Managing Challenging Behaviors in the Older Adult Population

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Managing Challenging Behaviors in the Older Adult
Population

• Lori N. Waldberg, MSW, LCSW
• Behavioral Health Specialists
• bhspecialists_at_aol.com
• 602-570-6788

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Communication

• The senior population is unique in their
  communication style and comfort level.
• They tend to respond best with elements of
  formality and respect.

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Non-verbal Communication

• Personal Space be aware most people prefer 1 ½
  to 3 feet of space around them.
• Assess their mood and attitude.
• Stand or sit off to the side.
• Utilize congruent facial expressions.
• Use gestures to clarify your point.
• (Crisis Prevention Institute, Inc. 2005)

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Non-verbal Communication

• Make eye contact and stand at an angle.
• Promotes respect, safety and less threatening.
• Speak at eye level, making sure you have their
  attention (squat near wheelchair).
• (Crisis Prevention Institute, Inc. 2005)

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Paraverbal Communication

• Be aware of how your message is perceived.
• Attend to tone respectful
• Assess volume HOH (move closer)
• Attend to cadence keep your rhythm slow and
  deliberate.
• (Crisis Prevention Institute, Inc. 2005)

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Verbal Communication

• Use simple, direct statements.
• Enunciate words.
• Avoid terms of endearment or infantilizing.
• Utilize Mr. or Mrs., Ms. until granted permission
  otherwise.Ask!
• Respect, respect, respect.

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Verbal Communication

• Always acknowledge the client directly.
• Address the family or caregiver second.
• Never ignore the client.
• POA is only an enforced power when the patient
  becomes incapacitated.

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Quotes

• Please dont use the term elderlythat is for an
  old person!
• I am not like those old people.
• Why isnt the doctor talking to me?

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Empathic Listening

• An active process.
• Undivided attention.
• Non-judgmental approach.
• Seek the real message (feelings and facts).
• Restate, rephrase and clarify.
• Allow for silence.
• (Crisis Prevention Institute, Inc. 2005)

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Verbal Communication

• Ask open ended questions.
• Dont skirt issues (depression, suicide, alcohol,
  finances, abuse).
• Dont fill in blanks.
• Allow plenty of time for responses.

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Personality Issues

• Seniors often will minimize their relational
  difficulties as they age, but some have
  personality disorders that become more prominent
  with age.

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Personality Issues

• People with paranoid, socially isolative, and
  anxious personalities or people with avoidant,
  dependent, and obsessive-compulsive personalities
  tend to experience significantly more difficulty
  as they age.
• (Personality Disorders Over Time, Daniel DeNoon
  2002)

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Setting Effective Limits

• Critical in working with challenging behaviors
  and personalities
• Simple and concise
• Reasonable
• Enforceable
• Consistent
• Set appropriate boundaries (time)
• (Crisis Prevention Institute, Inc. 2005)

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Barriers to Communication

• Hearing impaired
• Stand directly in front of the person, make sure
  you have that individuals attention and you are
  close enough to the person before you begin
  speaking.
• Reduce or eliminate background noise as much as
  possible.

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Quote

• Honey, I can hear every word you are saying, no
  need to shout!
• Just cause I am older doesnt mean I cant hear
  you!
• I dont see well, but can hear you just fine.

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Barriers to Communication

• Visually impaired
• Explain what you are doing as you are doing it.
• Ask how you may help increasing the light,
  reading the document, describing where things
  are, or in some other way.

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Barriers to Communication

• Paranoia
• Avoid confrontation.
• Accept that their beliefs are very real to them.
• Validate feelings.
• Do not try to reason or explain.

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Special Populations

• Cultural Diversity
• Ask questions about background
• In what country were you born?
• What language did you first learn to speak?

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Special Populations

• Cultural Diversity
• Ask questions about support system
• Who are the people closest to you?
• Who helps you make decisions about your health?

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Special Populations

• Cultural Diversity
• Ask questions about beliefs regarding health
• What does it mean to be sick?
• What is the tradition of healing in your culture?
• How to you stay healthy?
• (Stanford University, 2001)

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Special Populations Dementia

• Dementia
• Introduce yourself each time.
• Prompt, do not test.
• Use short simple sentences or questions.
• Give plenty of time for the person to respond.

