REALIZE … • It Takes TWO to Tango … or tangle…
When Something Is Not Working Well… What Do We Tend to Do?
Being ‘right’ doesn’t necessarily translate into a good outcome for both OR either of you
Deciding to change your approach and behavior WILL REQUIRE you to stay alert and make choices…it is WORK
It’s the relationship that is MOST critical NOT the outcome of one encounter
Who Are YOUR Challenging People? Who Challenges YOU?
By managing your own behavior, actions, words & reactions you can change the outcome of an interaction.
REALLY Ask Yourself… Is this Behavior a Problem Behavior OR is this a “So What” Behavior An “Annoying” Behavior
Is it REALLY a Problem?Is it a RISKY BEHAVIOR? • Risk to that person (physical, emotional, physiological risk)? • Risk to the caregiver? • Risk to Others? • Is the RISK REAL and IMMEDIATE? • If NOT, it is a ‘SO WHAT’ behavior
If it is a ‘SO WHAT’ Behavior… • Leave it ALONE! • Figure out how to let go of it … • Let it go!
If it is RISKY… • Describe the behavior – OBJECTIVELY • WHO? • WHAT? • WHERE? • WHEN? • WHAT helps… WHAT makes it worse? • Frequency & Intensity?
SIX Pieces to the Puzzle • Personal history and preferences • Level of cognitive function • Other conditions & sensory losses • Environmental conditions • Care partner approach and behaviors • What happened – full day & all players
Knowing the Person • History • Values and beliefs • Habits and routines • Personality and stress behaviors • Work & family history • Leisure and spiritual history • Hot buttons & comforts
Level of Cognitive Function What CAN the person do? What can the person NOT do? What CUES are effective? Ineffective? What are interests based on level? Consistency of Cognitive Level?
Brain Failure The person’s brain is dying
Normal Brain Alzheimers Brain
Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains Early Alzheimer’s Late Alzheimer’s Normal Child G. Small, UCLA School of Medicine.
Memory damage Can’t learn new things Forgets immediate past Does time & space travel Uses old memories like new May not ID self or others correctly CONFABULATES Follows visual cues Seeks out the familiar Can get stuck on an old emotional memory track Language damage Has very concrete understanding of words Misses 1 our of 4 words – may miss “Don’t…” Word finding problems Word salad problems COVERS Follows your cues Gets very vague & repeats Uses automatic responses Mis-speaks So… what is happening?
Impulse Control Problems Say whatever they are thinking Swear easily Use sex words or racial slurs when stressed Act impulsively Not think thru consequences Can’t hold back on thoughts or actions Responds quickly & strongly to perceived threats Flight, fight, fright Performance Problems Thinks they can do better than they can Can sometimes DO BETTER under pressure – sometimes worse Uses old habits Attempts can be dangerous or fatal They will tell you one thing and then do another… Families may over or under ‘limit’ activities So… what is happening?
Persistent ‘going’ inability to terminate not able to anything else discomfort Eloping - escaping following cues wanting to leave going somewhere Constant talking or vocalizing Trying to communicate Self-stimulating Lack of Initiation Won’t move or cooperate Lost and ‘Looking’ can’t find places looking for familiar Invading space automatic actions following interests & habits no awareness of ‘personal space’ Shadowing looking for help Comfort Resisting care Self-care Movement How do these losses relate to some risky behaviors?
