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A Systematic Approach to Managing Aggressive Behaviour in Dementia
The support and care of a person with dementia benefits, as does all care and support, from a systematic approach. Observation of run of the mill dementia care, often staffed by relatively untrained carers, usually shows up an unplanned approach, with the consequence that the same behaviour is seen time and time again, and staff can be seen to become more and more frustrated and demotivated.
The application of normal care planning techniques may go some way to breaking this vicious circle. The approach focusses on planned management solutions rather than leaving care to be reactive, thereby being more inclined to produce less negative results. However, the application of specific management techniques in the case of dementia has been shown by academic studies and experience to be the most positive way forward, producing actual and tangible improvement in problematic behaviour. This improvement has a positive effect on the quality of life of the person with dementia, their carers, those being cared for in the same environment and the relatives of the person with dementia. If care staff are aware of and use the right techniques, then the care environment can shift from one of reaction and tension, to one of proactive management and reduced stress. The benefits to those being cared for are obvious. Less obvious, but no less tangible, is the improvement in staff morale, reduced sickness, and reduced turnover with a consequent reduction in the cost of any particular care level. A planned and systematic approach will include the steps: (a) assess the situation; (b) formulate a plan to manage the challenge at hand; (c) implementing the treatment plan; (d) evaluation and if necessary, modification of the treatment plan.
A technique which is academically researched and widely used is ABC charting. This approach can be defined as:
“A” – what are the antecedents or triggers of the challenging behaviour? The idea is that all behaviours are triggered by something; they are not random. The trigger could be an environmental issue (too hot, too cold, too noisy?), an unmet need (want the WC, hungry, thirsty?) or a disease (pain, headache, not-well feeling developing?).
“B” – is the challenging behaviour which is causing the problem.
“C” – is the consequence of the behaviour, or the reaction of those affected by the behaviour. The way that we react to challenging behaviours can have a large impact on whether that behaviour is more or less likely to re-occur.
Fred is 75 and suffers from dementia; he wanders aimlessly and is seen as intrusive. He becomes aggressive when confronted.
Communication techniques are important to the successful outcome of the process. Some tips on effective (and non-effective) communication techniques follow.
- Position yourself to maintain eye contact and be at the person’s eye level;
- Look at the person directly and make sure that you have their attention before you speak. Always identify yourself first and tell them what you are intending to do;
- Ensure that the tone of voice used is one which conveys respect and dignity. Think about how you communicate, don’t just react;
- Use visual clues wherever possible;
- Make sure your expectations of them are realistic. For instance, ask for only one action at a time;
- Watch the person’s body language and non-verbal communication and try to interpret it;
- Use a calm and reassuring tone of voice and wherever possible, paraphrase what you just said;
- Always speak slowly, but not patronisingly so, and enunciate your words clearly. If the person is hearing-impaired, manage your communication to overcome or alleviate that;
- Talk about things which are familiar to the person;
- Use touch if that is appropriate.
- Do not talk to the person as if they were a child or use baby talk;
- Do not use complex words or phrases or long sentences;
- Do not glare at the person you are speaking to or otherwise visually challenge them;
- Do not try to compete with a distracting environment; change the environment or move;
- Do not start to speak without having first said who you are;
- Do not break eye contact while speaking, for instance by going off and doing something in the room while carrying on speaking;
- Do not cause more confusion and confrontation by asking for unrealistic things, such as asking the person to do more than one thing;
- Do not ignore your own body language – be aware of it and manage it positively;
- Do not ramble – keep to the point;
- Do not interrupt the person unless it is absolutely necessary;
- Do not attempt to touch the person, or invade their personal space if they are showing any fear or aggression.
Some techniques for communicating with a person with dementia:
- Ensure that you communicate only in a quiet place that is free from distraction;
- Be aware of the person’s language and culture (a consequence of good care planning and Life History recording) and take these into account in your communication behaviour;
- Be aware of the person’s perception capability, attention span, intellectual level and degree of understanding (again a consequence of good care planning), and take that into account when communicating. Stay within the person’s perception and understanding boundaries;
- Ensure that the communication is open and conveys respect and trust. Patronising speech or talking to the person with dementia in a child-like way may either foster a sense of helplessness and dependency or trigger an angry and defensive response;
- Pause often, making sure that the person has an opportunity to respond;
- Make sure that sensory aids (hearing aids, spectacles) are appropriately utilised and sensory impairments (wax, cataracts) are treated.
How to make sure you are heard and seen:
- Check that their hearing aid is on and working (if applicable);
- Stand in front of the person where they can see you;
- Face the person directly so they can see your facial expression and mouth;
- Place yourself at eye level when talking or listening;
- Identify yourself by name;
- Use the person’s name.
