Handling Difficult Patient Behaviors

aring Connection C

The

C

aregivers can feel frustrated with the behavior of the older adult for whom they provide care. Difficult behavior may occur for many reasons. One of the many types of dementia can cause difficult behavior. In addition, there may be physical or emotional reasons. Here are the most frequent causes. 1. Medication—either over medication, undesirable side effects, or the interaction of medications. Symptoms may include falling, drowsiness, a sudden increase in agitation, paranoia, and strange hand or mouth movements. Tranquilizers and sedatives may cause incontinence. 2. Impaired vision or hearing. When an elder has trouble seeing or hearing, it may lead to fear, paranoia, or feelings of being left out. 3. Acute illness. Such illnesses as urinary tract infection, pneumonia, gastro-intestinal infection or fever may lead to confusion. 4. Chronic illness. Angina, congestive heart failure, diabetes can affect mood. Arthritis, ulcers, or headaches may cause irritability.

Handling difficult behavior This issue explores problem behaviors—some reasons why they occur and suggestions for handling them.

Issue Six

5. Dehydration. This may cause dizziness, confusion, refusal to drink, dry skin, flushing and fever, and rapid pulse. 6. Constipation leading to bowel impaction. Constipation may contribute to delusional behavior. 7. Depression that results in impaired concentration, memory loss, apathy, and sleep disturbances. This may cause behaviors such as unwillingness to talk, listlessness, or, in some cases, hyperactivity. 8. Dementia. This leads to loss of memory and confusion. (Issue 10 will contain more on dementia.)

Visit the physician When difficult behavior creates problems for the elder and the caregiver, the first step is to help the elder make an appointment for a complete physical examination. Take containers with all medicines being used, including over-the-counter medications. Describe the behavior you are concerned about. Before a treatment can be prescribed, the doctor needs to determine whether the difficult behavior is caused by medication or by a physical or emotional disorder. It also may be necessary to have vision and hearing tests or to consult a psychologist or family therapist. In the case of sudden onset of unusual behavior, it is important to seek medical attention at once. Some serious and treatable illnesses have symptoms such as confusion or falling. Pm-1515f | September 1993

The Caring Connection

O

nce the doctor, therapist, or counselor determines that nothing more can be done through medical or psychological treatment, it is up to you, the caregiver, to learn the best ways to cope with behavior problems. Confusion about place or self. How to handle confusion or memory problems depends on how much loss of functioning the elder experiences. In the early stages, in which a person is mentally clear at times, it probably is helpful to give verbal and physical reminders (e.g. “Today is Tuesday and we’re going shopping today”) or circling the date on the calender. Later, when the person really is not aware of present reality, it is best to go along with them. For example, when an older woman with dementia talks about having to go home to fix dinner for the children, say “Tell me what the children like for dinner” or “Tell me about your children.” Arguing or trying to change the person’s perception only makes matters worse.

Handling Common Behaviors Remember the five Rs of dealing with difficult behavior: • remain calm • respond to the person’s feelings • reassure the person • remove yourself • return when you are calm

Wandering. The need to move about is one that raises important safety and supervision issues. Some elders may be trying to find a place in the present environment such as the bathroom, or they may be searching, in their mind, for a place from former times. For others, movement appears to fill a need for exercise or is a response to stress. Provide a safe environment for wandering. To guide the person back from wandering, fall in step with them and gently divert their attention to the direction you desire. Catastrophic reactions. Some elders experience emotional outbursts or over-reactions to a situation that has become overwhelming or threatening. The outbursts signal emotional overload. Calm the person, giving him or her time to recover. Offer reassurance and gently divert their attention to a calm activity. Reduce confusion in the environment and make your approach slower, simpler, and calmer. Quiet music may be helpful.

Delusions/Hallucinations. Individuals suffering from a form of dementia, like Alzheimer’s, often Agitation or restlessness. Try to imagine they are in a different place or calm the individual. Offer reassurtime or may think you are another ance, especially through touch or eye person. When the person talks as though contact. Try to follow a daily routine, this imaginary world is present, it’s best scheduling regular times for eating, to go along with the situation. Often, bathing, and exercise. Keep the physi- behaviors that don’t make sense to cal environment simple and eliminate you have meaning to the older people background noise, like the radio or TV. in their memory of other times and Instead, when restlessness is a probplaces. Sometimes you can learn more lem, use soothing music that the elder from watching their body language, seems to enjoy. Many elders who nonverbal communication, and voice experience confusion have more prob- tone than from the words they say. lems in the late afternoon and Maintain a calm and secure environevening. Schedule your own work so ment and avoid confronting the older that you have less to do at times when person. The person often forgets the the elder is apt to be agitated. incident in a short period of time.

