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Rehabilitation NURSING



KEY WORDS dementia non-pharmacological interventions problem behaviors The older adult with dementia who exhibits problem behaviors is likely to be experiencing physical or psychological distress. Both can negatively affect the health, rehabilitation, and quality of life for the older adult. Managing problem behaviors can challenge the skills of the most experienced nurse. Being able to identify the origins of these behaviors can help caregivers respond in a way that will achieve behavioral management and preserve the dignity of the older adult. This article presents some practical measures to assist nurses with minimizing the negative effects of dementia-associated problem behaviors in older adults.

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Managing Problem Behaviors Associated with Dementia

Ruth Remington, PhD APRN BC · Lisa Abdallah, PhD RN · Karen Devereaux Melillo, PhD APRN BC FAANP · Jane Flanagan, PhD APRN BC


Problem behaviors among older adults are prevalent in the rehabilitation setting and can negatively affect the patient's health and quality of life. The effects of these behaviors are also felt by caregivers and other patients. Nurses providing direct care to patients in the rehabilitation setting are in the position to identify factors that precipitate problem behaviors and to intervene promptly, minimizing the negative consequences. Agitation, disruptive behaviors, dysfunctional behaviors, confusion, and behavior disturbance are terms used to describe problem behaviors associated with dementia. Problem behaviors are not clearly or consistently described in the literature. Common themes among these descriptions are that problem behaviors are either verbal or vocal in nature, can be either aggressive or nonaggressive, are always inappropriate, and have negative consequences for the individual or others in the environment. Origins of Problem Behaviors Many older adults who exhibit problem behaviors suffer from some form of cognitive impairment. This presents as either dementia or delirium. Dementia is a chronic cognitive impairment. Delirium, or acute cognitive impairment, develops in the presence of infection or other reversible metabolic processes. Delirium can cause confusion and agitation that is difficult to distinguish from dementia. However, after the underlying cause of the delirium is identified and treated, the patient's behavior returns to baseline, while the cognitive impairment of dementia is progressive and permanent (Smith & Buckwalter, 2005). When changes in the brain occur that impair memory, reasoning, language, and other communication skills, behavior becomes a primary method of nonverbal expression. Stress in the older adult exemplifies this effect. The loss of brain cells in dementia

makes a person less able to tolerate stress. Stressors, such as fatigue, acute illness, pain, change in routine, or confusing stimuli, can trigger the occurrence of problem behaviors (Gerdner & Buckwalter, 1994). Understanding Problem Behaviors A problem behavior is one that endangers the safety and well-being of the patient and others in the environment (Buhr & White, 2006). In the patient with dementia, determining whether a particular behavior is problematic depends on several things, such as environmental influences, the perception of caregivers, and the meaning of the behavior to the person. The behavior of a patient who wanders is problematic due to the considerable risk for falls or getting lost. Furthermore if this wandering patient were to enter another's room, it could trigger agitation or aggression in the other patient. Patients' problem behaviors also affect caregivers, who may experience job stress, burnout, and rapid turnover of personnel. These factors further jeopardize the care of the rehabilitation patient and, in fact, the health and safety of the caregiver (Beck et al., 2002). Consequently, problem behaviors increase the likelihood that the patient will be exposed to physical or pharmacological restraint. The severity of problem behaviors is often attributed to the amount of physical risk to the patient or others. For example, physically aggressive agitated behaviors, such as hitting or kicking, tend to pose a more harmful risk than verbally agitated behaviors, such as repetitive vocalizations. When trying to understand problem behaviors, it is helpful for healthcare professionals to keep in mind that all behavior has meaning, even though it may be difficult for caregivers to discern the meaning (Hall & Buckwalter, 1987). Because individuals with dementia are unable to think logically, the meaning of their behavior is difficult to understand. It is important to remember that the rehabilitation

