11/19/2014

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Reframing Challenging Behaviors: 

Meeting Unmet Needs & Learning to Interpret & Respond When Dementia is Part of the 

Picture 

What Causes Distress or Resistance?

• Mis-match between:– What we expect versus what happens

– What we can do versus what is needed

– What was versus what is

– What we want versus what we get

– What we want versus what the other wants

– Who we are with versus who we want to be with

– Where we are versus where we want to be

– Who we are versus who we want to be…..

Why Is This So Difficult for People Living with Dementia?

• MANY abilities are affected– Thoughts– Words– Actions– Feelings

• It is variable – Moment to moment– Morning to night– Day to day– Person to person– Place to place 

• Some changes are predictable BUT complicated– Specific brain parts– Typical spread– Some parts preserved

• It is progressive… – More brain dies over time– Different parts get hit– Constant changing

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What Do We Notice First?

In most cases BEHAVIOR!!!!

What behaviors are we talking about?

So WHY is this happening?

What is DRIVING the Behavior?

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My Examples • No F PoA or HC PoA –• Going to MD problems• ‘Losing’ Important Things• Getting Lost – time, place, situation• Unsafe task performance• Repeated calls & contacts• Refusing help & care• ‘Bad mouthing’ you to others  • Making up stories ‐ confabulation• Undoing what is done• Swearing/cursing, sex talk, racial slur, 

ugly words• Making 911 calls• Mixing day & night• Sleep problems – too much or too little• Not following care/rx plans ‐ denying• No initiation – can’t get started• Perseveration – can’t stop repeating• Not talking any more

• Paranoid/delusional thinking• Shadowing ‐ following• Eloping or Wandering• Seeing things & people not there ‐

hallucinations• Getting ‘into’ things• Threatening caregivers• Undressing in public – not changing 

when needed• Problems w/intimacy & sexuality• Being rude ‐ intruding• Feeling ‘sick’ – not doing ‘anything’• Use of drugs or alcohol to ‘cope’• Striking out at others• Falls & injuries• Contractures & immobility• Infections & pneumonias• Problems w/ eating or drinking

Rethink ‘Challenging Behaviors’REFRAME asUnmet Needs

Top TEN!

Unmet Physical Needs• Hungry or Thirsty

• Tired or Over‐energized

• Elimination – need to/did

• Discomfort – not right for me

– Temperature, texture, fit, senses

• IN PAIN!!!– Joints ‐ skeleton

– Inside systems (head, chest, gut, output)

– Creases or folds & skin

– Surfaces that contact other surfaces

Unmet Emotional Needs

• Angry

• Sad

• Lonely

• Scared

• BORED

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What Makes ‘BEHAVIORS’ Happen?

• SIX pieces…

– The person & who they have been

• Personality, preferences & history

– Other medical conditions & sensory status

– The type & level of cognitive impairment … NOW

– People ‐ How the helper helps ‐

• Approach, behaviors, words, actions, & reactions

– The environment – setting, sound, sights

– The whole day… how things fit together

First Piece of the Puzzle

The person & who they have been• Personality, preferences & history

Life Long Personality Traits & Preferences Make a Difference

• We are more of who we have always been… UNLESS

• We have always been covering up who we really are – we decide to ‘let go’…  OR

• Dementia robs us of our ability to be the way we want to be… OR

• Dementia causes us forget ‘how’ we are supposed to be and lets us be ‘free’

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Personal Preferences Matter

• We like what we like!

• With DEMENTIA the ‘likes’ can change

• Old preferences will need to be revisited

• The Challenge is to HONOR what is important BUT change what is needed

• Our willingness to meet the person’s changing NEEDS is essential

• Changes are made harder by our sense of LOSS and GRIEF

Some Personal Preferences 

• Appearance

• Behaviors

• Language

• Daily routines

• Foods & Drinks

• Music

• Touch & Textures & Noise & Space

• Worship – Spiritual practices

How Does Dementia Affect This?

• Memory

• Language – understanding & production

• Self‐care skills

• Sensation

• Emotional control

• Reasoning & thinking

• Vision

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How Might This Work with YOU?

Personality traits

Personality Traits

Who are you? 

• Introvert‐Extrovert

• Lots of Details – Big Picture only

• Logical – Emotional

• Planning ahead – Being in the moment

Who is the person you are trying to help?

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Some ‘stuff’ we think/feel people do on purpose

is really just ‘WHO’ they are

Which is BETTER?

There is no BETTER

Just Different…

Just Ranges…

What About the Person with Dementia?

• They are at HOME

• They have needs – how will we help?

• How can we change the environment to help?

• Who needs to know this?

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Second Piece of the Puzzle

Other medical conditions

Sensory status – vision, hearing, sense of touch, balance, smell, taste

Medications

Third piece of the puzzle:type(s) and current state of 

dementia…

Complicated!!!!

The Three D’s:

Is it dementia?

Is it JUST dementia?

Is it dementia PLUS?

