Behaviour Management and BPSD

Challenging behaviours are a common symptom of many conditions, such as intellectual disability, autism and dementia.

When poorly managed, these behaviours can have far-reaching effects, including distress for the client, disruptions to the lives and comfort of other clients, and added stress and workloads to healthcare workers.

BPSD: Behavioural and Psychological Symptoms of Dementia

In a home or aged care setting, the behavioural and psychological symptoms of dementia (or BPSD) are common, however, still remain one of the biggest challenges to care staff. One study found that while many residential aged care staff understood the underlying causes of BPSD, they lacked the appropriate management skills and resources to deal with them appropriately (Ervin et al. 2012).

Mishandling of BPSD can lead to cases of overuse of chemical and physical restraints, which should be a last resort to care staff, but have time and time again been incorrectly used as a frontline approach to challenging behaviours.

Appropriate behavioural management is not only essential to maintaining a high quality of life and comfort for all clients, but it is also directly tied to Standard’s 1, 7 and 8 of the Aged Care Quality Standards.

The following tips will provide carers with a foundational understanding of behaviour management to ensure their clients receive effective person-centred care when displaying challenging behaviours.

Managing Behaviours: Person-Centred Approach

There are countless ways to handle challenging behaviours, however, approaching the situation methodically with an assessment tool like the ABC approach examines the behaviour from a person-centred perspective. The aim of this type of approach is to help us understand the etiology of the behaviour and develop a suitable, consistent response for ongoing support (Crombie et al. 2007; Autism Spectrum Australia n.d.; Krishnamoorthy, A & Anderson, D n.d.).

ABC Approach to Behaviour Management

• A: Antecedents / Activating Event – What led to or caused the behaviour?
• B: Behaviour – What is the behaviour?
• C: Consequences – What is the result of the behaviour?
• D: Decide and Debrief - What will be done differently to disrupt the behaviour?

(Bendigo Health n.d.)

A: Antecedent or Activating Event

The antecedent or activating event looks at direct or indirect triggers of the behaviour; the why, what, when, where and who.

These stimuli could include:

• Organic causes - e.g. health conditions, pain, fatigue, effects of medicine etc.
• Emotional state - e.g. happiness, anger etc.
• Cognitions - e.g. what the person may be thinking.
• Environmental factors - e.g. a noisy or unfamiliar environment.
• Social relationships - e.g. interactions with other people.

(ABIOS 2017)

B: Behaviour

The challenging behaviour should be defined clearly. Types of BPSD commonly seen include:

• Wandering or absconding;
• Depression;
• Sundowning;
• Anxiety or agitation;
• Aggression;
• Disruptive or intrusive behaviour;
• Hallucinations or delusions;
• Socially inappropriate or disinhibited behaviour.

(Tible et al. 2017; Health.vic 2020)

Note, simply labelling the behaviour is not sufficient. You must be able to describe what was observed. For example, did the client yell, cry, punch or use particular words?

C: Consequences

The consequences of the behaviour are the responses from everyone involved. These could include those of the staff, family members or other residents who were witness to the behaviours.

• Were they emotional and panicked in their response?
• Did they simply ignore the behaviour?
• Did they reprimand the client?
• Were their actions calm and respectful?

(Synapse 2020)

D: Decide and Debrief

The final and additional step to the ABC approach is to decide and debrief. This step allows the care team to come together to consider their findings and collaborate on the best way to manage the situation. Remember that in true client-directed care, the client themselves is part of the care team and should be involved in this process, or alternatively the client’s family or designated decision-makers.

Decisions on what actions to take could involve:

• Using a calm, gentle manner when communicating with the person;
• Reducing the number of staff who interact with the person;
• Offering more stimulating or distracting activities or exercises;
• Stronger, more effective means of communication between staff about potential triggers;
• Removing certain stimuli from the environment, such as overly-bright lights or loud noises;
• Closely monitoring interactions between particular people;
• Addressing underlying emotions and referring to other healthcare services when necessary.

(Alzheimer’s Society 2020; Health.vic 2020)

The ABC Approach in Practice

Scenario: Ted is an 87-year-old resident in a secure aged care facility who is living with dementia. In his younger years, Ted was extremely active and would wake early every morning to walk to the corner milk bar to buy the newspaper.

