Main image courtesy of AgingInPlace.org.

‍

Caring for senior residents in a nursing facility is rewarding, but it can be challenging at times, especially when those in your care have dementia. Although there are different stages of this disease and symptoms can manifest in various ways, many dementia patients can exhibit difficult or challenging behaviors while under the supervision of staff. 

‍

One common behavior that can manifest is what is referred to as shadowing. But what exactly is shadowing, and how can you manage it in your facility? Mariposa Training suggests that using behavior-based mapping is one of the best ways to help discover successful ways to alleviate these challenging behaviors.

So how do we identify shadowing and manage it specifically? This article will go a little deeper into topics such as:

‍

• Defining shadowing
• Why it’s considered a challenging behavior
• How to manage shadowing in dementia patients

What is shadowing in dementia patients?

How to identify shadowing in dementia patients 

Shadowing is a behavior commonly exhibited by dementia patients to their primary caregivers. It can cause stress for both the caregiver and patient.  Image courtesy of Right at Home.

‍

While you may already be aware of shadowing in the career sector, which is when a younger person accompanies an experienced employee to see how they accomplish tasks during the day, shadowing is also used in the context of dementia care. Shadowing in the dementia context typically refers to the behavior that a patient exhibits when they follow around their caregiver, and even mimic their actions. It can also surface as repeatedly asking the same questions, or just speaking non-stop to the caregiver.

‍

It can be difficult for caregivers to understand and adapt to this sort of behavior. Many residents exhibit this type of behavior because they are trying to keep their caregiver or someone familiar to them in their sights. They want to always be able to see and hear them, because when they can’t, this can cause fear, anxiety, and agitation. 

‍

Some of the causes behind shadowing include:

Fear

Dementia patients can be dealing with a lot of confusion when they start to exhibit shadowing behaviors. This can lead to fear if they cannot recognize people or their surroundings. When they’re scared, dementia patients will try to reach out to someone that is familiar to them, and believe that as long as they’re with them, things are fine. This is how shadowing develops. 

‍

Fear can not only lead to shadowing, but it can also lead to wandering if the person is looking for the primary caregiver and does not see them. 

Sundowning

Sundowning refers to behaviors that develop in a dementia patient in the late afternoon or early evening hours. Many patients with dementia tend to get restless or particularly agitated at this time of day. This could be triggered by the reduction in natural lighting, which may cause an uptick in fear as the patient may not be able to see things as clearly. Recognizing familiar places and people is important to keeping dementia patients calm and prevent wandering. 

Needing a purpose

Shadowing can also develop as a response to not being engaged or stimulated. Dementia patients could be engaging in shadowing behavior because they can’t find something else fulfilling to occupy their time. They may also still be seeking a sense of purpose, and believe that they have somewhere to be or something to do. When they follow a caregiver and exhibit shadowing behavior, they may be trying to communicate this need.

‍

Shadowing can seem like a suffocating behavior, which does not allow alone time for a caregiver. It’s common for dementia patients with this type of behavior to follow people who are caring for them everywhere, not leaving them a moment alone. While this can be difficult, it’s important to understand what that person is really trying to say. 

Is shadowing considered a challenging behavior?

Challenging behaviors and what they say about dementia patients’ needs

Sometimes behaviors are the only way a dementia patient can communicate their needs. Image courtesy of A Place for Mom. 

‍

Shadowing is considered a challenging behavior, however it is not the only one common to dementia patients. Other challenging behaviors can include:

‍

• Resisting care
• Abusive language
• Wandering
• Hoarding
• Inappropriate sexual behavior
• Attention seeking

‍

The job of long term care facility staff is to understand what is causing these behaviors in the first place. To do this requires getting to the root of the issue, as well as learning to understand why dementia patients are communicating in these ways.

‍

All behaviors occur for a reason, and learning what causes or triggers these challenging behaviors is the key to learning how to find solutions. When examining a behavior such as shadowing, it’s important to first understand that dementia patients are using this behavior because they are trying to communicate and find a solution to an unmet need. They cannot effectively get this across to staff because of their cognitive impairment, so behavior is their means of communication.

‍

In order to see what the dementia patient is actually trying to communicate, staff should start a process of behavior management and mapping, and determine what are the common causes that lead to patients exhibiting this type of behavior. Let’s start at the beginning, because it’s crucial to understand the four antecedents that can lead to challenging behaviors.

‍

Human factor

If the shadowing or other challenging behavior is the result of a human factor, this could be the patient trying to say that they:

‍

• Are in pain
• Are fatigued
• Have an undiagnosed condition
• Are not adequately stimulated
• Or are feeling the impact of a new medication

‍

While these are not the only human factor reasons a dementia patient may develop shadowing behavior, they could very well be the root cause.

