A Comparison of the Effectiveness of Distractors Identified Through Stimulus Preference Assessment Versus Caregiver Opinion

The effect of a distraction-based intervention on positive affect and aggressive and distress-related behaviors during morning activities of daily living in an elderly dementia patient was tested. Concurrently, the effectiveness of distractors chosen by staff and family report as compared to those chosen through a stimulus preference assessment (SPA) was tested. An alternating treatment design was used to implement identified distractors and a direct observation system was used to measure outcomes. Though staff reported increases in positive affect when using an edible chocolate distractor, no significant changes in positive affect or distress related behaviors were noted by the end of the final treatment phase when compared to initial baseline responding. This was likely due, in part, to the participant’s decline in physical health over the course of the study. With regard to the comparison of methods for identifying distractors, data tended to support the usefulness of a SPA for identifying effective distractors over that of family opinion, but was equally as effective as caregiver opinion. Further research is needed to better understand these outcomes. Running Head: A COMPARISON OF THE EFFECTIVENESS OF DISTRACTORS v Table of Contents Chapter Page I. Introduction . 1 II. Method . 10 III. Results . 17 IV. Discussion . 24 V. References . 33 Appendices . 39 Running Head: A COMPARISON OF THE EFFECTIVENESS OF DISTRACTORS 1 Chapter 1 Introduction Dementia Dementia is a pervasive disorder characterized by multiple cognitive deficits, the culmination of which leads to significant impairment in social, occupational, and general daily functioning (APA, 2002). Several causes, both organic and environmental (e.g., Alzheimer’s disease, frontotemporal degeneration, traumatic brain injury), have been associated with the development of dementia and, depending on the etiology, may or may not be reversible. Previous studies have identified prevalence rates of general dementia ranging from 1.4-67.7% in individuals 58 years of age or older (APA, 2002; Larrea, Fisk, Graham, & Stadnyk, 2000; Plassman et al., 2007; Rosenblatt et al., 2004; Silver, Jilianskaia, & Perls, 2001). In general, this range is directly correlated with age, with rates of prevalence doubling every five years after the age of 65 (Cummings & Jeste, 1999). Cognitive and Behavioral Features As the disease progresses with age, symptoms associated with the disease become more severe. Cognitive symptoms are those that are necessary for an initial diagnosis, as described by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR; APA, 2002). These symptoms necessarily include memory impairment, which is characterized by an inability to remember old information or learn new information, as well as one disturbance of language, motor activity, recognition, or executive functioning. Running Head: A COMPARISON OF THE EFFECTIVENESS OF DISTRACTORS 2 While symptoms related to cognitive impairment are necessary for an official diagnosis of dementia, behavioral symptoms commonly occur as well. Some common behavioral symptoms include, but are not limited to, disruptive vocalizations (Zimmer, Watson, & Treat, 1984), food refusal (Lin, Watson, & Wu, 2008), and wandering (Aud, 2004). Another very common behavior problem that can have important negative consequences is aggressive behavior. According to a review of previous literature on the topic, Buchanan, Christenson, Ostrom, and Hofman (2007) identified that 13-86% of individuals diagnosed with dementia exhibit symptoms labeled as “aggressive. ” These aggressive behaviors included both physical indicators such as hitting, pinching, and biting, and verbal indicators such as cursing and threatening. The majority of these behaviors have been shown to coincide with staff-patient interactions such as activities of daily living (ADLs; Colenda & Hamer, 1991; Hagen & Sayers, 1995). Although both verbal and physical aggression can occur during ADLs, patients with dementia may indicate distress/displeasure during ADLs in ways other than physical or verbal aggression. Other researchers have compiled a more comprehensive list of behaviors that also include these non-aggressive behaviors that indicate general distress. For example, Williams, Herman, Gajewski, and Wilson (2009) conducted a study to identify the relationship between infantile speech patterns known as “elderspeak” and behavior problems in long-term care dementia patients. The authors offered a list of 13 problem behaviors (e.g., hitting, pushing, threatening, crying, screaming) to be observed during the study. This