Principles of Behavior Management and Avoiding Over-stimulation with Dementia – Principle 7

Understanding the changes in mental or cognitive functioning that come with dementia gives caregivers effective approaches to reduce or avoid behavior problems. These behavioral approaches can minimize emotional flare-ups, power struggles, and physical outbursts. Ideally, these approaches can also reduce the amount of psychoactive medications that are needed.

This is another CoHealth blog on caring for individuals with dementia, whether they are residing in nursing homes, residential and assisted living settings, or in their own homes. An important principle in behavior management is to use isolation when the person becomes agitated due to over-stimulation, and move him to another room or setting that is less stressful and less stimulating. This can frequently occur in residential settings, where the level of activity and programming can be too stressful and demanding for the impaired resident to comprehend and process. Dementia produces a difficulty in processing incoming information, generally both auditory and visual information, and too much stimulation can lead to agitation, restlessness and irritability. A related principle is to be on the lookout for what are called precursor behaviors, or signs of an imminent outburst. These include rocking, pacing, clenched fists, or flushed face, all of which suggest more serious problems are on their way. Stay attuned and intervene quickly in the face of these precursor behaviors, and more serious outbursts can be avoided. When settled down again, the person can return back to the activity.

The more behavioral interventions we have in our caregiving repertoire, the more we can minimize potential problems and the more we can focus on the positive experiences of these individuals under our care. More approaches can be found in the CoHealth website's online courses, such as behavior management, understanding and differentiating depression, dementia, and delirium, and helping families with nursing home placement.

Principle of Behavior Management and Distraction with Dementia – Principle 6

This blog addresses the use of distraction as a technique to minimize behavior problems in individuals with dementia. As said previously, when we understand what the underlying causes are for the undesirable behaviors, it is much easier to circumvent, or prevent them. Caregivers, both paid and unpaid, can adopt these approaches when the unwanted behaviors surface, regardless of whether the patient is at home, or in a residential setting, or a nursing setting.

Distraction is used when dealing with the argumentative or combative patient, directing him on to another topic or a different point of discussion. For example, when the patient is demanding to “go home” or “take a bus ride downtown,” rather than try and debate with the person and explain the reality of his situation, it is much more effective to shift the focus of the conversation. Instead of a dose of reality and explaining why he can’t go home or already is home, engage him in a conversation for a few minutes about his home. What was home like, who was at home, who did he live with, where did he grow up, what was it like in his family growing up? Shifting to this more desirable, pleasing conversation defuses some of the tension that may be surfacing, and importantly, avoids the power struggle that we are not going to win with the demented person. Logic and reasoning can be very ineffective with patients who have any type of cognitive impairment.

However, while defusing the situation, caregivers should always try to weave through the conversation reassurances that the person is safe and secure in this setting. These reassurances help to minimize the anxiety and distress that are easily triggered when the dementia person feels unsafe or threatened in any way. Even though there are other occasions when a reality orientation approach is necessary (i.e., where he is, why he is there, etc.), distraction is the preferred intervention for these occasions.

A better understanding of how dementia impacts the people we care for will minimize the causes of problem behaviors, and help the person function at his highest possible level.  Other educational programs for caregivers can be found on our website, http://www.cohealth.org/, including understanding Alzheimer's disease for family members and fundamentals on behavior management.

Principles of Behavior Management and Communication with Dementia – Principle No. 5

This is another post in a series about managing problem behaviors with older adults due to dementing illnesses, whether residing in nursing homes, assisted living facilities, or in their own homes. Because the person with dementia is gradually losing normal brain function and mental ability, caregivers need to adjust their caregiving approaches to avoid overwhelming the patient and, at the same time, not to overestimate what the patient can understand or accomplish.

One of the early changes occurring with dementia is the difficulty with language and self expression. Word finding difficulty is very common, and even though the person has an idea of what he is trying to say, he can’t put it into words. This is aphasia. It leaves the person frustrated and vulnerable to high distress if he cannot make his needs known, or express hunger, or pain, or need to use a toilet.  In terms of receptive language skills, the person with a dementing disorder can easily give the false impression that he fully comprehends words that are spoken by the caregiver. Though appearing as if he understands, in reality, there is little or no comprehension, thereby raising the caregiver’s frustration level, as well.

