1. 1 Behavioral Gerontology Linda LeBlanc and Allison Jay

2. 2 Aging in America  The proportion of the population over age 65 in the U.S. has risen from 4% to 13% in the 20 th 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

3. 3 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

4. 4 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

5. 5 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...

6. 6 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

7. 7 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

8. 8 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

9. 9 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

10. 10 Behaviorally... why  Depression and anxiety might increase because... –Motivative operations –Reinforcer availability/loss –Discriminative stimuli –Others

11. 11 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

12. 12 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

13. 13 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

14. 14 My Nieces: Caroline, Courtney, Jessica

15. 15 My favorite color is blue. My cat is Mr. Snuffles and he is a Siamese.

16. 16 I live at 427 Bloomfield Ave

17. 17 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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19. 19 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,

20. 20 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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22. 22  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?

23. 23 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

24. 24 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

25. 25 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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29. 29  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)

30. 30 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

31. 31  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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34. 34 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

35. 35 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

36. 36  Practicum for Psychology Students - WMU –Year round –3 credit hours Contact Allison Allison.Jay@wmich.edu http://wmu.aging.practicum.googlepages.com/home