Coping with
Challenging
Behaviors
REALIZE …
• It Takes TWO to Tango … or tangle…
Learn to Dance with Your
Partner
When Something Is Not
Working Well…
What Do We Tend to
Do?
Being ‘right’ doesn’t
necessarily translate into a
good outcome for both OR
either of you
Deciding to change your
approach and behavior
WILL REQUIRE you
to stay alert
and make choices…
it is WORK
It’s the relationship that is
MOST critical
NOT the outcome of one
encounter
Who Are
YOUR
Challenging People?
Who Challenges YOU?
What are the Challenging
Behaviors that
GET TO YOU?
What Are the Most Common Issues
That Come Up???
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Not going to the MD
‘Losing’ Important Things
Getting Lost
Unsafe task performance
Repeated calls &
contacts
Refusing
‘Bad mouthing’ you to
others
Making up stories
Resisting care
Swearing & cursing
Making 911 calls
Mixing day & night
Shadowing
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Eloping or Wandering
No solid sleep time
Getting ‘into’ things
Threatening caregivers
Undressing
Being rude
Feeling ‘sick’
Striking out at others
Falls & injuries
Infections & pneumonias
Seeing things & people
Not eating or drinking
Contractures & immobility
By managing your own
behavior, actions, words &
reactions you can change the
outcome of an interaction.
REALLY Ask Yourself…
Is this Behavior a Problem Behavior
OR
is this a “So What” Behavior
An “Annoying” Behavior
Is it REALLY a Problem?
Is it a RISKY BEHAVIOR?
• Risk to that person (physical, emotional,
physiological risk)?
• Risk to the caregiver?
• Risk to Others?
• Is the RISK REAL and IMMEDIATE?
• If NOT, it is a ‘SO WHAT’ behavior
If it is a ‘SO WHAT’ Behavior…
• Leave it ALONE!
• Figure out how to let go of it …
• Let it go!
If it is RISKY…
• Describe the behavior – OBJECTIVELY
– WHO?
– WHAT?
– WHERE?
– WHEN?
– WHAT helps… WHAT makes it worse?
– Frequency & Intensity?
SIX Pieces to the Puzzle
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Personal history and preferences
Type & current level of cognitive loss
Other conditions & sensory losses
Environmental conditions
Care partner approach and behaviors
What happened – full day & all players
Knowing the Person
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History
Values and beliefs
Habits and routines
Personality and stress behaviors
Work & family history
Leisure and spiritual history
Hot buttons & comforts
Level of Cognitive Function
What CAN the person do?
What can the person NOT do?
What CUES are effective? Ineffective?
What are interests based on level?
Consistency of Cognitive Level?
The person’s brain is dying
Normal Brain
Alzheimers Brain
Positron Emission Tomography (PET)
Alzheimer’s Disease Progression vs. Normal Brains
Normal
Early
Alzheimer’s
G. Small, UCLA School of Medicine.
Late
Alzheimer’s
Child
So… what is happening?
• Memory damage
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Can’t learn new things
Forgets immediate past
Does time & space travel
Uses old memories like new
May not ID self or others
correctly
CONFABULATES
Follows visual cues
Seeks out the familiar
Can get stuck on an old
emotional memory track
• Language damage
– Has very concrete
understanding of words
– Misses 1 our of 4 words –
may miss “Don’t…”
– Word finding problems
– Word salad problems
– COVERS
– Follows your cues
– Gets very vague & repeats
– Uses automatic responses
– Mis-speaks
So… what is happening?
• Impulse Control Problems
– Say whatever they are
thinking
– Swear easily
– Use sex words or racial slurs
when stressed
– Act impulsively
– Not think thru consequences
– Can’t hold back on thoughts
or actions
– Responds quickly & strongly
to perceived threats
• Flight, fight, fright
• Performance Problems
– Thinks they can do better
than they can
– Can sometimes DO
BETTER under pressure –
sometimes worse
– Uses old habits
– Attempts can be dangerous
or fatal
– They will tell you one thing
and then do another…
– Families may over or under
‘limit’ activities
How do these losses relate
to some risky behaviors?
• Persistent ‘going’
– inability to terminate
– not able to anything else
– discomfort
• Eloping - escaping
– following cues
– wanting to leave
– going somewhere
• Constant talking or
vocalizing
– Trying to communicate
– Self-stimulating
• Lack of Initiation
– Won’t move or cooperate
• Lost and ‘Looking’
– can’t find places
– looking for familiar
• Invading space
– automatic actions
– following interests & habits
– no awareness of ‘personal
space’
• Shadowing
– looking for help
– Comfort
• Resisting care
– Self-care
– Movement
Level 5 - Routines & Repeats
Diamonds
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Word finding problems
Logic problems
Place & time confusion
Very ‘independent’ or
seeking constant
reassurance
Resents take-over
Self-awareness varies
Fearful about what is
wrong
Typically resists outside
helpers
• Becomes anxious and
frustrated easily
• Has trouble with new
routines and locations
• Tries to maintain control &
social behavior
• May try to escape/leave
• Can use signage & cues
• Gets ‘turned around’
• Momentarily ‘disoriented’
• Does regular routines JUST
FINE!
