1. Verbal De-escalation Techniques and Working with Agitated Residents

2. What is a “Behavior”???

3. What are the possible causes of resident behavior???
Illness/Infection (ex: respiratory infection, urinary tract infection, depression, mental illnesses, etc.)
Disease (discuss dementia and the many common types of MI including the causes, symptoms, etc.)
C Medication
D. Loss of independence or personal power
E. Pain

4. Dementia
Dementia: is a gradual decline in mental and social functioning compared to an individual’s previous level of functioning. A resident may have memory loss, personality change, behavior problems, and loss of judgment, learning ability, attention and orientation to time and place and to oneself.
Alzheimer’s disease: is the most common cause of dementia. Alzheimer’s disease is a chronic, progressive debilitating illness. At first the symptoms are mild and might include difficulty remembering names and recent events, showing poor judgment and having a hard time learning new information. At this early stage the person often tries to deny their problems. Most difficulties at this time are with performing IADLs. As the disease progresses, the person is unable to judge between safe and unsafe conditions and will need help to dress, eat, bathe and make decisions. There may be personality changes such as increased suspiciousness. Unfamiliar people, places and activities can cause confusion and stress. The person shows less interest in others and wants to withdraw to familiar, predictable surroundings and routines. The person in later stages has difficulty performing basic ADLs. Some common behaviors associated with Alzheimer’s disease are rapid mood changes, crying, anger, pacing, wandering, doing things over and over, asking the same question, following people closely and inappropriate sexual behaviors

5. The Dementia Brain

6. Stages of Dementia in Comparison to Developmental Stages of Childhood
End Stage Dementia = 0-12 months of age
Often bedbound, nonambulatory. Functionally no speech but may make sounds. Highly dependent. May respond to high-contrast stimuli such as light, sound, touch, smell or taste. Can make eye contact, smile, grimace, gesture, cry out. Can feel and respond to love; needs for social contact and relationships
Late Stage Dementia = months of age
Difficulty communicating needs, may use single words. Vocalizes sounds for pain or discomfort. Moves extremities. May walk with assistance. Responds to yes/no questions. May use universal gestures: point, clap, wave, may even sing
Mid Stage Dementia = 18 month old-3 year old child
Memory of recent events may be impaired. May need some help with step-by-step self care. Repetitive speech patterns, but slow. Frustration and agitation may appear as anger or irritability. Overreaction to seemingly small events. May understand simple one-step directions. Eye-hand coordination; manipulations and uses objects. May benefit from visual and tactile cues.
Early Stage Dementia = 4-12 year old child
May read, but comprehension may be inaccurate. Difficulty with calculations and handling money. Poor awareness of safety hazards, poor judgment. Elopement risk but wants to return “home.” Time and place disorientation. Forgetful and may admit memory is not good. Some short-term new learning possible. Good verbal skills. Some problem-solving skills. Benefits from routine, structure, familiarity and can adjust to some minor changes. Able to follow many social rituals/routines, play simple games and take turns
Mild Cognitive Impairment = years old
Challenges with driving, child care and eldercare. May indirectly insult others with insensitive comments. Self-focused and little consideration for listener. May choose not to follow medical advice. May live alone, independent ADL’s and focuses on primary effect in activities. Knows about appointments and schedules them although may miss them. Learns from mistakes.
PURPOSE OF INFORMATION:
Individuals at different developmental levels may require different levels of assistance or supervision. Staff need to adjust their expectations for assistance, supervision and independence accordingly

7. Prevention/De-escalation
Knowing the triggers-
Is there a certain time of the day of which they get more agitated?
Is there a certain person (staff or other resident) that make them more agitated?
Sleeping Patterns: Do they need to be one of the first or last ones up for the day? Do they need to be one of the first or last to be put to bed?
Is there something in their past that may be contributing to the behavior? (Example: did they work 3rd shift and so therefore want to be more active at night?)

8. Activity #1
FIRST START OUT in your in-service by going up to one of your employees (pick one that won’t mind and is a good “sport”) and sit next to them.
Start discussing other items on your “agenda” and progressively get closer and closer to them (scoot your chair in) until you have for sure invaded their personal space.
As they start to get uncomfortable they may even start scooting away from you!
TO CONCLUDE this exercise ask them how it made them feel to have you invade their “personal space”

9. Prevention/De-escalation
Personal Space
The average person’s personal space comfort level is feet away.
Invading their personal space may increase their agitation
They may not recognize you and get upset if a “stranger” is trying to help them. Use re-assurance with their name in a calm, slow voice. Thoroughly explain what you are doing.
They might not see you very well. Ensure you do not make quick, abrupt movements.
They like to be able to see you, if you are working behind them where they can not “see” you it may scare them and increase agitation.

