Behavior Management Approaches
Regional Behavioral Health Center at Auburn
"Caring for Mature Minds"
Poor impulse control can place the individual and those around him/her in peril. It can show up as poor safety awareness or as aggressive, combative behaviors. It can be very frightening to family and friends. It is usually the result of a decline in brain functioning causing difficulty problem solving or a decline in social inhibitions. The behaviors are impulsive and are not thought out. They are often immediate responses to an external or internal stimulus. He or she is often acting on instinct and based on prior learned responses with little or no recognition that his/her level of functioning has changed. He/she may also be reacting purely on instinct in response to physical/psychological urges unchecked by previously intact learned social and moral boundaries.
Aggression and/or combativeness
Verbally abusive language. Hitting, biting, kicking, spitting. Destructive to property.
Physically or verbally threatening.
Determine if behavior is a reaction to un-communicated pain.
Make sure he/she is awake and alert as you approach. You don't want to surprise or startle him/her. Try placing him/her in a quiet environment where he/she is not over stimulated.
Remove any objects that could potentially serve as a weapon or source of danger (Cane, figurines, scissors...).
Back off when you see the behavior escalating. Don't get into an argument or try to reason when he/she is agitated.
Don't take it personally.
Poor safety awareness
Unassisted walking, getting out of bed. Crossing street without looking.
Trying to cook when unable to manage. Trying to do unsafe household chores. Opening car door while car is moving. Disregarding medical instructions.
Using unsafe tools. Driving when not allowed.
Eliminate temptations and known behavioral triggers - disable stove or place on a master switch, use non-keyed lock on car, remove power tools, lock away dangerous kitchen utensils and chemicals.....
Provide around the clock supervision. Install safety devices - locks, alarms....
Realize that the behavior is not "on purpose."
Provide activities that focus him/her away from the problem behavior.
Use alarms that signal when he/she is getting out of bed, up from chair, etc. Redirect to more appropriate behavior.
Anticipate needs and meet before he/she reacts.
Socially inappropriate behaviors
Undressing in public.
Sexual inappropriateness. Rude.
Stay calm. The behavior is not intentional. Do not feel obligated to offer an explanation, but when you feel one is necessary explain that he/she has medical problems that cause he/she to act erratic at times.
Distract him/her and redirect them toward more acceptable behavior. Remove him or her to a private place and return when behavior has stopped.
Do not chastise or confront. If he/she knew what he/she was doing, he/she wouldn't be doing it. If certain behaviors are ongoing, determine if there is a trigger and minimize or eliminate its occurrence. Avoid situations where the behavior will embarrass him/her, you or others.
Reduce problems with disrobing by using one piece garments and back closures. Dress in layers that can be removed or added as needed.
A chefs apron used as a bib can reduce soiled clothes. Keep a sheet handy to "cover up" a problem until you can address it.
Prepare family and friends for what to expect and how to react. Maintain your sense of humor.
Remember that the individual impulse control tells it like he or she sees it. The social and moral filters are no longer functioning effective. To mediate between what he/she thinks and says. ("Look at that fat woman." or "That person stinks." or "I don't like the way he sings.")
Hypersexual behaviors may be side effects of some medications. Check with his/her physician.
Delusions and Hallucinations
Seeing things, hearing voices, or expressing strange ideas can be the result of a brain disease, a reaction to prescribed medication, alcohol or illicit drugs, or a symptom or a physical problem. Most patients who experience these problems will have them resolved by the time they are discharged from the Geriatric Center.
In some cases however, the goal of treatment is to reduce the hallucinations and/or delusions to the extent they will not have a serious impact on the person's ability to function independently. Elders hallucinations and delusions are frequently accompanied by poor problem solving abilities and memory loss. This limits their ability to tell what is real from what is not. As long as their delusions and/or hallucinations are not causing serious difficulties in his/her ability to function, they are usually harmless. If you do notice an increase in agitation or a decline in self care related to the hallucinations and/or delusions, notify a doctor.
Any significant change in frequency, duration or nature of hallucinations and/or delusions should be discussed with a doctor. Such changes could indicate a problem with medication, a progression in the disease process, or a change in the individual's medical condition. Do not try to address the change through manipulating his/her medication on your own. This can lead to serious complications.
