Does your staff need support with responding to certain behavior?

Bernie conducts comprehensive behaviour assessments for clients and residents with cognitive impairment and for those with long-term behavioral difficulties that are not related to cognitive impairment. He draws on his experience in aged psychiatry to construct a detailed picture of the behaviour, the person and the context in which the problem is occurring.

Client confidentiality limits whom he can speak to about the assessment so a consent form will need to be signed before an appointment can take place.  This way Bernie has permission to speak to the aged care provider about the results of the behaviour assessment.

These evaluations usually involve a case discussion with managers or key staff, review of progress notes for the past several months, medication charts, behaviour charting, and care planning. If needed, family or others can have input to the review.

Before Bernie discusses his evaluation with staff an interview with or observation of the person will take place. An assessment will be written and sent to the facility. This may sometimes be followed by an education session for relevant staff so that strategies he recommends can be consistently implemented. If the person is not cognitively impaired Bernie may arrange to meet with them for subsequent psychotherapy.

The assessments usually take about two hours and the report takes about two to three hours to write. Bernie can also consult via Skype.

Difficult Changes in Dementia

One of the more difficult changes in dementia is an increased chance of aggressive reactions in some people who have dementia.

Dementia is a group of symptoms that are caused by changes in the way a person’s brain functions. These changes affect memory, thinking, feelings, behaviour and personality.

It needs to be said that not everyone with dementia becomes aggressive. It often depends on personality, previous life history, social patterns of relationships in the past and the current behaviour of others around the person. It can often occur because the person has become confused and lacks the usual social awareness that helps us control the expression of our emotions.

It is unlikely the person with dementia is intentionally causing harm by being aggressive. Mostly they are not able to form such complex intentions or plan and organise themselves to carry out these intentions. It is more likely that the person is acting on a momentary impulse of emotion that triggers off an impulsive aggressive action or discharge of angry emotion in words or actions.

Such actions are generally ‘protective’ rather than an attack intended to cause harm. This protective behaviour is triggered by a misinterpretation of what is happening around them. The person perceives a threat. Their brains are not making sense of the activity of other people and they react to parts of the situation that they can make sense of. They ‘put it together’ in a way that makes sense to them even though it may not have that meaning to us looking on.

They can perceive ‘threat’ where there is no threat. Be clear about your non-verbal behaviour: speed of approach, gestures, posture, facial expression, touch, eye-contact. Be clearly a ‘friend’ rather than a ‘foe’: Smile, nod, make nonthreatening eye contact, gesture with your palms out and fingers down.

Aggression can be made worse by our actions or reactions. Aggression can be made more likely if we act in a way that causes the person to feel ignored, overwhelmed or imposed upon (care done without permission), treated like a child, or treated coldly and in a matter-of-fact way or without respect. This may occur through our focus on tasks rather than on the wellbeing of the person or it may be through no fault of our own but because of a misperception by the person with dementia.

All of this may cause angry feelings in all of us if we are treated this way. It is important then to be aware that aggression from a person with dementia may be based on a reasonable feeling of anger about thinking they have been mistreated or threatened. Because the person with dementia may have less control over the impulse that comes with an increase in feelings of anger they are more likely to say or do something to discharge this angry feeling. You and I might be able to keep it under control, such as, not express it or maybe even not be aware that we feel angry.

Put yourself in their shoes – how are they seeing you and your colleagues? What are you or others doing or saying that may be contributing to this situation?

The most effective management of aggression is anticipation and defusing. By anticipating that aggression may occur we can prevent it by moving slowly, speaking in an unambiguous manner, smiling, giving them space, not blocking an exit, etc.

Know your resident well enough to know how to create wellbeing for them rather than illbeing. If you have a good knowledge of them as a person with a unique background and personality and needs you will be more likely to keep them in a good emotional state.

Defusing is also an essential skill for managing aggression. Non-verbal communication that is clear and friendly will often soothe a situation. Do not react to aggression with aggression. Back off if safe to do so. Keep your voice low and slow, smiling all the while.

Remove the audience or others close by who may be harmed or upset by a person’s aggression. Once this is done, you can work with your colleagues to calm the person slowly.

Avoid overpowering the angry person with too many staff. This can often lead to more aggression as the person may feel outnumbered and under threat. This is particularly important in the shower or toilet, where a person can feel overwhelmed by more than one staff member. Sometimes it is unavoidable to have two people in there but if there is an option go for fewer staff.

When speaking to an angry person keep it simple, speak quietly and calmly. Use familiar words and gestures. Always have an eye for your safety and do not get into situations that are hard to get out of. Prepare yourself by thinking ahead.

Remember aggression usually occurs after a period of build up or escalation. Ideally you should be reading the signs of escalation or at least be familiar with them so that you can anticipate the build up and head it off by taking small actions when feelings are less intense and the chance of reasonable responses from the angry person is more likely. Get to know the signs of escalation and make notes about them so that others can use this information in the future.

Please call BMAC Consulting on (03) 9431 0311 or email karenc@mccarthypsychology.com.au  to arrange a behaviour assessment and discuss ways to enrich the lives of the person with dementia and staff and family connected to that person.