Behavior Management for Dementia: The STAR Program

Behavior Management in Dementia and Linda Teri’s STAR program

So I think at this time I’m going to get briefly away from my current fixation on gerontechnology and gadgets and instead focus on something that’s been happening at my day job at the VA. Over at my job site we’ve instituted something called the “STAR-VA” program, which is based pretty closely on Linda Teri’s STAR and STAR-C programs (btw, STAR stands for Staff Training in Assisted living Residences).

Dr. Linda Teri’s STAR program has been trialed extensively at assisted living facilities (ALFs, as they say in the biz), nursing homes and also with family caregivers (the STAR-C program) and has been found to yield exceptionally good results. As I indicated above, it has now been ‘ported’ to the VA and although the data is somewhat preliminary, it appears that STAR-VA is an extremely effective non-pharmacological approach.

What is the STAR program? Well, you can find out by purchasing a kit over at Or, you can get hired by the VA as a nurse or psychologist, work for a VA Community Living Center (CLC, which is VA-speak for what we all know of as skilled nursing facilities, or nursing homes), and get trained in STAR-VA by their ongoing VA Central Office (VACO) training program. Or – you can listen to my very brief overview and commentary here (although that doesn’t substitute for the above – but will give you a sense of things). I have received the STAR-VA intensive training myself, as have my colleagues at the VA facility where I am employed.

Very briefly, the STAR program is designed to address what is an endemic problem in nursing homes and ALFs, specifically what is called “behavioral and psychological symptoms of dementia” (or BPSD for short) as the technical term currently in vogue, but also often called things like “agitation” or “behavior problems.”

A representative kind of behavior that the STAR program is designed to address is a problem that’s consistent and chronic (as opposed to a one-off behavior), takes place at reasonably consistent times, and isn’t the result of an unstable underlying medical condition (e.g., such as what you might see in a delirium). A prototypical behavior is “resistiveness to care,” such as when nursing staff (typically nursing assistants) are cleaning a patient, e.g., “ADL care.”

Imagine that you’re a patient in a hospital and you have trouble walking, controlling your bowels and bladder, and require assistance to keep yourself clean and toileted. Now imagine that you require assistance from other adults (nurses) to clean you every time you have a bowel movement or need to pee. Imagine how difficult (e.g., embarrassing, anxiety-provoking, and even somewhat demoralizing) that might be!

Now imagine what would happen if you were in the same situation, and you had *dementia.* Imagine you didn’t know where you were, and how you got there. Imagine that you’re lying in a bed, confused, and all of a sudden strangers come into the room and start squawking at you and saying unintelligible things, and start pulling off your pants and grabbing at your private area.

What would *you* do?

In many cases, these patients become aggressive, will yell, scream, physically resist, and at times try to hit nursing staff. Staff will respond by trying to reason or sweet-talk the patient. They may give “time outs” (leaving the room and coming back later, hopefully when the patient has calmed down). They may medicate the patient with pain pills and/or psychiatric medications. Also, in this situation I’ve seen nursing make use of multiple staff members (ostensibly to protect the staff giving the care from physical injury). Very frequently, these interventions either don’t work or make the problem behavior worse.

How do psychologists help with these problem behaviors in dementia?

In community nursing homes, where psychologists are typically reimbursed by Medicare, and the traditional “roving consultant” model applies, psychologists are restricted to being reimbursed for largely what is direct care services only. That is, they are reimbursed for seeing patients on a 1:1 basis for psychotherapy or to provide psychological assessment. Although there is a category of “behavior management” services that psychologists can be reimbursed for, it still requires the psychologist to be seeing the patient and only reimburses for 2-3 sessions at most.

This is not a very effective model for delivering effective behavior management approaches in residential care facilities where dementia is frequently a presenting issue.

We are not hamstrung by fee-for-service restrictions on care at the VA, which is fortunate, because I know as a geropsychologist with a decade’s experience in this field that the best way to address behavior problems in dementia requires approaches that embody the following:

  • The approach must be staff-driven. At best you’ll likely only have one psychologist available for an entire nursing home or ALF, who is only there part of the day or week. Therefore, all staff must be prepared and empowered to offer effective behavior management techniques on a 24/7 basis.
  • The approach must be interdisciplinary. Behavior problems are not just a “psychology problem” or a “nursing problem.” Older adult residents at ALFs or nursing homes interact with a wide variety of staff from janitors to food service to physicians and et cetera. Behavior management is a team effort!
  • The approach requires an intense focus on staff education and even a “cultural shift” in how dementia patients are looked at and cared for. Dementia is a disease unlike any other because it affects how patients see and understand the world and interact with others, it affects everything. It has no cure. There is no effective treatment that can restore people to normal functioning. It requires lifetime management for the sufferer. In order to provide the most compassionate and effective care, staff need to understand, appreciate, and as best as possible, empathize with the plight of these patients.

So, given the above, what is does the STAR approach entail? The STAR program has within it four distinct elements which embody key principles and approaches:

  • The ABCs of Problem Behaviors. This of course refers to the old “Antecedents, Behaviors, Consequences” model of looking at behavior problems in dementia (this is also a model that behavior analysts use to address behavior issues with developmentally disabled individuals, as an aside). An example of a simple “ABC card” is here. In working through this ABC model, where staff carefully define the behavior problem, look at the Who, What, When and Where of a behavior, and look for its triggers and consequences, staff can then find ways to alter the contingencies that may be maintaining the behavior issue, and ultimately, change it. In encourages staff to look at behavior problems in dementia as a “detective work” problem (since dementia patients typically can’t tell you what the problem is).
  • Increasing pleasant events. As I’ve worked on the STAR-VA program, I have found that this is a critically important piece – namely, that behavior problems in dementia patients becomes much less likely when they are regularly exposed to personally meaningful pleasant activities. In an unrelated aside, interestingly, a tried-and-true method for treating depression in intact adults was pioneered by psychologist Peter Lewinsohn, so-called “pleasant events therapy.” In the same way that systematically increasing exposure to pleasant events can result in remission of depressive symptoms, it can also result in decreases in behavior problems in dementia – almost as if these behavior problems are how dementia patients tend to express their distress!!
  • Promoting effective communication skills. Dementia patients have problems with language. They may have trouble expressing themselves verbally, or understanding language, or both. That means for staff to stand the best chances of having themselves and their intentions understood, they need to communicate with their patients differently. They need to SLOW DOWN when they speak. Speak clearly and in short, simple sentences. They need to pay attention to their nonverbals – because with dementia patients, it matters as much (and frequently more) in terms of how you say things as much as what you’re saying.
  • Realistic expectations. Of the four STAR principles, this one is probably the most purely educational in nature, and in my opinion, one of the most critically important. For caregivers to be in the position to interact calmly and compassionately (and therefore, the most effectively) with residents who have dementia, they will need to have the most accurate understanding possible of what exactly is the matter with their patients. What is a sign that a staff member does NOT have a realistic or accurate picture of a dementia patient? When a caregiver says, “oh, they have selective memory.” Or “they are doing it on purpose.” Or “they know what they are doing.” Obviously, these are not helpful ways to look at our dementia patients. Realistically, when dementia patients act out, forget things, and perhaps are even aggressive or combative, we know it’s because their brains are sick and not working properly. If we understand things thusly, then we are much more likely to react calmly and compassionately to them then to take it personally.

