One of the largest, most difficult questions to answer in the long-term care community today is, "How do we support our residents with challenging behaviors?" Specifically with residents suffering from dementia, challenging behaviors can be harmful to the residents themselves, their peers and staff members trying to intervene.
Some of the most common challenging behaviors include resisting care, obscene or abusive language, pacing/excessive wandering, socially inappropriate sexual behavior, exit seeking, hoarding, poor safety awareness and attention-seeking behavior. Frequently, well-intentioned care providers use medication in response to these actions.
While drugs may sometimes be necessary, further long-term care research suggests that in a majority of these situations, care providers would be medicating the symptom not the underlying cause for the behavior. This is why the behavior mapping approach to care is about stepping back from that perspective and looking at what actually prompted the residents' actions. Keith Savell Ph.D. of Mariposa Training and Geriatric Healthcare Consultants explained that residents always have a reason behind their behavior.
"How do we support our residents with challenging behaviors?"
He continued, it's up to the care providers to step into a detective role to figure out the reason behind the symptoms. This way, they can focus on treating the resident as a whole and hopefully improve their quality of life.
Behavioral mapping begins with understanding 'why?'
The secret to effective behavior management is recognizing that all behaviors occur for a reason. Within this line of thought, there is a difference between residents who are cognitively well and those who are cognitively impaired. Cognitively well residents are able to ask for what they want or need, so their challenging behavior is frequently based upon attention-seeking or manipulative motives.
Cognitively impaired residents may be unable to ask for what they want or need. In this way, their challenging behavior may be their way of communicating that they are frightened, in pain, have an undiagnosed illness or an unmet need, or desire. Effective behavior management therefore, simply requires staff members to begin to understand the language of resident behavior.
There are four main antecedents to challenging behavior(s) that all challenging behaviors will fall under:
- Human factor antecedents: This category includes those underlying reasons that occur from within the individual, such as undiagnosed illnesses, the effect of a new medication, the need to feel in control, social isolation or dehydration.
- Environmental antecedents: Environmental antecedents include factors which lie in the environment, such as temperature fluctuations, light changes (such as glare) and inappropriate stimulus levels (too much noise).
- Situational antecedents: Situational antecedents refer to events and/or factors which occur in the moment, such as staff or other residents infringing on a residents' personal space, fear of contact or changes in environment or routine. Residential relocation is a huge catalyst for delirium and challenging behavior, as well.
- Delivery of care antecedents: Even the most well-meaning care providers may fall short in regards to this category. Delivery of care antecedents refer to those unintentional acts by staff which may result in a resident's challenging behavior. This may include interacting with a resident in a disrespectful manner, misleading instructions, staff body language which may present as angry or impatient or even staff requests exceeding functional capacity and the lack of timely response to requests for assistance.
Care providers must define challenging behaviors
If a behavior happens once, it may be isolated. If it happens again, it is highly likely it will continue. It will keep occurring until care providers can figure out what causes it. In order to do so, care providers must ask themselves a few questions. These may include: Is the behavior truly a problem? Does the behavior impede the resident's functioning? Does the behavior present a danger to the resident or others?
Once providers define the challenging behavior, they must identify the behavioral antecedents. Employees can utilize behavioral mapping to document critical data points, track these antecedents and monitor the behavior overall. To start the process of behavioral mapping, care providers must ask:
- WHO was around the resident when the behavior occurred?
- WHAT happened within 24 hours of the behavior?
- WHEN did the behavior occur – what was the time of day when the behavior occurred?
- WHERE was the resident when the behavior unfolded?
The bottom line is that when residents demonstrate challenging behaviors, they always have a reason. Therefore, care providers must strive to identify the underlying cause of the challenging behaviors in order to address the immediate need, as well as prevent the need from reoccurring. Behavior mapping provides a powerful resource for the identification of behavioral antecedents.
To learn more, please visit the Mariposa Training website or watch Dr. Keith Savell's presentation about "Behavior Mapping for the Care of Dementia Based Behaviors."