3: Look at Context

Once you have ruled out medical explanations for challenging behaviors, the next step is to examine the context in which the behavior occurs. Before we describe how to talk about context with staff, it is important to dig a little deeper and explore the conceptual underpinnings of what we mean by context from a behavioral perspective.

Context is everything when it comes to behavioral challenges in persons with dementia. There are always stimuli, people, events, etc. occurring before the behavior in question. The behavior never arises in a vacuum. Sometimes those stimuli, people, events, etc. occur regularly before the behavior emerges. Those things might increase the likelihood that challenging behavior will emerge. Drastically increasing the ambient temperature might increase the likelihood that a person will take off his or her sweater. Drastically lowering the ambient temperature might, in contrast, increase the likelihood that a person will put it on.

When something in the environment increases the chances that a particular behavior emerges, we call this an antecedent. Antecedents come before behavior and make the behavior in question more likely. Often, there are certain easily identifiable aspects of the environment that seem to “trigger” the behavior. For example, Person A and Person B do not get along. When they sit right next to each another, a fight usually ensues. Person A, therefore, is an antecedent for person B. Person B might also serve as an antecedent for Person A, though the relationship does not always work both ways. Person B, for example, might simply be defending him- or herself.

Decreasing or increasing stimulation are common antecedents for persons with dementia presenting with behavioral challenges. Leaving a patient completely alone for extended periods of time and turning off his or her all-time favorite television show are examples of decreasing stimulation. Cranking the music on the stereo up (to the point of the speakers cutting out) or lots of staff going in and out of a person’s room are examples of increasing stimulation. In a manner of speaking, put simply: Increasing stimulation adds something to the environment and decreasing stimulation takes something away.

Antecedents come before the behavior of interest and increase the likelihood of behavior. For example, an individual might only start screaming when left alone (decreasing stimulation). In the same vein, turning on every light in the facility (if the person prefers the dark) might also increase the likelihood that he or she will start screaming (increasing stimulation). Physical care also increases stimulation. If a patient is injured, moving the affected limb [increasing (painful) stimulation] might increase the likelihood of challenging behavior. Because individuals with dementia often have difficultly filtering out noise from the signal, as it were, they become easily confused in noisy and/or busy environments (i.e., “stimulus overload”).

Behavior is also affected by what follows it, an outcome or consequence. A consequence can be (1) pleasant or (2) unpleasant. Getting the attention of someone you like is a pleasant consequence. Trying to get the attention of someone you like and she ignores you is an unpleasant consequence. When you attempt to sit in your favorite chair, coming to realize at once that it’s soaked in urine, is an obvious unpleasant consequence (a common consequence to anyone who has ever worked in assisted living or a skilled nursing facility).

An easy way to think about the consequences of behavior is to ask yourself: What happens when the person engages in this behavior? For example, do they get out of an unpleasant activity such as bathing? Or, do they get attention? Figuring out the consequences of behavior can help you determine the purpose or payoff of the behavior (i.e., what may be maintaining the behavior).

Please note: When we talk about the “purpose” of behavior, we do not mean that the patient did something on “purpose.” Persons with dementia behave in certain ways that appear unusual (e.g., behaving aggressively or in bizarre ways) on account of the disease; the problem behavior is not done on purpose. Because of the disease, persons with dementia are usually not aware of what they are even doing. You might want to convey to the staff on the phone – if they seem to be taking the behavior personally – that it is the dementia causing the behavior. If the patient says something mean, derogatory, racist, demeaning, sexist, etc. – it’s the “dementia talking.”

A simple way to organize your ideas on the influences of behavior is to use an ABC record form. The “A” stands for antecedent. The “B” stands for behavior. And the “C” stands for consequence. You might want to use this while you are talking with staff over the phone. You might also want to provide this to staff for them to document the behavior of interest.

Once you have (conceptualized and) described the behavior using (1) specific and (2) simple language, you might also consider using a scatterplot in addition to the ABC form or in lieu of it. A scatterplot nicely brings to light temporal patterns of behavioral challenges. For example, are there patterns that emerge on certain days, at certain time of the day, etc.?

If you see the behavioral challenges occurring at only certain times of the day, you might then want to look at the patient’s schedule. Perhaps, the behavior emerges in the presence of a particular staff member. Perhaps, the behavior emerges during specific activities, which involve lots of noise, etc. Sundowning, for example, often occurs in the late afternoon – coinciding with changes in sunlight. It is believed that this change in natural light confuses, disorients patients. Moreover, when less light comes in from outside, windows become mirror-like. Accordingly, rather than looking out at trees, birds, squirrels, clouds moving in the sky, etc., they are seeing elderly people who they don’t recognize milling about. Perhaps, they may not even recognize their own reflection as they approach the glass. From their perspective, their reflection might look like a stranger looking right back at them, quizzically. As a side note, it would be very disconcerting looking out your living room window, only to see a stranger peering in – his or her eyes following yours.