Some of the most common challenging behaviors include resisting care, obscene or abusive language, pacing/excessive wandering, socially inappropriate sexual behavior, exit seeking, hoarding, poor safety awareness, and attention-seeking behavior. Frequently, well-intentioned care providers prescribe medications in response to these actions.

While drugs may sometimes be necessary, further long-term care research suggests that, in a majority of these situations, care providers would be medicating the symptom rather than the underlying cause for the behavior. This is why the behavior mapping approach is employed. It requires caretakers to step back from a medication-focused perspective and assess what actually prompted the residents' actions.

Keith Savell Ph.D. of Mariposa Training and Geriatric Healthcare Consultants explained that residents always have a reason behind their behavior. It's up to the care providers to step into a detective role to determine the reason behind the behavior/symptoms. This way, they can focus on treating the resident as a whole and hopefully improve their quality of life.

In this guide, we will cover:

• Dementia-based behaviors to look out for
• Why these behaviors occur
• Behavior mapping and how it can help residents
• Finding the right solution for addressing these behaviors

Dementia Based Behaviors and Why They Occur

Behavioral mapping begins with understanding the 'why' behind actions.

Before we take a deep dive into behavior mapping, we need to examine dementia-based behaviors and what they could mean. Patients are often trying to tell us something through their behaviors. Issues with boredom, loneliness, overstimulation, and other problems may be communicated through these behaviors.

Dementia-Based Behaviors

Let’s take a closer look at some common dementia-based behaviors:

• Resisting care: Patients who are in the early stages of dementia may initially be resistant to receiving care. Relinquishing control over personal tasks like driving or organizing finances can be extremely tough for patients. But without a caregiver, the patients can inadvertently put themselves in danger. Developing communication skills and empathy is key for caregivers working with dementia patients who are resistant to care.
• Obscene or abusive language: Foul language and swearing often occurs during the middle stages of dementia. This behavior may include yelling, cursing, or throwing insults.   For some residents, especially those whose dementia has progressed to a point where they are essentially non-verbal, swearing may be the only words they can now “access”, and is their way of communicating, rather than an act of aggression. .
• Pacing/excessive wandering: Wandering is often caused by disorientation. Patients with Alzheimer’s disease have trouble recognizing places and faces. Common signs of wandering include returning from regular walks later than usual, forgetting how to travel to familiar spots, or getting nervous in crowded areas.
• Socially inappropriate sexual behavior: Patients with dementia may behave inappropriately with friends, family members, caregivers, or even strangers. This may include making unwanted sexual advances, using obscene gesturing, touching, or undressing.
• Exit seeking: Exit-seeking, which is related to wandering, occurs when a person with dementia attempts to escape a home or living facility. If the patient is in a noisy or busy environment, they might try to retreat and find an exit. Patients may also believe they need to “go to work” or “head to the bank,” which causes exit seeking behavior.
• Hoarding: People with dementia sometimes like to collect a massive amount of items with little or no value. They may hide such items, and will get upset if someone tries to get rid of these items. But hoarding can make the home unsafe.
• Poor safety awareness: Because of symptoms like confusion, disorientation, and memory loss, dementia patients are more prone to getting hurt. Garages, basements, and other areas that may be filled with hazardous items can be a danger to dementia patients.
• Sleep disturbances: Some dementia patients experience sleeping problems. They might wake up frequently during the night and feel drowsy during the day. People with dementia may also become restless or agitated around the late afternoon or early evening. This phenomenon is referred to as “sundowning.”
• Hallucinations: Some dementia patients may see, hear, or even smell something that isn’t actually there. These hallucinations can be frightening for patients. However, some hallucinations may seem completely normal to patients as they feature familiar people or objects.
• Shadowing: Shadowing occurs when a patient constantly follows their caretaker around. They may ask dozens of questions, imitate the caregiver, or just talk constantly.
• Repetitive Actions: Repeating a statement or activity over and over can be triggered by boredom or anxiety. They may also be indicative of a need, such as going to the bathroom.

Understanding Dementia-Based Behaviors

Watching dementia-based behaviors unfurl in people can be incredibly stressful for their loved ones. But it is important to remember that many of these behaviors stem from changes in the brain caused by Alzheimer’s disease or some other type of dementia. Because of the deterioration of their brain cells, an individual’s ability to make sense of the people and places around them also declines.

Dealing with these changes in the brain can cause aggression, discomfort, and frustration in the patient. Underlying medical conditions and environmental factors may also worsen these symptoms. Moving to a new home or starting a new prescription, for instance, can sometimes cause behavioral or psychiatric issues.

