8. Who Are
YOUR
Challenging People?
Who Challenges YOU?
9. What are the Challenging
Behaviors that
GET TO YOU?
10. What Are the Most Common Issues
That Come Up???
• Not going to the MD • Eloping or Wandering
• ‘Losing’ Important Things • No solid sleep time
• Getting Lost • Getting ‘into’ things
• Unsafe task performance • Threatening caregivers
• Repeated calls & • Undressing
contacts • Being rude
• Refusing • Feeling ‘sick’
• ‘Bad mouthing’ you to • Striking out at others
others • Falls & injuries
• Making up stories • Infections & pneumonias
• Resisting care • Seeing things & people
• Swearing & cursing • Not eating or drinking
• Making 911 calls • Contractures & immobility
• Mixing day & night
• Shadowing
11. By managing your own
behavior, actions, words &
reactions you can change the
outcome of an interaction.
12. REALLY Ask Yourself…
Is this Behavior a Problem Behavior
OR
is this a “So What” Behavior
An “Annoying” Behavior
13. Is it REALLY a Problem?
Is it a RISKY BEHAVIOR?
• Risk to that person (physical, emotional,
physiological risk)?
• Risk to the caregiver?
• Risk to Others?
• Is the RISK REAL and IMMEDIATE?
• If NOT, it is a ‘SO WHAT’ behavior
14. If it is a ‘SO WHAT’ Behavior…
• Leave it ALONE!
• Figure out how to let go of it …
• Let it go!
15. If it is RISKY…
• Describe the behavior – OBJECTIVELY
– WHO?
– WHAT?
– WHERE?
– WHEN?
– WHAT helps… WHAT makes it worse?
– Frequency & Intensity?
16. SIX Pieces to the Puzzle
• Personal history and preferences
• Type & current level of cognitive loss
• Other conditions & sensory losses
• Environmental conditions
• Care partner approach and behaviors
• What happened – full day & all players
17. Knowing the Person
• History
• Values and beliefs
• Habits and routines
• Personality and stress behaviors
• Work & family history
• Leisure and spiritual history
• Hot buttons & comforts
18. Level of Cognitive Function
What CAN the person do?
What can the person NOT do?
What CUES are effective? Ineffective?
What are interests based on level?
Consistency of Cognitive Level?
21. Positron Emission Tomography (PET)
Alzheimer’s Disease Progression vs. Normal Brains
Early Late
Normal Alzheimer’s Alzheimer’s Child
G. Small, UCLA School of Medicine.
22. So… what is happening?
• Memory damage • Language damage
– Can’t learn new things – Has very concrete
– Forgets immediate past understanding of words
– Does time & space travel – Misses 1 our of 4 words –
– Uses old memories like new may miss “Don’t…”
– May not ID self or others – Word finding problems
correctly – Word salad problems
– CONFABULATES – COVERS
– Follows visual cues – Follows your cues
– Seeks out the familiar – Gets very vague & repeats
– Can get stuck on an old – Uses automatic responses
emotional memory track – Mis-speaks
23. So… what is happening?
• Impulse Control Problems • Performance Problems
– Say whatever they are – Thinks they can do better
thinking than they can
– Swear easily – Can sometimes DO
– Use sex words or racial slurs BETTER under pressure –
when stressed sometimes worse
– Act impulsively – Uses old habits
– Not think thru consequences – Attempts can be dangerous
– Can’t hold back on thoughts or fatal
or actions – They will tell you one thing
– Responds quickly & strongly and then do another…
to perceived threats – Families may over or under
• Flight, fight, fright ‘limit’ activities
24. How do these losses relate
to some risky behaviors?
• Persistent ‘going’ • Lost and ‘Looking’
– inability to terminate – can’t find places
– not able to anything else – looking for familiar
– discomfort • Invading space
• Eloping - escaping – automatic actions
– following cues – following interests & habits
– wanting to leave – no awareness of ‘personal
space’
– going somewhere
• Shadowing
• Constant talking or – looking for help
vocalizing – Comfort
– Trying to communicate • Resisting care
– Self-stimulating – Self-care
• Lack of Initiation – Movement
– Won’t move or cooperate
25. Diamonds - Routines & Repeats
ACL 5
• Word finding problems • Becomes anxious and
• Logic problems frustrated easily
• Place & time confusion • Has trouble with new
• Very ‘independent’ or routines and locations
seeking constant • Tries to maintain control &
reassurance social behavior
• Resents take-over • May try to escape/leave
• Self-awareness varies • Can use signage & cues
• Fearful about what is • Gets ‘turned around’
wrong • Momentarily ‘disoriented’
• Typically resists outside • Does regular routines JUST
helpers FINE!
