CHALLENGING BEHAVIOUR

1
CHALLENGING BEHAVIOUR

• Understanding the reasons behind challenging
  behaviour in the elderly and how to better cope,
  manage and care for these behaviours

2
UNMET NEEDS

• Widely accepted that most challenging behaviour
  in dementia is an attempt at communicating unmet
  needs
• Kitwood (1997) well being will only be
  attained when we address meaningfully the needs
  of those with dementia
• Stokes (2001) we must attend to the
  psychological needs of people with dementia if we
  want to improve their well being

3
THE BRAIN BEHAVIOUR

• When a person has dementia one or more areas of
  the brain are damaged with the areas of damage
  different for each person. THEY ARE STILL
  INDIVIDUALS
• The person cannot help their behaviour resulting
  from this brain damage.
• People with dementia do not have the ability to
  manipulate or use their behaviour purposefully
  due to this damage

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What are BPSD?

• The Behavioural and Psychological Symptoms of
  Dementia (BPSD) are defined by the International
  Psychogeriatric Association (IPA) as
• Behaviour symptoms include restlessness,
  physical 1aggression, screaming, 2agitation,
  3wandering, culturally inappropriate behaviours,
  sexual disinhibition, hoarding, cursing
  shadowing.
• Psychological symptoms includeAnxiety, depressed
  mood, hallucinations delusions
• see www.ipa-online.org

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UNDERSTANDING AGGRESSION

• Defensive behaviour reaction to a perceived
  threat or invasion of personal space
• INTIMATE CARE CAN BE A FRIGHTENING EXPERIENCE
• Reality Confrontation exposing a confused
  person to the upsetting reality that they are
  unwell and in hospital can distress them,
  explaining that a loved one has passed away will
  just make them relive the painful memory over
  again
• Alarm abrupt or sudden approaches to a person
  who is poorly sighted/hard of hearing as well as
  confused, especially if from behind or involving
  unexpected physical contact.

6
UNDERSTANDING AGGRESSION

• Goal Frustration staff attempting to restrict
  or control the wishes and choices of the person.
  Giving instructions to STOP IT or act differently
  may provoke an aggressive response
• Psychosis aggression may be linked to delusions
  fixed false beliefs which cannot be reasoned
  with eg) that the neighbours are trying to kill
  them or poison them
• However it is important to remember that
  delusions may also be misperceptions of their
  environment or the situation in hand. Which can
  lead to an aggressive incident

7
AGITATION

• AGITATION can be further defined
• Aggressive behaviour Physical and verbal
• Physical non aggressive behaviour pacing,
  restlessness and wandering
• Verbal agitated behaviour screaming and
  repeated requests for attention
• (Cohen Mansfield Billig 1986)

8
WANDERING

• WANDERING can be further categorised into
• Exit seeking behaviour repeatedly attempting to
  leave the ward or unit
• Modellers shadowing or following other patients
  or staff members
• Self stimulators these patients are bored or
  understimulated and may pace or wander around the
  ward or unit
• Akathisiacs these patients are restless as a
  side effect of certain medications
• (Lawlor 1995)

9
Understanding Behaviour

• The behaviour should not just be considered as
  confusion or agitation
• Behaviour is usually a form of communication and
  often represents an unmet need
• Care givers cannot change the behaviour of the
  person with dementia, however, they can change
  their own behaviour and the working environment

10
CAUSES OF BPSD

• PHYSICAL
• ENVIRONMENTAL
• COMMUNICATION
• PSYCHOLOGICAL

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CAUSES OF BPSD

• Physical
• medically unwell (especially delirium)
• impaired vision / hearing
• medication effects
• fatigue
• pain
• constipation
• Note due to communication difficulties
• acute health issues can be difficult to
• identify

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CAUSES OF BPSD

• Environmental
• New/change in environment
• Over/under stimulating
• Lack of orientation cues
• Lighting - dim/glare
• Too restrictive - no place to wander, restraint
• Temperature - too hot/cold

13
CAUSES OF BPSD

• Communication difficulties
• Client
• is unable to communicate needs
• has communication problem (eg due to CVA)
• has sensory deficit (hearing, sight)

14
CAUSES OF BPSD

• Communication difficulties
• Communication is too complicated
• Communication is too confronting
• Lack of communication - not explaining things
  properly to the person

15
COMMUNICATION
16
COMMUNICATION

• Remember, people with dementia will reflect the
  mood behaviour of others.
• When caring for a person with dementia who is
  having difficulty communicating, remember they
  will pick up on negative body language such as
  sighs raised eyebrows.

17
CAUSES OF BPSD

• PSYCHOLOGICAL
• We all need to feel psychologically safe.
• People with dementia feel they are in a
• world devoid of familiarity or reassurance
• feeling unsafe, uncertain, frightened.
• FEAR and FRUSTRATION is one of the main causes of
  BPSD derived from not knowing where they are,
  why they are there, not recognising faces around
  them distress and wanting to go home

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CAUSES OF BPSD

• PSYCHOLOGICAL
• To be engaged in occupation and have
• stimulation is fundamental to psychological
• well being.
• Over stimulation - can be typical in the acute
  care setting.
• Under stimulation INACTIVITY.. The usual
  activity in hospital is doing nothing or
  sleeping, yet when they try to do something WE
  STOP THEM.

