Conflict of interest: The authors report no conflict of interest.
Care staff training in residential homes for managing behavioural and psychological symptoms of dementia based on differential reinforcement procedures of applied behaviour analysis: a process research
Article first published online: 12 JUN 2013
© 2013 The Authors. Psychogeriatrics © 2013 Japanese Psychogeriatric Society
Volume 13, Issue 2, pages 108–117, June 2013
How to Cite
Noguchi, D., Kawano, Y. and Yamanaka, K. (2013), Care staff training in residential homes for managing behavioural and psychological symptoms of dementia based on differential reinforcement procedures of applied behaviour analysis: a process research. Psychogeriatrics, 13: 108–117. doi: 10.1111/psyg.12006
Description of authors' roles: D. Noguchi designed the study, trained the staff, collected data, performed statistical analysis, and wrote the paper. Y. Kawano assisted with the study design and the writing of the paper. K. Yamanaka supervised the study and edited several versions of the paper. All authors developed a training workbook.
- Issue published online: 12 JUN 2013
- Article first published online: 12 JUN 2013
- Manuscript Accepted: 27 DEC 2012
- Manuscript Revised: 25 OCT 2012
- Manuscript Received: 23 FEB 2012
- applied behaviour analysis;
- behavioural and psychological symptoms of dementia;
- care staff training;
- differential reinforcement procedures
Previous studies of care staff training programmes for managing behavioural and psychological symptoms of dementia (BPSD) based on the antecedent–behaviour–consequence analysis of applied behaviour analysis have not included definite intervention strategies. This case study examined the effects of such a programme when combined with differential reinforcement procedures. We examined two female care home residents with dementia of Alzheimer's type. One resident (C) exhibited difficulty in sitting in her seat and made frequent visits to the restroom. The other resident (D) avoided contact with others and insisted on staying in her room. These residents were cared for by 10 care staff trainees. Using an original workbook, we trained the staff regarding the antecedent–behaviour–consequence analysis with differential reinforcement procedures. On the basis of their training, the staff implemented individual care plans for these residents. This study comprised a baseline phase and an intervention phase (IN) to assess the effectiveness of this approach as a process research. One month after IN ended, data for the follow-up phase were collected. In both residents, the overall frequency of the target behaviour of BPSD decreased, whereas the overall rate of engaging in leisure activities as an alternative behaviour increased more during IN than during the baseline phase. In addition, the overall rate of staff actions to support residents' activities increased more during IN than during the baseline phase. However, the frequency of the target behaviour of BPSD gradually increased during IN and the follow-up phase in both residents. Simultaneously, the rate of engaging in leisure activities and the staff's treatment integrity gradually decreased for C. The training programme was effective in decreasing BPSD and increasing prosocial behaviours in these two cases. However, continuous support for the staff is essential for maintaining effects.
In long-term care homes, many residents with dementia suffer from behavioural and psychological symptoms of dementia (BPSD), including wandering, delusions, and agitation. According to a recent systematic review, the prevalence of BPSD in long-term care home residents with dementia ranged from 38% to 92%, and the median prevalence of BPSD was 78%. BPSD are associated with institutionalization, diminished quality of life, and a high workload for care staff. Therefore, BPSD management is an important problem.
Pharmacological and non-pharmacological therapies are available for BPSD management. Antipsychotics are frequently used as pharmacological therapy to treat BPSD. However, the use of antipsychotics may have serious negative side effects. The US Food and Drug Administration issued an advisory stating that atypical antipsychotic medications could increase mortality among elderly patients.[5, 6] Moreover, conventional antipsychotics may engender similar risks of death among elderly persons when used as atypical agents.
In contrast, various studies have shown that non-pharmacological therapies with fewer adverse effects can be used as an alternative to antipsychotics to manage BPSD. Previous systematic reviews that evaluated the effects of non-pharmacological therapies in Alzheimer's disease and related disorders found that behavioural management techniques improved BPSD.[8, 9] These techniques are based on the antecedent–behaviour–consequence (ABC) analysis of applied behaviour analysis (ABA). ABC analysis identifies the antecedents (A: what triggered the behaviour) and the consequences (C: what happened immediately after the behaviour and the behaviour's direct results) that modify a behaviour (B: BPSD). According to the analysis, care plans are then made to modify this sequence of events.