Dementia-based behaviors may also occur if the patient is trying but failing to communicate something to their caregiver. For instance, a patient might wander if they are feeling uncomfortable or nervous in a particular area.

Cognitively Well vs. Cognitively Impaired Residents

The secret to effective behavior management is recognizing that all behaviors occur for a reason. Within this line of thought, there is a difference between residents who are cognitively well and those who are cognitively impaired. Cognitively well residents are able to ask for what they want or need, so their challenging behavior is frequently based upon attention-seeking or manipulative motives.

Cognitively impaired residents may be unable to ask for what they want or need. In this way, their challenging behavior may be their way of communicating that they are frightened, in pain, have an undiagnosed illness, or have an unmet need, or desire. Effective behavior management, therefore, simply requires staff members to begin to understand the language of resident behavior.

Treating Dementia-Based Behaviors

Non-drug interventions and prescription medications are used to treat symptoms

There are two types of treatments used for managing dementia-based behaviors: non-drug interventions and prescription medications. Physicians usually recommend using non-drug interventions before prescribing new medication for patients.

But if the patient does not respond to these non-drug interventions, their physician may consider giving them prescription medications like antidepressants, anxiolytics or antipsychotics. The caregiver will need to closely monitor the patient’s drug intake, as these prescriptions can cause serious side effects.

Non-Drug Interventions

Caregivers should, however,  try a number of non-drug interventions before turning to medication. Adjusting the patient’s environment can make a huge difference. For instance, closing windows or turning on TVs can help block out distracting noise. If a sudden noise occurs, it’s best to acknowledge it rather than ignore it. You should also try to keep the house organized and clutter-free and adjust the lighting to make it nice and bright.

Adding structure to a patient’s regular routine can also improve their quality of life. Break down tasks into small steps and offer praise when your patient successfully completes them. These seemingly small and simple tasks can make a huge difference for your patient.

Some caregivers may try therapies like:

• Animal therapy: Use of trained animals such as dogs or cats to help patients cope with health problems
• Aromatherapy: Use of essential oils to help calm patients
• Music therapy: Listening or singing songs, which can help improve a patient’s communication skills
• Simulated presence therapy: Playing a personal video or audio recording of loved ones to help soothe a distressed patient
• Massage therapy: Can help alleviate anxiety and physical discomfort
• Art therapy: Watercolor painting, drawing, jewelry making, and other creative crafts are great for self-expression
• Reminiscence therapy: Talking with loved ones about events and people from their regular day-to-day lives
• Reminiscence Based Multi-Modal Sensory Stimulation:: Providing sensory stimuli to each of the senses using objects, images, odors, textures, etc. that illicit long term memories.
  

Light exercises like walking and cycling have also been shown to help manage challenging behaviors and even improve patients’ self-esteem. You should try to plan physical activities when your patient is feeling their best. Some patients have more energy in the morning while others feel more restless at night. Prioritizing a good sleep schedule and adding healthy foods into your patient’s diet can also help improve your patient’s mood.

Behavior mapping, which we will look at more closely in the next section, is a useful tool for helping providers make or adjust treatment plans.

Explaining Behaviors to Loved Ones

Whether you’re a caregiver or a family member to someone with dementia, it can sometimes feel incredibly stressful and emotionally-exhausting to care for them. For family members, watching their loved one turn into a stranger can be incredibly distressing. As a caretaker, it’s crucial to remind your patient’s family members that their actions are a result of their disease, not from an internal change of character or loss of love for them.

What is Behavior Mapping?

Overview of behavior mapping and the benefits of using it to help residents

In the previous section, we briefly touched upon using behavior mapping to address challenging behaviors in dementia patients. Now it’s time to take a deep dive into the purpose of behavior mapping and how it can help caretakers like you develop the best treatment plan for your patient. Below, you can also find a presentation on Behavior Mapping for the Care of Dementia Based Behaviors by Dr. Keith Savell.

The goal of behavior mapping is simple: to create a patient-centered care plan that takes in consideration the patient’s behavioral trends and their triggers. To start, you will want to consult your patient’s family members and physician. From there, you should begin to document the occurrence of dementia-based behaviors like:

• Physical or verbal aggression
• Hallucinating
• Wandering
• Sleep disturbances
  

The other dementia-based behaviors we covered in the previous section should also be recorded. While recording these behaviors, make sure you are writing detailed notes.   These notes should include the date, the time of day, the location of the resident where the behavior occurred, the exact words/behaviors of the resident, your thoughts as to what may have triggered the behavior, your response/actions to resolve the behavior and the effectiveness of your response.

