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Interventions to Minimize Behavioral
Symptoms of Dementia:
Moving Beyond Redirection
Part IV
Margaret Hoberg MSN, GNP-BC
Siobhan McMahon MSN MPH GNP-BC
Objectives
Learning Objectives
1.
Explain the effects of dementia on thinking, emotions and
communication
2.
Use a theory to help explain behavioral and communication changes
associated with dementia and to guide interventions
3.
Respond to behavioral changes with a calm, validating approach
4.
Comprehensively assess verbal and nonverbal messages, including those
that are associated with stress
5.
Develop a plan whose non-pharmacological interventions
reflect an understanding of and respect for the person and
their preferences.
Making a plan:
 Treat acute illness or exacerbation of chronic illness
 Manage dehydration, hunger, and thirst or wetness
 Manage pain

Trial scheduled Tylenol
 Remove offending medications
 Attend to patient’s sleep and eating patterns
 Replace poorly fitting hearing aids, eyeglasses, and dentures
 Ensure tailored activities are scheduled
 Develop a structured schedule (predictability is helpful)
 Ensure 1:1 meaningful interactions at least 2x/day for 20
minutes (reminiscence, storytelling, reading)
Documenting Target Behaviors
Problem-solving requires
good documentation!




Demanding?
In what way?
Disoriented?
To time? Place? Or person?
Delusional?
What about? What did she say? Do?
Agitated? What movements, words, actions indicate
agitation?
Evaluating the plan
 Evaluate Care
 Sleep patterns
 Weight
 Food & fluid intake
 Incidents and outbursts
How often?
 How long?
 How severe?


Medication use
Evaluation
 Once you choose intervention, include it in the plan,
implement it , evaluate and re-evaluate its
effectiveness, discuss the situation with the person,
their family and the interdisciplinary team then
adjust the plan accordingly.
Need-driven Dementia-Compromised Behavior
Theory: Lillian
Background factors
Heart disease
Mixed vascular/Alzheimer’s
dementia in moderate stage
Osteoarthritis
Proximal factors
Boredom,
Pain not controlled
Increased confusion
Behavioral
symptoms
Hitting others
Refusing help
Repeating
statements
Lillian
 Plan: Initial interventions included referring
husband to Alzheimer’s Association support group;
Risperdal .25mg BID; Inderol; Ativan TID and prn;
lortab scheduled.
 Initial Evaluation: Falls, confusion, exit
attempts, resistance to care, periods of apathy all
continued. Functional status declined.
Need-driven Dementia-Compromised Behavior
Theory: Lillian
Background factors
Heart disease
Mixed vascular/Alzheimer’s
dementia in moderate stage
Osteoarthritis
Proximal factors
Boredom,
Pain not controlled
Increased confusion
Caregiver stress (AA
referral)
Falls
Behavioral
symptoms
Hitting others
(risperdal; ativan;
inderol)
Refusing help
Repeating
statements
Exiting attempts
Apathy
Lillian
Adjusting the Plan:
Treated for UTI,
 Gradual Medication changes
 Structured environment /tailored activities (including in
cooking group; walks daily; encouraging to make day to day
decisions; reminiscing, group music)
 Several team-family meetings to develop plan

Re-evaluation:
Falls stopped
 Ambulatory with walker again
 No more exiting or refusing cares.
 Still wishes she could live with husband
 Occasional anger with staff and husband
 Occasional excessive worry about a health issue.

Ella
 A 82 -year-old woman
 propelling self in WC (use to walk), eating less, losing weight.
 Late at night she tends to pace throughout the assisted living; often entering
other residents rooms thereby interrupting their sleep. When approached she at
times becomes angry and swears
 She has stable Coronary Heart Disease and no other illnesses.
 She is widowed, her daughters are close to her and call her daily. They visit every
1-2 weeks from Grand Rapids MN.
 Gets assist of 1 with ADLs; able to express needs-- often nonverbally;
 Her sleep is intermittent; sleeps a lot during the day and for a few hours during
the night.