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patient who is exhibiting problem behaviors is not doing so deliberately. Dementia makes the person unable to control outbursts or irrational behaviors. Division of a Behavior Problem behaviors can be viewed as a three-part system: (1) an antecedent or trigger, (2) the problem behavior, and (3) the consequences. For example, a staff member begins to feed a patient (antecedent) who is playing with her food. The patient hits and pushes the staff member away (behavior). The staff avoids the patient (consequence). Nursing management of the patient who exhibits problem behaviors is challenging. Thorough assessment is essential. It is important for the nurse to be familiar with the person's traits and habits in order to understand what message the behavior may be conveying (Smith & Buckwalter, 2005). Identifying the patient's baseline behavior can help to determine what might be precipitating problem behaviors. It is beneficial for both patients and caregivers to recognize how nonverbal cues relate to the patient's feelings and moods, such as facial expressions and body language that accompany vocalizations. Observe patients to determine if behaviors are related to a specific time of day, such as late afternoon (also called sundowning), or a particular activity, such as mealtime or bath time. There are several practices that can be implemented to help care for patients who exhibit problem behaviors. Among these practices are addressing psychological needs; providing consistent routines; supporting cognitive function; providing opportunities for independence and a sense of control; and promoting patient safety.

Address Physiological Needs

periods of daytime napping should be discouraged and a regular daytime program of exercise and activities should be provided. If the patient awakens during the night, try offering a backrub, suggesting a light snack, or playing calming music. Assess patients regularly for potentially painful conditions that they may not be able to communicate to caregivers, such as a swollen arthritic joint, an ingrown toenail, or adverse reactions to medications. Suspect pain if your patient has a diagnosis known to cause pain, especially if problem behaviors occur or increase with movement, such as during personal care. Facial grimacing, rubbing, frowning, guarding, and fidgeting are common behavioral indicators of pain (Gerdner & Buckwalter, 1994; Remington & Futrell, 2005).

Provide Consistent Routine

Patients with dementia usually find change difficult to deal with, which taxes their ability to plan and adapt.

Patients with dementia usually find change difficult to deal with, taxing their ability to plan and adapt (Hall & Buckwalter, 1987). A change in routine is likely to cause an increase in anxiety that results in behavioral problems. Whenever possible, assign the same caregivers to patients. Schedule personal care activities and treatments at the same times, and perform them in the same way each day. Avoid making changes to the patients' rooms and common areas.

Support Cognitive Function

Problem behaviors can be triggered by physiological processes, such as infection, constipation, a full bladder, fatigue, and pain. An increase in problem behaviors can indicate the worsening of a medical condition. Prompt assessment and intervention can minimize behavioral changes. Frequently, the only presenting sign of infection, such as a urinary tract infection, in an older adult is problem behavior (Remington & Futrell, 2005). Exhibiting problem behavior is one way the patient may communicate the need to use the toilet; caregivers should monitor frequency of bowel movements to ensure adequate elimination and toilet the patient at regular intervals Fatigue is a trigger of problem behaviors that may be attributable to several causes. For example, wandering and pacing consume considerable energy. Sleep disturbances, such as nighttime awakening and excessive napping, are also common sources of fatigue in patients with dementia. Adequate sleep, balanced with adequate exercise during the day, is essential (Carlson, Fleming, Smith, & Evans, 1995). Long

Two simple but effective strategies in support of cognitive functioning are making sure that eyeglasses are clean and hearing aids are functioning properly and have fresh batteries. Make certain that there is adequate lighting to make up for visual deficits. When speaking to patients use communication techniques that will minimize confusion and help the patient feel secure. Make eye contact and speak at a slow rate, using simple words and short sentences. Allow plenty of time for the patient to process the information and respond. Avoid lengthy explanations or arguments that may demand an intellectual response that is beyond the patient's capability. Easy-to-read clocks and calendars may help to improve orientation. Pictures and labels can help to direct the person to the appropriate place. For example, a picture of a toilet on the bathroom door or a bed on the bedroom door. A picture of the patient on the doorway to his or her room can help direct a person to the right room. If using a patient's photograph consider obtaining a picture of the person when younger. Because of the loss of short-term memory, individuals often do not remember themselves as elderly, and may not recognize a current picture.

