Lesson 10: Managing Behaviors & Symptoms and Caregiving

Attention

At times, when we are in the presence of someone who exhibiting behavioral challeges (physical or verbal) we may feel concerned or wondering what our role might be in managing those behaviors!

Learning Outcomes

Upon completion of this lesson's material, students will be able to:

• Identify ways in which Behavioral and Psychological Symptoms of Dementia (BPSD) may be managed
• MHRT Outcome: Knowledge of generic community resources including available natural supports
• Learning about the concept of caregiving and understanding its impact on individuals

Teaching

Behavioral and Psychological Symptoms of Dementia - BPSD

The collection of behavioral issues that arise as a result of Alzheimer's and/or Dementia is known as "BPSD" or Behavioral and Psychological Symptoms of Dementia. These symptoms range widely in terms of type and severity, and they change over time. They manifest a great deal of distress and anxiety among caregivers, the patients themselves, and professionals.

The major goal of behavior management is to create a safe and comfortable living environment for everyone involved. To this end, there is much that we can do.

Psychological Symptoms

The psychological symptoms might present themselves as:

• Delusions and Hallucinations
• Misidentifications
• Depression
• Anxiety
• Apathy

Behavioral Symptoms

The behavioral symptoms might present themselves as:

• Violence and Physical Aggression
• Wandering
• Agitation
• Inappropriate Sexual Behavior

Managing Behaviors

As with any problem solving situation, we go through a set of steps to address behavior management issues.

1. Identify the problem and the symptoms. It is very important to identify WHO this is a problem for. Is it a problem for the patient/client, or for the caregiver, or the staff, or the facility?
2. Prioritize the problems (address the most important for safety and comfort FIRST)
3. Gather detailed information (the more detail about incidents we can gather the better we can identify antecedent factors and other solutions)
4. Identify consequences (identify what typically happens when a behavior occurs...often behaviors are functional...they manifest as inappropriate ways to meet legitimate needs...for instance, an inappropriate sexual comment or action may be a request for companionship)
5. Develop a specific plan (Plans give all parties specific directions as to what they are going to DO if the behavior happens...this provides a consistent message to the patient and empowers everyone involved with their responsibilities)
6. Work with everyone involved to develop PREVENTION strategies
7. Find ways to praise everyone involved...this work is CHALLENGING and it is often filled with failed attempts
8. Evaluate and modify the plan as needed
9. Pharmacological interventions MAY be indicated, but may not deal with all of the behaviors
10. Sexual related behaviors need to be approached directly and frankly with sensitivity to cultural differences among all involved.

Some of the ways in which we can modify environments in order to reduce some behaviors (in general) include:

• Structure in the environment to SHOW that people are safe
• Stimulating activities (but not TOO stimulating!)
• Involving patients/clients in their care (no matter how "absent" they may seem)
• Avoiding day time napping
• Early evening activities (to address "sundowner syndrome")
• Minimize noise
• Consistent times for bed, meals, activity, etc.
• Maintain lighting
• Provide adequate activities of daily living (ADLs) based on the person's functional abilities
• ACCEPT THE REALITY THAT THEY ARE PRESENTING...any delusions and hallucinations are REAL for these people...you cannot argue them out of it and it is better to PLAY ALONG and then see if you can DISTRACT them into another action.

  This app is called the BPSD Guide. It lists physical behavioral symptoms, psychological symptoms, psychotic symptoms and disihibited behaviors. Look through the types of behaviors and as you drill down into the topics you will find lists of symptoms, ways to assess, interventions to use and clinical scenarios. BPSD Guide https://itunes.apple.com/us/app/bpsd-guide-managing-behavioural-psychological-symptoms/id879315185?mt=8 The app is free. It will ask you on first entry if you want to particpate in a research study involving the use of the app. You should select Opt-out to not be including in the research study.

Family, Caregiver, and Residential Care

Caring for the elderly at home can create a lot of strain on families...planning for the care of both the client and the needs of the family are essential. Without a doubt, the care and welfare of the elderly depends greatly upon the availability of family members to serve as caregivers. The degree to which family members take on these responsibilities is highly influenced by the cultural expectations of the family.

Families, however, are increasingly dispersed and "busy" with jobs, childcare, and other responsibilities. While home-based care options are available, they fall short of the 24/7 that family members alone can provide. As Mental Health workers we know that the families of our clients can be available to meet diverse needs that exceed what agencies and funding provides. It behooves us to support the FAMILY members as much as we support the CLIENT. In fact, it might be more important to support the family member if that family member is all that stands between the client and institutionalization.

When working with families it is important to asses characteristics of the family that will determine its ability to provide care and support:

• Organization and disorganization in the family
• Medical and psychological sophistication of the family
• Degree of disruption the client's needs have on the family
• Patterns of conflict (current and old)
• Psychiatric and medical illnesses in other family members
• Marriage and family dynamics
• Racial, ethnic, and cultural beliefs and practices
• Recent traumatic events
• Family members' perceptions of the patient
• Age of caregivers
• Needs of youth

Phases of Family Caregiving

• To recognize and prioritize problems
• To overcome denial
• To manage emotions
• To build a collaborative relationship with family and professionals
• To balance needs and resources
• To move on after the patient has died

Specific Factors related to Caregivers

• Gender
• Relationship to the patient
• Racial group / ethnicity
• Cultural adaptation
• Patient's behavioral and emotional challenges
• ADL impairment (activities of daily living)
• Levels of religiosity
• Caregivers coping style
• Family / psychosocial support
• Use of community services
• Caregiver's psychiatric history
• Alcohol misuse / abuse

When we recognize barriers that might exist to good care in the home, we may be able to intervene and help the caregivers understand what is happening. This takes relationship building with the family members.

Assessment

Lesson 10 Discussion (for online course only)

Pick one or more of the characteristics of families listed in the Lesson Plan above and describe a personal experience with a family member that was a challenge, or would be a challenge, to provide good care to an older person in your life. Discuss potential interventions (things you could do to help improve a challenging situation) based upon your readings in this lesson.

Lesson 10 Assignment

For this assignment you have a specific scenario you are following:

Imagine you are working with an client who is an older adult and has just moved to live with her daughter and son-in-law. They live in Portland, Maine. Using only web-based resources, create a table (using template below) of all the CAREGIVER resources that might be available to this family. Be sure to include both formal (agencies and services) and natural supports (church, support groups, etc.).

Your document should include a title page with your name, date, name of assignment, name of class, name of Instructor. At the top of the table please include your name and then the TABLE should include the resource name, contact information (phone number, email, website, address) and a brief description of what services that resource might be able to offer your client's CAREGIVER(S). Here is an example and you may use these resources as a starting point for your own table: