Maximizing Our Potential toManage Responsive Behaviours in

Dementia Care

Long Term and Continuing Care Association of Manitoba

May 2019

Presenter: John Thomas

Responsive Behaviour Specialist

OBJECTIVES

1. Establish a starting point by way of a case example and identifying existing resources across long-term-care homes in Manitoba

2. Discuss considerations for revitalizing a personal care home’s capacity for developing behavioural care plans.

3. Define Cognitive Loss Compensation and its role in managing responsive behaviours

4. Discuss practical measures to better facilitate person-centred approaches in behavioural care plans

What are

“RESPONSIVE” BEHAVIOURS?

• Agitated, disturbing behaviours that challenge the skills, creativity and coping resources of the caregiver (Rewilak, 2007)

• This view acknowledges that someone with dementia may be displaying a behaviour in response to some kind of noxious, underlying cause

• Some causes are external (e.g. environment) while others may be internal (e.g. physical distress or cognitive impairment)

Case ExampleJoseph R.

• 87 year-old, widowed male admitted to a dementia-care residence after having maximized community resources in his own home

• Diagnoses included osteoarthritis, hypertension and Alzheimer’s type dementia, moderate

• Upon arrival, behaviours began in earnest including constant verbal demands to go home, resistance to most personal care including bathing, grooming, dressing and toileting; verbalizations to care providers that they are “stupid” and “don’t know what they’re doing”

Actions for Leadership

What do we do?Where do we start?

In cases where responsive behavioural expressions become problematic, we must determine parties who are in the best position to treat and/or manage symptoms.

Pharmacological Interventions May Be Warranted Early

(Video Summary)

• Although underlying medical contributors should be ruled out and non-pharmacological strategies should be tried first, psychiatry should be considered if the patient is in distress, is experiencing psychosis or is very aggressive

• It is important to define the behaviours to be targeted pharmacologically

• Behaviours such as aimless wandering, rummaging, hoarding, calling out and mild to moderate resistance to care tend not to respond to pharmacological treatment

• Hallucinations, severe agitation, anxiety, apathy, depression and very aggressive resistance to care tend to respond better to psychotropic medications

What is aBehavioural Care Plan?

• A concise description of clearly defined behaviours that a pose a challenge to the team

• Speculation of the underlying contributors to the behaviour(s)

• An action plan of specific strategies to address actionable contributors

• These actions should represent a shift in existing practice by members of the team who have agreed to take on the responsibilities of practice changes

Identifying Specific Staff Membersto Initiate the Behavioural Care Planning Process

A systematic, provincially recognized, simple to use framework is:

Putting the

P.I.E.C.E.S.TM

together

What does P.I.E.C.E.S.™

stand for?

P – Physical

I – Intellectual

E – Emotional

C – Capabilities

E – Environment

S – Social / Cultural

It is a framework that reminds us to consider many factors when trying to understand an individual and why his/her behaviour is occurring.

In Manitoba, we have a critical mass!

There is a growing body of scientific evidence that behavioural, non-pharmacological interventions for treating neuropsychiatric symptoms and reduce the severity and frequency of caregiving challenges (O’Neil, Freeman, Christensen, Telerant, Addleman and Kansagara, 2011)

• P.I.E.C.E.S. 3-Question template can be used as an effective behavioural assessment and care planning framework to develop those interventions

As of March 2018:

• 2436 nurses, 944 allied health professionals and 784 senior leaders have received full P.I.E.C.E.S. training (Source: Alzheimer Society of Manitoba)

Behavioural care planning involves efficiently using the

3-Question P.I.E.C.E.S.TM Template

1. What has changed?

• Avoid assumptions; think atypical; What behaviours are of concern to the team now?

2. What are the RISKS and possible causes?

• For causes, think P.I.E.C.E.S.

3. What is the action?

• Investigations / Interventions

• Interactions *

• Information

Identifying Champions

Although training front-line staff is an important first step, not everyone is positioned to lead the care team in developing behavioural care plans.

Questions for Leadership

1. Who has expressed an interest in care planning to manage responsive behaviours?

2. Have we discussed the core competencies of related training?

3. Have we had a conversation about explicitly incorporating this responsibility into one’s role including the allotment of time?

Clearly Defining theResponsive Behaviours(s)

Template Question 1

Before initiating the behavioural assessment process or referring to psychiatry, avoid vague terminology and describe concerns using specificlanguage.

Joseph R.

Vague Descriptions Clearly Defined Behaviours

Verbally responsive; calling out; agitated Tells family and members of the care team that he wants to go home

Resistive to care When care aides approach resident for dressing, grooming and bathing, he refuses help by telling staff that they are stupid and don’t know what they’re doing

Quickly Flagging RISKSTemplate Question 2

Although this may be subjective, flag any priority risk factors that require the care team’s immediate attention.

