Transcript Behavioral Gerontology

Behavioral Gerontology
Linda LeBlanc and Allison Jay
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Aging in America
 The proportion of the population over age 65
in the U.S. has risen from 4% to 13% in the
20th Century
– Predicted to be 20% of the population by 2030
 Many factors contribute
– Medical advances have increased life expectancy
• 1900: 47.3 years
• 1950: 67 years
• 2000: 76 years
– Aging of Baby Boomers
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Effects of Aging
 Living longer means a substantial portion of
elders live with chronic illness and
disability
– Higher total cost of care
– Greater care needs
– Potentially lower quality
of life
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Behavioral Gerontology
 Application of behavioral theory and principles to
aging issues
– Clinical/Rehabilitation Issues
– OBM/Staff Training Issues
 Small sub-field of behavior analysis that needs new
interested students
– Check out the Behavioral Gerontology SIG at ABA
 Different approach to aging from typical medical
model of inevitable biological decline
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Behavioral Gerontology
 From a behavioral perspective, when a
person ages
– Fewer discriminative stimuli control behavior
– Different establishing operations are likely
– Contingencies of reinforcement tend to support
the wrong behaviors
 Leads to behavioral deficits like
– memory problems, incontinence, overdependence
 And behavioral excesses like . . .
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Need For Behavioral Gerontology
 Behavior Excesses (Behavior Problems):
– Aggression, Wandering, Repetitive vocalizations
 Behavior problems are
– Major cause of caregiver stress
– The most common cause of institutionalization
• Not a health decline but “can’t take it anymore” on
the part of the caregiver
– Very common in nursing homes
• 64% have significant problems (Zimmer et al, 1984)
• Can lead to high staff turnover
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Obstacles to widespread behavioral
services
 Practitioners are reluctant to serve elders – no
training
 Older people and caregivers perceive stigma for
accessing mental health services
– Older adult: means “I’m crazy”
– Caregiver: “a good son/daughter/wife/husband” could
handle it without help
 Medical Model Myths
– Psychotropic medications are the only thing that will work
- most common intervention
– Once a skill is lost it cannot be regained
 Cost and effort constraints
– Simple and/or cheap will always be selected
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Common mental health problems
for elders
 Depression and Anxiety
 Dementia related behaviors
– Losses or declines in memory, conversation,
socialization, and activity engagement
– Incontinence
– Increases in problem behaviors
• Aggression
• Repetitive Vocalizations
• Wandering
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Anxiety and Depression
 Often undetected in elders because
– Physicians and patients fail to recognize it
• Focus on physical symptoms rather than mental health
• Emotional issues are reported as physical symptoms (e.g.,
fatigue, heart rate problems)
• View it as typical aging to be sad and worried
 Anxiety
– About 6% of healthy elders have clinical anxiety (APA,
1998)
– Higher rates in elders with medical conditions
 Depression
– Occur in 2 - 10% of older adults; 2x more in women
– 30-50% of people in nursing homes
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Behaviorally . . . why
 Depression and anxiety might increase
because . . .
– Motivative operations
– Reinforcer availability/loss
– Discriminative stimuli
– Others
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Behavior Therapy
 Individual or group based therapy that
focuses on the role of:
– Activity and social engagement
– Access to reinforcers for non-depressed
behaviors
– Negative self-statements
– Problem – solving skills
 Elders who complete therapy tend to benefit
as much or more than younger adults
– Often a preference for group therapy
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Nursing Homes
 Depressed affect can increase risk of nursing
home placement (Cohen-Mansfield & Wirtz, 2007)
 Nursing homes
– Absence of meaningful opportunities for
engagement
– No social interaction or conversations
– Increased depression and memory problems
– High rates of problem behavior
– Excess disability
 Behavioral gerontologists have tackled each of
these problems successfully
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Bourgeois (1993)
 “Effects of memory aids on dyadic conversations
of individuals with dementia”
 Patients with dementia appear incoherent in
conversation because they
– Substitute vague words for specifics
– Drop out content and theme
– Cannot spontaneously generate topics
 Interventions such as memory wallets result in
better conversations
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My Nieces:
Caroline, Courtney, Jessica
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My favorite color is blue.