Common behaviors associated with delusions and/or hallucinations:
Mumbling to him/herself Gesturing as if talking to someone
Unable to concentrate on task at hand
Listening when there is no external auditory stimuli Speaking of people or things that cannot be seen Expressing bizarre thoughts and/or ideas Interrupted sleep
Interventions to assist in managing behavior in elders:
Redirect to new activity.
Assure that medications are being taken/given Provide for his/her safety, comfort, and support. Reduce external stimulation.
In most cases, do not challenge his/her thoughts or ideas. It will only increase agitation and likelihood of escalated behavior problems. Go with the flow.
Check with him/her on a regular basis to determine if the voices are telling him/her to hurt self or others. If so, contact the doctor.
Maintain your sense of humor.
Explain to family that the bizarre behaviors are not dangerous and tell them what to expect before visiting.
Anxiety and Restlessness
Anxiety and restlessness can be reactions to a wide variety of emotions and events. It can be difficult for elders to identify the cause of these behaviors since they may be the result of frustrations and fears related to declining physical and cognitive abilities. At other times they may stem from demands of caregiving, unrealistic
expectations for themselves or concerns over the well being of others. Anxiety and restlessness are normal feelings, but can be a problem when they become so serious that they impact an individual's ability to maintain his/her level of functioning or cooperate with care.
Worrying is the most frequent symptom of anxiety and a very common behavior. When worry progresses to the point at which the concern becomes the focus oflife, it should be brought to the attention of the physician. Fear is another common symptom of anxiety and can become a serious problem when it interferes with an ability to accept care. As elders become more dependent on others for care their feelings of vulnerability increases and may trigger suspicion and fear. As a caregiver it is important to understand these fears can become exaggerated and although unfounded, very real to the person experiencing them. This anxiety can impact every part of his/her life. It can interrupt sleep, cause pacing and aggressive behavior, or result in hand wringing and affect eating.
Tips for effectively managing anxiety and restlessness include:
Provide an environment that is quite and calming when anxiety increases.
Try playing restful music in a room with a dim light (but not darkened which can increase anxiety).
If the frequency or intensity increases contact the physician or psychiatrist.
Provide quite reassurance that the person is safe and that his/her concerns are being addressed.
Look for a way that will distract the individual and help him/her to focus on an activity that will help refocus his/her thoughts and/or excessive energy. (Sweeping the floor, digging in the garden, sanding a piece of wood...)
Provide opportunities for physical exertion (walking, dancing, and doing exercises...) that will tire him/her, but avoid exhaustion which can make the agitation worse.
Do not bring up anxiety provoking issues if you do not have the time to discuss the issue and provide support.
Develop calming interludes in the day (a cup of tea in the afternoon, music before bedtime ) to
encourage slowing down and periods of rest.
Learning to relax takes practice. Elders often have not given themselves permission to be idle or developed leisure skills which help channel restlessness. Be patient and provide opportunities that fit his/her physical and cognitive abilities.
Memory Loss and Confusion Related to Dementing Illnesses
Memory loss and confusion are hallmarks of dementing illnesses such as Alzheimer's disease and also residual effects of problems such as cardiovascular disease. The effective management of the demented individual is a balancing act between independence and support. Memory loss and confusion increases as the disease progresses. At its most severe level an individual may forget how to swallow, to recognize the urge to go to the bathroom and how to communicate. Ultimately he/she will need 24 hour complete care.
The following tips can help you more effectively manage the demented individual's care:
Provide frequent reminders. Post a schedule for grooming, meals, and chores... Maintain routines. He/she need his/her environment to be predictable.
Tell, show, tell again and guide them through the activity.
Give instructions one step at a time. (Pick up the washcloth. Turn on the water. Wet the washcloth. Put soap on the cloth. Place the cloth on your face. Wash your face...)
Use receptive activities to engage him/her. (Folding towels, sanding a board, kneading dough, and sorting poker chips...)
Avoid arguing or trying to reason.
Give limited choices. Not which flavor ice cream would you like, but do you want vanilla? Not which shirt do you want to wear, but would you like to wear this?
If unable to make a choice, choose for them. (I always did think you looked good in blue. Let's put this shirt on.)
Don't move too quickly or rush the individual. Treat the individual as a peer and not as a child.
Use easy on and off clothes. Slip on shoes, elastic waist pants, open-neck pull over shirts. Avoid buttons, snaps, ties and zippers.
