hear approach to behavior management live webinar feb 1 2017

A non-pharmacological approach to

managing problematic behaviors in dementia

Andrew L. Heck, PsyD, ABPPLicensed Clinical PsychologistGeroPartners, LLC

Carol Garby, BSNVirginia Department of Social Services,Division of Licensing Programs

The Mythical Silver Bullet

What do you do when a

resident _________

[insert behavior problem here]?

Bad news:

There is no universal intervention that applies across all

people and problems (i.e., the “silver bullet”).

Good news:

There is a method we can use to develop

individualized solutions to individualized

problems.

BPSD: Behavioral Problems and Symptoms in Dementia

Effective interventions follow thorough assessments aimed at the problem’s specific cause

Management of BPSD must be comprehensive and systematic

Successful BPSD management blends reactive and proactive strategies

Key question:

Why is this

Behavior a Problem?Is it:

only problematic for the resident?

endangering/irritating/upsetting to other residents/family members/visitors/ staff?

interfering with care?

Clarifying the BPSD

OBSERVE AND DESCRIBE:

• Type

• Frequency

• Intensity

• Duration of the BPSD

THEN PERFORM:

• Functional analysis of behavior: an examination of what a behavior’s purpose (i.e., function) serves for the individual

Functional analysis of behavior

BehaviorDESCRIPTION:

What specific behavior(s) occurred, and if more than

one, did they ever occur together?

PREDICTION:

Did the behavior occur during specific time periods; any time when the behavior didn’t occur; was there a specific

setting, characteristic or stimuli present when the behavior occurred? When did the behavior NOT occur?

FUNCTION:

What function did the behavior serve; did it result in

consequences?

The HEAR approach

• Health

“H”

• Environmental

“E”• Approach

“A”

• Resident

“R”

Chronic back pain, depression

SSRI (antidepressant)

Recently was informed a close friend had died

Increase in back pain, tramadol added

Recent, sudden, and unpredictable confusion, aggression, clumsiness

Clumsiness also observed

HEAR: Health

Jane

ALF resident

HEAR: Health

Increase antidepressant,

thought depression / grieving was cause

All symptoms worsened

Jane had a fallALF

response

Pharmacy review of med regimen

Revealed likelihood of

‘serotonin syndrome’

Meds adjusted, Jane returned to

baseline

Preferred response

Definition:

• Medical or other physical factors that cause or influence behavioral problems

Common Health Factors

• Delirium

• Medication-related (single or interaction)

• Metabolic disturbance (e.g., hypothyroidism, B12 deficiency)

• Infection

• Sensory loss

• Pain, hunger, thirst

HEAR: Health

HEAR: Health

When a new behavior problem suddenly emerges:

Obtain a thorough medical

evaluation (including labs)

Arrange a comprehensive

pharmacy review of medication

regimen

Check for constipation /

impaction

Moved rooms 2 weeks ago

Yells repeatedly for help in the middle of the night, agitation grows

Verbally assaults staff when they respond: “You’re going to let me die!!”

HEAR: Environmental Factors

George

ALF resident

Memory Care Unit

HEAR: Environmental Factors

PRN anti-anxiety medication

George has a fall when getting out of bed

ALF

response

Rule out medical causes

Examining environment revealed

streetlight shining directly into room

through blinds at night, George yells for help

but forgets why by the time staff arrives

New opaque blinds installed, no more

awakening for George

Preferred response

HEAR: Environmental Factors

Definition:

• Any aspects of an individual’s surroundings that influence BPSD

Common Factors

• Both cognitively impaired and cognitively intact individuals can be very sensitive to even minor environmental irritants or changes

• Irritant/change + behavioral dyscontrol = potentially harmful reaction!

• Environmental changes are recommended in most circumstances

oNo adverse effects

oEasy to implement

Strikes out during toileting

Q 2-hour toileting schedule not followed due to staff fear

Severe skin irritation and pain due to often wet disposable undergarments

HEAR: Approach Factors

Mary

ALF resident

Memory Care Unit

HEAR: Approach Factors

Use 3 staff to toilet herMary fights on way to own

bathroom after being disrobed in room

ALF

response

Rule out medical and

environmental causes

Use one staff member at first, gently

lead by hand to bathroom

Attempt hand-over-hand disrobing, gradually introduce

second staff member if

needed

Rub shoulders during

disrobing to distract (tactile distraction) if

needed

Give verbal instructions one step at a time, praise

success

Preferred response

HEAR: Approach FactorsDefinition:

• The method(s) by which individuals are addressed by their caregivers that can influence BPSD

Common Examples

• Violations of personal space

• Caregiver attitude/response

• Verbal approach

• Stance/positioning issues

• Erratic schedules, unpredictable routine

Definition:

• The needs, wants, desires, or habits of an individual that influence behavioral problems

Common Examples

• Can also be considered “psychological” factors

• These constitute a broad array of potential contributing causes for BPSD

HEAR: Resident Factors

HEAR: Resident Factors

Psychotherapy

• Individuals with early-state dementia may benefit from some forms of psychotherapy

• Gather collateral information—family and others

• Pass along information and observations to therapist

Behavior Planning

• Some residents may benefit from behavior plans

• Works across different levels of cognitive ability

• Typically developed by a MH consultant, implemented by facility staff with training

• Aimed at bringing about desirable behaviors while discouraging or eliminating harmful behaviors

Facility role

Facilities are generally well-equipped to address

• Health,

• Environmental, and

• Approach factors with existing resources

If H, E, and A factors are ruled

out,

Resident Factors

It may be time to bring in a behaviorally-trained clinician to

address the specific behavior

Regulatory perspective

• Failure to address BPSD!•Assessment (UAI)•Public versus Private Pay•Not “sole source”•Static versus Dynamic

Individual Service Plan

Please make the ISP a “living, breathing” document!

Development of ISP

INDIVIDUAL-Absent or lacking

NO involvement of DCS

STATIC not DYNAMIC

TIPS

Don’t make assumptions!

Take action before small problems

become big ones

Gather informationLearn to think “outside the box”

Expect some failures.

Celebrate success!

In Summary…

Be thorough and systematic in examining potential contributors to

problem behaviors: HEAR!!

Avoid the temptation to leap to medication as a

first-line solution

For residents with behavioral issues, make

sure management of those behaviors are accounted for in the

individual’s ISP

Keep ISPs current with frequent re-evaluations

and updates

Contact information

Andrew L. Heck, PsyD, ABPP

GeroPartners, LLC

aheck@geropartners.com

www.geropartners.com

Carol Garby, BSN

Virginia Department of Social Services,

Division of Licensing Programs

carol.garby@dss.virginia.gov