TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia When Behavior Challenges: Responding to Behaviors Associated with Cognitive Loss Revised in 2013/2014 by Pamalyn Kearney, EdD, OTR/L Associate Professor, Georgia Regents University Elizabeth Dalton, MSN, GNP-BC Living Independently for Elders, University of Pennsylvania School of Nursing Originally developed by Lois K. Evans, DNSc, RN, FAAN Viola MacInnes Professor Co-Director, Geriatric Education Center of Greater Philadelphia

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Objectives With regard to older adults with dementia, direct care staff will be able to:  Analyze behavior as a form of communication.  Explain the influence of cognitive impairment, life story, cultural background, environment and current situation in predicting and explaining behaviors.  Use a range of assessment strategies to identify the meaning of behavior.  Individualize care to older adults with dementia to prevent and respond to behaviors.

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Understanding & Responding to Behaviors in Dementia n Behavior is communication n What influences behavior? n How does knowing the resident help to predict and explain the behavior?

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Behavior is Communication  A person with dementia communicates unmet needs through behavior  Making sense of behavior is critical to meeting the person’s needs  All behavior is meaningful

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Understanding Behavior Behavior may be understood in the context of the:  Elder  Elder’s health status  Environment  Current situation

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Understanding Behavior - Knowing the Person Who is this elder?:  life story  cultural background  past habits, behavior & routines  preferences & pleasures  activities  remaining abilities

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Understanding Behavior - Health Status n Current health issues can influence a particular elder’s behaviors. n Change in behaviors can be an indication of a change in health status. n Changes in behavior warrant a health assessment to identify any new or emerging concerns.

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Understanding Behavior – The Environment n Includes physical, temporal, and social elements n Persons with cognitive impairment can have difficulty “making sense of” the environment, which can influence behavior.

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Understanding Behavior – Current Situation What interactions or activities occurred just prior to the onset of the behavior? Did these “trigger” the behavior? –Location and characteristics –People involved and social environment –Emotional tone of any interaction –Activity (or lack of)

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Behavioral Assessment: Reframing Reframing the way one perceives behavior is essential to plan individualized interventions  Suspend judgment  Avoid ‘labeling’  Collect clues  Conduct behavioral assessment (use behavioral monitoring log)

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Common Behaviors n Wandering n Self Protective Behaviors n Noisemaking and Repetitive Vocalization

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia ‘Wandering’  Definition: Moving about in an apparent aimless or disoriented fashion where the goal is either unobtainable as stated by the resident or unclear to the observer  MAY lead to unsafe situations or undue fatigue

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Discovering the Individual’s Agenda  Alleviate loneliness, isolation, boredom  Seek safety in familiar surroundings  Satisfy physical needs  Relieve stress by walking  Communicate a change in health status (if new behavior)

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Methods for Preventing Unsafe Wandering Behavior  Provide safe environments for ambulation or movement  Increase opportunities for social contacts  Provide environmental stimulation  Maintain functional capacity for self- care

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Individualized Responses to Wandering Behavior  Attend to personal agenda  Provide opportunity for meaningful ‘work’  Implement protective interventions  Make environment ‘homelike’  Reduce exit cues, use visual barriers

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Self-Protective Behavior  Sometimes these behaviors are viewed as “aggressive” or “resisting care”  Definition: Psychomotor behaviors and vocalizations that may be an attempt to communicate and/or fulfill unmet needs for protection of self: A protective response  Prevalence: about 50% in LTC (verbal and/or physical)

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Self-Protective Behavior  Some may be related to neurological changes  Most can be prevented/reduced  Most of the time there is adequate warning, and precipitating factor can be identified  Observation and ‘knowing’ the person is critical

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Self-Protective Behavior  Pattern: occurs during day & during assistance with ADLs/personal care, ESPECIALLY BATHING  Associated with use of psychoactive drugs/ restraints  Associated with functional disability and problems with communication

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Goals for care Meeting the person’s needs to:  Feel safe  Feel in control  Feel comfortable  Experience optimal stress  Experience pleasure and satisfaction

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Individualized Strategies for Minimizing Self-Protective Behavior/Resistance to Care To prevent/reduce the behavior:  Environmental support  Calm approach  Communication and interpersonal strategies  Use of remaining abilities

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Individualized Strategies for Minimizing Self-Protective Behavior/Resistance to Care When the response has already begun  Distract/redirect activities  Remove trigger  Express your own fear, ask for feedback  Use ‘supportive stance’  Back off and re-approach later  Do not shout, confront, reason, argue with, touch an already aggressive person  Have a facility/unit plan in place; train staff

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Facility Planning for Prevention of Self-Protective Behavior Example: BATHING  Collect more information regarding bathing routines, environments, experiences of residents and caregivers  Consider the physical environment – could the area be warmer, do we need more lighting, would low flow shower heads help?  Identify ways to ‘normalize’ the bathing area and bathing experience - Homelike  Incorporate other ways to meet need for cleanliness: Towel bath vs. shower or tub

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia STOP Strategy for Caregivers S S - Slow Down T T - Think about what is happening O O - Options P P - Plan to have some time to yourself

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Noisemaking and Repetitive Vocalization (NRV)  Definition: Excessively loud utterances, nonsensical sounds, screaming, moaning/groaning, cursing and verbal repetitiveness

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Common Characteristics in Persons with NRV  Neurologic-cognitive impairment  Health status change  Sensory deprivation  Spiritual distress  Psychological distress/depression  Discomfort/pain, fatigue  Psychosis symptoms

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia What may trigger NRV?  Caregiver behaviors  Environmental stimuli  Individual aspects

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Assessment of NRV  Describe the behavior  Listen to the vocalizations in context and try to understand the message  Identify triggers  Evaluate physical-mental status  Identify patterns and frequency – use behavior logs to assist

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Interventions for NRV  Activities  Comfort and environmental measures  Social interaction  Videotape of family members  Music

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Objectives Review With regard to older adults with dementia, can you now:  Discuss behavior as a form of communication?  Describe the role of cognitive impairment, life story, the environment and current situation in predicting and explaining behaviors?  Use a range of assessment strategies to identify the meaning of behavior?  Individualize care to older adults with dementia to prevent and respond to behaviors?

TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia Thank you for your attention! The End

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