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The Science and Art The Science and Art of Behavior Managementof Behavior Management
Kelly Trevino, PhD
Clinical Psychologist
VA Boston Healthcare System
GRECC Audio Conference SeriesJuly 29, 2010
AcknowledgementsAcknowledgementsNurse Managers
◦ Annette Couchenour◦ Steve McGarry◦ Connie Soule◦ Mary Farren
Nursing Director◦ Ronald Molyneaux
CLC Nursing Staff
Medical Staff◦ Dr. Juman Hijab◦ Jack Earnshaw
Psychiatrists◦ Dr. Mohit Chopra◦ Dr. Ronald Gurrera
OutlineOutlineBackgroundThe Science
◦Learning Behavior Model◦Person-Environment Fit Model◦Need-Driven Behavior Model
The Art◦Staff Training◦Behavior Management Team (BMT)◦Lessons Learned
Behavior Management Program Implementation
BackgroundBackground5.3 million persons in the U.S. have Alzheimer's
Disease1
11-16 million persons in US will have AD by 20502
In 2004: 136,174 veterans with dementia using VHA3
◦ 2022: 205,781
47% of nursing home residents have dementia1
◦ Up to 70% have memory problems4
~66% of community elders and ~77% nursing home elders with dementia have disruptive behavior5,6
Disruptive behavior associated with negative outcomes7-9
Psychotropic Medications and RestraintsPsychotropic Medications and Restraints
Psychotropic Medication◦Limited effectiveness10
◦Negative side effects11,12
Restraints13
◦Higher rate of falls◦Negative psychological outcomes
THE SCIENCETHE SCIENCE
The Science: Learning The Science: Learning Behavior ModelBehavior Model
Learned relationship between antecedents, behaviors, and consequences (ABCs of behavior management)14
◦ A=Antecedents=Triggers◦ B=Behaviors◦ C=Consequences=Reinforcement or Punishment
Manipulate antecedents and consequences to change behavior◦ Provide new learning experience
Comprehensive functional analysis important
The Science: Learning The Science: Learning Behavior ModelBehavior Model
Instrumental Conditioning Principles15
◦Reinforcer contiguity◦Response-reinforcer contingency◦Reinforcement
Problems with punishment◦Negative affective reaction◦Focus on avoiding punishment (rather than
improving behavior)◦Negativity can generalize to other stimuli
(person, environment, time)
The Science: Learning The Science: Learning Behavior ModelBehavior ModelCharacteristics of Interventions16-18
◦ Staff education Topics: Dementia, Psychiatric disorders, Behavior
problems, ABCs of behavior management, communicating with persons with dementia
Method: Didactic, discussion, role playing, video case vignettes, handouts
◦ Assistance with care planning◦ On-site supervision◦ Increasing resident participation in pleasant
events◦ Peer support◦ Caregiver problem-solving skills◦ Exercise program
The Science: Person-The Science: Person-Environment Fit Environment Fit Dementia increases vulnerability to the
environment19
◦ Stimuli affect people with dementia at a lower threshold
People with dementia have fewer coping resources
Poor fit b/w person and environment impairs functioning and increases disruptive behavior
Intervention◦ Create a familiar and comforting environment◦ Stimulate through reliance on remote memory
and positive emotions
The Science: Person-The Science: Person-Environment Fit Environment Fit Characteristics of Interventions20-22
◦Simulated presence therapy◦Activity programming Based on mental and physical abilities Adjust for mood and behavior Incorporate periods of stimulation and
rest◦Individualized music◦Environmental modifications◦In-home counseling
The Science: Need-Driven The Science: Need-Driven BehaviorBehavior
Normal needs + Abnormal conditions = Disruptive behavior23
◦ Behavior is response to unmet need
Adjust environment and build on strengths/preferences of individual to meet and prevent unmet needs◦ Consider sensory deficits
Treatment Routes for Exploration of Agitation (TREA)24
◦ Identify correlates of particular behaviors◦ Provide suggestions for changing the correlates
General GuidelinesGeneral GuidelinesBasic principles
◦Specificity ◦ Individualization◦Consistency: Implementation and
documentationBehavior may increase initially
