10: Reducing Behavioral Deficits

The following are basic principles in recommending nonpharmacological interventions to staff. The suggestions below are mainly for reducing behavioral deficits (i.e., increasing the behavior you want, like activities of daily living).

The best care for patients with progressive dementia (memory problems that worsen over time) focuses on the remaining abilities rather than on the ever-increasing disabilities. We preserve freedom and dignity for as long as possible by concentrating our caregiving efforts on maximizing patients’ strengths.

How does this aspiration translate into caregiving practice? Caregivers should provide as much support as necessary that maintains repertoires for as long as possible. The term “repertoire” as used here refers to all the behavior a person is capable of at a particular point in time. For example, is the person fully able to dress, feed, and/or bathe herself? If not, what aspects of the task can she still do? Are the patient’s verbal skills relatively intact such that he or she can track speakers and respond appropriately during basic conversation? If not, what communication skills are still intact (e.g., the patient is able to track a conversation, as evidenced by following simple commands, though he or she cannot express her- or himself due to extreme word-finding difficulties)? Can the patient find his or her way around the residence? If not, what is the minimal support necessary for him or her to get around independently (i.e., without being physically escorted)?

We say “minimal” support because we want patients to do as much for themselves as possible. Too much or too little support can cause excess disability. With too much support, patients end up relying too much on others, and in so doing lose skills prematurely (“If you don’t use it, you lose it”). With too little support, patients may fail at the task. Many failed attempts at communication and other tasks (e.g., activities of daily living) also leads to excess disability, as people are embarrassed, lose confidence, and withdraw out of fear of failure. Withholding skills limits practice. Limiting practice causes the person to lose skills prematurely (if you don’t use it, you lose it).

With progressive dementia like Alzheimer’s disease, behavioral repertoires are reduced over time. Namely, patients in later stages of the disease are capable of far fewer behaviors than what they started with. For example, patients who were once able to dress, feed, and bathe themselves might be missing some of the behavior (not all) required to complete the tasks independently. Perhaps, due to problems with their thinking, they are unable to initiate the appropriate chain of actions. At any rate, patients at some point will require assistance from staff. Assistance can be provided using one of the techniques of prompting.

Prompts

Prompts are added support before or during performance that increase the chances that the behavior will be carried out effectively. The prompting techniques we will discuss in this lesson are verbal prompts, picture prompts, modeling and physical guidance. Other types of prompts will be taken up in the next lesson, Considerations in Applying an Environmental Approach to Dementia.

Verbal prompts. Verbal prompts are things we say or write that help patients perform a given task. Verbal prompts include instructions, rules and hints. For example, simple operating instructions can be attached to a microwave. The letters should be in large black font against a white background.

1. open door
2. place coffee cup inside
3. press 1
4. press 2
5. press 3
6. press “start”
7. open door after bell rings

Picture prompts. Picture prompts are photographs or illustrations that increase the chances that the behavior will be carried out effectively. Picture prompts are widely used with persons with dementia. Here are several examples. Family photographs displayed at the door help patients find their way to and from their rooms. Some phones are highly simplified using an automatic dialing system, where pictures replace numbers. Pictures placed on buttons correspond to phone numbers. For example, pressing the photo of “Cousin William” would dial that number. Picture prompts are also attached to enclosed spaces like cupboards and drawers. The figure below illustrates how a picture prompt can be used to locate “sock drawer.”

Modeling. Modeling involves 1) demonstrating the correct behavior to the patient. 2) The patient then imitates the behavior. 3) A reinforcer or reward immediately follows correct performance. For example, staff first demonstrates how to use a hairbrush. The person modeling the behavior then hands over the brush and the patient imitates the action. Should the patient imitate the task correctly, a reinforcer (e.g., praise) immediately follows. Should the patient imitate the behavior incorrectly, the model then repeats the action and the patient is provided with another opportunity to imitate the behavior. Should this trial also result in failure, the model might try repeating the action or using a more hands-on approach like physical guidance. Physical guidance will be described below.

The number of trials or opportunities to imitate the correct behavior depends on the patient. If the patient looks upset (e.g., worried or frustrated facial expression), reassure the patient that you are there to help and consider providing more hands-on support. If the patient is really upset, consider discontinuing the task and returning at a later time.

Modeling works best with higher functioning patients who are in the early-to-middle stages of dementia. The complexity of the behavior modeled depends on the patient’s overall level of impairment. Patients who are mildly impaired are capable of modeling behavior that is more complex (e.g., 5 behavioral steps). Patients who are moderately impaired are capable of modeling behavior that is less complex, involving fewer steps in the behavioral chain (e.g., 2 behavioral steps). Moreover, it sometimes helps to draw patients’ attention to the specific behaviors by describing the actions while performing them (e.g., “Fold this way. Fold this way”).

Physical guidance. Physical guidance involves physically assisting the person with the task. For example, toileting schedules have been found to reduce “accidents.” As patients seldom know the precise time when to use the restroom, staff need to prompt them. Should verbal prompts fail, staff should physically guide them to the toilet. Perhaps, gently taking them by the arm and walking them to the toilet is all that’s required.

Physical guidance should only be used with the cooperation of the patient, using as little force as possible. If the patient becomes upset, attend to their feelings and provide reassurance (e.g., “I’m here to help you”). If reassuring them doesn’t help, abandon your agenda for the moment and return when the patient has calmed down. Here, you might use distraction. You might also want to consider caregiving alternatives if toileting becomes a major issue (e.g., adult absorbent briefs).