Managing Difficult Behaviors in a Dementia
Care Setting
Alison L. Ray
Divisional Dementia Care Manager
Brookdale
It’s a Need, Not a Behavior
Objectives:
• What are our “perceived challenging behaviors” we face
as caregivers? Are they behaviors or communication?
• What can we do to manage the behavioral expressions of
the person with dementia and still provide safety for all
residents?
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Behavioral Expressions verses Difficult
Behaviors
• Need verses an initial negative word of behavior
• Can we manage difficult behaviors or should we be proactive
prior to the “expression/behavior”?
– What does this look like to be proactive or person centered prior
to the behavioral expression
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What are behavioral expressions we
face?
• Yelling
• Hitting
• Eliminating in
inappropriate areas
• Refusing care
• Wandering
• Spitting
• Eating/drinking nonfood items
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• Inappropriate sexual
behaviors
• Swearing
• Repetition
• Restlessness/Agitation
• Suspiciousness
• Sleep disturbances
What is the need behind the behavior?
Stop judging and become curious:
• Who?
• What?
• Where?
• When?
• Why?
Need to develop a detective mentality…
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Questions to explore:
• Is it an unmet physical need?
• Hungry?
• Thirsty?
• In pain?
• Looking for a bathroom?
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Questions to explore:
• Is it the environment?
• Too loud or noisy?
• Too hot, too cold?
• Distracting visually? (Shadows cause distress)
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Questions to explore:
Is it the task they have been asked to do?
• Physical challenges?
• Unable to decide/understand what to do next?
• Are they frustrated? (can’t express themselves, don’t
understand what you want them to do.)
• Expressive aphasia
• Receptive aphasia
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Questions to explore:
Is it how we are communicating to them?
• Speaking too fast, not loud enough
• Using too many directions
• Non-verbal appearance doesn’t match with what is
being said
• Is there a language/accent barrier?
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So how to get to the need behind the
behavioral expression?
• Be a detective
• Ask basic questions, look for common
patterns
• Ask yourself, what would I feel?
• What would I feel and what would I need?
• How could you meet my need?
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How do we utilize person centered
interventions once we know the need
behind expressions?
• Identify patterns/share them with others.
• Then, intervene BEFORE the expression emerges
–You must redirect the resident to “something
purposeful”, not just move them to a different place.
• Use their history as a means of refocusing their
thoughts.
• Create a program box with their “special items” in it to
use during challenging times.
• Give resident favorite food or drink as part of their
daily routine not when resident is upset
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If the behavior expression emerges, now
what?
• Change the scenery
• Go to another room turn on soft quiet music and
discuss new things in the room
• Ask someone else to step in: a fresh face.
• Take a walk, a drive
• Meet basic needs: offer coffee and cookie, juice, water,
ice cream (comfort foods), offer the bathroom
• Validate the persons feelings
• Offer your hand
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If the behavior emerges, now what?
• Assess for underlying pain: Look at footwear, denture fit,
clothing fit, diagnoses…administer pain meds as ordered.
• Initiate a new activity: give something purposeful to do
which has meaning to them.
• Evaluate the behavior: Is it dangerous? Who is it
bothering…you? The person with dementia should be
able to display their dementia.
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Other ideas of interventions
• Ask permission from person with dementia for all tasks
• Write a letter for the person who has dementia reassuring them (can be
from family or doctor)
• Video/audio tape family members telling a story or reassuring the
resident. DVD of the grandchildren, spouse or friend
• Encourage meaningful/purposeful activities (meaning must be created in
the present moment)
• Provide meaningful things for them to do
• Slow down and listen (allow the person with dementia time to respond)
• Focus on abilities (repetitive, sorting, etc)
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It’s a Need not a Behavior
Summary
Ask questions and get to the need behind the
behavior.
– Who, what, where, when, why?
– Is it an unmet physical need? Environment? Task too
hard? Communication? Pain?
– Use knowledge of their history.
– Ask what would “I” feel, need, if I were in their shoes.
– Look for warning signs and patterns and intervene
before the behavior emerges.
– Give yourself a break, use respite, ask help from other
caregivers.
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Questions?
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