology: Psychological Sciences, 47,P228-P237.

Levinson, R. W., Carstensen, L. L., Friesen, W. V., & Ekman, P. (1991).Emotion, physiology, and expression in old age. Psychology andAging, 6, 28-35.

Lewinsohn.P. M., Biglan, T., &Zeiss, A. (1976). Behavioral treatment ofdepression. In P. Davidson (Eds.), Behavioral management of anxiety,depression, andpain (pp. 91-146). New York: Brunner/Mazel.

Linn, B. S., Linn, M. W., & Gurel, L. (1968). The Cumulative IllnessRating Scale. Journal of the American Geriatrics Society, 16, 622-626.

Mace, N. (1989). A new method for studying the patient's experience ofcare. The American Journal of Alzheimer's Care and Related Disordersand Research, 4, 4—6.

Malatesta, C. Z., Fiore, M. J., & Messina, J. J. (1987). Affect, personality,and facial expressive characteristics of older people. Psychology andAging, 2, 64-69.

Malatesta, C. Z., Izard, C. E., Culver, C , & Nicolich, M. (1987). Emotioncommunication skills in young, middle-aged, and older women. Psy-chology and Aging, 2, 193-203.

Mattis, S. (1976). Mental status examination for organic mental syndromein the elderly patient. In L. Bellack & T. Karasua (Eds.), Handbook forpsychiatrists and family care physicians. New York: Grune & Stratton.

McKhann, G., Drachman, D., Folstein, M. F., Katzman, R., Price, D., &Stadian, E. (1984). Clinical diagnosis of Alzheimer's disease. Neurol-ogy, 34, 939-944.

Morris, J. N., Hawes, C , Fries, B. E., Phillips, C. D., Mor, V., Katz, S.,Murphy, K., Drugovich, M. L., & Friedlob, A. S. (1990). Designingthe national resident assessment instrument for nursing homes. TheGerontologist, 30, 293-302.

Reisberg, B., Ferris, S. H., deLeon, M. J., & Crook, T. (1982). TheGlobal Deterioration Scale (GDS): An instrument for assessment ofprimary degenerative dementia. American Journal of Psychiatry, 139,1136-1139.

Russell, J. A. (1980). A circumplex model of affect. Journal of Personalityand Social Psychology, 39, 1161-1178.

Tucker, D. M., & Williamson, P. A. (1984). Asymmetric neural controlsystems in human and self-regulation. Psychological Review, 91,185-215.

Watson, D., Clark, L. A., & Tellegen, A. (1988). Development andvalidation of brief measures of positive and negative affect. ThePANAS scales. Journal of Personality and Social Psychology, 54,1063-1070.

Watson, D., & Tellegen, A. (1985). Toward a consensual structure ofmood. Psychological Bulletin, 98, 219-235.

Zandi, T., Cooper, M., & Garrison, L. (1992). Facial recognition: Acognitive study of elderly dementia patients and normal older adults.International Psychogeriatrics, 4, 215-221.

Received March 13, 1995Accepted August 17, 1995