Behavior-analytic research on dementia in older adults

Increasing conversations between older adults with dementia using textual stimuli

Dementia often leads to behavior changes such as deficits in communication and social interaction; one effective antecedent strategy for improving communication involves rearranged or supplemental stimuli. In the present study, researchers placed individualized textual prompts on the dinner table of three women at an assisted-living facility. Textual stimuli included prompts such as "Debbie, ask Pat where she liked to travel," and led to increases in conversation duration. The results suggest that antecedent interventions can improve social interactions for individuals with dementia with minimal involvement of caregivers.Textual prompts may improve social communication between individuals with dementia.Salient stimuli, such as participants' names, may be necessary to facilitate conversation.The textual intervention requires minimal training and response effort from caregivers and care staff.Improvements in conversation duration maintained at 6 months post-study.

The Potential of a Relational Training Intervention to Improve Older Adults' Cognition

Behavioral gerontology rarely focuses on improving older adults' cognitive function. This gap in the literature should be addressed, as our aging population means that greater numbers of older adults are experiencing cognitive decline and reduced functional independence. If cognitive training interventions are to be socially significant, they should target improvements in core executive functions (EFs) that are critical for everyday cognition and functioning independence. Evidence from the cognitive sciences suggests that a cognitive training intervention targeting "relational knowledge" and "cognitive flexibility," which are core EFs, could translate to improvements in cognition and functioning for older adults. Behavioral researchers, interested in the effects of relational training on cognition, have shown a relationship between complex and flexible arbitrarily applicable relational responding (AARRing) and improved performance on measures of intelligence in children and young adults. However, data examining the impact of AARRing on the cognition of older adults are lacking. This article suggests that complex and flexible AARRing may be synonymous with the aforementioned EFs of relational knowledge and cognitive flexibility, and that a behaviorally oriented relational training intervention might improve cognition and functioning for healthy older adults or those experiencing cognitive decline. The article initially presents a brief overview of research in behavioral gerontology and older adult cognition, followed by a detailed explanation of how training complexity and flexibility in AARRing could result in improvements in core EFs. Specific suggestions for designing a relational training intervention and assessing relevant outcomes are provided.

An Assessment Method for Identifying Acceptable and Effective Ways to Present Demands to an Adult With Dementia

Simple instructions are often recommended for presenting demands to people with dementia; however, simple instructions may be perceived as authoritative and may not be appropriate for all individuals. We conducted a demand assessment with a woman with dementia who engaged in problem behaviors in response to direct instructions. We measured latency to compliance and verbal behavior when demands were presented as questions, rules, simple instructions, or demands embedded in social chatter. In contrast to the other conditions, simple instructions resulted in the most undesirable behavior and were least likely to evoke compliance. We conducted an intervention in which demands were phrased as requests for assistance.

Consensus statement of the international summit on intellectual disability and Dementia related to post-diagnostic support. Aging Ment Health 2018;22:1406-1415. [PMID: 28880125 DOI: 10.1080/13607863.2017.1373065]

OBJECTIVES

Post diagnostic support (PDS) has varied definitions within mainstream dementia services and different health and social care organizations, encompassing a range of supports that are offered to adults once diagnosed with dementia until death.

METHOD

An international summit on intellectual disability and dementia held in Glasgow, Scotland in 2016 identified how PDS applies to adults with an intellectual disability and dementia. The Summit proposed a model that encompassed seven focal areas: post-diagnostic counseling; psychological and medical surveillance; periodic reviews and adjustments to the dementia care plan; early identification of behaviour and psychological symptoms; reviews of care practices and supports for advanced dementia and end of life; supports to carers/ support staff; and evaluation of quality of life. It also explored current practices in providing PDS in intellectual disability services.

RESULTS

The Summit concluded that although there is limited research evidence for pharmacological or non-pharmacological interventions for people with intellectual disability and dementia, viable resources and guidelines describe practical approaches drawn from clinical practice. Post diagnostic support is essential, and the model components in place for the general population, and proposed here for use within the intellectual disability field, need to be individualized and adapted to the person's needs as dementia progresses.

CONCLUSIONS

Recommendations for future research include examining the prevalence and nature of behavioral and psychological symptoms (BPSD) in adults with an intellectual disability who develop dementia, the effectiveness of different non-pharmacological interventions, the interaction between pharmacological and non-pharmacological interventions, and the utility of different models of support.

Behavior-Analytic Approaches to Working with People with Intellectual and Developmental Disabilities who Develop Dementia: a Review of the Literature

Behavior analysis has made contributions in the development of evidence-based interventions for people with intellectual and developmental disabilities (IDD), and there is a growing evidence base for behavior-analytic interventions for older adults with dementia. As there is an increased number of adults with IDD living to old age, and an increased prevalence of comorbid dementia in people with IDD, a review of the behavior-analytic contributions with this population is warranted. We searched Web of Science and PsycInfo and manually reviewed the last 20 years of five behavioral journals. Six behavior-analytic studies with people with IDD and dementia were identified, and all but one were published outside of core behavior-analytic journals. These articles were analyzed in terms of Baer, Wolf, and Risley's (Journal of Applied Behavior Analysis, 1, 91-97, 1968) seven dimensions of applied behavior analysis (ABA). The possible explanations and implications of these findings are discussed with consideration of the unique features of a comorbid diagnosis of IDD and dementia that may make it appropriate for increased focus in behavior-analytic research and practice.

