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Increasing Activity Attendance and Engagement in Individuals with Dementia Using Descriptive Prompts

February 2008
Journal of Applied Behavior Analysis 41(2):273-7

DOI:10.1901/jaba.2008.41-273

Source
PubMed

Authors:

Kim A. Schulze

St. Cloud State University

John T. Rapp

Auburn University

The effects of providing descriptive prompts to increase activity attendance and engagement in 6 individuals with dementia were evaluated using a reversal design. The results showed that providing descriptive prompts increased activity attendance and engagement for all participants. The results support the use of antecedent interventions for increasing appropriate behavior by individuals with dementia.

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INCREASING ACTIVITY ATTENDANCE AND ENGAGEMENT IN

INDIVIDUALS WITH DEMENTIA USING DESCRIPTIVE PROMPTS

HASTA BRENSKE,ERIC H. RUDRUD,KIMBERLY A. SCHULZE, AND JOHN T. RAPP

ST. CLOUD STATE UNIVERSITY

The effects of providing descriptive prompts to increase activity attendance and engagement in 6

individuals with dementia were evaluated using a reversal design. The results showed that

providing descriptive prompts increased activity attendance and engagement for all participants.

The results support the use of antecedent interventions for increasing appropriate behavior by

individuals with dementia.

DESCRIPTORS: attendance, dementia, descriptive prompts, engagement, stimulus control

_______________________________________________________________________________

Friman (2006) recently noted that the

Journal of Applied Behavior Analysis contained

only a handful of studies on geriatric issues such

as interventions for individuals who suffer from

dementia. Because the National Center for

Health Statistics reported that approximately

40% of individuals who were admitted to

nursing homes had a diagnosis of Alzheimer’s

disease or other disorders characterized by

dementia ( Jones, 2002), additional studies on

this topic are clearly warranted.

Common problem behaviors exhibited by

nursing home residents who have been diag-

nosed with dementia and related disorders

include physical aggression, wandering, han-

dling objects inappropriately, repetitive vocaliz-

ing, cursing, and screaming (Cohen-Mansfield,

2001; McCarthy, Blow, & Kales, 2004). Ice

(2002) observed 27 nursing home residents for

13 hr per day and found that as a group they

spent 65% of their time doing ‘‘little or

nothing’’ and only 12% of their time engaged

in social activities. Similarly, Kuhn, Fulton, and

Edelman (2004) and Shore, Lerman, Smith,

Iwata, and DeLeon (1995) found low activity

levels among individuals with dementia who

resided in nursing homes. Kuhn et al. suggested

that nursing home residents with dementia may

be at a higher risk for understimulation because

they lack the initiative to begin or sustain leisure

activities. From an operant perspective, low

activity engagement by individuals with demen-

tia may be the result of weak stimulus control of

activities. Specifically, as a function of neuro-

logical changes, some stimuli, such as verbal

instructions or the sight of activities, may no

longer evoke appropriate behavior even though

reinforcement for such behavior is still available.

Engelman, Altus, and Mathews (1999) found

that prompts, contingent praise, and opportu-

nities to choose increased the daily living

activities of several individuals with dementia.

However, it is possible that prompts alone may

have increased participants’ engagement in

appropriate activities. The purpose of the

current study was to extend the results of

Engelman et al. by evaluating the effects of an

antecedent intervention that involved descrip-

tive prompts for increasing activity engagement

by individuals with dementia.

METHOD

Participants, Setting, and Materials

Six individuals (5 men and 1 woman)

ranging from 57 to 87 years of age who had

been diagnosed with dementia participated in

this study. Three ambulated independently, 2

ambulated with the assistance of a wheelchair,

This study was completed in partial fulfillment of a

Masters degree in Behavior Analysis by the first author at

Saint Cloud State University, St. Cloud, Minnesota.