In future posts, I’d like to talk more about the STAR program components in detail.

Smart Homes for Seniors

So in doing some reading about sensor technology and smart homes I encountered yet again some issues about ethics and technology acceptance both in older adults and in general.

Backing up a second – the future, of course, is already here when it comes to technology. We carry around these things called “smartphones” which contain within them technology that easily eclipses the wildest imaginations of people just a few decades ago (puts Gene Roddenberry’s communicator device thingies to shame). We’re all instantaneously connected to each other now with social media, Twitter, Facebook, etc. Disruptive technologies like AirBNB and Uber are fast-becoming a feature of the landscape.

With all of these technologies we’ve traded a portion of our privacy in exchange for what is in many cases a whopping dose of utility. This is the whole point of so many of these disruptive technologies. Imagine 20 years ago the idea of more or less offering up your apartment for short-term rental to a bunch of strangers using AirBNB, or sharing your personal life via daily updates over social media, or advertising even your garage sale over Craigslist for the world to see?

So in just the last few year alone, privacy has become really a commodity that we’re willing to trade in order to receive concrete benefits in return. (I’ll leave to the side the question of government officials essentially forcibly taking your privacy away via electronic snooping – which I consider a different animal entirely).

This takes us to the question of a potentially very useful technology for a population that, as always, is near and dear to my heart – older adults. The technology in question, broadly speaking, is sensor technology, and typically networked sensor technology (because what good are sensors if you can’t collect and manipulate the data in real-time?). Think positional sensors, such as geotagging, bed alarms, chair alarms. Think movement, such as accelerometers and zone alarms. Think physiological sensor technology, such as heart rate and respiration.

Now think about the real challenge facing us when it comes to the coming” demographic tsunami” that I’ve spoke of repeatedly in past blog posts. What seems to be increasingly clear about this wave of Baby Boomers that are currently beginning to retire and getting old is that they will be faced with a historic deficit of residential care options, particularly long term care, but also assisted living – but on the other hand, may not need these options nearly as much as previous generations due to advances in this particular cohorts ability to maintain their physical condition. This means they’ll be older, physically healthier (and therefore may not need nursing homes), but even if they need them, nursing homes and assisted living facilities will be expensive and harder to find.

This is where technology comes in. Just focusing on sensor technology – lets say my mother (who is getting a bit older) develops dementia. But, she strenuously wishes to stay in her home and remain independent for as long as possible – as do I. So I make some purchases. I outfit her oven, stove, and her faucets with sensors and shutoff systems (e.g., for example, so that if she leaves the stove on and forgets about it, it will shut off automatically – or I can do it remotely myself). I somehow tag mom (with wearable RFID tags, somehow) and set up monitors in various rooms to track her positions and give me real-time updates. I enable a perimeter alarm to let me know when she leaves the home. I give myself remote access to lighting and power within the home. I enable administrator access through my iPad which I carry around with me all the time.

There are a number of products which piece together these functions and can be enabled right now with some minimal know how and configuration, although many of these systems right now are not designed or enabled with older adult care and monitoring purposes in mind. However, there are now technology startups (such as BeClose ( and Lively ( which offer products tailored for elder care. Additional useful tasks these integrated, tailored systems can offer is biometrics (e.g., heart rate, respiration, step counting – think FitBit for seniors), which is valuable data that can be fed back to an older adult’s physician. These systems can also offer essentially what amounts to predictive analytic modeling of behavior – e.g., for example after a system observes a senior in their home for a given amount of time, the system can then tell the user where are the most well-traveled areas of the house (and therefore the parts of the house than need the most attention in terms of maintaining safety and livability).

These developments are completely exciting. This means that any number of adults alive today can now realistically expect to be able extend the time they’ll be living independently within their own homes significantly beyond what’s currently the norm. This could spell a reduced need for expensive facility-based care (such as skilled nursing homes or assisted living facilities) and also may provide for reduced costs of facility care as well (the as-yet-unrealized “smart nursing home” of the future).

However, technology positivism should always be tempered with some realism. First of all, there is no one-size-fits-all technology fix for any problem, and that always goes double (and then some) with older adults, who are inherently a far more diverse group than their younger adult or child counterparts – any technology solution to a “problem” of aging or dementia-related issue needs to be carefully tailored and individualized to account for specific functional, cognitive, and sensory changes in older adults.

Also, with monitoring and sensor technology comes ethical issues. How monitoring systems are deployed and used, how consent (always a tricky issue with the cognitively impaired) is navigated, all of these issues come with ethical and moral pitfalls. Moreover, older adults are by their nature more suspicious of monitoring and sensor technology than their younger adult counterparts, although their acceptance of monitoring and sensor technology tends to be tempered by their discomfort with monitoring depending on 1) who is doing the monitoring (e.g., family, physician, government) and 2) the level of invasiveness or ‘granularity’ of the monitoring (e.g. video and audio, audio only, or just positional?). Also, acceptance of monitoring is greater when, for example, an older adult is assured they are not being monitored in the bathroom. Which is tricky – because bathrooms are a frequent, if not predominant location / source of falls and accidents for older adults in the home.

I remain, of course, a gerontechnology booster. If I ever find myself in private practice, I imagine that gerontechnology consulting for in-home caregivers and crafting personalized solutions will be a big part of the work I do – and I’m excited, because the upside potential is clearly huge!

Older Adults and Sexuality… and Does Your Nursing Home have a “Pornography Policy”?

Okay, first – disclaimer. This may or may not be a NSFW (Not Safe For Work) posting (I think it is, though). I will be talking, at times, somewhat explicitly about sex here. First – onto the more general topic of sexuality and older adulthood.

There are a lot of misconceptions about older adults and sex.


  • Older adults aren’t interested in sex.

Of course, that’s hooey. I am reminded of a centarian (that’s someone who is 100+ years old, BTW) who I worked with and who was a patient at one of my facilities, who was wheelchair-bound, demented, had multiple medical issues, but still found the time to occasionally (cheerfully) sexually proposition his nursing staff, and, at times, would still find the time to masturbate in his room. Of course, since his memory and executive functioning was so poor, he required the assistance of nursing staff to maintain his privacy (staff would draw his blinds for him). As an aside – there is not much difference between older adult females and males in that regard, in case you’re wondering. Sexual desire does not diminish with age.

  • Older adults can’t have sex.

While it’s true that older adult males may have trouble achieving and maintaining erections the way they did when they were younger, and older adult females may have more trouble with vaginal lubrication, these issues are surmountable and frankly aren’t really that pronounced for older adults. For example, apparently 75 percent of older adult males surveyed over the age of 70 report little or no issues with erective dysfunction as they age. They’ve still got it!

  • Older adults shouldn’t have sex.

I think there are people who actually do actually think this. Obviously there’s an ageist bias at work here. The idea is that sex is something only appropriate for the youth, and that it’s somehow unseemly or inappropriate, or perhaps even unhealthy for older adults to be engaging in sexual activity (you know, might give grandpa a heart attack or something). The fact is all the things you heard about sexual activity for us young people (relatively young people, anyways) is true for older adults. It lowers blood pressure, it makes you happier, it helps you relax – heck, it’s good exercise – all true. Like anything, if you have medical issues that specifically precludes sexual activity, that’s something that shouldn’t be ignored. However, older adults can, and if they want to – should – have sex!

