Slides presented at the HEAR Approach to Behavior Management live webinar of February 1, 2017, featuring presentations from Dr. Andrew Heck and Carol Garby.

1. A non-pharmacological approach to
managing problematic behaviors in dementia
Andrew L. Heck, PsyD, ABPP
Licensed Clinical Psychologist
GeroPartners, LLC
Carol Garby, BSN
Virginia Department of Social Services,
Division of Licensing Programs

2. The Mythical Silver Bullet
What do you
do when a
resident
_________
[insert behavior problem here]?
Bad news:
There is no universal
intervention that
applies across all
people and problems
(i.e., the “silver bullet”).
Good news:
There is a method we
can use to develop
individualized solutions
to individualized
problems.

3. BPSD:
Behavioral Problems and Symptoms in Dementia
Effective interventions follow thorough assessments
aimed at the problem’s specific cause
Management of BPSD must be comprehensive and
systematic
Successful BPSD management blends reactive and
proactive strategies

4. Key question:
Why is this
Behavior a Problem?
Is it:
only problematic for the
resident?
endangering/irritating/upsetting
to other residents/family
members/visitors/ staff?
interfering with care?

5. Clarifying the BPSD
OBSERVE AND
DESCRIBE:
• Type
• Frequency
• Intensity
• Duration of the BPSD
THEN PERFORM:
• Functional analysis of
behavior: an examination
of what a behavior’s
purpose (i.e., function)
serves for the individual

6. Functional analysis of behavior
BehaviorDESCRIPTION:
What specific behavior(s)
occurred, and if more than
one, did they ever occur
together?
PREDICTION:
Did the behavior occur during specific time periods; any
time when the behavior didn’t occur; was there a specific
setting, characteristic or stimuli present when the
behavior occurred?When did the behavior NOT occur?
FUNCTION:
What function did the
behavior serve; did it result in
consequences?

7. The HEAR approach
• Health
“H”
• Environmental
“E” • Approach
“A”
• Resident
“R”

8. Chronic back pain, depression
SSRI (antidepressant)
Recently was informed a close friend had died
Increase in back pain, tramadol added
Recent, sudden, and unpredictable confusion, aggression, clumsiness
Clumsiness also observed
HEAR: Health
Jane
ALF resident

9. HEAR: Health
Increase
antidepressant,
thought depression /
grieving was cause
All symptoms
worsened
Jane had a fall
ALF
response
Pharmacy review
of med regimen
Revealed
likelihood of
‘serotonin
syndrome’
Meds adjusted,
Jane returned to
baseline
Preferred
response

10. Definition:
• Medical or other physical factors that cause or influence behavioral
problems
Common Health Factors
• Delirium
• Medication-related (single or interaction)
• Metabolic disturbance (e.g., hypothyroidism, B12 deficiency)
• Infection
• Sensory loss
• Pain, hunger, thirst
HEAR: Health

11. HEAR: Health
When a new behavior
problem suddenly emerges:
Obtain a thorough
medical
evaluation
(including labs)
Arrange a
comprehensive
pharmacy review
of medication
regimen
Check for
constipation /
impaction

12. Moved rooms 2 weeks ago
Yells repeatedly for help in the middle
of the night, agitation grows
Verbally assaults staff when they
respond: “You’re going to let me die!!”
HEAR: Environmental Factors
George
ALF resident
Memory CareUnit

13. HEAR: Environmental Factors
PRN anti-anxiety
medication
George has a fall when
getting out of bed
ALF
response
Rule out medical causes
Examining
environment revealed
streetlight shining
directly into room
through blinds at night,
George yells for help
but forgets why by the
time staff arrives
New opaque blinds
installed, no more
awakening for George
Preferred
response

14. HEAR: Environmental Factors
Definition:
• Any aspects of an individual’s surroundings that influence BPSD
Common Factors
• Both cognitively impaired and cognitively intact individuals can be very sensitive
to even minor environmental irritants or changes
• Irritant/change + behavioral dyscontrol = potentially harmful reaction!
• Environmental changes are recommended in most circumstances
oNo adverse effects
oEasy to implement

15. Strikes out during toileting
Q 2-hour toileting schedule not
followed due to staff fear
Severe skin irritation and pain due to
often wet disposable undergarments
HEAR: Approach Factors
Mary
ALF resident
Memory CareUnit

16. HEAR: Approach Factors
Use 3 staff to toilet her
Mary fights on way to own
bathroom after being disrobed in
room
ALF
response
Rule out
medical and
environmental
causes
Use one staff
member at
first, gently
lead by hand to
bathroom
Attempt hand-
over-hand
disrobing,
gradually
introduce
second staff
member if
needed
Rub shoulders
during
disrobing to
distract (tactile
distraction) if
needed
Give verbal
instructions
one step at a
time, praise
success
Preferred
response

17. HEAR: Approach Factors
Definition:
• The method(s) by which individuals are addressed by their caregivers that can
influence BPSD
Common Examples
• Violations of personal space
• Caregiver attitude/response
• Verbal approach
• Stance/positioning issues
• Erratic schedules, unpredictable routine

18. Definition:
• The needs, wants, desires, or habits of an individual that influence
behavioral problems
Common Examples
• Can also be considered “psychological” factors
• These constitute a broad array of potential contributing
causes for BPSD
HEAR: Resident Factors

19. HEAR: Resident Factors
Psychotherapy
• Individuals with early-state
dementia may benefit from some
forms of psychotherapy
• Gather collateral information—
family and others
• Pass along information and
observations to therapist
Behavior Planning
• Some residents may benefit from
behavior plans
• Works across different levels of
cognitive ability
• Typically developed by a MH
consultant, implemented by
facility staff with training
• Aimed at bringing about desirable
behaviors while discouraging or
eliminating harmful behaviors

20. Facility role
Facilities are generally
well-equipped to address
•Health,
•Environmental, and
•Approach factors with
existing resources
If H, E, and
A factors
are ruled
out,
Resident Factors
It may be time to bring in a
behaviorally-trained clinician to
address the specific behavior

21. Regulatory perspective
• Failure to address BPSD!
• Assessment (UAI)
• Public versus Private Pay
• Not “sole source”
• Static versus Dynamic

22. Individual Service Plan
Please make the ISP a “living, breathing” document!
Development of
ISP
INDIVIDUAL-Absent or
lacking
NO involvement of DCS
STATIC not DYNAMIC

23. TIPS
Don’t make
assumptions!
Take action before
small problems
become big ones
Gather informationLearn to think
“outside the box”
Expect some
failures.
Celebrate success!

24. In Summary…
Be thorough and
systematic in examining
potential contributors to
problem behaviors:
HEAR!!
Avoid the temptation to
leap to medication as a
first-line solution
For residents with
behavioral issues, make
sure management of
those behaviors are
accounted for in the
individual’s ISP
Keep ISPs current with
frequent re-evaluations
and updates

25. Contact information
Andrew L. Heck, PsyD, ABPP
GeroPartners, LLC
aheck@geropartners.com
www.geropartners.com
Carol Garby, BSN
Virginia Department of Social Services,
Division of Licensing Programs
carol.garby@dss.virginia.gov