Cognitive rehabilitation for early stage Alzheimer’s disease: a pilot study with an Irish population

Objectives

Research shows that cognitive rehabilitation (CR) has the potential to improve goal performance and enhance well-being for people with early stage Alzheimer’s disease (AD). This single subject, multiple baseline design (MBD) research investigated the clinical efficacy of an 8-week individualised CR intervention for individuals with early stage AD.

Methods

Three participants with early stage AD were recruited to take part in the study. The intervention consisted of eight sessions of 60–90 minutes of CR. Outcomes included goal performance and satisfaction, quality of life, cognitive and everyday functioning, mood, and memory self-efficacy for participants with AD; and carer burden, general mental health, quality of life, and mood of carers.

Results

Visual analysis of MBD data demonstrated a functional relationship between CR and improvements in participants’ goal performance. Subjective ratings of goal performance and satisfaction increased from baseline to post-test for three participants and were maintained at follow-up for two. Baseline to post-test quality of life scores improved for three participants, whereas cognitive function and memory self-efficacy scores improved for two.

Conclusions

Our findings demonstrate that CR can improve goal performance, and is a socially acceptable intervention that can be implemented by practitioners with assistance from carers between sessions. This study represents one of the promising first step towards filling a practice gap in this area. Further research and randomised-controlled trials are required.

Behavior analysts in the war on poverty: A review of the use of financial incentives to promote education and employment

Poverty is a pervasive risk factor underlying poor health. Many interventions that have sought to reduce health disparities associated with poverty have focused on improving health-related behaviors of low-income adults. Poverty itself could be targeted to improve health, but this approach would require programs that can consistently move poor individuals out of poverty. Governments and other organizations in the United States have tested a diverse range of antipoverty programs, generally on a large scale and in conjunction with welfare reform initiatives. This paper reviews antipoverty programs that used financial incentives to promote education and employment among welfare recipients and other low-income adults. The incentive-based, antipoverty programs had small or no effects on the target behaviors; they were implemented on large scales from the outset, without systematic development and evaluation of their components; and they did not apply principles of operant conditioning that have been shown to determine the effectiveness of incentive or reinforcement interventions. By applying basic principles of operant conditioning, behavior analysts could help address poverty and improve health through development of effective antipoverty programs. This paper describes a potential framework for a behavior-analytic antipoverty program, with the goal of illustrating that behavior analysts could be uniquely suited to make substantial contributions to the war on poverty.

Nanoscale drug delivery systems and the blood-brain barrier

The protective properties of the blood–brain barrier (BBB) are conferred by the intricate architecture of its endothelium coupled with multiple specific transport systems expressed on the surface of endothelial cells (ECs) in the brain’s vasculature. When the stringent control of the BBB is disrupted, such as following EC damage, substances that are safe for peripheral tissues but toxic to neurons have easier access to the central nervous system (CNS). As a consequence, CNS disorders, including degenerative diseases, can occur independently of an individual’s age. Although the BBB is crucial in regulating the biochemical environment that is essential for maintaining neuronal integrity, it limits drug delivery to the CNS. This makes it difficult to deliver beneficial drugs across the BBB while preventing the passage of potential neurotoxins. Available options include transport of drugs across the ECs through traversing occludins and claudins in the tight junctions or by attaching drugs to one of the existing transport systems. Either way, access must specifically allow only the passage of a particular drug. In general, the BBB allows small molecules to enter the CNS; however, most drugs with the potential to treat neurological disorders other than infections have large structures. Several mechanisms, such as modifications of the built-in pumping-out system of drugs and utilization of nanocarriers and liposomes, are among the drug-delivery systems that have been tested; however, each has its limitations and constraints. This review comprehensively discusses the functional morphology of the BBB and the challenges that must be overcome by drug-delivery systems and elaborates on the potential targets, mechanisms, and formulations to improve drug delivery to the CNS.

Expanding the consumer base for behavior-analytic services: meeting the needs of consumers in the 21st century

A growing workforce of behavior analysts provides services to individuals with autism and intellectual disabilities as legislative initiatives have spurred a growth of funding options to support these services. Though many opportunities currently exist for serving individuals with autism, the growing demand for these services may wane or, at some point, the growth in service providers will meet that demand. Other consumer groups could benefit from behavior analytic services, but typically have limited access to qualified providers. Individuals with dementia and traumatic brain injury are used as example consumer groups to illustrate the necessary tasks for a behavior analyst to expand their scope of practice to a new population. This paper provides strategies for developing competence and creating employment opportunities with new consumer groups.

What is evidence-based behavior analysis?

Although applied behavior analysts often say they engage in evidence-based practice, they express differing views on what constitutes "evidence" and "practice." This article describes a practice as a service offered by a provider to help solve a problem presented by a consumer. Solving most problems (e.g., increasing or decreasing a behavior and maintaining this change) requires multiple intervention procedures (i.e., a package). Single-subject studies are invaluable in investigating individual procedures, but researchers still need to integrate the procedures into a package. The package must be standardized enough for independent providers to replicate yet flexible enough to allow individualization; intervention manuals are the primary technology for achieving this balance. To test whether the package is effective in solving consumers' problems, researchers must evaluate outcomes of the package as a whole, usually in group studies such as randomized controlled trials. From this perspective, establishing an evidence-based practice involves more than analyzing the effects of discrete intervention procedures on behavior; it requires synthesizing information so as to offer thorough solutions to problems. Recognizing the need for synthesis offers behavior analysts many promising opportunities to build on their existing research to increase the quality and quantity of evidence-based practices.