An Algorithm For Determining The Underlying Causes Of Behavioral Problems

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Whenever a problematic behavior occurs and an intervention is requested, it is critical that the first question be "Why is this person behaving in this way?" The answer cannot be "Because he/she has dementia." That is an extreme example of circular reasoning. ("And how do we know that he/she has dementia?" Because he/she is behaving in this way.) It is also not conducive to discovering an appropriate intervention.

Williams and colleagues (Williams, Wood, Moorleghen, & Chittuluru, 1995) developed a decision model to assist in the management of disruptive behavior problems among individuals with dementia residing in long-term care settings (see Figure 13.1). This model highlights four decision modules to assist clinicians (and caregivers) in the identification of causes of an individual's behavior problem. Before entering into the decision modules, it must first be determined whether the behavior has a somatic cause. At this point, an assessment should be made to determine if sensory deficits may be a factor in the problematic behavior (e.g., Is the person's hearing aid working or should the battery be replaced? Has his or her vision worsened?). Infections (e.g., UTIs), poor hydration, pain (e.g., Do poorly fitting dentures result in problematic behaviors at meals?), and so on also should be ruled out before proceeding to the first module and attempting to create interventions for functional causes. Of course, communication problems associated with dementia and/or cultural differences/use of a foreign language can exacerbate problems of somatic origins and make their detection and treatment more challenging.

If the behavior has a functional cause, the first module comes into play. It must then be decided if the individual is experiencing an appropriate amount of stimulation; that is, are they being over- or understimulated? Here, activities such as Montessori-based programming take on the role of an intervention for problematic behaviors. In our research, we have often seen persons with dementia exhibit behaviors such as repetitive vocalizations outside of Montessori-based activities programming but who exhibit no such behaviors during these activities. Rather than decry the lack of generalization of the effects of the intervention outside the context of providing activities, we recommend finding more opportunities for such activities to be made available throughout the course of the day.

Of course, problematic behaviors produced by overstimulation are generally approached by reducing the level of stimulation impinging on the person with dementia. Long-term care units can often be extremely noisy places, with call bells and alarms ringing throughout the day. Playing music can be a cause of overstimulation if it is too loud, especially if the music being played fits the tastes of staff as opposed to residents. Music played during meals should be subtle and subdued. Trying to have a meal and a conversation in an atmosphere that is too noisy is an uncomfortable experience, whether dining out in a restaurant or having lunch on a long-term care unit.

The second module involves determining who "owns" the problem—the person with dementia or the caregiver. Translating the original model to a

A means "change"

Etiology

Assess

Stop

and Treat

Somatic

Accordingly

Start

A means "change"

Figure 13.1 The disruptive behavior decision model. Printed with permission of the publisher.

home setting, consider the following situation. A woman was serving as caregiver for her spouse in their home. The wife reported that her husband would get frustrated when grandchildren came to visit because he could not remember their names. It was suggested that the grandchildren wear name tags during visits so that their grandfather could simply read their names and, therefore, circumvent his memory loss. His wife responded, "But that would be cheating!" In this case, intervention with the caregiver to reduce unrealistic expectations or assumptions was required. In long-term care, residents who have taken baths all of their lives may appear resistant to taking showers, or residents who were used to showers may exhibit "problematic behaviors" when told to take a bath. Developing some flexibility on the part of staff so that the means of cleaning residents fits residents' past experiences may be the best intervention in these circumstances.

If the behavior has a functional etiology and is owned by the person with dementia, the next module involves environmental alteration. Consider the case of holocaust survivors who develop dementia and are placed in long-term care. Taking these persons into a sterile, institutional shower can create catastrophic reactions. This is an example of how an environmental alteration is called for to alleviate "problematic behavior."

Lawton (2001) emphasized that environments for persons with dementia should address four general classes of needs: decreasing disturbing behavior, increasing social behavior, increasing activity, and increasing positive affect while decreasing negative affect. Note that most of his emphasis was on using environmental configurations to have positive impact on the quality of life for persons with dementia, not simply reducing problematic behaviors.

Cohen and Diaz Moore (1999) are exploring environmental correlates of cultural and ethnic experiences in assisted living settings. Day, Carreon, and Stump (2000) give an excellent overview of environmental alterations for persons with dementia, as does Brawley (2001). Calkins (2001) provides an integrated model of place, examining the effects of different dimensions of settings (organizational, social, individual, physical) and levels of settings (microsystem, e.g., rules, staff ratios; mesosystem, e.g., institutional values as to safety versus privacy; macrosystem, e.g., cultural values) that can serve as a useful heuristic for understanding how environment influences behaviors in dementia care settings.

Finally, if the behavior has not decreased or stopped after altering the environment, clinicians should engage in applied behavior analysis to attempt to control the problem. Antecedents and consequences of behaviors are identified and changed on an individual basis to attempt to control a problem. Consider a case in which several women with dementia in a long-term care setting began to refuse to take showers because they did not want to be seen naked by men. The "men" referred to in this case involved a group of female NAs who had decided to get their hair cut fashionably short. In this case, the antecedent was the length of the NAs' hair. The intervention, involving a change of the antecedent, consisted of the unit acquiring a set of cheap, long-haired wigs that could be donned by nurse assistants before taking female residents to the shower and taken off afterwards.

As to altering consequences, persons with dementia sometimes are inadvertently rewarded with attention (albeit negative attention) when they engage in problematic behaviors. By removing attention following an incident of problem behavior, the negative behavior is often extinguished. Camp and Foss (1997) described a case in which an adult day health care client was engaging in repetitive questioning behavior more than 800 times per day on a consistent basis; that is, "When is my husband going to pick me up?" It was next determined that the client already knew the answer to the question and that staff generally provided reassurance that he was indeed going to come for her that day in addition to saying "6:30" when answering the question. At that point, staff began providing reassurance that her husband was coming to pick her up when the woman was not asking the question, especially if the woman was engaged in a desirable behavior such as social interactions with other clients, taking part in a group activity, and so on. When she asked her question, staff would politely say, "When do you think?" The woman would respond "6:30" and staff would reply " That's right; now I have to help someone else," and leave to work with another client. By changing consequences, staff were able to significantly reduce the woman's problematic behavior and increase her ability to benefit from the center's activities.

Williams and colleagues (1995) reported a positive response from nursing staff who used this model in long-term care settings. It is a model that should work well across caregiving settings. The critical feature of the model, as is the case with designing any intervention for persons with dementia, is the assumption that behavior is not random. Persons with dementia are persons with dementia, and their behavior reflects genuinely human attempts to cope and make sense out of what is happening to and around them. Under the same circumstances, the readers of this work would (and will) behave similarly. We all, therefore, have a personal stake in the development of better nonpharmacological interventions for persons with dementia.

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