|Leilani Feliciano, PhD|
Scrutiny of the use of antipsychotic medications in nursing homes has increased exponentially in the last 24 months, driven largely by congressional mandates to the Office of the Inspector General and the Centers for Medicare and Medicaid Services. Nearly every call for their reduction has been accompanied by suggestions that nonpharmacological approaches should be used first. Such suggestions are not new, and were first enshrined in the nursing home reform amendments of the 1987 Omnibus Budget and Reconciliation Act, or OBRA. All documentation of antipsychotic use should, OBRA holds, be preceded by attempts at nonpharmacological management.
This sounds well and good, but most geriatric psychiatrists know firsthand that there are important limitations to these approaches for treating behavioral disturbances. First, they involve heterogeneous techniques ranging from sensory stimulation like music and pet therapy, to caregiver training, to addressing unmet needs, among many others, without clear guidelines on which approaches work best for which individuals and under which circumstances. Jiska Cohen-Mansfield, PhD, ABPP, has stressed the importance of individual assessment to best select a modality, but this requires time and training that is at a premium in most long-term care settings. Second, nonpharmacological approaches have only modest evidence of benefit, and certainly have not been shown to be more efficacious than pharmacological approaches. Although they are assumed to be safer, no one has studied the morbidity associated with behavioral disturbances that were not treated with more aggressive pharmacotherapy. What if it turned out, for example, that injuries caused by behavioral disturbances were greater when nonpharmacological approaches were favored over pharmacological ones? And finally and perhaps most importantly, nonpharmacological approaches lack both efficacy and safety when used for severe psychotic symptoms or in behavioral emergencies where the imminent risk of harm to self or others demands rapid pharmacological intervention.
There is a way, however, to be more systematic in the application of a nonpharmacological approach, namely, the use of applied behavior analysis or ABA, as is commonly used for behavioral disturbances in children with autism spectrum disorders (as labeled in DSM-V, replacing pervasive developmental disorders in DSM-IV-TR). As a means of exploring this area, I recently interviewed AAGP member Leilani Feliciano, PhD, who serves as an assistant professor in the Department of Psychology at the University of Colorado, Colorado Springs (UCCS). She previously completed a two-year post-doctoral fellowship sponsored by the National Institute of Mental Health, which focused on developing community partnerships and research with underserved populations. She earned her PhD in clinical psychology from Western Michigan University in 2005 and her MA in clinical psychology with an emphasis in behavioral medicine from the University of the Pacific in 2000. At UCCS she teaches graduate and undergraduate clinical courses and supervises a clinical practicum rotation. Dr. Feliciano's research interests include studying and applying behavioral interventions for clinical problems and mental disorders in older adults (called behavioral gerontology). Specific areas of interest include late-life depression, anxiety, co-morbid psychological and medical problems, and behavioral problems associated with dementia.
Dr. Feliciano has over 12 years of experience working as a behavior specialist designing behavior modification programs, training staff, implementing interventions, conducting outcome evaluations, and supervising graduate students in these areas. She has worked on multidisciplinary teams across a variety of settings. Her research and clinical program explores 1) how psychological, behavioral and environmental factors contribute to the development and management of challenging behaviors with older individuals with cognitive impairments or other mental disorders and their caregivers and 2) the application of behavioral interventions for chronic medical conditions that have a behavioral component. I posed to her several questions relevant to the everyday work of geriatric psychiatry.
GPN: To someone who has never utilized Applied Behavior Analysis (ABA), can you define exactly what it is? How is it currently used with children?
Feliciano: Applied behavior analysis is a discipline which focuses on using behavioral principles to solve important clinical problems, problems that have social relevance. As part of this process we use a system of direct or indirect observation, objective measurements (the data drives the intervention), and single-case experimental designs. Early on, the field primarily evolved around psychology and education. I was just speaking the other day with my doctoral student Allison Jay, MA, a board-certified behavior analyst who works with developmental disabilities across the lifespan, about this topic. She captured this beautifully, "I would define ABA as the utilization of behavioral principles and learning contingencies to create an environment that promotes functional and adaptive skills. It is used with children with developmental and intellectual disabilities to build new skills (e.g., academic, social skills) and create environmental contingencies that support these skills. ABA is also used to manage problematic behaviors by identifying functional relationships (i.e., between the behaviors and specific reinforcers) and creating an environment that addresses the needs of that individual in other ways."
Authorís note: There is an extensive literature base of the effective use of ABA for children with a variety of concerns from food selectivity in normally developing children, to Attention Deficit Hyperactivity Disorder, to Pervasive Developmental Disorders including autism and Asperger's. This supportive literature dates back to the 1970s.
GPN: How can ABA be applied to older patients with behavioral disturbances?
Feliciano: As you may know, when working with individuals with cognitive impairment, a main source of concern is in the management of neuropsychiatric symptoms, including depression, anxiety, and behavioral disturbances. As a behavioral gerontologist, my approach to using ABA not only considers the neuropsychiatric contributors to agitation but also the physical and environmental factors. Uncovering and addressing the reasons for the behavior (e.g., emotional, environmental, and medical factors) are likely to result in better management. In my research program Iíve looked at both direct interventions with the affected individual and training caregivers in long-term care facilities.