Teri et al. developed Staff Training in Assisted Living Residences., It is a comprehensive, dementia-specific behavioural management training programme, to improve care and reduce problems in care home residents with dementia. After staff training, residents in intervention groups exhibited significantly reduced levels of general behavioural disturbances, depression, and anxiety compared with control residents, as assessed through observational questionnaires. Moreover, trained staff reported fewer adverse effects from and reactions to residents' problems and more job satisfaction compared with the control staff.
In the assessment of the Staff Training in Assisted Living Residences programme's effectiveness, the randomized controlled trial did not include definite intervention strategies based on ABC analysis such as differential reinforcement procedures. Differential reinforcement procedures play a central role in ABA interventions; these interventions shape prosocial behaviours and decrease problem behaviours. Therefore, it is of primary importance for care staff to understand and master these interventions. Previous studies have examined the effect of training, including differential reinforcement procedures to help staff and teachers improve behavioural problems in children with developmental disabilities in Japan.[11, 12] Although the effectiveness of such training has been argued in a previous review, there have been no studies examining the effectiveness of this approach in BPSD. Therefore, this case study examined the effects of staff training in a residential home on the basis of ABA for BPSD management and focused on differential reinforcement procedures.
We examined two female residents diagnosed with dementia of Alzheimer's type. Consistent with the behaviour of agitation, one 70-year-old resident (C) exhibited difficulty sitting in her seat and made frequent visits to the restroom in residential home A. She scored 8/30 (score based on repetition, naming, and graphic depiction) on the Mini-Mental State Examination. Her clinical dementia rating was 2 and her functional assessment staging was stage 5.[15, 16] She took a cholinesterase inhibitor and antipsychotics. These medications were not changed during the present study.
Consistent with the behaviour of social withdrawal, an 84-year-old resident (D) avoided contact with others and insisted on staying in her room in residential home B. She scored 4/30 (score based on repetition and naming) on the Mini-Mental State Examination. Her clinical dementia rating was 2 and her functional assessment staging was stage 6. She took a cholinesterase inhibitor. The medication was not changed during the present study.
The staff at their respective residential homes had had difficulties in understanding the causes of their behaviours and finding a method to cope with these behaviours. Moreover, according to their doctors, there was no causal relationship between their behaviour and their medical condition. Therefore, we decided to use an intervention based on ABC analysis that was strongly recommended by the previous systematic reviews for the management of BPSD.[8, 9]
Five care staff members (four men; one woman) in residential home A and five care staff (four men; one woman) in residential home B were the trainees. Their mean age was 36.6 ± 14.4 years and their mean experience as a care worker was 2.8 ± 2.2 years. All trainees directly worked for residents in this study.
The study protocol was approved by the Ethics Committee of the Graduate School of Comprehensive Human Sciences, University of Tsukuba (Tsukuba, Japan), and written consent was obtained from the residents' proxies and from the 10 trainees.
Study period and design
This study had two phases, a baseline phase (BL) and an intervention phase (IN), and used an AB design, where A = baseline and B = intervention. The AB design was used to assess this approach's degree of effectiveness as a process research. One month after IN, data for the follow-up phase (FU) were collected. Data were collected during BL for approximately 2 weeks, IN for 1 month, and FU for 2 weeks. The present study was conducted in residential home A from July to October of year X and in residential home B from August to November of year X.
Interviews and direct observations
We prepared a checklist to obtain BPSD data for elderly residents with dementia. This checklist was based on one for children with intellectual and developmental disabilities . We also collected information on residents' daily lives and life histories from the staff. This information was gathered to shape prosocial alternative behaviours to BPSD. Regarding BPSD, author D. N. directly observed each resident to identify the time and context when these symptoms occurred as well as the manner in which the staff coped with them. On the basis of the interviews and observations, we defined target behaviours and target settings for each resident.