To compensate for these losses in language skills, keep communication as simple as possible, limited to short phrases and directions. Instead of a question like, “Would you like to come to the dining room and listen to some nice music, or would you rather sit outside in the nice sunshine?” Rather, “Would you like to listen to music or sit outside?” is a simpler question, and a simpler choice. If you have to repeat yourself, repeat the same words exactly to avoid confusion that comes with trying to process the first question, and now hearing a different one. Also, if the person is having trouble finding the right word, it is a good idea to supply the word, if you know it. Simple sentences, simple choices, reassurance, good eye contact, and patience help to keep the frustration level to a minimum.

There’s a useful saying that applies to care with the dementia patient:  pay now or pay later. Taking a little longer to understand a patient’s communications, even when rushed, prevents bigger problems later on when the behavior problems and distress escalate. Prevention is the key to behavior management. For more insights into these issues, see the CoHealth online courses on differentiating among depression, dementia, and delirium, improving quality of life in long term care, and on managing problem behaviors in dementia patients.

Principles of Behavior Management with Dementia – Principle No. 4

There is an art and a science to caring for individuals with a dementing illness. There are now well established caregiving approaches for the different symptoms of this disease.  And, the best treatments require an understanding of what losses in functioning occur as a result of the disease. These losses will be in mental, emotional, behavioral, and self-care capacities.

This CoHealth blog on behavior management, the fourth in a series, addresses the need to recognize the person’s remaining strengths, also known as residual strengths, in the face of all the deficits that are evident. The person is gradually losing her communication and reasoning skills, the ability to remember the names of loved ones and to remember important events, and even to carry out routine activities. So, for example, if there are residual skills in grooming and hygiene, provide opportunities for her to do this activity herself, and then recognize and reinforce this positive behavior by pointing out how well she does on the task.

There are two very good reasons for this. First, by reinforcing the desirable behaviors, there is a greater chance that they will continue in the future. So, attention, praise, positive comments all will help to reinforce the behaviors, and will increase the likelihood that they will be carried out again. A second, perhaps more important reason is to strike a balance between the losses and the successes the patient experiences. Dementia is riddled with declines and losses.  Successes give the person an opportunity to feel good about something, to derive a sense of positive self-esteem in the face of all of the other losses that are taking place. Help the patient to continue doing whatever self-care is possible and try to avoid any unnecessary feelings of failure, or taxing the person beyond her capabilities. Tap into those residual strengths, provide opportunities for success, and reinforce the desired behaviors whenever possible. Ideally, the caregiver will allow her to continue doing whatever she can, even if it takes longer than if the caregiver were to do it himself. The sense of accomplishment and reward for carrying out a simple behavior can offset the many negatives she sees in her world. And, for awhile, they will help the person feel good about herself again.

As we better understand how dementia impacts the people we care for, we will develop a better appreciation of how to minimize the causes of problem behaviors, and how to help the person function at her highest possible level.  For more information, see our online program on managing problem behaviors in dementia and differentiating among depression, dementia, and delirium.

Principles of Behavior Management with Dementia – Principle No. 3

This is the third in a series about managing problem behaviors with older adults due to dementing illnesses, in nursing homes, assisted living facilities, or those residing in their own homes. These principles are based on proven methods to modify or change behaviors, or prevent them from worsening.  The approaches are based on the cognitive, behavioral, and emotional impairments that accompany dementia.

The third principle is to keep expectations realistic.  Do not be deceived by how much we think the person with dementia follows what we are saying. One of the hallmarks of this condition is the tendency to deny, or disguise the extent of cognitive changes occurring from the disease. The individual does not complain or emphasize the various problems he is experiencing, such as with memory, concentration, or attention to details. On the contrary, we can expect this person to minimize or mask these problems. Consequently, if we do not lower our expectations, it is very easy to overestimate what the person is understanding or comprehending in our communications. So we might think the person is perfectly okay with the explanation that we are giving, but in fact, it will probably be too complicated to process. For example, we might quickly explain why there is a change in the meal schedule or eating location. We assume the person follows our explanation, by nodding and agreeing, but eventually, the person’s distress builds because of the change from the familiar, from the routine. Even though she acts as though she is understanding and following what we are saying, the result is a lot of frustration on both the caregiver’s part and the patient’s part because of that inability to fully understand and follow that communication.  If we tax the person too much beyond her capabilities, we might trigger a catastrophic reaction, which is an intense outburst and strong emotional reaction to the task demands.  These reactions can quickly cascade into behavioral outbursts and severe behavior problems.

