The Science and Art of Behavior Management -

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: PersonEnvironment 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: PersonEnvironment 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 DONT PANIC ABCs of behavior management Unmet needs Questions behaviors for describing context of ABCs of Challenging Behavior Staff Training: Creating/Implementing Basic

Behavior principlesPlans Specificity Individualization Consistency: Implementation and documentation Behavior may increase initially Re-examine plan after 2-3 days Behaviors are not Questions

for identifying new ABCs Voluntary or purposeful Rudeness Due to a bad attitude Attempt to make your job difficult 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 BMT Management Plan Primary BMT Member: Reason for Referral: Behavior 1: Goal: Frequency of behavior: Disruptiveness: Not at all A little Type of Behavior:

Physical Non-aggressive Extremely Aggressive Verbal Psychology: Psychiatry: Recreation Therapy: Medical: Nursing: Moderately Very much

Physical 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 (Residents 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 todays BMT Rounds):

CONTINUED RECOMMENDATIONS (based on previous BMT assessments): BMT Outcomes Participants 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.

Measures 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 Resources Limitations fit Lessons Learned: Program Implementation

Education First step to buy-in Hands-on demonstration Dont be afraid to make mistakes Observe impact and make changes Be flexible Sustainability Repeat education Leadership support

Policy Questions References 1. Alzheimers Association (2010). 2010 Alzheimers Disease Facts and Figures (2010). Alzheimers & Dementia, vol.6. 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 Alzheimers disease for the total, enrolled, and patient veteran populations age 65 or over. 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. 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;14:191210. 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;294:19341943. 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 dementiaspecific 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), 44652. 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 SpeechLanguage 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). Need-driven dementia-compromised behavior: an alternative view of disruptive behavior. Am J of Alzheimers Dis Other Demen, 11, 10-19. 24. Cohen-Mansfield J. (2000). Nonpharmacological management of behavioral problems in persons with dementia: the TREA model. Alzheimers Care Quarterly, 1, 22-34.

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