Quality in Practice (Winterbourne)
Dignity in Dementia Care
Denise J Mackey
Derbyshire County Council
Learning and Development Adult Care
In relation to people with a
Recognition that supporting people with what could be described as
behaviour that challenges is not easy, developing the right services
and building up expertise is a complex task. However, there is clear
evidence and guidance on what works. There are no excuses for
continuing to commission the wrong model of care.
People whose behaviour challenges has tended to refer to people
with learning or intellectual disabilities, including those people who
have autism, who display challenging behaviour. However there are
a number of other groups of people that may also be described as
so, people with a dementia, and people with severe mental health
What is ‘challenging
On separate post it notes write down behaviours
that you find either:
• Difficult to understand
• Difficult to support a person that is using them
• Difficult to deal with on a personal level
Remember a behaviour is something that others
can see or hear !
How we can define
‘challenging behaviour’.
‘ Culturally abnormal behaviour of such an intensity, frequency or
duration that the physical safety of the person or others is likely to
be places in serious jeopardy, or behavior which is likely to
seriously limit the use of, or result in the person being denied
access to, ordinary community facilities’.
(Emerson 1995)
‘Behaviour can be described as challenging when it is of such an
intensity frequency or duration as to threaten the quality of life
and/or the physical safety of the individual or others and is likely to
lead to responses that are restrictive, aversive or result in
(Royal College of Psychiatrists, British Psychological Society and
Royal College of Speech and Language Therapists. 2007)
So, who uses challenging
Challenging behaviour is most often
exhibited by people with developmental
disabilities, dementia, psychosis and by
children, although such behaviours can be
displayed by any person.
The facts:
750,000 people with dementia in the UK, approximately one
third live in care homes.
People will experience a range of symptoms, some can affect
their behaviour.
More than 90% of people will experience BPSD as part of their
Two thirds of people living in care homes are experiencing these
Around one quarter of people in care homes are on an
antipsychotic drug.
These have potentially serious adverse effects.
The effects of a dementia
Will for many people:
Have damaged their short term memory.
Be finding verbal communication more difficult.
Make it harder to retrieve more recent memories.
Make them unable to process a lot of information or follow
a logical explanation.
• Mean that they misinterpret some visual information.
• Mean that they may make unwise choices
• Mean that the rely more on emotional memories or
memories from long ago, how does this situation make
me feel, or who does this person remind me of?
Understanding distressed behaviour,
(behavioural and psychological symptoms of
• It is important to recognise that BPSD are not ‘bad
behaviours’ on the part of the person. These are
symptoms caused by chemical changes in the brain
which are out of their control.
• Behaviour rarely occurs in isolation and is affected by
social and physical environments and people’s
• The purpose of our behaviour is to get our needs met,
it may communicate something about a person’s
unmet needs.
• In general behaviour will serve a useful purpose within
the environment in which it occurs.
• Simple adjustments to social interactions and the
environment can make a difference.
• In order to be effective and caring when responding to
behaviour we find difficult to understand, it is helpful if we
know as much as possible about the person and their
• Think about distressed behaviour as way of adapting to
unfamiliar or confusing situations.
• We all have attitudes, values and beliefs that can affect
our perception of what is deemed as challenging
behaviour. The uniqueness of the individual must be
valued and respected at all times.
• Challenging behaviour can ultimately affect a person’s
quality of life.
NICE and SCIE Guidance:
• People with a dementia who develop non-cognitive
symptoms that cause them significant distress or who
develop behaviour that challenges should be offered an
assessment at an early opportunity to establish the likely
factors that may generate, aggravate or improve such
behaviour. The assessment should be comprehensive
and include:
The person’s physical health
Possible undetected pain or discomfort
Side effects of medication
Individual biography, including religious beliefs and
spiritual and cultural identity
• Psychosocial
• Physical environment factors
• Behavioural and functional analysis conducted by people
with specific skills, in conjunction with carers and care
• Individually tailored care plans that help carers and staff
address the behaviour that challenges should be
developed, recorded in the notes and reviewed regularly.
The frequency of the review should be agreed by the
cares and staff involved and written in the notes.
Key principles in supporting
people with distressed behaviour.
• Knowing as much as we can about the person, often the
clue to why they are acting in a certain way is in the past.
• Analysing the purpose of people’s behaviour.
• Good care planning and behaviour support planning and
• Having a range of alternative strategies and therapies so
that inappropriate anti-psychotic medication can be
• Not responding reactively to situations, understanding the
impact of internal and external antecedents.
• Joined up services.
• Appropriate training and support for staff.
• Good leadership and management.