26. Emeralds- Task Oriented
ACL 4
• Has trouble sequencing • Uses visual information to
thru tasks & activities figure out what to do
• Often skips steps • Follows samples & demos
• Looking for what to do • Can’t do an activity if visual
and where to be prompt is not there
• Believes they can do it • Specifics and content in
• ‘Don’t need your help’ speech can be limited
• Has a mission in mind • Gets stuck on ‘stuff’
• Goes back in time • Needs to be involved
• Gets lost in place • Looks for ‘stuff’ to do
27. Ambers- Hunting & Gathering
ACL 3
• Uses hands to touch, • Imitates actions – copies you
feel, handle, hold • Tool use is challenging
• Explores what is visible • Follows others
and hidden • Investigates the environment
• Invade other’s space to • May taste or eat what they
explore see
• Difficulty terminating
• Repeats actions over
and over • Difficulty getting focused on
care tasks
• Sees in pieces not whole • Becomes easily distressed
• Impulsive or indecisive with unpleasant tasks
• Understands few words • Asks ?s mechanically
28. Rubies - Stuck on GO
ACL 2
• Gross motor only • Can’t stop or sound
• Poor finger use asleep
• Limited visual processing • Copies your mood –
• Very limited facial expressions
communication skills • Can’t grade strength
• Unable to do more • Better with rhythm and
complex motor actions repetitive movements
• Imitates those around • Loses weight
• Problems with chewing • On the move – wanders
and swallowing forward – no safety
awareness
29. Pearls – Reflexes Rule
ACL 1
• Bed bound or chair bound • Swallowing and eating
• Unable to sit up for any problems
length of time • Muscles shorten and
• Unable to communicate contractures forms
verbally • Pressure areas develop
• Lots of reflexes because of no movement
• Breathing changes & limited intake
• Moments of being • Responds to touch, voice,
present movement, smells
• Can make eye contact & • Startles easily
some automatic • Motor agitation indicates
responses needs
30. Health & Illness
• Mobility problems?
• Pain?
• Sensory problems?
• Mental health issues?
• Other diagnoses of importance?
41. Your Approach
• Use a consistent positive physical
approach
– pause at edge of public space
– approach within visual range
– approach slowly
– offer your hand & make eye contact
– call the person by name
– stand to the side to communicate
– respect intimate space
– wait for a response
43. Your interaction…
• Communicate with awareness
– look, listen, think!
– give your name
– make an empathetic observational statement
• “You look busy...”
• “It looks like you are tired…”
• “It sounds like you are upset…”
– wait for a response
44. Give information
• Keep it short and simple
– “ It’s lunch time”
– “Let’s go this way”
– “Here’s your socks”
• Use familiar words and phrases
• Use gestures and props to help
45. Encourage Engagement
• ask a person to try • use props or objects
• ask a person to help • gesture
you • demonstrate
• give simple positive • guide
directions - 1 step at a • distract
time
• redirect
46. Daily Routines &
Client-Centered Programming
• Old habits and routines
• Patterns during the 24 hrs
• A time to rest, work, play…socialize
• Your needs… my time
47. To Cope with Challenging
Behaviors…
• Where will you start???
– An idea –
• Care partner education
• Care partner skill building
48. Then…
• Observe & document the risky behavior
thoroughly
– what is the pattern
– when does it happen
– where does it happen
– who is involved
– what is said, done, attempted
– what makes it better… worse
49. Is it really a problem?
… A RISK
• If NO - leave it alone
• If YES - its time to problem solve
– call the team together
– put on the thinking caps
50. REMEMBER
Explore all of the following -
• Personal background information
• Type & Level of cognitive function
• Health information
• Environmental issues
• Caregiver approach & assistance
• Habits, schedules & time of day
51. Re-look at the problematic
challenging behavior…
• What does the person need?
• What is the meaning of the the behavior?
• Do you understand the risky behavior better?
52. Make a PLAN!
• Who will do what
• When will it be done
• How will it work
• What environmental change is needed
• What props are needed - where will they
be
53. Implement your plan!
• Keep track of progress
• Document what is happening
• Communicate among the team members
• Rethink - if it isn’t working….
• CELEBRATE - if it is!
54. How can we help…
better?
It all starts with
your approach!
55. How you help…
• Sight or Visual cues
• Verbal or Auditory cues
• Touch or Tactile cues
56. What Do They Do?
• Question
• Refuse
• Release – verbal
• Intimidate – physical
• Tension reduction
57. What Should You Do?
• Be supportive
• Offer choices & be directive
• Set realistic limits
• Act – Take control
• Re-connect
59. What shouldn’t we do???
• Argue
• Make up stuff that is NOT true
• Ignore problem behaviors
• Try a possible solution only once
• Give up
• Let them do whatever they want to
• Force them to do it
60. So WHAT should we do???
Remember
who
has the healthy brain!
