Document Type


Date of Degree

Fall 2014

Degree Name

PhD (Doctor of Philosophy)

Degree In


First Advisor

Specht, Janet K.

First Committee Member

Gardner, Sue E.

Second Committee Member

Algase, Donna L.

Third Committee Member

Williams, Kristine

Fourth Committee Member

Carr, Lucas J.


Objective: This dissertation includes three projects that study care environments and apathy in dementia as well as measures of activity. Project 1 developed the Person-Environment Apathy Rating (PEAR) scale to measure environmental stimulation and apathy, and tested its psychometrics. Project 2 examined the association between care environments and apathy in persons with dementia. Project 3 tested the accuracy of ActiGraph and activPALTM activity monitors in measuring weight-bearing activities among persons with previous diabetic foot ulcers.

Methods: The PEAR consists of environment (PEAR-Environment) and apathy (PEAR-Apathy) subscales. The validity and reliability of the PEAR was examined through video observation of 24 participants. Project 2 selected 40 participants with dementia in order to examine the association between apathy and environmental stimulation, ambiance, crowding, staff familiarity, and light and sound. Study procedures involved video observation and data extraction. Project 3 enrolled 31 participants to test the accuracy of ActiGraph and activPALTM in measuring number of steps taken and duration of walking, standing, sitting, and lying.

Results: The PEAR-Environment subscale had significant but fair correlation with the Crowding Index (Ρ=.27, p<.01), suggesting fair validity. The PEAR-Apathy highly correlated with the Passivity in Dementia Scale (ρ=.81) and Neuropsychiatry Inventory (NPI)-Apathy subscale (ρ=.266), and moderately correlated with the NPI-Depression subscale (ρ=.46), indicating good convergent validity and moderate discriminate validity. The PEAR also demonstrated good internal consistency (Cronbach's Α= .84 -.85) and moderate to good inter-rater (Weighted Kappa=.47-.94) and intra-rater (Weighted Kappa=.47-.94) reliability. Project 2 revealed that stimulation clarity and strength were significantly associated with a low apathy level (p<.001). An increase of 1 point on stimulation clarity and strength corresponded to a decrease on apathy score of 1.3 and 1.9 points, respectively. Project 3 revealed that ActiGraph had widely varied accuracy in measuring duration of standing, walking, sitting, and lying (0-100%) and in measuring number of steps taken (43-81%). In contrast, activPALTM showed consistently high accuracy in measuring duration of standing, walking, sitting, and lying (97-100%) and in measuring number of steps of taken (91-99%).

Discussion: The PEAR is a valid and reliable measure of care environment and apathy in long-term care residents with dementia. Care environments that contain clear and sufficiently strong environmental stimulation are significantly associated with lower apathy levels, providing a foundation for interventions targeting apathy. ActivPALTM is a valid tool to measure weight-bearing activity in persons with diabetes in order to examine the role of weight-bearing activity in foot ulceration. This monitor may also be useful as a supplemental measure for apathy in persons with dementia.


Activity, Apathy, Care environment, Dementia, Diabetic foot ulcer, Nursing home


ix, 126 pages


Includes bibliographical references (pages 121-126).


Copyright 2014 Ying-Ling Jao

Included in

Nursing Commons