Dementia Behaviors Can Give Specific Message
By: S. Worcester;; 08/04/14

Several techniques can be used to better understand and reduce resistance to care among dementia patients who present behavioral challenges, according to “a common sense approach to dementia care.”

Success in improving the care of dementia patients – and probably reducing unnecessary antipsychotic medication use at all levels of patient care – begins with “demystifying” challenging behaviors, according to Dr. Rollin M. Wright, an assistant professor at the University of Pittsburgh.

In dementia patients, the neurologic basis of communication is compromised and it is therefore necessary for caregivers to “decode” behavioral and nonverbal attempts at communication, which can often provide important clues to discomfort, said Dr. Wright. He and a panel of other dementia specialists presented the commons sense approach at the AMDA annual conference this spring.

“I think that a lot of the challenging behaviors that we find in dementia are … attempts by the demented patient to communicate something to the world and the people around them,” she said. Pacing, wandering, picking, yelling, calling out, anxiety, resistance, and restlessness are among the behaviors that could signal discomfort or unmet needs: hunger, uncomfortable positioning, pain, a need to void, depression, difficulty breathing, or boredom, for example.

It may take some detective work, but specific behaviors provide clues as to underlying issues, Dr. Wright said. A patient who is pacing may be uncomfortable, may need to void, or may be experiencing pain, for example.

Words to describe the underlying problem may escape the patient, but behaviors often tell the story for them, according to Teepa Snow, an occupational therapist and patient advocate who developed the “Positive Approach to Care” communication method and presented it at the conference.

Simply “I’m Thirsty”

Ms. Snow acted out a scenario involving an agitated patient who was pacing and complaining. As she repeatedly stated, “I want to go home, I want to go home,” she picked up a pitcher of water that was sitting on a table. Her words said one thing, but her actions said “I’m thirsty” (“I want to go home and get a drink of water”), Ms. Snow explained.

Part of what interferes with understanding such behavioral clues is caregiver tendencies to respond reflexively. Reflexive responses may include pharmacology (more drugs), physical restraint of the patient (in a reclining chair with a seat belt, for example), and words meant to stop the behavior rather than to explore and understand it.

Care providers often reflexively infantilize or use a pejorative tone, increase volume in a misguided effort to get through to the patient, or talk incessantly and quickly in an effort to redirect the patient (a habit Dr. Wright called “diarrhea of the mouth”).

Decoding behaviors, however, requires ruling out and searching for unmet needs. The ability to decode behaviors is enhanced by knowing the patient’s history, learning the patient's behavior patterns and what they mean, and performing a physical examination, she said.

Why demystify behaviors? Because improved understanding of behavioral communication helps avoid harm to the patient, improve the person’s quality of life, heal what is wrong, and provide satisfaction to the care provider, Ms. Snow said.

She gave three rules for solving problems before they start:

Make a connection.

Respond, don’t react.

Change your own behavior first.

A demented person’s behaviors, when unaddressed, often lead to negative outcomes, while addressing and modifying them can improve outcomes, she explained. “Our job is to translate this complex array of facts and knowledge about neuronal activity, neuronal cell death, and how that leads to communication disasters into the practical in order for us to help our facilities provide high-quality care,” she said. Attention to the needs, comfort, and dignity of cognitively impaired people depends on optimal communication strategies, she added.

One particularly important factor in optimizing communication and interaction is the way a caregiver physically approaches a patient, according to Peg Chabala, a dementia-education coordinator at Asbury Heights Retirement Community in Pittsburgh.

Incorporating “PPA”

The “Positive Physical Approach” (PPA) is a widely recommended technique that Ms. Chabala and Ms. Snow have incorporated into the Positive Approach to Care program. PPA is based on the idea that it is the relationship with the patient that is most critical, not the outcome of a single encounter.

First, connect visually, Ms. Chabala and Ms. Snow said. Pause at the edge of the public space beyond the person’s personal space, about 6 ft. away, allowing the patient to notice you are in the public space. This shows acknowledgement of the person and respect for the patient's personal and intimate space.

