Challenging Resident Behavior as Communication:
Management of Dementia-related Behavior Disturbances

by: Dr. Laura P. Etre, Psy.D.

There was a time in the not so distant past when dementia-related behaviors were viewed largely as a medication management issue.  The focus was on eliminating the identified problem behavior versus understanding and treating the stimulus behind the behavior.  The initiative to reduce off-label use of anti-psychotics, along with our own outreach and education, has helped our long-term care settings to view non-pharmacologic intervention as the first line approach to minimizing dementia-related behaviors.  With Nursing staff depending more on psychologists and social workers for behavior analyses and plans, it is useful to have a framework from which to build treatment recommendations.  One practical approach is to consider the four “C’s” when gathering and organizing information: Clinical history, Cognitive assessment, Chain analysis and Culture of facility. 

As clinicians we are trained to gather an extensive clinical history at the outset of treatment.  Given that residents in long-term care settings aren’t always reliable historians, depending on other information sources such as staff and family input and patient charts is imperative.  The clinical history provides us with the backdrop to a case that allows us to place the specific maladaptive behaviors within a larger context.  A grasp of the onset and course of the resident’s dementia and associated psychological and behavioral symptoms, along with an understanding of the interplay of physical conditions, informs the clinician’s next steps.   For example, a case would likely be approached differently if a resident had a long history of combativeness versus if this was a new presentation of the behavior.

The findings from a brief cognitive assessment will also contribute to the development of a resident’s behavioral plan.  An assessment of the resident’s cognitive strengths and weaknesses provides answers to some important questions.  How much insight does the resident have into their behavior?  What cognitive limitations need to be considered as interventions are shaped? How involved can we expect the resident to be in modifying their behavior?  In the case of a resident with severe dementia who presents with significantly impaired executive functioning and memory, we will focus our interventions on adapting the environment to help minimize the behavior.  A resident with less impairment in these cognitive domains might have the ability to participate with reinforcement from staff.

The chain analysis provides a detailed look at the function behind the target behavior as identified by long-term care staff.  As clinicians we are more interested in the function of the behavior then we are about the actual behavior. What exactly is the resident trying to communicate?  A behavior does not occur in isolation, but instead in response to one or more triggering events.  For example, the resident might be in pain, be over-stimulated or be disoriented.  Interventions are designed to reduce these triggering events to minimize the undesirable behavioral response.  In order to perform a thorough chain analysis, observations from staff members will need to be gathered.  Ideally staff members will be able to share the frequency, the timing and the duration of the target behavior.   Providing a behavioral chart to staff can assist with organizing this type of data.

Once the clinical history, the cognitive assessment and the chain analysis have been explored, interventions can be developed.  Facility culture should be considered at this point.  The importance of culture in our long-term care settings cannot be understated.  Facility culture dictates the level of collaboration that can be expected.   Because clinicians depend on staff collaboration to gather the necessary clinical information and to implement interventions, the culture will ultimately influence the success of a behavioral plan.  Tailoring recommendations to what is realistic within a particular setting will increase the chances of a successful outcome.   Some settings are willing and eager to implement a detailed behavioral plan. In settings where staff members tend to be more stretched, focusing on reinforcing one or two key interventions will likely result in greater adherence to a behavioral plan.  Staff education that highlights effective management of dementia-related behaviors remains pivotal.

It is clear that our long-term care settings are increasingly looking toward MedOptions clinicians for non-pharmacological strategies to reduce dementia-related behaviors.   We are collectively moving in the right direction to best serve our residents.  Ongoing clinician education and training aimed at furthering this goal is a MedOptions priority.