CHALLENGING BEHAVIORS
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Persons with AD and other dementias generally are not intentionally difficult, irrational, stubborn, or angry. They simply cannot explain their needs or frustrations as they once could. Sometimes a person with Alzheimer’s becomes angry when they feel out of control or when they are asked to do more than they can handle. Assume that persons with Alzheimer’s are distressed by their loss of control and independence. They need help, support, guidance and validation of their emotional feelings.
Persons with AD and other dementias are adults and must be treated with dignity and respect at all times. Treating adults like children only makes things worse for everyone, especially persons with dementia, who are very sensitive to tone of voice and body language. They can “read” your gritted teeth, anger, impatience, rolling of your eyes, or shaking your head or a finger at them. Persons with dementia are more cooperative and trusting when they feel competent, successful, and understood
The Ten Absolutes
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Never argue; instead agree
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Never shame; instead distract
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Never say remember; instead reminisce
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Never say “you can’t”; instead say “do what you can”
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Never condescend; instead encourage and praise
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Never reason; instead divert
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Never lecture; instead reassure
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Never say “I told you”; instead repeat
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Never command or demand; instead ask or model
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Never force; instead reinforce
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Tips for Working with Behaviors:
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Remember: Behavior has meaning and can be a symptom of the illness or a response to a stressful environment or an unmet emotional or physical need.
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Rethink: Is the behavior harmful or scary to the person or others or can you accept it?
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Redirect: If the person is pacing, agitated, or scared, provide a more positive activity, such as a walk, a dusting job, or a memory box to sort through.
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Remind: Take every change to greet and let the person know that you think of him/her often.
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Restrict: Stop the person from doing things that are harmful. Take dangerous objects from their room.
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Celebrate and capitalize on retained skills. Give a former a nurse a clipboard for charting, for example.
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Create moments of fun.
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Distract: Snacks, treats, a cup of tea, a rock in the rocker, an offer of a manicure, or even a hug may divert or calm an agitated person.
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Soothe: Note security objects that reassure and comfort the person – a sweater over the shoulder or a favorite hat or purse can be offered when the person is upset.
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Reassure: Say, “I know you’re upset. May I help you?” If the person is searching frantically, calmly join in his/her search while suggesting that you know you can find the lost item together. Let him/her know that he/she is not alone and that you understand how important the missing item is to him/her.
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Be present: Nothing comforts better than standing by a person who is upset, offering sympathy, understanding, a shoulder to cry on, a tissue, or a knowing kind look. Do not ask a lot of questions.
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Routines, rituals, repetition: Knowing what is to happen next reassures people with Alzheimer’s and other dementias. Bedtime or late afternoon rituals help, such as handing a resident his/her favorite afghan or playing his/her favorite audiotape or videotape.
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Slow down and simplify: Avoid busy, crowded or noisy places when the person is upset or needs to concentrate on a task. Rushing scares and confuses people with dementia.
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Back down from accomplishing tasks if the person with dementia becomes upset. Say, “This isn’t a good time for us to do this. Let’s try again later.”
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Break down big tasks into small pieces: Provide one-step guidance and tell the person that you two are doing fine after each step.
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Compensate: Do for her what she can no longer do with ease.
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Let forgetting work for the person. Don’t remind, argue, scold, lecture, or confront persons with dementia after an outburst.
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Safety precautions help: Prevent wandering or accidents by disguising exits with stop signs or black floor mats, or by alarming exits.
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Register all persons with dementia, especially wanderers, with the Alzheimer’s Association’s Safe Return Program. Contact your local Chapter for more information.
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Be a model: Let other caregivers see you reassure or distract a the person so they can learn from your approach.
IDEAS TO CONSIDER WHEN DEALING WITH CHALLENGING BEHAVIORS
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Play quiet music in the late afternoon instead of loud TV
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Try to remember that the person does not have control over behavior. The inability of the brain to sort out a confusing environment can be causing the behavior
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Never restrain or attempt to restrain the person
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Do not argue with persons with dementia
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Do not ask the person to explain what is bothering him; he doesn’t know and can’t tell you
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If the person is restless, try to get him interested in some quiet activity like folding towels
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If the person is on medication, check with the doctor about appropriate schedules
UNDERSTANDING DIFFICULT BEHAVIORS
Caregivers may find it helpful to try to understand why the person with dementia is behaving in a certain way. If caregivers can figure out what may be causing or triggering the behavior the behavior, it may be possible to prevent it from recurring.