Care staff training, plan implementation, and feedback
Using an original workbook, we trained the staff regarding ABC analysis with differential reinforcement procedures in a single 120-min session. We created workbook that referred to Teri's training manual for caregivers responsible for daily care or supervision of dementia patients and on two books on ABC analysis with differential reinforcement procedures of behavioural problems in children with intellectual and developmental disabilities[18-20]. After the training, the staff devised individualized care plans in their case conferences using information based on C and D's respective BPSD, daily lives, life histories, and cognitive functions. Author D. N. assisted the staff in making this plans. The staff implemented each plan for the residents. Author D. N. provided the staff with positive and constructive feedback once a week after monitoring residents' BPSD during IN.
One month after IN, the FU data were collected.
Behavioural management plan
The behavioural management plan for resident C
From staff interviews, we obtained the following information regarding C's BPSD. C frequently left her seat to visit the restroom; this behaviour was more frequent in the evening, specifically ≥10 times per hour. C rarely left her seat during meal and activity times. According to her doctor, there was no causal relationship between this behaviour and her medical condition. However, C feared incontinence before reaching the restroom as a result of her difficulty in walking. The staff were quite embarrassed that they did not understand the cause of this behaviour or have a method for coping with it.
Author D. N. directly observed C and the staff and obtained the following information. The peak time of her BPSD was from 15:30 to 16:30. Although C was free during this period and had nothing to do in the dining room, she was almost always there. The low frequency of these behaviours during meal and activity times was consistent with the information from the interview. The staff devoted themselves to the physical care of other residents and daily housework.
Interpretation from ABC analysis
Based on the interview and direct observations, we formulated the following hypotheses of C's BPSD using ABC analysis: behaviour (B) was leaving her seat for the restroom, antecedents (A) were sustained boredom and an anxiety about incontinence. The consequence (C) of this behaviour was that she was relieved of boredom and anxiety. However, it was possible that she repeatedly left her seat because of the impairments in her recent memory. Therefore, we hypothesized that her behavioural contingencies and memory impairments maintained her BPSD.
Shaping alternative behaviours and planning the intervention
We expected C's BPSD to decrease if we established some prosocial alternative activities in which she could engage, supported by differential reinforcement procedures. Considering her profile of cognitive dysfunction, interests, and preferences, we allowed her to colour and browse fashion magazines as alternative behaviours.
In our new care plan for C, the staff were required to provide items for her leisure activities (e.g. paper to colour) (antecedent control) and use reinforcing feedback (e.g. praise) to encourage alternative behaviours during her leisure time, which is a form of differential reinforcement of alternative behaviour. The staff were to make contact with her once every 5 min during her leisure time and demonstrate how to use the items provided because she had severely impaired cognitive function. Regarding the interval of staff contact with her, we considered the burdens on the staff in addition to her impairment of recent memory.
The behavioural management plan for resident D
From staff interviews, we obtained the following information regarding D's BPSD. D showed social withdrawal with anxiety and agitation that often occurred when other residents whom she did not like were near her, particularly in the evening. In contrast, these symptoms rarely appeared during meal and activity times. The staff searched for her every time she disappeared. They were quite embarrassed that they did not understand the cause of these symptoms or have a method of coping with her BPSD.
Author D. N. obtained the following information by directly observing D and her care staff. D avoided contact with other residents and mostly stayed alone in her room from 15:30 to 17:30. Her symptoms were more frequent when other residents approached her. Her symptoms seemed to be more frequent during free time than during meal and activity times, which was consistent with the information from the interview. The staff did not have sufficient time to provide her a continuous intervention because they had to care for other residents with severe physical disabilities.
Interpretation from ABC analysis
Based on information from staff interviews and direct observations, we formulated the following hypotheses of D's BPSD using ABC analysis. The antecedents (A) were excessive contact with other residents, whom she did not like, and sustained boredom. The behaviour (B) was avoiding contact with other residents by insisting on staying in her room. The consequence (C) of the behaviour was that she could be relieved of excessive contact with other residents and boredom.
