'Managing Behaviours Which Challenge Services Andy Shewan NHS Tayside When asking home care staff what the most useful things for them at the conf would be they said that home care staff coping with people with behaviour which challenge services is an issue for them, and therefore some more positive guidance on this would be helpful. I know that you will be able to present this in an upbeat fashion and be able to give us some useful tips on how to manage behaviours which challenges us. I suppose this will be largely related to people with dementia but also includes other mental health conditions I’ve been asked to provide an upbeat presentation around this subject. 20 minutes to give a lifetime of learning and development! Not an easy task in a subject which is constantly evolving! What are the behaviours anybody in this room will display when elderly and in need of care? I would like everybody in the room to think about something they do on a daily basis. Work? Sport? Will your beliefs and assumptions impact on this? How are you going to feel when unable to do this? Angry? Frustrated?

Behaviours That Challenge Delusions Hallucinations Anxiety Depression Apathy Agitation Aggression Wandering Disinhibition

Background to Behaviours Pre-morbid personality Lifestyle Perceived on-going responsibilities Anxiety over needs

Triggers and Causes of distressed Behaviour Biological Having physical illness Experiencing pain Being dehydrated Being constipated Psychological Disinhibition Loneliness Low mood Social and Environmental Too hot or too cold Too much stimuli – light, noise etc Misidentifying people as partners Uncomfortable clothing, seating etc

Medications Only have modest efficacy Have significant side effects Potential detrimental impact on quality of life 180,000 being treated with anti-psychotics – only 20% will benefit (Banerjee 2009)

Non-Pharmacological Interventions Functional Analysis – sometimes referred to as behavioural modification, behavioural management or behavioural intervention. Interventions which derive an understanding of the purpose or meaning of an individuals behaviour. Also known as ‘ABC’ approach

Functional Analysis Requires clear cataloguing or the problem behaviour (B) (B) is understood in terms of the observed influence of events preceding it (antecedents ‘A’) And the consequent events upon it (C). Traditional ‘ABC’ behavioural interventions imply that behaviour is always observable and linear in nature

This is not always true for the development and maintenance of challenging behaviour in dementia. Staff anxiety may be a consequence (‘C’) of a challenging behaviour (‘B’) but staff behaviour (including anxiety) can simultaneously act as an antecedent (‘A’)

Example 1 A man’s unobservable (superstitious) belief (‘A’), precipitated aggression (‘B’), which led to use of an anti-psychotic (‘C’), which in turn reduced his mobility (‘A’), requiring increased staff supervision (‘A’) which further exacerbated his aggression (‘B’).

Example 2 A student approached a lady with dementia and offered her a tea cup with orange juice in it. The lady took one sip from the tea cup and promptly threw the tea over the student. The student then reacted by shouting at the lady asking the lady why she threw the tea. A staff nurse intervened and settled the situation by getting the lady a hot cup of tea. The student required to change, the bed required changing, the floor required cleaning. This happened a couple of weeks ago. I will let you determine the ‘A’, ‘B’, ‘C’ of it.

Core Values Dignity Compassion Respect In my experience staff often go to work with the attitude that it is going to be a problem shift. This will cause stress and therefor have an effect on staff’s quality of life

Resources Promoting psychological wellbeing for people with dementia and their carers: An enhanced practice resource Promoting Excellence – A framework for all health and social services staff working with people with Dementia, their family and carers

Other Options Cognitive Stimulation Therapy (CST) Acceptance & Commitment Therapy (ACT) Interpersonal Therapy (IPT)

Andy Shewan NHS Tayside Stress & Distress Andy Shewan NHS Tayside This would have been the correct title for the presentation. I would like to leave you with a thought – as long as we continue to use the term ‘challenging behaviour’ individuals with Dementia may be viewed as causing carers problems. A person who is challenging invokes a response from us. A person who is ‘stressed or distressed’ invokes a different response from even the hardest heart.