Scandinavian Journal of Psychology, 1990, 31,2-8
The effect of prompting and reinforcement of activity in elderly demented inpatients K. GUNNAR GOTESTAM' and LENNART MELIN? 'Department of Psychiatry and Behavioural Medicine, and University of Trondheim, 0stmarka Hospital, Trondheim, Norway, 'Department of Clinical Psychology, University of Uppsala, Uppsala, Sweden
Gotestam, K. G. & Melin, L. (1990).The effect of prompting and reinforcement of activity in elderly demented inpatients. Scandinavian Journal of Psychology, 31, 2-8.
On a ward for 24 psychogeriatric patients, 18 were randomly assigned to three groups with different experimental conditions. The first group was prompted and reinforced for different activities; the second was only prompted; and the third served as a control group. Activities, both the trained ones and others, were continuously monitored throughout the five week study. The results showed a clear increase in the trained activities after training. The prompting condition was effective, and the addition of reinforcement did not add any to the effects. There was no generalization to untrained activities, and the effects did not last at the 1 hr or 21 hr assessments, but was clearly visible at 5 min after training. Time seemed to be more important than place, i.e. the effect ceased with elapsed time, not because of changes in the situation. Key wordr: Activity, demented patients, prompting, reinforcement, reality orientation. K. Gunnar Gotestam, Department of Psychiatry and Behavioural Medicine, University of Trondheim, P. 0 . Box 3008 Lade, N-7002 Trondheim, Norway.
Among chronic psychogeriatric patients, persons with dementia (including both Alzheimer type senile dementia based on cerebral atrophy, and multi-infarct dementia based on cerebral athero-sclerosis) is the most common group. The main symptoms are memory impairment and reduced reality orientation, which may severely handicap the patients' ability to take care of themselves. As therapeutic means are lacking, these symptoms are seen as irreversible, and the staff is obliged to take care of all of the patients' needs and functions. This is a severe problem, both in psychogeriatric wards, and in nursing homes, as well as in homes for the aged. As part of the pessimistic view on the work with these patients, geriatric patients in mental institutions are generally considered to be hopeless cases, and apart from medical care they seldom receive any specific treatment. Some recent studies have shown the effect of different psychological approaches (see Gotestam, 1980). The effect of environmental cues for communication and reality orientation was early appreciated by Cameron (1941) and later by Sommer & Ross (1958). During the last decades, several authors have reported improvements in the behaviour of geriatric patients by use of psychological treatment techniques (Volpe Sr Kastenbaum, 1967; Sommer, 1969; MacDonald & Butler, 1974; McClannahan & Risley, 1975; Melin & Gotestam, 1981). A review of studies, both on psychotherapy, and on mileu therapy in a broader sense than usual has been made by Gotestam (1980). Reality orientation is a common name for different training programmes to counteract the deterioration in both temporal and spatial orientation, as well as orientation to other persons. Few studies have empirically investigated improvements in reality orientation (for a review see Holden &Woods, 1982), and when studied, it has been difficult to distinguish between the effect of training and the effect of environmental cues or support (Gotestam, 1987). The present study was performed to study and compare the effects of two different
Scand J Psycho1 31 (1990)
Reinforcement of activity in dementia
approaches to increase activity; prompting alone, or prompting plus reinforcement. Also, the study included differential testing of the generalization of the gains both spatially and temporally.
METHODS Ward and patieno The ward had 24 patients in 4-bed, 2-bed, and single rooms. Six patients were excluded because they had reduced mobility, thus 18 patients participated in the study. Twelve were demented, either with (a) senile dementia Alzheimer type (n=6), (b) multi-infarct dementia ( 5 )or (c) presenile dementia (I), whereas (d) six suffered from chronic schizophrenia. Their main age was 78.0 (Group 1: 80.8,2: 78.5,3: 74.8) years, with the mixed demented sample having a mean age of 82.7 and the schizophrenic sample a mean age of 40.4. The mean time of hospitalization for the total sample was 15.5(Group 1: 9.5,2: 18.2,3: 18.7) (mixed demented sample 2.7, schizophrenic sample 40.4) years. None of the patients could attend to their own hygiene and toilet behaviours, and about half of them were fed by the staff. The staff consisted of one head nurse, one nurse and 12 attendants. During the day, the staff-patient ratio was 0.33.