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CAUSES OF BPSD

• PSYCHOLOGICAL
• Social and human contact
• Social contact is crucial to well being and has a
  protective effect against psychological distress,
  BUT isolation can be the norm for people with
  dementia!
• Isolation can lead to them calling out or follow
  others around them
• Eye contact, a smile, a hand held, sitting with
  the person can often help to meet this need

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UNDERSTANDING BEHAVIOUR

• Behaviour that is misunderstood and managed
  inappropriately may escalate.
• Think A B C
• A Activating Event (what was the trigger)
• B Behaviour (what behaviour resulted)
• C Consequence What was the consequence

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A Activating event - Joe wanders into
co-patients room. Co-patient orders Joe out.
E Escalation - Joes aggression escalates from
verbal to physical.
B Behaviour - Joe responds with verbal
aggression.
C Consequence Joe is removed from the room in a
firm and decisive manner. Joe becomes physically
aggressive to staff.
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A Activating event - Joe wanders into
co-patients room. Co-patient orders Joe out.
D De-escalate Debrief - Joes aggression
de-escalates staff others undergo debriefing.
B Behaviour - Joe responds with verbal
aggression.
C Consequence - staff assess the situation and
talk to Joe in a warm and friendly manner that is
respectful and maintains dignity. Staff use
communication techniques aimed at diffusing the
aggressive situation.
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WHAT NOT TO DO RE BPSD

• Dont be confrontational
• Dont raise your voice
• Dont attempt to lead the person away or initiate
  any other form of physical contact, as such
  actions can be easily misunderstood
• Dont attempt to approach from behind
• Dont corner them as this will heighten feelings
  of threat and alarm
• Dont crowd them by calling for assistance
• Dont blame tease or ridicule
• Dont attempt to use restraint
• Dont show fear, alarm or anxiety, as this may
  encourage the agitation/aggression by
  demonstrating that it is not they who are unable
  to cope, but you as well

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RESPONSES TO BPSD

• Stay calm, this will demonstrate that you are in
  control.
• Respect their personal space this also helps to
  reduce threat and enables staff to maintain a
  safe distance
• Stand at an angle of 45 degrees
• Use tone of voice to convey reassurance
• Acknowledge how they are feeling try to
  identify what the problem is
• Listen to what they actually say be accepting
  not rejecting
• Do not disagree with what they believe to be true
  to them
• Seek points of similarity rather then difference
• Use multi step re direction

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MULTI STEP REDIRECTION

• Validate the apparent emotional state of the
  person. Eg You look worried/concerned/upset
  This helps to establish a rapport.
• Next the caregiver should join in with the
  persons behaviour as much as possible. Eg
  Youre looking for something/someone? Im trying
  to find something too, lets look together
• Once this common goal is established distraction
  can be easier. Eg this is thirsty work, should
  we get a cup of tea?
• Finally redirecting the person away from their
  original goal has been established. Eg lets sit
  down and have that cup of tea?

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HOW TO SUCCEED CAREGIVING STRATEGIES THAT
PROVIDE ANSWERS FOR COMMON BEHAVIOUR THEMES.

• REMEMBER BEHAVIOUR IS COMMUNICATING
• Enter their world The key to solving confusion
  is to help people with dementia feel safe and
  listened to, and find something familiar for them
  to anchor to.
• Reassure and acknowledge what they are expressing
  even if it is about their past. Help them to
  name what they are feeling
• Validate their feelings - when you find out what
  is confusing from their point of view
• Reminisce switch them from asking about people
  from their past to reminiscing about them instead
• Anchor them - direct them to something familiar
  a routine, a song, a touch, a favourite activity.
  If over stimulated simplify the situation by
  eliminating distractions and slowing down the
  pace of the environment.

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Rationale for this care approach

• The person with dementia cannot always perceive
  our reality due to the damaged areas of the
  brain
• What the person remembers from the past has
  largely become his present
• Things from the past are familiar and comforting
  to discuss, remember and do connecting with the
  past is a way of reassuring safety and
  familiarity in a confusing world
• It is important to respect the persons memory
  without correcting ie believing a parent is
  still alive..correcting can re traumatize the
  person by reminding them of a past traumatic
  event. The correction will probably be forgotten
  in a few moments and so makes it a futile
  exercise for both caregiver and the person
• Confusion can also result from forgetting steps
  in doing a task, feeling overwhelmed by the
  number of things going on in the environment, or
  simple inability to recognize anything as
  familiar.

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BPSD Assessment

• Characterise the behaviour precisely with special
  attention to the circumstances under which it
  occurs. Was it gradual or sudden.
• If it appears inappropriate to us, consider
  whether the patient has an underlying goal or if
  they are misperceiving their environment or the
  situation
• Review the patients past psychiatric history,
  social history and premorbid personality.
• Review the medication list
• Be vigilant of the ongoing progression of the
  patients dementia and the potential change in
  symptoms
• Examine the patient with attention to changes in
  mental status from baseline. Look for signs of
  painful/uncomfortable physical conditions

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THANK YOU

• ANY QUESTIONS OR COMMENTS?
• Joanne Flood RPN, PG Dip Gerontological Nursing,
  MSc (Hons) Mental Health Nursing of Older People