◦Re-examine plan after 2-3 daysBehaviors are not
◦ Voluntary or purposeful◦ Rudeness◦ Due to a “bad attitude”◦ Attempt to make your job difficult
THE ARTTHE ARTBehavior Management Team (BMT)Behavior Management Team (BMT)
Boston VA CLC
BMT: CreationBMT: CreationRecognition of a problemWeekly interdisciplinary meetings
◦Psychology, nursing, medicineIdentified:
◦Problem◦Goals◦Process◦Staff Training◦Documentation
Staff Training: BMTStaff Training: BMTWhat is the BMT
◦ Explain why◦ Explain how◦ Get feedback/ideas
BMT Documentation◦ Focus on BMT Shift
Note
Outcome measures◦ Frequency of
behaviors◦ Severity of behaviors◦ Referrals to BMT◦ Medications for
behaviors◦ Inpatient psych
transfers◦ Code greens for
behaviors◦ Staff feedback on BMT
Staff Training: Functional Staff Training: Functional Analysis Analysis
Prevalence of behaviorsDifficulty of managing behaviorsDefine types of behaviors and correlates
DON’T PANICABCs of behavior managementUnmet needs
Questions for describing context of behaviors
ABCs of Challenging ABCs of Challenging BehaviorBehavior
Staff Training: Staff Training: Creating/Implementing Creating/Implementing Behavior PlansBehavior PlansBasic principles
◦Specificity ◦ Individualization◦Consistency: Implementation and
documentationBehavior may increase initially
◦Re-examine plan after 2-3 daysBehaviors are not
◦ Voluntary or purposeful◦ Rudeness◦ Due to a “bad attitude”◦ Attempt to make your job difficult
Questions for identifying new ABCs
Time
Start Behavior Plan
The Art: Behavior The Art: Behavior Management TeamManagement Team
◦BMT Members: Psychologist Nursing staff Nurse manager MD/PA Geriatric psychiatrist consulted, as needed
Identification of residents◦CPRS consult◦Direct communication from staff
The Art: Behavior The Art: Behavior Management TeamManagement TeamInclusion criteria
◦ Demonstrate physical and/or verbal behaviors that: Create potential harm/distress to the resident, staff, other
veterans Are difficult to manage (are not re-directable) Do NOT refer residents that are an immediate safety risk
Treatment implementation◦Functional analysis of behavior◦Create behavior plan
Set behavioral goal◦Monitor over time◦Change as needed◦Discharge when goal met 2 consecutive
weeks
The Art: Behavior The Art: Behavior Management TeamManagement Team
Weekly meeting on each unit◦Learning circle◦“Rounding”◦Meet with floor staff and PA, then consult
nurse manager
Documentation◦BMT Management Plan◦BMT Shift Note◦BMT Weekly note
The Art: Behavior Management Team
BMT Management PlanBMT Management PlanPrimary BMT Member:Reason for Referral:Behavior 1:Goal:Frequency of behavior: Disruptiveness: Not at all A little Moderately Very much
Extremely
Type of Behavior: Verbal Physical Non-aggressive Physical Aggressive
Psychology:Psychiatry:Recreation Therapy:Medical:Nursing:
BMT Shift NoteBMT Shift NoteTarget Behaviors (from BMT Management
Plan):1.Frequency of behavior this shift: Disruptiveness: Not at all A little Moderately Very much
Extremely
Times of behavior:Locations of behavior:Antecedents (what happened before):Interventions (what action was taken):Outcomes (Resident’s response to intervention):
BMT Weekly NoteBMT Weekly NoteSession Type: BMT RoundsTime spent discussing veteran:Review for week of:CONSULTATIONS:*******************************************************************Behavior: Goal:Frequency of behavior this week: Disruptiveness of behavior this week: Behavior frequency: Percent change from previous week: Disruptiveness: Description of behavior:a. Times: b. Locations: c. Antecedents (what happened before):d. Interventions (what actions were taken): e. Outcomes (resident's responses to intervention):*******************************************************************NEW RECOMMENDATIONS (based on today’s BMT Rounds): CONTINUED RECOMMENDATIONS (based on previous BMT assessments):
BMT OutcomesBMT Outcomes Participants
◦ n=24; Residents of the VA Boston CLC◦ Age: M=74.75; SD=11.39◦ Gender: 95.8% Male◦ Residential Status: LTC (54.2%); Rehab (37.5%); Transitional
(8.3%).◦ Approved by the IRB of the VA Boston Healthcare System.