  • The older adult body isn’t sexy.

Says who? Younger people?

Pornography and Sex in Long Term Care

Let’s talk about pornography. Which is really what inspired this post of mine in the first place.

One thing that’s been clear to anyone who hasn’t been living under a rock for the past 20 years is that the availability, consumption, and production of pornography in the Western world, particularly the United States, has skyrocketed.

Depending on who you ask, porn is a 10 billion dollar a year industry in the United States, making it larger than major league baseball, and even possibly Hollywood. It’s “no longer a sideshow to the mainstream…it is the mainstream,” according to NY Times columnist Frank Rich.

With the much greater accessibility of pornography, and the advent of mobile technology (tablets, smartphones, and soon – wearable technology), pornography will soon be a real issue to be grappled with in long term care. Is pornography use a normal variation in human sexual behavior, is it more akin to a ‘kink,’ ‘fetish,’ or paraphilia, or is it something else? I’ll leave that to the side for now. Suffice it to say, it’s something that’s here to stay. Pornography is something many, many adults use, both males and even a significant chunk of females. Most seem to use it without becoming addicted to it (certainly a concern), or without gravitating towards illicit forms. In many ways, pornography seems analogous to drugs and alcohol. Used responsibly, it seems to be fairly harmless to most. Arguably, I suppose. Again, to be debated at another juncture, perhaps.

A recent issue that came up in my nursing home involved an older adult male in his late 60s who is being cared for due to complications secondary to stroke. This resident, we’ll call him Bob, is wheelchair-bound, essentially paralyzed on his left side, incontinent of bowel and bladder, and requires extensive assistance with his activities of daily living (ADLs).

Bob also has been known to exhibit some behavior issues in the past, approximately a year ago he distinguished himself by being combative with nursing staff (primarily during ADL care, e.g., such as when he has been cleaned up). Although I worked with him a bit more extensively in the beginning of his time with us at the nursing home, for approximately the last year I haven’t had much contact with him, and by all indications Bob seemed to have adjusted to being at our nursing home.

However, recently I began to hear some interesting information about Bob. First, I began to hear about how Bob had begun shredding his incontinence briefs (which are basically large adult diapers) – he was doing this, of course, to access his private parts for the purposes of masturbation. Well, no big deal – we just replace the briefs after he’s done, correct? Otherwise, nursing staff were encouraged to continue to maintain Bob’s privacy when he needed it (e.g., to draw his blinds for him, that kind of thing).

Then, I heard some accounts of Bob engaging in some sexually explicit language with nursing staff, and, most recently, with one of our recreation therapy staff, e.g., asking staff members to sleep with him, things of that nature. Some of this was documented.

Shortly after this, I learned that Bob had made a specific request of his physician to obtain a portable DVD player so that he could watch “his (pornographic) movies.” This request was communicated to our recreation therapy staff (who handle offering loaner DVD players to residents) and this caused a minor controversy / uproar amongst them.

I should say that the prospect of nursing home residents accessing and using pornography is not in fact new at our VA nursing home. In fact, in doing some research on this issue (which was sparked by the case of Bob), I found out about a few of our past and current residents at the nursing home who used porn (overwhelmingly via use of portable DVD players), and was amused to find that there was an informal trade in these materials that goes on between a small subset of our patients.

That being said, in all of the cases of porn use in other residents that I found out about, all of them involved veterans who were, for the most part, *independent* in their use of pornography. They were able to place DVD discs in players, cue them up, hit the play, pause, rewind, and stop buttons, and adjust the volume (and use headphones where necessary). Aside from cues, reminders, and perhaps some assistance in drawing their blinds for privacy, these were veterans who did not require “setup assistance” in using pornography.

So, here was the difficulty with Bob. He apparently expressed an interest in using porn. Let’s say his family even supplied him some pornography. RT has an existing policy of loaning out DVD players to residents who wants them. Who’s to say that this veteran can’t access porn if he wants to?

Well, the answer was, he would need assistance with it – in other words, with this resident we would be faced with the prospect of nursing staff setting up his porn, pressing play, and perhaps even pause and rewind on his porn videos; adjusting the volume, et cetera. This is not exactly what I consider to be the job of professional nursing staff, but perhaps my view is old-fashioned and unfairly restrictive.

Of course, other issues came into play with Bob as well. He had some significant dementia, which seemed pretty clearly to result in some disinhibition leading to inappropriate behavior with our younger, female staff members – not cool. And so the question was raised (prominently by me), would facilitating Bob’s use of sexually explicit materials somehow inadvertently be fueling his sexually inappropriate behavior? Would we want to risk more of that by effectively supercharging his access to porn (e.g., by upgrading his capabilities from magazines to full-length porn videos)?

What do you think – is actively facilitating the use of porn by nursing home residents a job for nursing or ALF staff?

Before you say a horrified NO!, consider the movement towards patient-centered, individualized care and the provision of a “homelike environment” for long-term care residents. Why isn’t the use of legal pornography a recreational preference to be respected just like any other recreational preference? What makes it special unlike any other recreational activity? In my research for this blog post, I was forwarded a 1992 article from “Advance for Occupational Therapists” (sorry, haven’t figured out how to link to it – but I can email the article to you on request) where apparently an assisted living residence actually had taken it upon themselves to sanction and help run a ‘porno night’ at their facility. Which I found a bit boggling, particularly for the early 90s!!! So, attitudes on this issue can certainly range.

I could take this further – wouldn’t we consider it a form of discrimination to allow patients who are independent enough with their functioning to use porn in a nursing home, but those who are impaired in some important way, say, a quadriplegic resident – they are *not* allowed to access their pornographic materials, because they require substantial assistance from nursing staff?

So this is the quandary we were faced with. Here’s what I did – as I indicated earlier (like any dutiful VA Community Living Center geropsychologist) I queried my VA nursing home psychologist listserv, and got a number of responses.

One of the most notable included this– it’s one of the few nursing homes out there that has developed a specific protocol for addressing “sexual expression” amongst their residents, and to their credit, it spells out much more than I’ve seen from nursing homes out there on average. However, even then it’s somewhat vague as to how to treat the use of sexually explicit materials by nursing home residents:

“Residents have the right to access and/or obtain, for private use, materials with legal but sexually explicit content: books, magazines, film, video, audio, pictures, or drawings.”

So what does “access” mean, in practice? What does “private use” mean? Et cetera?

As internet use becomes more and more ubiquitous amongst older adults, and sexual attitudes continue to liberalize – I think that nursing homes will need to all have their own “sexual expressions” policies – and moreover, it will need to specifically address pornography use. I can’t see how we’ll be able to avoid it!

Online Dating and Nursing Home “Roommate Matching”

I will eventually talk about nursing homes and older adults today, but first I wanted to talk about online dating. Wait, what? Yes, I’m recently single, but that’s not why I’m on this subject.

Bear with me. So I was watching a TED Talk video recently, plus browsing some articles about predictive analytics and predictive matching algorithms. The video was here and yes, it relates to romantic matchmaking – increasingly an important way that single adults find romantic partners in this day and age.

