Principles of Behavior Management and Reality Orientation with Dementia – Principle 8

The information in this blog series is intended to help paid and unpaid caregivers manage problem behaviors caused by dementia. The slow insidious decline that we see in dementia is characterized by losses in mental, emotional, behavioral, and self-care capacities. The recommended interventions offered are considered milieu-based, or environmentally-based because they help to create an environment that is structured and anxiety-reducing, settings that reinforce appropriate behaviors while avoiding interactions that trigger unwanted behaviors.

This blog describes the need for extraordinary structure, explanation, and cues to make up for what is missing due to the loss of general awareness and information that accompanies dementia. This loss is manifested in little or no awareness of everyday events, like holidays, important facts, seasons, local or world events, anything that you and I may take for granted. Because the person with dementia is unaware of these facts, it is essential to communicate these to the patient, and repeating as often as necessary. This is referred to as reality orientation, and should take place whenever interacting with the person. We want to communicate what’s happening to the individual: explain what is going to happen, what just happened, what the daily schedule is, what the day and date and seasons and upcoming holidays are, when the next meal is, even what we’re having for the next meal or had for the last meal, and so on. We see this on the activity boards in the nursing home, though the verbal interaction between caregiver and patient is much more effective.

We take this information all around us for granted, but for the confused, disoriented person, it is necessary to replace this missing information. And, the need for this information sharing is not short term or temporary, but permanent. The term “prosthetic environment” is used to describe the permanent, extraordinary atmosphere that we want to create: multiple cues and reminders, continually offering explanations, facts, everyday information, in short, anything and everything that helps to orient the person, and helps her feel safe and secure. This is called a prosthetic environment for good reason: a prosthesis is a device used to replace a missing part of the body, such as a leg. And, just as a prosthetic leg is needed permanently, a prosthetic environment is also needed permanently for those with brain impairment to minimize confusion, disorientation, anxiety, and distress. Whatever structure, communication, and reality orientation we can provide, the better. In the absence of this, the person gets more anxious because she cannot tolerate uncertainty, ambiguity, or the unknown. The more the anxiety level escalates, the more likely she is to engage in problem behaviors.

As we learn the many ways that dementia impairs a person’s functioning, we can be better prepared to anticipate, make up for, or replace some of the losses that the patient experiences. This means better management of potential behavior problems, and helping the person function at her highest possible level.

Many of these concepts can be found in the caregiver educational programs on our website, http://www.cohealth.org/. Some of the titles include behavior management, understanding Alzheimer’s disease, nursing home placement, and end of life decision making.

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.