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Training Caregivers of Elders with Dementia Who Exhibit Challenging Behaviors to Take a Functional Approach

Ryan Gutterson, M.S., B.C.B.A. California State University, Los Angeles


Relevant Statistics !! ~4.5

million individuals in U.S. in 2000

"! Three

times this in 2050

!! Annual

Cost: $189 Billion in 2007 !! Annual cost per individual: "! $18,400

for mild/early AD "! $36,000 and up for advanced

California State University – Los Angeles


Examples of Successful Application Reduction of incontinence (Engel et al., 1990; Burgio, 1986) !! Reduction of seizure-like behaviors (Burgio et al., 1985) !! Reduction of wandering (Heard & Watson, 1999) !! Reduction of disruptive vocalizations (Buchanan & Fisher, 2002; Dwyer-Moore & Dixon, 2007) !! Reduction of aggression (Baker et al., 2006) !! Increasing rational speech (Beaton et al., 2006) !!


Preference and Relative Effectiveness for Behavioral Methods !! Primary

treatment:

"! Neuroleptic

and antipsychotic medications "! Modest efficacy and significant health risks (Bird & Cook, 2008, Sink, Holden & Yaffe, 2005, Schneider, Pollock, & Lyness, 1990) !! DRI/Extinction "! Preferred

and Time-Out:

by physicians/family

California State University – Los Angeles


Functional Analysis !!

Seminal Study: Iwata, Dorsey, Slifer, Bauman & Richman (1982/1994) "!

Broadly replicated

" ! FA-based interventions may have higher probability of

success than those that do not specifically/causally address behavior function (Iwata, Kahng, Wallace & Lindberg, 2000).

California State University – Los Angeles


Current Research !!

!!

!!

!!

Buchanan & Fisher (2002). Functional assessment and non-contingent reinforcement in the treatment of disruptive vocalization in elderly dementia patients. Journal of Applied Behavior Analysis, 35(1), 99-103. Beaton, Peeler, & Harvey (2006). A functional analysis and treatment of the irrational and rational statements of an elderly woman with Alzheimer’s disease. Behavioral Interventions, 21, 1-12. Dwyer-Moore & Dixon (2007). Functional analysis and treatment of problem behavior of elderly adults in long-term care. Journal of Applied Behavior Analysis. 40(4), 267-283. Baker, Hanley, & Mathews (2006). Staff-administered functional analysis and treatment of aggression by an elder with dementia. Journal of Applied Behavior Analysis, 39(4), 469-474.

California State University – Los Angeles


Purpose !! Train

non-professional caregivers at home

"! Understand

basic principles of behavior analysis "! Conduct FAs "! Carry out function-based intervention plans !! Investigate

prolongation of expensive residential care

placement.

California State University – Los Angeles


Participants !! Hilary

and Harry:

"! Both

75 years old "! Hilary, diagnosed with moderate-severe Alzheimer’s disease, and her husband/care-provider. !! Al

and Jane:

"! Al,

an 88-year-old man diagnosed with severe Alzheimer’s disease, and his 75-year-old wife/care-provider.

!! Behaviors: "! Hilary:

Resistance to steps in nighttime routine "! Al: Perseverative requests to go on outings California State University – Los Angeles


Experimental Design and IOA !! Non-concurrent

multiple-baseline design across

participants !! IOA: 52% of sessions across all participants "! Harry:

M=94%, range 83-100% "! Jane: M=89%, range 37-100%

California State University – Los Angeles


Methodology Baseline !!

Typical Routine

Training Operant Principles, Data Collection/Videos !! Pre/Post Quizzes !! Intervention Protocols !!

FA Hilary: 5 min !! Al: 15 min with extended pair-wise condition !!

California State University – Los Angeles


5

Frequency

4

3 Attention 2

Control Demand

1

Hilary

0 1

2

3

4

5

6

7

8

9

Sessions

Four-Condition Functional Analysis

18

Pair-Wise Condition

16 14

Frequency

12 10

Attention

8

Demand Access

6

Control

4 2

Al

0 1

2

3

4

5

6

7

8

9

10

11

12

13

Sessions California State University – Los Angeles

14


Methodology !! Intervention: "! Hilary

and Harry: NCR-Attention, DRA, EXT-Escape "! Al and Jane: NCR-Access, VM-DRO-15, EXT-Attention !! Follow-Up "! Hilary

and Harry: 2 and 5 weeks "! Al and Jane: 2 and 4 weeks !! Social

Validity-Likert Scale

California State University – Los Angeles


Baseline

Intervention

Follow-Up

Percent of Steps in Task Analysis

100 90 80 70 60 50 40

Compliance

30

Resistance

20 10 6 Weeks/No Staff

Sessions

5 Weeks

2 Weeks

12

11

10

9

8

7

6

5

4

3

2

1

0

35

25 20 15

Perseverative Utterances

10

Sessions

19

18

17

16

14

13

12

11

10

9

8

7

6

California State University – Los Angeles 5

4

3

2

0

15

5

1

Frequency of Utterances

30


Results Behavior Intervention !! Hilary "! Mean

decrease in percentage of steps with resistance behavior from 30% to 6% of steps "! Total overall decrease of 88% !! Al "! Mean

decrease in perseverative requests from 13 to .5 per

hour "! Total overall decrease of 96% California State University – Los Angeles


Results Functional Analysis Integrity !! 87% of Sessions: "! Harry:

M=98%, range 94-100% adherence "! Jane: M=54%, range 37-71% adherence #! M

Prompted=34% #! Mean steps conducted accurately=88%

Intervention Integrity "! Harry:

M=98%, range 94-100% "! Jane: M=83%, range 59-96% California State University – Los Angeles


Results Social Validity !! Harry "! "!

!!

Jane "!

!!

Stress levels associated with routine reduced from highest to lowest level Satisfaction and confidence in interaction with Hilary from lowest to highest levels Jane’s results indicate a reduction from high to low stress, and an increase in confidence and satisfaction from low to neutral

Both "!

No change in likelihood of residential care placement, very satisfied/ comfortable with intervention and training. California State University – Los Angeles


Discussion !! Training

of non-behavioral caregivers successful in producing a differentiated functional analyses and successful function-based interventions "! High

treatment integrity and IOA

!! Replication

of functional analysis with dementia

caregivers !! Expansion by training non-professional family caregivers, and in home settings "! Treatment

successful! California State University – Los Angeles


Possible Limitations !! Caregiver

profession !! Introduction of medication !! Resistance to positive-attention points of intervention "! Very

Common "! Threatens treatment integrity long-term !! Health

complications

California State University – Los Angeles


Future Research !! ABA training

nearer to initial diagnosis.

"! Potential

for increased prolongation of residential placement.

!! Multiple

baseline across behaviors with one patient. !! Potential combined approach of biomedical and behavioral interventions in tandem. !! Potential for group training in ABA and FA methodologies for groups of staff in residential facilities. California State University – Los Angeles


Final Implication Total Lack of Memory !! No effect on success of intervention!

California State University – Los Angeles

Gutterson (ABAI, 2011)  

An aging presentation at the 37th Annual Association for Behavior Analysis International Conference in Denver, CO .

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