Use a calm, soft voice.
Simplify the environment. Store throw rugs, pillows, vases and other items to reduce visual stimulation. Turn off the clock chime, lower the volume on the telephone ring to reduce audio stimulation.
Do not talk about the individual as if he/she was not in the room. Include them in the conversation. Encourage family and friends to respect the individual's routine and plan visits at the time of the day when confusion is the lowest.
Ask one question at a time and wait for a response.
Keep up outside involvement as long as possible. If you explain, "Mary has some problems remembering things" they will be understanding and helpful. When behavior is such that the person is making him/herself uncomfortable or too disruptive when others are around, it may be best to provide structured socialization in an adult day care/health settings.
Make certain that you have a break from your caregiver duties. Your need time to rebuild your energy, relax and interact with others.
Sleep Related Problems
Sleep disturbances can be a symptom of physiological and/or psychological related problems. Excessive or lack of sleep is a common side effect of some medications. Physiological changes often associated with aging and diseases such as diabetes may result in frequent urination that can interrupt sleep. Certain dementias can make it difficult for sufferers to regulate their internal clocks. Some sleep disturbances may be the result of environmental issues that cause an individual's sleep patterns to differ from those normally expected. Each of these may require a different approach and several may be impacting sleep behaviors at once requiring a combination of approaches.
Medication induced sleep disturbances
Check with the doctor to see if the time of day the medication is given can be adjusted or the dosage spread out through the day.
See if there is an alternative medication that does not produce the unwanted side effect. Determine if an over-the-counter medication could be producing the agitation or sedation.
Reduce fluid intake after 6:00PM.
Encourage a bed time snack - cheese and crackers and a juice or a small glass of milk and toast. Consider adult incontinence aids to minimize sleep disruption.
Consult with the physician to see if there are medical treatments available.
Adjust room temperature - add a fan or extra blanket Minimize intrusive sounds - use a fan or white noise machine. Try warm milk before bedtime.
Avoid coffee, tea, colas, or other caffeinated beverages after 2:00PM.
Determine routine times for going to bed and getting up. (Often elders living by themselves will go to bed at dark in the winter - which may be as early as 7:00PM and then wake at 3:00AM and complain they are unable to sleep).
Establish an exercise routine earlier in the day that will help promote sleep at night.
Reduce stimulation prior to bedtime. Turn off the television and plan some relaxing music or try a book on tape.
Remember that someone who routinely got up at 5:00AM all of his/her life may be responding to established sleep habits and he/she does not see as a problem.
Make sure sleepwear is comfortable and non-restricting.
Adjust naptime to fit into the overall sleep requirement. A two-hour nap in the afternoon may mean that he/she needs only six hours a night.
Use a night-light to decrease confusion upon awaking in the dark. Establish routine bed and waking times.
Use a large easy to read clock in the room (If still able to tell time). Make sure the bathroom is easily accessible.
Use adult incontinence aids as appropriate.
Make sure adequate opportunity for exercise are available during the day. Reduce stimulating activity in the evening - avoid visitors, television....
Adjust room temperature and noise - Night agitation may be a result of discomfort he/she is unable to communicate.
Regulate naptime, including naps in determining the amount of sleep needed/received.
Remember that different individuals have different sleep needs. Consult with the doctor if you see significant changes in sleep or if the sleep patterns are interfering with the provision of care. Sleep medications may be useful in certain circumstances, but consult the doctor rather than trying over-the-counter medications that may have unwanted interactions with other medications or produce side effects.
Tearfulness and Sadness
Sadness is a normal human response in many situations. Feelings of sadness can be triggered by feelings ofloss and regret. They can also be a response to the emotions of others. In most cases, the feelings of sadness are temporary and reduce as time passes or the cause diminishes. An individual who is clinically depressed or who has experienced head trauma (such as injury or stroke) may have a difficult time controlling his/her emotional responses. Since these conditions are often accompanied by a decreased ability to communicate, it may be hard to determine the cause of the tearfulness and the sadness.
Many elders respond to the decline in physical functioning with sadness. They are grieving their loss of independence. As a caregiver or loved one, you may see a reoccurrence of his/her sadness as the individual transitions from one stage of a disease process to another. When a person ages he/she is more frequently faced with loss. Friends and relatives die, children leave home, jobs are lost through retirement, and homes are downsized and life-long dreams become unrealistic and unattainable. Sadness is not an infrequent emotion.