10. Supportive Stance WHY USE THE SUPPORTIVE STANCE:
It is non-threatening/non challenging (more comfortable)
It communicates respect
Personal safety…. “kicking and punching distance away” If you are close enough to touch them…. they are close enough to touch you!!!!

11. Active Listening-
Active Listening- take the time to really listen to what they are saying and what their needs are in order to effectively meet them. We get so busy throughout the day that sometimes we forget why we do what we do and the real reason why we are here.

12. Re-direction – Avoiding the Power Struggle
Give them two good options (stating the positive one first). Instead of saying “It’s time for your shower” say “Hi _______________, would you like to brush your teeth or shower first today?”
If suffering from confusion or memory loss, try to go along with their thought instead of trying to get them to understand that they are confused and bring them back to reality.
Don’t keep pressing them; it will only make matters worse.
Try to redirect them into some other activity or task to get their mind off of it

13. Keep in Control of Yourself
If you start to feel yourself getting agitated and your heart rate increasing… it is probably time to step away.
Come back later
Let someone else handle the situation

14. Controlling the environment-
Where is the location that the behavior is occurring? Do we need to move them to a quieter location at meals?
When they start to get agitated you need to isolate the situation by removing the audience or visa-versa
It might not be the right time – come back later.
Try to not push the resident into an acting out behavior episode.
If it is not absolutely necessary to get that task done at that very moment, walk away and try again later

15. Activity #2 – Verbal Cueing
Divide group into pairs. Have them select one of the following: brushing teeth, planting flowers, cooking a meal, going to a medical appointment or paying bills. Have them INDIVIDUALLY write down the sequence of the events needed to complete the task.
Then have the “pairs” compare notes
Choose 1 or 2 groups and compare the differences between each
PURPOSE OF THE EXERCISE: It is important to break task down into smaller steps to help those with cognitive challenges and issues related memory, attention or sequencing that may cause behaviors. Many tasks such as “brush your teeth” are overwhelming to them and must be broken down into smaller tasks with encouragement at each task

16. Communication
Communicate with the resident in clear and concise phrases. Use a proper tone and volume to ensure that they understand what you are saying.
Communicate with the nurse overseeing the care of the resident to ensure safety and health of the resident (medication, pain, etc.)
Ensure that all shifts (Nurses and C.N.A.’s) are communicating to happenings of the day such as increase in behaviors and what is working/not working
Ensure that the Director of Nursing and Administrator know about the acting out behavior if you do not notice changes in interventions or directives
Ensure that the Care Plan Coordinator is aware of the behavior and that the entire nursing department is effectively caring out the orders of the individual Care Plan.
Ensure that the treating physician is aware of the behavior
Ensure that the family is aware of the behavior

17. Communication Do’s & Don’ts
Gain attention. Gain the listener's attention before you begin talking. Approach the person from the front, identify yourself, and call him or her by name.
Maintain eye contact. Visual communication is very important. Facial expressions and body language add vital information to the communication. For example, you are able to "see" a person's anger, frustration, excitement, or lack of comprehension by watching the expression on his or her face.
Be attentive. Show that you are listening and trying to understand what is being said. Use a gentle and relaxed tone of voice, as well as friendly facial expressions.
Hands away. When talking, try to keep your hands away from your face. Also, avoid mumbling or talking with food in your mouth. If you smoke, don't talk with a cigarette between your lips.
Speak naturally. Speak distinctly, but don't shout. Speak at a normal rate, not too fast or too slow. Use pauses to give the person time to process what you're saying. Use short, simple, and familiar words.
Keep it simple. Give one-step directions. Ask only one question at a time. Identify people and things by name, avoiding pronouns.
Be positive. Instead of saying, "Don't do that," say, "Let's try this."
Rephrase rather than repeat. If the listener has difficulty understanding what you're saying, find a different way of saying it. If he or she didn't understand the words the first time, it is unlikely he or she will understand them a second time.
Adapt to your listener. Try to understand the words and gestures your loved one is using to communicate. Adapt to his or her way of communicating; don't force your loved one to try to understand your way of communicating.
Reduce background noise. Try to reduce background noise, such as from the TV or radio, when speaking. In addition to making it harder to hear, the TV or radio can compete with you for the listener's attention.
Be patient. Encourage the person to continue to express his or her thoughts, even if he or she is having difficulty. Be careful not to interrupt. Avoid criticizing, correcting, and arguing.
Do not “gang up.” The patient may feel intimidated or threatened when too many staff are around. Only one staff member at a time should be talking and instructing.