How to make contact with the person:
- Keep yourself and those around you calm and relaxed;
- Touch the person gently, if they like to be touched (care planning again);
- Smile and use humour.
How to make communication easy to understand:
Wherever you can use gestures, pictures and/or signs to explain or express things;
Always avoid talking over/across/about the person;
Always speak gently and clearly at an even pace - avoid shouting;
Always ask just one question at a time;
Always use specific names of people and places instead of pronouns: e.g.; Jim, our neighbour, or Sally, our dog, not “him” or “it”;
Wherever you can, use a statement rather than ask a question;
Always wait for a response after you speak;
Always explain what you are going to do and what you are doing;
Always repeat or rephrase your message if there is no response.
Some other ideas:
- Always talk normally - then they will understand how you are feeling, even if they are not fully aware of what you say;
- Always use hand gestures and facial expressions such as smiles to reinforce your words;
- Always allow for the time a damaged brain takes to process messages;
- Always show your concern with reassurance and acceptance;
- Always give praise when it’s appropriate;
- Always respond to the feelings expressed by the person;
- When talking in a group, place the person so that the conversation is around them and they won’t feel ‘left out’;
- Make it easy to join in conversation by asking questions that only need a ‘yes’ or ‘no’ answer;
- Always avoid arguments over mistaken ideas: e.g.; If the person insists they have seen a TV program a million times before even though it is a first run say: “Oh well, I don’t think I’ve seen it before. It’s interesting isn’t it?”;
- Remember that touching enhances feeling of security, especially if the person is upset. Unless they respond aggressively.
In order to assist the recording and analysis of the ABC process, some simple records and charts can be used and included within the care plans.
The ABC behaviour chart can be used to record incidents which require assessment.
|ABC Behaviour Chart|
|Service User name:|
|Date and Time, and reporters name||Antecedent:What triggered or came before the behaviour?||Behaviour:Describe the behaviour including location and environment, for instance noise levels, lighting issues||Consequence:What did you do or what happened to the behaviour?||Final outcome:What did the observed person do when the incident was over?|
|25/11/11, 8 amJane Doe||I was going to put his dentures in.||He was sitting up in bed; the bedroom was sunny and bright. He punched me in the chest as I offered the dentures||I pulled away and cried out in pain, told him not to hit me and left the room||I returned a few minutes later to find him asleep so I left him like that.|
|Next report -|
|Next report etc.|
A Frequency Tally Sheet can be used to record the frequency of behaviour which is has been identified and is being assessed
|Frequency Tally Sheet|
|Date:||Observation time Start End|
|Challenging behaviour being observed is:1
|Instructions: Place a tick in the relevant box (i.e. 1 for behaviour 1, 2 for behaviour 2) each time the behaviour occurs during the observation period. You can choose to watch for a period of time (e.g., 30 minutes), or you can choose to watch a specific event (e.g., eating lunch.) Try to watch at the same time or during the same event each day for several days to get a sense of how often the behaviour is occurring.|
|Behaviour 1||Behaviour 2
|Number of times that the behaviour occurred during the observation period.||Number of times that the behaviour occurred during the observation period.|
A checklist can be useful in helping you step through the process of changing challenging behaviour.
Challenging behaviour Checklist.
Tick off the following steps as you complete them:
Step 1: Identifying the problem
- Who finds the behaviour challenging?
- What is the behaviour you are interested in changing?
Does the behaviour occur:
- Too much;
- Too little;
- In the wrong place;
- At the wrong time;
- What behaviour will you prioritize?
Step 2: Setting goals
- What can you realistically expect to achieve?
- What behaviour will you prioritize?
Step 3: Monitoring the behaviour
- How frequently does the behaviour occur?
- Are there any times of the day when the behaviour is most likely to occur?
- What are the ABC's of the behaviour?
Step 4: Generate Ideas
- Have you brainstormed with others to develop ideas about possible interventions?
- Have you prioritised the ideas so you know what to work on first?
Step 5: The medical review
- Do infections or metabolic changes cause the behaviour?
- Do medication side-effects contribute to the behaviour?
- Is pain or physical illness an issue?
- Do eyes, ears or teeth need to be checked?
Step 6: Putting ideas into practice
- Have you tried strategies for preventing the behaviour?
- Have you correctly identified signs that behaviour will occur and acted upon them?
- Have you tried rewarding a behaviour you would like to see more of?
- Is everyone being consistent?
- Have you developed a good training plan if required?
- Have you tried a combination of behavioural and medical treatment interventions if required?
Step 7: Evaluating what you've done
- What is the frequency of the behaviour now?
- Was everyone consistent?
- Was there a change in the behaviour?
- Have you congratulated yourself for your hard work?
- What is the next area to focus on?