As a caregiver or loved one here are some keys to managing the tearfulness and sadness:
Allow time and space for the appropriate expression of sadness and adjustment to loss.
Remember what may be a minor set back for you; can seem devastating to an elder. Don't trivialize the loss and the feelings attached.
If the tearfulness or sadness begins to severely interfere with his/her ability to meet the demands of daily living (eating, sleeping, bathing, socializing ), consult the physician.
Provide an opportunity for the individual to communicate his/her feelings. Set aside time to talk, go through a photo album, and listen to old songs. If verbal communication is limited, try providing art materials or if cognition is limited he/she may find comfort in a repetitive task such as sanding a board or rocking a doll.
Encourage physical exercise such as walking.
Check to make sure that there is no physical pain underlying the crying.
Prepare him/her in advance for any changes that may be interpreted as loss. (Moving to a residential facility, a relative moving away, 24- hour supervision starting, loss of driver's license ).
Offer new experiences to help compensate for the loss of old pleasures or look for ways to make old interests still accessible. (Put some plants in a raised container so he/she can continue to garden, look into books on tape or large print books, try an afternoon at the Senior Center, go to the skate park and watch the kids on their skate boards )
Provide opportunities for him/her to feel useful and needed. (Ask him/her to help fold the towels before the guests arrive, tear the lettuce for dinner salad, shine your shoes for an important meeting, stamp the envelopes on mail that needs to go out ).
Unable to Ask for Help
At times individuals may be unable to make their needs known to those around them. This can be the result of the loss of his/her ability to speak because of a stroke or other medical problem, the result of a decline in brain functioning such as in certain dementias or a progressive illness such as Parkinson's Disease. Others may be unable to seek help because of physical limitations that reduce or prevent mobility.
Loss or decline in speech
If he/she has retained the ability to write, provide a hard backed pad of paper with a pen attached. Consider the large pens now available with a padded grip for ease in holding. Make sure the pen glides smoothly. Look for a thicker point and use light colored paper, rather than white, to reduce glare.
Make sure that regular appointments are made to check hearing and vision.
Use picture cards to communicate needs - telephone, toilet, drink, food, hot, cold, happy, sad (Make
your own or look in teaching supply stores for things that might be adaptable.)
The individual may be able to use a computer or a telephone designed for those who have speech or hearing problems. Talk to the telephone company and ask about available options.
Use a personal monitoring service that provides for an alarm that can be worn and activated when there is an emergency to call a number(s) for help.
Provide a bell to alert others in the house that there is a need.
Install simple buzzers in areas prone to accidents- bathroom, kitchen, garage, and basement....
Use medical alert jewelry in the event he/she is wanders away or the caregiver becomes incapacitated.
Dementia and other brain diseases
When problems start, schedule frequent monitoring of his/her well being.
Use community assistance to monitor an individual - postal worker, newspaper delivery persons, meals on wheels volunteers and others offering monitoring programs.
Make sure fire and smoke alarms are functioning. Consider those with both audio and visual alerts. As a disease progresses he/she may require 24-hour supervision if problem solving abilities decline. Ask simple, easy to answer questions. "Would you like a drink?" "Are you in pain?"
Consider using monitors (such as those designed for infants) placed in frequently used rooms bedroom, bathroom. Some transmit sound and others incorporate video.
Monitor food and fluid intake, medications, weight, skin condition, bowel and bladder functioning to identify problems hen they are starting rather than when it becomes an emergency.
Use medical alert jewelry in the event he/she is wanders away or the caregiver becomes incapacitated.
Fearfulness is often related to increased confusion and failing problem solving. It stems from the individual's inability to manage his/her environment and the resulting feeling of powerlessness that comes with this lack of control. Fearfulness is a common behavior in individuals that are experiencing changes in mental status, relocation to new environments or loss. It is important that caregivers differentiate realistic fears from those that are unfounded. When possible, eliminate or minimize the source of the unfounded fears.
