(Michelle E. Kelly, BCBA-D)
Behavioural Gerontology is the application of behaviour analysis to ageing and age-related issues. Behavioural Gerontology is also a Special Interest Group (SIG) of the Association for Behavior Analysis International (ABAI). The BG-SIG’s mission is to foster interest among behaviour analysts in addressing and researching ageing-related issues. Their website is http://bgsig.wordpress.com/; Facebook https://www.facebook.com/behavioralgerontology.
I was recently contacted by Dr Miranda Trahan (BCBA), a member of the BG-SIG, as we both share an interest in the application of behaviour analysis to dementia populations. Miranda runs Trahan Behavioural Services, an ABA service in the U.S. that focuses on keeping older adults with dementia independent for as long as possible. Goals include (i) teaching older adults and their caregivers the skills necessary to improve their quality of life; (ii) increasing appropriate behaviours; and (iii) manage challenging behaviours with individualized non-pharmacological interventions. Miranda writes blogs on the practical applications of ABA for people with dementia – these are well worth a read. For more information, check out her website and blog pages at – http://marandatrahan.com/.
For those of you who may not be familiar with the benefits of behaviour analysis for people with dementia and their families, here is a snapshot of how ABA can be readily applied and hugely beneficial in remediating a number of concerns throughout the dementia journey.
Dementia is an umbrella term that describes a range of conditions that cause damage to the brain. There are many different causes of dementia including vascular dementia, fronto-temporal dementia, and the most common cause, Alzheimer’s disease. These are the diseases that cause the symptoms.
Over 35.6 million people are currently living with dementia worldwide. This is estimated to almost double by 2030 to 65.7 million. Currently in Ireland there are approximately 48,000 people living with dementia (4,066 aged under 65). This figure is also expected to double to around 96,000 in the next 20 years. This means that increasingly greater numbers of people will require interventions and services to ensure they can live well with their diagnosis. It is important therefore, that behaviour analysts can identify relevant applications of their skills for working with people with dementia; and that people with dementia, their families, and health and social care professionals recognise the potential of behavioural interventions.
Behaviour Analysis at Diagnosis
At diagnosis a behaviour analyst is well placed to advise individuals with dementia and their families on changes that may be required, such as the adaptation of living environments, implementing schedules or routines, or changes in how people carry out their daily tasks.
Behaviour therapists are also particularly important at this stage. There is considerable evidence that assuming the role of caregiver is stressful and that, as a result, caregivers may be at an increased risk for psychological health problems. Research shows that both Cognitive Behaviour Therapy (CBT) and Acceptance and Commitment Therapy (ACT) can help. For example, a group of psychologists in Spain recently published a report in PSIGE (Faculty of Psychology for Older People) on CBT and ACT indicating promising results for both, although preliminary findings suggest ACT may result in the most positive outcomes for carers.
More focus is required on the potential applications and effects of CBT and ACT for people with dementia themselves however, particularly given that around 60% are thought to experience anxiety or depression post-dementia diagnosis. Although some research indicated that a modified version of CBT (CBT-AD) was beneficial for treating people with dementia, a lot more research is needed.
At the early stages of the disease, there should be an emphasis on maintenance of existing abilities to compensate for decline. Focus should not be on what has been lost but rather on maximising existing capabilities.
In my own work, I implemented an early intervention called “Cognitive Rehabilitation” or CR with three people with early stage dementia. The intervention focused on individualised personal rehabilitation goals and implemented practical interventions and strategies. I worked on a 1:1 basis with participants once a week for about 8 weeks on goals that they identified as important to them. Examples included remembering names, phone numbers, appointments, or using a mobile phone. I used strategies such as discrete trial training, precision teaching, spaced retrieval, and errorless learning. I also encouraged the use of memory aids and routines, adapted environments, and worked on relaxation skills. After the intervention, each participant’s ratings of goal performance and satisfaction improved, as did carer ratings of their loved ones performance. Importantly, quality of life and cognitive function (as measured by standardised cognitive tests; MoCA and RBANS) also improved for participants from baseline to follow-up.