Assessment According to a sampling procedure described by Schaefer and Martin (1969), four different specified activities were recorded daily at three occasions (5 min, 1 hr and 21 hr after training), in a situation which was different from the training situation. All four activities were observed in each patient for 15 sec for a total of four periods (i.e. 1 min) for each of the three occasions.
Design The patients were randomly assigned to three different groups (N=8 in each, two schizophrenia in each group) two treatment and one untreated control group. The two treatment groups were then systematically trained according to a replication (ABABA) design, where baseline conditions were repeated three times for one week each (A phases), and one treatment was instituted during Week 2 ( B l ) and another during Week 4 (B2).
Procedure The experiment started with dispersing activity material on the ward. The first group received prompting and reinforcement (reinforcement only during week 2) for certain activities (see below), the second group received only prompting, and the third group served as a control group. Four activities were selected for intervention. During Week 2, Activity 1 and 2 were prompted and reinforced or prompted only. During Week 4 Activity 3 and 4 were prompted for the two experimental groups. All other conditions included only exposure to activity material and baseline assessments.
Activity training The four activities selected for intervention were (1) Communication, (2) Writing and drawng, (3) Reading papers and books, and ( 3 ) Playing card games. The training was performed in a special room on the ward, five days a week in a 20 min training session. All training was performed in that room, and to minimize distraction the door was shut to the rest of the ward. The patients in Group 1 and 2 were cued to the activities mentioned above by a combination of verbal and physical prompts. The prompting was individualized, but was varied in relation to ongoing activities on the ward, as the activities chosen were specifically selected for the study. No attempts in fading the prompting over time were made. The patients in Group 1were (only during week 2) contingent upon appropriate behaviours during the session reinforced verbally and by goodies. Immediately after the prompting session they received coffee and a cake as a reinforcer. These types of reinforcers used were normally occumng on the ward. The other groups did not receive reinforcers during the session (the trainers were quite neutral in their verbal comments on activity), and to avoid confounding they had to wait for the ordinary coffee on the ward about one hour after the session.
Statistics and reliability Statistical analyses were performed with dependent f-tests for intragroup comparisons and independent f-tests for intergroup comparisons.
3
4
K. G. Gotestam and L. Melin
Scand J Psycho131 (1990)
Interrater reliabilities for two graduate students who served as raters were calculated at three time points in the study. The reliability was 1.00 in the beginning, 0.96 in the middle and 0.96 at the end of the study.
RESULTS
Effect of training Fig. 1shows the level 5 min after training during the two intervention weeks (Week 2 and 4)of trained activities (Communication, writing and drawing during Week 2 ; Reading and playing
ACTIVITY 1 AND 2 PROMPT X 42
02
43
60
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10
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21
A
25
DAYS
ACTIVITY 3 AND 4 PROMPT X
PROMPT(+Rfl
0
100
m a 0
80
cf 60
Y I-
$ 40 u
B a
20 0
0
5
10
20
25
DAYS.
Fig. 1. Daily (fromfive days a week) activity levels 5 min after training in the three different experimental conditions (prompting and reinforcement, only prompting, control group) for Activity 1(communication) and 2 (writingand drawing) (Panel A), and Activity 3 (reading) and 4 (playing card games) (Panel B). The figureshows thesumoftwo activities(l+2inPanelA,3+4inPanelB). During Week4bothexperimental groups received only prompting. Therefore Group 1is indicated with “Prompt(+Rf)”. The symbols used often occur in combinations, as several points fall on the same spot.