Shaping alternative behaviours and planning for the intervention
We expected that D's BPSD would decrease if we established differential reinforcement of alternative behaviour. It was also important for her to be in a calm situation that kept her away from other residents. Considering her profile of cognitive dysfunction, interests, and preferences, we allowed her to browse magazines with many photographs of babies and animals as an alternative behaviour.
In our new care plan for D, the staff let her stay in her room and monitored her from 15:30 to16:30. However, from 16:30 to 17:30, when it was quite difficult to care for all residents individually because of staff shortages, the staff provided her sufficient personal space in the communal living room so that she would not have excessive contact with other residents. Thus, antecedent control and differential reinforcement of alternative behaviour were also established for resident D, as they were for resident C.
Assessment measures and analyses
For C, we recorded the occurrences of her leaving her seat for the restroom during the observation period. We calculated the rate of touching and operating items for both residents during their leisure activities as target alternative behaviours to their BPSD. We also calculated the percentage of time D spent in the living room as her target alternative behaviour to social withdrawal. Simultaneously, we calculated the rate of staff provision of items to support eachresident's activities as the staff target behaviour. These data were accumulated using a time interval method that examined whether the target behaviours occurred at a 1-min interval. The occurrence rates of behaviours were calculated by dividing the number of intervals in which target behaviours occurred by the total number of intervals and then multiplying by 100.
Correlation analyses were performed to examine any relationship among the various targets, alternatives, and staff support behaviours.
To examine whether the observer (D. N.) in this study reliably extracted the target behaviours, the agreement between the observer and another observer was calculated using 30% of videotaped data for each resident.
Standardized BPSD rating scale
Psychological scales of staff
To examine whether the ABA approach promoted self-efficacy and decreased burnout and distress in the staff, the General Self-Efficacy Scale, the Maslach Burnout Inventory Japanese version, and the elderly care staff stressor rating scale were administrated to the staff during BL, IN, and FU. We analysed the data from these scales using IBM SPSS Statistics for Windows 19.0 (Tokyo, Japan) and performed anova to examine whether there were significant differences between BL, IN, and FU. Otherwise, Friedman's test was performed when the data were non-parametric.
Social validity scale
Social validity is important in ABA because it shows whether the modification of the target behaviour is socially meaningful. On the basis of previous ABA studies, simple Likert-type questions were used to measure social validity. Therefore, we prepared eight simple Likert-type questions and administrated them to the staff. These questions (e.g. Did you feel burdened in this approach? and Do you want to use this approach continuously in the future?) provided 5-point responses ranging from ‘strongly agree’ to ‘strongly disagree’.
Case C in residential home A
The upper part of Figure 1 shows the frequency of C leaving her seat for the restroom as her BPSD and the rate of engaging in leisure activities as her alternative behaviour during the observation period (15:30–16:30). The lower part of Figure 1 shows the rate of staff provision of items to support C's activities as their support behaviour during the same observation period.
As shown in the upper part of Figure 1, the frequency of C leaving her seat for the restroom decreased from 5.73 times on average during BL to 2.83 times during IN. However, it increased from 2.83 times during IN to 3.91 times during FU. The rate of C engaging in leisure activities increased from 26.4% on average during BL to 54.6% during IN, whereas it decreased from 54.6% during IN to 29.0% during FU. Moreover, a significant negative correlation was observed between the frequency of C leaving her seat and the rate of C engaging in leisure activities (ρ = −0.28, P < 0.05).
The scores of frequency, severity, and caregivers' distress on C's NPI-D in each period are shown in Table 1. These scores were not significantly different over the various stages of the study.
|Aberrant motor behaviour||Frequency||4||4||4|
As shown on the lower part of Figure 1, the rate of staff provision of items to support C's activities increased from 28.2% on an average during BL to 58.8% during IN. However, it decreased from 58.8% during IN to 35.1% during FU.
Moreover, a significant positive correlation was observed between the rate of provision of items by the staff and the rate of C engaging in leisure activities (ρ = 0.97, P < 0.01).