Typical fear related behaviors: Striking out Barricading self in
Accusing others of stealing, hiding things, saying things Not sleeping
Spying on others Refusing to eat
Whispering so others can't hear Keeping to self
Constant worrying about specific things Easily distracted
Do not try to convince him/her that the fears are unfounded Assure the individual that he/she is in a safe place
Minimize changes in environment and routine Introduce new people or routines gradually
Develop comfort routines - looking under bed, in closets... Distract with pleasurable activities
Communicate in simple direct statements
Do not dismiss a new fear as irrational until you have checked it out Try soft music to mask outside sounds
Provide a stuffed animal or doll for comfort Serve familiar foods
Avoid over tiring and minimize stress Use strategically placed nightlights
Provide bright, but not glaring lighting throughout the house Consider low voltage lighting outside
Minimize shadows and reflections
One of the most frequent behaviors leading to placement in a residential facility is wandering. Caregivers often find themselves trying to contain a wanderer to the home or yard. It is not unusual for a caregiver to answer the door to find the wanderer being returned home by a friend, neighbor or the police. The key to reducing wandering is to manage the environment rather than controlling the wanderer.
Fence the yard and eliminate the gate or place the latch on the outside where it is more difficult to access.
Establish a designated time for walks and a set path. (In the even the wanderer does get out, it is likely that he/she will follow and existing pattern making locating him/her easier).
Try placing door locks at the bottom of the door rather than mid-way or at the top. It is less likely to be noticed and unlocked.
Use Velcro banners with a stop sign hung across the door covering the doorknob. Wanderers often react to retained memory and will obey the stop sign. The banner also serves as a barrier and at the same time eliminates the visual cue of the doorknob.
Consider medical alert bracelets, or check the Alzheimer's Association for other ideas on how to let someone know where to return a person discovered wandering.
Never leave a wanderer unattended or lock him/her in his/her room or house alone. Never try to restrain a wanderer by tying him/her in any manner.
If wandering is accompanied by agitation, ask the doctor if medication could help.
If possible, provide a safe course for wandering throughout the house. Lock off unsafe areas and remove hazards.
Try redirecting the wanderer and using distraction to focus him/her on a new activity.
Often the wanderers are looking for someone or something. You can use this as a clue on how to best redirect him/her. (Someone looking for "the baby" may respond to a lifelike doll. A wanderer looking for his job may settle down with a box of nuts and bolts to fit together or a board and sandpaper). A person wanting to go catch a bus may respond to a redirection such as saying the bus is late and you will let them know when it is time to go.
Never yell at or confront a wanderer. If he/she is in a dangerous situation you are likely to startle him/her and make the situation worse, move quickly and calmly to distract and remove him/her from the situation.
Withdrawal and/or Isolation
There are a number of causes for withdrawal and isolation. Most of them are related to loss of self-esteem and individual's decline in functioning. Caregivers and loved ones need to understand the causes of this behavior and encourage increased interaction without increasing the stressors.
Difficulty coping with physical changes in appearance:
o Schedule occasional trips for a hair cut or manicure.
o Provide grooming assistance either by a caregiver or visiting aide.
o Explore devices that can simplify with applying make-up, shaving, and bathing.
o Provide attractive hats, scarves, and wigs if hair loss is an issue.
o Purchase clothing that fits well and if necessary can accommodate incontinence aids, monitors, and changes in posture.
o Provide sincere praise and support for appearance.
o Give time to adjust to changes in appearance.
Refusal to engage in activities outside the home:
o Encourage participation in gradual steps. Make a trip through the drive through at a fast food place or bank a few times. Next, ask them to go in with you.
o Take him/her on a brief accompanied visit to senior center a few times. Then try to involve them in activity while you are there. Next try to leave them for a few minutes and gradually increase the time away.
o Schedule outings when the individual's energy and stamina are highest. Leave if he/she shows signs of fatigue or anxiety increasing.
o Build on past interests.
o Check out options for socialization to determine the "best fit."
Refusal to interact with others:
o Determine if this is a significant change in behavior or the recurrent manifestation of old patterns of behavior.
o Encourage, but don't nag.
o Be aware of changes in his/her ability to process information. Isolation may be an attempt to cover up loss of memory or confusion.
o Don't be afraid to ask how a person is feeling. If you suspect he/she may be a danger to self, do not hesitate to ask if they are thinking about hurting themselves.
o Make sure they are able to hear adequately. Gradual unnoticed hearing decline can result in isolation because of difficulty in understanding what is being said. The individual may not be aware of the cause of his/her withdrawal in this situation since it may have had a very slow progression.