Dementia, Part III Handout #1

Anatomy of a Behavioral Symptom

Person perceives unmet need (such as need for space, communication, self-esteem, autonomy, personal identity, own time, comfort, cognitive understanding)

AND

Feels a threat to safety, security, self-esteem, independence

AND

Experiences anxiety (mild to severe)

AND

Feels a loss of control and helplessness

AND

Person makes an effort to decrease anxiety and restore feelings of controls

AND

Person uses behaviors which have been successful in the past to reduce anxiety and restore feelings of control

Dementia, Part III Handout #2

Behavior Management Strategies(note to facilitator: these are examples and are not all-inclusive)

• Manipulative Behaviors– Give choices– Provide information and ask questions– Help make decisions and follow up– Provide positive reinforcement– Avoid power struggles– Know what makes you feel angry

• Unjustified Complaining– Listen– Assure that appropriate care has been provided– Set limits on same issue– Don’t ask how resident feels– Give lots of reassurance– Reinforce positive aspects about resident– Ask entire staff to take turns with resident– Make list of positive topics; change topics often

• Unsafe Movement– Approach calmly; do not startle– Give person interesting object to hold– Create safe environment– Install pressure alarms– Use seating devices– Teach resident how to call for help– Schedule regular supervised periods of physical movement– Place large mat on floor with soft barricades and allow person to move freely on mat

• Sleep Disturbance– Reorient if confused and remind that it is time to sleep– If frightened, give comfort– Allow resident to get up – Provide snack, activity, etc.– Provide regular exercise– Reduce daytime napping– Reduce caffeine in late afternoon and evening– Provide relaxing bedtime routine– Do not set bedtime too early– Is resident in pain?– Observe sleep patterns and accept preferences

Dementia, Part III Handout #3

Developing a Plan for Behavioral Intervention

The most effective interventions in dealing with the stressed, confused person will vary from situation to situation. Certain basic factors should be considered in any plan of care:

1. Assess patient’s previous coping mechanisms to stress. Marked deviation may alert staff to patient’s deteriorating abilities to use previously effective methods.

2. Assess which of the commonly used interventions appear to be effective; e.g., diversion, music, walking. Try them first.

3. Recognize that radical changes in routines and happenings will greatly challenge the declining capabilities of demented persons and will be stressful. Avoid them, if possible.

4. Provide structure, order and consistency.

5. Give the person as much control in situations as they are capable of handling.

6. Include families when planning care. Previous behavioral patterns can be explored and validated.

Professional caregivers need to carefully observe, assess and record the person’s behavioral patterns in stressful situations.

Dementia, Part III Handout #4

ABC Behavior Questionnaire

Antecedent – What happened just before the behavior began?

Date: __________________________________ Time of Day: _________________________

Where did the behavior occur? (e.g., dining room, day room, bathroom, hallway, etc.)

______________________________________________________________________________

Who was with the person?_________________________________________________________

Behavior – What did the person do?

Briefly describe the event _________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Consequences – What were the consequences of the person’s behavior? Were there serious safety consequences?

What actions were taken by the staff? _______________________________________________

______________________________________________________________________________

______________________________________________________________________________

If you were present with the person when the behavior occurred, did you anticipate it? If so, what were the clues?_________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

List strategies for prevention:______________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Dementia, Part III Handout #5

Scenario #1 (activities directors)

Mrs. Jones is participating with other residents in a craft activity. She appears to be having difficulty completing a simple task. Mrs. Jones is becoming more agitated and anxious. Suddenly, Mrs. Jones becomes very upset and starts to scream and strike out at other people.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #6

Scenario #2 (nursing)

It is 9:00 a.m. and time for Mr. Smith’s bath. He gets upset when bath time is announced and insists he has taken one himself earlier in the morning. He has to be almost dragged into the bathroom. Often he becomes combative, flailing his arms and shouting obscenities whenever anyone turns on the water and starts to undress him. Appearing to be stubborn and uncooperative, Mr. Jones insists he can bathe himself. He becomes more and more agitated as bath time progresses.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #7

Scenario #3 (any staff)

Mrs. Miller was an attractive, sprightly woman in her early 60s who appeared alert, socially prominent and sweet to all casual visitors. She always dressed in a suit and heels every day, and she always seemed to be on her way someplace. She was often found in other women’s rooms rearranging the drawers, cleaning their closets, or picking up fruit and candy left by other visitors. She even took silverware from the dining room after each meal. She didn’t respond well to being told that those things didn’t belong to her. Finally, she would often return to her room, yelling at her roommate to, “Get out of here! You don’t belong here – that’s my sister’s bed!”