An unmet emotional and/or physical need is behind most challenging behavior.Some of the potential causes may be the following:
Causes related to the person’s physical & emotional health
Effects of medication
Sensory impairment
Acute illness
Urinary tract infection
Pneumonia
Fever
Dehydration
Constipation
Depression
Fatigue
Physical discomfort
Causes related to the environment
Too large, too cluttered
Excessive stimulation
No orientation information or cues
Poor sensory environment
Unstructured area, unfamiliar
Causes related to task
Task too complicated
Too many steps combined
Task not modified for increasing impairment
Task unfamiliar
Causes related to communication
Not understanding what is being said
Inability to make themselves understood
Caregiver using the wrong approach
SUNDOWNING
Behavior problems may worsen in the late afternoon and evening, possibly after a day’s activities, when everyone is tired and less able to handle stress. Often the person with dementia feels they should be doing something, yet don’t remember what it is, since this is the time they would normally be either coming home from work or making the evening meal etc. This time often brings about increased confusion, agitation and anxiety, along with pacing, wandering, wringing hands, and intensification of any behavior problem.
Encourage a nap or quiet time with soft music after lunch if it does not interfere with sleeping at night.
An early dinner or late afternoon snack may help.
Decrease your expectations of the person during this time of the day.
It may be helpful to encourage the person to either tell you what they typically would do at this time of day, or maybe help you with things that would make them feel useful. If you know about things they did during this time of day assure them that those things are being done, such as milking cows, picking up groceries, making dinner etc.
Reassure the patient that you are with him, and perhaps involve him in a simple task near you.
Schedule daily routines that require cooperation, such as baths and medications, to another time of the day.
Reduce the number of stimulating large group activities in the late afternoon and evening.
Alternate activity with programmed rest if coping abilities appear consumed by normal activities.
Observe situation to determine if there is a specific cause for the behavior.
Allow person to pace in a visible, secure area. Do not restrain. Take for a walk if possible.
Increase security and comfort by offering stuffed animals, soothing music, and the opportunity for a favorite activity.
Schedule appointments and trips for the earlier part of the day.
ABC METHOD
One method of managing difficult behavior with Alzheimer’s patients is called the ABC Method of problem solving.
All behaviors result for a cause. Determining what conditions seem to trigger a behavior can help in managing behavior.
First: Identify problem behavior
Look at only one behavior at a time
Observe clearly and objectively, only what you see
Second: Identify what happened immediately before the behavior or the specific caregiver or approach being used
Third: Identify what happened immediately after the behavior
Usually our energy is directed at(which we do to try to control the behavior)
If we shift that energy to(what triggers the behavior) we may be more effective at changing the behavior.
This will not happen quickly but when we consistently try the same approach, we will probably see some resulting change in the behavior.
This type of behavior management is called antecedent or stimulus control.
CATASTROPHIC REACTIONS
Definition: An Over Reaction to a Common Simple Occurrence
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Loud Noise – Radio – TV – Person
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Multiple questions
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“Why” questions
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Feeling insecure – Being left out
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Small accidents
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Being reprimanded
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Arguments
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Tense or irritable caregiver
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Over extended capabilities
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Changing living environment
The 5 R’s in Dealing with Catastrophic Reactions
Remain Calm
Respond to Feelings
Reassure the Person
Remover Yourself
Return Later
Physical Aggression
People with dementia often resort to a primitive means of communicating such as screaming and hitting.
Professional staff or family caregivers can quickly become frustrated and discouraged. The negative effects of this stress include emotional exhaustion, decreased feelings of personal achievement, and increased resentment toward and detachment from residents. Training staff in the use of effective behavior management strategies provides them with alternatives to physical and chemical restraints. It also empowers them to handle challenging situations in ways that increase their sense of personal achievement and self-esteem.
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Providing choices to the person with dementia when appropriate
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Validating their realities and concerns
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Responding to persistent persons in a calm, patient manner
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Instructing the person in a basic step-by-step process
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Encouraging a persons attempts at common tasks to maintain remaining capabilities
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Using behavior management strategies, such as redirection and diffusion, taught in training sessions
No magic formulas consistently resolve the problems encountered by caregivers who care for older people with dementia, but providing them with a variety of approaches and strategies that promote confidence and competence will improve caregiver morale, and most important, improve the quality of dementia care.