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

16: Difficult Behavior Associated with Dementia

Select the best answers from the list of choices following each question.

Click here to open Certificate of Completion
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