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Special Populations Dementia

• Dementia
• Maintain a calm demeanor, often they mirror
  emotion.
• Offer choices.
• Redirect and distract out of stressful situations.

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Dementia Common Types of Behaviors

• Agitation
• Aggression
• Psychosis
• Sundowning
• Repetitive questioning

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Dementia Understanding Behaviors

• 80 of those with dementia will experience some
  behavioral disturbance.
• Most behaviors occur in the moderate stages of
  Alzheimers disease.

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Dementia Understanding BehaviorsThe Brain

• Dementia affects areas in the brain that control
  emotion and behavior.
• The persons ability for insight and judgment are
  impaired.

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Dementia Understanding BehaviorsConfusion

• Confusion limits ones ability to understand
  their surrounding and express themselves
  conventionally.
• A confused person will often act out due to fear
  and the inability to express themselves
  adequately.

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Dementia Understanding BehaviorsCare

• The person with dementia often requires a great
  deal of hands-on care.
• This puts caregivers in a position of being
  intrusive and limiting privacy.

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Dementia Understanding BehaviorPhysical Pain

• Victims of dementia experience a great deal of
  physical pain.
• Often pain is expressed though emotional lability
  and behavior.
• Often pain goes untreated in these people.

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Dementia Understanding BehaviorDelirium

• People with dementia are susceptible to
  infections.
• Often it is difficult to discern what may be
  delirium and what is dementia.
• Often infections go untreated in this population.

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Dementia Understanding BehaviorDelirium

• People with dementia are high risk for adverse
  medication reactions.
• Acute changes in mood, cognition and behavior
  are often signs of delirium.

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Dementia Understanding BehaviorDelirium

• Psychotic symptoms are another indication
• hallucinations, delusional thinking, paranoia,
  and bizarre behaviors are often symptomatic of
  delirium.
• A medical evaluation is a necessary intervention.

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Dementia Understanding BehaviorEnvironment

• An over-stimulating (noisy) environment can cause
  a spike in behavior.
• A change in environment (a move or travel) can
  cause an increase in behavior.
• An under-stimulating setting (boredom) can also
  lead to behavioral disturbance.

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Dementia Understanding BehaviorEnvironment

• People with dementia require a calm yet
  structured setting.
• Often people with dementia living alone without
  support have increased behaviors and appear more
  confused because they are overwhelmed.
• Sign that they need more support to function
  adequately.

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Dementia Communication

• I have learned the importance of patience. Her
  patience with me.
• Critical need for patience, flexibility and
  creativity in care giving.

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Dementia Communication

• Simplify your approach
• Speak slowly using simple sentences.
• Ask simple questions that require a choice or a
  yes/no answer.
• Use concrete terms and familiar words.

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Dementia Communication

• Always introduce yourself, dont expect the
  person to know your name no matter how long you
  have known them.
• Prompt the person with information instead of
  testing their knowledge.
• Offer choices when possible (Do you live at home
  or with family?).
• Redirect and distract out of stressful situations.

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Dementia Communication

• Nonverbal cues
• If you look irritated or angry the person with
  dementia will mirror your emotion.
• Avoid approaching the person from behind.

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Dementia Communication

• Use touch when appropriate and eye contact.
• Use gestures and visual cues to get your message
  across.

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Dementia Communication

• Use of tone
• Speak in a warm, easy-going, pleasant manner.
• Use a calm, non-demanding and gentle approach.
• Sometimes animating your voice helps.

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Dementia Communication

• Use humor and cheerfulness when possible.
• Again, the person is hard of hearing, speak into
  their ear instead of yelling louder.
• Consider the use of hearing aids or a headset
  amplifier.

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Dementia Communication

• Respect
• Even more important with memory impairment.
• Folks tend to feel unsure of themselves and
  self-conscious.
• Never argue with the person, it will only
  escalate the situation.

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Dementia Communication

• Apologize when the person with dementia is upset,
  no matter if you feel your behavior contributed.
• Never speak about the person in front of them.
• Often that person can understand more than they
  can express.

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Dementia Communication

• Validation and Reassurance
• Dont try to implement reason as this will only
  increase frustration and anger.
• Provide ongoing reassurance.
• You are safe here or I am here to help.

