Functional Analysis and Noncontingent Reinforcement in Dementia Patients

There are a variety of ways to address behavior problems in dementia sufferers, which I’ve addressed in the past (such as here). A lot of what I do in my day-to-day life as a Geropsychologist at a VA Community Living Center (CLC, AKA skilled nursing facility) is trying to address some of the vexing and often mysterious behaviors exhibited by residents with dementia. I would like to focus on a specific type of patient, a specific type of problem, and a specific way (potentially) of addressing the behavior issue.

The kind of patient I’m referring to here is one who has slipped from mild to now, more moderate to severe dementia. A patient like that is as follows (this is a de-identified composite of patients I’ve had over the years). He’s in his 80s, he’s had some strokes, he’s at times been difficult with nursing staff due to his constant use of the call light for minor issues (e.g., requests to move a water glass, to chat with staff, to change a TV channel, et cetera, ad nauseam). He has had occasional falls due to poor safety awareness and impulsiveness. He has documented memory problems and issues with executive functioning (e.g., planning, judgment, reasoning, etc). He has had episodes of verbal assaultiveness at times in the past (e.g., cursing out nursing staff) but no physical assaults. However, with a recent hospitalization after a nursing staff noted alteration of consciousness, poor food intake, and nonresponsiveness, he returns to our facility and staff now report the patient regularly has episodes of trying to hit, bite, or kick staff when they attempt to render care to him (e.g., changing his incontinence briefs, bathing him, or changing his clothes, etc). Staff has responded to this patient’s assaultiveness by when he has an episode, they simply cease care and leave the room, what they think of as “giving him a break.” They try to take more time to explain what they are trying to do before they do it. They may try to bribe him with snacks, or soothe him with music before the care is rendered. Unfortunately, over the long term these interventions do not seem to yield any great results. He is also taking some psychotropic medications and pain medications, but given that he also refuses to take medications, these don’t help either (not that they probably would that much anyways).

So what is staff to do?

Of course, the traditional view of behavior problems in dementia is that these distressing, vexing, bizarre, and sometimes dangerous behaviors are simply the symptoms being emitted by a sick brain – they have no particular meaning and they simply are something that need to be treated with pharmacology, or nonpharmacological approaches to ‘calm the patient down’ (because it at least seems fair to suppose that this is connected to the patient being anxious or ‘agitated,’ to use the popular descriptor).

There’s a somewhat different viewpoint than the above. Imagine you’re the demented resident. Imagine that you’ve lost your ability to understand spoken language. Imagine you’ve forgotten why you’re in a hospital – or that you’ve even forgotten that you’re in a hospital. Imagine that you’re lying in bed, confused, with difficulty moving or ambulating, perhaps in some pain, and then one or two unfamiliar people come into your room and start talking. What they say doesn’t really make sense. Suddenly, without warning, their garbled verbalizations end and then they just start grabbing at you, in your most private places. When you yell in protest, they speak more excitedly and they begin to move faster at what they do, grabbing at you more. You try to swing at them to make them stop. They may hold one or both of your arms to prevent you from swinging, still talking quickly and excitedly. You start kicking, spitting, and yelling, wondering why they don’t stop. Finally, they stop and leave you alone. You’re left by yourself, relieved they’ve stopped, but anxious that they may return.

This, I think, is pretty much the experience of dementia patients when they start exhibiting this very familiar pattern of assaultiveness that I’ve been consulted on time and time again now. It’s very challenging for everyone to address. So, what is happening here?

First, obviously, the patient isn’t able to understand (or understands very little) the explanation that nursing staff give prior to rendering care, either due to decline in the patients receptive language abilities, language barrier (nursing staff may speak English as a second language), or both. So, the act of explaining what they are doing as nurses doesn’t really help. Not that they shouldn’t try!

Second, when the patient begins to yell at strike out at the nursing staff, it’s a behavior that superficially looks inexplicable when seen from the eyes of us, as nominally cognitively intact people – but makes perfect sense from the perspective of a disoriented person with severe memory and receptive language problems. It’s “fight or flight” at base level. What would you do if random strangers walked into your room, spoke garbled nonsense for a few minutes, and then started grabbing at your private areas?