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Managing Problem Behaviors Associated with Dementia

Provide for Independence and Control

Memory losses make planning and completion of tasks difficult or overwhelming for patients with dementia. Provide opportunities for patients to have as much control over their routines as possible. Encourage them to do as much as possible for themselves. By breaking down tasks into manageable steps and allowing plenty of time for completion, patients have a better chance of being successful. For example, giving the patient a washcloth with instructions to wash the face is much more manageable than providing a washbasin and expecting the patient to complete morning care. Offer choices, such as what to wear or what to eat. Insisting that clothing be perfectly matched or a meal be eaten before dessert will likely cause stress for the patient that could escalate into problem behaviors. Avoid external confinements, such as the application of restraints that severely limit the patient's mobility and sense of control. These should only be used as a last resort to protect patient safety (Allen, 1999; Gerdner & Buckwalter, 1994).

Promote Safety

be calming for some individuals. However, if this intensifies the problem behavior, attempt the use of familiar words or items. Try saying "Let's have a snack" or "Let's sing a song" (Buhr & White, 2006). If that does not work, try singing yourself. Caregiver singing has been shown to enhance communication among older adults with dementia (Gotell, Brown, & Ekman, 2002). Interventions to Manage Problem Behaviors It is now generally accepted that physical restraints should be used only as a last resort to protect the patient's safety. Sedation and associated adverse effects attributed to chemical restraint can delay recovery and considerably increase the cost of care. There is no single intervention that is universally effective in reducing problem behaviors. Currently, the initial approach to treatment of problem behaviors is the use of nonpharmacological interventions. However, combining similar interventions does not always increase the positive effect (Remington, 2002). Whether used alone or in combination, the most effective interventions are ones that are individualized and based on continuing assessment of the patient. Interventions to manage problem behaviors are most effective when carried out before the patient's behaviors reach their peak. Investigations of nonpharmacological interventions to reduce problem behaviors have demonstrated favorable results. These interventions will be discussed in three categories: (1) subject-centered, (2) environment-centered, and (3) caregiver-centered. The goal of each type of intervention is to reduce the occurrence of problem behaviors. Subject-centered interventions are directed toward an individual or group of patients to modify their behaviors. Environmentcentered interventions refer to modifications in the environment that compensate for impaired function and cognition. Caregiver-centered interventions are directed toward supporting direct-care staff members in an attempt to alleviate the physical and emotional stress associated with caring for patients with problem behaviors (Remington, Gerdner, & Buckwalter, 2005). Subject-Centered Interventions

Reality Orientation

Maintain safety by removing clutter and other obvious hazards to ambulation. This will allow the patient to pace and wander safely within a controlled environment and reduce the risk of injury to self and others. Ensure that windows and doors are locked and alarms are turned on. Potentially harmful items, such as sharp objects and cleaning fluids, should be removed from the patients' environment. Highly polished floors or scatter rugs can lead to falls in patients with unsteady gait. In order for cognitively impaired individuals to rely on habit and routine to negotiate the environment, it is important that furniture and patient belongings are not rearranged. Responding to Problem Behaviors While a patient is exhibiting problem behaviors, it is important that the nurse remain calm. Shouting or reprimanding will only increase patient anxiety and exacerbate the behavior. Because standing above the patient can be perceived as threatening, position yourself at eye level and establish eye contact. Try to redirect the patient to a less stimulating environment (Smith & Buckwalter, 2005). Because of impaired short-term memory, removal from the environment may help the patient forget what caused the outburst. Avoid approaching the patient from the side or back, which may be viewed as an invasion of personal space and could lead to aggressive behavior. Reassure the patient that he or she is safe. Gentle physical contact, such as holding hands, may

A common method for minimizing confusion is reality orientation, which helps patients be more aware of themselves in relation to the environment and time. The patient should be provided with familiar objects to stimulate memory. Start with a few items, for example, a photograph or scrapbook.


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Introducing objects from home too rapidly can be confusing because the patient may associate the object with home and view it as out of place in the rehabilitation setting. Memory aids, such as large, easy-to-read calendars and clocks, labels on doors and equipment, and signs are also forms of reality orientation. Reality orientation has been criticized as insensitive and confrontational. In helping to orient the patient, statements such as "Today is Monday, February 18. It is winter, and it is snowing outside" may be made. If the patient says it is Friday, do not disagree. Arguing with the patient will only increase stress and may exacerbate problem behaviors (Gibson, 2004).

