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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, over-

dependence

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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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

Engelman, Altus & Mathews (1999)

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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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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)

Engelman, Altus, Mosier & Mathews (2003)

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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 AllisonAllison.Jay@wmich.edu

http://wmu.aging.practicum.googlepages.com/home