In last week’s tidbit, we discussed the DICE process for assessing and managing behavioral issues in patients with dementia. We focused on the “D”—describing a resident’s behavior with specific details that provide important clues about the cause of the behavior.
This week we focus on the “I”—Investigate. Once we have a detailed description of the behavior, we can investigate the influence of factors such as cognitive status, environment, caregiver approach, medical disorders, and psychiatric symptoms on the resident’s behavior. In many cases, a person with dementia is having difficulty communicating something to us. She could be trying to tell us that she is in pain or depressed, that we are rushing her, that it’s too noisy in the room, or that she simply doesn’t understand what we are asking her to do. When we don’t get the message, the person can become agitated, resistant to care, anxious or even aggressive.
Cognitive impairment includes amnesia (memory loss); aphasia (language impairment–receptive or expressive); apraxia (impairment of learned motor skills); and agnosia (perceptual impairment). Cognitive impairment can have a significant impact on behavior. It can lead to behaviors such as a person urinating in a trash can instead of the toilet, pushing caregivers away when they try to take her to the bathroom, or using a call button constantly to ask for someone to take her home and complaining that no one is helping her.
We should also consider the environment: temperature, noise level, over and under stimulation, too much or too little space, familiarity and routine. An alteration to an element of the environment (and being in a new environment like the hospital) can have an immediate impact on a person’s behavior, and can lead to anxiety and stress for a patient with dementia. Lack of stimulation can lead to boredom, which can result in behaviors such as wandering or disruptive vocalizations.
Caregiver approach can also influence a person’s behavior. Older adults with moderate to severe dementia have difficulty understanding verbal directions. They can also misinterpret touch that occurs during care activities, perceiving it as a threat. When this happens, a person can become fearful and either fight the caregiver (hitting, biting, etc.) or flee (resist care).
Medical disorders in older adults with dementia can result in pain, constipation, infection and medication use (with a variety of side effects). Do any of these examples sound familiar?: “He’s so sleepy it’s hard to get him to eat. The food runs out of his mouth”; “He cries when we get him up to transfer to the chair”; “She’s up at night asking to go to the bathroom every 30 minutes.” Reviewing a patient’s medical conditions and the possible side effects of their medications can help you identify possible causes of their behaviors.
Psychiatric disorders obviously affect behavior. Some examples: “She has been tearful almost every evening and doesn’t want to get out of bed in the morning”; “She thinks someone took her children”; “He doesn’t sleep and is so irritable”; “She saw a snake outside her window.”
Now that you’ve learned about describing a problem behavior and investigating possible causes of it, next week we’ll discuss…you guessed it—the “C” in DICE, which stands for Create a plan. We’ll review interventions you can use to address these challenging behaviors.
Have a great week!