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DementiaDeliriumDepression

What’s What?

What’s What – For Each D

• Onset

• Hx & Duration

• Alertness & Arousal

• Orientation responses

• Mood & Affect

• Causes

• Treatment for the cause/condition

• Treatment for the behavioral symptoms

Determine First –Is this Dementia, Delirium, OR 

Delirium?• Delirium can be dangerous & deadly

• Get a good behavior history – look for change

• Assess for possible PAIN or discomfort

• Assess for infections 

• Assess for med changes or side effects

• Assess for physiological issues – dehydration, blood 

chemistry, O2 sat

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2nd –Is it Dementia or Depression

• Depression is treatable

• Many elders with ‘depression’ describe themselves as having ‘memory problems’  or having ‘somatic’ complaints

• Look for typical & atypical depression

• Look for changes in appetite, sleep, self‐care, pleasures, irritability, ‘can’t take this’, movement, schedule changes

If it looks like dementia…

• Explore possible types & causes

• Explore what care staff & family members know and believe about dementia & the person

• Determine stage or level compared with support available & what we are providing

• Seek consult and further assessment, if documentation does NOT match what you find out

Alzheimer’sDisease

•Young Onset•Late Life Onset

VascularDementias(Multi-infarct)

Lewy Body Dementia

DEMENTIA

Other Dementias•Genetic syndromes•Metabolic pxs•ETOH related•Drugs/toxin exposure•White matter diseases•Mass effects•Depression(?) or Other Mental conditions•Infections – BBB cross•Parkinson’s

Fronto-Temporal Lobe Dementias

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Dementia – What Changes?

• Structural changes –permanent

– Cells are shrinking and dying

• Chemical changes ‐ variable

– Cells are producing and sending less chemicals

– Can ‘shine’ when least expected – chemical rush

Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains

G. Small, UCLA School of Medicine.

Normal Early Alzheimer’s

Late Alzheimer’s

Child

Normal Brain Alzheimers Brain

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Learning & Memory Center

HippocampusBIG CHANGE

Understanding Language – BIG CHANGE

Hearing Sound – Not Changed

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Sensory StripMotor StripWhite Matter ConnectionsBIG CHANGES

Formal Speech & LanguageCenter

HUGE CHANGES

Automatic SpeechRhythm – Music

ExpletivesPRESERVED

Executive Control Center

Emotions Behavior  JudgmentReasoning

Vision Center – BIG CHANGES

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So, You are NOTICING CHANGES…

What Should You DO?

Get it assessed –

Think about what needs to CHANGE!

The Real Three D’s

Dementia

Delirium

Depression

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REALITY…

• Its NOT 3 clean or neat categories

• The 3 are MIXED together

• Which ‘D’ is causing what you are seeing NOW?

• Are all three D’s being addressed?

– Immediate

– Short‐term

– Long‐term

What Could It Be?

• Another medical condition

• Medication side‐effect

• Hearing loss or vision loss

• Depression

• Acute illness 

• Severe but unrecognized pain

• Other things…

Drugs that can affect cognition

• Anti‐arrhythmic agents

• Antibiotics

• Antihistamines ‐decongestants

• Tricyclic antidepressants

• Anti‐hypertensives

• Anti‐cholinergic agents

• Anti‐convulsants

• Anti‐emetics

• Histamine receptor blockers

• Immunosuppressant agents

• Muscle relaxants

• Narcotic analgesics

• Sedative hypnotics

• Anti‐Parkinsonian agents

Washington Manual Geriatrics Subspecialty Consults edited by Kyle C. Moylan (pg 15) – published by Lippencott, Wilkins & Williams , 2003

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Another Complication:Progression

More changes over time

Not a stable condition

Progression of Dementia

What Level Is the Person At?

Stages – in a positive way

SapphiresDiamondsEmeraldsAmbersRubiesPearls

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GEMS a positive approach…

Sapphires – True Blue – Slower BUT Fine

Diamonds – Repeats & Routines, Cutting

Emeralds – Going – Time Travel – Where?

Ambers – In the moment - Sensations

Rubies – Stop & Go – No Fine ControlPearls – Hidden in a Shell - Immobile

Fourth Piece of the Puzzle

YOU

AND OTHERS

What shouldn’t we do???

• Argue

• Make up stuff that is NOT true

• Ignore problem behaviors

• Try a possible solution only once

• Give up

• Let them do whatever they want to

• Force them to do it 

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So WHAT should we do???

Build  & Use Skills!

Remember

who has the healthy brain!

Believe ‐

People with dementia

Are doing

The BEST they can!

Fifth Piece of the Puzzle

Environment

Physical

Sensory

Social

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Looking At the Environment

What Helps – What Hurts???

Supportive Environments

• Include 2 Factors

– What you LIKE…

Supportive Environments

• Include 2 Factors

– What you LIKE…

– What’s GOOD for you!