Next, connect verbally. Greet the patient by bringing your flat, open palm up near your face as a visual cue for the patient to look at you, and then say “Hi!” using the person’s preferred name. This provides a verbal cue for the patient to look at you. Look friendly, smile, and make eye contact, Ms. Snow said.

Step three of the method is to offer your hand in greeting, which represents a request for permission to enter the patient’s personal space. Watch carefully for the person’s reaction. If there is hesitation or withdrawal, stay in the public space, but turn your body sideways in a supportive stance, or kneel or sit down. Hold back if the patient remains hesitant.

Step four is to move slowly toward the person, entering the patient's personal space. It is important at this stage to respect that the patient may have slowed response time and an impaired ability to do two things at one time. Next, move into the supportive stance, shifting your body toward the person’s dominant side, turning your trunk sideways. Stay at arm’s length, and keep your face and chest back away from the patient. Shake hands.

Going further, switch from a normal handshake into the hand-under-hand position to provide protection for both the patient and for you. This helps you avoid hurting the person’s wrist, arm, or fingers and keeps him or her from squeezing your knuckles or hitting or grabbing you. It also helps make a connection with the patient while allowing a sense of control.

Lower your body either by sitting, kneeling, or squatting, if necessary, to get to the patient’s level while respecting intimate space and allowing eye contact to a person with a limited visual field. Wait for a response or acknowledgement. Make sure you have a connection before starting your message

“Rewiring” the Team

Successfully integrating the Positive Approach to Care into a nursing home is a process that can take up to 2 years, as it requires training and “rewiring” the entire team from housekeeping to the executive level, Ms. Snow said. Achieving success requires working through the four levels of the program (awareness, knowledge, skill, and competence).

Achieving positive change with respect to the care of dementia patients requires regular attention and feedback, accountability, and an emphasis on development across the four levels of change, she said.

Level one involves reviewing common behavioral symptoms that are part of living with dementia, focusing on the importance of connecting and forming positive relationships prior to focusing on tasks, understanding the three types of helping cues (visual, verbal, and tactile), and using the Positive Physical Approach method in every interaction.

Level two involves recognizing the value of connecting, using observational skills to identify the functional level of the resident, and matching visual, verbal, and physical cues to each resident’s needs and remaining abilities (personalizing the person’s room, installing directional signs, and creating familiar and inviting environments, for example).

Level three involves learning each person’s life history and personal preferences; delivering programming throughout each day to meet physical, cognitive, social, emotional, leisure, and productive needs; and understanding the patient’s degree of dementia to help determine the appropriate level and type of physical emotional, social, and environmental support.

Providing meaningful activities for dementia patients is a particularly important part of the Positive Approach to Care, Ms. Snow said. Productive activities (such as helping another person, making something, sorting things, or fixing things), active or passive leisure activities (such as socials, sports, games, watching television), self -care and wellness programs (such as exercise, balance tasks, and personal care tasks), and restorative activities (such as naps, listening to quite music, rocking in a chair, or swinging in a porch swing) are examples of meaningful activities.

Ms. Snow’s rules for successfully implementing the method include music at least twice daily, a productive activity for appropriate patients, play, smooth transitions, supportive care (allowing patients to do what they can on their own, providing encouragement and offering thanks for their efforts), respect for space preferences, and matching sensory experience to preferences.

Level four of the approach involves use of validation, empathy, and supportive communication techniques to address unmet needs and to cope with challenging behaviors; troubleshoot, plan, and change care as needed; and communicate effectively with other team members and family members.

If what you are trying is not working, then stop, back off, think it through, and approach the patient in a slightly different way, Ms. Snow advised. Implementing the Positive Approach to Care requires that team members step outside of their comfort zones, she said.

“If we really want to impact how people [with dementia] live their lives, we’ve got to get out of the safety zone, we’ve got to move beyond what we’re good at and [being] comfortable with our successful brain, and be willing to step out on that ledge for the person whose brain is dying. They are stuck on this journey. We know where they are going to end. The question is not where, it’s how,” she said.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


Feb 3, 2008

The Interdisciplinary Team; The Role of the Psychiatrist

by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication