Understanding Behaviour

that Challenges

Jenny Mullin (clinical psychologist)

Janet Parry (community mental health nurse)

Lancashire Care NHS Trust

‘Violence is the voice of the unheard’ – Martin Luther King

Exercise

• If there was one thing you would like other

people to know about you, what would it

be?

• Think about in the context of not being

able to communicate your needs when

cared for by someone else.

What is BC?

• Defining BC in terms of behaviour detracts fromunderlying causes

• “ … actions that detract from the well-being of individuals due to the physical or psychological distress they cause within the settings they are performed. The individuals affected may be either the instigators of the acts or those in the immediate surroundings” (James, 2011, p.12.)

• E.g. Hitting, spitting, throwing objects, shouting, selfharm, repetitive questions, pacing, excessiveeating/drinking, smearing, hoarding, falling intentionally,masturbating in public, urinating in inappropriateplaces…. (and not limited to those with Dementia).

Contributing Factors

P - Pain M - Medication

I – Infection E - Environment

N - Nutrition

C - Constipation

H - Hydration

Difficulties with the more traditional

approaches

• Traditionally seen as neuropsychiatric symptoms of dementia – BPSD.

• BUT… Why are only some people with dementia ‘challenging’?

• Challenging behaviour is not a diagnosable disorder.

• Challenging behaviour is not a symptom of dementia despite the term Biological and Psychological Symptoms of dementia (BPSD).

• It is socially constructed, context and time-bound.

1. Group task: What are the behaviours/actions of others that we find difficult in our work and home lives.

2. Think of times when you might have engaged in similar behaviours/actions. What needs were attempting to be met? How might that feel?

3. What might we appreciate from others in this situation?

The needs-led approach in understanding of BC

Maslow’s Hierarchy of need

Challenging behaviour is…..

An expression of need!!

It does not exist in a vacuum it is an interaction between social physical,

environmental, psychological, historical and cultural factors. (Kitwood, 1997)

PEOPLE with dementia

Person with DEMENTIA

PERSON with dementia.

Person centred care

• A positive social environment to enable the person with dementia to experience relative well being.

• Enabling – we need to recognise the strengths & abilities of people with dementia & ensure opportunities exist for them to be utilised.

• Understanding the person as a whole being – knowledge of what was important & how spiritual comfort was achieved.

• The individuality of people with dementia with their unique personality & life experiences among the influences on their response to the dementia.

• Personhood – the recognition of a sense of self, who we are & the place we hold in the world around us.

Rementia is possible

• The meaning of ‘recovery’ can vary from person to person. However, the general message is one of hope in empowering people to lead fulfilling lives even though they may experience difficult symptoms as a result of mental health problems, (Lester & Gask, 2006).

• Recovery represents a move away from pathology, illness and symptoms to health, strengths and wellness (Read & Sole).

The Needs led Approach -

Assessment & Formulation

• CB is an expression of need but we may not know exactly what the need is.

• Assessment helps us get to know the person, their life history and what the needs are likely to be.

• We use this understanding to help us know how to intervene.

Model of Unmet Need (Cohen-

Mansfield, 2000).

Background details of

the person, environment

and diagnosis

BC Information about

behaviour

Understanding of behaviour and interpret as a way of communicating a need

- e.g.

physical (pain), security, occupation (boredom), social contact, respect, dignity

Resolution through managing need rather than purely focusing

on behaviour

How a subsequent need can be met in a practical way

Links between behaviour and causes

(James 2011)

Behaviours

Medication

– side effects

Beliefs – I’m 28 years

Of age; I still work

the early shift

Mental Health

Perceptual difficulties

Personality

Physical Difficulties

Cognitive changes – e.g. frontal lobe

Metabolic changes - appetite, energy, irritability

Environment

and carer

interactions Surface

Being Detectives

• How do we work out what the behaviour is telling us –

the unmet need (what a person is thinking and feeling)?