In terms of direct interventions, we explore how making alterations in the environment affects the individualís behavior. That is, we examine the context in which the behavior occurs and use a process called functional assessment to determine what factors may be driving the behavior. Once we have identified what we believe the function of the behavior may be, we can restructure the environment in such a way to either reduce or prevent the behavior from occurring. For example, if a person with dementia is hitting the caregiver during bathing, we would examine the consequences of this behavior to see what may be maintaining it. In this situation, if our observations determined that hitting results in the caregiver ceasing his attempts to bathe the resident, we would classify this behavior as being escape maintained; that is, hitting results in escaping from the aversive situation. We would then devise a behavior plan to see if we could reduce the hitting, by altering variables in the environment and use single case design methodology to evaluate the effectiveness of our intervention. We have successfully used this approach for a variety of other behaviors including individuals with dementia who wander (Feliciano et al, 2004) and with normally developing adults with poor dietary habits (Feliciano et al, 2010), depression, and type 2 diabetes (manuscript under submission).
Other research studies involving examination of the effects of environmental manipulation on challenging behaviors are also being conducted in my lab. For example, currently we (Allison and I) are running a project investigating wayfinding abilities of older adults with dementia at two residential care facilities. For this project we are systematically evaluating the utility of using a memory box (a shadow box that would showcase either general stimuli or personal memorabilia) to promote room-finding in individuals with moderate to severe dementia.
There are numerous ways that we can apply ABA to the older adult population and these are just a few examples. ABA can and has been utilized for increasing lost skills such as ambulation and continence, improving exercise and healthy dietary behaviors, decreasing problem behaviors, etc. in healthy and cognitively impaired populations, as well as training staff in behavior modification procedures that serve to increase ambulation, hydration, more independent self-care behaviors, and decrease depression, agitation/aggression, etc. Behavioral gerontology, while it has waxed and waned in interest to the general ABA community since the 1980s, has really just begun to rebound within the last decade or so. While we are still a small contingency within the applied behavior analytic community, we are certainly growing and attracting new students within the field. It is an exciting time to be within the field.
There is currently a large and growing body of research supporting ABA techniques in children with autism, as well as a burgeoning professional association of therapists. Largely due to activism on the part of parents with autistic children, an increasing number of insurance companies are covering ABA therapy, and 30 states currently require health insurance plans to include it. In fact, the U.S. Office of Personnel Management recently stated that there is sufficient evidence for ABA therapy to classify it as a medical rather than an educational service. Such a ruling has led to mandated health plan coverage for this therapy being offered to all government workers by 2013. In addition, a recent ruling by a Florida judge ordered Medicaid to cover ABA services.
Given the fact that nonpharmacological approaches are being mandated as first-line treatments for dementia-associated behavioral disturbances, the question is whether the government will actually pay for such services, with ABA being a logical, empirically-supported option. Medicare does not currently cover ABA per se, although a psychologist administering ABA along with other therapeutic approaches could ostensibly be reimbursed under existing psychotherapy codes. But what Alzheimerís disease still lacks are advocacy groups with the passion and clout of parents with autistic children who have largely spearheaded efforts to get coverage of ABA.
Geriatric psychiatrists and psychologists can clearly benefit from learning about ABA from specialists like Dr. Feliciano (who will be presenting on ABA in a symposium at the upcoming AAGP Annual Meeting, chaired by this author) given the current climate in long-term care as well as concerns about limited efficacy of pharmacological approaches for behavioral disturbances.
Marc E. Agronin, MD, medical editor of Geriatric Psychiatry News, is the medical director of mental health services and clinical research, Miami Jewish Health Systems, and affiliate associate professor of psychiatry at the University of Miami Miller School of Medicine. He is also a member of the AAGP Board of Directors. Agronin can be reached at MAgronin@mjhha.org.
For Further Reading:
Ayalon L, Gum A, Feliciano L, AreŠn PA (2006). The effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: A systematic review. Archives of Internal Medicine, 166, 2182-2188.
Feliciano L, LeBlanc LA, Feeney, B. (2010). Assessment and management of barriers to fluid intake in community dwelling older adults. Journal of Behavioral Health and Medicine, 1, 3-14.
Feliciano L, Steers ME, Elite-Marcandonatou A, McLane M, AreŠn PA. (2009). Applications of preference assessment procedures in depression and agitation management in elders with dementia. Clinical Gerontologist, 32(3), 239-259.
Feliciano L, Vore J, LeBlanc LA, Baker JC. (2004). Decreasing entry into a restricted area using a cloth barrier. Journal of Applied Behavior Analysis, 37(1), 107-110.
LeBlanc LA, Cherup SM, Feliciano L, Sidener TM. (2006). An evaluation of the utility of choice assessments in increasing activity engagement and positive affect in elders with dementia. American Journal of Alzheimer's Disease and Other Dementias, 21(5), 318-325.
LeBlanc LA, Raetz P, Feliciano L. (2011). Behavioral gerontology. In W.W. Fisher, C. C. Piazza, and H. Roane (Eds), Handbook of applied behavior analysis (pp. 472-486). New York: Guilford Press.