BEHAVIOR MANAGEMENT

Behavior management refers to a class of therapeutic techniques for altering behavior by changing one or more aspects of an individual's environment. The aspects that are changed are those believed to contribute most significantly to the occurrence or maintenance of behaviors that are problematic for the individual himself/herself or for other individuals in the environment. Environmental changes are also made for the purpose of increasing positive behaviors that are considered desirable or adaptive. Behavior management techniques have been used most often with older adults to decrease problem behaviors that result from dementing illnesses, such as Alzheimer's disease (AD). Behavior problems associated with dementia are very common and place a great deal of stress and burden on the people who care for these elders. Behavior problems associated with dementia include disruptive vocalization (e.g., repetitive questions, cursing, chronic screaming), physical aggression (e.g., hitting, pinching, biting), and motor restlessness (e.g., wandering, inappropriate disrobing). Techniques that focus on environmental change are used with older adults who have dementia because their cognitive limitations (e.g., problems with memory and abstract reasoning) often prohibit the use of other therapeutic techniques, such as cognitive-behavioral or insight-oriented therapy, that rely on more complex cognitive abilities for success.

Behavior management techniques are derived from Albert Bandura's social learning theory, which asserts that observable behaviors emerge from an interaction between the person and environmental events. Antecedent events precede a behavior in time and can elicit the behavior or decrease the probability that a behavior will occur. For example, approaching a dementia patient from behind (antecedent) can startle the patient and elicit physical aggression (problematic behavior). Conversely, if a patient appears anxious, using calming speech and soothing touch (antecedent) can prevent physical aggression (problematic behavior) from occurring. Environmental events that follow a behavior in time (i.e., consequent events) can similarly increase or decrease the probability that the behavior will continue once it occurs or that it will reoccur in the future. For example, if the therapeutic goal is to increase an isolated nursing home resident's social interactions with other residents, staff provision of positive attention (consequent) when the resident interacts socially can serve to reinforce or increase the probability of the resident's interaction (desirable behavior). Conversely, if a resident becomes agitated during a social situation, relocating the resident to his/her bedroom (consequent) can serve to suppress the agitation, or decrease the probability that it will reoccur during similar social situations (desirable behavior).

Thus, behavior management techniques can be classified into two categories: (1) antecedent strategies, which are used before a behavior occurs in an effort to prevent or elicit a behavior, and (2) consequent strategies, which are used after a behavior occurs in an effort to prevent the continuation and recurrence of a behavior or to reinforce a behavior. Although both can be effective, antecedent techniques are used more often than consequent strategies with older adults because they are easier to apply, require less caregiver time, and are generally considered less manipulative, and therefore more acceptable, by caregivers and professionals.

Antecedent strategies

Several variations of antecedent strategies have been used in nursing homes and community settings. Strategies that have been researched include altering the general physical and/or social environment of elders, teaching communication skills to caregivers, and providing auditory stimulation for elders.

Early work in this area emphasized altering the physical environment in nursing homes to reduce disorientation, provide sensory stimulus variation, and increase social interaction. Disorientation, understimulation, and infrequent social interaction contribute to problem behaviors such as repetitive questions and wandering, as well as to psychopathologies such as depression and anxiety. Procedures for altering the physical environment include creating a more homelike environment and constructing environments that reduce unnecessary environmental stimuli while providing adequate variation of sensory stimuli. Planned environments consisting of a very large central area with bedrooms on the periphery (to reduce disorientation), individualized personal areas, and soothing colors have been used effectively for increasing interest in the environment and increasing the frequency of pleasurable activities, such as reading. With the specific goal of increasing social interaction, other effective antecedent strategies include rearranging furniture; adding plants, pictures, and other decorations; providing conversational partners such as peers, children, or pets; and offering group activities. Another antecedent strategy to promote social interaction is the use of communication books. These handheld books contain pictures of relatives and friends, along with descriptions of the pictures, and are designed to promote and enhance the conversations of nursing home residents with other individuals in their environment. In the community, similar strategies have been used effectively to address the common and stressful problem of repetitive questions and statements. The use of environmental cues, such as signs, labels, color codes, and calendars that help the individual interact with the environment, without asking repetitive questions, has been particularly useful.