Antecedent or Activating Event:	After waking early one morning, Ted attempts to leave through the front entrance of the facility, with the intention of walking to the shop to buy the newspaper, however, he is halted by the locked security-door, which requires a keycode to open.
Behaviour:	Ted gets agitated and upset finding himself locked behind the door and begins to try to rattle and break the door latch. He is panicked and loudly demanding to be let out.
Consequences:	The staff member on shift, who has been on behaviour in a confrontational manner (‘Hey! Stop that! What are you doing?! You’ll break the door! Go back to bed!’), attempting to stop Ted from waking and disturbing other residents. The staff member forcefully grabs hold of Ted’s wrists in an attempt to stop him from breaking the door lock. The staff member’s response only makes Ted more upset, increasing his distress. His behaviour continues to escalate into yelling and physical aggression.
Decide and Debrief:	After the incident, the care team debrief with Ted’s family and learn about his history, habits and preferences of walking to get the newspaper each morning. The team also note that the staff member on shift’s response was inappropriate and recommend they take a day away from work to de-stress and undergo further communication and de-escalation education. The team decide that the staff member rostered on each morning should now have a newspaper ready to offer Ted when he gets up in the morning, and respectfully offer to walk with him around the facility before returning him back to his room.

Conclusion

The ABC approach to behavioural management works best when the challenging behaviour is clearly documented and understood. The first approach should always be non-pharmacological and should involve tweaking the personal and environmental elements that contributed to the event.

The client’s medical prescriber may consider a medications review if the behaviours are still ongoing. Many milder challenging behaviours tend to run a course and can resolve in time, and so patience and support is often the best response in these cases (Krishnamoorthy & Anderson n.d.).

Note: Always refer to your facility's policy on dealing with difficult or aggressive behaviours. If there is a real risk of danger to you or your clients, security may need to be called.

Additional Resources

• The Dementia Behaviour Management Advisory Service (DBMAS)
• Communicating with Someone Who Has Dementia
• Purposeful Engagement and Activities for People with Dementia



References

• Acquired Brain Injury Outreach Service (ABIOS) 2017, Behaviour Intervention: The ABC of Behaviour, The State of Queensland (Queensland Health), viewed 26 May 2020, https://www.health.qld.gov.au/__data/assets/pdf_file/0022/384070/abc_behaviour_pro.pdf.
• Alzheimer’s Society 2020, Reducing and managing behaviour that challenges, Alzheimer’s Society UK, viewed 26 May 2020, https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/symptoms/managing-behaviour-changes.
• Autism Spectrum Australia n.d. Aspect Positive Behaviour Support: Early Years, Autism Spectrum Australia (Aspect), NSW, viewed 26 May 2020, https://www.autismspectrum.org.au/uploads/documents/Aspect%20Practice/PBS/Aspect-Practicet-BB-Positive-Behaviour-Suppor-Early-Years.pdf.
• Bendigo Health n.d. ABC of Behaviour Management, Bendigo Health Loddon Mallee Regional Dementia Management Strategy, viewed 26 May 2020, http://www.dementiamanagementstrategy.com/Pages/ABC_of_behaviour_management.aspx.
• Crombie, A, Snell, T & Boyd, J 2007, Simple strategies for complex behaviours – Do you know your ABCs?, Dementia Australia, viewed 26 May 2020, https://www.dementia.org.au/sites/default/files/20070530_Nat_CON_CrombieSimpleStratBeh.pdf.
• Ervin, L, Finlayson, S & Cross, Maddalena 2012, ‘The management of behavioural problems associated with dementia in rural aged care’, Collegian, vol. 19, no. 2, pp. 85-95. Viewed 26 May 2020, https://www.collegianjournal.com/article/S1322-7696(12)00016-9/pdf.
• Health.vic 2020, Managing behavioural and psychological symptoms of dementia, Victoria State Government, viewed 26 May 2020, https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/older-people/cognition/dementia/dementia-bpsd.
• Krishnamoorthy, A & Anderson, D n.d. ‘Managing challenging behaviour in older adults with dementia’, Progress in Neurology and Psychiatry, pp. 20-7, viewed 26 May 2020, https://onlinelibrary.wiley.com/doi/pdf/10.1002/pnp.199.
• The Royal Australian & New Zealand College of Psychiatrists 2013, Assessment and Management of People with Behavioural and Psychological Symptoms of Dementia (BPSD), NSW Ministry of Health, viewed 26 May 2020, https://www.ranzcp.org/files/resources/reports/a-handbook-for-nsw-health-clinicians-bpsd_june13_w.aspx.
• Synapse 2020, The ABC Approach to Behaviour Support, Synapse, West End, QLD, viewed 26 May 2020, https://synapse.org.au/fact-sheet/the-abc-approach-to-behaviour-support/.
• Tible, OP, Riese, F, Savaskan, E & von Gunten, A 2017, ‘Best practice in the management of behavioural and psychological symptoms of dementia’, Therapeutic Advances in Neurological Disorders, vol. 10, no. 8, pp. 297-309, viewed 26 May 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5518961/.