Joseph R.

RISKS? Yes / No

Roaming (Leaving the building unsafely, wandering into unwelcomed territory)

No

Imminent Physical Danger (Falls, Frailty, Injury, Infections)

No

Suicide (Ideation or Plan) No

Kinship (Compromised Relationships) Yes – Family and care providers

Self-Neglect (Willfully compromising safety or well-being)

No

Behavioural care plan must have an action to address identified risks!

Speculating Causes of Identified BehavioursTemplate Question 2

Use P.I.E.C.E.S. to speculate the causes behind the behaviour(s). Note: Not all contributors are actionable.

Joseph R.

Type of Contributor Speculated Causes Actionable? Yes/No

Physical Query discomfort; pain relief regimen is PRN; can he reliably self-report pain?

Yes

Intellectual Deficits include memory loss, lack of insight and trouble with executive functioning including poor judgment

Yes

Emotional Query adjustment No

Remember to remain focused on trying to explain the behaviours identified in Question 1!

Speculating Causes of Identified Behaviours(Continued)

Template Question 2Use P.I.E.C.E.S. to speculate the causes behind the behaviour(s). Remember: Not all contributors are actionable!

Joseph R.

Type of Contributor Speculated Causes Actionable? Yes/No

Capabilities N/A Functional assessment is recent and health care aides facilitate active participation in his care

No

Environment N/A No

Social / Cultural Query whether care attendants are blending familiar themes from his history into their care approaches or have they been task-focused?

Yes

Reckoning with Intellectual ContributorsManagement of responsive behaviours includes understanding the world of

the individual living with dementia…

Indeed, identifying specific cognitive changes can inspire compensatory Interaction strategies!

“Cognitive Loss Compensation”

Principal Cognitive Changes of Dementia

Amnesia – Trouble with memory

Aphasia – Difficulty using and understanding language

Agnosia – Trouble recognizing people, places, objects and sounds

Apraxia – Trouble with purposeful movements

Anosognosia – Lack of awareness or insight

Altered Perception – Trouble perceiving the world accurately; psychosis

Apathy – Lack of initiation or motivation

Trouble with Executive Functioning – Difficulty with planning, sequencing, organizing, calculating, ceasing, abstract thinking and good judgment

Common Behaviours

• Wandering and exit-seeking

• Disruptive vocalizations (screaming, yelling)

• Hitting, slapping, punching during care / resistance

• Hoarding

• Repetitiveness

• Lack of engagement in activities

• Sexually unwelcomed behaviour

• Territoriality

• Suspiciousness and false beliefs

• Voiding in inappropriate places

Common BehavioursCognitive Deficit Contributors

• Wandering and exit-seeking Amnesia

• Disruptive vocalizations (screaming, yelling) Aphasia

• Hitting, slapping, punching during care / resistance Anosognosia, Altered Perception, Aphasia

• Hoarding Amnesia, Altered Perception

• Repetitiveness Amnesia

• Lack of engagement in activities Apathy

• Sexually unwelcomed behaviour Anosognosia, Executive Functioning

• Territoriality Altered Perception

• Suspiciousness and false beliefs Altered Perception

• Voiding in inappropriate places Agnosia

Let’s Compensate for

Aphasia (Trouble Using and Understanding Language)

How many ways can we alter our interaction style to compensate for this deficit?

Strategies to Compensate for Aphasia

Expressive Aphasia

• Make eye contact with the individual and show that you’re interested in what they’re saying, even if you don’t understand

• Reflect back the emotion they are feeling. For example, if they’re sad or upset, show with your facial expressions that you’re concerned

• Be patient as it may take longer for the individual to convey something verbally

• Repeat back to the individual the last two or three words or syllables they have said to you. This creates the impression that you’ve understood, even though you may not have

• Use closed-ended, “Yes/No” questions instead of open ones

Strategies to Compensate for Aphasia(Continued)

Receptive Aphasia

• Speak clearly and slower than usual, without sounding condescending

• Incorporate actions or gestures into your communication. A lot of our communication is non-verbal anyway

• Show, rather than tell the individual something

• Ensure you have the individual’s attention before trying to tell (or show) them something

• Use simple words and short sentences

Cognitive Loss Compensation

(Video Summary)

Compensating for Lack Insight / Awareness (Anosognosia)

• Focus on remaining resident abilities and feign that they are capable

• Offer assistance as complementary

• Blend care with something social

Compensating for Trouble Recognizing (Agnosia)

• Remove objects that can be misidentified

• Identify objects in the moment

• Identify oneself by name

Cognitive Change Strategies to Compensate

Trouble with Memory(Amnesia)

• Don’t quiz by asking, “Do you remember?• Provide cues and gentle reminders• Normalize lapses in memory (e.g. I forget too. Let’s find out

together)• Treat all repetitions as if it were the first time• Reminisce about the distant past

Trouble with PurposefulMovement(Apraxia)

• Hand over/under hand assistance

Trouble Perceiving the WorldAccurately / Psychosis(Altered Perception)

• Avoid arguing• Avoid imposing reality• Use Validation by stepping into the person’s world; focus on the

individual’s feelings, not facts• Alter environment to minimize misinterpretations

Trouble with Executive Functioning

• Simplify the task• Provide step by step instructions• Prepare the environment by setting up a task as needed ahead of

time• Be concrete when communicating

Efficacy of Cognitive Loss Compensation…Something new?

