Coping with Challenging Behaviors

REALIZE … It Takes TWO to Tango … or tangle…

Learn to Dance with Your Partner

When Something Is Not Working Well… What Do We Tend to Do?

Being ‘right’ doesn’t necessarily translate into a good outcome for both OR either of you

Deciding to change your approach and behavior WILL REQUIRE you to stay alert and make choices… it is WORK

It’s the relationship that is MOST critical NOT the outcome of one encounter

Who Are YOUR Challenging People? Who Challenges YOU?

What are the Challenging Behaviors that GET TO YOU?

What Are the Most Common Issues That Come Up??? Not going to the MD ‘Losing’ Important Things Getting Lost Unsafe task performance Repeated calls & contacts Refusing ‘Bad mouthing’ you to others Making up stories Resisting care Swearing & cursing Making 911 calls Mixing day & night Shadowing Eloping or Wandering No solid sleep time Getting ‘into’ things Threatening caregivers Undressing Being rude Feeling ‘sick’ Striking out at others Falls & injuries Infections & pneumonias Seeing things & people Not eating or drinking Contractures & immobility

By managing your own behavior, actions, words & reactions you can change the outcome of an interaction.

REALLY Ask Yourself… Is this Behavior a Problem Behavior OR is this a “So What” Behavior An “Annoying” Behavior

Is it REALLY a Problem? Is it a RISKY BEHAVIOR? Risk to that person (physical, emotional, physiological risk)? Risk to the caregiver? Risk to Others? Is the RISK REAL and IMMEDIATE? If NOT, it is a ‘SO WHAT’ behavior

If it is a ‘SO WHAT’ Behavior… Leave it ALONE! Figure out how to let go of it … Let it go!

If it is RISKY… Describe the behavior – OBJECTIVELY –WHO? –WHAT? –WHERE? –WHEN? –WHAT helps… WHAT makes it worse? –Frequency & Intensity?

SIX Pieces to the Puzzle Personal history and preferences Type & current level of cognitive loss Other conditions & sensory losses Environmental conditions Care partner approach and behaviors What happened – full day & all players

Knowing the Person History Values and beliefs Habits and routines Personality and stress behaviors Work & family history Leisure and spiritual history Hot buttons & comforts

Level of Cognitive Function What CAN the person do? What can the person NOT do? What CUES are effective? Ineffective? What are interests based on level? Consistency of Cognitive Level?

The person’s brain is dying

Normal BrainAlzheimers Brain

Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains G. Small, UCLA School of Medicine. Normal Early Alzheimer’s Late Alzheimer’s Child

So… what is happening? Memory damage –Can’t learn new things –Forgets immediate past –Does time & space travel –Uses old memories like new –May not ID self or others correctly –CONFABULATES –Follows visual cues –Seeks out the familiar –Can get stuck on an old emotional memory track Language damage –Has very concrete understanding of words –Misses 1 our of 4 words – may miss “Don’t…” –Word finding problems –Word salad problems –COVERS –Follows your cues –Gets very vague & repeats –Uses automatic responses –Mis-speaks

So… what is happening? Impulse Control Problems –Say whatever they are thinking –Swear easily –Use sex words or racial slurs when stressed –Act impulsively –Not think thru consequences –Can’t hold back on thoughts or actions –Responds quickly & strongly to perceived threats Flight, fight, fright Performance Problems –Thinks they can do better than they can –Can sometimes DO BETTER under pressure – sometimes worse –Uses old habits –Attempts can be dangerous or fatal –They will tell you one thing and then do another… –Families may over or under ‘limit’ activities

How do these losses relate to some risky behaviors? Persistent ‘going’ –inability to terminate –not able to anything else –discomfort Eloping - escaping –following cues –wanting to leave –going somewhere Constant talking or vocalizing –Trying to communicate –Self-stimulating Lack of Initiation –Won’t move or cooperate Lost and ‘Looking’ –can’t find places –looking for familiar Invading space –automatic actions –following interests & habits –no awareness of ‘personal space’ Shadowing –looking for help –Comfort Resisting care –Self-care –Movement

Level 5 - Routines & Repeats Diamonds Word finding problems Logic problems Place & time confusion Very ‘independent’ or seeking constant reassurance Resents take-over Self-awareness varies Fearful about what is wrong Typically resists outside helpers Becomes anxious and frustrated easily Has trouble with new routines and locations Tries to maintain control & social behavior May try to escape/leave Can use signage & cues Gets ‘turned around’ Momentarily ‘disoriented’ Does regular routines JUST FINE!