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Supportive EnvironmentsThe 3 Positive P’s

• Physical Environment

• People—the ways they act and respond

• Programming

Finding Balance

• Support or impair

• Too much or too little

The Supportive Sensory Environment

• What you See• What you Hear• What you Feel• What you Smell• What you Taste

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Environments Can

Support Life!

Use them Wisely

Sixth Piece of the Puzzle

Daily Routines and Programming

Filling the Day with Valued Engagement

Gem Level Programming

Examples of Meaningful Activities

•Productive Activities – sense of value & purpose

•Leisure Activities – having fun & interacting

•Self‐Care & Wellness – personal care of body & brain

•Restorative Activities – re‐energize & restore spirit 

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Productive Activities

• Helping another person

• Helping staff

• Completing community tasks

• Making something

• Sorting things

• Fixing things

• Building things

• Organizing things

• Caring for things

• Counting things

• Folding things

• Marking things

• Cleaning things

• Taking things apart

• Moving things

• Cooking/baking

• Setting up/breaking down

• Other ideas….

Active Passive

• Socials

• Sports

• Games

• Dancing

• Singing

• Visiting

• Hobbies

• Doing, Talking, Looking

• Entertainers

• Sport Program/event

• Presenters

• Lobby sitting

• TV programs – watched

• Activity watchers

• Being done to

Leisure Activities

Cognitive Physical

• Table top tasks

– Matching, sorting, organizing, playing

• Table top games

– Cards, board games, puzzles…

• Group games– Categories, crosswords, word 

play, old memories

• Exercise

• Walking

• Strengthening tasks

• Coordination tasks

• Balance tasks

• Flexibility tasks

• Aerobic tasks

• Personal care tasks

Self‐Care & Wellness Activities

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Rest & Restorative Activities

• Sleep – Naps

• Listen to quiet music with lights dimmed

• Look at the newspaper

• Look at a calm video on TV screen

• Rock in a chair

• Swing in a porch swing

• Walk outside

• Listen to reading from a book of faith

• Listen to poetry or stories

• Listen to or attend a worship service

• Stroke a pet or animal

• Stroke fabric

• Get a hand or shoulder massage

• Get a foot soak & rub

• Listen to wind chimes

• Aroma therapy

Teepa’s Rules

• Music at least TWICE a DAY

• Something Productive for each EMERALD resident• Play with people – keep it adult - watch for cues

• Smooth out Transitions -• If they can DO something support their doing, don’t

do to them or for them

• Encourage helping and ALWAYS say THANK YOU

• Respect space preferences – introverts/extroverts• Match Sensory Experience to Preferences

– Sight, sound, smell, touch, taste

Each DAY

• Before Breakfast– What do we want?

– How will we do it?

• Breakfast

• After Breakfast– What do we want?

– How will we do it?

• Lunch

• After Lunch– What do we want?

– How will we do it?

• Dinner– What do we want?

– How will we do it?

• Bedtime– What do we want?

– How will we do it?

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So – A Quick Look at ‘C’

Consequences – What Happens?

What Happens?Traditionally

• We wait till it gets ‘dangerous’ or at least ‘risky’

• We blame …

• We ‘knee jerk’ react

• We treat the immediate

• We become ‘parental’

• We become judges

• We give up

• We go thru the motions

• We go to drugs – #1 

–anti‐anxiety & anti‐psychotic

Non‐Traditionally

• Behavior = Unmet Need

• ABC  ‘Annoying’ behaviors

• Become a detective

• Get EVERYONE involved early and often

• Re‐look & monitor ‐ lots

• Change what is easiest first

• Change what can be controlled

• Celebrate all improvements

• Start by changing OURSELVES

What Can YOU Control? OR NOT!

CONTROL…

– The environment –setting, sound, sights

– The whole day… how things fit together

– How the helper helps ‐• Approach, behaviors, words, actions, & reactions

NOT CONTROL

– The person & who they have been

• Personality, preferences & history

– The type & level of impairment … NOW

– Other medical conditions & sensory status

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For your persons with problem behaviors…REFRAME…

Get interested and excitedbe challenged!

Describe the Behavior

• Consider video to investigate

• Use objective language to describe “THE BEHAVIOR”

• Investigate NON‐CHALLENGING BEHAVIOR ‐investigate what is going on when ‘the behavior’ is NOT happening…..

• Check it out from all perspectives… 360 

Investigate Carefully!!!

From Microscope to Telescope….

• Use a sensory approach

– look, listen, feel, smell, taste, movement

• Check out the environment

– Look at public, personal, intimate space issues

– Get in their ‘shoes’ & position

• Pay attention to cues and responses

• Look at timing, sequencing, & responses

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What Makes ‘BEHAVIORS’ Happen?

• SIX pieces…

– The type & level of cognitive impairment … NOW

– The person & who they have been

• Personality, preferences & history

– Other medical conditions & sensory status

– The environment – setting, sound, sights

– The whole day… how things fit together

– People ‐ How the helper helps ‐

• Approach, behaviors, words, actions, & reactions