My cat is Mr. Snuffles and he is a Siamese.
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I live at 427 Bloomfield Ave
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Bourgeois (1993)
 Two demented patients in conversation
 Participants: 5 women & 1 man at adult day
care centers
 Memory aid for one of the two was used in
each conversation
– Interviewed family members to develop list of
facts and topics
– Took corresponding pictures to include in
wallet
 5 minute conversations 3 times per week
– Measured on-topic statements and statements
related to the memory aid
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Bourgeois (1993)
 Research design =
– Reversal (BAB)
 Effects
– Noticeably more on-topic statements related to aids and
to other areas (except one) for target client
– Also more for the partner - it wasn’t their aid!
– Least effects were when both partners were extremely
impaired
 Social Validity
– 13 Speech Staff listened to tapes and rated quality
– Aided conversations rated higher on staying on topic,
ambiguity, comfortability,
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Heard & Watson (1999)
 Targeted wandering in demented individuals in
nursing homes using a functional behavioral
approach
 Tracked wandering in 35-40 minute episodes; in
how many intervals did it occur
 Found different reasons or functions for why
wandering occurred
– Attention
– Access to food
– Sensory stimulation
 Used that reinforcer in a DRO procedure to
decrease wandering
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 Research Design =
– Reversal (ABAB)
 Effects =
– Clear effects for each participant
– Decreased intervals with wandering by ½ for
each participant
• What implication for this continued level of
behavior?
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The Intersection of
Gerontology and OBM
 Direct care staff in nursing homes
– Are called CNAs (Certified Nursing Assistant)
– Are often receiving low pay and working long hours
– Have many potentially unpleasant aspects to their job
– Are often kind people who sincerely want to help
– Often have no idea that their actions are directly
contributing to an environment that
• Suppresses independence and activity
• Reinforces problematic behavior
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The Intersection of
Gerontology and OBM
 Staff training and performance monitoring
are a critical part of providing good care in
nursing home settings
 Staff will often acquire knowledge of
procedures in in-service then fail to use the
procedures when they interact with clients
– No system in place to make it worthwhile or
feasible to maintain new procedures
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Engelman, Altus & Mathews (1999)
 Increasing engagement in daily activities
 5 residents with dementia
 Intervention:
– CNA training to get staff
• Interacting with each client every 15 min
• Offering activity choices
• Praising activity
– Written feedback on CNA performance
 Measured appropriate engagement,
inappropriate engagement, no engagement
 Research Design =
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Engelman, Altus & Mathews (1999)
 Results =
– All participants experienced increased
appropriate engagement
• over 80% of intervals in morning
• over 70% of intervals in afternoon
– Greater diversity of activities
• 7 in baseline, over 20 in intervention
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Engelman, Altus, Mosier &
Mathews (2003)
 Well meaning staff may increase resident
dependence by doing everything for them
 System of “Least to Most” Prompts ensures
opportunity to perform independently
– Verbal
– Gestural
– Physical
 Intervention
– Interactive 30 min training on SLP (model, rehearse,
feedback)
– Feedback on job; Daily Monitoring of Client
Performance by CNA
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Engelman, Altus, Mosier &
Mathews (2003)
 Participants: 2 CNAs; 3 elders with dementia
 Measured
– CNA use of SLP
– Time it took to dress***
 Research Design = multiple baseline across
participants
 Results =
– Prompts increased for all CNAs across elders
– No increase in time it took to dress elder (6.7 vs. 6.5
min)
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Conclusions
 Increasing need for
professionals with
experience and expertise
in aging
 Opportunity to create new
models for service
delivery that allow
individuals to retain
independence as long as
possible
 Allows you to blend
clinical and OBM interests
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Practicum in Behavioral
Gerontology
 New model of service delivery
– Day program so they live at home longer
– Respite for caregivers
– Activities and care for participants
 Physical, Medical, Cognitive Disabilities
 Active Behavioral Programming
– Increased engagement, decreased problem behavior
 Advanced Practicum if you do well
– OBM and clinical opportunities
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 Practicum for Psychology Students - WMU
– Year round
– 3 credit hours
Contact Allison
[email protected]
http://wmu.aging.practicum.googlepages.com/home
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