Validation Therapy

provides for a sense of mastery and control. A variety of colors, shapes, and textures provides sensory stimulation (Gerdner, 2000). When using art as an intervention, the challenge is to identify an art form that is manageable for the patient but not too childlike. For example, for the patient who is only able to master coloring with crayons, offer simple landscapes or other adult themes, rather than a coloring book with pictures of dolls and toy trucks.

Therapeutic Use of Touch

Not all patients will welcome touch therapy and ongoing assessment of their response is essential.

Validation therapy is another approach to dealing with agitation. This approach, developed by Fiel, is based on the belief that the feelings and memories of the disoriented person should be respected and validated, even though they are inconsistent with reality. The goal of this therapy is to understand the meaning of the behavior to the individual. It promotes respect for the individual's sense of reality, rather than focusing on correcting factual errors. Techniques used in validation therapy include active listening and rephrasing to facilitate communication (Feil, 1993; Gibson, 2004). For example, if a person becomes agitated because it appears that the environment is too confusing, the caregiver might say "This noise seems to be frightening you." This response links the patient's behavior with the feeling that it represents.

Reminiscence Therapy

Hands-on touch therapies have been practiced by nurses throughout history and shown to elicit therapeutic responses. Touch is another nonverbal method of communicating with patients. Hand massage is calming and can reduce agitation. Back massage, using light pressure, an even rhythm, and slow strokes, can promote relaxation and comfort. Both of these touch-therapy techniques require little training and can be performed by professional and lay caregivers with positive results. Ongoing assessment is essential, as not all patients will welcome touch therapy and may view it as invasion of their personal space (Remington, 2002).

Therapeutic Activity Kits

Reminiscence therapy, sometimes called recall or life review, is more than just remembering the past. It is an ordered process of reflection on significant life events. Most patients with dementia can participate in reminiscence therapy because the ability to retrieve information from long-term memory is preserved further into the disease than the ability to recall information from short-term memory. Memory aids, such as pictures, music, or food, can be used to trigger recall. Reminiscence therapy can improve communication and self-esteem for the patient, and it can also help staff members to better understand the older adult and form closer relationships (Gibson, 2004).

Art Therapy

A therapeutic activity kit contains a collection of items that can be used to provide cognitive and sensory stimulation. The items can be individualized with the help of family members to increase personal meaning. Photographs, audiotapes of family members, favorite music, art supplies, and playing cards are appropriate items for a therapeutic activity kit (Conedera & Mitchell, 2004). Sometimes the items can be tailored to the patient's former activities. For example, a former banker might enjoy sorting a container of coins or a homemaker can be given a basket of laundry to sort and fold.

Doll Therapy

Dolls and stuffed animals can be used therapeutically to provide sensory stimulation and comfort to patients. Doll therapy can also stimulate communication. Items used should be well constructed, with no removable small parts that could be swallowed (Enfield & Bergman, 1995). Care must be taken to avoid infantilizing patients by talking to them in a childlike manner when doll therapy is being utilized.

Simulated Presence Therapy

Art is another way of stimulating communication for the patient who, because of dementia, is unable to communicate using language. Manipulating art media allows the patient to make decisions in a controlled setting. Art also allows expression of self and

Personalized conversations on video or audiotape can be used to simulate communication or reminiscence. Ask family members to tape their part of a conversation about pleasant experiences, personal memories, or anecdotes, leaving pauses for a response. The pauses will encourage the patient to

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Managing Problem Behaviors Associated with Dementia

reply and engage in the conversation. This technique can be a positive experience for the family as well (Remington et al., 2005). Environment-Centered Interventions