Level 4 - Task Oriented Emeralds Has trouble sequencing thru tasks & activities Often skips steps Looking for what to do and where to be Believes they can do it ‘Don’t need your help’ Has a mission in mind Goes back in time Gets lost in place Uses visual information to figure out what to do Follows samples & demos Can’t do an activity if visual prompt is not there Specifics and content in speech can be limited Gets stuck on ‘stuff’ Needs to be involved Looks for ‘stuff’ to do

Level 3 - Hunting & Gathering Ambers Uses hands to touch, feel, handle, hold Explores what is visible and hidden Invade other’s space to explore Repeats actions over and over Sees in pieces not whole Impulsive or indecisive Understands few words Imitates actions – copies you Tool use is challenging Follows others Investigates the environment May taste or eat what they see Difficulty terminating Difficulty getting focused on care tasks Becomes easily distressed with unpleasant tasks Asks ?s mechanically

Level 2 - Stuck on GO Rubies Gross motor only Poor finger use Limited visual processing Very limited communication skills Unable to do more complex motor actions Imitates those around Problems with chewing and swallowing Can’t stop or sound asleep Copies your mood – facial expressions Can’t grade strength Better with rhythm and repetitive movements Loses weight On the move – wanders forward – no safety awareness

Level 1 – Reflexes Rule Pearls Bed bound or chair bound Unable to sit up for any length of time Unable to communicate verbally Lots of reflexes Breathing changes Moments of being present Can make eye contact & some automatic responses Swallowing and eating problems Muscles shorten and contractures forms Pressure areas develop because of no movement & limited intake Responds to touch, voice, movement, smells Startles easily Motor agitation indicates needs

Health & Illness Mobility problems? Pain? Sensory problems? Mental health issues? Other diagnoses of importance?

Comparison of Fat Pads

Environmental Factors & Changes Physical Environment People Programming

Environmental Aids Setting –familiar –friendly –functional –forgiving (safe)

Environmental Aids Props –visible & invisible –timely –available –matched to ability –matched to interests

Care Partner Approach Knowledge Skills

Three Reasons to Communicate Get something DONE Have a conversation Help with distress

Communication – Getting the person to DO Something Form a relationship FIRST Then Work on Task Attempt

Connect 1 st – Visually 2 nd – Verbally 3 rd – Physically 4 th – Emotionally 5 th – Individually - Spiritually

How you help… Sight or Visual cues Verbal or Auditory cues Touch or Tactile cues

To Connect Use the Positive Physical Approach

Your Approach Use a consistent positive physical approach –pause at edge of public space –approach within visual range –approach slowly –offer your hand & make eye contact –call the person by name –stand to the side to communicate –respect intimate space –wait for a response

Hand-Under-Hand Position

Your interaction… Communicate with awareness –look, listen, think! –give your name –make an empathetic observational statement “You look busy...” “It looks like you are tired…” “It sounds like you are upset…” –wait for a response

Give information Keep it short and simple –“ It’s lunch time” –“Let’s go this way” –“Here’s your socks” Use familiar words and phrases Use gestures and props to help

Encourage Engagement ask a person to try ask a person to help you give simple positive directions - 1 step at a time use props or objects gesture demonstrate guide distract redirect

Daily Routines & Client-Centered Programming Old habits and routines Patterns during the 24 hrs A time to rest, work, play…socialize Your needs… my time

To Cope with Challenging Behaviors… Where will you start??? –An idea – Care partner education Care partner skill building

Then… Observe & document the risky behavior thoroughly –what is the pattern –when does it happen –where does it happen –who is involved –what is said, done, attempted –what makes it better… worse

Is it really a problem? … A RISK If NO - leave it alone If YES - its time to problem solve –call the team together –put on the thinking caps

REMEMBER Explore all of the following - Personal background information Level of cognitive function Health information Environmental issues Caregiver approach & assistance Habits, schedules & time of day

Re-look at the problematic challenging behavior… What does the person need? What is the meaning of the the behavior? Do you understand the risky behavior better?

Make a PLAN! Who will do what When will it be done How will it work What environmental change is needed What props are needed - where will they be

Implement your plan! Keep track of progress Document what is happening Communicate among the team members Rethink - if it isn’t working…. CELEBRATE - if it is!

How can we help… better? It all starts with your approach!

How you help… Sight or Visual cues Verbal or Auditory cues Touch or Tactile cues

What Do They Do? Question Refuse Release – verbal Intimidate – physical Tension reduction

What Should You Do? Be supportive Offer choices & be directive Set realistic limits Act – Take control Re-connect

Believe - People Are doing The BEST they can!

What shouldn’t we do??? Argue Make up stuff that is NOT true Ignore problem behaviors Try a possible solution only once Give up Let them do whatever they want to Force them to do it

So WHAT should we do??? Remember who has the healthy brain!