I am frequently asked to consult about “inappropriate” behavior in skilled nursing facilities. The question is usually something like: “We have a resident who is doing ‘X behavior’— what should we do?” (You can fill in the X with behaviors like wandering, yelling, hitting, hoarding, etc). My answer is always along these lines: “I have no idea what to do, but please let’s talk about this particular resident.”
There is no single-fit solution to any challenging behavior, and there is no pill that targets individual behaviors. For many years the default SNF response to problematic behaviors was to sedate the resident with either an anti-psychotic or a benzodiazepine — interventions that are terrific in the short run but so significantly problematic in the long run that they are now discouraged, to say the least, in the post-acute arena.
A holistic and resident-centered approach to unwanted behavior is one that assumes that any behavior is goal-directed and meaningful in some way for the resident. I view behavior as a form of communication, and I know that when staff are able to understand what is being communicated there is an opportunity to address the underlying issue and eliminate or reduce the behavior at its root. Solving the mystery and eliminating the behavior at this level is always preferable to having to implement a full-scale behavior management intervention (to be discussed in Part 3 of this series). The resident’s needs are met, and to the extent that the problem is well-understood and measures are taken to avoid the circumstances that are now known to create it, the unwanted behavior becomes unnecessary.
You have no idea how many persistent behavioral problems have been solved by ensuring that a resident always has a glass of ice water at hand, or that he is able to return to a quiet area at the first sign of agitation, or that a female resident is bathed only by a female CNA.
The problem is that the vast majority of residents who present with persistent behavioral disturbances are suffering from disorders that can make it extremely difficult to “connect the dots” from the unwanted behavior back to its underlying cause — the goal that the resident is trying to achieve or the issue that the resident is trying to communicate. There is often a disconnect between the behavior and its precipitating cause.
The most common disorders that lie at the root of challenging behavior in SNFs are personality disorders, significant psychiatric disorders such as schizophrenia and bipolar disorder, and, especially, dementia. These disorders can make it difficult to ferret out the precipitating factors behind unwanted behaviors. The fact that it can be so challenging helps explain why post-acute care has over-relied on psychotropics as a tool for managing behavior in the past. As the use of psychotropics becomes less available to SNFs, it’s imperative that facilities become more adept at understanding challenging behavior, one resident at a time, and intervening in a person-centered way that appreciates the uniqueness of each resident.
The process of understanding challenging behavior should always begin with a thorough psychological diagnostic interview by a psychologist, psychiatrist or psychiatric nurse practitioner that, at a minimum, establishes an accurate diagnosis. If the person has a personality disorder, establishing its nature will often provide valuable clues as to the cause of problematic behavior. For example, think about how staff might want to approach a male resident diagnosed with a paranoid personality disorder. Ideally, staff members would go out of their way to provide frequent reassurance, to consistently explain the reason why they have approached him and what he can expect to happen during their time together, to make sure that he has adequate personal space at all times, to avoid challenging the resident unnecessarily and to ensure that he knows how to ask for help if he feels threatened.
Once an accurate diagnosis is made, the findings must be communicated to the facility staff that provide care to the resident on a regular basis. Knowing that the resident has a paranoid personality disorder, post-traumatic stress disorder, schizophrenia or dementia automatically puts a staff member in a better position to provide resident-informed care. But a good psychiatric interview should go well beyond the diagnosis.
For example, a diagnosis of dementia alone provides little assistance to the staff that are trying to find the best approach to an individual resident. They need to know the extent of memory impairment in order to be able to take advantage of areas of intact memory that can help the resident feel grounded. They will benefit from knowing the resident’s relative cognitive strengths and weaknesses so that their communications with the resident are not confusing and their directions to the resident can be clearly understood. And they need to know to what extent the resident is capable of new learning.
It is commonly believed that residents with dementia are uniformly unable to learn and to change, but that is actually far from the truth. The vast majority of nursing home residents can acquire new learning — it’s just the way that they learn, and especially the number of repetitions that are required for new learning to take hold, is different for residents who aren’t cognitively intact. As we shall see, this concept will become especially critical when we explore behavior management interventions, which are predicated on the foundation that specific, well-considered, consistent responses to unwanted behaviors will, over time, create behavioral change.
Often, the psychiatric interview combined with the medical assessment, a good family and personal history from the facility social worker, and the knowledge gleaned by nursing staff over time provides all of the information needed to come to a good understanding of what needs, goals or communications are imbedded in a resident’s unwanted behavior. Fully digesting all of this available information will often reveal that a resident’s unwanted behavior is really a response to fear, overstimulation, pain, fatigue, confusion, hunger, boredom or medication side effects. The ultimate goal is to come to an understanding of what we, the facility and especially its staff may be inadvertently doing to precipitate unwanted behavior and how we can change our collective approach in order to preclude the need for the resident to behave in an unwanted manner.
Of course, although it would be optimal if all unwanted behaviors in the SNF could be eliminated in this way, clearly there are many situations in which only a “full court press” on the behavior itself will do. That will be the subject of the third and final article in this series on managing behavior.
Richard Juman, PsyD, is the National Director of Psychological Services for TeamHealth.