Download The Science and Art of Behavior Management

The Science and Art
of Behavior Management
Kelly Trevino, PhD
Clinical Psychologist
VA Boston Healthcare System
GRECC Audio Conference Series
July 29, 2010
Acknowledgements

Nurse Managers
◦
◦
◦
◦

Annette Couchenour
Steve McGarry
Connie Soule
Mary Farren
Nursing Director
◦ Ronald Molyneaux

CLC Nursing Staff

Medical Staff
◦ Dr. Juman Hijab
◦ Jack Earnshaw

Psychiatrists
◦ Dr. Mohit Chopra
◦ Dr. Ronald Gurrera
Outline


Background
The Science
◦ Learning Behavior Model
◦ Person-Environment Fit Model
◦ Need-Driven Behavior Model

The Art
◦ Staff Training
◦ Behavior Management Team (BMT)
◦ Lessons Learned
 Behavior Management
 Program Implementation
Background

5.3 million persons in the U.S. have Alzheimer's
Disease1

11-16 million persons in US will have AD by 20502

In 2004: 136,174 veterans with dementia using VHA3
◦ 2022: 205,781

47% of nursing home residents have dementia1
◦ Up to 70% have memory problems4

~66% of community elders and ~77% nursing home
elders with dementia have disruptive behavior5,6

Disruptive behavior associated with negative
outcomes7-9
Psychotropic Medications and Restraints

Psychotropic Medication
◦ Limited effectiveness10
◦ Negative side effects11,12

Restraints13
◦ Higher rate of falls
◦ Negative psychological outcomes
THE SCIENCE

The Science: Learning Behavior
Model
Learned relationship between antecedents, behaviors,
and consequences (ABCs of behavior management)14
◦ A=Antecedents=Triggers
◦ B=Behaviors
◦ C=Consequences=Reinforcement or Punishment

Manipulate antecedents and consequences to change
behavior
◦ Provide new learning experience

Comprehensive functional analysis important
The Science: Learning Behavior
Model

Instrumental Conditioning Principles15
◦ Reinforcer contiguity
◦ Response-reinforcer contingency
◦ Reinforcement

Problems with punishment
◦ Negative affective reaction
◦ Focus on avoiding punishment (rather than improving
behavior)
◦ Negativity can generalize to other stimuli (person,
environment, time)
The Science: Learning Behavior
Model

Characteristics of Interventions16-18
◦ Staff education
 Topics: Dementia, Psychiatric disorders, Behavior problems,
ABCs of behavior management, communicating with persons
with dementia
 Method: Didactic, discussion, role playing, video case vignettes,
handouts
◦
◦
◦
◦
◦
◦
Assistance with care planning
On-site supervision
Increasing resident participation in pleasant events
Peer support
Caregiver problem-solving skills
Exercise program
The Science: Person-Environment
Fit

Dementia increases vulnerability to the
environment19
◦ Stimuli affect people with dementia at a lower threshold

People with dementia have fewer coping resources

Poor fit b/w person and environment impairs
functioning and increases disruptive behavior

Intervention
◦ Create a familiar and comforting environment
◦ Stimulate through reliance on remote memory and
positive emotions
The Science: Person-Environment
Fit

Characteristics of Interventions20-22
◦ Simulated presence therapy
◦ Activity programming
 Based on mental and physical abilities
 Adjust for mood and behavior
 Incorporate periods of stimulation and rest
◦ Individualized music
◦ Environmental modifications
◦ In-home counseling
The Science: Need-Driven Behavior

Normal needs + Abnormal conditions = Disruptive
behavior23
◦ Behavior is response to unmet need

Adjust environment and build on strengths/preferences
of individual to meet and prevent unmet needs
◦ Consider sensory deficits

Treatment Routes for Exploration of Agitation (TREA)24
◦ Identify correlates of particular behaviors
◦ Provide suggestions for changing the correlates
General Guidelines

Basic principles
◦ Specificity
◦ Individualization
◦ Consistency: Implementation and documentation