Music can have a calming effect on the patient who exhibits problem behaviors. Calming qualities of music include a tempo slower than the resting heart rate, soft dynamic levels, and repetitive themes. Stringed instruments tend to be more calming than brass or percussion instruments. Choose musical selections without words or familiar melodies to reduce the cognitive effort needed to process the music and allow the patient to relax with the music. If the goal is to encourage active group work, music with a faster tempo played by an ensemble such as a "big band" is likely to be stimulating. Alternatively, choosing familiar music based on patient's preference can stimulate remote memory associated with positive feelings, which can be calming and prevent or alleviate agitation. Consult with family members about the patient's preferences for types of music and the importance that music has played in his or her life. Carefully selected music is a relatively inexpensive intervention that is easily administered and requires little training. It can be used in the individuals' rooms or for groups in a day room or dining room (Remington et al., 2005).


reduced so much that the patient experiences sensory deprivation, which may cause boredom and result in an increase in agitation and confusion (Davis, Buckwalter, & Burgio, 1997). Visual barriers, also called environmental camouflage, can help prevent exit-seeking and intrusion behaviors. Cloth panels over door knobs can decrease attempts to open doors, and grid patterns taped to the floor in front of doorways can discourage attempts to leave. Other strategies include using stop signs at restricted areas. Also artistically painting doors that lead to off-limits areas create the impression of art rather than exits. Paint and wallpaper can also be used to disguise or camouflage closets, thermostats, and other potential architectural hazards. Caregiver-Centered Interventions Caring for the patient with problem behaviors is emotionally and physically taxing for the caregiver. The demands of managed care, regulatory agencies, increased workloads, and staff shortages can create additional stress. Nurses are often so busy performing their daily tasks that they do not take the time to assess their own emotional, physical, and spiritual well-being. Nurses need to learn to recognize their reactions to stress and develop coping strategies to overcome the sources of stress. Some of the symptoms of stress and burnout include changes in appetite, headache, stomach upset, fatigue, memory disturbances, and anger. Caregivers should take care of themselves by eating well and not skip lunch or dinner. They should try regular exercise and relaxing activities, such as massage or warm baths. Meditation and calming music will help caregivers ease the stresses of the day. Caregivers should get plenty of rest. They should set aside some time each day for activities that nurture the mind, body, and spirit. Staff training is one organizational coping strategy that has been effective in reducing job stress. Frequent training and review of techniques to manage problem behaviors may be beneficial by increasing staff confidence in their skills, helping to reduce stress for both caregivers and patients, and, ultimately, improving the quality of care. Training alone is not enough to guarantee that knowledge and skills will be retained over time. Taking advantage of the opportunity to mentor and support other nurses in the development of expertise in the care of older adults will enhance autonomy and skill performance in the long term. Although most nurses do not have direct control over many institutional stressors, they can seek administrative support for things such as adequate

The concept of Snoezelen was developed in the Netherlands. It is a method of facilitating relaxation for persons with intellectual or sensory disabilities. Projected images, fiber-optic lights, bubble tubes, tactile objects, calming music, and aroma therapy are used to gently stimulate the senses and enhance relaxation. Participants are free to explore and discover at their own pace, allowing for a sense of control. There is no need for intellectual reasoning to obtain positive results. Being in a Snoezelen room takes patients away from the demands of their usual environment, so there is less pressure to perform in a specified way (Remington et al., 2005).

Environmental Modifications

The patient's environment can have a significant effect on the development of problem behaviors. A patient who is in an area that is too noisy or overly stimulating may become frightened and confused. Therefore, it is best to avoid competitive activities. Also the television volume should be kept low and programming should be monitored for suitability. However, environmental stimuli should not be