18. ROLE PLAYING: Let’s see what you’ve learned!

19. To Start………
Line staff up in 2 lines facing each other. Have them “partner off” and “wave” to the person directly across from them
Assign one group the “residents” and one the “staff” Have your “residents” meet you in the hallway… and have you “staff” come up with a directive that they use everyday…. “its time to take your meds” its time to take a shower” etc.

20. Defensive Behavior – Questioning
Instruct your “residents” to “question” the directive that your “staff” is going to give them… one question right after another.
Take them back inside in their two lines. Tell the staff to slowly approach their residents, get into the supportive stand and offer their directive. Let the “role play” for a few minutes and then pull them back into their two lines”

21. Questing… the results!
Ask your “staff” what they were doing. Then ask for solutions that when a resident is “questioning” how we should respond:
Perhaps politely answer their question – even if you already have
Stick to the topic. Ignore the “challenge” and not the person
Re-direct them

22. Defensive Behavior - Refusal
Switch roles and again take your new “residents” out into the hallway. Instruct them to REFUSE. No matter what… REFUSE… ignore them… walk away… ABSOLUTE REFUSAL.
Take them back inside and again… have the “staff” approach them by getting into their supportive stance and offering their directive.

23. Refusal… the results!
After a few minutes pull them back into the lines and ask the “staff” what the “residents” were doing. Ask how we should respond:
Perhaps REAPPROACH at a later time
Switch caregivers?
And much, much more!!!
And always remember… the harder we push them the harder they will push back.

24. Defensive Behavior - Release
Reverse again… same as before except RELEASE… have them throw A TRUE TEMPER TANTRUM. This is on the cutting edge of “an acting out individual” and so therefore is incredibly important that we verbally deescalate the situation before it gets dangerous
Release… the results!!!!
How do we respond?
Remove the audience
Isolate the situation
Let them vent, etc.

25. Defensive Behavior - Intimidation
Again, reverse roles and do the same as before except now INTIMIDATION… it can be a personal intimidation such as “I’m going to hit you” or professional such as “I’m going to call the state…” “I’m going to call the police…”
Intimidation….the results!
how do we respond?
DOCUMENT, DOCUMENT, DOCUMENT
Use a “team” approach
Take the threat seriously – even if they say they are going to hit you and they never have… there is a first time for everything!

26. Teamwork
Don’t take the acting out behavior personally. Understand that you may not be the right person on that day.
Communicate with the resident’s family as to things that may work for them or stories/family names/dog names/etc. so that you can get to know the resident better in order to help calm them down and comfort them.
Communicate with your fellow co-workers as different tactics that work or don’t work for them.

27. Activity #4 –
Ask a participant to think of 2 residents - one they know very well and the other not so much. Please describe BOTH residents.
Ask them to explain how knowing someone’s life story improve the quality of care?

28. Put yourself in their shoes
Understand that they are with you because they need you
Understand that they may be suffering from illness/disease that makes them confused and disoriented and they can’t help it
Understand how you would feel if someone took your independence away from you (not being able to take yourself to the restroom, not being able to get in your car and go to the store or out to eat, sharing a room with a complete stranger, having arthritis so bad that you can’t pick things up, not being able to see who you are talking to, having a hard time hearing instructions from someone trying to help you, having to take a shower when it is convenient for someone else, etc.)
Always remember that you are working in THEIR home. Treat them as you want to be treated in your own home.

29. Come back in 20 minutes after they have had time to calm down.
Staff Safety - What should you do if you are working with a resident that has become agitated?
Step away. The harder that you push to get the task accomplished, the harder they will resist but ALWAYS ensure their safety
Go get help. Sometimes you are just not the right person on the right day. They may do the task for someone else.
Come back in 20 minutes after they have had time to calm down.
If they are time sensitive on completing tasks ensure this fits in to you schedule (showers, first up, last up, first to the dining room, etc.)
Don’t take acting out or agitation personal
Don’t let it bother you because the minute that it does it will only worsen the scenario.
Always remember… if they are close enough to touch them—they are close enough to touch/grab you, Keep you personal space and a good distance apart!