Scand J Psycho1 31 (1990)
Reinforcement of activity in dementia
card games during Week 4). The day to day time course of the different activities is also shown in Fig. 1 (Fig. la: Activity 1+2; Fig. l b : Activity 3+4). The total activity was calculated as proportion of total activity possible with the assessment technique employed. There was a significant difference between the two treatment groups on one side and the control group on the other, during both Week2 ( ~ 2 . 6 0t=3.05,p
The effect of prompting and reinforcement of activity in elderly demented inpatients K. GUNNAR GOTESTAM' and LENNART MELIN? 'Department of Psychiatry and Behavioural Medicine, and University of Trondheim, 0stmarka Hospital, Trondheim, Norway, 'Department of Clinical Psychology, University of Uppsala, Uppsala, Sweden
Gotestam, K. G. & Melin, L. (1990).The effect of prompting and reinforcement of activity in elderly demented inpatients. Scandinavian Journal of Psychology, 31, 2-8.
On a ward for 24 psychogeriatric patients, 18 were randomly assigned to three groups with different experimental conditions. The first group was prompted and reinforced for different activities; the second was only prompted; and the third served as a control group. Activities, both the trained ones and others, were continuously monitored throughout the five week study. The results showed a clear increase in the trained activities after training. The prompting condition was effective, and the addition of reinforcement did not add any to the effects. There was no generalization to untrained activities, and the effects did not last at the 1 hr or 21 hr assessments, but was clearly visible at 5 min after training. Time seemed to be more important than place, i.e. the effect ceased with elapsed time, not because of changes in the situation. Key wordr: Activity, demented patients, prompting, reinforcement, reality orientation. K. Gunnar Gotestam, Department of Psychiatry and Behavioural Medicine, University of Trondheim, P. 0 . Box 3008 Lade, N-7002 Trondheim, Norway.
Among chronic psychogeriatric patients, persons with dementia (including both Alzheimer type senile dementia based on cerebral atrophy, and multi-infarct dementia based on cerebral athero-sclerosis) is the most common group. The main symptoms are memory impairment and reduced reality orientation, which may severely handicap the patients' ability to take care of themselves. As therapeutic means are lacking, these symptoms are seen as irreversible, and the staff is obliged to take care of all of the patients' needs and functions. This is a severe problem, both in psychogeriatric wards, and in nursing homes, as well as in homes for the aged. As part of the pessimistic view on the work with these patients, geriatric patients in mental institutions are generally considered to be hopeless cases, and apart from medical care they seldom receive any specific treatment. Some recent studies have shown the effect of different psychological approaches (see Gotestam, 1980). The effect of environmental cues for communication and reality orientation was early appreciated by Cameron (1941) and later by Sommer & Ross (1958). During the last decades, several authors have reported improvements in the behaviour of geriatric patients by use of psychological treatment techniques (Volpe Sr Kastenbaum, 1967; Sommer, 1969; MacDonald & Butler, 1974; McClannahan & Risley, 1975; Melin & Gotestam, 1981). A review of studies, both on psychotherapy, and on mileu therapy in a broader sense than usual has been made by Gotestam (1980). Reality orientation is a common name for different training programmes to counteract the deterioration in both temporal and spatial orientation, as well as orientation to other persons. Few studies have empirically investigated improvements in reality orientation (for a review see Holden &Woods, 1982), and when studied, it has been difficult to distinguish between the effect of training and the effect of environmental cues or support (Gotestam, 1987). The present study was performed to study and compare the effects of two different
Scand J Psycho1 31 (1990)
Reinforcement of activity in dementia
approaches to increase activity; prompting alone, or prompting plus reinforcement. Also, the study included differential testing of the generalization of the gains both spatially and temporally.
METHODS Ward and patieno The ward had 24 patients in 4-bed, 2-bed, and single rooms. Six patients were excluded because they had reduced mobility, thus 18 patients participated in the study. Twelve were demented, either with (a) senile dementia Alzheimer type (n=6), (b) multi-infarct dementia ( 5 )or (c) presenile dementia (I), whereas (d) six suffered from chronic schizophrenia. Their main age was 78.0 (Group 1: 80.8,2: 78.5,3: 74.8) years, with the mixed demented sample having a mean age of 82.7 and the schizophrenic sample a mean age of 40.4. The mean time of hospitalization for the total sample was 15.5(Group 1: 9.5,2: 18.2,3: 18.7) (mixed demented sample 2.7, schizophrenic sample 40.4) years. None of the patients could attend to their own hygiene and toilet behaviours, and about half of them were fed by the staff. The staff consisted of one head nurse, one nurse and 12 attendants. During the day, the staff-patient ratio was 0.33.
