Making Behaviour Management as easy as ABC! · behavioural and psychological symptoms of dementia — is it as easy as ABC? Angela Crombie Joy Boyd ... (remember communication is

Assisting Assisting ruralrural and and regionalregionalfacilitiesfacilities to manage people with to manage people with behaviouralbehavioural andand psychologicalpsychological

symptomssymptoms of of dementiadementia —— isis it as it as easy as ABC?easy as ABC?

Angela CrombieAngela CrombieJoy BoydJoy Boyd

Dr Tony SnellDr Tony SnellMarch 2007March 2007

BackgroundBackground

!! Regional Dementia Management Strategy Regional Dementia Management Strategy (RDMS)(RDMS)

!! 'Building the capacity of rural acute and 'Building the capacity of rural acute and residential aged care facilities to manage residential aged care facilities to manage challenging behaviour in dementia' projectchallenging behaviour in dementia' project

!! Both funded by Department of Human Both funded by Department of Human ServicesServices

Regional Dementia Management Regional Dementia Management StrategyStrategy ((RDMS)RDMS)

!! Outlines a pathway for dementia care from the Outlines a pathway for dementia care from the community, through the acute setting and back community, through the acute setting and back into the community or residential careinto the community or residential care

!! Provides decision trees, checklists and Provides decision trees, checklists and guidelines for dementia assessment and guidelines for dementia assessment and management at each stage along the care management at each stage along the care continuum continuum

Regional Dementia Management Strategy - Pathway Overview

Community Health:"Ambulance checklist"Police checklist"Primary care assessment pathway for GPs"HACC checklist"Day Centre checklist

Emergency Department:"Emergency department pathway for care of the 'confused older person'

Public Awareness Information:"Information brochure"Promotional poster

Displayed in community health centres & GP clinicsFor more information contact

www.alzvic.asn.au

Health professionals information:"Dementia information kit for HACC workers/PCAs

"Dementia information kit for Registered nursesAvailable in power point format

Acute Hospitals:"Barwon Health Delirium guideline

Residential Care:"ABC behaviour management model overview"ABC behaviour management model scenarios"Specific behaviour management strategies"Ten Top Tips for dealing with people who have dementia"Communication strategies"Referral protocols

RDMSRDMS

!! Carer focus groups were conducted with both Carer focus groups were conducted with both informal carers (family/friends) and with formal informal carers (family/friends) and with formal carers (acute, subacute and residential care carers (acute, subacute and residential care workers) throughout the region. workers) throughout the region.

!! A major theme that emerged from these focus A major theme that emerged from these focus groups was that challenging behaviours associated groups was that challenging behaviours associated with dementia are poorly managed and that the with dementia are poorly managed and that the staff working in acute and residential care facilities staff working in acute and residential care facilities ((RCFsRCFs) are not adequately trained to deal with ) are not adequately trained to deal with these challenging behaviours. these challenging behaviours.

What did we do about it?What did we do about it?

!! 'Building the capacity of rural acute and 'Building the capacity of rural acute and residential aged care facilities to manage residential aged care facilities to manage challenging behaviour in dementia' projectchallenging behaviour in dementia' project

!! Surveyed all acute & residential aged care Surveyed all acute & residential aged care facilities in the region:facilities in the region:!! Acute = 31Acute = 31

!! Residential aged care facilities = 71Residential aged care facilities = 71

What did we ask?What did we ask?

!! Questions to quantify the extent of challenging Questions to quantify the extent of challenging behaviours and the strategies and resources with which behaviours and the strategies and resources with which they are managedthey are managed

!! Both surveys consisted of six sections:Both surveys consisted of six sections:!! EnvironmentEnvironment!! PoliciesPolicies!! StaffingStaffing!! Staff education and trainingStaff education and training!! Behaviour managementBehaviour management!! GeneralGeneral

What did we find?What did we find?

