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The Science and Art of Behavior Management

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1 The Science and Art of Behavior Management
Kelly Trevino, PhD Clinical Psychologist VA Boston Healthcare System GRECC Audio Conference Series July 29, 2010

2 Acknowledgements Nurse Managers Medical Staff Psychiatrists
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

3 Outline Background The Science The Art 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

4 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

5 Psychotropic Medications and Restraints
Limited effectiveness10 Negative side effects11,12 Restraints13 Higher rate of falls Negative psychological outcomes


7 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

8 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)

9 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

10 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

11 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

12 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

13 General Guidelines Basic principles Behavior may increase initially
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

14 THE ART Behavior Management Team (BMT)
Boston VA CLC THE ART Behavior Management Team (BMT)

15 BMT: Creation Weekly interdisciplinary meetings
Recognition of a problem Weekly interdisciplinary meetings Psychology, nursing, medicine Identified: Problem Goals Process Staff Training Documentation

16 Staff Training: BMT Outcome measures What is the BMT BMT Documentation
Frequency of behaviors Severity of behaviors Referrals to BMT Medications for behaviors Inpatient psych transfers Code greens for behaviors Staff feedback on BMT What is the BMT Explain why Explain how Get feedback/ideas BMT Documentation Focus on BMT Shift Note

17 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

18 ABCs of Challenging Behavior
Consequences (C) Antecedents (A)

19 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

20 Behavior Frequency/Severity
Start Behavior Plan Time

21 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

22 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

23 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

24 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 MD/PA decides to consult BMT MD/PA enters consult for BMT BMT responds within one business day BMT conducts evaluation BMT creates behavior management plan BMT enters “BMT Management Plan” BMT consults with direct care staff Nursing staff continues to complete “BMT Shift Note “ BMT monitors behavior and consults with treatment team weekly Behavior goals met: Resident discharged from BMT Staff continue to implement behavior plan

25 BMT Management Plan Primary BMT Member: Reason for Referral:
Behavior 1: Goal: Frequency of behavior: Disruptiveness: Not at all A little Moderately Very much Extremely Type of Behavior: Verbal Physical Non-aggressive Physical Aggressive Psychology: Psychiatry: Recreation Therapy: Medical: Nursing:

26 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):

27 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):

28 BMT Outcomes Participants Measures Method
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)





33 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

34 Lessons Learned: Program Implementation
Identify and include relevant stakeholders Facility specific All services All levels Union Include early Intervention-setting fit Resources Limitations

35 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

36 Questions

37 References Alzheimer’s Association (2010) Alzheimer’s Disease Facts and Figures (2010). Alzheimer’s & Dementia, vol.6. 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, 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. Kraus, N.A., & Altman, B.M. (1998). Characteristics of Nursing Home residents Agency for Health Care Policy and Research, MEPS Research Findings No. 5, AHCPR Pub No 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, 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,

38 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, 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, 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, 14. Cohen-Mansfield, J. (2001). Nonpharmacologic interventions for inappropriate behaviors in dementia. American Journal of Geriatric Psychiatry, 9, 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,

39 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, 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, 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, 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), 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. 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), 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 Alzheimer’s Dis Other Demen, 11, 24. Cohen-Mansfield J. (2000). Nonpharmacological management of behavioral problems in persons with dementia: the TREA model. Alzheimer’s Care Quarterly, 1,

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