There are a number of dating sites out there. Many take the approach of simply having their clientele create a profile, add pictures, give them access to other profiles, and then allow people to somehow message each other for dates. This is basically the approach of sites like Blendr / Badoo, or AdultFriendFinder – you see something you like, you message them. There are other sites that cater to “special interests” – such as married people who want to cheat on their spouses (, or for specifically finding and dating school alumni (

I wanted to focus on the sites that do predictive analytics, or predictive matching. These are sites like, which uses a personality profile matching system to find you good dating partners – Eharmony was apparently founded by a psychologist and they tend to be staffed by people schooled in statistical techniques and personality theory.

Then there’s OKCupid (my personal favorite!). Unlike EHarmony, they don’t focus exclusively on personality as part of their matching algorithm. What they do is when users log on, after they create a profile they must answer a large number (at least 75, if I remember correctly) in order to optimize the algorithm and start getting good match predictions from their proprietary system. A lot of the questions seem rather random, and relate to issues like politics, lifestyle, aesthetics, etc.

So how do they construct this algorithm? Basically they do three things. First, they ask you the questions, and then you, as the user, are required to provide your answer. Second, they ask you to rate how you’d like the other person to answer (‘answers you’d accept’) and then third, they ask you to rate the importance of the question. After tabulating your answer, this allows OKC to weight your answer and then use it to calculate a match percentage. On OKC, if you have a match of 85 percent or more with someone else, its widely considered that you should probably check them out and maybe even go see ‘em for a date (of course, there’s debate about whether this faith in these proprietary matching algorithms is misplaced or not).

In practice, the OKC algorithm operates both using theory and empiricism. To a certain degree, the OKC algorithm doesn’t appear to care what the user says when they answer – it just needs to know how each person answers a particular question and then provides them with a match percentage that’s based ideally on the desired outcome (which in OKCs case, is whether you’d disabled your profile and indicated you’ve done so because you’ve successfully found someone to be exclusive with). In other words, OKC’s software is interested in the following: based on past experience of successful matches, how likely is it that a pair of potential partners who each answer a given question in a particular way or pattern going to be a successful match?

To be fair, it appears based on the little I know about the OKC algorithm, there is some theory in how they construct their questions. But I wanted to focus on empirical test design and pure empirical matching algorithms. I often think that psychologists and social scientists spend too much time on theory and not enough time on utilizing the raw predictive power potentially found in computational mathematics.

How can this apply to nursing homes? One thing that I was thinking about is the periodic issue of poor roommate matches. Here at the VA nursing home where I work, a majority of the patients are in double rooms, some are in four-person rooms. There’s a lot of issues that go into putting roommates together in nursing homes. The ‘first cut’ issues, of course, are things like microbe compatibility (MRSA positive / negative), whether a resident needs access to wall oxygen, a bariatric room (e.g., larger toilet, larger bed, etc).

Once those issues are taken care of, then the “art” of roommate matching takes over. What this looks like, in practice, is an animated discussion which takes place primarily between nurse managers and the physicians (with me occasionally joining in). It’s clearly a fun discussion for most, because of the inexact nature of it. It goes like this:

“So we should put Mr. X in with Mr. Y. Mr. X. is quiet and so is Mr. Y.”

“But Mr. Y. is African-American. Didn’t you say Mr. X has made some racial comments in the past?”

“Yes, but I’ve seen them chatting pleasantly. They both like football too.”

“I think Mr. Z. would be a better choice.”

“But Mr. Z is a night owl, and Mr. Y likes to get to sleep by 8pm.”

Et cetera.

Over the years, I’ve observed that when roommate matches go poorly, it can result in all sorts of untoward events. It can result in time and labor-intensive moves of patients and their belongings. It can result in “behavior problems.” It can result in fights. All of these things are negatives for patient health and well-being, and are an unnecessary drain on nursing resources.

Years ago, I witnessed how bad this problem can get. We had a resident (let’s call him Mr. Bob). He was a latino male, and was very sensitive about his racial background and very sensitive about sleights and perceived them frequently as being borne of racism (which may be based on many painful, real experiences he has had in his life). He also had issues with paranoia that were likely at least somewhat secondary to his previous cerebrovascular hemmorage, which had left him wheelchair-bound and with some cognitive impairments.

Well, we tried to get this gentleman properly matched up with roommates. His first roommate was a 90-plus year old gentleman and Air Force veteran, who was born and raised in the Bay Area but whom Mr. Bob immediately had trouble getting along with. They began sniping at each other almost immediately. We moved Mr. Bob, and moved him in with another older, white gentleman (most of our residents are Caucasians) and Marine veteran, but one whom we thought would be a good match with Mr. Bob has they both had asked to room with each other…. Guess what, it was even worse. The two eventually stopped speaking to each other, were calling the nursing station and hitting their call buttons constantly to complain about each other – it was a nightmare!

After a couple more moves, we found a roommate for Mr. Bob that seemed to work and he’s been fine now, more or less, for the last few years – but obviously it required a significant degree of trial-and-error to get the job done, a lot of nursing hours and time wasted, and along the way, lots of unneeded “behavior problems,” fights, and lost sleep of residents that may have been avoidable.

There is a good deal of theory and anecdote out there as to what makes for good roommate matches in the long term care environment. There’s a body of research on roommate matching that can be drawn from studies of undergraduates (who are often the preferred guineau pigs of psychology departments, since they are the most available), but that may have limited applicability to the geriatric, long-term-care crowd.

But the thing I’ve been struggling with is how to go about tracking this as an outcome. In the case of OKCupid, they have a great way of doing this – when people disable their accounts, they are asked as they are leaving, “why are you leaving?” Users are then able to tell them that they found someone, and then OKC asks them who. Bingo, there’s the outcome data, which can later be mined for variables to further optimize their matching algorithm. How would this get done in the nursing home environment?

Well, we could ask, I suppose – via questionnaires and the like (which of course now starts to sound like it would require formal research – given the issues with privacy and risk posed by “rating” each other). Of course, there’s the issue that sometimes, roommates (like romantic partners) may be attracted to each other as potential matches, but may in fact be terrible for each other (like the above example).

Sure, there are any number of potential issues, such as personality, politics, race, culture, medical issues, family visits, et cetera, that may make or break roommate matches. But until we start tracking this important outcome, I don’t think there will be a way to get a handle on this in the future.

Take Nursing Home, add a Dash of Innovative Technology and Futurism

What I want to do today is try and stitch together several of the innovations I’ve been thinking about, and try to knit them all together, so we can all sit back and imagine the idealized, technologically-savvy nursing home of the future. Futurism is fun. Given as heavily regulated as nursing homes are, in my humble opinion its difficult for a culture of innovation to thrive in these sorts of places. However, I’m going to try.

What will the nursing home of the future look like? What will it offer its residents?

Social robotics and the use of ‘virtual companions.’ Whether it’s by introducing use of devices like the Paro robot (which I’ve written about previously here), or via the use of virtual companions like ALICEBOT (friendly chatterbots), nursing homes will increasingly make use of technologies to outsource some of the work involved to keep residents happy and socially engaged in their world. Like it or not, social technologies and social robotics are niches (albeit small right now) that’s here to stay and will become only larger as time goes on. I predict that AI will allow the introduction of virtual companions in the nursing home world as well that will be increasingly convincing and useful in that regard as well. Both will allow us to stretch our limited nursing home dollars that much further.