Measures1. Demographic information: Age, gender, residential status2. BMT Shift Notes a.) Frequency of behaviors: b.) Severity of Behaviors
Method
◦ Medical record review of residents treated in the first six months of BMT implementation (July 28, 2009-February 1, 2010)
Lessons Learned: Behavior Lessons Learned: Behavior ManagementManagementPerson-centered care
◦Implement WITH the resident, not TO the resident
Interdisciplinary◦Consider role of MD/PA
IndividualizationConsistencyCommunication
◦Team ◦Ask/Talk to the resident
Dementia-care skills
Lessons Learned: Lessons Learned: Program ImplementationProgram ImplementationIdentify and include relevant
stakeholders◦Facility specific◦All services◦All levels
Union◦Include early
Intervention-setting fit◦Resources◦Limitations
Lessons Learned: Lessons Learned: Program ImplementationProgram Implementation
Education◦First step to buy-in
Hands-on demonstration◦Don’t be afraid to make mistakes
Observe impact and make changes◦Be flexible
Sustainability◦Repeat education◦Leadership support
Policy
QuestionsQuestions
ReferencesReferences1. Alzheimer’s Association (2010). 2010 Alzheimer’s Disease Facts and Figures
(2010). Alzheimer’s & Dementia, vol.6. http://www.alz.org/alzheimers_disease_facts_figures.asp
2. Hebert, L.E., Scherr, P.A., Bienias, J.L., Bennett, D.A., & Evans, D.A. (2003). Alzheimer disease in the U.S. population: prevalence estimates using the 2000 census. Arch Neurol, 60, 1119-1122.
3. Office of the Assistant Deputy Under Secretary for Health (2004). Projections of the prevalence and incidence of dementias including Alzheimer’s disease for the total, enrolled, and patient veteran populations age 65 or over. http://www.index.va.gov/search/va/va_search.jsp?QT=dementia&SQ=url:http%3A%2F%2Fwww4.va.gov%2FHEALTHPOLICYPLANNING%2F
4. Kraus, N.A., & Altman, B.M. (1998). Characteristics of Nursing Home residents-1996. Agency for Health Care Policy and Research, MEPS Research Findings No. 5, AHCPR Pub No. 99-0006. http://www.meps.ahrq.gov/mepsweb/data_files/publications/rf5/rf5.shtml
5. Bartels D.J., Horn, S.D., Smout, R.J., Dums, A.R., Flaherty, E., Jones, J.K., Monane, M., Taler, G.A., & Voss, A.C. (2003). Agitation and depression in frail nursing home elderly patients with dementia: Treatment characteristics and service. Am J of Geriatr Psych, 11, 231-238.
6. Chan, D.C., Kasper, J.D., Black, B.S., & Rabins, P.V. (2003). Prevalence and correlates of behavioral and psychiatric symptoms in community-dwelling elders with dementia or mild cognitive impairment: the memory and medical care study. Int J of Geriatr Psyc,18, 174-182.
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9. Conely, L. & Campbell, L. (1991). The use of restraints in caring for the elderly: realities, consequences and alternatives. Nurs Pract, 16, 48-52.
10. Schneider, L.S., Dagerman, K., & Insel, P.S. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14:191–210.
11. Schneider, L.S., Dagerman, K.S., & Insel, P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294:1934–1943.
12. Kales, H.C., Valenstein, M., Kim, H.M., McCarthy, J.F., Ganoczy, D., Cunningham, F., & Blow, F.C. (2007). Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications. American Journal of Psychiatry, 164, 1568 – 76.
13. Cotter, V.T. (2005). Restraint free care in older adults with dementia. Keio J Med, 54, 80-84.
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15. Tarpy, R.M. (1997). Contemporary Learning Theory and Research. McGraw Hill: Boston.
16. Proctor, R., Burns, A., Powell, H.S., Tarrier, N., Faragher, B., Richardson, G., et al. (1999). Behavioural management in nursing and residential homes: A randomized controlled trial. Lancet, 354, 26-29.
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dementia-specific training program for staff in assisted living residences. The Gerontologist, 45, 686-693.
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