Behaviours of concern in dementia care are known under many different terms; behaviours that challenge, inappropriate behaviour, problem behaviour, unacceptable behaviour and many more. The behaviours can include wandering, agitation, physical and verbal aggression, suspiciousness, paranoia, repetitiveness, apathy, inappropriate or impulsive sexual behaviour, hallucinations, sundowning and sleep disturbance. Whatever they are called and how they manifest themselves, managing these behaviours is likely to take up a large part of your working day in a care home setting.
Rather than assuming that these behaviours are an expected symptom of dementia, these behaviours can be easier to understand if we try to think of them as an attempt to express distress or communicate an unmet need (physical, environmental or emotional). It is a reaction to something that is not right for the person and generally occurs when the person has a need that is not being met. The need could be something physical like being in pain or too hot but could just as easily be an emotional or spiritual need such as the need for respect, love or happiness.
5 of the most common unmet emotional needs are:
- To be needed and useful
- To have the opportunity to care/nurture
- To love and be loved
- To have self-esteem or confidence boosted
- To have the power to choose.
The diagnosis and the move to residential care can result in a multitude of losses. Familiar roles and jobs are lost and the person may no longer feel useful or needed. Family and friends may withdraw from the relationship for a variety of reasons and this unfortunately can diminish the opportunity to love and be loved. The loss of their home and pets can lead to having no-one or nothing to care for and the person’s identity changes as they begin to be defined by their diagnosis, problems and weaknesses rather than what they are still capable of, resulting in low self-esteem. Last is the loss of control of almost every aspect of daily life as others make decisions and routines are changed.
When we experience these behaviours, we are the ones who define them as “difficult”. It is all too easy to focus on the problem and only see the situation from our own point of view. Knowing that challenging behaviour is a reaction to something that isn’t right or in other words an unmet need can help us to change our focus from only looking at what’s wrong with the person physically, to compassionately searching for what the person’s unmet needs might be. If we can acknowledge the person’s need for love, respect or to feel useful we are at least part of the way towards finding a solution.
Take a moment to imagine you are one of the people for whom you care, how would you respond to the following question?
How long would it be before I started to react to the control and supervision I experience here with behaviour that could be branded as “challenging”?
Add the fact that you might not be able to communicate your concern or disapproval in words or fluent sentences. What means would you have to show your disapproval other than to lash out, spit or even throw yourself on the floor? And if you did react like this you might easily be labelled as “inappropriate”, “difficult” or “challenging”!