17: Managing Difficult Behaviors

• Preventing and managing defficult behaviours

• There are no easy answer when its comes to the care of another
• Our hope is to offer you useful information and guidelines for caring for someone with dementia
• These guidelines will need to be adjusted to suit your own individual needs

VERBALLY NON AGGRESSIVE

• Complaining
• Negativism
• Repetitive questions
• Constant requests for help

VERBALLY AGGRESSIVE

• Cursing
• Making distressed noises
• Verbal sexual advances
• Screaming

PHYSICALLY NON AGGRESSIVE

• Disrobing
• Eating inappropriate things
• Handling or moving items
• Wandering
• Hoarding
• Hiding

PHYSICALLY AGGRESSIVE

• Physical sexual advances
• Hurting self or others
• Throwing items
• Grabbing, pushing and hitting
• Spitting, kicking and biting
• “Is there a need or reason that explains the behavior even if not apparent to the observer?”
• All behavior has meaning, and it is the caregiver’s responsibility to figure out that meaning
• Pain, distress, fatigue, thirst, hunger, toileting needs, constipation, fever, medication issue, and infection or other medical issue
• Address needs before difficult behaviors occur or escalate
• The person is not intentionally being difficult — It is the disease, not the person, causing the behavior

• Identify specific problem behaviors and design specific interventions
• Set appropriate and realistic goals
• Make ongoing assessments and adjustments
• Try new and creative approaches
  • Environments
  • Care routines
  • Activities
  • Diet
  • Family programs
  • Staff training
• Combination of medication and behavior approaches
• Use flexible problem-solving to prevent problems
  • Anticipate needs
• Develop “person-centered” strategies

• Individualizes the care to the person’s wants, needs and values
• Considers the person’s past life experiences and roles, preferred habits and routines, cultural norms, expectations, and spiritual preferences
• Builds upon the person’s retained skills and capacities
• Validation promotes the belief that each and every individual has value
• Know the person’s life history
• Use empathy to build trust, reduce anxiety and promote dignity

• Reducing the person’s frustration and fear can prevent difficult behaviors
• Engage the person
• Be pleasant and supportive
• Reduce clutter
• Remove potential threats
• Create a comforting environment
• Play favorite music
• Use relaxing fragrances
• Essential oil of lemon balm (melissa officinalis)
• Lavender oil (lavandula angustifolia, formerly lavender officinalis)
• Get to know people and what might trigger their fear or frustration
• Observe behavior and other non-verbal messages to know their mood and levels of stress and anxiety
• Simplify and slow down activities

SAFE PHYSICAL ENVIRONMENT

• Safe from wandering away from home
• Safe from injuries, poisons, falls, and sharp objects

SAFE HUMAN ENVIRONMENT

• Safe from physical or emotional abuse
• Safe medical care
• Feeling secure in the physical and human environments
• Familiar people, objects, sounds, smells, and familiar routines
• Look for subtle signs of discomfort
• Play preferred music and provide relaxing aromas
• Provide calm and reassuring human support
• Minimize exposure to complex, noisy, or unfamiliar environments

COMFORT

• Check frequently for needs
• Try to anticipate needs and meet them
• Provide clean, comfortable clothing occasion that is easy to manage
• Offer layers of clothing
• Set the thermostat at a comfort temperature for them

• Show love and respect
• Respect privacy and modesty
• Respect the person’s comfort level for affection and touch
• These attributes should be encouraged
• Support the person’s retained capacities
• provide guidance at the individual’s level of abilities without taking over

• How one says something is just as important as what is said
• Use clear, simple sentences
• Use familiar language with only one message in a sentence
• Say the important word last
• Use relaxed, pleasant inflections and tone of voice
• Project a joyful attitude

• Present Information in one or two phrases at a time
• Break down instructions into simple steps
• Providing only small pieces at a time are less likely to cause confusion or stress
• Use redirection or distraction
• Introduce a positive topic or activity

• The capacity to understand body language persists longer than the capacity to understand words
• Facial expressions, body posture, and gestures will override the words you use
• Body language should match your words
• Use reassuring words with a smile, gentle tone of voice, and comforting gestures in a non-threatening posture