The agreement coefficient of the frequency of C leaving her seat for the restroom was 100%, the rate of C engaging in leisure activities 99.8%, and the rate of staff provision of items was 99.9%.
Case D in residential home B
The upper part of Figure 2 shows the rate of D engaging in leisure activities and the percentage of time D spent in the living room as an alternative behaviour to her BPSD during the observation period (16:30–17:30). The lower part of Figure 2 shows the rate of staff provision of items to support D's activities as their support behaviour during the same observation period.
The upper part of Figure 2 shows that the rate of D engaging in leisure activities increased from 6.4% on average during BL to 49.0% during IN. However, it decreased from 49.0% during IN to 27.0% during FU. The percentage of time spent in the living room by D increased from 7.6% on average during BL to 56.5% during IN, whereas it decreased from 56.5% during IN to 49.3% during FU.
The scores of frequency, severity, and caregivers' distress on D's NPI-D in each period are shown in Table 2.
|Aberrant motor behaviour||Frequency||4||4||4|
Using NPI-D, we found that D's distress score of delusions, frequency score of agitation/aggression, distress score of anxiety decreased during IN.
The lower part of Figure 2 shows that the rate of staff provision of items to support D's activities increased from 6.4% on an average during BL to 86.4% during IN. Furthermore, it increased from 86.4% during IN to 87.1% during FU.
A significant positive correlation was observed between the rate of staff provision of items and the rate of D engaging in leisure activities (ρ = 0.64, P < 0.01) and between the rate of staff provision of items and the percentage of time spent in the living room by D (ρ = 0.60, P < 0.01).
The agreement coefficient of the rate of D engaging in leisure activities was 99.6%, the percentage of time spent in the living room by D was 100%, and the rate of staff provision of items was 100%.
Results of overall evaluation in residential homes A and B
Psychological scales of the staff
Table 3 shows the results of the General Self-Efficacy Scale, the Maslach Burnout Inventory, and the elderly care staff stressor rating scale as evaluated by the staff in both residential homes during BL, IN, and FU. Although no significant difference was observed in the scores on the psychological scales between the observation periods, positive outcomes were observed in the total scores on all three scales during IN.
|Mean ± SD||Mean ± SD||Mean ± SD|
|GSES||Total||16||7.3 ± 2.3||8.2 ± 2.4||6.6 ± 2.1||0.072|
|Activeness in behaviour||7||2.7 ± 1.4||3.4 ± 1.8||2.9 ± 2.0||0.466|
|Anxiety on failure||5||2.7 ± 1.7||2.6 ± 2.0||2.3 ± 1.9||0.459|
|Social locus of ability||4||1.9 ± 1.4||2.2 ± 1.2||1.4 ± 1.3||0.092|
|MBI||Total||154||63.5 ± 14.8||60.7 ± 15.6||67.6 ± 18.9||0.355|
|Exhaustion||56||27.2 ± 11.4||23.8 ± 10.2||28.2 ± 11.1||0.139|
|Personal accomplishment||56||25.4 ± 6.5||25.6 ± 6.3||28.4 ± 7.6||0.151|
|Depersonalization||42||10.9 ± 6.5||11.3 ± 6.2||11.0 ± 8.3||0.767|
|The elderly care staff stressor rating scale||Total||87||55.5 ± 5.0||53.9 ± 10.4||53.6 ± 8.3||0.696|
|Conflict with supervisors||27||16.9 ± 4.2||15.5 ± 4.8||14.6 ± 4.8||0.211|
|Job load||24||17.0 ± 2.4||17.7 ± 3.4||17.4 ± 2.8||0.747|
|Conflict with clients||18||11.2 ± 2.7||10.2 ± 2.6||10.4 ± 3.0||0.405|
|Conflict with co-workers||18||10.4 ± 2.7||10.5 ± 3.2||11.2 ± 3.0||0.672|
Figure 3 shows the results of the social validity questionnaire. Ninety per cent of the staff indicated that ‘Resident's BPSD was reduced in the intervention period’ and ‘I want to use this approach continuously in the future’. In contrast, two staff members answered ‘I felt burdens in this approach’.