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Dementia Communication

• Use the person with dementias fearful
  expressions to validate feelings and reminisce.
• If she is looking for a deceased spouse, You
  must miss your husband. How did you two meet?
• Use gentle approach.

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Dementia Communication

• Communicating with someone who is repetitive
• Use repetition to respond even when it feels
  frustrating.
• Give brief or short answers to respond to the
  request.
• It isnt useful to go into explanations.

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Dementia Communication

• Communicating with someone who is repetitive
• Assist them in note-taking.
• Assist in marking things on a calendar.
• Ask family to assist with reminders.
• Use a medical alert system for safety and
  medication prompting.

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Dementia Managing Behaviors ofAgitation

• Look for sensory overload loud television and
  other loud noises can quickly agitate the person.
  
• Look for the early signs of agitation and try to
  intervene immediately.
• Anticipate needs, be aware that person may be
  overwhelmed.

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Dementia Managing Behaviors ofAgitation

• If agitated folks are not given structured
  activities particularly early in the day, they
  will become agitated from boredom.
• Assist people I looking for missing belongings,
  never scold.
• Allow persons to carry transitional objects wear
  hat, carry purse, old keys, change or paper money
  if it makes them feel more comfortable.

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Dementia Managing Behaviors ofAgitation

• Consider behavioral logs and behavioral plans to
  make approaches consistent and to identify
  patterns of behavior.
• Allow for enough rest and short afternoon naps.
• Be aware that persons with dementia who stay in
  bed during the day, may have depression and
  greater agitation.

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Dementia Managing Behaviors ofPsychosis

• Paranoia or unrealistic fears are common.
• Often people refuse medications or food because
  they are afraid.
• Sometimes offering sealed food can make them more
  comfortable.
• Family can discuss with the physician the
  possibility of crushing medications.

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Dementia Managing Behaviors ofPsychosis

• Delusions of other types are also quite common.
• Believing one has to get to work or pick-up
  children from school.
• Step into that persons reality.
• Listening rather than contradicting them.

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Dementia Managing Behaviors of Psychosis

• Never argue, reminisce about the work instead.
• If the person becomes demanding, respond as if
  you work for them, I will take care of that
  immediately.

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Dementia Managing Behaviors of Psychosis

• If the person feels they need to leave, reason
  that it will take you some time to get a ride
  arranged.
• Then distract with an activity or snack while
  they are waiting.

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Dementia Managing Behaviors ofPsychosis

• Hallucinations (hearing or seeing things) are
  less common and indicate a need for a psychiatric
  evaluation.
• Keep in mind the sensory deprived are more apt to
  experience psychosis.
• Example She cant hear well, so she will
  interpret staff humor as laughing at them.

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Dementia Managing Behaviors ofPsychosis

• Avoid trying to implement your reality.
• If they are discussing a dead spouse, they will
  either grieve or think you are lying if you
  remind them the person is gone.
• Instead reminisce about that person. How did
  you meet? What kind of work did he do? Was it
  love a first sight?

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Dementia Managing Behaviors ofPsychosis

• Provide reassurance, That must be scary. Or,
  How can I help?
• Often psychosis is seen in the middle stages of
  Alzheimers but occurs in the early stages of
  Lewy Body Dementia.
• Medication can be useful but only if the
  psychosis is distressing or impacting functions
  of daily living.

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Managing Challenging Behaviors in the Older Adult
Population

• In summary
• Managing challenging behaviors in older adults
  involves being aware of elements of respect,
  sensitivity to uniqueness of the communication
  style of this generation.
• Awareness of special populations and approach.

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Managing Challenging Behaviors in the Older Adult
Population

• In summary
• Self-awareness of ones own biases.
• A client centered approach in using empathy to
  step into that persons shoes.
• Paying mind not only to who that person sitting
  front you is nowbut who they have been
  throughout their life.

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Quality of Life

• Beautiful young people are accidents of nature,
  but beautiful old people are works of art. --
  Eleanor Roosevelt
• And in the end, it's not the years in your life
  that count. It's the life in your years. --
  Abraham Lincoln

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Managing Challenging Behaviors in the Older Adult
Population

• QUESTIONS?Lori N. Waldberg, MSW, LCSW
• Behavioral Health Specialists
• bhspecialists_at_aol.com
• 602-570-6788