• Tune in to what people are trying to say and be patient
• Respect their attempt to communicate even if facts and grammar are wrong
• Avoid logical discussions and disagreements
• Focus on feelings and intent
• Listen attentively and show interest
• Engage with people
• Get the individual’s attention by sitting close and making eye contact
• Say the person’s name and wait for a response
• Introduce yourself to the person
• Check for signs of understanding versus distress before acting
• Match your facial expressions and body language with your words

• Fear and frustration associated with ADLs are the source of most difficult behaviors
• Approach assisting with ADLs with understanding, respect, and compassion
• Assisting someone in pleasant, meaningful activities can help prevent difficult behaviors
• Productive and pleasant occupations
• Physical exercise
• Modify activities to promote autonomy and increase the likelihood of success

• Reverse development retrogenesis: functional abilities are lost in the reverse order that they were gained
• Understanding this concept is very useful in explaining behaviors and in developing ways to handle them
• Call upon their own experiences to understand and address the behaviors
• Towards the end of the early stages of Alzheimer’s, a person may be functionally similar to a 7 to 12 yr old child

• The middle stages of Alzheimer’s is functionally similar to a 4 to 5 year old child
• The late or terminal stage of Alzheimer’s is functionally similar to an infant
• Some of the approaches used on children may work on adults with Alzheimer’s
• Knowing about reverse development will help you to understand what is going on and may relieve some of your own frustration

• Alzheimer’s disease lowers the person’s tolerance for stress (stress threshold)
• React in more primitive ways, such as lashing out, wandering, pacing, or combativeness
• The caregiver’s job is to look for signs that people are approaching their stress threshold
• Look for signs that people are approaching their stress threshold
• Restlessness, pacing, tense facial expressions, irritability, calling out, scratching, or hand wringing
• Reduce their stress before it results in agitation behaviors
• Use exercise
• Taking a break
• Redirect to relaxing activities
• Use relaxing fragrances
• Essential oil of lemon balm (also known as Melissa oil)
• Lavender oil
• Play favorite soothing music

Click here to learn more about Progressively Lowered Stress Threshold (PLST)

• Always keep in mind your safety as well as that of others
• Do not confront the person
• Do not touch the person during the angry outburst
• Give people time and space to be angry by themselves
• Watch to make sure they do not cause harm to themselves or others
• Wait until it is safe to approach them
• Approach with a calm manner
• In general, restraints are not the best approach
• Lap-top tables may be used occasionally to prevent a person from getting up or falling during activities
• Be patient and try your best

Difficult behavior categories

• Behavior excesses
• Behavior deficits

Managing behavior excesses

• Redirecting: refocus someone’s attention on a positive topic or activity
• Withdrawing attention
• Offer a pleasant activity
• Change the environment
• Provide a positive, meaningful interaction

• Withdrawing attention (cont’d)
• Ignore the difficult behavior, not the person
• Reward positive behaviors and show value to the person with attention, and withdraw attention during negative behavior excesses
• Attention and positive interactions should be provided throughout the day
• People should not have to resort to negative behavior to get attention

TYPES OF WANDERING

• Purposeful
• Escapist
• Aimless
• Searching
• Modeling

STRATEGIES FOR MANAGING WANDERING

• Modify the environment to provide safe areas
• Provide points of interest
• Plan mini-breaks or rest periods.
• Provide comfortable, safe shoes
• Offer regular hydration and trips to the toilet.
• Offer activities
• Orient and reassure the person if she or he is confused
• Place a locator device or wanderer alert device on the person
• Enroll the person in the Safe Return^® Program
  Click here to learn about the Safe Return^® Program

• Strategies for managing rummaging or gathering
• Set up rummaging boxes
• Designate drawers for rummaging
• Set out purses or a briefcase
• Create a packet of cards, letters, or papers
• Exclude any dangerous objects
• Provide a “safe” place for storing items
• Help the person find what they are looking for
• Redirect to an activity that the person enjoys doing that uses similar repetitive motions

• Apathy is a dulled emotional state characterized by indifference, diminished initiative, poor persistence and interest in activities, low social interaction, blunted emotional response, and lack of insight
• Depression is a mental illness that usually presents with a marked lack of interest, loss of motivation, feelings of hopelessness, fatigue, poor concentration, difficulty making decisions, suicidal thoughts, and low self-esteem
• Apathy or depression can lead to difficulty performing tasks, withdrawal, immobility, malnourishment, poor dental hygiene and faster functional and physical decline

