Abstract
Abstract This article provides guidance on the management of challenging behaviours (CBs) in dementia care, and introduces concepts from positive behavioural support not usually applied to dementia. While the use of formulations has received a lot of attention in recent years, the mechanisms of how to apply the formulation-led interventions requires more consideration. In order to assist caregivers to deliver effective interventions we need to have a better understanding of the CBs we are attempting to manage, and also produce management strategies with clearer goals. Ideally we would also want caregivers to be able to describe the skills they employ in a coherent manner in order to facilitate self-reflection and to be able to pass on their skills to junior colleagues. This paper attempts to fulfil these needs by integrating two new models with philosophies already used in dementia care. In terms of new concepts, the first is the Arousal Cycle, which gives caregivers an awareness of the five phases of a typical CB (wellbeing, trigger, escalation, CB, and recovery phase). In relation to the second, the Traffic Light analogy examines CBs in terms of four management stages: primary prevention, secondary prevention, reactive strategies, and calming strategies. It is proposed that we distinguish between these stages when composing our formulations and care plans, and thereby produce better targeted interventions. By the end of the paper the reader will have been presented with material integrating concepts from the fields of dementia and intellectual impairment, and been introduced to new ways of managing CBs. Key learning aims After reading this article people will: (1) Be provided with more specific guidance regarding the management of challenging behaviour (CB) in dementia; such guidance was not provided by the update of the NICE guidelines for dementia (2018). (2) Appreciate that the unmet needs perspective helps us both to understand why CB occur and to select appropriate management strategies. (3) Have an increased awareness and knowledge of new models from outside of the field of dementia. For example, through the use of the ‘arousal cycle’ people can recognise that a CB should more realistically be seen as having different phases (beginning, middle, end) rather than being perceived as a single action. (4) Be introduced to the traffic light conceptualisation which provides a useful way for guiding management strategies. (5) Be aware of when best to use resource-intensive formulations. (6) Recognise that in addition to conceptualising the person in relation to the CB, it is helpful to conceptualise the structural elements of the behaviour too. (7) Appreciate the need to help caregivers to recognise their existing skills, and to give carers the means to be able to articulate these abilities. Many care home staff currently work intuitively in the way they deliver care; as such we think they require practical frameworks and protocols to help them better elucidate what they do.
Highlights
Introduction to challenging behaviours In theUK the most recent NICE (2018) guidelines for the treatment of non-cognitive symptoms state it is important to: explore possible reasons for people’s distress; check for and address clinical or environmental causes; and offer personalised activities to promote engagement, pleasure and interest
NICE (2018) suggests the use of non-pharmacological treatments as first-line approaches, but does not provide any specific guidance on what approaches to use for challenging behaviours (CBs)
The present paper provides some models that will be unfamiliar to many people working in dementia care and that link directly to management strategies
Summary
Dental pain; delirium; infections; constipation; thyroid functioning; diabetes; brain metastases. Poor layout of the environment; over/under stimulation; setting felt as being overly restrictive; physical discomfort due to temperature, noise, smells, furniture and fixings, including lighting. Sense of isolation and loneliness; lack of a sense of belonging; verbal and non-verbal behaviour of other people in the environment, including caregivers wellbeing and coping skills in that setting. It is important to remember that some of the above causes are routinely treated with psychotropic medication. This can produce unwanted side-effects: e.g. increasing levels of confusion, tiredness, agitation, constipation and, in the case of some medications for Parkinson’s disease, hyper-sexuality (Banerjee, 2009). Owing to the severity of the side-effects for many people with dementia, there has been a national programme to reduce the prescribing rates of anti-pychotics, which has achieved partial success (HSJ, 2020)
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