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When Behavior Challenges:
Responding to Behaviors
Associated with Cognitive Loss
Revised in 2013/2014 by
Pamalyn Kearney, EdD, OTR/L
Associate Professor, Georgia Regents University
Elizabeth Dalton, MSN, GNP-BC
Living Independently for Elders,
University of Pennsylvania School of Nursing
Originally developed by
Lois K. Evans, DNSc, RN, FAAN
Viola MacInnes Professor
Co-Director, Geriatric Education Center of Greater Philadelphia
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Objectives
With regard to older adults with dementia, direct care
staff will be able to:
 Analyze behavior as a form of communication.
 Explain the influence of cognitive impairment, life
story, cultural background, environment and current
situation in predicting and explaining behaviors.
 Use a range of assessment strategies to identify the
meaning of behavior.
 Individualize care to older adults with dementia to
prevent and respond to behaviors.
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Understanding & Responding to
Behaviors in Dementia
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Behavior is communication
What influences behavior?
How does knowing the resident
help to predict and explain the
behavior?
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Behavior is Communication
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A person with dementia communicates
unmet needs through behavior
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Making sense of behavior is critical to
meeting the person’s needs
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All behavior is meaningful
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Understanding Behavior
Behavior may be understood in the
context of the:
 Elder
 Elder’s health status
 Environment
 Current situation
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Understanding Behavior Knowing the Person
Who is this elder?:
 life story
 cultural background
 past habits, behavior & routines
 preferences & pleasures
 activities
 remaining abilities
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Understanding Behavior Health Status
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Current health issues can influence
a particular elder’s behaviors.
Change in behaviors can be an
indication of a change in health
status.
Changes in behavior warrant a
health assessment to identify any
new or emerging concerns.
Geriatric Education Center of Greater Philadelphia
Understanding Behavior –
The Environment
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Includes physical, temporal, and social
elements
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Persons with cognitive impairment can
have difficulty “making sense of” the
environment, which can influence
behavior.
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Understanding Behavior –
Current Situation
What interactions or activities occurred
just prior to the onset of the behavior?
Did these “trigger” the behavior?
– Location and characteristics
– People involved and social environment
– Emotional tone of any interaction
– Activity (or lack of)
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Behavioral Assessment:
Reframing
Reframing the way one perceives
behavior is essential to plan
individualized interventions
 Suspend judgment
 Avoid ‘labeling’
 Collect clues
 Conduct behavioral assessment
(use behavioral monitoring log)
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Common Behaviors
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Wandering
Self Protective Behaviors
Noisemaking and Repetitive
Vocalization
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‘Wandering’
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Definition: Moving about in an apparent
aimless or disoriented fashion where the
goal is either unobtainable as stated by
the resident or unclear to the observer
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MAY lead to unsafe situations or undue
fatigue
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Discovering the
Individual’s Agenda
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Alleviate loneliness, isolation, boredom
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Seek safety in familiar surroundings
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Satisfy physical needs
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Relieve stress by walking
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Communicate a change in health status
(if new behavior)
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Methods for Preventing
Unsafe Wandering Behavior
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Provide safe environments for
ambulation or movement
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Increase opportunities for social
contacts
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Provide environmental stimulation
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Maintain functional capacity for selfcare
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Individualized Responses
to Wandering Behavior
 Attend
to personal agenda
 Provide
opportunity for meaningful ‘work’
 Implement
 Make
protective interventions
environment ‘homelike’
 Reduce
exit cues, use visual barriers
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Self-Protective Behavior
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Sometimes these behaviors are viewed as
“aggressive” or “resisting care”
Definition: Psychomotor behaviors and
vocalizations that may be an attempt to
communicate and/or fulfill unmet needs for
protection of self: A protective response
Prevalence: about 50% in LTC (verbal and/or
physical)
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Self-Protective Behavior
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Some may be related to neurological
changes
Most can be prevented/reduced
Most of the time there is adequate
warning, and precipitating factor can
be identified
Observation and ‘knowing’ the
person is critical
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Self-Protective Behavior
 Pattern:
occurs during day & during
assistance with ADLs/personal care,
ESPECIALLY BATHING
 Associated
with use of psychoactive
drugs/ restraints
 Associated
with functional disability and
problems with communication
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Goals for care
Meeting the person’s needs to:
 Feel safe
 Feel in control
 Feel comfortable
 Experience optimal stress
 Experience pleasure and
satisfaction
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Individualized Strategies for
Minimizing Self-Protective
Behavior/Resistance to Care
To prevent/reduce the behavior:
 Environmental support
 Calm approach
 Communication and interpersonal
strategies
 Use of remaining abilities
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Individualized Strategies for
Minimizing Self-Protective
Behavior/Resistance to Care
When the response has already begun
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Distract/redirect activities
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Remove trigger
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Express your own fear, ask for feedback
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Use ‘supportive stance’
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Back off and re-approach later
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Do not shout, confront, reason, argue with, touch an
already aggressive person
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Have a facility/unit plan in place; train staff
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Facility Planning for Prevention
of Self-Protective Behavior
Example: BATHING
 Collect more information regarding bathing
routines, environments, experiences of residents
and caregivers
 Consider the physical environment – could the
area be warmer, do we need more lighting, would
low flow shower heads help?
 Identify ways to ‘normalize’ the bathing area and
bathing experience - Homelike
 Incorporate other ways to meet need for
cleanliness: Towel bath vs. shower or tub
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STOP
Strategy for Caregivers
S - Slow Down
T - Think about what is happening
O - Options
P - Plan to have some time to yourself
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Noisemaking and Repetitive
Vocalization (NRV)
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Definition: Excessively loud
utterances, nonsensical sounds,
screaming, moaning/groaning,
cursing and verbal repetitiveness
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Common Characteristics in
Persons with NRV
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Neurologic-cognitive impairment
Health status change
Sensory deprivation
Spiritual distress
Psychological distress/depression
Discomfort/pain, fatigue
Psychosis symptoms
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What may trigger NRV?
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Caregiver behaviors
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Environmental stimuli
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Individual aspects
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Assessment of NRV
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Describe the behavior
Listen to the vocalizations in context
and try to understand the message
Identify triggers
Evaluate physical-mental status
Identify patterns and frequency – use
behavior logs to assist
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Interventions for NRV
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Activities
Comfort and environmental measures
Social interaction
Videotape of family members
Music
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Objectives Review
With regard to older adults with dementia, can you now:
 Discuss behavior as a form of communication?
 Describe the role of cognitive impairment, life story,
the environment and current situation in predicting
and explaining behaviors?
 Use a range of assessment strategies to identify the
meaning of behavior?
 Individualize care to older adults with dementia to
prevent and respond to behaviors?
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Thank you for your attention!
The End
Geriatric Education Center of Greater Philadelphia
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Geriatric Education Center of Greater Philadelphia
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Geriatric Education Center of Greater Philadelphia
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Geriatric Education Center of Greater Philadelphia