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #8

Scenario #4 (administration, office staff)

Mr. Ellison, a 72-year-old former businessman, hung around the front door of the nursing home politely asking for a “lift home.” He usually said his car was in the shop, and his wife wouldn’t help him out. One time, he was seen thumbing a ride in front of a facility, dressed like an executive on his way to the country club. When his wife visited him at the facility, he always followed her outside to her car. A struggle would follow and she usually left in tears. He called her constantly from the private phone in his room, sometimes telling her that he was in prison, and she needed to come right over with the bail money. He often asked the nurses when the next train left for his home. At these times, he told visitors that he was either in a hotel (which burned down twenty years before) or his country club restaurant. (Much to everyone’s amusement, he never failed to leave a tip in the nursing home dining room.) Occasionally, his room became “his office” and his bedside table, “his files.” The staff questioned their liability with his need for constant surveillance. One cold night, he was picked up by the police wandering in a nearby neighborhood in his pajamas. Exposure or exploitation is a realistic risk. He called newspapers regularly, stating that he was being held against his will. He also called the sheriff’s office, police station, and his attorney at all hours. Unfortunately, due to his previous prominence, he aroused public statement with his pleas for “justice and freedom.” As if this weren’t bad enough, several other memory-impaired residents of the facility began following him out the door like robots.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #9

Scenario #5 (any staff)

Mr. Pierson, a 78-year-old former attorney, stayed home for several years after his diagnosis of dementia. His wife would be driven to distraction with little things – each morning he’d count his underwear and turn to her insisting someone had stolen some of it during the night.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #10

Scenario #6 (any staff)

Mrs. Thomas, a 66-year-old dementia patient in a rest home, would constantly fiddle with her false teeth, trying to flush them down the toilet each night. She accused her roommate of wearing her teeth all the time.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #11

Scenario #7 (dining services)

Mrs. Bacon, an 80-year-old dementia patient, told everyone in the nursing home dining room that she was forced to move into “this poor house” when her children stole all her money and sold her house while she was vacationing in Florida. The house was sold during her hospitalization to pay for her nursing home care. Before her hospitalization, Mrs. Bacon used up all her savings buying bogus magazine subscriptions from unscrupulous door-to-door salesmen. Her children took measures to protect her only after they realized what she was doing.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #12

Scenario #8 (any staff)

Mr. McAden, a 74-year-old AD patient, was sure he was being watched all the time. He hid everything in the flowerpot dirt in his room, but he could never remember where it was hidden. He was sure his orderly waited for him to go into the bathroom before stealing his glasses, socks or money.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #13

Scenario #9 (administration, office staff)

Mrs. McAlpin, a newly admitted dementia resident, appeared sweet and compliant to staff. Her daughter would arrive each day after work to hear her mother say that she was too weak to visit much because she was still waiting for her breakfast tray. Her daughter knew her mother only as a strong, proud woman who never complained, never told stories on people, and never got others into trouble. Her daughter felt guilty enough about the placement without hearing her worst fears of patient neglect borne out in her mother’s situation. The staff knew little about Mrs. McAlpin’s previous personality. When they saw the daughter storming toward the administrator’s office, all they thought was “another guilty daughter here to stir up trouble for us.”

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #14

Scenario #10 (nursing)

Mr. Smith, the wanderer, also has delusions. He believed he was in jail about to be put on trail unjustly. He believed his room was an office and his bedside table was his file. Before he came to the facility, his wife cared for him at home 24 hours a day. In spite of her constant attention, he accused her of having affairs with the actors on the soap opera she watched each afternoon.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #15

Scenario #11 (nursing)

Mrs. Bollman, an 88-year-old AD patient, would get up each night and creep out to the nursing station. She’d whisper, “There’s a man in my bed who won’t let me get a minute’s peace. You, girls, should patrol this place better!”

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #16

Scenario #12 (any staff)

Reverand Simmons, a 70-year-old AD patient, often came roaring out of his room shouting, “Yes, Lord, I’m coming. I’m your servant, Lord ...” He insisted that a messenger from God visited him and told him what needed to be done to rescue the sinners in this facility.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #17

Scenario #13 (dining services and nursing)

Mrs. Manning told her doctor, on his monthly visits, that her food was poisoned with bugs. As soon as she swallowed a spoonful of soup, the bugs crawled all over her throat. She knew they were there because they also crawled up and down her arms when she lay in bed at night. She was terrified to sleep or eat, and kept a constant vigilant eye. She suggested her doctor report the facility to the health department sanitation board.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #18