Virtual reality. I recently attended the 2014 American Psychological Association conference and saw no less than three different booths demonstrating commercially-available virtual reality software and hardware designed for clinical purposes. That being said, use of virtual reality technologies for clinical purposes is definitely novel and is largely being used for addressing things like simple phobias and posttraumatic stress disorder (e.g., basically virtualized exposure therapy).

My thinking is that virtual reality can be used for other purposes in long term care. Some applications include:


  • ‘Virtualized mobility.’ Basically in all the years I’ve been working in long term care, one of the most frequent (and mournful) things I hear from my older adult clientele is that they would give anything if they could walk ‘just one more time.’ Well, what if we could do that for them? Or how about one better, what if we could provide them with the experience of running, or flying? What if we could recreate the experience of them ambulating around their own homes, or a favorite vacation spot?
  • Pain management. One of the more compelling demonstrations I’ve seen is using virtual reality, which is a very immersive, highly transportive technology (I’ve experienced it myself) as basically the ultimate distraction tool – and reserve it for specific, highly painful interventions, such as wound care (video on this approach is here), or perhaps lymphedema therapy. Wound care happens regularly at our facility.
  • ‘Virtual Snoezelen rooms.’ A really novel idea proposed by one of my Recreation Therapy colleagues (when I was excitedly recounting my experience with touring the VR booths at APA) was the idea of a virtual Snoezelen Room (more on Snoezelen rooms here). Snoezelen Rooms are basically a very systematic and well-developed method of offering dementia patients sensory stimulation, with the aim of calming and distracting them from whatever agitation or state was driving their behavioral issues. Its been found to be effective – but one of the big downsides of Snoezelen Rooms is that they tend to require something that many long term care facilities have in very short supply – physical space. Virtual Reality technology obviously is a great workaround for this basic logistical issue.

Information technology “hubs.” This was an idea I proposed a week or so ago. The idea here is that there are several simple, tried-and-true interventions for addressing behavior issues in dementia patients (or, really, just addressing risk factors for depression and loneliness in LTC). The idea here would be to outfit all residents in a nursing home with tablet computers mounted near their beds. These tablet computers could nominally function as televisions and be hooked to cable television. However, they would also be computers hooked to the internet, so that residents can:

  • Utilize videoconferencing technology to communicate with staff and family.
  • Send and receive emails.
  • Watch ‘internet TV’ like Netflix, Youtube, Hulu, etc.

However, these tablet computers could also be outfitted with specialized technology that is hooked to the facilities’ intranet. The idea here would be to allow staff to ‘push’ content to residents computers, specifically the ones who are more impaired and require more assertive intervention by staff to manage behavior issues. Family would be encouraged to supply content to nursing staff members so that staff can provide

  • ‘Reminiscence therapy.’ A tried-and-true nursing-driven mental health counseling technique (not actually psychotherapy, but related to the psychotherapeutic technique of Life Review), it involves engaging the patient in discussion of treasured, pleasant memories. Family and friends could assist staff in encouraging pleasant reminiscence by providing the following kinds of content which could be ‘pushed’ to the residents tablet computer:
    • Family photos, photos from the residents’ childhood, and other visual cues
    • Music, such as favorite songs from when the resident was younger and ‘of age’
    • Videos of family and friends, maybe favorite movies.


  • ‘Simulated presence therapy.’ A powerful use of internet-connected devices in residents rooms would potentially be ones where staff could push pre-recorded audio (or even video) recordings of family, friends, and others saying encouraging or calming things to residents who have dementia. Simulated presence therapy already has a powerful literature base but it’s probably not used frequently enough in long term care due to logistical and practical issues. A seamless information technology strategy implemented in the LTC environment could easily help to facilitate the use of this technique.

How would it work? Say you have a resident with dementia who becomes agitated during ADL care (e.g., cleanings after brief changes, for example). Staff already knows that this resident becomes much more calm and cooperative if he is able to hear his daughter’s voice when care is rendered. What if staff could simply tap a button on the residents room tablet computer to play various prerecorded statements by the residents daughter while they are rendering care, ones that the daughter recorded in her own home or at work on her iPhone, and emailed in to the nursing home?

Cognitive orthotics. This is an intervention with increasing popularity with younger brain-injured patients, but has some obvious applications with older adults with mild cognitive impairment or mild dementia in long term care (which I have written about previously here). The basic idea here is that (at least in my opinion!) the overriding philosophy, or goal, in long term care facilities is for residents to be as independent as possible given their physical, functional, and cognitive limitations. So, for example, if a resident requires a walker for mobility, we encourage them to use a walker, as opposed to a wheelchair. Likewise, if the resident has mild memory problems, we encourage them to use external memory aids (such as cognitive orthotics) to assist with their cognitive functioning, rather than solely depend on nursing staff to supply them with cues and reminders… which, of course, nursing staff don’t have a lot of time to do anyways!

RFID technology (and FitBits, perhaps!). The idea here is that there is often a lot of time spent trying to locate patients in the long term care environment. Some patients even engage in “wandering” or “exit seeking.” Oftentimes they are just stubbornly independent and uncooperative people (sarcasm) who want to do their own thing and visit with friends or go outside and spontaneously sunbathe (or what have you) when they are supposed to be at the nursing station for their afternoon medication pass. Or something.

Well, what if nursing staff could easily locate residents on the premises without having to physically search for them? Moreover, if residents were outfitted with three-dimensional activity tracking devices (the FitBit being an obvious commercially-available technology) staff would have available to them a wealth of information that could be used to inform care planning. For example, residents who are sundowning could be identified quickly. Weak points in the facility could be identified to improve security when it comes to persistent wanderers. These monitors might be used to more accurately alert nursing staff when residents are unsafely ambulating (as opposed to using the annoying bed and chair pressure alarms which tend to offer so many false positives!). Sleep disorders could be diagnosed more quickly via actigraphy. The possibilities, like many of the technologies proposed here, are potentially endless!

What other innovative technologies would you like to be seen employed in the nursing home of the future?

Implementing IT “hubs” in nursing homes for families and patients?

Been awhile since I’ve posted, lots of personal taking me away from focusing on the professional (although contributing to my blog is what I consider pleasure, and not business!).

Anyways, I was having one of those “water cooler” type conversations with Recreation Therapy staff at the Livermore Community Living Center (the CLC, where I am, of course, employed as their staff Geropsychologist and have been for the past 7 years). We had been discussing some strategies for how to implement “simulated presence therapy” (or SPT for short) more efficiently and effectively in our CLC (AKA VA nursing home) and as we often do, we began to discuss how technology and mobile applications could possibly help facilitate the use of non-pharmacological interventions with our veterans.

Let’s just back up and talk about SPT for a second. What is it? It’s not really therapy per se (e.g., as in a set of specialized techniques that only trained therapists can deliver). SPT is a technique, really, used with patients who have moderate to severe dementia, to help to reduce their agitation or other behavior issues, by typically playing them recordings of family members or friends voices. In the case of the veteran we were working with, we simply obtained a recording of the daughter saying to her father, “Dad, this is X, you’re doing OK,” and reportedly this calms this veteran down immediately – a big relief given this particular veteran has lots of issues with physical combativeness and psychotic behavior.

