By BETSY TAYLOR
When a resident in a long-term care facility becomes disruptive, a staff trained in observation and teamwork is best prepared to detect what is prompting the challenging behavior and to develop and test interventions that soothe the individual and keep the peace for everyone.
Alfred W. Norwood, president and founder of Behavior Science in Rochester, N.Y., told participants in a CHA webinar last month that when an elderly person is adjusting to a new environment, or feels a loss of control or lack of social support in a care setting, the person's stress levels increase. Some people may react by yelling unexpectedly, by becoming aggressive or by engaging in other untoward behaviors. Norwood spoke about behavioral changes associated with dementia and the temporary, but serious disorientation some frail elderly individuals experience when they move to a long-term care facility.
He noted that other factors, such as being in pain or an interaction between medications, also may be at the root of challenging behaviors. Potential medical causes of disruptive behavior should be investigated and eliminated first before behavioral interventions are attempted, he said.
Norwood co-taught the webinar with Sr. M. Peter Lillian DiMaria, O CARM. She directs the Avila Institute of Gerontology in Germantown, N.Y., the education arm of the Carmelite Sisters for the Aged and Infirm. Norwood is a behavioral specialist, who consults with long-term care systems and trains staff to develop individualized and non-pharmaceutical behavior modification and care plans for patients with moderate to severe dementia.
He provided an overview of research related to the body, brain and perceptions as people age. Certain cognitive changes would be more pronounced in someone with dementia, but he said in some cases elderly people without dementia may exhibit symptoms commonly associated with dementia for a few months after moving from their long-time home into a long-term care facility. They're readjusting their brain to where they are, and how they'll manage it, he said.
"We're finding out more and more that the environment affects how we age," he added. He pointed to work by Harvard psychologist Ellen Langer, including a landmark study in which she asked a group of elderly men to briefly live as though it were the year 1959, the time when they were 20 years younger. Those men showed signs of physical and mental improvement immediately afterward.
Both speakers encouraged a team approach to reducing challenging behaviors in long-term care settings. Sr. DiMaria said those who are "involved in making a decision about a resident's behavior" including nursing assistants and others who provide direct care should work to get to know patients as individuals. This familiarity makes staff more perceptive in detecting behavior triggers.
Sr. DiMaria recommends that staff keep written behavior logs in which they share observations on individual residents' challenging behaviors. From patterns that emerge, staff can make informed guesses about what is triggering an outburst. Logs should include details such as the setting, intensity, frequency and duration of a behavior. Follow-on entries track the success or failure of tactics to avoid the triggers, or soothe an agitated resident.
She gave an example of a resident who shouts every time she is brought into the dining room unless she is the first diner to enter. Staff might adapt by seating her first and ensuring she is served her meal before everyone else.
Both presenters noted the importance of making sure everyone on the team knows exactly his or her role in assisting a person who exhibits a challenging behavior. "State specifically who will do what, when, where and how," Sr. DiMaria said.
Both said keeping residents busy can be helpful. Norwood suggested creating individualized "busy boxes." For example, if care providers know someone likes baseball, they could fill a box with baseball cards and other mementos from a resident's favorite team. Playing music that the resident enjoys also can keep anxiety at bay, or soothe distress. Playing music at the same time of day, such as in the morning when a resident awakens, can orient the individual to the environment.
The webinar "Behavior Management in Catholic Long-Term Care Facilities: A Compassionate Approach to Caring for Residents with Challenging Behaviors" is available in CHA's online learning resource center.