abbreviated list consists of both aggressive and non-aggressive indicators of general distress that can be categorized into three primary groups: behaviors Running Head: A COMPARISON OF THE EFFECTIVENESS OF DISTRACTORS 3 that are physical in nature, those that are verbal, and those that are emotional. This more comprehensive definition may have greater utility than only targeting “aggression” because distress can be expressed in many ways and studies designed to improve ADL interactions would likely want to target this broad class of behaviors as opposed to just aggressive behaviors. Causes Given the prevalence of both aggressive and non-aggressive behavior problems during ADLs in persons with dementia, it is reasonable to ask what causes these challenging behaviors. One explanation for the presence of these behaviors is that they are symptoms of the disease itself. In other words, these behaviors may be due to the physical damage that is occurring to the brain as a result of the disease process. The implication of this assumption is that behavior problems should be treated medically (i.e., with medications). However, this approach has significant downsides. Recent research (e.g., Kolanowski, Fick, Waller, & Ahern, 2006) suggests increases in delirium, emotional disturbances, gait disturbances, and hip fractures in dementia patients prescribed antipsychotic medications for behavior problems. Ballard et al. (2009) also identified increased mortality rates among individuals prescribed these medications. Furthermore, the Omnibus Budget Reconciliation Act (OBRA) of 1987 indicates that psychotropic medications should not be the first-line treatment for most behavioral problems unless medically indicated (e.g., anti-psychotics to treat psychotic behaviors). This leaves nursing home staff and administrators to find alternative, restraint-free interventions for behavioral problems (Buchanan, 2006). Running Head: A COMPARISON OF THE EFFECTIVENESS OF DISTRACTORS 4 The disease itself, however, may not be the only reason for the presence of challenging behaviors during ADLs (or, for that matter, any other behavioral problem exhibited by persons with dementia). The individual’s environment may also be related to increases in these behaviors. ADLs, for example, often evoke these responses. Specifically, ADLs such as bathing, dressing, and changing of soiled undergarments have been reported as instances that often result in increased levels of challenging behaviors (Fisher, Buchanan, & Hadden, 2008; Sloane et al., 2004; Somboontanont et al., 2004; Whall et al., 1997). To understand from a behavior analytic perspective why problem behaviors occur during ADLs, one must first have an understanding of establishing operations. Michael (1982) described establishing operations as changes in the environment that alter two aspects of reinforcement. The first is the strength of a particular reinforcer, and the second is the frequency of behaviors related to obtaining the reinforcer. In other words, as a reinforcer becomes more or less potent there will be a concomitant increase or decrease in behaviors that previously led to obtaining that reinforcer. Michael eventually narrows this discussion by looking specifically at aversive stimulation and its relationship with establishing operations. Specifically, aversive stimulation alters the environment in such a way that escape (negative reinforcement) becomes highly motivating. As a result, there will likely be an increase in behaviors (such as yelling, hitting, cursing) previously associated with escape. Caregiving tasks can also be conceptualized in this way. Initiating a caregiving task results in a change in an individual’s environment. If the individual finds this task Running Head: A COMPARISON OF THE EFFECTIVENESS OF DISTRACTORS 5 particularly aversive (e.g., the individual is being touched, is having their clothes removed, is cold), this environmental change will likely lead to an increase in the potency of escape as a reinforcer, thereby resulting in an increase in behaviors previously associated with escape (e.g., screaming, hitting). Given an individual’s decreased repertoire for communication due to dementia, the individual may not be able to adequately express their aversion to the task verbally (e.g., saying, “please stop, you are hurting me”). As a result, these challenging behaviors may become an individual’s primary mode for indicating distress during a caregiving task. In other words, these indicators of distress serve a function or purpose for the individual and are not simply a symptom of dementia. It is this conceptualization of distress upon which the remainder of this paper is based. Cost of Behavioral Problems These behaviors,