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???

• 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

• 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

• 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

• 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

G. Small, UCLA School of Medicine.G. Small, UCLA School of Medicine.

NormalNormalEarly Early Alzheimer’sAlzheimer’s

Late Late Alzheimer’sAlzheimer’s ChildChild

So… what is happening?

• Memory damage – 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 & RepeatsDiamonds

• 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 OrientedEmeralds

• 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 & GatheringAmbers

• 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

• 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 GORubies

• 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 RulePearls

• 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

• 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

SomethingForm 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

• use props or objects• gesture• demonstrate• guide• distract• redirect

Daily Routines & Client-Centered Programming

• 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

REMEMBERExplore all of the following -

• 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!

• 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?

• Question

• Refuse

• Release – verbal

• Intimidate – physical

• Tension reduction

What Should You Do?

• 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???

• 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!