Guidelines for Coping with Disruptive Behaviors

Introduction

Disruptive or agitated behaviors in residents with dementia pose significant care challenges for everyone in long-term care settings. These behaviors can frighten other residents and put residents and staff alike at risk of physical harm. They may trigger fear, anger and guilt in staff, and they may reduce quality of life for all concerned.

One of the most challenging aspects of coping with disruptive behaviors has been deciding which approach to use from among the many strategies and approaches available for intervening when these behaviors occur. A common but ineffective approach is simply to label these behaviors (see below). This "intervention strategy" primarily reflects the caregivers' view of how the behavior affects them but doesn't identify what is at the root of the behavior from the perspective of the person with dementia or identify what to do about it. While these potentially dangerous behaviors may interfere with or disrupt clinical care routines and cause significant stress in everyone in the care setting, these behaviors may signify more importantly that the resident is actually communicating about an unmet need or goal. When viewed in this way, it becomes possible to understand what the possible bases for these behaviors might be in residents, and plan interventions that are aimed at meeting the needs that the resident is no longer able to meet on his/her own.

Even when staff members recognize disruptive behaviors as signals of resident needs, care staff may be unsure about how best to choose from among the many interventions for disruptive behaviors available today. It can be quite a challenge to identify the approach (es) that might have the best chances of success with a particular resident or group of residents in any particular setting.

We have summarized below some of the major issues found in the research literature that may make the choice problematic, and have provided hints for readers to use when evaluating how applicable the intervention approaches and research reports are to their settings as they consider possibilities in the literature to use in their settings.

The issues that effect whether an approach used in various research reports might be applicable in your setting include, both alone and in combinations:

1. Issue: Different terms and vocabulary are used within the field to denote the many varied behaviors. Terms like "agitation", "disruptive behavior", "wandering" vs. "searching", "verbally aggressive," and "regressed" are just some of the terms used by various care providers, researchers, clinicians, regulators and family members in ways that lack agreed upon meanings that everyone shares. Depending on the source, terms are often used (incorrectly) as though they were interchangeable or synonymous, a practice that can make the use of these terms and related terms confusing or misleading. It therefore becomes easy to think that the term you may use is being used by others to mean the same thing when it is not.
   Hint: Check the definitions used in the research report and see if you use the same terms in the same way. If not, look for another term in the report that fits your terminology or comes closes to it.
2. Issue: Research design problems. Many studies of interventions for these behaviors of necessity have had to rely on small samples, making it difficult to generalize their findings. There are many logistical problems researchers encounter when undertaking and successfully concluding outcome research on the many specific intervention approaches (e.g. high drop out rates of subjects due to illness or death, withdrawal of consent to name a few). The process of doing well-controlled studies with samples large enough to achieve statistical significance has historically presented too many challenges in the nursing home setting. Thus, many small sample studies can be found that have results that are less than conclusive and therefore lack a clear and definitive basis with which to guide care providers should they wish to replicate the techniques used in the study.
   Hint: Look in the Discussion section of the research report to see if the authors note small sample size as a potential drawback of their study. If they do, follow their lead about how much caution to use when evaluation their results. You may want to try an intervention from a report of this kind on one or two residents that are similar to the subjects used in this kind of study and see how this kind of pilot project works in your setting.
3. Issue: Differences in inclusion-exclusion criteria of research subjects. It is not unusual for different studies to use different inclusion-exclusion criteria, such as what the allowable severity of dementia and/or behavioral problem of the study subjects will be, the accuracy of the diagnostic protocols used to classify subjects with dementia and the type(s) of dementia (probable Alzheimer's disease only vs. vascular dementia vs. other types that may have been included by accident or by design), and for these studies to differ according to which diagnostic criteria they use. These differences all make the picture murkier for care providers who may wish to compare results of a number of studies but find that they are not directly comparable due to significant differences in sample selection processes or inclusion criteria.
   Hint: See whether the residents whose behavior you want to target with the particular intervention share the same diagnosis, determined in the same manner, and see if they are comparable in cognitive level and severity of behavioral problems to the sample in the research report.
4. Issue: Differences in targets of intervention. Studies often differ as to which "symptom" among the many that make up these syndromes they will try to influence with their intervention, so that study outcomes are often not directly comparable even though a number of research reports may claim to have "agitation" or "physically disruptive behavior" as their target
   Hint: Check that the research report clearly defines the behavioral target of the intervention it is evaluating and that the "symptoms" you have identified as needing intervention are similar or the same.
5. Issue: Differences in metrics. Another difficulty occurs when different researchers use some of the different scales or measures that are currently available, but that are not directly comparable, to measure pre-post differences in frequency, severity, intensity, etc. of targeted behaviors. You may not be able to compare directly which report had better results if each one has used a different measure.
   Hint: When you look at a number of research reports describing interventions that you wish to try in your setting, check to see which scales and metrics each uses. We are not recommending one scale or the other, but recommend that you become familiar with the different scales and adopt the one to use for your outcome measures that is the same one used in the report whose results you are trying to apply.