Address correspondence to John T. Rapp, Educational

Leadership and Community Psychology, St. Cloud State

University, 720 Fourth Avenue S, St. Cloud, Minnesota

56301 (e-mail: jtrapp@stcloudstate.edu).

doi: 10.1901/jaba.2008.41-273

JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2008, 41, 273–277 NUMBER 2(SUMMER 2008)

273

and 1 required complete staff assistance for

mobility. The study took place in a 403-bed

nursing care facility. Observations were con-

ducted in a room that contained five tables and

approximately five chairs.

The targeted activities included engagement

with playing cards, an art kit, drawing paper,

bridge, puzzles, crosswords, bean bag toss, a ball

to play catch, table air hockey, mini handheld

games, battery operated blackjack, Connect

Four, mental mind teasers, magazines, and a

book with classic movie pictures. Activities were

chosen based on a brief preference questionnaire

that had been completed for each participant

prior to the implementation of baseline. The

questionnaire consisted of a list of 22 items that

were identified verbally by each participant as

either preferred or nonpreferred. The items

chosen for the preference assessment were based

on recommendations from the recreation ther-

apist and item availability.

Target Behavior and Interobserver Agreement

For each participant, the dependent variables

were presence and engagement. Presence was

scored when a participant was in the designated

activity room and standing or sitting within

1 m of any activity. Engagement was defined as

any of the following: talking with another

person in the room, manipulation of an activity

item (e.g., holding a pen to write, lifting a bean

bag to throw) or waiting for a turn in a game

with another person. For a participant to be

considered waiting for a turn, that participant

had to be (a) within 1 m of another individual

and an activity, (b) visually oriented toward the

activity, and (c) speaking with another partic-

ipant who was either currently or was recently

engaged in the activity during the previous

interval. Engagement was scored only if an

individual also was present in the activity room.

Presence and engagement were measured

concurrently, using 1-min momentary time

sampling (with paper and pencil) during 40-

min sessions. Vibrating pagers prompted the

observers to collect data at the beginning of each

interval. Each participant was observed for

approximately 3 s. If a participant was not

present, it generally took 1 s to identify the

absence and 1 s to record it. Subsequently, the

observer waited an additional second and then

observed the next person in a predetermined

sequence. The mean percentage of intervals in

which individuals were present was calculated

based on the number of participants in the study

who were present within the facility. The

percentage of intervals in which participants

were physically present in the activity room was

calculated by totaling the numbers of intervals

present, dividing by the total number of intervals

(40), and then multiplying by 100%. The

percentage of intervals in which participants

were engaged was calculated by totaling the

number of intervals engaged and dividing by the

number of intervals scored as present and then

multiplying by 100%. For both dependent

measures, interobserver agreement was calculated

by dividing the total number of agreements by

the total number of agreements plus disagree-

ments and multiplying by 100%. Interobserver

agreement was assessed for 27% of baseline and

42% of treatment conditions; scores were 97%

or higher across conditions for each participant.

Experimental Design and Procedure

A reversal (ABAB) design was used to

evaluate the effects of descriptive prompts on

participants’ presence in the activity room and

the effects of low-frequency prompts on

engagement with activities. Observations took

place on weekdays from approximately 4:00

p.m. to 5:00 p.m. During baseline, activities

were arranged in the designated activity room.

The same activities were available across all

sessions. Each participant was asked if he or she

knew the location of the room and was then

given a general prompt to attend the activity

room (e.g., ‘‘there are activities in the room by

the elevators’’). Assistance was offered to

individuals who could not ambulate indepen-

dently. Individuals were not awakened if they

were sleeping during the activity period. Each

274 SHASTA BRENSKE et al.

participant missed two or more scheduled

sessions across phases (M 5 4; range, 2 to 7)

because he or she was either sleeping or absent

from the facility grounds. For each session, data

collection began 2 min after the last participant

was given the general prompt. The available

activities were described to participants after

they entered the room. Participants were

informed that they could leave the activity

room at any time, and no subsequent prompts

were provided. If a participant inquired about

an activity, he or she was told, ‘‘You should do

that on your own.’’

