What is Behavioral Gerontology?

Behavioral gerontology is the application of the principles of applied behavior analysis, including careful examination of the antecedents and consequences of behavior, in elderly patients and to address problems of aging.

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The demand for applied behavior analysts (ABAs) in healthcare has, since the mid-1990s, largely revolved around filling positions treating children with Autism Spectrum Disorders (ASD). The explosion in ASD diagnoses effectively soaked up much of the attention in the ABA world. According to a 2015 study commissioned by the Behavior Analyst Certification Board (BACB), more than half of all job postings in the field were for positions treating autism.

If autism created the last great wave in demand for ABAs, however, it’s likely that the demands of an aging population will create the next. According to the 2010 Census, 39 million people, or 13 percent of the population, was over 65 years of age, and 10 percent of them had been diagnosed with dementia.

By 2050, that number will shoot up to 88 million, or around 20 percent of the population. And while the average lifespan has been increasing for almost a century now, the physical and mental issues associated with advanced age have not been as easily addressed. Elderly patients frequently experience problems such as:

  • Dementia
  • Alzheimer’s Disease
  • Depression
  • Anxiety

As a result of or in combination with other physical infirmities, these conditions lead to a variety of problematic behavioral issues, including:

  • Abusiveness
  • Decreasing personal hygiene
  • Confusion and apathy
  • Hoarding
  • Paranoia and obsessive/compulsive disorders (OCD)

Many of these issues are exactly the same as those faced in autistic populations. And ABAs are beginning to apply the same treatments in geriatric populations. There is not as much research on the use of applied behavior analysis in geriatric populations, but what study has been done is encouraging.

A Shifting Emphasis in Geriatric Medicine Leads to Applied Behavior Analysis

Traditionally, most issues suffered by geriatric patients have been treated pharmacologically rather than psychologically, for reasons both of cost and culture—there are fewer cultural inhibitions to widespread drug prescriptions in older populations, who are commonly already on cocktails designed to treat medical issues. According to a 2005 study, many older Americans associate stigmas with psychiatric treatments and are resistant to such therapy. And despite the expense of prescription medicines, they remain less expensive than the cost of one-to-one therapy.

But some providers have begun to question the wisdom of relying primarily on drugs to treat behavioral problems that are not necessarily medical in nature. At least one study has found that behavioral issues in older populations can stem not just from medical problems, but from environmental issues. Notably, once elderly patients deteriorate to the point where they have to be committed to long-term residential care facilities, they are immersed in a new and shared environment that is both strange and sometimes crowded.

ABAs may be uniquely suited to address these issues because they look carefully at the context in which problematic behaviors occur. Behavior analysis revolves around a concept known as the ABCs of ABA:

  • Antecedent – The prompt, or initial situation, leading to a behavior.
  • Behavior – The action or behavior in response to the antecedent.
  • Consequence – The reinforcement mechanism associated with the behavior.

Because of their functional approach and emphasis on environmental factors, ABAs can address various age-related maladies and infirmities as another variable that can influence behaviors—for example, the biological changes leading to worsening balance and weaker muscles and bones present antecedents with dramatic consequences (falls and broken bones) that result in very cautious and withdrawn behaviors.

Those behaviors, in turn, can lead to other worsening biological issues, creating just the sort of reinforcement cycles that ABAs know how to break. By adjusting either the antecedent or the consequence, an ABA can dramatically improve the quality of life and prognosis for elderly patients.

Working in Geriatric Medicine as an Applied Behavior Analyst

ABAs involved in geriatric medicine most commonly work in hospitals or long-term care facilities. They may work with older patients either one-on-one or in a group setting, using methods such as creating token economies to encourage appropriate behaviors across all patients in the facility.

Implementing a token economy involves distributing tokens to participants as a reward for engaging in appropriate behaviors. At some point, a set number of tokens may be exchanged for goods or activities that offer positive encouragement to the patient. This encourages consistent and long-term behavior changes and is easily managed even by non-professional caregivers once put in place by a behavior analyst.

In one case involving 80 chronic geriatric mental health patients in a long-term care facility, over the course of six months in a token economy, the majority exhibited:

  • Fewer episodes of bizarre behavioral outbursts
  • Decreased incidents of incontinence
  • Increase vigor and physical activity

A token economy is one standard, out-of-the-box treatment common in applied behavior analysis. But the real strength of ABAs in gerontology lies in their analysis and manipulation of antecedents in the patient environment.

To understand the patient and environment, ABAs conduct a Functional Behavior Assessment (FBA). This involves interviewing the patient, examining medical and other records, and carefully considering the patterns and circumstances of their daily routine.

In one case in two geriatric residential care facilities, dementia patients were chronically getting lost when looking for their rooms. As they conducted their FBA, the behavior analysts recognized that many patients suffering from dementia may not have good short-term memory—they couldn’t remember their room numbers. But since the same patients can often recall older memories clearly, the ABAs experimented with building shadow boxes containing personalized memorabilia to mark their rooms.

This sort of solution can improve the mood and attitude of previously frustrated and depressed patients, helping to encourage socializing and movement, which in turn promote other positive behaviors, all without the use of drugs or punitive techniques.

The solutions devised are incorporated into a Behavior Intervention Plan (BIP) that may involve:

  • Direct intervention and therapy by the ABA
  • Environmental changes (such as the shadowboxes)
  • Rewards implemented as consequences for positive behaviors
  • Alterations in routines to be implemented by other professional caregivers

ABAs continue to work directly with patients in BIPs and also oversee other staff, family members, or medical providers who share responsibility for implementing the plan. The BIP may be changed over time as certain therapies prove more or less effective, or as changes behavior warrant other focuses in treatment.

Preparing for a Career as an Applied Behavior Analyst in Geriatrics

Applied behavior analysts working in gerontology are almost uniformly required to hold advanced degrees. A master’s degree or higher in psychology or applied behavior analysis will provide the best educational basis.

Most positions in hospitals or nursing homes for ABAs require that applicants possess a BCBA® (Board Certified Behavior Analyst) certification from the BACB. Earning this certificate requires a master’s or doctoral degree, together with practical experience and relevant coursework, all validated by a national test. Some employers will hire applicants who have not yet received, but who are working toward, their BACB.

A medical background, such as an undergraduate degree in biology, psychology, gerontology, or pre-medicine can also be helpful in preparing for a job in behavioral gerontology. Some colleges offer a specific focus in gerontology in behavioral science bachelor’s programs.

Many hospitals and long-term care facilities have volunteer opportunities open to individuals who want to gain some experience in the field prior to embarking on a degree program. Although these positions might not directly involve applications of applied behavior analysis, they do offer good exposure to the environment and patient populations you would end up working with as a behavioral gerontologist.

A background check is almost always required for work with elderly populations, so maintaining a clean criminal record is of paramount importance.

Further Reading in Behavioral Gerontology

American Psychological Association Mental and Behavioral Health Issues in Older Americans – A compendium of issues, studies, and treatments researched by the APA found in the care of geriatric populations.

Behavior-Analytic Research on Dementia in Older Adults – A review of studies and publications in scientific literature relating to applied behavior analysis as applied to dementia cases.

Top Behavior Problems of Elderly Parents – An overview of common behavioral issues in older adults.

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