9: Reducing behavioral excesses

The following are basic principles in recommending nonpharmacological interventions to staff. The suggestions below are mainly for reducing behavioral excesses.

Intervention Strategies: Basic Principles

There are three basic approaches to managing problem behavior: 1) Reduce identified antecedents for problem behavior; 2) reduce identified consequences that maintain problem behavior; 3) reward desired behaviors. Either of these or a combination of two or more strategies can be used for any given behavior.

1. Reduce identified antecedents for problem behavior

- Reduce situations that trigger behavior. Example: Not arguing with patients.
- Help patients get needs met in appropriate ways. Example: When patients masturbate in public, interrupt them before orgasm. Redirect them to their private rooms. Make visual sexual stimuli only available in patients’ rooms. Masturbation in private is a more appropriate way of managing patients’ sexual arousal. As a side note, contrary to popular believe, elderly people often require sex as much as younger individuals.

2. Reduce identified consequences that maintain problem behavior

- Minimize the effectiveness of problem behavior in getting needs met. Example: Ignore mildly annoying behavior, the purpose of which is attention-seeking. Provide lots of attention for more appropriate behavior that isn’t as annoying to you.

3. Reward desired behaviors

- Immediately and frequently. Example: Reward appropriate verbal behavior seconds after the person responds.

Specific Behavior Management Strategies

In addition to the three general strategies above, the three specific strategies below are tried and true techniques designed to make problem behavior unnecessary.

Distraction

• Distraction is redirecting the person’s attention to a more pleasant activity.
• This is the most useful strategy in managing problem behavior because persons with dementia are easily redirected. Moreover, because of short-term memory impairment, they can quickly forget why they were angry in the first place (this is especially the case when distracted by a highly preferred activity).
• The key to using distraction successfully is knowing the patient. What gets or holds the person’s attention?
• Distraction can be a verbal or nonverbal strategy. An example of a verbal strategy is changing the conversation. An example of a nonverbal strategy is gently leading the patient to another activity.
• Distraction can be used for a variety of behavior problems.

Ignoring and Reinforcement

• When the problem behavior is not dangerous or overly disruptive, ignore it.
• Also, while ignoring mildly disruptive behavior, reinforce more appropriate behavior.
• Find out what is reinforcing for the patient.
• Present reinforcers immediately following the desired behavior(s), consistently and frequently.

Embedding

• Some tasks may be very unpleasant. Bathing, dressing, and toileting are several of the most common unpleasant activities that seem to trigger problem behavior in persons with dementia. As a side note, it is important to know whether an individual has a sexual assault history. Challenging behavior is oftentimes defensive behavior. Bathing, dressing an individual, might trigger thoughts, emotions, etc. of past abuse, which might be why he or she lashes out.
• The solution to this problem is to make the environment more pleasant by placing preferred objects in the unpleasant environment (e.g., pleasant odors, music, people). This technique is called embedding.