Humour therapy significantly reduces agitation in nursing home residents, an Australian cluster randomised trial has shown.

Seventeen homes (189 residents) received the intervention and 18 homes (209 residents) received usual care. The residents had a mean age of 84. Around three quarters (77%) were female and 78% had a diagnosis of dementia. Residents with a fear of clowns were excluded from the study.

One member of staff from each of the intervention homes was chosen to be the LaughterBoss: the modern-day equivalent of a court jester.

LaughterBosses attended a one day training course, dressed distinctively and were given ‘permission to be silly.’ ¹

A professional performer the ElderClown visited the home on 9 to 12 occasions during the three-month intervention period. ElderClowns don’t wear garish make-up, oversized clothes and large floppy shoes. They interact with residents on a personal level, telling jokes, singing songs and asking for advice (e.g. about which hat suits them best — the sensible hat, the sailor hat or the silly hat).²

Participants were assessed at baseline, at the end of the 13-week intervention and at 26 weeks.

The primary outcome was depression, measured using the Cornell Scale for Depression in Dementia, a 19-item questionnaire designed for older people with dementia who can at least communicate basic needs.

A score  ≥ 8 indicates significant depression symptoms and a score of  ≥ 12 suggests significant depression.³ The mean baseline scores were 7.8 in the control group and 8.5 in the intervention group.

At 26 weeks, the scores had fallen to 6.3 and 6.4 respectively. The mean adjusted change difference between the two groups was not significant.

The failure of humour therapy to improve depression may be explained by the fact that depressed patients have difficulty understanding and appreciating humour.⁴ There was also no significant improvement in behavioural disturbances (other than agitation), social engagement or quality of life.

The secondary outcome of agitation was measured using the Cohen-Mansfield Agitation Inventory which rates 29 agitated behaviours on a seven-point scale from never (1 point) to several times an hour (7 points). There are four categories of behaviour:

• Physically aggressive (e.g. hitting)

• Physically non-aggressive

(e.g. pacing)

• Verbally aggressive (e.g. screaming)

• Verbally non-aggressive (e.g. negativism).⁵

Humour therapy significantly reduced agitation at 26-week follow-up (adjusted mean difference after correction for data skewness 0.17 (95% CI:0.004-0.34, P = 0.045).

The authors estimate that the reduction in agitation achieved with humour therapy is equivalent to a reduction in the frequency of two agitated behaviours from daily to once a week. This is a similar effect to that seen with risperidone.

Agitation can be caused by environmental factors (e.g. lack of attention from carers), physical illness (e.g. infection), pain, side effects of medication, or depression. These must be identified and addressed before any consideration is given towards prescribing antipsychotic medication. Systematic pain management appears to be just as effective as risperidone.⁶

A late colleague of mine kept a fez in his desk and was a very skilled practitioner of humour therapy.

The findings of this study suggest that we should follow his example. The next time you are asked to treat an agitated nursing home resident, may I suggest that you reach for the fez rather than the prescription pad!

Dr Phillip Bland