Scenario #14 (nursing)

It was time for Ms. Morris’ bath and none of the personal care attendance wanted to do it. Ms. Morris was stubborn about bathing – she would get real uppity and insist she had taken one herself earlier. As Helen walked into the room, Ms. Morris was standing with her back to the door rocking a doll and singing. Helen approached and reached out to put the doll down. Ms. Morris whirled around, striking Helen in the face with her free hand and screaming, “You witch, get out of here before I call the police!” The day before Mrs. Morris told Helen that she was the “best nurse on the floor.” Two days earlier, Ms. Morris attended a baking activity group in which she stirred the flour and liquid and some of the flour was brushed out of the bowl onto her skirt. She suddenly became hysterical, shouting “It didn’t work again. I made a mess again. I’m no good to anybody – I’m gonna kill myself.” She couldn’t be consoled for the rest of the afternoon.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #19

Scenario #15 (nursing and therapy)

Mrs. Keller, an 84-year-old AD patient (with the energy level of a five-year-old), became impossible to manage from about 5 p.m. until after midnight. She screamed if confined in a Geri chair, or she’d pace up and down the same hallway near the front door, pulling at her clothes, and mumbling, “Help me – I wanna die!” Sometimes, she’d even pull long and hard enough on her clothes that they would tear or come off. She scared the afterwork visitors away with her strange, hysterical appearance or her constant begging of each visitor to “take me home!” After dark, she’d get worse. She would empty clothes out of her drawers, packing them in any available container for her “trip home.” The nurses requested extra sedation, but her children wouldn’t allow the doctor to “drug” their mother. At the same time, her children were so embarrassed by her behavior that they visited only briefly after church on Sunday mornings. The nurses resented Mrs. Keller’s children’s “tying their hands” in their efforts to restrain her and they resented Mrs. Keller’s hanging around the nursing station during each shift’s report, making them all nervous with her constant fidgeting.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #20

Scenario #16 (any staff)

The staff had been forced to remove everything from Mrs. Krummen’s room. She was constantly putting things in her mouth that could be poisonous or dangerous. Last week she put the dirt and a loose button in her mouth. Her room was so barren and unstimulating that she preferred to sit in the living room and watch the fish rank. Her daughter was horrified to walk in one day and see her mother putting the pebbles from the bottom of the fish tank into her mouth. “Can’t you people protect her any better that that? This place is dangerous to her health!” said the angry daughter as she marched to the nursing station pulling pebbles out of her mother’s mouth.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #21

Scenario #17 (any staff)

Mr. Monroe had few pleasures left in his life, and the staff hated to deny him cigarettes. He frequently burned his fingers and mouth on the cigarettes, even when smoking in supervised areas. One evening, smoke from Mr. Monroe’s room set off the facility fire alarm. As the nurse rushed in, she was able to stamp out the fire on his lap blanket as it dropped to the floor. The staff couldn’t figure out how he had found a cigarette. They learned that, two weeks prior, he paid his roommate’s grandson $5.00 to find him a cigarette. The boy had long since forgotten about it.

List things that may be causing problem(s)

Antecedent/Cause

Behavior

Consequences

Dementia, Part III Handout #22

Session Evaluation

Session Title: Dementia, Part III: Behavioral Interventions Date: ________________

Name: ________________________________________________________________________

Thank you for taking a few minutes to complete this questionnaire. Your candid, honest responses will be instrumental in helping us evaluate this session.

What do you like best about this session? ____________________________________________

______________________________________________________________________________

What do you like least about this session? ____________________________________________

______________________________________________________________________________

Were the objectives for the session met? Yes No

Please Comment: _______________________________________________________________

Please circle your most appropriate response to the next series of questions on a 1-5 scale, where 1 is the lowest rating and 5 is the highest.

Did the Instructor ...

1. Make efficient use of class time? (lowest) 1 2 3 4 5 (highest)

2. Stimulate you to discover new things on your own? (lowest) 1 2 3 4 5 (highest)

3. Make you feel comfortable? (lowest) 1 2 3 4 5 (highest)

4. Pace the session well? (lowest) 1 2 3 4 5 (highest)

5. Cover the expected material? (lowest) 1 2 3 4 5 (highest)

6. Show enthusiasm for teaching? (lowest) 1 2 3 4 5 (highest)

7. Use examples/illustrations to clarify instruction? (lowest) 1 2 3 4 5 (highest)

8. Prepare and have good knowledge of the subject? (lowest) 1 2 3 4 5 (highest)

What suggestions do you have for improving this session?_______________________________

______________________________________________________________________________