Identifying Challenging Behaviors

Care providers must define challenging behaviors

If a behavior happens once, it may be isolated. If it happens again, it is highly likely it will continue. It will keep occurring until care providers can determine what causes it. In order to do so, care providers must ask themselves a few questions. These may include:

• Is the behavior truly a problem?
• Does the behavior impede the resident's functioning?
• Does the behavior present a danger to the resident or others?

Main Antecedents to Challenging Behavior

Once providers define the challenging behavior, they must identify the behavioral antecedents (what came before the behavior).. There are four main antecedents to challenging behavior(s) that all challenging behaviors will fall under:

1. Human factor antecedents: This category includes those underlying reasons that occur from within the individual, such as undiagnosed illnesses, the effect of a new medication, the need to feel in control, social isolation, or dehydration.
2. Environmental antecedents: Environmental antecedents include factors that lie in the environment, such as temperature fluctuations, light changes (such as glare), and inappropriate stimulus levels (too much noise).
3. Situational antecedents: Situational antecedents refer to events and/or factors that occur in the moment, such as staff or other residents infringing on a residents' personal space, fear of contact, or changes in environment or routine. Residential relocation is a huge catalyst for delirium and challenging behavior, as well.
4. Delivery of care antecedents: Even the most well-meaning care providers may fall short in regards to this category. Delivery of care antecedents refers to those unintentional acts by staff which may result in a resident's challenging behavior.  This may include interacting with a resident in a disrespectful manner, misleading instructions, staff body language which may present as angry or impatience or even staff requests exceeding functional capacity, and the lack of timely response to requests for assistance.
   

Employees can utilize behavioral mapping to document critical data points, track these antecedents and monitor the behavior overall. To start the process of behavioral mapping, care providers must ask:

• WHO was around the resident when the behavior occurred?
• WHAT happened within 24 hours of the behavior?
• WHEN did the behavior occur - what was the time of day when the behavior occurred?
• WHERE was the resident when the behavior unfolded?
  

Context is also key. Did your patient get enough sleep the prior night? Were they in a noisy environment? Did your patient just start a new medication? As you record these behaviors, remember to make note of the patient’s response as well as any staff intervention that occured.

The bottom line is that when residents demonstrate challenging behaviors, they always have a reason. Therefore, care providers must strive to identify the underlying cause of the challenging behaviors in order to address the immediate need, as well as prevent the need from reoccurring.

Behavior mapping provides a powerful resource for the identification of behavioral antecedents. Once you have recorded several behavioral incidents, you may then be able to see a pattern - and to identify the causal factors (antecedents) behind the behavior.  This then will allow you to develop a care plan to resolve the issue and perhaps prevent such behaviors from occurring again in the future.

FAQ on Behavior Mapping to Manage Dementia-Based Behaviors

Still have questions about behavior mapping and managing dementia-based behaviors? Check out our FAQ section!

How long should I use behavior mapping? You should continue to monitor and document behaviors until you’re able to identify the root cause of the behavior.  This might take a few days or even a few weeks, but if you continue to strive to identify the reason behind the behavior, you’ll eventually figure it out..

What do I do if my patient starts exhibiting troubling behavior again? If your patient starts exhibiting old behaviors, you should start observing and recording them again. This will allow you to modify and improve your current plan to better manage these behaviors.

How can I create a calm environment for my patient? Clearing up the clutter in your patient’s home and reducing outside noise can help calm your patient down. Keeping furniture and household objects in their regular places can also instill a sense of security in your patient.

My patient is getting agitated. How can I calm them down? Remember to stay calm. Try not to raise your voice or argue with your patient. Instead, use positive and soothing statements to help calm them down.

Where can I find trends in my observation chart? Try to look for behaviors that occur during certain times of the day or around certain people. A patient waking up early three days in a row feeling agitated and stressed, that is a pattern you need to record.

Final Thoughts

Taking care of dementia patients is no simple task. It takes patience and compassion to become a great caregiver for your patient. There is no cure for Alzheimer’s, but that doesn’t mean you can’t help your patient lead a happy and meaningful life. Behavior mapping allows you to create a personalized treatment plan for your patient. It requires serious work, but it can make a huge difference in your patient’s life.

Mariposa offers 60+ classes and certifications for long-term care and nursing home professionals interested in cost-effective web-based training. To learn more, please visit the Mariposa Training website or watch Dr. Keith Savell's presentation about "Behavior Mapping for the Care of Dementia Based Behaviors."