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.

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5 thoughts on “Functional Analysis and Noncontingent Reinforcement in Dementia Patients

  1. Dr. Lane, I’m a certified nursing assistant who provides care to elders in their homes. Most of my clients with dementia are in the fairly early stages of their disease, so they are independent in personal hygiene and other activities of daily living. Still, some years ago I worked in the dementia care unit at an assisted living facility, and I remember vividly how confused and angry residents sometimes became when I would try to help them with toileting, bathing, and the like. Could you tell us more about how dementia patients in your facility respond to noncontingent reinforcement when caregivers follow the instruction to “stop every thirty seconds and simply pause for ten, and then resume” personal care? Also, how does the facility train its caregivers in this process, and what do caregivers have to say about their experiences in learning and practicing this kind of care?

    • Mary Ann, great question. Unfortunately I’ll be blunt – when I talk about functional analysis with nursing staff (and specifically NCR – which forms the basis for the “stop every thirty and pause for ten” instruction) it’s often treated with some skepticism, and I haven’t seen it put into practice in the consistent manner that I like with patients who are physically aggressive (although nursing staff have made use of it successfully in a different context, where violence wasn’t at issue).

      And that’s the problem with this kind of intervention – unlike pills or “time outs,” which are immediately effective (but over the medium to long term make the behavior almost invariably worse), interventions like NCR take time and consistency to implement and only yield benefits over the medium and long term. And when you’re faced with physical aggression from a patient there’s understandable urgency in getting the problem fixed *right now* (which makes the situation ripe, unfortunately, for penny-wise, pound-foolish interventions).

      For some academic references (both of these are papers I’ve re-read several times over the years):

      Baker, J. C., Hanley, G. P., & Mathews, R. M. (2006). Staff-administered functional analysis and treatment of aggression by an elder with dementia. Journal of Applied Behavior Analysis. 39, 469-474.

      Buchanan, J. A. & Fisher, J. E. (2002). Functional assessment and noncontingent reinforcement in the treatment of disruptive vocalization in elderly dementia patients. Journal of Applied Behavior Analysis. 35, 99-103.

  2. Dr. Lane, I have a husband with mild to moderate Alzheimer’s and we have a game that helps us. if he is getting agitated about something, he can still understand me well enough, I pretend that I am the problem. He has always been critical of other drivers on the road. He will start telling the car in-front of us to move and his voice changes, then I know that he is getting stressed. I then take responsibility for moving slow, for waiting for the light, for not paying attention. All of these I do in a joyful voice with as little stress as possible. I have found that I can depressurize the situation immediately. I am counting on this to help when we get farther into the disease process.
    2) I had a friend who had dementia and was in the later stages. One day I went to visit and the large man that answered the door was more than glad to see me. He was giving up trying to get my friend off the toilet. They had been yelling at each other and getting no where. I stepped in and saw my friend down the hall in the bathroom. Paying no attention to the situation, I smiled and waved in a very happy attitude. He responded immediately and was able to allow the worker to remove him from the bathroom.
    3) At work – senior residence we had a resident who was agitated everyday. She would frighten the other residents with her cussing and yelling. I would agree with her when she said something was wrong. My response would be darn it you are right that just no good.
    I know these are not in bed biting, I did work with many in that situation when I was nursing. However, the key that I found is as I have read, dementia patients respond to feelings. If the person taking care of them is frightened, stressed, upset, in a hurry, judgmental, or angry. the patient is going to respond in like manner. How much can we change by changing our initial attitude to the person?

    • Barbara, I couldn’t agree more with what you’re trying to communicate here. One of the clinical principles inculcated in me when I began working with dementia patients was that even as patients’ ability to communicate verbally or logically tends to decline, their ability to understand nonverbal communications (body posture, facial expression, tone of voice, et cetera) remains – and possibly even becomes heightened as their verbal skills leave them.

      Just thinking out loud – it would be a great demonstration project if we could have nursing staff engage in staff-wide training on mindfulness meditation or something similar, so when they work with their demented residents, their nonverbals communicate an easy-going, good-natured, relaxed demeanor. Which, I think, is exactly what you seem to be taking pains to deliver when you are interacting with your husband, or with your friend with dementia, or at work.

      Thanks so much for your thoughts – they make complete sense!

      • Dr. Lane,
        Thank you for your comments, you totally understand what I was trying to relate. It is difficult at first to keep up the positive response, however my husbands response has been so rewarding, I am encouraged and trained to respond in a positive way. I believe that the staff can do this and the results will help improve their interaction with each new patient. The staff here at the senior apartment building, where I work, have learned to have more compassion and understanding, it all helps.
        Thank you for all your hard work, I have hope for the future with the knowledge that there is a passion for returning each person to a respected person no matter what has happened to their brain.

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