Workshop 1 Introduction Background on AD Behavioral Management

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Workshop 1 Introduction Background on
AD Behavioral Management

• Laura Lee Phillips MALou Burgio PhD
• The University of Alabama
• Center for Mental Health and Aging

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Dementia Caregiving

• 4 million persons are diagnosed with Alzheimers
  disease or related disorders (ADRD) in the USA
• Most persons with ADRD are cared for at the home
• Caregiving occurs over an extended period of time
  
• Average course of disease is 8 years
• Range 4 to 20 years
• High personal and societal healthcare costs

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Caregiving Facts You are not Alone!

• More than 54 million people provided care for a
  chronically ill, disabled or aged family member
  or friend in the last year
• 59 of adult population is or expects to be a
  family care giver.

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• People over 85 years of age are the fastest
  growing segment of the population and half of
  them need help with personal care
• Families provide 196 billion dollars worth of
  care for free annually.
• American businesses lose between 11 and 29
  billion each ear due to employees need to care
  for loved ones over the age of 50.

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Who are Caregivers of Persons with ADRD?

• Most caregivers are
• Women (spouses and daughters)
• Spouses
• Older adults
• Caregiving occurs across all racial, ethnic and
  socioeconomic groups.
• Caregiving does not stop with nursing home
  placement.

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The Risks of Caregiving

• Caregivers are at risk for
• Depression (gt 50 caregivers are depressed)
• Morbidity
• Financial loss
• Social isolation
• Extreme fatigue stress
• Anxiety, upset, feeling overwhelmed
• Mortality
• Schultz, et al. 1995. The Gerontologist, 35,
  771-791 Ory et al., 1999 The Gerontologist, 37,
  804 815 Schultz Beach 1999, JAMA 282, 2215
  2219.

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Discussion

• What things do you miss doing?
• What behaviors are the most problematic?
• How do you cope with these behaviors?
• What works well to help you care for your loved
  one?
• When do these things work best?

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The ABCs of problem behaviors

• Identify the problem and gather information
• A Antecedents
• things that happen prior to the behavior
• B Behavior
• the behavior we want to change
• C Consequence
• what happens following the behavior

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• Even though your loved one may be confused
  behaviors they show result from a cause.
• By looking at behavior in terms of stages, A, B,
  C, you can see how behavior almost always has a
  trigger (A) and a consequence (C) which you can
  see and describe.
• Thus behavior rarely happens for no reason.

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ABCs Step 1

• What is the behavior?
• What is happening
• Describe the action
• The care recipient yelled
• The care recipient paced
• The care recipient asked the same question 10
  times

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ABCs Step 2

• Now look for the A what happened prior to the
  behavior?
• Did anyone or something trigger the event?
• Was someone asking for too much?
• Was someone angry at the person?
• What was going on in the environment?

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ABCs Step 3

• Now look for the consequence of the behavior.
• These are changes in the environment or behavior
  of others as a result of the care recipients
  behavior (B).
• This may be feelings or reactions of the
  caregiver.

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An Example

• The story of Mattie and Sam Jones
• What is the behavior?

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B Behavior of Sam

• Sam tells Mattie there is a stranger in the house.

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Antecedent

• What was the antecedent in this story?

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A Antecedent of Sams behavior

• Sam goes into the room
• Mattie is out of sight
• Sam looks in the mirror and thinks he sees
  someone in the room.

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Consequence

• What is the consequence of this behavior?

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C Consequence of Sams behavior

• Mattie tries to convince Sam that nobody is
  there.
• Mattie becomes frustrated
• There is an argument
• Both people are very upset

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Changing the behavior

• One of two ways
• Change the Antecedents
• Change the Consequences

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Changing the Antecedents

• How might Mattie avoid this scene again?
• What can she do?

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Changing the Antecedents

• Remove the mirrors or cover them up.
• Write Sams name backwards on a name tag for him
  to wear. Then when he sees him self in the mirror
  he will recognize his name.

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Changing the Consequences

• How can Mattie change the consequences of Sams
  behavior?
• What might she do differently?

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Changing the Consequences

• Do not argue with Sam. Logic will not convince
  him Mattie is correct.
• Say calming reassuring things to him
• Distract him by involving him in an activity.

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The bad news

• Unfortunately, logic and reasoning will not work
  with a person who is suffering from memory loss.
• Arguing simply will make both people more upset
• You cannot win an argument with someone who does
  not remember.

