When Behavior Challenges: Responding to Behaviors Associated with Cognitive Loss
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When Behavior Challenges: Responding to Behaviors Associated with Cognitive Loss by Lois K. Evans, DNSc, RN, FAAN Viola MacInnes Professor Co-Director, Delaware Valley Geriatric Education Center. With regard to older adults with dementia, direct care staff will be able to:

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When Behavior Challenges: Responding to Behaviors Associated with Cognitive Loss

by

Lois K. Evans, DNSc, RN, FAAN

Viola MacInnes Professor

Co-Director, Delaware Valley Geriatric Education Center


Objectives

With regard to older adults with dementia, direct care staff will be able to:

Discuss behavior as a form of communication.

Describe the role of cognitive impairment, life story, the environment and current situation in predicting and explaining behaviors.

Use a range of assessment strategies to identify the meaning of behavior.

Individualize care to older adults with dementia to prevent and respond to behaviors.

Objectives

2


Understanding and Responding to will be able to:

Behaviors in Dementia

3


Behavior as communication

A person with dementia communicates unmet needs through behavior

Making sense of behavior is critical to meeting the person’s needs

All behavior is meaningful

Behavior as Communication

4


Understanding behavior

Behavior may be understood in the context of : behavior

person

health status

environment, and

current situation.

Understanding Behavior

5


Knowing the person the key to understanding care

Patient as a person: behavior

life story

cultural background

past habits & usual behavior

preferences & pleasures

activities

remaining abilities

Knowing the Person: The Key to Understanding Care

6


Behavioral assessment reframing

Reframing the way one perceives behavior is essential to plan individualized interventions

Suspend judgment

Avoid ‘labeling’

Collect clues

Conduct behavioral assessment

(use behavioral monitoring log)

Behavioral Assessment: Reframing

7


Wandering

Definition: Moving about in an apparent aimless or disoriented fashion where the goal is either unobtainable as stated by the resident or unclear to the observer

Frequency: 1 in 5 ambulatory, cognitively impaired nursing home residents

MAY lead to unsafe situations or undue fatigue

‘Wandering’

8


Discovering the agenda

To alleviate loneliness, isolation, boredom disoriented fashion where the goal is either unobtainable as stated by the resident or unclear to the observer

To seek safety in familiar surroundings

To satisfy physical needs

To relieve stress by walking

To communicate a change in health status (if new behavior)

Discovering the Agenda

9


Methods for preventing unsafe wandering behavior

Provide safe environments for ambulation or movement disoriented fashion where the goal is either unobtainable as stated by the resident or unclear to the observer

Increase opportunities for social contacts

Provide environmental stimulation

Maintain functional capacity for self-care

Methods for Preventing Unsafe Wandering Behavior

10


Individualized responses to wandering behavior

Attend to personal agenda disoriented fashion where the goal is either unobtainable as stated by the resident or unclear to the observer

Provide opportunity for meaningful ‘work’

Implement protective interventions

Make environment ‘homelike’

Reduce exit cues, use visual barriers

Individualized Responses to Wandering Behavior

11


Self protective behavior

Sometimes these behaviors are viewed as “aggressive” or “resisting care”

Definition: Psychomotor behaviors and vocalizations that may be an attempt to communicate and/or fulfill unmet needs for protection of self: A protective response

Prevalence: about 50% in LTC (verbal and/or physical)

Self-Protective Behavior

12


Self protective behavior summary

Pattern: occurs during day & during assistance with ADLs/personal care,

ESPECIALLY BATHING

Associated with use of psychoactive drugs/ restraints

Associated with functional disability and problems with communication

Self-Protective Behavior: Summary

13


Self protective behavior1

Some may be related to neurological changes ADLs/personal care,

Most can be prevented/reduced

Most of the time there is adequate warning, and precipitating factor can be identified

Observation and ‘knowing’ the person is critical

Self-Protective Behavior

14


Goals for care

Meeting the person’s needs to: ADLs/personal care,

Feel safe

Feel in control

Feel comfortable

Experience optimal stress

Experience pleasure and satisfaction

Goals for care

15


Individualized strategies in self protective behavior

To prevent/reduce the behavior: ADLs/personal care,

Environmental support

Calm approach

Communication and interpersonal strategies

Use of remaining abilities

Individualized Strategies in Self-Protective Behavior

16


Individualized strategies for minimizing self protective behavior

When the response has already begun ADLs/personal care,

Distract/redirect activities

Remove trigger

Express your own fear, ask for feedback

Use ‘supportive stance’

Back off and re-approach later

Do not shout, confront, reason, argue with, touch an already aggressive person

Have a facility/unit plan in place; train staff

Individualized Strategies for Minimizing Self-Protective Behavior

17


Stop strategy for caregivers

S ADLs/personal care, - Slow Down

T - Think about what is happening

O - Options

P - Plan to have some time to yourself

STOP Strategy for Caregivers

18


Noisemaking and repetitive vocalization nrv

Definition: Excessively loud utterances, nonsensical sounds, screaming, moaning/groaning, cursing and verbal repetitiveness

Prevalence: 25-41% in long term care

Noisemaking and Repetitive Vocalization (NRV)

19


Common characteristics in persons with nrv

Neurologic-cognitive impairment screaming, moaning/groaning, cursing and verbal repetitiveness

Sensory deprivation

Psychological distress

Discomfort/pain, fatigue

Psychosis symptoms

Common Characteristics in Persons with NRV?

20


What may trigger nrv

Caregiver behaviors screaming, moaning/groaning, cursing and verbal repetitiveness

Environmental stimuli

What may trigger NRV?

21


Assessment of nrv

Describe the behavior screaming, moaning/groaning, cursing and verbal repetitiveness

Listen to the vocalizations in context and try to understand the message

Identify triggers

Evaluate physical-mental status

Assessment of NRV

22


Interventions for nrv

Activities (for the less cognitively impaired)

Comfort and environmental measures (for persons with advanced dementia)

Social interaction

Videotape of family members

Music

Interventions for NRV

23


Facility planning for prevention of self protective behavior

Example: (for the less cognitively impaired)BATHING

Collect more information regarding bathing routines, environments, experiences of residents and caregivers

Identify ways to ‘normalize’ the bathing area and bathing experience: Homelike

Incorporate other ways to meet need for cleanliness: Towel bath vs. shower or tub

Facility Planning for Prevention of Self-Protective Behavior

24


25 (for the less cognitively impaired)


26 (for the less cognitively impaired)


27 (for the less cognitively impaired)


Objectives review

With regard to older adults with dementia, can you now: (for the less cognitively impaired)

Discuss behavior as a form of communication?

Describe the role of cognitive impairment, life story, the environment and current situation in predicting and explaining behaviors?

Use a range of assessment strategies to identify the meaning of behavior?

Individualize care to older adults with dementia to prevent and respond to behaviors?

Objectives Review

28


Thank you for your attention the end
Thank you for your attention! (for the less cognitively impaired)The End

29


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