We’ve done a number of posts about behavior problems in nursing homes. Nursing homes are challenging places for patients to live. Residents suffer from chronic, disabling illness, often with no hope of cure. They may have chronic pain, and about 50-70 percent of the residents may suffer from dementia. Patients are depressed, confused, and sick; this is a recipe for behavior problems. Patients scream and yell inconsolably, they may become assaultive (verbally or physically), they may refuse to eat, they may be tearful and depressed, all sorts of negative things can happen.
So how is behavior management done in the nursing home? Why do we do it?
The second question is easier than the first. We do behavior management (specifically non-pharmacological behavior management strategies) because the alternative is, of course, to throw pills at the problem. Nursing home residents are typically older adults – they are susceptible to falls and increased confusion. They are often less able to physically process drugs due, for example, to impaired kidney and liver function as a result of chronic disease. In short, drugs aren’t a very safe and effective way to control behavior problems in nursing home residents, and even when drugs work, sometimes the side effects are worse than the cure (see my previous posts on use of pharmacological means of behavior management here and here).
So, behavior management is a great idea! Does it work? It depends on a number of factors. First, if a patient is cognitively intact, a provider may wish to directly approach the patient and try to engage him or her in some behavioral contracting. Behavioral contracting is basically a sort of therapeutic “you scratch my back and I’ll scratch yours” deal that providers make with patients. For example, let’s say that Mr. Jones can’t seem to follow the rules against smoking at the local community skilled nursing facility. To encourage him to follow the rules, the nursing staff proposes that if he can go one month without breaking the smoking rules, he can check out an additional DVD from the recreation therapy staff office. Mr. Jones agrees to the contract.
Obviously, this approach doesn’t work very well with demented patients, particularly when the dementia becomes more severe. Because so many dementia patients also have problems with executive functioning, they may be unable to adhere to the terms of a behavioral contract. A provider who tries to implement a contract with such a person is potentially setting the dementia patient up for failure.
Just as behavioral contracting typically does not work well with individuals who suffer from dementia, neither does negotiating, pleading, convincing, or arguing. To work with dementia patients appropriately, it may be necessary to give up on the idea that these individuals have a meaningful level of control over their behavior. For many family caregivers and many paid caregivers, this is a huge shift in thinking to make. Even to this day, I hear nurses tell me, “oh, that Mr. so and so, I know you say he’s demented, but I’m convinced he knows what he’s doing” (and he’s doing it to annoy me!).
Once the care providers in a nursing home have made this shift in thinking, what should the next step be? Research tends to support two approaches that consistently help eliminate problem behaviors (such as aggression and agitation) in adults with dementia. The first approach is to increase the amount of pleasurable, enjoyable activities (so-called “pleasant events”) that this patient is engaging in. The second approach is to try to actively change, via trial and error, what might have been causing the behavior problem in the first place.
According to the “ABC model” (Antecedents, Behaviors & Consequences), every problem behavior in dementia patients is preceded by a predictable pattern of events, and a predictable set of responses then follow. If we can fairly precisely define the problem behavior in question, and carefully identify and change these “triggers” (antecedents) for the behavior, we can potentially reduce the incidence of the behavior. Finally, if we can change the environment’s response to the behavior, we can also reduce the harm of the behavior and its further occurrence.
Let’s take an example. Say that Judy is at home with her husband Sam, who has dementia. Sam exhibits sundowning behavior: every evening as he’s sitting in his comfy chair (where he sits after dinner, usually watching TV with his wife) he starts to get more and more confused and agitated and starts to go for the door, repeating the same worried-sounding phrase over and over again, “I need to go home, I need to go home!” Of course, he is home, and Judy exhaustedly goes through the same routine every night of trying to keep him safe from falls (as he keeps bolting to the door from his comfy chair) and convincing him that he is, in fact, home (which doesn’t seem to reassure him at all). Eventually, they both tire, and often late into the evening, Sam passes out in their bed. Judy is able to maybe get a few minutes to clean up the house before she collapses.
The “ABC model” approaches this scenario as follows:
ANTECEDENTS: Evening hours, after dinner, watching TV.
BEHAVIOR: “I want to go home,” ambulates unsafely, exit-seeking.
CONSEQUENCES: “You’re already home!”
So what do we do? From what we see above, Sam has a full belly, and he’s sitting in his comfy chair. It’s evening – the shadows are longer, the lighting is poorer. He’s probably getting tired. Judy could try not having the TV on, or the couple could sit in a more well-lit area of the house after dinner. Sam could try taking a nap earlier in the day to avoid confusion and agitation at night. None of these ideas are guaranteed to work, but by using trial and error, Judy and Sam can implement changes that might eliminate the triggers for the behavior.
What about Judy’s reaction? In the example, every time Sam complains about wanting to “go home,” Judy responds by trying to convince him that he is, in fact, already home, but this doesn’t seem to quiet him. Instead of challenging Sam’s perception, Judy could try to sooth things over: “all right, Sam, we’ll go home first thing tomorrow. You’re staying with me tonight. It’s a vacation!” Judy could try offering him a stuffed animal (or, if she has six thousand dollars lying around, a Paro Robot), or some other pleasant thing.
The key here is for Judy to track Sam’s behavior after she systematically makes these changes to his environment; this will allow her to determine what works and what doesn’t.
In my training as a geropsychologist, I have found that engaging a caregiver in this type of problem-solving exercise (usually in the form of brainstorming techniques), is by itself an extremely powerful method of getting a handle on behavior problems in the home.
Sometimes, though, behavior problems become so intractable that the use of medications to treat agitation and behavior problems is unavoidable. That’s okay! I am not anti-drug therapy. Medications can help, when used judiciously, when the “start low and go slow” rule is followed, and when polypharmacy is avoided at all costs.