Level 4 - Task Oriented
Emeralds
• Has trouble sequencing
thru tasks & activities
• Often skips steps
• Looking for what to do
and where to be
• Believes they can do it
• ‘Don’t need your help’
• Has a mission in mind
• Goes back in time
• Gets lost in place
• Uses visual information to
figure out what to do
• Follows samples & demos
• Can’t do an activity if visual
prompt is not there
• Specifics and content in
speech can be limited
• Gets stuck on ‘stuff’
• Needs to be involved
• Looks for ‘stuff’ to do
Level 3 - Hunting & Gathering
Ambers
• Uses hands to touch,
feel, handle, hold
• Explores what is visible
and hidden
• Invade other’s space to
explore
• Repeats actions over
and over
• Sees in pieces not whole
• Impulsive or indecisive
• Understands few words
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Imitates actions – copies you
Tool use is challenging
Follows others
Investigates the environment
May taste or eat what they
see
Difficulty terminating
Difficulty getting focused on
care tasks
Becomes easily distressed
with unpleasant tasks
Asks ?s mechanically
Level 2 - Stuck on GO
Rubies
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Gross motor only
Poor finger use
Limited visual processing
Very limited
communication skills
• Unable to do more
complex motor actions
• Imitates those around
• Problems with chewing
and swallowing
• Can’t stop or sound
asleep
• Copies your mood –
facial expressions
• Can’t grade strength
• Better with rhythm and
repetitive movements
• Loses weight
• On the move – wanders
forward – no safety
awareness
Level 1 – Reflexes Rule
Pearls
• Bed bound or chair bound
• Unable to sit up for any
length of time
• Unable to communicate
verbally
• Lots of reflexes
• Breathing changes
• Moments of being
present
• Can make eye contact &
some automatic
responses
• Swallowing and eating
problems
• Muscles shorten and
contractures forms
• Pressure areas develop
because of no movement
& limited intake
• Responds to touch, voice,
movement, smells
• Startles easily
• Motor agitation indicates
needs
Health & Illness
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Mobility problems?
Pain?
Sensory problems?
Mental health issues?
Other diagnoses of importance?
Comparison of Fat Pads
Environmental Factors &
Changes
• Physical Environment
• People
• Programming
Environmental Aids
• Setting
– familiar
– friendly
– functional
– forgiving (safe)
Environmental Aids
• Props
– visible & invisible
– timely
– available
– matched to ability
– matched to interests
Care Partner
Approach
Knowledge
Skills
Three Reasons to
Communicate
• Get something DONE
• Have a conversation
• Help with distress
Communication –
Getting the person to DO
Something
Form a relationship FIRST
Then Work on Task Attempt
Connect
• 1st – Visually
• 2nd – Verbally
• 3rd – Physically
• 4th – Emotionally
• 5th – Individually - Spiritually
How you help…
• Sight or Visual cues
• Verbal or Auditory cues
• Touch or Tactile cues
To Connect
Use the Positive
Physical Approach
Your Approach
• Use a consistent positive physical
approach
– pause at edge of public space
– approach within visual range
– approach slowly
– offer your hand & make eye contact
– call the person by name
– stand to the side to communicate
– respect intimate space
– wait for a response
Hand-Under-Hand Position
Your interaction…
• Communicate with awareness
– look, listen, think!
– give your name
– make an empathetic observational statement
• “You look busy...”
• “It looks like you are tired…”
• “It sounds like you are upset…”
– wait for a response
Give information
• Keep it short and simple
– “ It’s lunch time”
– “Let’s go this way”
– “Here’s your socks”
• Use familiar words and phrases
• Use gestures and props to help
Encourage Engagement
• ask a person to try
• ask a person to help
you
• give simple positive
directions - 1 step at a
time
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use props or objects
gesture
demonstrate
guide
distract
redirect
Daily Routines &
Client-Centered Programming
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Old habits and routines
Patterns during the 24 hrs
A time to rest, work, play…socialize
Your needs… my time
To Cope with Challenging
Behaviors…
• Where will you start???
– An idea –
• Care partner education
• Care partner skill building
Then…
• Observe & document the risky behavior
thoroughly
– what is the pattern
– when does it happen
– where does it happen
– who is involved
– what is said, done, attempted
– what makes it better… worse
Is it really a problem?
… A RISK
• If NO - leave it alone
• If YES - its time to problem solve
– call the team together
– put on the thinking caps
REMEMBER
Explore all of the following •
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Personal background information
Level of cognitive function
Health information
Environmental issues
Caregiver approach & assistance
Habits, schedules & time of day
Re-look at the problematic
challenging behavior…
• What does the person need?
• What is the meaning of the the behavior?
• Do you understand the risky behavior better?
Make a PLAN!
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Who will do what
When will it be done
How will it work
What environmental change is needed
What props are needed - where will they
be
Implement your plan!
• Keep track of progress
• Document what is happening
• Communicate among the team members
• Rethink - if it isn’t working….
• CELEBRATE - if it is!
How can we help…
better?
It all starts with
your approach!
How you help…
• Sight or Visual cues
• Verbal or Auditory cues
• Touch or Tactile cues
What Do They Do?
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Question
Refuse
Release – verbal
Intimidate – physical
Tension reduction
What Should You Do?
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Be supportive
Offer choices & be directive
Set realistic limits
Act – Take control
Re-connect
Believe People
Are doing
The BEST they can!
What shouldn’t we do???
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Argue
Make up stuff that is NOT true
Ignore problem behaviors
Try a possible solution only once
Give up
Let them do whatever they want to
Force them to do it
So WHAT should we do???
Remember
who
has the healthy brain!