She loves spaghetti but needing more cueing to eat.
 Nurses wonder if ambien or something for sleep would help to correct her
sleep/wake cycle changes and make her more comfortable.
Additional assessment
 Physical exam
 Review History
 Observe antecedents and
consequences to behavior
 Discuss with daughters
 Observe caregiver responses
Need-driven Dementia-Compromised Behavior
Theory: Ella
Background factors
CAD
Widowed
Osteoarthritis
Strong family support
Proximal factors
Sleep wake cycle
alteration
Behavioral
symptoms
Pacing at night
Anger with swearing
at night
Ella
Acute illness, pain, unmet physical social or
emotional need ruled out; what will you
recommend next :
1.
Ambien 2.5mg po q HS or Ativan 1 mg po q HS prn
2. Refer for psychotherapy or psychiatry
3. Ignore night time behaviors
4. Use stepped re-direction to encourage patient to sleep
instead of wander at night.
5. Design strategies to develop an activity plan during the
day based on her preferences.
Ella
Acute illness, pain, unmet physical social or
emotional need ruled out; what will you
recommend next :
1. Ambien 2.5mg po q HS or Ativan 1 mg po q HS prn
2. Refer for psychotherapy or psychiatry
3. Ignore night time behaviors
4. Use stepped re-direction to encourage patient to
sleep instead of wander at night.
5. Design strategies to develop an activity plan during
the day based on her preferences.
SUMMARY
 Persons with dementia may express their basic needs and
feelings in different ways (verbal, non-verbal and behavioral).
 When a resident has different behaviors, think about the
Need-driven Dementia-Compromised Behavior Theory and
then begin assessing for

Background factors (medical illnesses , history)

Proximal factors (delirium / pain / environmental stress / Unmet
physical, social or emotional needs)

Describe the behavior in specific terms instead of general terms to
help monitor over time
SUMMARY
 Non-pharmacological interventions are considered first line

Psychotropic medications, benzodiazipines , medications with
anti-cholinergic properties, and hypnotic agents have dangerous
side effects and limited efficacy.
 Collaborate with caregivers, loved ones and other health care
professionals to choose individualized interventions that
reflect the resident’s preferences, past hobbies, personality.
SUMMARY
Consider these non-pharmacological strategies as first line:
 Activities that are tailored to patients preferences, cognitive status, and energy level
(Simple pleasures, music, aromatherpy, walking, chair exercises)
 Physical environments that minimize social and spatial crowding
 Staff trained to be sensitive and to validate the non-verbal expression of emotion
 Individualized schedules that use varied activities to correct arousal imbalance
 Use verbal and non verbal communication that is positive including validation
approaches
 Think of redirection as “stepped redirection” (validate concerns, make a plan to
investigate, invite to discuss, invite to help with …)
References
Gitlein, L., Winter, L., Vause Earland, T., Herge, E.A., Chernett, N.L., Piersol, C.V., & Burke, J.P.
(2009). The tailored activity program to reduce behavioral symptoms in individuals with
dementia: feasibility, acceptablity, and replication potential. The Gerontologist, 49, 428-430.
Kverno, K.S., Black, B.S., Nolan, M.T., Rabins, P.V. (2009). Research on treating
neuropsychiatric symptoms of advanced dementia with non-pharmacological strategies 19982008: a systematic literature review. International Psychogeriatrics, 21, 825-843..
Kolanowski, A., Litaker, M., Buettner (2005). Efficacy of a theory-based activities for behavioral
symptoms of dementia. Nursing Research, 54, 210-228.
Kovach, C.R.; Kelber, S.T. Simpson, M., Wells, T.(2006). Behaviors of nursing home residents
with dementia examining nurse responses, Journal of Gerontological Nursing, 13-21.
Smith, M. (2005). Revised from K.C. Buckwalter and M. Smith (1993), “When You Forget That
You Forgot: Recognizing and Managing Alzheimer’s Type Dementia,” The Geriatric Mental
Health Training Series, for the John A. Hartford Center of Geriatric Nursing Excellence,
College of Nursing, University of Iowa.
Watson, N.M. (2005). Simple pleasures a new intervention transforms one long term care
facility. American Journal of Nursing, 105, 53-55.