Environmental

Another antecedent that could be the precursor to challenging behaviors such as shadowing could be due to the environment the patient is in. Dementia patients may become fearful or anxious if they can no longer recognize their environment, causing them to shadow caregivers. It is worth the effort to ensure staff also examine the type of environment the patient is in, and if any of the triggers to their challenging behavior could be environmentally based.

‍

Some environmental antecedents include:

‍

• Noise levels
• People coming and going
• Changes in the level and intensity of light
• Changes in temperature

Situational

Challenging behaviors can also surface as a result of situational causes. Because dementia patients feel less fearful and agitated when they are surrounded by familiar faces or spaces, changing rooms or changing routines and staff members who assist them can be a trigger for shadowing. Additionally, you may find that situational antecedents such as:

‍

• Fear of contact
• Relocation of objects 
• Needing to be close to others

‍

can also be at the root of challenging behaviors. 

Delivery of care 

Finally, there are delivery of care antecedents such as:

‍

• Lack of responses from staff
• Staff who are unfamiliar with their routines and preferences
• Lack of activities or tasks that are appropriate for their cognitive abilities

‍

Once you ask the question why is a dementia patient exhibiting shadowing (or other challenging behavior) you can start to peel back the layers and see what they’re really trying to communicate. 

How to manage shadowing in dementia patients

What are some of the best ways to manage shadowing behavior?

It’s vital that nursing facility staff make senior residents with dementia feel calm and less disoriented. There are a few ways in which they can help those who are engaging in shadowing behavior. Image courtesy of HelpGuide.

‍

Behavior mapping allows staff in nursing facilities to track when shadowing occurs, what seems to trigger the behavior (one of the four antecedents), and the results of responding to this behavior. Eventually, this should yield some of the causes for the behavior, as well as shed light on what the patient is attempting to communicate. If your residents are exhibiting symptoms of shadowing, and while you work out exactly what is causing this behavior, there are some ways to manage it. Just know that it may take a few attempts of trial and error to determine which methods work best. 

‍

Reassurance

A great way to help immediately address shadowing is to offer the patient reassurance. This can come in the form of a statement or an action. Try repeating reassuring statements such as, “Everything is okay, and you’re okay,” or “You are safe,” to offer verbal reassurance to the person. If you have a good relationship with them, you may also want to offer reassurance in the form of a hug, or holding their hand.

‍

Shadowing happens for many reasons, but one of them can be fear. Kind, reassuring words or actions can help the dementia patient recognize that everything is okay. 

Keep routines

Keeping routines and a familiar, comforting environment can also go a long way in helping to manage shadowing behaviors. Knowing that there is a structure to the day and that there are routines to follow may help alleviate some of the fear, anxiety, or uncertainty that a person with dementia may have. 

Create an audio recording or video

If there is a particular staff member or a family member who the dementia patient is particularly familiar with, it may be a good idea to make a voice or video recording of them. Just seeing their face or hearing their voice can offer comfort and help calm down fears. This may be especially helpful when that staff member is not on rotation for a day. You can read portions of a book out loud, sing, or just speak like you’re having a conversation, all of it can help reassure a resident. 

Create tasks for them

Sometimes shadowing behavior is the result of not having something to do, or the patient could benefit from a more engaging activity. While this will differ in every facility, there should be a way to create tasks or jobs for dementia patients that will keep them engaged and occupied. Sorting items, folding things such as fabrics, or clipping magazine coupons are all ways to give a task that can take some time to complete. Offering praise after a task is complete can go a long way!

Use a timer

Hand held timers (like egg timers) are also a good way to keep a dementia patient who is shadowing occupied while a staff member attends to other duties or patients. It is visual and can be held, allowing the patient to have something they can see while they wait. You can set the timer to a particular amount of time, and the patient can watch it until the time is up and the staff member can return. 

Encourage phone calls or visits with family

Having a weekly or bi-weekly phone call or visit with a family member to look forward to may be a good addition to their routine. This could be a good opportunity to get recordings of conversations that can be reassuring when played back later. 

Alternative therapies

In addition to these strategies to help manage shadowing, you may also want to consider alternative therapies to keep dementia patients calm and less likely to be scared.

‍

• Animal therapy
• Music therapy
• Massage therapy
• Art therapy
• Aroma therapy

‍

These kinds of therapeutic activities have successfully been incorporated into many nursing facilities’ programs.

Medication

If there are additional conditions affecting the dementia patient, it could be time to consult a physician. Many dementia patients may also be dealing with depression or anxiety, which could be intensifying their shadowing behavior. There may be medication that could help alleviate this concern and improve their quality of life.

‍

Shadowing is a challenging behavior seen in dementia patients. In order to better manage it, you need to get to the root of the issue and determine what antecedent is causing it. Tracking this behavior can help with determining the cause, which will help staff develop successful shadowing management techniques. 

‍