Managing Difficult Behaviors in a Dementia Care Setting

Alison L. Ray Divisional Dementia Care Manager

Brookdale

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It’s a Need, Not a Behavior

Objectives:

• What are our “perceived challenging behaviors” we face as caregivers? Are they behaviors or communication?

• What can we do to manage the behavioral expressions of the person with dementia and still provide safety for all residents?

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Behavioral Expressions verses Difficult Behaviors

• Need verses an initial negative word of behavior • Can we manage difficult behaviors or should we be proactive

prior to the “expression/behavior”? – What does this look like to be proactive or person centered prior

to the behavioral expression

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What are behavioral expressions we face?

• Yelling• Hitting• Eliminating in

inappropriate areas • Refusing care• Wandering• Spitting• Eating/drinking non-

food items

• Inappropriate sexual behaviors

• Swearing• Repetition• Restlessness/Agitation• Suspiciousness• Sleep disturbances

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What is the need behind the behavior?

Stop judging and become curious:•Who?•What?•Where?•When?•Why?

Need to develop a detective mentality…

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Questions to explore:

• Is it an unmet physical need? • Hungry?• Thirsty?• In pain?• Looking for a bathroom?

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Questions to explore:

• Is it the environment? • Too loud or noisy?• Too hot, too cold?• Distracting visually? (Shadows cause distress)

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Questions to explore:

Is it the task they have been asked to do?• Physical challenges?• Unable to decide/understand what to do next?• Are they frustrated? (can’t express themselves, don’t

understand what you want them to do.)• Expressive aphasia• Receptive aphasia

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Questions to explore:

Is it how we are communicating to them?• Speaking too fast, not loud enough• Using too many directions• Non-verbal appearance doesn’t match with what is

being said• Is there a language/accent barrier?

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So how to get to the need behind the behavioral expression?

• Be a detective•Ask basic questions, look for common patterns

• Ask yourself, what would I feel? •What would I feel and what would I need?•How could you meet my need?

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How do we utilize person centered interventions once we know the need behind expressions?

• Identify patterns/share them with others.• Then, intervene BEFORE the expression emerges

–You must redirect the resident to “something purposeful”, not just move them to a different place.

• Use their history as a means of refocusing their thoughts.

• Create a program box with their “special items” in it to use during challenging times.

• Give resident favorite food or drink as part of their daily routine not when resident is upset

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If the behavior expression emerges, now what?

• Change the scenery• Go to another room turn on soft quiet music and

discuss new things in the room• Ask someone else to step in: a fresh face.• Take a walk, a drive

• Meet basic needs: offer coffee and cookie, juice, water, ice cream (comfort foods), offer the bathroom

• Validate the persons feelings• Offer your hand

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If the behavior emerges, now what?

• Assess for underlying pain: Look at footwear, denture fit, clothing fit, diagnoses…administer pain meds as ordered.

• Initiate a new activity: give something purposeful to do which has meaning to them.

• Evaluate the behavior: Is it dangerous? Who is it bothering…you? The person with dementia should be able to display their dementia.

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Other ideas of interventions

• Ask permission from person with dementia for all tasks

• Write a letter for the person who has dementia reassuring them (can be from family or doctor)

• Video/audio tape family members telling a story or reassuring the resident. DVD of the grandchildren, spouse or friend

• Encourage meaningful/purposeful activities (meaning must be created in the present moment)

• Provide meaningful things for them to do

• Slow down and listen (allow the person with dementia time to respond)

• Focus on abilities (repetitive, sorting, etc)

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It’s a Need not a Behavior

SummaryAsk questions and get to the need behind the behavior.

– Who, what, where, when, why?– Is it an unmet physical need? Environment? Task too

hard? Communication? Pain?– Use knowledge of their history.– Ask what would “I” feel, need, if I were in their shoes.– Look for warning signs and patterns and intervene

before the behavior emerges.– Give yourself a break, use respite, ask help from other

caregivers.

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Questions?