Behaviours of residents and staff
This case study examined the effects of staff training on the management of BPSD. The focus was on differential reinforcement procedures, based on ABC analysis, as intervention strategies in residential homes.
The two subjects from different residential homes engaged in leisure activities as alternative behaviours at a higher rate during IN than during BL. Along with these increases, the frequencies of the target BPSD decreased. Furthermore, significant positive correlations were observed between the rate of staff provision of items to support these alternative behaviours and the rate of residents engaging in leisure activities. Also, a significant negative correlation was observed between the frequencies of the residents' BPSD and the rate of residents engaging in leisure activities.
On D's NPI-D, the scores of her BPSD decreased during IN than during BL. This suggests that the present training and practice, including differential reinforcement procedures, may effectively decrease BPSD and increase prosocial behaviour. A previous study described the effects of training based on ABC analysis for managing BPSD with observational questionnaires.
In contrast to these promising results, the frequency of C leaving her seat for the restroom increased and the rate of her engaging in leisure activities decreased gradually during IN. Moreover, these rates were not maintained at the same level during FU as during IN. Simultaneously, the rate of staff provision of items in residential home A decreased. A significant positive correlation was observed between the rate of staff provision of items and the rate of C engaging in leisure activities. The increase in the resident's BPSD could have been caused by a decrease in the treatment integrity of the staff. In such a case, continuous support for the staff is necessary to more effectively decrease BPSD and increase prosocial behaviours in residents in the future.
Similarly, the rate of D engaging in leisure activities decreased during FU. However, it was different from the case of C in that the rate of staff provision of items during FU was maintained at the same level as during IN. According to staff interviews, D was gradually satiated by the items provided by the staff. Therefore, the staff provided her with new but similar magazines after FU, and D turned her attention to browsing magazines again. In such a case, we need to collect data regularly and modify the care plan as necessary.
It was thought that this management strategy based on differential reinforcement procedures could be effective for other people with BPSD. However, additional sampling will be needed to obtain more evidence in the future. Furthermore, we think that ABA combined with this strategy might not be applicable for some BPSD patients who seem to be severely affected by organic changes to the brain. Therefore, based on the behaviour diagnostic model, medical and physiological conditions, pain, or discomfort contributing to BPSD should be ruled out before initiating ABC analysis in the same way as this study.
Psychological effects on the staff
In this study, although no significant difference was observed in the scores on psychological scales between the observation periods, positive outcomes were observed in the total scores on all three scales during IN. The lack of significant differences in these scores also suggested that this approach did not increase staff burden. Decreasing BPSD without incurring excess staff burden means that this approach provides value and understanding for care staff.
In a previous study, trained staff reported fewer adverse effects and reactions to residents' problems and more job satisfaction compared with control staff. In this study, we devised a care plan for only one resident in each residential home. Because the intervention period in our study was shorter than that in the previous study, the psychological effects on the staff may not have been as great as in the previous study. To completely validate this approach, it will be necessary to examine the effects of its wide and long-term application in actual care in the future.
Social validity of the intervention
According to a previous study, a training programme using ABC analysis was exceptionally well received by the staff in an assisted living facility. The present study also showed that such an approach was well received by the staff in Japanese residential homes. In contrast, a few staff members answered ‘I felt burdens in this approach’ in the present study. The previous study also reported that some staff may feel anxious about using a new approach and the burden of training. Although some staff members may feel that new training and practice is a burden, it is possible that the perceived burdens will decrease as they become accustomed to this approach, receive continuous support, and apply it to actual care.
Limitations and future research
The treatment integrity of the staff is important to decrease BPSD and increase prosocial behaviours in residents. Moreover, the staff themselves must create and modify the care plans. Therefore, continuous support for the staff is necessary, and we should examine its effects in the future.
The training programme was effective in decreasing BPSD and increasing prosocial behaviours in the presented cases. However, continuous support for staff is necessary to achieve more persistent effects in the future.
We thank the care staff and residents who participated in and devoted their time to this study.
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