Word finding problems Logic problems Place & time confusion Very ‘independent’ or seeking constant reassurance Resents take-over Self-awareness varies Fearful about what is wrong Typically resists outside helpers Becomes anxious and frustrated easily Has trouble with new routines and locations Tries to maintain control & social behavior May try to escape/leave Can use signage & cues Gets ‘turned around’ Momentarily ‘disoriented’ Does regular routines JUST FINE! Level 5 - Routines & RepeatsDiamonds
Has trouble sequencing thru tasks & activities Often skips steps Looking for what to do and where to be Believes they can do it ‘Don’t need your help’ Has a mission in mind Goes back in time Gets lost in place Uses visual information to figure out what to do Follows samples & demos Can’t do an activity if visual prompt is not there Specifics and content in speech can be limited Gets stuck on ‘stuff’ Needs to be involved Looks for ‘stuff’ to do Level 4 - Task OrientedEmeralds
Uses hands to touch, feel, handle, hold Explores what is visible and hidden Invade other’s space to explore Repeats actions over and over Sees in pieces not whole Impulsive or indecisive Understands few words Imitates actions – copies you Tool use is challenging Follows others Investigates the environment May taste or eat what they see Difficulty terminating Difficulty getting focused on care tasks Becomes easily distressed with unpleasant tasks Asks ?s mechanically Level 3 - Hunting & GatheringAmbers
Gross motor only Poor finger use Limited visual processing Very limited communication skills Unable to do more complex motor actions Imitates those around Problems with chewing and swallowing Can’t stop or sound asleep Copies your mood – facial expressions Can’t grade strength Better with rhythm and repetitive movements Loses weight On the move – wanders forward – no safety awareness Level 2 - Stuck on GORubies
Bed bound or chair bound Unable to sit up for any length of time Unable to communicate verbally Lots of reflexes Breathing changes Moments of being present Can make eye contact & some automatic responses Swallowing and eating problems Muscles shorten and contractures forms Pressure areas develop because of no movement & limited intake Responds to touch, voice, movement, smells Startles easily Motor agitation indicates needs Level 1 – Reflexes RulePearls
Health & Illness • Mobility problems? • Pain? • Sensory problems? • Mental health issues? • Other diagnoses of importance?
Environmental Factors & Changes • Physical Environment • People • Programming
Environmental Aids • Setting • familiar • friendly • functional • forgiving (safe)
Environmental Aids • Props • visible & invisible • timely • available • matched to ability • matched to interests
Care Partner Approach Knowledge Skills
Three Reasons to Communicate • Get something DONE • Have a conversation • Help with distress
Communication – Getting the person to DO Something Form a relationship FIRST Then Work on Task Attempt
Connect • 1st – Visually • 2nd – Verbally • 3rd – Physically • 4th – Emotionally • 5th – Individually - Spiritually
How you help… • Sight or Visual cues • Verbal or Auditory cues • Touch or Tactile cues
To Connect Use the Positive Physical Approach
Your Approach • Use a consistent positive physical approach • pause at edge of public space • approach within visual range • approach slowly • offer your hand & make eye contact • call the person by name • stand to the side to communicate • respect intimate space • wait for a response
Your interaction… • Communicate with awareness • look, listen, think! • give your name • make an empathetic observational statement • “You look busy...” • “It looks like you are tired…” • “It sounds like you are upset…” • wait for a response
Give information • Keep it short and simple • “ It’s lunch time” • “Let’s go this way” • “Here’s your socks” • Use familiar words and phrases • Use gestures and props to help
ask a person to try ask a person to help you give simple positive directions - 1 step at a time use props or objects gesture demonstrate guide distract redirect Encourage Engagement
Daily Routines & Client-Centered Programming • Old habits and routines • Patterns during the 24 hrs • A time to rest, work, play…socialize • Your needs… my time
To Cope with Challenging Behaviors… • Where will you start??? • An idea – • Care partner education • Care partner skill building
Then… • Observe & document the risky behavior thoroughly • what is the pattern • when does it happen • where does it happen • who is involved • what is said, done, attempted • what makes it better… worse
Is it really a problem?… A RISK • If NO - leave it alone • If YES - its time to problem solve • call the team together • put on the thinking caps
REMEMBERExplore all of the following - • Personal background information • Level of cognitive function • Health information • Environmental issues • Caregiver approach & assistance • Habits, schedules & time of day
Re-look at the problematic challenging behavior… • What does the person need? • What is the meaning of the the behavior? • Do you understand the risky behavior better?