hear approach to behavior management live webinar feb 1 2017
TRANSCRIPT
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
www.geropartners.com
Carol Garby, BSN
Virginia Department of Social Services,
Division of Licensing Programs