Behavior may increase initially
◦ Re-examine plan after 2-3 days

Behaviors are not
◦
◦
◦
◦
Voluntary or purposeful
Rudeness
Due to a “bad attitude”
Attempt to make your job difficult
Boston VA CLC
THE ART
Behavior Management Team (BMT)
BMT: Creation
 Recognition
of a problem
 Weekly interdisciplinary meetings
◦ Psychology, nursing, medicine
 Identified:
◦ Problem
◦ Goals
◦ Process
◦ Staff Training
◦ Documentation
Staff Training: BMT

What is the BMT
◦ Explain why
◦ Explain how
◦ Get feedback/ideas

BMT Documentation
◦ Focus on BMT Shift Note

Outcome measures
◦
◦
◦
◦
◦
◦
◦
Frequency of behaviors
Severity of behaviors
Referrals to BMT
Medications for behaviors
Inpatient psych transfers
Code greens for behaviors
Staff feedback on BMT
Staff Training: Functional Analysis
Prevalence of behaviors
 Difficulty of managing behaviors
 Define types of behaviors and correlates

DON’T PANIC
 ABCs of behavior management
 Unmet needs


Questions for describing context of behaviors
ABCs of Challenging Behavior
Behavior
(B)
Antecedents
(A)
Consequences
(C)
Staff Training:
Creating/Implementing Behavior
Plans
 Basic
principles
◦ Specificity
◦ Individualization
◦ Consistency: Implementation and documentation

Behavior may increase initially
◦ Re-examine plan after 2-3 days

Behaviors are not
◦
◦
◦
◦

Voluntary or purposeful
Rudeness
Due to a “bad attitude”
Attempt to make your job difficult
Questions for identifying new ABCs
Behavior Frequency/Severity
Start Behavior Plan
Time
The Art: Behavior Management
Team
◦ BMT Members:






Psychologist
Nursing staff
Nurse manager
MD/PA
Geriatric psychiatrist consulted, as needed
Identification of residents
◦ CPRS consult
◦ Direct communication from staff
The Art: Behavior Management
Team

Inclusion criteria
◦ Demonstrate physical and/or verbal behaviors that:
 Create potential harm/distress to the resident, staff, other veterans
 Are difficult to manage (are not re-directable)
 Do NOT refer residents that are an immediate safety risk

Treatment implementation
◦ Functional analysis of behavior
◦ Create behavior plan
 Set behavioral goal
◦ Monitor over time
◦ Change as needed
◦ Discharge when goal met 2 consecutive weeks
The Art: Behavior Management
Team

Weekly meeting on each unit
◦ Learning circle
◦ “Rounding”
◦ Meet with floor staff and PA, then consult nurse
manager

Documentation
◦ BMT Management Plan
◦ BMT Shift Note
◦ BMT Weekly note
The Art: Behavior Management Team
Nursing staff
observe
disruptive
behavior
Nurse (RN)
documents
behavior AND
adds MD/PA as
cosignor
Nurse
consults with
MD/PA
BMT consults
with direct care
staff
BMT enters
“BMT
Management
Plan”
Nursing staff
continues to
complete
“BMT Shift
Note “
BMT monitors
behavior and
consults with
treatment team
weekly
MD/PA
decides to
consult BMT
MD/PA enters
consult for
BMT
BMT creates
behavior
management
plan
BMT conducts
evaluation
BMT
responds
within one
business day
Behavior
goals met:
Resident
discharged
from BMT
Staff
continue to
implement
behavior plan
BMT Management Plan
Primary BMT Member:
Reason for Referral:
Behavior 1:
Goal:
Frequency of behavior:
Disruptiveness: Not at all A little Moderately
Type of Behavior: Verbal Physical Non-aggressive
Psychology:
Psychiatry:
Recreation Therapy:
Medical:
Nursing:
Very much
Extremely
Physical Aggressive
BMT Shift Note
Target Behaviors (from BMT Management Plan):
1.
Frequency of behavior this shift:
Disruptiveness: Not at all A little Moderately Very much Extremely
Times of behavior:
Locations of behavior:
Antecedents (what happened before):
Interventions (what action was taken):
Outcomes (Resident’s response to intervention):
BMT Weekly Note
Session Type: BMT Rounds
Time spent discussing veteran:
Review for week of:
CONSULTATIONS:
*******************************************************************
Behavior:
Goal:
Frequency of behavior this week:
Disruptiveness of behavior this week:
Behavior frequency:
Percent change from previous week:
Disruptiveness:
Description of behavior:
a. Times:
b. Locations:
c. Antecedents (what happened before):
d. Interventions (what actions were taken):
e. Outcomes (resident's responses to intervention):
*******************************************************************
NEW RECOMMENDATIONS (based on today’s BMT Rounds):
CONTINUED RECOMMENDATIONS (based on previous BMT assessments):
BMT Outcomes