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The good news

• There are other ways to change a behavior than
  reasoning and logic.
• You can alter the behavior by finding ways to
  change the antecedents (A) and consequences (C).
• You can also use the ABCs to increase the
  likelihood of behaviors you want!

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Changing Behaviors by Changing Antecedents

• Change antecedents by using cues.
• Visual Cues name tags, labels, gestures, LARGE
  letters, underlined words, daily calendar
• Auditory Cues verbal reminders, a bell, music,
  door closing, timer going off.
• Tactile (touch) Cues a handshake, touch on the
  elbow, hug, or a kiss.

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Changing Problem Behaviors by Changing Antecedents

• Other ways to change Antecedents
• Keep your loved one INVOLVED in an activity
• Take him or her to the bathroom at regular
  intervals to prevent accidents
• Take the knobs off the stove to prevent a burn or
  fire

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Changing Behaviors by Changing Consequences

• Positive Reinforcement is rewarding a behavior
  you WANT to see more of.
• Giving them something they like
• Food, an object, attention, a smile
• Saying something positive
• Conversing, praising, instructing, appreciating
• Doing something kind
• Assisting, comforting, hugging
• Be careful not to reinforce a problem behavior!

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Redirect or Distract

• Sometimes the best way to change the consequence
  of a behavior is to draw attention to something
  else
• Lets take a break, heres a snack
• Lets look at this picture book
• Please help me fold some clothing
• Lets play some music while we wait what do you
  want to listen to?

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Adjusting OUR thoughts and responses

• Ignore the problem behavior it may go away.
• DO NOT ARGUE. You cannot win, and it will upset
  you both.
• Stop negative thoughts in your mind make them
  positive or neutral.
• If you feel yourself getting angry take a time
  out. Take deep breaths, comforting phrases, or go
  to another room for a minute.
• How important is it REALLY?
• Make sure you keep your expectations realistic
  both of yourself and your loved one.

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Behavioral Prescriptions

• Define the problem
• Gather information
• List possible solutions
• Decision making and prescribing solutions
• Solution implementation
• Tracking progress towards goal

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Defining the Problem

• Identify and name the target problem
• Define how success will be measured (goal
  setting)

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Identify and Name the Target Problem

• This is VERY important.
• Rushing this step can result in a poor outcome
• Try to identify the very core of the problem.

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An example

• The problem Jims disruptive behaviors
• When dinner time, right after we sit down
• How yelling, cussing
• Where in the living room
• Why is this a problem for you?
• I miss my dinner with my family. I dont get to
  talk with them or relax
• Why might Jim be doing this?
• Feels left out
• Hungry
• Tired
• Bored
• Core problem I miss my family time, and I cannot
  enjoy dinner with Jim yelling and cussing

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TIME OUT

• What is your problem?
• What are the ABCs ?
• When
• How
• Where
• Why
• What is core problem?

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Setting Goals

• Concrete, easy to measure
• Realistic expectations
• May be either
• Problem-focused
• Actual changes in the problem behavior
• Emotion-focused
• Changes in the way you feel about the problem
  behavior

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An example

• Problem Focused
• Jims behavior will last only for 5 minutes
• I wont miss ALL of dinner (maximum I am willing
  to miss is 10 minutes)
• Emotion Focused
• I am allowed to be frustrated I miss dinner, but
  will make the best of the situation by enjoying
  time with Jim (reading aloud, looking at
  pictures).
• I will take 10 deep breaths and focus, and try to
  remain relaxed.

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TIME OUT

• What goals might you set?
• Problem-based
• Emotion-based
• How will you know you succeeded?

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Gather Information

• Identify Antecedents
• Identify Consequences
• What can be changed?
• What cannot be?
• What is the ideal?

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Listing Solutions BRAIN STORMING!

• What are all the POSSIBLE solutions?
• Do not criticize
• Try to be creative
• Establish ground rules for what is the minimum
  change that will work.
• After brainstorming rule out unacceptable
  solutions.
• Review solutions in order to select the most
  appropriate strategy.
• Design a Behavioral Prescription

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Closing

• Next session you will be given a behavioral
  prescription based upon the problem you
  identified.
• Please bring music that you feels relaxes you
  that youd like to share with others. (CD or
  Tape)
• Talk with one another they may be your best
  resource.