Utilizing ABA in Dementia Management, Part 2: ABA Principles and Treatment Techniques

This text-based course is a transcript of the webinar, Utilizing ABA in Dementia Management, Part 2: ABA Principles and Treatment Techniques, presented by Mary Beth Mason-Baughman, PhD, CCC-SLP.Introduction and OverviewDr. Mary Beth Mason-Baughman:  Today, we are going to talk about the principles of applied behavioral analysis (ABA) and specific treatment techniques that can be used for behaviors that typically seen in the dementia population. I have no financial or nonfinancial consideration or relationship relevant to course content that compromises or has the potential to compromise professional judgment.  When I discuss techniques or tests, it is because I think they are of value, not because I am getting any kickbacks from them. Anytime I present on dementia, I like to include the following information about my father. My father passed away from frontotemporal degeneration in 2011.  I like people to know that I understand this topic from a professional standpoint, but also from being a family member and caregiver for someone with dementia, and specifically a dementia that resulted in behavioral changes. The learning objectives for this continuing education activity are that participants will be able to 1) explain the seven dimensions of applied behavioral analysis and how they relate to management of inappropriate behaviors noted in adults with dementia; 2) identify at least three behavioral strategies that can be implemented in cognitive-communicative treatment plans for adults with dementia; and 3) describe the rationale for using various behavioral approaches for different types of dementia. We are going to start with the seven principles and dimensions of ABA. We will talk in general about some behavioral frameworks, and how these approaches have been utilized successfully in other clinical populations -- specifically autism and traumatic brain injury (TBI). We will then do an overview of specific behavioral techniques, including environmental modifications, error-less learning, and reinforcement schedules, as well as talk about specific techniques for inappropriate behaviors. Behaviors Related to Cognitive-Communicative BreakdownsWhen we look at the dementia population, most of us could relate to some of these examples.  We see behaviors that are not necessarily socially appropriate.  When we think about what is causing these behaviors, it could be that there is a cognitive-communicative breakdown.  An example is a person throwing food items because they are unable to verbally communicate that they do not like it.  They do not want pureed chicken again, but they do not have the cognitive-communicative ability to verbalize that.  Therefore, their behavior is throwing the food to communicate.  It is not the best way to communicate, but it is a way to communicate when verbal communication abilities are not sufficient.  Another example could be a person urinating in a public area, because they are verbally unable to communicate the need to use the bathroom, or cognitively, they do not have the ability to independently locate the bathroom.  It could be a person repeatedly asking where her husband is because she cannot remember that she is in a nursing home.  Again, the antecedent would be that she has cognitive deficits and memory deficits.  Another example could be a person resisting care because he does not recognize the caregiver and is afraid or anxious with this unfamiliar caregiver, but is unable to communicate that.  These are things that we see on a daily basis. I plan to share some frameworks and behavioral approaches to help intervene and modify those behaviors.  If nothing else, I want to give you some terminology for activities that you may be doing already but are unsure of what to call it or if there is evidence to support it. Existing ResearchWhen I started researching this topic in earnest several years ago, I found a great article from Jeffery A. Buchanan (2006), who is a psychologist.  I recommend that you look at his article.  He suggested that medical interventions such as prescription medications can often lead to additional new issues for patients with dementia.  They are prescribed medications to control behaviors, but they actually create unwanted side effects.  There can be adverse interactions between the medications, and we know that older adults typically take multiple medications, so polypharmacy can be an issue.  There is always the question of how effective those medications are when they are interacting, and just in general.  When a disordered brain is on medication, it does not metabolize the medications as well.  That is another issue with the effectiveness of the medication. Buchanan reviewed how behaviors can be targeted using a behavioral approach instead of a medication approach.  He looked at depression, wandering, disruptive vocalizations, decreased socialization, and inappropriate sexual activity such as disrobing in public areas, public masturbation, etc. Successful Dementia Treatment Approaches Utilizing ABA ConceptsThere is evidence to support some behavioral approaches for individuals with dementia.  There is evidence to support that Montessori programming results in positive outcomes for patients with dementia.  Montessori programming was designed for children with special needs, but can be utilized with adults.  It is utilized in educational programs for children who are typically developing as well.  This approach uses tasks that are tailored to an individual’s level of function.  When a person can participate in a task in a meaningful way because it is individualized to their level of function, they will be able to participate more. That participation is going to reinforce the person’s feeling of success; thus, they will want to participate more.  If we make activities realistic for our patients with dementia and something that they can participate in in a meaningful way, they will want to participate in more activities. Spaced retrieval is another evidence-based practice that uses a behavioral approach.  It is the systematic pairing of verbal information and strategy, typically looking for some type of motor or procedural memory response.  It utilizes errorless learning and graduated prompting, where we increase the intervals during which the person must retain the information.  You start with 30 seconds of retention, then go up to 60 seconds, 2 minutes, 4 minutes, and so on. ABA Principles and Behavioral FrameworksThe Seven ABA PrinciplesLet’s look at the basic principles of behavioral analysis; there are seven.  The first...