• How do we work out what to do as a result?

• The more information we collect about a behaviour (or

different behaviours) the more accurate our picture will

be.

Our behaviour and the environment

• The systems around clients (including ourselves)

might unwittingly be inadvertently making unhelpful

behaviour stronger or making helpful behaviour

decrease – this should be part of the understanding.

• e.g. environment, trying to reason with people,

bringing people into our time frame, being offended

by behaviour.

Understanding the Person - Discovery

• Our history and experience moulds and shapes who we are today.

• We learn important lessons from our past- about our selves, the world and others.

• We learn how to relate to others through experience.

• We are all individuals that see the world differently.

• Important to consider a person’s history, their ways of relating to others, likes/dislikes, roles in life.

• REMEMBER – behaviour is more than dementia (it involves an interaction between social, physical, environmental, psychological, historical and cultural factors).

Trigger (A)

Anything seen prior to behaviour

Life Story (including hobbies,

likes/dislikes)–

e.g. impact of previous loss and

trauma during process of

dementia

Social Environment (past and present) –

Structural and social environment affect

wellbeing – having some control/choice is

important for us all

Mental Health–life

experience/beliefs/rules

e.g. impact of past

difficulties

Cognitive Abilities

Strengths as well as

difficulties

e.g. impact of frontal lobe

damage on behaviour –

disinibition, poor

planning/decision making,

concrete thinking.

Personality–

Carries on through

dementia – e.g. religion,

food, superstition

Physical Health/medication–

e.g. visual/auditory

problems, arthritis,

backache, toothache,

constipation, difficulties

related to chiropody.

Appearance

Can give clues to feelings –

scared, anxious, angry, low

etc.

Conversation/Vocalisations

Include yells, moans, repetition

Interpersonal relationships

Impact on intervention – e.g.

relationship with family and

staff

Behaviour (B)

Exactly what happened – labels like

aggression/wandering not helpful in knowing

what they are doing or why they may be

doing it

Consequences (C)

How behaviour responded to and it’s impact

on behaviour

What is the person trying to communicate?

What are their needs?

What Happens Next?

Intervention linked to understanding of the

person

Types of interventionsEnjoyable activities, increase activity, Art/dance, distraction

Music Therapy

– e.g. can reduce agitation at mealtimes (Chang et al., 2005) – history of likes/dislikes important

Giving space –leave and return

1:1 time

Pain relief

Favourite food/drink

Offer simple choices

Reassurance

Appropriate touch –hold hand

Therapeutic lies

Team consistency including beliefs

Interventions

Memory cues and environmental orientation

- signposting

Ensuring environment isn’t over or under stimulating

– Impact of background noise

Reminiscence/life story

– person with even severe dementia can benefit e.g. favourite record (history taking important re difficult experiences due to cognitive deficits making memory more

difficult to manage)

Methods to promote dignity in care situations

Communication

– tone of voice, pace, use of visual aids. Validate feelings, may need to give space, don’t argue.

Aromatherapy

– results from lavender and lemon balm though efficacy scarce.

Doll therapy

Snoezelen

– sensory stimulation

Pets for Therapy

Interventions

Reality Orientation

• Confusion often caused by problems with memory/orientation.

• Orient to present e.g. clock, calendar, newspaper, signs, picture boards, conversation.

• Needs to be done sensitively. Some disadvantages – e.g. can lead to repeated confrontation and reminders of deterioration.

Validation

• Argues against the need to orientate

• Acceptance of reality and personal truth of another’s experience (Kitwood, 1996).

• Works on feelings rather than facts.

• Aim isn’t to disagree or agree but to understand and empathise with emotion.

Remember…

• What works on one occasion might not

be appropriate the next time

• Not about finding an ultimate cure but is

ongoing, flexible and based on the

person’s needs

Measures

• The Cornell Depression Scale (Alexopoulos et al., 1988)

• Rating Anxiety in Dementia (RAID; Shankar et al., 1999).