!! Facilities in our region identified Facilities in our region identified shortcomings in their ability to manage shortcomings in their ability to manage effectively people with behavioural and effectively people with behavioural and psychological symptoms of dementiapsychological symptoms of dementia

!! Anecdotal evidence suggests that these Anecdotal evidence suggests that these shortcomings are not unique and are shortcomings are not unique and are actually common to all facilities, both actually common to all facilities, both regional and metropolitan regional and metropolitan

““Is your facility able to manage Is your facility able to manage people with dementia who display people with dementia who display

challenging behaviours?” challenging behaviours?”

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““Please describe the behaviours that Please describe the behaviours that you are not able to manage in your you are not able to manage in your

facility.” facility.”

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What did we do about it?What did we do about it?

!! Focused on the main training needs of regional Focused on the main training needs of regional nursesnurses

!! Developed a ‘Train the Trainer” education Developed a ‘Train the Trainer” education program for ‘dementia champions’program for ‘dementia champions’

!! Based education on the ABC behaviour Based education on the ABC behaviour management modelmanagement model

!! Provided resources for champions to use in their Provided resources for champions to use in their own facilitiesown facilities

Did it work?Did it work?

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16

Workshop 1 - July2003

Workshop 2 - August2003

12 month update -Nov 2004

Aver

age

scor

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pre postsustained

What is the ABC framework?What is the ABC framework?

A way of characterising events and resultant A way of characterising events and resultant behaviours:behaviours:

!! A = Activating eventA = Activating event!! B = BehaviourB = Behaviour!! C = ConsequenceC = Consequence

The ABC can be applied in all settingsThe ABC can be applied in all settings

ABCABC

!! A behaviour in response to an activating event A behaviour in response to an activating event generates a consequencegenerates a consequence

!! If the consequence is inappropriately managed, If the consequence is inappropriately managed, the situation may escalate & become another the situation may escalate & become another activating eventactivating event

Preventing & Managing Aggression

A = Activating EventTo prevent aggression, follow the Ten Top Tips for

dealing with people who have dementia. If aggression occurs establish the activating event, or trigger.

There is always an A.

B = BehaviourWhat happened as a result of A? Describe the actual behaviour, ie;

verbal/physical aggression; weapon used (urinal, walking stick etc)

STOP!Decision point!

Back off or continue?

C = ConsequenceWhat was the consequence of B?

Assess why the person was aggressive - are they unwell, in pain?Think about appropriate referrals - GP, pain management, Geriatrician, Aged

Persons Mental Health Service (APMHS)

D = Decide & DebriefWhat changes do you need to make -

environmental, staffing.How can you change A to better

manage B? Brainstorm!

D = De-escalateAllow time for recovery

Behaviour will escalate if it's not well managed.

Immediate management strategies:•Remove other people from danger•Remove potential weapons•Give the person space (stand back)•Communicate in a calm, non-confronting way - avoid asking 'What' or 'Why' - (remember communication is 55% body language, 38% tone of voice & only 7% words)•Encourage the person to talk about how they are feeling•Empathise, ie: I can see you are very angry, frightened etc………….•Allow the person time to talk through their issues & establish what the problem is (try to put yourself in their shoes)

See specific strategies to manage aggression for ongoing management.

Activating EventsActivating Events

!! When & where did the behaviour occur?When & where did the behaviour occur?

!! What was the person doing immediately before What was the person doing immediately before the behaviour occurred?the behaviour occurred?

!! What was happening around the person at the What was happening around the person at the time?time?

Assess environmental factors:Assess environmental factors:!! Noise (eg. TV loud, music loud, staff change of shift, meal timeNoise (eg. TV loud, music loud, staff change of shift, meal time

clatter)clatter)!! Clutter (eg. Furniture, people)Clutter (eg. Furniture, people)!! Bright lights/glare on the floorBright lights/glare on the floor!! MirrorsMirrors!! Temperature (eg. Too hot/cold)Temperature (eg. Too hot/cold)!! Recent changes to environment (eg. Renovations, staff/resident Recent changes to environment (eg. Renovations, staff/resident

changes)changes)!! Does the environment provide a safe area for residents to Does the environment provide a safe area for residents to

wander around?wander around?!! Does the environment encourage independence, dignity and Does the environment encourage independence, dignity and

mobility?mobility?!! Does the environment accept the client's cultural and lifestyle Does the environment accept the client's cultural and lifestyle

habits habits

Assess physical factors:Assess physical factors:

