Challenging behavior of patients with frontal dysfunction managed successfully with behavioral intervention
Jin Narumoto MD PhD, Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan. Email: email@example.com
Herein, we report on two clinical cases in which behavioral disturbances occurred due to frontal dysfunction. Both patients were treated successfully with behavioral intervention. In the first case, the patient's challenging behavior of repeatedly entering his wife's workplace and interrupting her work was reduced after the patient's wife changed her response to the behavior and her schedule prior to work to ensure that she spent time with him in the morning. In the second case, the patient's challenging behavior of urinating in the street was reduced by changing his walking route. The successful outcome in both cases suggests that behavioral intervention based on Antecedents, Behavior, and Consequences (ABC) analysis is useful in the management of behavioral disturbance due to frontal dysfunction.
The behavioral and psychiatric symptoms of dementia (BPSD) are difficult to treat and can be a major risk factor for caregiver distress.1 In particular, behavioral disorders of patients with frontal dysfunction respond poorly to medication and can be extremely difficult to manage.2 Behavioral interventions are one type of non-pharmacological approach3 for the management of these sorts of disorders, but they have been underrecognized in geriatric psychiatry even though they are used extensively, and have proven successful, with children and younger adults in a variety of clinical settings. Recently, the usefulness of behavioral interventions in geriatric psychiatry has been suggested for the management of inappropriate behaviors in dementia.4
Behavioral approaches are based on the assumption that behavior is lawful; that is, the occurrence of particular behaviors is influenced systematically by environmental events. Specifically, for every occurrence of a specific behavior there are events that trigger it and events that encourage its repetition. Assessments based on this assumption are referred to as Antecedents, Behavior and Consequences (ABC) analysis, where ‘antecedents’ refer to the triggering events and ‘consequences’ refers to events that maintain the behavior. Herein, we report on two clinical cases in which inappropriate behavior due to frontal dysfunction was managed successfully by the patients' caregivers using behavioral interventions suggested by results of ABC analysis.
A 64-year-old, right-handed man with 16 years of school education was referred to our clinic for behavioral changes, including reduced spontaneous speech, disinhibition and agitated behavior. He scored 13/30 on the Mini-Mental State Examination (MMSE), in which he showed marked perseveration and was easily distracted. On the verbal fluency test, he also showed perseveration and repeated the meaningless word ‘Ade’. He could not answer questions about similarities between oranges and apples or about the meaning of proverbs that he should have been familiar with given his level of education. Sequential motor movement was also impaired due to perseveration. The patient's Neuropsychiatric Inventory (NPI)5 score was 60, reflecting agitation, apathy, disinhibition, and aberrant motor behavior. He was diagnosed with frontotemporal dementia based on the characteristic behavioral changes, frontal dysfunction indicated by neuropsychological tests, and frontal hypoperfusion according to the clinical diagnostic criteria of frontotemporal lobar degeneration (FTLD).6 Other medical conditions that may have caused the dementia and/or behavioral changes were ruled out using laboratory tests. The patient had been living in his house with his wife and a son; his wife worked from one room of the house as a masseuse. The patient required considerable assistance from and supervision by his wife. Of his behaviors, his habit of entering his wife's workplace and interrupting her work was reported by her to be the most distressing. Therefore, we focused on this behavior as a target and started behavioral assessment in order to provide advice to his wife as to how best to manage it.
First, we asked the patient's wife to document every occurrence of the behavior over a 1 week period, with particular emphasis on the events preceding and following it. The aim was to determine the baseline frequency of the behavior, as well as to identify any factors that may have triggered and maintained the behavior (i.e. ABC analysis). The results of ABC charting showed that the frequency of the behavior was > 10 times/day and, following the behavior, the patient's wife became increasingly involved with him (e.g. she tried to appease him with food and drink). Charting also revealed a higher frequency on the days he slept late when he did not have breakfast with his wife. She reported that she let him sleep unless he got up voluntarily because she felt comfortable not taking care of him before beginning her work. Hence, in this case, the ‘antecedents’ corresponded to a lack of contact with his wife, ‘behavior’ was entering his wife's workplace, and the ‘consequences’ were getting attention from his wife.
We provided the patient's wife with feedback from the behavioral assessment. After the characteristic behavioral patterns of patients with frontal dysfunction were explained to the patient's wife, including difficulty concentrating and perseveration, the results of the ABC charting were given to her. We discussed the factors that were triggering and maintaining her husband's behavior with her and she recognized that her responses to his intrusions into her workplace were maintaining his behavior and that the morning schedule before she started work was related to the frequency of the problematic behavior. Because our hypothesis was that the behavior had increased and started to become a habit because of the lack of time the patient spent with his wife in the morning, we instructed the patient's wife to ignore the behavior whenever it occurred and to get him up in the mornings, even if he slept, and to take a walk with him.