• Challenging Behaviour Scale (CBS; Moniz-Cook et al., 2001).

• The Montreal Cognitive Assessment (MOCA; Nasreddine, 2003). www.mocatest.org

• Kingston Standardised Cognitive Assessment (KSCA; Hopkins & Killik, 2009).

References/Reading list

Alexopoulos, G.S., Abrams, R.C., Young, R.C. & Shamoian, C. A. (1988). Cornell scale for depression in dementia. Biological Psychiatry, 23, 271-284.

Cheston, R. & Bender, M. (1999). Understanding Dementia: The man with the worried eyes. London: Jessica Kingsley.

Cohen-Mansfield, J. (2000). Nonpharmacological management of behavioural problems in persons with dementia: the TREA model. Alzheimer Care Quarterly, 1, 22-34.

Emerson E, Barrett S, Bell C, Cummings R, McCool C, Toogood A & Mansell J, (1987) 'Developing services for people with severe learning difficulties and challenging behaviour: Report of the early work of the Special Development Team in Kent‘.

Hopkins, R.W., Kilik , L.A., Day, D.J., Roes, C.P., & Hamilton, P.F. (2005), 20(3), 227-231.

James, I. A. (2011). Understanding Behaviour in Dementia that Challenges: A Guide to Assessment and Treatment. London: Jessica Kingsley.

James, I., Mackenzie, L., Stephenson, M. & Roe, T. (2006). Dealing with challenging behaviour through an anlysis of need: the columbo approach. In M. Marshall (ed) On the Move: Walking not Wandering. Hawker Press.

Kitwood, T. (1996). A Dialectical Framework for Dementia. In Woods R.T. (ed). Handbook of the Clinical Psychology of Aging. Chichester. John Wiley.

Lester, H., & Gask, L. (2006). Delivering medical care for patients with serious mental illness or promoting a collaborative model of recovery? British Journal of Psychiatry, 188, 401-402.

References/Reading list

Moniz-Cook, E., Woods, R., Gardiner, E., Silver, M & Agar, S. (2001). The Challenging Behaviour Scale (CBS): Development of a scale for staff caring for older people in residential and nursing homes. British Journal of Clinical Psychology, 40, 3, 309-322.

Marshall, M. & Allen, K. (Eds.) (2006). Dementia: Walking not wandering: Fresh approaches to understanding and practice. London: Hawker.

Miesen, B.M.L. Dementia in close-up. London: Routledge.

Moniz-cook, E., Woods, R. & Richards, C. (Functional analysis of challenging behaviour in dementia: The role of superstition. International Journal of Geriatric Psychiatry, 16, 45-56.

Nasreddine, Z.S., Phillips, N. A., Bedirian, V., Charbonneau, S., Whitehead, V., Colin, I.,Cummings, J.L., Chertkow, H. (2005). The Montreal Cognitive Assessment (MoCA): A brief screening tool for mild cognitive impairment. Journal of the American Geriatric Society, 53, 655-659.

Reed, L., & Sole, K. Recovery and Older People Presentation. Downloaded 2010.

Roberts, P, H., Verhey, F.R.J., Byrne, E.J., Hurt, C (2005) Grouping for behavioural and psychological symptoms in dementia: clinical and biological aspects. European Psychiatry, 20, 490-496.

Shankar, K., Walker, M., Frost, D & Orrell, M. (1999). The development of a valid and reliable scale for rating anxiety in dementia (RAID). Aging and Mental Health, 3, 39-49.

Stokes, G. (2000). Challenging behaviour in dementia. Oxon: Speechmark Publishing Ltd.

Stokes, G. (2008). And still the music plays: Stories of people with dementia. London: Hawker.

Any Questions?

Janet.parry@lancashirecare.nhs.uk

Jenny.mullin@lancashirecare.nhs.uk

All behaviour is a means of communication

– THINK!