MetabolicMetabolic Hyper/Hypo thyroidism, Hypercalcemia, HyponatremiaHyper/Hypo thyroidism, Hypercalcemia, Hyponatremia

InfectionsInfections Urinary tract infection, pneumonia, septicaemiaUrinary tract infection, pneumonia, septicaemia

TraumaticTraumatic Chronic pain, head trauma, fractures such as hip & ribChronic pain, head trauma, fractures such as hip & rib

SystemicSystemic Hypoglycaemia, Vitamin B12 deficiency, folate deficiencyHypoglycaemia, Vitamin B12 deficiency, folate deficiency

MedicationsMedications Sedatives, antihistamines, alcohol, polypharmacySedatives, antihistamines, alcohol, polypharmacy

ImpactionImpaction FaecalFaecal

Adapted from Adapted from BanazakBanazak D. (1996) Difficult Dementia: Six steps to control problem behaD. (1996) Difficult Dementia: Six steps to control problem behaviours. viours. Geriatrics, Geriatrics, Vol 51:2Vol 51:2

Assess physical factors (cont):Assess physical factors (cont):

!! Has there been a recent change in medication?Has there been a recent change in medication?!! Does the person have:Does the person have:

!! Impaired vision or hearingImpaired vision or hearing!! Acute illnessAcute illness!! Chronic illness (eg; angina, CCF, Diabetes)Chronic illness (eg; angina, CCF, Diabetes)!! Chronic pain (eg; arthritis, ulcers, headaches)Chronic pain (eg; arthritis, ulcers, headaches)!! DehydrationDehydration!! Fatigue or physical discomfortFatigue or physical discomfort

Assess psychological factors:Assess psychological factors:

!! History of psychiatric illnessHistory of psychiatric illness

!! Recent loss or accumulation of lossesRecent loss or accumulation of losses

!! Appear sad Appear sad –– tearful, withdrawntearful, withdrawn

!! Past events Past events –– Post traumatic stress, P.O.W.Post traumatic stress, P.O.W.

!! Responding to hallucinationsResponding to hallucinations

BehaviourBehaviour

!! IPA defines BPSD as IPA defines BPSD as “Symptoms of disturbed “Symptoms of disturbed perception, thought content, mood or behaviour that perception, thought content, mood or behaviour that frequently occur in patients with dementia”. frequently occur in patients with dementia”.

BPSDBPSD

Behavioural symptomsBehavioural symptoms Psychological symptomsPsychological symptomsPhysical aggressionPhysical aggression AnxietyAnxiety

ScreamingScreaming Depressive moodDepressive mood

RestlessnessRestlessness ParanoiaParanoia

AgitationAgitation HallucinationsHallucinations

WanderingWandering DelusionsDelusions

Culturally inappropriate behavioursCulturally inappropriate behaviours

Sexual Sexual disinhibitiondisinhibition

HoardingHoarding

Constant questioningConstant questioning

CursingCursing

ShadowingShadowing

ConsequenceConsequence

!! What was the consequence of the behaviour for What was the consequence of the behaviour for the person, staff & others?the person, staff & others?!! IgnoredIgnored!! ReprimandedReprimanded!! RestrainedRestrained!! SedatedSedated

!! Very dependent on staff interpretation & Very dependent on staff interpretation & reaction to the behaviourreaction to the behaviour

CommunicationCommunication

55%38%

7%

Body languageTone & pitch of voiceWords we use

When reviewing the ABC with the When reviewing the ABC with the person, their family & the care team person, their family & the care team the following questions should be the following questions should be

posed:posed:!! What is the actual problem & whose problem is What is the actual problem & whose problem is

it?it?!! What are the contributing factorsWhat are the contributing factors!! How can we better manage this? Brainstorm How can we better manage this? Brainstorm

ideas to come up with an effective management ideas to come up with an effective management planplan

!! Where to from here? Is referral to a specialist Where to from here? Is referral to a specialist service required?service required?