Assessment According to a sampling procedure described by Schaefer and Martin (1969), four different specified activities were recorded daily at three occasions (5 min, 1 hr and 21 hr after training), in a situation which was different from the training situation. All four activities were observed in each patient for 15 sec for a total of four periods (i.e. 1 min) for each of the three occasions.
Design The patients were randomly assigned to three different groups (N=8 in each, two schizophrenia in each group) two treatment and one untreated control group. The two treatment groups were then systematically trained according to a replication (ABABA) design, where baseline conditions were repeated three times for one week each (A phases), and one treatment was instituted during Week 2 ( B l ) and another during Week 4 (B2).
Procedure The experiment started with dispersing activity material on the ward. The first group received prompting and reinforcement (reinforcement only during week 2) for certain activities (see below), the second group received only prompting, and the third group served as a control group. Four activities were selected for intervention. During Week 2, Activity 1 and 2 were prompted and reinforced or prompted only. During Week 4 Activity 3 and 4 were prompted for the two experimental groups. All other conditions included only exposure to activity material and baseline assessments.
Activity training The four activities selected for intervention were (1) Communication, (2) Writing and drawng, (3) Reading papers and books, and ( 3 ) Playing card games. The training was performed in a special room on the ward, five days a week in a 20 min training session. All training was performed in that room, and to minimize distraction the door was shut to the rest of the ward. The patients in Group 1 and 2 were cued to the activities mentioned above by a combination of verbal and physical prompts. The prompting was individualized, but was varied in relation to ongoing activities on the ward, as the activities chosen were specifically selected for the study. No attempts in fading the prompting over time were made. The patients in Group 1were (only during week 2) contingent upon appropriate behaviours during the session reinforced verbally and by goodies. Immediately after the prompting session they received coffee and a cake as a reinforcer. These types of reinforcers used were normally occumng on the ward. The other groups did not receive reinforcers during the session (the trainers were quite neutral in their verbal comments on activity), and to avoid confounding they had to wait for the ordinary coffee on the ward about one hour after the session.
Statistics and reliability Statistical analyses were performed with dependent f-tests for intragroup comparisons and independent f-tests for intergroup comparisons.
3
4
K. G. Gotestam and L. Melin
Scand J Psycho131 (1990)
Interrater reliabilities for two graduate students who served as raters were calculated at three time points in the study. The reliability was 1.00 in the beginning, 0.96 in the middle and 0.96 at the end of the study.
RESULTS
Effect of training Fig. 1shows the level 5 min after training during the two intervention weeks (Week 2 and 4)of trained activities (Communication, writing and drawing during Week 2 ; Reading and playing
ACTIVITY 1 AND 2 PROMPT X 42
02
43
60
Y
a b 6
/
10
I!
21
A
25
DAYS
ACTIVITY 3 AND 4 PROMPT X
PROMPT(+Rfl
0
100
m a 0
80
cf 60
Y I-
$ 40 u
B a
20 0
0
5
10
20
25
DAYS.
Fig. 1. Daily (fromfive days a week) activity levels 5 min after training in the three different experimental conditions (prompting and reinforcement, only prompting, control group) for Activity 1(communication) and 2 (writingand drawing) (Panel A), and Activity 3 (reading) and 4 (playing card games) (Panel B). The figureshows thesumoftwo activities(l+2inPanelA,3+4inPanelB). During Week4bothexperimental groups received only prompting. Therefore Group 1is indicated with “Prompt(+Rf)”. The symbols used often occur in combinations, as several points fall on the same spot.
Scand J Psycho1 31 (1990)
Reinforcement of activity in dementia
card games during Week 4). The day to day time course of the different activities is also shown in Fig. 1 (Fig. la: Activity 1+2; Fig. l b : Activity 3+4). The total activity was calculated as proportion of total activity possible with the assessment technique employed. There was a significant difference between the two treatment groups on one side and the control group on the other, during both Week2 ( ~ 2 . 6 0t=3.05,p