The lesson here is to not assume the dementia person is understanding us just because she is superficially agreeing. In fact, in the next minute, it may appear as though no explanation was given at all, and we have to start the conversation all over again, from the beginning.

As we better understand the various losses that occur with a dementing illness, we can minimize the triggers or causes of problem behaviors, and how to de-escalate the problem after it has occurred. For more insights into these issues, see the CoHealth online courses on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients.

Principles of Behavior Management with Dementia – Principle No. 2

This is a second in a series about managing problem behaviors with older adults due to dementing illnesses, whether residing in nursing homes, independent or assisted living facilities, or their own homes. There are many sound, proven approaches for managing these problem behaviors. Psychotropic medications are one choice, but other approaches that are milieu or environmentally-based can complement the psychoactive interventions, and may allow for a reduction or elimination of the drugs altogether.

These caregiving approaches are formulated around the impairments that come with dementia, especially in the areas of cognitive, behavioral, and interpersonal functioning. These approaches recognize that the most effective interventions incorporate an understanding of why the person is behaving the way he is. For example, this blog discusses the need for consistency in all interactions and routines with these individuals, whenever possible. Because the dementia patient is unable to learn and process new information, it becomes necessary to rely on previously learned knowledge and information as much as possible. In long term care settings, this means providing familiar caregivers, familiar rooms for activities and seating arrangements in the dining room, and familiar roommates. Anything that is being provided for this individual should be the same, predictable and consistent as possible. In private homes, meal times, preferred seating locations, and even dressing and hygiene activities should be consistent from one day to the next.

When there are changes in routine, as with new caregivers, or changes in a schedule, roommates, or meal times, those familiar to the person should take extra time to explain the change, as unimportant as it may seem. Without the explanation and extra structuring of the event, we can tax the person’s feelings of security and safety, something that can easily lead to increases in anxiety and agitation. Even when we might think a little change of pace might be enjoyable or refreshing, the person whose neurons in the brain are not firing normally will likely not appreciate the unfamiliar change. And she may become more distressed by it.

As we better understand the various losses that occur with a dementing illness, we can minimize the triggers or causes of these behaviors, and how to de-escalate the problem after it has occurred. For more insights into these issues, see my online courses on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients, and families facing Alzheimer's disease.

Principles of Behavior Management with Dementia Patients

There are many sound, proven approaches for managing problem behaviors in nursing homes and other settings, especially those behavior problems resulting from dementia. Of course, psychotropic medications are usually the treatment of choice for these, which can be very effective when judiciously monitored and adjusted as necessary. However, there are non-medication, milieu-oriented approaches that are equally effective whatever the setting, and should also be considered, especially to maintain compliance with OBRA laws, and to avoid unnecessary medications.

This CoHealth blog – and upcoming blogs – will present a series of behavior management principles for use by paid and unpaid caregivers. These principles are formulated around the impairments in cognitive, behavioral, and interpersonal functioning that accompany dementia, and recognize that the most effective interventions incorporate an understanding of why the person is behaving the way he is. Once we understand the various losses that occur with a dementing illness, we have a better appreciation of how to minimize the triggers or causes of these behaviors, and how to de-escalate the problem after it has occurred. For example, the deficits in language expressiveness and comprehension, the inability to learn new information, and the difficulty in processing complex communication all will contribute to problematic behaviors.

The first principle has to do with creating a calm and reassuring environment. The dementia person is reacting to his environment, so to the extent that we can control the environment, we can also control the person’s behavior. First of all, we need to be sure it is not over-stimulating. We cannot have too much going on in these settings, or present more stimulation than the person handle, such as a loud television, radio, and overhead PA system - all on at the same time.  Excessive stimuli create anxiety and restlessness in the individual because the dementia patient has difficulty processing complex information, and filtering out unwanted or unnecessary sounds. So, with excessive stimulation we create the setting, the opportunity, and the risk for rising agitation and the potential for behavior problems. The more secure and safe the individual feels, the less anxiety he experiences, and the less anxiety, the less chance of a behavior outburst.   Principle number one, then, is to create a milieu or environment that does not over-tax the individual's ability to process all that he is sensing thru visual or auditory channels.

There is also a risk of too little stimulation being available so the patient does not become too disconnected from his world, but the priority here is for structured, familiar, and reassuring communication. This will be addressed in an upcoming blog.

If interested in learning more about this topic see my online course on Behavior Management, including Prevention of Aggressive Behavior and De-escalation Techniques at CoHealth.org.