Third, what’s the natural response from nursing staff when they are faced with a patient who hits and yells when they attempt to render care? They do one or two things (or they do both) – they first try to speed up what they are doing, to get it done and over with. This, of course, just agitates the patient more. They could also simply just cease rendering care the moment the violence escalates significantly – they just stop. While in the short term, this halts the behavior, ironically over the long term this very response from nursing staff insures that the patient continues being assaultive, through a phenomenon known as escape / avoidance conditioning – which is a form of behavioral conditioning highly resistant to extinction. Once a patient has been “trained” to engage in this behavior, it’s very difficult to “untrain” them.

So what are we to do?

Well, what I’ve been talking about here is essentially the thinking behind functional analytics as they regard behavior problems in dementia. Functional analysis, which is most popularly used in managing problem behaviors in patients with developmental disabilities, has at its base level the assumption that all behavior has a purpose (in the operant-conditioning sense of the word). In the case of the above patient, there may be only a few different approaches that may make sense here.

What I’ve sketched out, above, is basically perform a descriptive functional analysis (DFA). I’ve done a pretty good job (if I do say so myself) narratively explaining the reinforcement contingencies (escape) that are encouraging this behavior (assaultiveness), which leads to a small set of ways of addressing it.

Now, I could have performed an experimental functional analysis (EFA), just to be sure. What makes an EFA different than DFA is that instead of just trusting the interventionists’ narrative description of what might be incentivizing a behavior problem, the interventionist goes ahead an directly manipulates the environment to see what might be pulling for this behavior. Unfortunately, in the case of the dementia patient it would require as part of the analysis for the staff to at times let themselves be hit (without withdrawing from the care situation) as a way to determine whether in fact a behavior was maintained by, say, escape conditioning or attention conditioning (here’s a great link to how EFA can be done outside of a situation where assault is an issue).

So, EFA is out, DFA is in, we’re pretty sure escape/avoidance is what maintains the behavior, and so what do we do? Well, like I said, there’s only a couple of different ways to go. Ideally we would want to engage in differential reinforcement of other behavior (or DRO) which means just what it sounds like – we would find another behavior (like smiling, cooperating, whatever) that we could reinforce with something a patient likes (praise, backrubs, cookies, whatever) and when the patient engages in the behavior we don’t like – we don’t respond to it. Again, since the behavior we don’t like is hitting – we can’t actually do that.

The only approach left that I’m aware of, from an operant conditioning perspective, is engaging in something called noncontingent reinforcement, or NCR. Unlike DRO, nursing staff could continue to withdraw (as they should) when the patient swings at them. However, what they would also be instructed to do is when they care for the patient is to provide him with escape / avoidance – but have it be provided irrespective of his physical aggression. The typical instruction I give to nursing staff is to stop every thirty seconds and simply pause for ten, and then resume. The idea there is that this breaks the link (eventually) between escape / avoidance and aggression.

The difficulty, of course, is that this intervention (NCR) is not a pill, and does not work immediately – it works over the medium to long term. Nursing staff would have to also apply this kind of intervention consistently and constantly over a period of days (or even weeks) across shifts to see positive effects. So, organizationally, this kind of intervention is extremely challenging to use. Ironically, it’s probably got the most solid body of logic and science behind it – much more so than using chemicals (e.g., antipsychotics) or blindly applying nonpharmacologic techniques to nonspecifically “calm” a patient.

What’s in a name: Senility, Dementia, or Neurocognitive Disorder – and Does it Matter?

It used to be called “senility” – which, according to the online etymology dictionary, comes from the French,  sénile, or “suited to old age,” from Latin senilis “of old age,” etc. Senility, or what we now generally call dementia, was initially considered to be simply part and parcel with the aging process. We no longer recognize that to be the case (as memory and cognitive loss is *not* a normal part of aging!), and generally the term “senility” has gone out of fashion to being outright discouraged (see here, and here), due to its ageist connotations.