• Directing
• Engage people in activities by pointing out what they need to do and encouraging them to participate and respond
• Use a gentle, respectful approach
• Mealtime can be an opportunity to engage people in a pleasant occasion
• Simplifying
• Activities can be adapted to match the level of the person’s capacities and skills
• Break up the activity into simple steps
• Set up activities and equipment in ways that the person can manage
• Shorten activities
• Slow down the pace

• Treating apathy and depression
• Encourage regular exercise
• Consult a healthcare professional

• Frightening hallucinations, illusions and delusions can trigger difficult behaviors
• Hallucination
• Perception of something that is not there
• Can involve any of the senses (sight, hearing, smell, taste, or touch)
• Visual and auditory hallucinations can occur together
• Illusion
• Misperception or misinterpretation of an object or person
• Caused by damage to the parts of the brain that process sensory information, so they seem very real to the person

• Delusion
• False idea or belief that is strongly held

Paranoia

• Unwarranted or exaggerated mistrust or suspiciousness of others that causes excessive fear and anxiety
• Paranoia can reach the point of being a delusion
• Even though people with dementia have poor memory, they can retain a strong sense of territory and belongings
• Caregivers need to be careful not to give any reason to be suspicious

General approaches

• Empathize, never argue or criticize
• Offer reassurance and comfort
• Find “solutions” with the person
• Redirect and provide a new environment

• Look for possible causes for the misperception in the environment
• Check for shadows, mirrors, and uncovered windows
• Adjust lighting and objects in the room to reduce shadows
• Remove hazardous objects
• Acknowledge and respect the person’s concerns
• Check for sources of noise
• Paging systems, the television next door, or people conversing within earshot
• Offer reassurance
• Stay with them for a while
• Make sure there is no danger of harm to self or others

• Use diversion or redirecting to something pleasant
• Reminisce
• Look over a family photo album
• Offer a snack
• Listen to music
• Managing delusions and paranoia
• Do not argue; offer reassurance instead
• Redirect their attention
• Try complementing and building up their self-esteem
• Promote self-worth and allow people to reminisce about happy times
• Consult a healthcare professional about medications

CHANGE BEHAVIORS USING TWO APPROACHES

• 1.By changing the antecedents: modifying things in the environment that may be may be triggering the behavior
• 2.By changing the consequences in order to prevent negative reactions (difficult behaviors)
• “A” in the ABCs of behavior management stands for Antecedent

• “B” in the ABCs stands for Behavior
• “C” in the ABCs stands for Consequence
• Asking about his children, or asking about his hobbies
• Observe, take notes, and discuss things with others

Click here to learn more about ABC’s of Behavior Management

• Consult a healthcare professional about medications
• Use the minimal effective dose to reduce side effects such as sedation
• Consult a healthcare professional if there are sudden or significant changes in behavior or functional abilities

KEY APPROACHES FOR MANAGING DIFFICULT BEHAVIORS

• Identifying specific behaviors and design specific interventions
• Setting appropriate and realistic goals
• Making ongoing assessments and adjustments
• Being willing to try new and creative strategies

PRINCIPLES

• Reduce frustration and fear
• Provide safety, security and comfort
• Use good communication techniques
• Use person-centered care
• Anticipate needs and address them before they lead to difficult behaviors

PREVENTING DIFFICULT BEHAVIORS

• Look for signs that people are approaching their stress threshold and reduce their stress

MANAGING DIFFICULT BEHAVIORS

• Use reassuring words with a smile, gentle tone of voice, and comforting body language
• Music therapy, aromatherapy, exercise, pleasant activities, and meaningful interactions
• ABCs of behavior management

STRATEGIES FOR MANAGING BEHAVIOR EXCESSES

• Redirecting
• Withdrawing attention
• Directing
• Simplifying
• Physical exercise
• Strategies for managing behavior deficits such as apathy and depression
• Wandering, pacing, rummaging and gathering may be allowed in safe settings

STRATEGIES FOR MANAGING HALLUCINATIONS, ILLUSIONS, AND DELUSIONS

• Reassurance
• Environmental modifications
• Distraction
• During an episode of aggressive behavior, do not try to discuss the behavior or touch the person until it is safe
• A combination of medication and behavior approaches can help reduce many difficult behaviors

Written by:
Catherine M. Harris, PhD, RNCS.
Mindy J. Kim-Miller, MD, PhD

Edited by:
Sasha Asdourian

www.LightBridgeHealthcare.com

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