Participants

Measures
◦
◦
◦
◦
◦
n=24; Residents of the VA Boston CLC
Age: M=74.75; SD=11.39
Gender: 95.8% Male
Residential Status: LTC (54.2%); Rehab (37.5%); Transitional (8.3%).
Approved by the IRB of the VA Boston Healthcare System.
1. Demographic information: Age, gender, residential status
2. BMT Shift Notes
a.) Frequency of behaviors:
b.) Severity of Behaviors

Method
◦ Medical record review of residents treated in the first six months of BMT
implementation (July 28, 2009-February 1, 2010)

Lessons Learned: Behavior
Management
Person-centered care
◦ Implement WITH the resident, not TO the resident

Interdisciplinary
◦ Consider role of MD/PA
Individualization
 Consistency
 Communication

◦ Team
◦ Ask/Talk to the resident

Dementia-care skills
Lessons Learned:
Program Implementation

Identify and include relevant stakeholders
◦ Facility specific
◦ All services
◦ All levels

Union
◦ Include early

Intervention-setting fit
◦ Resources
◦ Limitations
Lessons Learned:
Program Implementation

Education
◦ First step to buy-in

Hands-on demonstration
◦ Don’t be afraid to make mistakes

Observe impact and make changes
◦ Be flexible

Sustainability
◦ Repeat education
◦ Leadership support

Policy
Questions
References
1.
Alzheimer’s Association (2010). 2010 Alzheimer’s Disease Facts and Figures (2010). Alzheimer’s
& Dementia, vol.6. http://www.alz.org/alzheimers_disease_facts_figures.asp
2.
Hebert, L.E., Scherr, P.A., Bienias, J.L., Bennett, D.A., & Evans, D.A. (2003). Alzheimer disease in
the U.S. population: prevalence estimates using the 2000 census. Arch Neurol, 60, 1119-1122.
3.
Office of the Assistant Deputy Under Secretary for Health (2004). Projections of the prevalence
and incidence of dementias including Alzheimer’s disease for the total, enrolled, and patient
veteran populations age 65 or over.
http://www.index.va.gov/search/va/va_search.jsp?QT=dementia&SQ=url:http%3A%2F%2Fwww4.
va.gov%2FHEALTHPOLICYPLANNING%2F
4.
Kraus, N.A., & Altman, B.M. (1998). Characteristics of Nursing Home residents-1996. Agency
for Health Care Policy and Research, MEPS Research Findings No. 5, AHCPR Pub No. 99-0006.
http://www.meps.ahrq.gov/mepsweb/data_files/publications/rf5/rf5.shtml
5.
Bartels D.J., Horn, S.D., Smout, R.J., Dums, A.R., Flaherty, E., Jones, J.K., Monane, M., Taler, G.A., &
Voss, A.C. (2003). Agitation and depression in frail nursing home elderly patients with dementia:
Treatment characteristics and service. Am J of Geriatr Psych, 11, 231-238.
6.
Chan, D.C., Kasper, J.D., Black, B.S., & Rabins, P.V. (2003). Prevalence and correlates of behavioral
and psychiatric symptoms in community-dwelling elders with dementia or mild cognitive
impairment: the memory and medical care study. Int J of Geriatr Psyc,18, 174-182.
References
7. Burgio, L.D., Jones, L.T., Butler, F., & Engler, B.T. (1988). Behavior problems in an urban nursing home. J of
Gerontol Nurs, 14, 31-34.
8. Brotons, M. & Pickett-Cooper, P. (1996). The effects of music therapy intervention on agitation behaviours