What we learntWhat we learnt

!! Do not assume basic level of knowledgeDo not assume basic level of knowledge

!! Sustainable Sustainable -- focus on creating change in focus on creating change in attitudes & culture of careattitudes & culture of care

!! Build the capacity at a local levelBuild the capacity at a local level

!! Train the trainer Train the trainer -- develop peer supportdevelop peer support

ABC ResourcesABC Resources!! Ten Top Tips for Dealing with People who have DementiaTen Top Tips for Dealing with People who have Dementia

!! Do’s & Don’ts of CommunicationDo’s & Don’ts of Communication

!! ABC ScenariosABC Scenarios

!! Specific strategies Specific strategies

!! http://www.bendigohealth.org.au/Regionalhttp://www.bendigohealth.org.au/Regional--DementiaDementia--Management/default.htmManagement/default.htm

http://www.bendigohealth.org.au/Regional-Dementia-Management/default.htm

Scenario 1.

81 year old Mrs Betty Baxter has recently been diagnosed with dementia and has moved to Shady Haven Nursing Home. She is well known around the town as a forthright (some might even say argumentative) lady, and the local CWA , and the regional Red Cross all breathed a sigh of relief when she resigned from the committee.

Mrs (“I don’t like being called Betty”) Baxter has many medical problems and her medications were recently changed, with some doses having a higher dose with less tablets, due to her pharmacist recommending a cheaper brand.

Yesterday she refused her heart medication and became quite abusive and threw the glass of water, when the agency nurse tried to insist that

she take the medication as prescribed. When the nurse politely but firmly reminded Betty, that this was not appropriate behaviour, Mrs

Baxter slapped the nurse on the face.

Today her sister has come to visit and Betty will not allow her to come in to her room. Attempts by her sister to clarify the situation lead to verbal abuse and incoherent muttering.

What are the issues?

• For Betty ?• For the staff?

• Behaviour that is misunderstood and managed inappropriately may escalate.

• How would we apply the ABC of behaviour management?

A = Activating Event (what was the trigger)

B = Behaviour (what behaviour resulted)

C = Consequence What was the consequence

Scenario 2Mr Cyril Bogg is a retired security guard who has lived in an aged care facility for six months.

Staff have become increasingly concerned that over the last few weeks, Cyril has been wandering in to peoples rooms at night. He is becoming increasingly intrusive & has frightened several elderly woman after they awoke to find him in their room.

Staff are concerned at his manipulative behaviour as he is not intrusive through the day, and are worried that he has ulterior motives.

Attempts to get Mr Bloggs to return to his room are unsuccessful & usually result in a verbal abuse. The GP has just commenced night sedation.


• For Cyril?• For the staff?






Scenario 3AliceAlice is an 83 yr old lady, who, until recently lived at home

with 87 yr old husb. She has a long history of dependant personality / anxiety. Her daughter has recently moved to WA.

Since her daughter has left, Alice has refused to participate inactivities and the staff have begun using a wheelchair to encourage her to leave her room. Staff are aware that Alice is trying to make her daughter feel guilty and are becoming increasingly frustrated at Alice’s manipulative behaviour.

She resists the staff each time, crying out for her daughter, clutching at the arms of the nurses & crying inconsolably. When she is left alone her behavioural symptoms disappear.


• For Alice ?• For the staff?






Case Scenario 4PercyPercy is a 79 year old ex-hotelier, who ran a very busy

local pub. He was popular with the blokes for his sexist jokes( usually told over a cold glass of ale) & his ability to ‘sort out trouble’.

Since his stroke he has been unable to manage at home.Since his admission to the Hostel, Percy has been causing

several staff to feel uncomfortable because of his suggestive remarks.

He has also refused to eat with the other residents and refuses to leave the plates in the dining table alone.

Attempts to reason with Percy usually end in loud altercations and the staff have asked that Percy be admitted to a more appropriate environment.


• For Percy ?• For the staff?






Documents

Making Behaviour Management as easy as ABC! · behavioural and psychological symptoms of dementia — is it as easy as ABC? Angela Crombie Joy Boyd ... (remember communication is