Now, of course, even the term “dementia” is going out of fashion with the advent of the DSM-V (which I touched on previously in my last post)… and the preferred term is “major neurocognitive disorder” or MNCD. A couple of things to remember here – since we’re talking about etymologies (that is, the origin of words), the origin of the word “dementia” may even be a bit harsh as well, from the perspective of those who carry the diagnosis – according to the same etymology dictionary “dementia” originates from the latin term demens –  literally “mad, raving.”.

Around the time when psychiatrists were regularly referred to as “alienists” and Kraepelinian classification schemes for psychiatric disorders were all the rage (e.g., the early 1900s or so), schizophrenia was referred to as dementia praecox, as in “precocious” or “premature” dementia. While Emil Kraepelin, the physician who coined this term, didn’t actually intend to equate what we now call schizophrenia with the progressive cognitive decline noted in dementia and commonly seen in older adults, unfortunately – that’s what I think happened. Up until recently, Alzheimer’s disease (one of the most common forms of dementia) was commonly treated by relying on involuntary hospitalization in psychiatric institutions, and using physical and chemical restraints. In other words, dementia was considered (and maybe still is considered, see here) simply another form of chronic, incurable madness, as opposed to a neurological illness such as a stroke, or Parkinsons Disease. While dementia praecox is a term that is out of vogue now (replaced by the term “schizophrenia”), the use of the term “dementia” (for things like Alzheimers) persists, and perhaps with all the baggage of the madhouses and sanitariums of yesteryear carried along with it. This may be why the American Psychiatric Association (or “the big APA” as we psychologists call it) decided to push for a major semantic shift in referring to “dementia” instead as “neurocognitive disorder.”

Much like the science of psychology has for a long time suffered from what is often called “physics envy” (e.g., the idea that we should model psychological science on the precise methodology and measurement tools found in the science of physics), psychiatry has suffered from similar issues with “neurology envy.” While others more kind to psychiatry refer to it as being an ‘overlapping’ discipline, psychiatry has basically since its inception struggled to justify its standalone scientific basis, it’s raison d’être. It suffers from a very difficult, almost epistemological problem – if mental disorders are “disorders of the brain” (as the National Institutes of Mental Health, or NIMH, loves to regularly point out) – then why aren’t they the purview of neurologists? Often the rejoinder here is, “well, psychiatrists treat neurological disease when the cause isn’t completely understood.” If we don’t know that mental disorder is actually caused by discrete neurological illness, then why do we treat it as if it’s a disease at all? I should note that while I’m asking tough questions of institutional psychiatry – I say all of this as a practitioner, of course, who relies frequently and gratefully on the assistance of psychiatrists when I work with patients.

Enough of my neo-Szaszian digression.  The basic point is that clearly, Alzheimers Disease and the other so-called senile dementias (that is, dementias common to older adults) are in fact diseases of the brain, and we know this because we have increasingly reliable and valid histopathologic methods for identifying the sufferers (definitively via post-mortem as well as increasingly via the use of live biomarkers) and the disease has characteristic symptoms that professionals like me can readily and reliably identify. Will this gradual jettisoning of the term “dementia” be effective or useful in affecting de-stigmatization? Notably, the DSM-V does not proscribe providers from using the term “dementia,” they just suggest the new term, which I think they prefer because it sounds, well, more neurological.

But now I’ll turn the tables a bit – let’s go back to “dementia syndrome of depression” which I wrote about several months ago (and turns out to be one of my most popular posts!) remember that technically speaking, an older adult can be suffering from a (reversible) dementia caused entirely by the condition of being depressed, what they used to call “pseudo-dementia” or “pseudo-senility.” Does it change things to refer to a depressed older adult who may have problems with memory and concentration due to their depression as having a “neurocognitive disorder”? Is it less of a stigma to be referred to as having a dementia (that you’re ‘out of your mind’) or having a neurocognitive disorder (implying that you have a clearly, structurally sick brain – even if all you are is clinically depressed and in need of psychotherapy)? I honestly don’t have any idea – it’s worth noting that at one time, it was thought to be less stigmatizing to use the term “dementia” rather than “senility.” Two steps forward, one step backwards?