Promoting Positive Interactions

Hello Everyone,

In addition to the information we provided about inappropriate sexual behavior in last week’s tidbit, Dr. Elizabeth Galik, one of the investigators on our study, has written an article on this topic for Bottom Line Health. You can read it online here:

https://bottomlineinc.com/health/memory/dementia-and-inappropriate-sexual-behavior

This week, we’d like to discuss how to approach a resident with challenging behaviors in a way that can result in more positive interactions between the caregiver and resident. For example, if a resident scratches, swears or tries to hit a nursing assistant while she is helping the resident with morning care, how does that experience affect her? How will she approach her next encounter with the resident later in the day?

First, we as caregivers should be mindful that people with the dementia are exhibiting these challenging behaviors because of their disease. By not taking their angry words or actions towards us personally, we can objectively think about effective ways to react to their behavior that can result in increased expressions of wellbeing by the resident. Here are some ideas to help:

  • Before approaching a resident that you know can be challenging based on past experiences, take a deep breath and acknowledge your feelings. Are you angry? Anxious? Frustrated? If you enter the resident’s room while projecting these feelings, the resident will often pick up on them and respond accordingly. Try to “reset” yourself before you approach the resident and start with a clean emotional slate.
  • Put aside your expectations of what the resident will do. These expectations can turn into self-fulfilling prophecies.
  • Take a moment to put yourself in the shoes of the resident. Are they scared? Frustrated? Sad? In pain? If they aren’t able to articulate their feelings verbally, they will do this through their behavior. Try to figure out what they may be trying to communicate.
  • Remember the TMT-TMT rule: Too Much Talk and Too Much Touch by the caregiver can sometimes over-stimulate and agitate a resident. In these cases, a simple gesture and silent cuing may suffice. Also be aware of your body language. Standing over a resident can result in a “fight or flight” response. How would you feel if someone stood over you and tried to shove a toothbrush in your mouth?
  • Now, smile and take a few minutes to sit eye-to-eye with the resident (not standing over him), and talk about something you know the person enjoys….sports, upcoming holidays, weather, pets, etc. Starting with some brief moments of calm can have a positive impact on the rest of your visit and help establish trust.

You may have heard something similar to this before—while you cannot control the behavior of a person, you CAN control your response to it. Keep this in mind this week and see if this changes the way you interact with some of your residents.

Have a great week!

Investigating behaviors- The second step in the DICE model

Hello everyone,

In last week’s tidbit we discussed the DICE process for assessing and managing behavioral issues in residents with BPSD. We focused on the “D”—describing a resident’s behavior with specific details that provide important clues about the cause of the behavior.

This week we focus in the “I”—Investigate. Once we have a detailed description of the behavior, we can investigate the influence of factors such as cognitive status, environment, caregiver approach, physical/medical disorders, and psychiatric symptoms on the resident’s behavior.

In many cases, a resident with dementia is having difficulty communicating something to us. She could be trying to tell us that she is in pain or depressed, that we are rushing her, that it’s too noisy in the room, or that she simply doesn’t understand what we are asking her to do. When we don’t get the message, the resident can become agitated, resistant to care, anxious or even aggressive.

Cognitive impairment includes amnesia (memory loss); aphasia (language impairment, receptive or expressive); apraxia (impairment of learned motor skills); and agnosia (perceptual impairment). Cognitive impairment can have a significant impact on behavior. It can lead to  behaviors such as a resident urinating in a trash can instead of the toilet, pushing caregivers away when they try to take her to the bathroom, or using a call button constantly to ask for someone to take her home and complaining that no one is helping her.

We should also consider the environment: temperature, noise level, over and under stimulation, too much or too little space, familiarity and routine. An alteration to an element of the environment can have an immediate impact on a person’s behavior. For example, construction work being done in a facility brings noise, new people and changes to a space. These can all lead to anxiety and stress for a resident with dementia. Under stimulation can lead to boredom, which can lead to behaviors such as wandering or disruptive vocalizations.

Caregiver approach can also influence a resident’s behavior. Older adults with moderate to severe dementia have difficulty understanding verbal directions. They can also misinterpret touch that occurs during care activities, perceiving it is a threat. When this happens, a resident can become fearful and either fight the caregiver (hitting, biting, etc.) or flee (resist care).

Physical/medical disorders in older adults with dementia can result in pain, constipation, infection and medication use (with a variety of side effects). Do any of these examples sound familiar?: “He’s so sleepy it’s hard to get him to eat. The food runs out of his mouth”; “He cries when we get him up to transfer to the chair”; “She’s up at night asking to go to the bathroom every 30 minutes.”

Psychiatric disorders obviously affect behavior. Some examples: “She has been tearful almost every evening and doesn’t want to get out of bed in the morning”; “She thinks someone took her children”; “He doesn’t sleep and is so irritable”; “She saw a snake outside her window.”

Now that you’ve read about describing a problem behavior and investigating possible causes of it, next week we’ll discuss…you guessed it—the “C” in DICE, which stands for Create a plan. We’ll review interventions you can use to address these challenging behaviors.

Have a great week!