I am currently working with clinical psychologists and geriatricians to develop a CR manual, designed for use by psychologists and healthcare professionals working with people with dementia. I will provide further information when the manual is complete.
Moderate to Later Stage Dementia
Over 50% of people with dementia experience Behavioural and Psychological Symptoms of Dementia (BPSD) at some point; with more difficult symptoms often occurring in moderate to later stages. BPSDs include depressive symptoms, anxiety, apathy, sleep problems, irritability, psychosis, wandering, elation and agitation. These symptoms can be highly distressing, and may result in challenging behaviour. BPSDs are also associated with a more rapid rate of cognitive decline, greater impairment in activities of daily living, diminished quality of life, and can often be a reason for placement into residential care. Although there is little or no evidence to suggest that traditional antipsychotic medications have any utility in treating BPSDs, these are still the ‘go-to’ solution in most cases.
Behaviour analysts won’t be surprised to hear that a recent Cochrane Review (one of the highest standards of reviews in evidence-based medicine) concluded that Functional Assessments (FAs) for the management of challenging behaviour are a promising alternative to traditional BPSD management. With FAs, the behaviour analyst can determine the function of the challenging behaviour, and develop and evaluate hypothesis driven strategies that can aid family and staff to reduce and resolve the person’s distress and associated behavioural manifestations.
Communication difficulties are another area where behaviour analysts might intervene, particularly given that communication interventions are so commonly implemented by behaviour analysts in applied practice. Aphasia (a reduction in the ability to express or comprehend language) is common in moderate to later stages of dementia, meaning that alternative methods of communication are often required. Talking Mats, very similar to what most of us behaviour analysts know as PECS, are often used with people with dementia, and have been shown to be an effective method of communication. Behaviour analysts can not only train the individual in the use of Talking Mats or PECS, but can also train staff and family members to use them effectively.
Finally, improving activity engagement in residential and long term care is an area that can be addressed by behaviour analysis. In a study of 27 nursing homes (observed for 13 hours per day), 65% of residents’ time was spent doing nothing and only 12% in social activities. Low activity engagement was shown to be a result of weak stimulus control of activities, and was quite easily remediated with reinforcer sampling, modelling, and the implementation of schedules of reinforcement for activity engagement.
Suggested Journal Articles
Dwyer-Moore & Dixon (2007) – Functional Analysis and Treatment of Problem Behavior of Elderly Adults in Long-Term Care: Functional analyses were conducted for the problem behaviour of 3 older adults in a long-term care setting. Two of the problem behaviours were maintained by attention, and a third was maintained by escape from demands. Function-based interventions were implemented that resulted in decreases in problem behaviour in each case. Implications for the use of functional analysis and function-based interventions in the field of gerontology are discussed – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2078575/
Trahan et al. (2011) – Behaviour Analytic Research on Dementia in Older Adults: It is estimated that 1 in 10 adults aged 65 years and older have been diagnosed with dementia, which is associated with numerous behavioral excesses and deficits. Despite the publication of a special section of the Journal of Applied Behavior Analysis (JABA) on behavioral gerontology (Iwata, 1986), there continues to be a paucity of behavior-analytic research with this population. This review compares the research published before and after the behavioral gerontology special section and evaluates the most recently published aging articles in JABA – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177357/
Sample Lecture Slides
Training Caregivers of Elders with Dementia who Exhibit Challenging Behaviours to Take a Functional Approach – http://bgsig.files.wordpress.com/2011/03/talk_gutterson.pdf
Behaviour Analysis and Dementia in Ireland (directly related to the content above) http://behaviouranalysisinireland.wordpress.com/2013/11/01/dr-michelle-kelly-behaviour-analysis-and-dementia/
*Thanks to the Alzheimer Society of Ireland for the infographics on dementia.