Although no studies to date have been designed to evaluate “cognitive loss compensation”, we do know that:

• Validation therapy assists “in the moment” when individuals are experiencing altered perception

• A meta-analysis of research examining the efficacy of reminiscence therapy (compensatory strategy for amnesia) revealed a broad range of positive outcomes (Pinquart & Forstmeier,

Aging and Mental Health, 2012)

A Care Plan Emerges for Joseph R…Template Question 3

RISK or Speculated Cause Specific Action(s) Team Member(s) Responsible

Kinship – Care providers stressed from constant demands from resident to take him home

• Provide coaching to care providers on using validation

• Rotate staff if any team member is feeling overwhelmed

Staff EducatorAssistant Director of Care

Physical – Pain from osteoarthritis;analgesic regimen is PRN; query whether he can reliably self-report discomfort

• Assess for pain once per shift and before care

• Discuss with MD switching to regularly scheduled analgesic

Pain assessment – health care aide and registered staffRegistered staff for conveying assessment findings to MD

Intellectual – Cognitive deficits of lack of insight and trouble with executive functioning

• Feign capability instead of telling resident that he needs help

• Introduce care in a fashion that fits in with his reality

Health care aides

Social / Cultural – What do we know about Joseph?

???

A Care Plan Emerges for Joseph R…Template Question 3

RISK or Speculated Cause Specific Action(s) Team Member(s) Responsible

Kinship – Care providers stressed from constant demands from resident to take him home

• Provide coaching to care providers on using validation

• Rotate staff if any team member is feeling overwhelmed

Staff EducatorAssistant Director of Care

Physical – Pain from osteoarthritis;analgesic regimen is PRN; query whether he can reliably self-report discomfort

• Assess for pain once per shift and before care

• Discuss with MD switching to regularly scheduled analgesic

Pain assessment – health care aide and registered staffRegistered staff for conveying assessment findings to MD

Intellectual – Cognitive deficits of lack of insight and trouble with executive functioning

• Feign capability instead of telling resident that he needs help

• Introduce care in a fashion that fits in with his reality

Health Care Aides

Social / Cultural – Extremely organized, always in control, values punctuality

• Begin care interactions with something unrelated to the task

• Feign that you’re there to help Joseph prepare for his busy schedule

Health Care Aides

Maximizing the Potential for Using Personhood

The importance of blending personhood into care provision is well-understood (Teri, McKenzie, Logsdon et al, 2012). However, front-line care providers often report that such information is either difficult to access or captured in formats that are not user-friendly.

• Ask front-line care providers what will work for them as they will be expected to use the reference

• Keep it simple, keep it brief (less than one page)

• Access the family to determine what information should receive priority

• Emphasize proper names of people and places

• As memory impairment becomes more profound, earlier memories will resonate more

Sample History

“What are some things the care team should know about your family member or friend?”

SUMMARY

Key Messages for Leadership

• Continue to recognize the importance of pairing psychiatry with non-pharmacological interventions; use the former judiciously

• Identify internal champions – staff members who have an interest in behavioural care planning, feel that they have been adequately trained and have been allotted sufficient time to execute an assessment template

• Although the importance of person-centred approaches is well-understood, each personal care home must initiate collaboration with family and friends to focus on the most meaningful historical elements about the resident; tap into care provider preferences to determine the best way to share information about a resident’s personhood

SUMMARY

Key Messages for Front-line Care Providers

• When responsive behaviours are first identified, describe them using specific language

• P.I.E.C.E.S. 3-Question template provides a well-recognized foundation for assessing behaviours and generating meaningful, specific strategies inspired by underlying causes. Don’t forget to delegate actions to specific members of the team!

• Cognitive loss compensation provides a crucial tool for care providers to manage behaviours, particularly resistance to care

• Until we have information about what is meaningful for a resident, we are ill-equipped to truly be person-centred in our care approaches

• Try anything and everything…twice!

• Success can be found in a mere reduction in severity and frequency of behaviours. Celebrate improvements and never give up!

ACKNOWLEDGEMENTS

Halton Seniors Mental Health Outreach Team

Geriatric Mental Health Program

John ThomasBSO Responsive Behaviour Specialist

(905) 529-7030john.thomas@alzda.ca