The effects of teaching nursing home staff and family caregivers about effective communication skills has also been researched. The verbal interactions of nursing staff and family caregivers can strongly influence the occurrence of behavioral problems among individuals with dementia. Caregivers can be taught to announce care activities (e.g., bathing) to reduce disorientation and anxiety, and thus also reduce the likelihood of physical aggression by the individual with dementia during a care activity.

Auditory stimulation strategies have been used effectively to decrease disruptive vocalization, the most common form of agitation in the nursing home. These strategies include the use of relaxing music and comforting sounds or voices. Specifically, environmental sounds (e.g., gentle ocean, country stream) and relaxation audiotapes have been used, as well as audiotapes that contain conversations about cherished memories, anecdotes about family, and other treasured experiences of the resident's life.

Consequent strategies

Although providing consequences, such as relocating a resident to his/her bedroom after agitation occurs, has been used successfully, most consequent strategies involve the use of verbal praise or planned ignoring, and are integrated into a treatment plan that focuses on antecedent techniques. Planned ignoring involves terminating caregiver attention when it is believed that attention is reinforcing the problem behavior. For example, caregivers are taught never to argue with a dementia patient because, although arguing may appear aversive, this response can actually reinforce a patient's contentious behavior (e.g., insisting that this is not her home). Planned ignoring of the patient's statements, combined with getting him/her onto another topic (an antecedent strategy), is often effective in diverting an unpleasant verbal interaction.

Another example of consequent strategies combined with antecedents is the use of prompted voiding for urinary incontinence. In prompted voiding, patients with dementia are verbally prompted (i.e., reminded) to use the bathroom every one or two hours. Verbal prompting is an antecedent to using the bathroom. However, an important component of prompted voiding is the provision of verbal praise after the patient uses the toilet appropriately (reinforcing consequence).

Behavior management techniques are considered by many to be the most effective form of treatment for the unique problems and psychopathologies associated with dementia. Other forms of behavioral therapy, including problem-solving skills training and cognitive-behavioral therapy are used commonly among older adult populations without dementia-related impairments.

Louis D. Burgio Susan E. Fisher

See also Alzheimer's Disease; Anxiety; Congnitive-Behavorial Therapy; Dementia; Depression.

BIBLIOGRAPHY

Allen-Burge, R. S.; Stevens, A. B.; and Burgio, L. D. "Effective Behavioral Interventions for Decreasing Dementia-Related Challenging Behavior in Nursing Homes." International Journal of Geriatric Psychiatry 14 (1999): 213–232.

Bandura, A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, N.J.: Prentice-Hall, 1986.

Burgio, L. D., and Fisher, S. E.. "Application of Psychosocial Interventions for Treating Behavioral and Psychological Symptoms of Dementia." International Psychogeriatrics 12 (2000): 351–358.

Burgio, L. D., and Stevens, A. B. "Behavioral Interventions and Motivational Systems in the Nursing Home." In Annual Review of Gerontology and Geriatrics. Edited by R. Schulz, G. Maddox, and M. P. Lawton. New York: Springer, 1998.

Kennet, J.; Burgio, L. D.; and Schulz, R. "Interventions for In-Home Caregivers: A Review of Research 1990 to Present." In Handbook of Dementia Caregiving: Evidence-Based Interventions for Family Caregivers. Edited by R. Shultz. New York: Oxford University Press, 2000. Pages 69–98.

Lawton, M. P. "Environmental Approaches to Research and Treatment of Alzheimer's Disease." In Alzheimer's Disease, Treatment, and Family Stress. Edited by E. Light and B. Lebowitz. Rockville, Md.: National Institute of Mental Health, 1989. Pages 340–362.