My personal belief in the many years I’ve been working at the CLC and in nursing homes is that SPT is a highly underutilized intervention, and that a big reason for this is a combination logistical and technological barriers and lack of outreach by nursing staff. It usually requires an enterprising and energetic social worker or psychologist to get something like this going with a resident. Requires that the resident be identified as having a discrete behavior problem that would actually be amenable to SPT in the first place – which, in the “throw pills at everything” culture that still remains embedded in many nursing facilities, is a difficult thing to accomplish.

As I chatted with the RT staff, it occurred to me that there’s a potential here for technology to help facilitate the use of these and other techniques in nursing homes. Not just SPT, but also via use of music therapy (e.g., offering specialized music to patients based on individualized preferences), reminiscence therapy via use of family photos and video files.

How would this be accomplished? The simplest and cheapest “fix” I considered was simply just having each nursing station be outfitted with their own tablet computer, that has its own email address where family can send sound files, pictures, and music that staff might be able to use for personalized interventions with residents.

A more expensive but comprehensive fix that I envisioned (and may become the subject of another VA Employee Innovation Proposal) is that of creating “hubs” that can be visited online (say, through a Facebook page, or via a custom-build Sharepoint site), family can sign up for with a secure account.

The idea there, as I envisioned it, would be that the family could then freely upload all of the content they wished, which would then be accessible to nursing staff for the purposes of calming or entertaining the resident – ideally via networked devices located in patients rooms (with client software loaded and enabled).

So far I’ve mentioned this idea to one or two nursing staff members here at the CLC – they have responded that in their opinion, cohort issues would prevent such a system from being widely utilized by families of our current crop of veterans. Truthfully, a majority of our veterans are from the Central Valley, have very modest means, and their average age is somewhere in the 70s. Although older adults are increasing their use of information technology and mobile computing at a faster rate than most other age groups, the increase is still from a relatively small base, AND this is a population (lower SES) where technology adoption is pretty limited anyways.

But is this idea viable and just ahead of its time, or could there be some other, more immediate way of using technology to facilitate greater use of SPT, reminiscence, or individualized music therapy with nursing home residents? Curious what you think.



Pseudodementia / Dementia Syndrome of Depression Revisited

A little over a year ago I authored this blog post, which quietly became, far and away, the most popular blog post I’ve ever written. To date, it currently gets at least a half-dozen or more page views per day. In part, this is due to some propitious circumstances as far as Google search results go – if you do a search for “pseudodementia,” my article has the distinction of being the seventh hit for this search term (valuable real estate indeed!).

While convenient search result placement likely has much to do with the popularity of the article, I can’t help but somewhat buy into a theory I’ve heard my ex-wife voice on this subject. I don’t recall exactly what she said, but it was something to the effect of, “people want to have a reason not to fear for the worst.” In other words, there is certainly some attractiveness to the pseudodementia / dementia syndrome of depression (DSD) concept, and something that goes beyond just its parsimoniousness from a clinical science perspective. Caregivers, family members, and dementia sufferers all would like to believe that the memory problems they are seeing are not a harbinger of an irreversible dementia such as Alzheimers.

So let’s revisit the issue. Psychiatrist Walter Brown notes:

“…The long-term prognosis for this condition is not as benign as we originally thought or as the term suggests. Elderly patients with depression and cognitive impairment, even when the impairment improves somewhat as the depression lifts, are at a substantially greater risk for dementia than their nondepressed counterparts.14 Pseudodementia may be an early sign of “true” dementia…” – See more at: (may require an email to read the entire article).

Basically, there is apparently some considerable support for the position that so-called “pseudodementia” (which, regardless of how you look at it, is not “pseudo” at all – regardless of the cause, it’s a dementia) may not be so apparently benign, and may simply be heralding the onset of chronic, progressive dementia frequently of the Alzheimers type or secondary to cerebrovascular accident, etc. One of the things I should point out (and I didn’t do so in my original blog article) was that in my approximately decade of experience in geriatrics, I cannot recall a single instance where I or my colleagues had erroneously identified a dementia as being secondary to, say, Alzheimers Disease, and later found out that depression was in fact the cause! This appears to agree with a meta-analysis on this subject – amongst community-dwelling older adults averaging in their mid-70s (74.4), the number of older adults who are found to have reversible dementia (presumably due to depression) was 11% – with only 3% completely reversing. That means that according to this meta-analysis – out of 100 older adults with dementia, you can expect perhaps three of them to completely reverse if their depression is aggressively treated. This doesn’t sound like DSD is a particularly widespread phenomenon…

I do recall one case where I was an intern performing neuropsychological testing in my role at the Dementia Diagnostic Clinic at the University of Medicine and Dentistry of New Jersey. There was a patient who showed evidence of confusion / disorientation, some short-term memory difficulties, and problems with her alertness. I recall a couple of issues that made her stand out from the typical patients at our clinic: one, she was young… if I recall correctly, she was somewhere in her mid-50s. Two, she had a notable, almost twitchy kind of tremor in her extremities, which was not the classic “pill-rolling” or primarily resting tremor you associate with Parkinson’s disease, nor the constant action tremor associated with essential tremor. This woman also suffered from Bipolar Disease and as we found out, had been chronically overdosing on her lithium medication – her cognitive symptoms, confusion, and tremulousness were all symptoms of lithium toxicity… which apparently is actually not hard to do if one, for example, does not stay properly hydrated!

Aside from that, in every other case I’ve seen where dementia was suspected due to a patient’s significant cognitive impairment, aside from where it was found later to be a delirium (e.g., cognitive impairment due to illness or infection) which later resolves, it always ended up being just that – irreversible dementia. Still, I do from time to time recommend that my patients be treated with an antidepressant, or receive therapy when I suspect DSD. Just in case.

Giving Call Bell Technology a Facelift using Skeuomorphic Design Concepts

I’d like to bring together two of my previous blog articles. I’ve written previously on mobile apps and their applications to older adults with dementia here, and I’ve written about a nifty, potential way of addressing wait times for patients receiving help in long term care, here.

The problem with getting older adults to use mobile app technology remains that of cohort effects. Essentially, even though contemporary polling data (such as the Pew Center’s regular polling on this subject) suggests that while the fastest-growing adopters of Information Technology, or IT, is older adults and baby boomers – older adults, particularly those in their 70s and up, are still behind everyone else in terms of their use, familiarity, and comfort with IT. In other words, growth in IT use in older adults is growing faster than any other age group, but it’s growing from a much smaller base.

So, any attempt to introduce technology in the long-term-care environment, such as cognitive orthotics, will be running up against potential issues with possible hostility to technology, or technophobia (fear of technology), lack of familiarity, et cetera.

Before I go further, I wanted to introduce a couple of user interface / user design concepts that I’ve run into over the past year or so. The first one is the concept of skeuomorphs, which is defined as: “a derivative object that retains ornamental design cues from structures that were necessary in the original.” Many of you reading this blog use Macintoshes (I do). Apple is notorious for use of skeuomorphic design, such as in the design of it’s Address Book app found on the iOS operating system (e.g., iPhones, etc):


The idea behind skeumorphs, I think, is to (at least in part) capitalize on another, related design concept I’d like to mention, the principle of least astonishment (POLA, for those of you that like acronyms). From Wikipedia: “If a necessary feature has a high astonishment factor, it may be necessary to redesign the feature.”