30. CPI Recommendations for Wrist Grab Release

31. Physical Restraints
We should focus on VERBAL DEESCALTION techniques early with individuals experiencing anxiety and defensive behavior in order to decrease the likelihood that they become an acting out individual and potentially cause harm to themselves or others
Physical Restraints (beyond lap buddies, alarms, etc. that are care planned appropriately) shall NOT be used to control an acting out individual

32. Specific Behavior Management
Wandering - Wandering around the facility may be irritating to the caregivers, but not necessarily unsafe for the patient. In this case, you may need to adjust your anxiety level about wandering. On the other hand, some wandering can be dangerous and must be prevented: going into areas of the house that are off-limits, especially stairwells,
Two characteristic precursors to wandering are restlessness and disorientation.
Redirecting behaviors, distracting, orienting, and encouraging physical exercise therefore, serve to reduce the incidence of wandering. Some suggestions are:
Immediately redirect pacing or restless behavior into productive activity or purposeful exercise.
Make sure the Alzheimer's resident gets plenty of exercise and movement. Even consider singing and dancing! If you allowing them to walk outdoors, make sure that you and the patient have clothing that shelters from cold, rain, and sun.
Make sure the person is involved in many productive daily activities.
Reassure the person if they appear disoriented.
If wandering tends to occur at a particular time of day, distract the person at that time.
Reduce noise levels and confusion. These can disorient the person.
DO NOT invade their personal space and/or put your hands on them to redirect them as this will only increase their anxiety and agitation
Disorientation can be a result of medication side-effects, drug interactions, or over-medicating. If disorientation is becoming a problem, consult your nurse.

33. Specific Behavior Management
Rummaging around or hiding things - Caring for a resident who rummages around or hides things in the facility is a challenge, but not an insurmountable one.
Protecting property - Ensure to lock certain rooms or cabinets to protect their contents, and lock up all valuables. If items do disappear, learn the person’s preferred hiding places and look there first to find hidden objects.
Protecting Alzheimer’s patients from harming themselves - Remove or prevent access to unsafe substances, such as cleaning products, alcohol, and medications. Residents with dementia sometimes overdose on alcohol. It may also be helpful to designate a special drawer of items that the person can safely “play” with when they are bored.

34. Specific Behavior Management
Management of hallucinations, illusions or paranoia
Hallucinations can be the result of failing senses. Unidentifiable sounds, shadows, and highly contrasting colors all can become the basis for fantasy. Decrease the number of things in the environment that can be misinterpreted as something else, such as patterned wallpaper or bright, contrasting surfaces or objects. Increase lighting so that there are few shadows while avoiding glare, and remove or cover mirrors if they cause problems. Maintaining sameness in the environment may also help reduce hallucinations. Also, violent movies or television can contribute to paranoia – avoid letting the resident watch disturbing programs.
When hallucinations or illusions do occur, don’t argue about what is real and what is fantasy. Discuss the resident’s feelings relative to what they imagine they see. Respond to the emotional content of what the person is saying, rather than to the factual/fictional content.
Please monitor these hallucinations and behaviors and keep your nursing staff and interdisciplinary team well informed.
Do not try to bring the resident into present-time by addressing that they are hallucinating as this will only make them more upset.

35. Specific Behavior Management
Management of nighttime wakefulness and other sleep problems - Brain disease often disrupts the sleep-wake cycle. Alzheimer's patients may have wakefulness, disorientation, and confusion beginning at dusk and continuing throughout the night. This is called “sundowning.” There are two aspects to sundowning. First, confusion, over-stimulation, and fatigue during the day may result in increased confusion, restlessness, and insecurity at night. And second, some Alzheimer's patients have fear of the dark, perhaps because of the lack of familiar daytime noises and activity. The patient may seek out security and protection at night to alleviate their discomfort.
Following are some strategies to reduce nighttime restlessness:
Improve sleep hygiene
Physical activities will help the person feel more tired at bedtime. Walk with the person during the day. If the person seems very fatigued during the day, give them a short rest in the afternoon to regain their composure. This can lead to a better night’s sleep. But don’t let them sleep too long – too much daytime napping can increase nighttime wakefulness. Also, limit the patient’s caffeine intake.
Be consistent with the time for sleeping, and keep a routine for getting ready for bed

36. Questions???