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staffing, supplies, and workload. Staff and management need to have a shared understanding of professional roles and performance expectations (Shanks, 2005; Sherman, 2004). Educational Resources There are several organizations devoted to caring for older adults with dementia. The John A. Hartford Foundation Institute of Geriatric Nursing publishes Try This, a series of best practices in nursing care of older adults. The series offers brief presentations on topics related specifically to nursing care of older adults to help nurses understand and make use of the highest standards of practice. Try This and other geriatric nursing resources can be accessed at www. Other educational resources include the Alzheimer's Association at; Eldercare Locator at; and National Institute on Aging (NIA) at Summary Caring for older adults with dementia-associated problem behaviors is challenging for caregivers because they are called upon to treat behaviors for which the cause is often not evident. Any one of a variety of stressors could be the trigger for problem behaviors. However, no single stressor is universally responsible. Similarly, no single intervention will work equally well for all agitated persons. Thorough assessment is necessary to gather data for planning nonpharmacological interventions that have the greatest liklihood of success. While an intervention is being carried out, ongoing assessment is essential to ensure that it is having the desired effect. After a plan has been implemented, continuing education and support of nursing staff is necessary. Treatment plans that attend to the patient, the environment, and the caregiver have the greatest potential to maintain the dignity and quality of life for older adult patients with problem behaviors. About the Authors

Ruth Remington, PhD APRN BC, is an assistant professor at the University of Massachusetts Lowell. She is an adult and gerontological nurse practitioner with extensive clinical experience in care of older adults in an office practice, in home care, in the nursing home, and acute care hospital. Her area of research is in dementia, with particular interest in nonpharmacological interventions to manage agitation. Lisa M. Abdallah, Phd RN, holds a masters of science in nursing with nursing administration and gerontological nursing focus, and has previous experience as a staff development coordinator and director of nursing in a long term care facility. She is an assistant professor in nursing, teaching a clinical rotation with nursing students on a Medicare-certified unit

in long-term care facility. Her dissertation research focused on NP/MD collaborative primary care delivery model in nursing homes. Dr. Abdallah's current area of research focused on quality improvement in nursing homes, health promotion, and risk reduction in the elderly. Karen Devereaux Melillo, PhD APRN BC FAANP, holds an associate of science degree, nursing, from Massachusetts Bay Community College, a bachelor of science degree, nursing, from Salem State College, a master of science degree, in gerontological nursing, University of Lowell, and a doctorate in social policy from Brandeis University. Jane Flanagan, PhD APRN BC, is an assistant professor of nursing at Boston College Connell School of Nursing where she teaches in the adult and geriatric nurse practitioner program. She has previously taught in both the undergraduate and graduate programs at the University of Massachusetts at Lowell. She was the first Carol Ghiloni Nursing Faculty Fellow at Massachusetts General Hospital (MGH) and is an associate clinical scientist at the Phyllis Cantor Center at the Dana Farber Cancer Institute. She has worked at MGH for over 20 years in a variety of clinical settings and continues to maintain a clinical practice there on the General Clinical Research Unit as a nurse practitioner. She has provided guest lectures at several Boston area colleges and hospitals on a variety of nursing care issues including health assessment, laboratory values, and caring environments. Her research interests are bearing witness to illness, spirituality, palliative care, the patient experience during and after hospitalization, and the integration of nursing theory and aesthetics into nursing models of care.


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Hall, G. R., & Buckwalter, K. C. (1987). Progressively lowered stress threshold: A conceptual model for care of adults with Alzheimer's disease. Archives of Psychiatric Nursing, 1(6), 399­406. Remington, R. (2002). Calming music and hand massage with agitated elderly. Nursing Research, 51, 5. Remington, R., & Futrell, M. (2005) Addressing problem behaviors common to late-life dementias. In K. D. Melillo, & S. C. Houde (Eds.). Geriatric and mental health nursing. Sudbury, MA: Jones & Bartlett. Remington, R., Gerdner, L. A., & Buckwalter, K. C. (2005). Nursing management of clients experiencing late life dementias: Establishing individualized treatment plans. In K. D. Melillo & S. C. Houde (eds.). Geriatric and mental health nursing. Sudbury, MA: Jones & Bartlett. Shanks, L. K. (2005). A caregiver's guide to alzheimer's. Lincoln, NE: University of Nebraska Press. Sherman, D. W. (2004). Nurses' stress and burnout. American Journal of Nursing, 104(5), 48­56. Smith, M., & Buckwalter, K. C. (2005). Behaviors associated with dementia: Whether resisting care or exhibiting apathy, an older adult with dementia is attempting communication. Nurses and other caregivers must learn to "hear this language." American Journal of Nursing, 105(7), 40­52.

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