The EDGE guidelines: definitions

Jiska Cohen-Mansfield and her colleagues (references) have studied disruptive behaviors in nursing home residents for many years. Their meticulous research about the underlying bases for, and most effective responses to, disruptive behaviors provides us with insights and approaches that help to overcome the problems raised above when it comes to understanding and evaluation which approach (es) might work best with your residents.

For the sake of greatest precision and clarity, we will use Cohen-Mansfield's (2000) terminology that describes disruptive behaviors in nursing home residents as consisting of three syndromes of agitation. These symptoms are:

1. Aggressive behaviors - hitting, kicking, pushing, scratching, tearing things, biting, spitting, cursing, or verbal aggression
2. Physically non-aggressive behaviors - pacing, inappropriate dressing and undressing, trying to get to a different place, handling things inappropriately, general restlessness, and repetitious mannerisms.
3. Verbal and vocal agitated behaviors - complaining, constant requests for attention, negativism, repetitious sentences or questions, and screaming.

Factors associated with these syndromes

Their research found that there were identifiable correlates for each syndrome, which suggest possible avenues for assessment and intervention (PDF, 16KB, 2pg.) to attempt to reduce their occurrence. These were:

1. Aggressive behaviors:
   • Medical and psychosocial correlates - male, cognitive impairment, poor quality of social relationships, and sleep problems.
   • Environmental correlates - appears to be a response to an intrusion of personal space, as in social situations, or when resident is in close contact with another person, as during bathing, and when person is cold.
2. Physically non-aggressive behaviors:
   • Medical and psychosocial correlates - Cognitive impairment, moderate to high ADL impairment, relatively good health, sleep problems, and past stress.
   • Environmental correlates - wandering and pacing: resident in corridor and near nurses' station, normal conditions of light, noise and temperature (suggesting that these behaviors are self-stimulation activity and not responses to environmentally induced discomfort).
3. Verbally agitated:
   • Medical and psychosocial correlates - Females, depression, poor health, pain, relatively cognitively intact, poor quality of social relationships, and sleep problems.
   • Environmental correlates - When residents are alone, or physically restrained, in the evening, or during ADLs, especially toileting and bathing (suggesting that these behaviors are associated with discomfort, pain or unmet social needs).

As a result of their research, Cohen-Mansfield (2000) and her associates concluded that "most agitated behaviors are manifestations of unmet needs." They go on to formulate a most helpful operational model in understanding the origins of and strategic directions for coping with agitated behaviors.

"Because of the effects of dementia, including a combination of perceptual problems, communication difficulties, an inability to manipulate the environment through appropriate channels, the elderly resident in unable to fulfill these needs. Disinhibition is an aggravating factor in the manifestation of these needs. The goal of treatment is to uncover the unmet need (emphasis added)." (p.49)

This analysis of disruptive behavior provides a way for the care team to help reduce or eliminate disruptive behaviors using a collaborative, interdisciplinary process of evaluation, intervention and outcome assessment.