As America’s population grows older, so does the threat of age-related dementia.
In 2010, almost 40 million people, representing 13 percent of the overall population, were over 65 years of age. Ten percent of those had been diagnosed with dementia.
By 2050, the percentage of people over 65 will increase to 20 percent of the population, or 88 million people. If the trend of dementia diagnosis continues, that will mean 8.8 million of those people will suffer from dementia, much of it caused by Alzheimer’s disease, an incurable condition that already is the 6th leading cause of death in America.
As distressing as death can be, for many families who have an older member with Alzheimer’s and dementia, the struggle leading up to it can be the most debilitating part. The Alzheimer’s Association estimates that, in 2015 alone, almost 15 million private individuals devoted more than 18 billion hours in uncompensated care for Alzheimer’s patients… feeding, clothing, and managing a devastating disease that progressively robs both memory and physical function from its victims.
Applied behavior analysts work with families and healthcare providers to use techniques of operant conditioning to ease the process of managing those patients.
Behavioral Issues Dominate Symptoms of Dementia
Dementia, whether caused by Alzheimer’s or other age-related infirmities, is primarily expressed and diagnosed through abnormal behaviors. Dementia patients exhibit:
- Severe memory loss, particularly of short-term memory
- Decreased logic and reasoning skills
- Difficulty communicating
- Depression and anxiety
- Inappropriate behavior and personality change
All of these issues can be successfully addressed through the use of applied behavior analysis techniques, either applied individually or as part of comprehensive systemic adjustments in the environment of care facilities.
Applied behavior analysts view these behaviors through the so-called ABCs of ABA:
- Antecedent – The prompt, or initial situation, leading to a behavior.
- Behavior – The action or behavior in response to the antecedent.
- Consequence – The reinforcement mechanism associated with the behavior.
Although the short-term memory issues that usually accompany dementia can make consequences irrelevant to shaping future behaviors (the patient cannot remember them), a clear understanding of antecedents can still help caregivers adjust environmental factors to make life easier for dementia patients.
Adjusting the antecedents can even be directly focused on coping with memory problems. In one experiment, the use of personalized shadow boxes helped some dementia patients find their rooms easier in a long-term care facility. The ABA treating the patients recognized that short-term memory failure made it difficult for the patients to remember their room numbers in the unfamiliar facility. But long-term memories are often preserved. By taking personal items and pictures that the patients were long familiar with and using those to mark the rooms, patients were more easily able to identify their rooms.
Solving these types of issues not only addresses the immediate problems facing dementia patients, but also serves to reduce the frustrations of their daily lives. This can solve secondary issues arising from dementia, including:
- Depression
- Anxiety and agitation
- Verbal outbursts and aggression
To determine what antecedents apply and how to alter them, ABAs perform a study of the patient or situation called a Functional Behavior Assessment (FBA). This can involve looking at records of patient care from other providers, reviewing health records, making direct observations of the patient, and interviewing the patient directly.
The FBA will provide the basis for creating a behavior intervention plan, or BIP. The BIP will include the specific accommodations or treatments to be offered to the patient. ABAs or other professional caregivers may implement the specific details of the BIP directly, as can the patient’s family. In cases with particularly high-functioning patients, the patient plays an active role themselves. The ABA will continue to assess and observer through the course of treatment, adjusting the BIP as necessary to accommodate unforeseen issues or to handle improvements in behavior.
ABAs may also engage in group therapies, working with multiple patients in long-term care facilities. They might work with facility staff to help organize activities and routines to better reinforce acceptable social behaviors, or to improve the moods and attitudes of patients. In one study of a token economy implementation in an 80-patient geriatric care facility, behavioral outbursts among patients were reduced and increased vigor and physical activity were observed.
Common ABA techniques used in dementia cases include:
- The Montessori Method, a technique originally developed for young children, which involves a great deal of environmental interaction designed, for dementia patients, to invoke intact long-term memories over defunct short-term memories.
- Spaced Retrieval, a differential reinforcement method that has proven successful in improving short-term memory skills in some patients.
- Token economies, a technique usually used in multi-patient settings to control asocial behavior by offering token rewards that can later be exchanged for items of value to the patients.
These systems all serve to make patients more at ease and more manageable as their physical and mental capacities decrease.
Some Dementias are Curable and Some Patients Can Be Retrained Using ABA Techniques
Applied behavior analysis is not only for coping with the long, inevitable slide of incurable Alzheimer’s patients, however. There are a number of causes of dementia that are potentially reversible, including:
- Infections and immune disorders
- Brain tumors, strokes, and traumatic brain injuries
- Metabolic reactions and adverse reactions to medication
In these cases, ABAs not only work to help dementia patients cope with life impacted by memory loss and confusion, but actively help to retrain their brains to learn forgotten skills as the underlying causes of their dementia are corrected.
Although the patients may be older, the methods used for recovering dementia patients are often the same as those used in schoolchildren with Attention Deficit/Hyperactivity Disorder or Autism Spectrum Disorders (ASDs).
These include:
- Discrete Trial Training (DTT) – Involves breaking down complex behaviors into a number of elements, which are separately and sequentially reinforced to build up into the desired behavior.
- Pivotal Response Treatment (PRT) – Rather than targeting specific behaviors, PRT involves a holistic examination of motivations and responsiveness in the patient.
Preparing for a Career as an Applied Behavior Analyst Working With Dementia and Alzheimer’s Patients
A master’s degree or higher is required to become an ABA working with dementia patients. Almost all positions in long-term care facilities, hospitals, or with private clinics specializing in geriatric disabilities require a Board Certified Behavior Analyst (BCBA®) certification from the Behavior Analyst Certification Board.
The BCBA® certification requires a master’s or better degree in psychology, education, or applied behavior analysis. However, other advanced degrees may also be accepted if a verified course sequence in applied behavior analysis is also taken, and a strong medical background can be an asset when applying for positions in hospitals or geriatric care facilities, where most dementia patients will also be coping with a host of unrelated medical issues. An advanced degree in biology, pre-medicine, or gerontology in combination with a BCBA® may be the ideal approach.
It’s also a good idea to gain some experience in the field before investing the time and money required to obtain an advanced degree. Many hospitals and geriatric care facilities offer volunteer positions to individuals who hope to obtain hands-on experience with dementia patients. Although a direct application of applied behavioral analysis techniques might not be part of these positions, they will still provide good exposure to the realities of working in geriatric medicine.
Working in any sort of medical environment will usually require passing a criminal background check, so it’s a good idea to keep a clean record, too!
Further Resources for Applied Behavior Analysis in Dementia Treatment
American Psychological Association Mental and Behavioral Health Issues in Older Americans – A compendium of issues, studies, and treatments researched by the APA for the care of geriatric populations, including dementia cases.
Behavior-Analytic Research on Dementia in Older Adults – A review of studies and publications in scientific literature relating to applied behavior analysis as applied to dementia cases.
The Alzheimer’s Association – Founded in 1980, this non-profit seeks to advance research into Alzheimer’s disease and dementia while improving care for those living with the disease.
The National Institutes of Health Alzheimer’s and Dementia Resources for Professionals – The NIH publishes best practices and other informational resources for professionals dealing with Alzheimer’s and dementia patients.
Association for Behavior Analysis International Special Interest Group – The ABAI has a Behavioral Gerontology special interest group for ABAs practicing with elderly and dementia patients to connect and share feedback and resources.