DIMENSIONS Winter 1999

THE ABC's OF BEHAVIORAL MANAGEMENT

By Linda Teri and Julie Cleveland

People who have Alzheimer's disease often pose severe behavior management problems for those who provide care. Since Alzheimer's disease and other dementias attack the brain in different places and at different rates, you will find that each person's behavior is different. But, overall when caring for dementia patients, you will see certain types of behavior problems. You can learn techniques to change behaviors that may be making your job difficult. Most importantly though, these techniques will help you observe and manage patient behaviors as they change over time and will allow you to adapt and change your interactions for the best results.

One technique used to help caregivers deal with the problem characteristics of dementia has been called the ABC's of behavior change. "A" is the antecedent or triggering event that precedes the problem behavior; "B" is the behavior; and "C" is the consequence of that behavior. The following overview of the ABC's offers a systematic and easy to-follow approach to problems that often seem difficult to treat.

1. Identify the B--the behavior, the problem of concern. A clear definition of the problem is the first step in changing behavior. What is the current behavior? What is happening? What did the person do? It is best to begin with one behavioral problem at a time, and choose a behavior that is easily observable.

2. Gather information about B. Once the problem is identified and defined, gather as much information as possible about the problem. How often does the behavior occur? When and where does it happen most?

3. Identify what happens before and after the B--the A (antecedent) and the C (consequence.)

The A: Did anyone or anything trigger the behavior? What was happening before the behavior started? Look for clues, like somebody demanding too much, being angry at the person, or for disturbing noise or activity around the person. Were there any changes in the environment be forehand?

The C: What is the consequence of the behavior? What happens as a result of the behavior? What changes occurred in the environment or in the behavior of other people because of the patient's behavior?

4. Set realistic goals and make plans. Problems are rarely simple--usually several factors are involved, and the more that you understand how they fit together, the more likely that you will be able to successfully intervene. For a treatment plan to work, it must be creative but realistic, and tailored to the individual. Start with a small achievable goal and proceed step by step. Be practical, and allow plenty of time for change to occur. Do not expect major changes to occur overnight. If possible, generate several alternatives and then decide which one to try first.

5. Reward yourself and others for achieving goals. Changing behavior can be hard work for everyone involved. It is very important to reward yourself and the patient for successes, no matter how small.

6. Continually evaluate and modify plans. It is important to be consistent and flexible in carrying out plans. Strategies will change as you discover what does and does not work. Decide how to determine whether the plan is working--e.g., by monitoring the amount of time the behavior occurs, tracking the number of instances of the behavior, etc. Over time, as the patient's cognitive disability increases, what does and does not work may change.

Demented patients show a variety of different behavioral problems, including (but not limited to) anger, agitation, depression, suspiciousness, paranoia, wandering, sexual inappropriateness, hallucinations, and delusions. Two common problems, difficulty communicating and depression, will be addressed below.

Difficulty communicating

Effective communication is an exchange of thoughts, information, and other messages from one person to another. Alzheimer's disease interferes with this process. Word finding and other communication problems can leave patients feeling anxious, agitated, and upset. To help minimize these problems, remember to:

Depression

20 to 30 percent of patients with Alzheimer's disease also develop depression. Depression is treatable. Make sure you are aware of the symptoms and seek help for the patient when they occur. Here are some common signs of depression:

What can you do to reduce depression in a patient? Emotions, behavior, and thought all work together to maintain depression. In a depressed patient, it is important to try to break the cycle of inactivity and increase pleasant events.

Use your knowledge of the patient to find enjoyable activities. Make a list of these activities and schedule them regularly (such as daily or weekly). Give the patient lots of reassurance and support for participating. Some ideas for pleasant activities include listening to music, looking at old photos, and going on walks or rides. For pleasant events to be successful, they must be fun, introduced slowly, done in small steps, fit the patient's abilities,and be used with encouragement.

Information in this article was taken from the Understanding Alzheimer's booklet available from the ADRC. Contact Julie Cleveland at 206-616-1079.


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