After 1 week of treatment, there was a significant decrease in the frequency of the behavior. We encouraged the patient's wife to persevere with the program by recognizing her efforts and her appropriate responses and, after 3 weeks, there was a marked reduction in the incidence of the behavior.
A 76-year-old, right-handed man with 16 years of education was referred to our clinic for inappropriate behaviors, including urinating in the street, stealing cigarettes from a car, and stereotyped behavior, in which he strictly followed the same schedule every day. At 74 years of age, the patient had undergone surgery for chronic subdural hematoma on the right frontal lobe and his behavioral changes had started after the operation. The patient scored 24/30 on the MMSE and 8/18 on the Frontal Assessment Battery (FAB). He could not produce any words on the verbal fluency test and suppress the finger-tapping response induced by examiner's action on the go/no-go test, but he could recall two of three words on the delayed recall test and had relatively preserved memory function. His NPI score was 28, reflecting apathy, disinhibition, and aberrant motor behavior. The patient was diagnosed with frontal syndrome due to irreversible brain damage from the hematoma (DSM-IV, 294.11 Dementia Due to Other General Medical Conditions with Behavioral Disturbance7), based on hypoperfusion in the right frontal cortex and frontal dysfunction indicated by neuropsychological assessment. Other medical conditions that may have caused the dementia and/or the behavior were ruled out by laboratory tests. The patient had been living at home with his wife and required considerable assistance from and supervision by his wife. Of his behaviors, his wife reported that urinating in the street was the most distressing for her because her husband had been accused of this by her neighbors.
As in Case 1, we asked the patient's wife to record every occurrence of the behavior over a 1 week period, with particular emphasis on the events preceding and following it. The patient's wife followed him around his walk. The results of ABC charting showed that the patient tried to urinate each time in the same alley that was part of his routine walk. This sort of persistence is frequently observed in patients with frontal dysfunction. Hence, in this case, ‘antecedents’ correspond to the alley, ‘behavior’ to urinating, and ‘consequences’ to the patient's feeling that he needed to urinate.
We advised the patient's wife to try to change his route, because our hypothesis was that if the patient found himself in the alley, this would trigger his urinating behavior. Another option could be to change his routined by getting him to urinate before he went out on his walk. However, the patient refused to go to the bathroom before his walk, so this approach was not successful. However, based on our advice, the patient's wife repeatedly guided him on an alternative route whenever he left home and finally the intervention succeeded. As a result of this intervention, the patient eventually stopped urinating anywhere in the street. After this had been confirmed, the patient's wife only watched the beginning of the patient's walk to make sure that he was leaving in the right direction.
In both cases reported herein, behavioral approaches successfully reduced the behaviors that were most distressing for the patients' caregivers, improved the relationship between the patient and his caregiver, and prevented the patients from being institutionalized. In addition, the caregivers became confident in managing the patients' behavior, despite their feelings of confusion and hopelessness prior to treatment. In this respect, behavioral approaches are more beneficial than medication.
In Case 1, we used interventions comprised of extinction and a change in the establishing operation. Extinction is based on the theory that the frequency of a behavior that is not accompanied by a reward will decrease. In this case, we hypothesized that the reward that maintained the patient's behavior was the attention his wife paid to him after his intrusion. Conversely, an establishing operation is defined as an operation that changes the effect of a reward on a behavior. Here, we hypothesized that the effect of his wife's attention as a reward could be enhanced by the patient not seeing her in the morning. Consistent with this hypothesis, the frequency of the problematic behavior was reduced when the patient's wife started to spend some time with him regularly in the morning. This change reduced the effect of her attention on the behavior.
In Case 2, we prevented the patient from finding himself in environment in which he frequently urinated by changing the route of his walk (i.e. we changed the circumstances surrounding him). According to behavioral theory, circumstance can be considered as a discriminative stimulus, which enhances the occurrence of a behavior. Therefore, this intervention was considered a modification of the discriminative stimulus. It can be hypothesized that the patient acquired the behavior through successful episodes of urination without scolding under similar circumstances.
There are some limitations to this approach. First, it requires the caregiver to have the ability to understand and follow the instructions of the therapist. Family caregivers, for example, who are also cognitively disabled or very old find it difficult to understand and follow our advice. This approach is suitable for patients with frontotemporal dementia, which usually starts after middle age, because the patients' spouses are also likely to be young enough to understand and follow our instructions. Second, it is difficult to apply changes to behavior, particularly in cases accompanied by delirium or physical disease. From this point of view, inappropriate behaviors due to frontal dysfunction are suitable for treatment with behavioural intervention because they are persistent and are often triggered or maintained by external stimuli or circumstances because of their tendency to be affected by external stimuli. Changes in a patient's response to the reward can be considered as changes to the establishing operation itself.
This work was supported by grants from Pfizer Health Research Foundation and KAKENHI (19790830).