So why am I bringing up skeumorphs and POLA? Let’s get back to this:

Hospital call bell

Say hello again to the oh-so-analog, getting-rather-long-in-the-tooth, but almost universally recognizable hospital call bell. As I mentioned in my post last week, the call bell hasn’t really changed that much in terms of functionality since patients in hospitals literally had bells in their rooms for the purposes of calling in nursing staff – while over the years there have been some minor feature upgrades to call bells (e.g., addition of analog technology, a flashing light above patients rooms, addition of a 2-way intercom system, etc.); generally, overwhelmingly, hospital call bell technology hasn’t changed much over the last 50 years.

Here’s the rub though – call bells are very, very familiar, very unsurprising and un-astonishing, it’s a highly expected feature of the hospital and nursing home environment. I’m quite certain that very large proportions of us – from the very young to the very old, knows what a hospital call bell is, and what it looks like, and what it does. Conversely, only a small (albeit rapidly growing) proportion of my nursing home residents are familiar or comfortable with smartphones and tablet computers.

So, it hit on me the other day – the call bell is probably an almost ideal skeumorphic vehicle for the introduction of mobile app technology within the long term care and hospital environment! Capitalizing on POLA by making deliberate use of skeumorphic design concepts to shift call bell design to a digital, mobile-app based platform will allow for much more easy introduction of the potential array of useful features available in the mobile app development platform (such as cognitive orthotics, medication reminders, more flexible forms of communication between staff and patients, etc). In other words, while many older adults today may recoil if you try to get them to start using iPhones or Droid tablets (how many times have you heard an older adult friend or family member of yours exclaim, “I’ll never use one of those things!” when presented with a smartphone or tablet computer?), it’s a far easier sell to get older adults in long term care to use an upgraded, digital version of a call bell – since they’re all already using call buttons, and many have been using them for many years already.

What would a mobile app-based call bell look like? That’s a question for the design geeks to answer.

Reducing “Road Rage” in Nursing Home Residents

So, maybe in seeing this title, what came to mind for you was the idea of nursing home residents crowding hallways and griping at each other about who gets to pass first (I work in a nursing home for veterans – a nearly all-male facility, so this actually happens fairly frequently). So, no, wheelchair “traffic jams” isn’t what I had in mind…. Although that might be a good topic for another post. I’ll make the connection in a few paragraphs here, below.

What I had in mind was the subject of the “call button,” something all residents of nursing homes (and pretty much anyone who’s ever spent any time as a patient in a hospital) knows about:

Hospital call bell

For residents in nursing homes, overwhelmingly older adults, many of whom who are completely dependent on nursing staff for their mobility, food, water, and other ADLs, the call button represents pretty much a lifeline. If you have a need to use the bathroom (and you’re able to use the toilet), but you need help from a staff member to get up from your bed safely, you hit the call button.

And you wait. And sometimes, you wait some more.

Although I haven’t run the numbers myself at the Community Living Center I work at (e.g., the nursing home care unit of the Palo Alto VA system), I would guess a significant proportion of both falls and behavioral issues such as yelling, verbal abusiveness, and agitation, are related to the interval between the time a call bell is answered (e.g., via intercom – a nurse usually answers and a disembodied voice speaks in the patients room, “how can I help you”), and the time it takes for a nurse to arrive in a residents’ room. There seems to be some consensus that extended wait times for call bells to be answered can be a contributor to fall risk (see here).

This makes intuitive sense, of course – the longer you wait (and the more urgent your need is), the more agitated and anxious you will be if you’re a resident / nursing home patient in need, correct? This seems to suggest a straightforward, technological or human-resources approach to fix to the problem – just increase staffing, or more intelligently balance staffing in order to minimize as much as possible the amount of time it takes for nursing staff to reach a patient who has depressed their call button.

Of course, there’s another take on this. While the above approach of increasing staffing obviously helps with the task of offering quality nursing care – it ignores the psychological dimension, and a possible psychological solution to the problem of the call button wait time intervals (as an aside, for a wonderful discussion of the value of paying homage to the psychological dimension in addressing human problems, I highly recommend viewing this “TED Talk” with UK advertising executive Rory Sutherland…. Goes to show you that sometimes the best psychologists are often people in the marketing field).

So what’s this possible solution? This brings us back to “road rage.” Imagine yourself at a red light (not hard to imagine for many of you – you may have had to wade through a dozen of them prior to getting to the office this morning). How many of you feel agitated, impatient, somewhat anxious when you’re at a red light and you’re on your way to an appointment, or to work? Most of us. Of course, studies have reportedly shown that longer, unjustified wait times for red lights increases driver frustration and can lead to increases in accidents – so again, the simple, technological approach, is to use advanced signaling technology, more intelligent use of sensors, etc., to minimize unjustified wait times at intersections, and to therefore decrease driver frustration and accidents. Of course, there’s a problem – drivers will still have to wait.

Enter the Eko Stoplight (mentioned in the TED Talk, referenced above):

Eko Stop Light

This stoplight, a really brilliant invention in my view, has as a feature a visual progress bar which gives immediate feedback to drivers at intersections how long they have to wait prior to the signal changing to green. Apparently there is data from Korea and also other data from the manufacturer that strongly suggests that this innovation significantly decreases red light running and accidents at intersections. Put simply – without even changing the wait time interval at traffic intersections, people are more able to be patient and wait, because they know how long they have to wait. And as you know, a minute at an intersection when you’re late for an appointment can sometimes feel like a hour!

So what if such an innovation could be applied to wait times for residents in nursing homes? As far as I can tell – although there is active work on improving call-bell technology in inpatient units (e.g., experimenting with wireless technology and IP-based call systems), as yet I have not seen this idea applied to the nursing home environment. But maybe it should! It would take some work – as my wife pointed out the other night, the Eko Stoplight idea doesn’t precisely map onto the nursing home situation – while the interval between when a stoplight goes from red to green is known precisely (thereby allowing the Eko to precisely calibrate the progress bar), the amount of time it takes for a nurse to reach your room after a call bell is activated tends to vary based on staffing, workload, and other factors. Still, one way of getting around that is allowing individual nurses to calibrate their assigned residents’ progress bars (their ‘Eko timers’) on-the-fly. As long as a nurse arrived before the progress bar elapsed in the patients’ room, I think this psychological, calming effect would still potentially hold. There could be other ways of implementing this idea.

What do you think?

Geropsychology as a Career? My unsolicited advice.

So I’m going to digress a bit here, and try and explain the long and winding path I took in my life to end up here – working in geriatric psychology. I wish I could tell you that I knew from a very young age that I wanted to work with older people, but I don’t have a neat story like that. Here’s what I can tell you – my parents (currently in their 70s, obviously at this point older adults themselves) told me they always thought from an early age I seemed more comfortable than most children speaking casually with adults, even as a toddler, at times I seemed to almost prefer the company of older people.