During the descriptive prompts condition,

sessions were the same as in baseline except that

if the general prompt did not evoke a

commitment to attend (e.g., the participant

saying, ‘‘yes, I am coming’’), a descriptive

prompt was delivered. A descriptive prompt

involved a specific description of one or more of

the available activities that was known to be of

interest to the individual based on either the

preference questionnaire or engagement in an

activity during a previous session (e.g., an

experimenter saying, ‘‘Are you sure you won’t

go? There will be crossword puzzles.’’). Indi-

viduals who were dependent on staff assistance

for mobilization were assisted to the activity

room only after they verbally committed to

attend. These procedures were repeated later for

any participant who was not present at the

midpoint of each session. After entering the

activity room, if a participant did not chose an

activity within 2 min, staff modeled engage-

ment in a specific activity and then provided a

verbal prompt for the individual to engage in

that activity. Staff provided one brief (10 to

15 s) statement of praise (e.g., ‘‘You are really

good at that game!’’) to each participant

contingent on engagement during each descrip-

tive prompt session.

RESULTS AND DISCUSSION

Figure 1 shows the percentage of intervals

during which the participants were present and

engaged with activities. During the initial

baseline, presence (M 5 17%) was low and

activity engagement (M 5 78%) was decreasing

across sessions. Following the introduction of

descriptive prompts, presence (M 5 75%) and

engagement (M 5 92%) increased. The

removal of descriptive prompts decreased both

presence (M 5 17%) and engagement (M 5

44%) to prior baseline levels. Finally, the

reintroduction of descriptive prompts again

increased both presence (M 5 69%) and

engagement (M 5 79%). (The results for

individual participants are available from the

fourth author.)

The results of the current study suggest that

descriptive prompts increased the number of

individuals in areas furnished with activities and

the amount of time each engaged with those

activities. Although praise was delivered during

each session (once to each participant) contin-

gent on activity engagement, it is unlikely that

such a thin schedule of reinforcement supported

each participant’s activity engagement. Instead, it

is more probable that descriptive prompts evoked

behavior that ultimately contacted natural sourc-

es of reinforcement generated by engagement

with the activities, engagement with other

individuals, or both. Alternatively, it is possible

that descriptive prompts functioned as an

establishing operation for stimulation produced

by the specified activity. For example, hearing a

staff person say ‘‘there are crossword puzzles’’

may have established crossword puzzles as a

reinforcer and thereby evoked behavior that

historically produced access to crossword puzzles

(i.e., walking to the room by the elevators).

Regardless of the mechanism responsible for the

behavior change observed in this study, the

results extend those of Engelman et al. (1999) by

showing that providing descriptive prompts,

with limited programmed reinforcement, in-

creased the presence of individuals in the activity

room and engagement with activities.

Some limitations to this study should also be

noted. First, prior to the intervention, very few of

INCREASING ACTIVITY ATTENDANCE 275

Figure 1. The percentage of intervals during which participants were present (top) and engaged in an activity

(bottom) across phases.

276 SHASTA BRENSKE et al.

the participants entered the activity area. Thus, it

is possible that participants’ engagement with

activities would have increased if the intervention

had simply increased participants’ attendance to

the activity area. Second, data on the occurrence

of appropriate social interactions (i.e., talking

with other participants) during the activity

sessions were not collected. Third, follow-up

data were not collected to evaluate the continued

use of descriptive prompts by staff or the transfer

of stimulus control to a general prompt. Finally,

although descriptive prompts increased engage-

ment during the course of this investigation, it is

possible that the evocative effects of those

prompts may have diminished across time if

the participants’ dementia worsened.

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Received February 7, 2007

Final acceptance June 26, 2007

Action Editor, Henry Roane

INCREASING ACTIVITY ATTENDANCE 277

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Trends in research Association for Behavior Analysis International Newsletter

Jan 2006
4-5

P C Friman

Friman, P. C. (2006). Trends in research. Association for Behavior Analysis International Newsletter, 29, 4–5.

Increasing Activity Attendance and Engagement in Individuals with Dementia Using Descriptive Prompts

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