When Behavior Challenges: Responding to Behaviors Associated with Cognitive Loss

1. 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

2. 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. Objectives

3. Behavior is communication What influences behavior? How does knowing the resident help to predict and explain the behavior? Understanding & Responding to Behaviors in Dementia

4. 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 Behavior is Communication

5. Behavior may be understood in the context of the: Elder Elder’s health status Environment Current situation Understanding Behavior

6. Who is this elder?: life story cultural background past habits, behavior& routines preferences & pleasures activities remaining abilities Understanding Behavior - Knowing the Person

7. Understanding Behavior -Health Status • Current health issues can influence a particular elder’s behaviors. • Change in behaviors can be an indication of a change in health status. • Changes in behavior warrant a health assessment to identify any new or emerging concerns.

8. Understanding Behavior – The Environment • Includes physical, temporal, and social elements • Persons with cognitive impairment can have difficulty “making sense of” the environment, which can influence behavior.

9. 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)

10. 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) Behavioral Assessment: Reframing

11. Common Behaviors • Wandering • Self Protective Behaviors • Noisemaking and Repetitive Vocalization

12. 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 ‘Wandering’

13. 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) Discovering the Individual’sAgenda

14. Provide safe environments for ambulation or movement Increase opportunities for social contacts Provide environmental stimulation Maintain functional capacity for self-care Methods for Preventing Unsafe Wandering Behavior

15. Attend to personal agenda Provide opportunity for meaningful ‘work’ Implement protective interventions Make environment ‘homelike’ Reduce exit cues, use visual barriers Individualized Responses to Wandering Behavior

16. 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) Self-Protective Behavior

17. 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 Self-Protective Behavior

18. 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 Self-Protective Behavior

19. Meeting the person’s needs to: Feel safe Feel in control Feel comfortable Experience optimal stress Experience pleasure and satisfaction Goals for care

20. To prevent/reduce the behavior: Environmental support Calm approach Communication and interpersonal strategies Use of remaining abilities Individualized Strategies for Minimizing Self-Protective Behavior/Resistance to Care

21. 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 Individualized Strategies for Minimizing Self-Protective Behavior/Resistance to Care

22. 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 Facility Planning for Prevention of Self-Protective Behavior

23. S - Slow Down T - Think about what is happening O - Options P - Plan to have some time to yourself STOP Strategy for Caregivers

24. Definition: Excessively loud utterances, nonsensical sounds, screaming, moaning/groaning, cursing and verbal repetitiveness Noisemaking and Repetitive Vocalization (NRV)

25. Neurologic-cognitive impairment Health status change Sensory deprivation Spiritual distress Psychological distress/depression Discomfort/pain, fatigue Psychosis symptoms Common Characteristics in Persons with NRV

26. Caregiver behaviors Environmental stimuli Individual aspects What may trigger NRV?

27. 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 Assessment of NRV

28. Activities Comfort and environmental measures Social interaction Videotape of family members Music Interventions for NRV

29. 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? Objectives Review

30. Thank you for your attention!The End