Aside from that, however, there wasn’t much about my life as a child that seemed to speak to a later career in geriatrics (defined as “of or relating to old people, esp. with regard to their health care”). I liked the company of adults, I felt comfortable with people a generation or two ahead of me, I was reasonably intelligent and curious about myself and others, and I was reasonably extraverted. That was about it – as a child, the idea of specific career aspirations was a confusing abstraction for the most part. I knew what I liked to do – reading nonfiction, writing stories, doing theatre camp, I remember at one point I did a summer camp where I worked in a local cable access TV production studio and made short films with other kids. I enjoyed myself, but through high school and into college, I was all over the map. Which I guess is typical.

When I got out of high school (which I was only too glad to do) and started undergraduate training I took some advice from adults and soft-pedaled my interests in television and entertainment. I was told that getting meaningfully employed in the entertainment world was something akin to winning the lottery – and the sacrifices in time and my personal life in order to be successful in such a field would be huge with a highly uncertain promise of reward. OK, fine. I wanted to be realistic, after all.

Fortunately, I found myself passionate about something else – psychology. While theatre and entertainment-related things scratched my itch for approval from others, one of my many hang-ups (applause after a good performance definitely scratches that itch), studying psychology scratched my own itch for self-reflection and self-knowledge. Or, at least, my yearning to “know thyself” at least provided some pretty strong motivation to move forward in it. While I don’t advise people to pursue psychology as a career because they’re curious about themselves, it’s undeniably a motivator for many, and potentially a powerful one.

I went to Reed College in the mid 90s. At the time, Reed was known in some circles as a place where students studied intensely hard, studied humanities, and where fraternities and sororities had no footprint, but at the time had a reputation that generally marked it as a school for the proverbial undergraduate “square pegs” who didn’t fit into the collegiate round holes of Stanford, Yale, etc. Since I left Reed, it’s reputation has only increased in prominence and respect, and now it’s considered one of the most academically challenging private colleges in the United States, at least by some metrics. I graduated in 1996 with a degree in psychology, with some emphasis on biology (I took biology courses at Reed, which I found incredibly daunting, and also did an honors thesis on neuropsychology).

After college, I did some traveling with my then-girlfriend and now-wife (Beth Trittipo, bio is here) worked as a research assistant for about year prior to attending graduate school at Pacific Graduate School of Psychology (now known as Palo Alto University, or PAU).

A brief, but I think important digression on graduate school in psychology. There may be any number of psychology students, or prospective graduate students in clinical psychology reading this blog who’ve considered the route of attending a professional doctoral program in clinical psychology, which overwhelming refers to unfunded doctoral programs. PAU is one of those programs. Granted, it tends to have a good reputation (arguably one of, if not the best) of unfunded professional programs. An overwhelming majority of its graduates (100% of its Psy.D. students as of last year) secure coveted internships accredited by the American Psychological Association, and tend to do well in terms of research productivity, licensure rates, and scoring high on the EPPP.

However, the biggest problem with professional programs in psychology, without a doubt, is the debt-to-income ratio that most students are left with. It’s a growing problem with all types of graduate and undergraduate degrees, but with students of professional (largely Psy.D.) programs, the problem has gotten out of control, with the average Psy.D. student leaving doctoral programs in psychology with 120K in student debt. At PAU, (which is in Palo Alto, after all) the average debt load is likely more than upwards of 250K at this point.

While 250K of student debt is manageable for a graduate of, say, a physician graduate of medical school who may begin earning six-figures or more immediately upon graduation, the median salary of a psychologist currently in the US is around 70,000 dollars per year according to the Bureau of Labor Statistics. That means if you have 200K-plus of debt as a graduate from a psychology professional program (very common these days), and you land a job paying around the median salary, even with the various repayment programs available to graduates these days (e.g., such as Income Contingent Repayment), the graduate could be sending out half a grand a month in loan repayments. If the graduate has private loans (which don’t qualify for these federal programs), this could drive up the costs further.

I graduated from PAU about a decade ago. While I have significant student loans from that adventure, they don’t approach the numbers I’m currently seeing with many clinical psychology graduate students, my interest rate is extremely low, and my payments, while annoying, are affordable with my VA salary. In short – I think I got lucky and I think I’m probably one of the last generation of professional student graduates from pricey schools like PGSP / PAU that can make the math even somewhat work. Even so, I pay several hundred dollars per month towards student loans, and that’s money that I definitely miss.

Anyways, off my soapbox.

So, I got into PGSP and began my studies. For me, getting into geropsychology was a matter of a bit of taking advantage of luck and propitious circumstance, and then capitalizing on the experiences gained even further, and then lather, rinse, and repeat. In graduate school, after languishing for a year or so doing generalist practicum experiences and toiling unproductively in a research group not related to geropsychology, I approached Larry Thompson and by extension, Dolores Gallagher-Thompson, both geropsychologists with stellar records of accomplishment and who were running a large-scale arm of the REACH-II (Resources for Enhancing Alzheimer Caregiver Health) research project on dementia caregiver interventions through the Older Adult and Family Center (OAFC) at the Menlo Park Department of Veterans Affairs.

Larry Thompson was very kind to me and offered to work with me on a dissertation project, and also found me a practicum training opportunity at the OAFC. This highly successful experience allowed me to attain an internship in geropsychology at the University of Medicine and Dentistry of New Jersey (UMDNJ), and then a fellowship in geropsychology at the University of Rochester Medical Center in Rochester, New York.

Since then, I’ve attained licensure as a psychologist, I’ve worked in community nursing homes, coordinated research projects, published articles, given talks, and have worked at the VA in Livermore as their staff Geropsychologist for approximately seven years now. I love my job, I enjoy what I do, and I think I’m very lucky.

So, what advice would I give to a student considering a career in geropsychology or geriatric mental health, in the future? I’ll break it down for you:

1) Don’t attend a doctoral program at a professional school in psychology, unless you’re independently wealthy or you receive some other form of funding. Just don’t. Make yourself competitive for funded programs. Get stellar grades in college. Get on publications, do research assisting for a year or two before you apply to graduate programs, and get a stellar GRE score, whatever you need to do. Moreover, short from a select number of professional programs like Rutgers, Baylor, perhaps PAU / PGSP, for the most part professional programs in psychology tend to struggle to match the reputations of funded programs, which is an extra cross to bear for professional school graduates. So, don’t do it.

2) Consider applying to nurse practitioner programs (medicine is OK too, but I see reimbursements declining, while tuition continues to rise). One side effect of Obamacare that I can see is that with all of the pressure being put on physicians due to what will supposedly be increased enrollment of the previously uninsured, demand for nurse practitioners will increase. And NPs command significantly greater salaries than psychologists. Consider masters-level programs in counseling or social work, with an emphasis in geriatric mental health as well (far less money and time for a degree that allows you to do many, if not most of the things professional clinical psychologists do).

3) If you’re bent on attending graduate programs in psychology, and you want to go into geropsychology, my advice is specialize, and specialize early. Make sure you get the specialty practicum, internship, and postdoctoral training opportunities where possible, and don’t forget to get elective coursework in geriatric mental health, geriatric neuropsychological assessment – as this will be critical in attaining later boarding as a Geropsychologist with the American Board of Professional Psychology (ABPP, something I talked about here). Geropsychology is a specialty, and in order to get specialized jobs, you’ll need specialized training.

4) Be prepared to not make a ton of money in geriatrics. This is not a glamorous field. Medicare continues to nickel-and-dime us to death. Don’t expect to get rich.

That’s it for now.