The Caring Connection

A

behavior may be easier to manage if you can determine when and how it occurs. Here are some steps to help you manage behavior problems. 1. Analyze the problem. Focus on only one problem at a time. Answer the questions listed below in a log book. This will give you a written record of what happened before the problem, what strategy was used to deal with the behavior, and what the outcome was. Look for patterns that may trigger the behavior. • When does the problem behavior occur? • Who is involved? • Who is affected by the behavior? • What emotions were expressed? • How did you respond? • Did it work? 2. Make an “educated guess” as to the cause. 3. Develop a list of alternative strategies. 4. Select one and try it. If the first alternative doesn’t work, try another. Remember, it is a trial and error process. 5. Reassure the person after the upsetting interaction. Let the person know that you are trying to understand and that you do care. Fred, age 87, is being cared for by his 64-year-old daughter, Ruth. Fred moved to Ruth’s home six months ago as he was no longer able to climb the stairs. After moving in with Ruth, he was confused, unable to find the bathroom. He was sometimes irritable, sometimes depressed.

Ruth was very concerned about his apparent mental deterioration. She couldn’t understand why he was doing so poorly. Then, Ruth decided to use the problem-solving strategy to help her father. 1. Ruth observed Fred, noting that the problem usually occurred late in the afternoon. She usually was present that time of day. Both she and her husband were affected, and the emotions they expressed included fear and anger. Ruth noted the fact that she yelled at her father for being so forgetful. 2. After doing some reading and visiting with the public health nurse, she made an educated guess as to the cause. She thought maybe the new surroundings were confusing him.

How to plan a strategy for problem solving

3. Alternatives she considered included: 1) moving him back to his house, installing a downstairs bathroom, and hiring a home health aide to help him, 2) hiring a companion for him in her home, 3) putting a big sign on the bathroom door and tape on the floor leading to the bathroom. 4. She decided to try the third alternative. After explaining to her father what the tape meant and showing him the sign, his irritability and confusion were relieved. She became more patient with her father once she had tried this new strategy.

The Caring Connection

Key points to remember

Helpful resources:

1. Try to understand what is causing the person’s behavior. 2. Avoid arguing. It makes things worse. 3. Change the environment rather than trying to change the person. 4. Remember that most problem behaviors are not deliberate. 5. Accept your own frustration with the behavior. Get support from family and friends.

Gwyther, Lisa P., Care of Alzheimer’s Patients: A Manual for Nursing Home Staff. American Health Care Association & Alzheimer’s Disease and Related Disorders Association. 1985. Robinson, Anne, Spencer, Beth, & White, Laurie. Understanding Difficult Behavior. Geriatric Education Center of Michigan, Eastern Michigan University. 1989. Alzheimer’s 101: Basics of Caregiving Behavior. Developed by the Commission on Aging in South Carolina. 1989.

Prepared by Iowa State University Extension specialists: Virginia Molgaard, human development and family life; Eloise Caltvedt, family life, and Phyllis Zalenski, family resource management. Edited by Carol Ouverson, ISU Extension communication specialist.

“Dealing with Alzheimer’s: A common sense approach to communication.” A videotape developed by the Ramsey Foundation, 640 Jackson St., St. Paul, Minnesota 55101. 1990.

File: Family Life 1

. . . and justice for all The Iowa Cooperative Extension Service’s programs and policies are consistent with pertinent federal and state laws and regulations on nondiscrimination regarding race, color, national origin, religion, sex, age and disability.

ISU Extension Publications Distribution 119 Printing and Publications Building Iowa State University Ames, IA 50011

Cooperative Extension Service, Iowa State University of Science and Technology and the United States Department of Agriculture cooperating. Robert M. Anderson, Jr., director, Ames, Iowa. Distributed in furtherance of the Acts of Congress of May 8 and June 30, 1914.