of Alzheimer's disease patients. J Music Ther, 33 (1), 2-18.
9. Conely, L. & Campbell, L. (1991). The use of restraints in caring for the elderly: realities, consequences
and alternatives. Nurs Pract, 16, 48-52.
10. Schneider, L.S., Dagerman, K., & Insel, P.S. Efficacy and adverse effects of atypical antipsychotics for
dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14:191–
210.
11. Schneider, L.S., Dagerman, K.S., & Insel, P. Risk of death with atypical antipsychotic drug treatment for
dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294:1934–1943.
12. Kales, H.C., Valenstein, M., Kim, H.M., McCarthy, J.F., Ganoczy, D., Cunningham, F., & Blow, F.C. (2007).
Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric
medications. American Journal of Psychiatry, 164, 1568 – 76.
13. Cotter, V.T. (2005). Restraint free care in older adults with dementia. Keio J Med, 54, 80-84.
14. Cohen-Mansfield, J. (2001). Nonpharmacologic interventions for inappropriate behaviors in dementia.
American Journal of Geriatric Psychiatry, 9, 361-381.
15. Tarpy, R.M. (1997). Contemporary Learning Theory and Research. McGraw Hill: Boston.
16. Proctor, R., Burns, A., Powell, H.S., Tarrier, N., Faragher, B., Richardson, G., et al. (1999). Behavioural
management in nursing and residential homes: A randomized controlled trial. Lancet, 354, 26-29.

References
17. Teri, L., Huda, P., Gibbons, L., Young, H., van Leynseele, J. (2005) STAR: A dementia-specific
training program for staff in assisted living residences. The Gerontologist, 45, 686-693.
18. Lichtenberg, P.A., Kemp-Havican, J., MacNeill, S.E., & Schafer Johnson, A. (2005). Pilot study of
behavioral treatment in dementia care units. The Gerontologist, 45, 406-410.
19. Lawton, M.P., & Nahemow, L. Ecology and the aging process. (1973). In: The Psychology of Adult
development and Aging, Eisdorfer L, Lawton MP. (eds). Washington DC, 619-674.
20.
Camberg, L., Woods, P., Ooi, W.L., Hurley, A., Volicer, L., Ashley, J., Odenheimer, G. & McIntyre, K.
(1999). Evaluation of Simulated Presence: a personalized approach to enhance well-being in
persons with Alzheimer's disease. J Am Geriatr Soc, 47(4), 446-52.
21.
Boyle, M., Bayles, K.A., Kim, E., Chapman, S.B., Zientz, J., Rackley, A., Mahendra, N., Hopper, T., &
Cleary, S.J. (2006). Evidence-based practice recommendations for working with individuals with
dementia: Simulated Presence Therapy. Journal of Medical Speech-Language Pathology, 14 (3), xiii-xxi.
22.
Volicer, L., Simard, J., Pupa, J., Medrek, R., & Riordan, M. (2007). Effects of continuous activity
programming on behavioral symptoms of dementia. J American Medical Directors Association, 7(7),
426-431.
23. Algase, D., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K., & Beatty, E. (1996). Needdriven dementia-compromised behavior: an alternative view of disruptive behavior. Am J of
Alzheimer’s Dis Other Demen, 11, 10-19.
24. Cohen-Mansfield J. (2000). Nonpharmacological management of behavioral problems in persons
with dementia: the TREA model. Alzheimer’s Care Quarterly, 1, 22-34.