We know that dementia can result in behavior problems, due to its effect on judgment, memory, reasoning, and inhibitions. What we often overlook is that the environment also plays a huge role in causing or escalating these problems. The environment is something that we can (to some extent) manipulate to decrease behavior problems.

Things in the environment that can adversely affect residents' behavior are: over-stimulation (too many people, too much noise, too much activity); lack of privacy, especially with bathing, dressing and bathroom use; lack of autonomy; inconsistent staff approaches; and communication difficulties. Always consider that behaviors have meaning. Behavior problems may be maladaptive attempts to meet one's needs. Is the resident hungry, bored, lonely, afraid, in pain.? A resident may not be able to verbalize appropriately but is communicating via his behavior. The best behavior management plans are developed by investigating the cause of the behavior for each resident and individualizing the intervention to his needs. A person who worked the night shift may require a late bedtime, a late breakfast, and a busy activity during the late night hours. We need to think out of the box and change the way we normally do things to help residents cope without acting out.

As much as we try, it's not always possible to determine the cause of the behavior. There are some general interventions that can be helpful. In the environment, eliminate as much noise and clutter as possible. Label drawers, rooms, clothing, etc. to promote independence. Make sure hearing aides, dentures, and glasses fit properly and are working well. Ensure respect and privacy when residents are using the bathroom, bathing or dressing. Allow residents to make as many of their own decisions as possible - help them to feel they have some control over their lives. Encourage a sense of self with personal belongings and reminiscing about their lives. Encourage social interaction, exercise and activities that the resident prefers. Be aware of activities that may be too difficult and lead to frustration.

Staff interaction with residents and the way staff react to behavior problems can also provide effective interventions. Residents should always be approached calmly with a verbal greeting or gesture so they are not startled. Speak in a slow, clear voice, using simple instructions. Avoid arguing, confronting, or contradicting when behavior starts to escalate. Instead, reassure the resident that you understand how he feels and will try to resolve the concern. If this is not effective, try distraction by changing the subject, offering food or drink, or engaging him in a simple activity. Avoid involving too many staff to try to handle a problem - this can overwhelm the resident and escalate his behavior. Try to use one person the resident trusts, or even leave him alone for a while with a "time out" to allow him to calm down. Consistent staff and routines can also build trust and reduce behavior problems.

A final thing to remember is the principle of reinforcement. We usually give the most attention to residents when they are acting out. Even though this is not positive attention, the attention itself can serve to reinforce the negative behavior. When dealing with behavior problems, keep the interaction as brief and unemotional as possible. Try as often as possible to provide positive attention (reinforcement) to a resident when his behavior is appropriate. Behavior can also improve when a resident feels secure, cared for, has a sense of purpose in his life, and has some control over his surroundings.

Lori Ammon, LSW

Resources: Mitchell, J. R., "Alzheimer's Disease - Managing Behavioral Symptoms", Social Work Today, Vol. 2, No. 22, Oct.28, 2002.

"Mental Health Issues in Long Term Care", Seminar and Handouts by Linda K. Shumaker, RNC, MA, on 9/27/02.