The use of behavioural reinforcement in the management of behaviours of concern associated with dementia.
Introduction People with dementia often require high-level care due to behaviours that are associated with dementia such as verbal and physical aggression. Behavioural therapies that utilise approaches such as behavioural reinforcement are one possible strategy to manage such behaviours.Aims The objective of this review was to synthesise the best available evidence in relation to the use of behavioural reinforcement in the management of behaviours associated with dementia.


METHODS
Types of participants Participants were adults aged over 60 years who had a clinical diagnosis of dementia and who exhibited any of the following behaviours associated with dementia e.g. verbal and physical aggression, vocalisations and wandering.Types of intervention Any behaviour therapy modality that used reinforcement techniques was considered.Types of outcomes The outcome of interest was a change in the behaviour associated with dementia.Types of studies Any quantitative or qualitative study designs were considered. In the absence of high quality studies, designs such as case series were considered.Search strategy The search strategy aimed to find both published and unpublished studies using a three-step approach. Papers were limited to the English language and a date restriction of 1990 to 2009 was set.
Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Disagreements that arose between the reviewers were resolved through discussion.Data extraction Quantitative data was extracted from papers included in the review using a standardised data extraction tool.Data synthesis Only quantitative papers met the review's inclusion criteria and were subsequently included. Due to the heterogeneity in the study design, populations, interventions and outcomes of papers, meta-analyses could not be undertaken. A narrative summary of each paper is thus provided.Results Only five papers were included; one repeated measures quasi-experimental study, three case series and one case report. Priority was given to the quasi-experimental study due to its design and quality score. The methodological quality of the other papers was weak. In total only eleven subjects were included that focussed on different schedules of reinforcement and different behaviours. The quasi-experimental study did not demonstrate significant results between presenting a visual stimulus continuously or intermittently and wandering. The preliminary evidence from the case series/report all reported a reduction in the undesirable behaviour following implementation of a reinforcement method.Conclusions Due to the evidence currently available, the utilisation of reinforcement approaches to assist in reducing or eliminating behaviours associated with dementia can be neither recommended nor refuted.Implications for practice There is weak evidence to suggest that implementing a reinforcement schedule may reduce behaviours such as physical or verbal aggression and vocalisations. The evidence for wandering is equivocal. Making a decision to utilise this type of behavioural approach should be based on clinical judgement, the preference of the patient or family and the context in which the care is delivered.Implications for research Due to the limited available evidence on this topic that can only provide weak empirical evidence, further experimental investigations such as controlled trials should be conducted to test the hypothesis that reinforcement strategies may assist in reducing or eliminating behaviour/s associated with dementia.
1. Ms Cindy Stern BHSc(Hons) PhD Candidate, Research Fellow - The Joanna Briggs Institute, University of Adelaide, Australia 2. Professor Heather Gibb RN BA(Hons) MPsych, PhD, The Joanna Briggs Institute, University of Adelaide, Australia.
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