The Science and Art The Science and Art of Behavior Managementof Behavior Management

Kelly Trevino, PhD

Clinical Psychologist

VA Boston Healthcare System

GRECC Audio Conference SeriesJuly 29, 2010

AcknowledgementsAcknowledgementsNurse Managers

◦ Annette Couchenour◦ Steve McGarry◦ Connie Soule◦ Mary Farren

Nursing Director◦ Ronald Molyneaux

CLC Nursing Staff

Medical Staff◦ Dr. Juman Hijab◦ Jack Earnshaw

Psychiatrists◦ Dr. Mohit Chopra◦ Dr. Ronald Gurrera

OutlineOutlineBackgroundThe Science

◦Learning Behavior Model◦Person-Environment Fit Model◦Need-Driven Behavior Model

The Art◦Staff Training◦Behavior Management Team (BMT)◦Lessons Learned

Behavior Management Program Implementation

BackgroundBackground5.3 million persons in the U.S. have Alzheimer's

Disease1

11-16 million persons in US will have AD by 20502

In 2004: 136,174 veterans with dementia using VHA3

◦ 2022: 205,781

47% of nursing home residents have dementia1

◦ Up to 70% have memory problems4

~66% of community elders and ~77% nursing home elders with dementia have disruptive behavior5,6

Disruptive behavior associated with negative outcomes7-9

Psychotropic Medications and RestraintsPsychotropic Medications and Restraints

Psychotropic Medication◦Limited effectiveness10

◦Negative side effects11,12

Restraints13

◦Higher rate of falls◦Negative psychological outcomes

THE SCIENCETHE SCIENCE

The Science: Learning The Science: Learning Behavior ModelBehavior Model

Learned relationship between antecedents, behaviors, and consequences (ABCs of behavior management)14

◦ A=Antecedents=Triggers◦ B=Behaviors◦ C=Consequences=Reinforcement or Punishment

Manipulate antecedents and consequences to change behavior◦ Provide new learning experience

Comprehensive functional analysis important

The Science: Learning The Science: Learning Behavior ModelBehavior Model

Instrumental Conditioning Principles15

◦Reinforcer contiguity◦Response-reinforcer contingency◦Reinforcement

Problems with punishment◦Negative affective reaction◦Focus on avoiding punishment (rather than

improving behavior)◦Negativity can generalize to other stimuli

(person, environment, time)

The Science: Learning The Science: Learning Behavior ModelBehavior ModelCharacteristics of Interventions16-18

◦ Staff education Topics: Dementia, Psychiatric disorders, Behavior

problems, ABCs of behavior management, communicating with persons with dementia

Method: Didactic, discussion, role playing, video case vignettes, handouts

◦ Assistance with care planning◦ On-site supervision◦ Increasing resident participation in pleasant

events◦ Peer support◦ Caregiver problem-solving skills◦ Exercise program

The Science: Person-The Science: Person-Environment Fit Environment Fit Dementia increases vulnerability to the

environment19

◦ Stimuli affect people with dementia at a lower threshold

People with dementia have fewer coping resources

Poor fit b/w person and environment impairs functioning and increases disruptive behavior

Intervention◦ Create a familiar and comforting environment◦ Stimulate through reliance on remote memory

and positive emotions

The Science: Person-The Science: Person-Environment Fit Environment Fit Characteristics of Interventions20-22

◦Simulated presence therapy◦Activity programming Based on mental and physical abilities Adjust for mood and behavior Incorporate periods of stimulation and

rest◦Individualized music◦Environmental modifications◦In-home counseling

The Science: Need-Driven The Science: Need-Driven BehaviorBehavior

Normal needs + Abnormal conditions = Disruptive behavior23

◦ Behavior is response to unmet need

Adjust environment and build on strengths/preferences of individual to meet and prevent unmet needs◦ Consider sensory deficits

Treatment Routes for Exploration of Agitation (TREA)24

◦ Identify correlates of particular behaviors◦ Provide suggestions for changing the correlates

General GuidelinesGeneral GuidelinesBasic principles

◦Specificity ◦ Individualization◦Consistency: Implementation and

documentationBehavior may increase initially

◦Re-examine plan after 2-3 daysBehaviors are not

◦ Voluntary or purposeful◦ Rudeness◦ Due to a “bad attitude”◦ Attempt to make your job difficult

THE ARTTHE ARTBehavior Management Team (BMT)Behavior Management Team (BMT)

Boston VA CLC

BMT: CreationBMT: CreationRecognition of a problemWeekly interdisciplinary meetings

◦Psychology, nursing, medicineIdentified:

◦Problem◦Goals◦Process◦Staff Training◦Documentation

Staff Training: BMTStaff Training: BMTWhat is the BMT

◦ Explain why◦ Explain how◦ Get feedback/ideas

BMT Documentation◦ Focus on BMT Shift

Note

Outcome measures◦ Frequency of

behaviors◦ Severity of behaviors◦ Referrals to BMT◦ Medications for

behaviors◦ Inpatient psych

transfers◦ Code greens for

behaviors◦ Staff feedback on BMT

Staff Training: Functional Staff Training: Functional Analysis Analysis

Prevalence of behaviorsDifficulty of managing behaviorsDefine types of behaviors and correlates

DON’T PANICABCs of behavior managementUnmet needs

Questions for describing context of behaviors

ABCs of Challenging ABCs of Challenging BehaviorBehavior

Staff Training: Staff Training: Creating/Implementing Creating/Implementing Behavior PlansBehavior PlansBasic principles

◦Specificity ◦ Individualization◦Consistency: Implementation and

documentationBehavior may increase initially

◦Re-examine plan after 2-3 daysBehaviors are not

◦ Voluntary or purposeful◦ Rudeness◦ Due to a “bad attitude”◦ Attempt to make your job difficult

Questions for identifying new ABCs

Time

Start Behavior Plan

The Art: Behavior The Art: Behavior Management TeamManagement Team

◦BMT Members: Psychologist Nursing staff Nurse manager MD/PA Geriatric psychiatrist consulted, as needed

Identification of residents◦CPRS consult◦Direct communication from staff

The Art: Behavior The Art: Behavior Management TeamManagement TeamInclusion criteria

◦ Demonstrate physical and/or verbal behaviors that: Create potential harm/distress to the resident, staff, other

veterans Are difficult to manage (are not re-directable) Do NOT refer residents that are an immediate safety risk

Treatment implementation◦Functional analysis of behavior◦Create behavior plan

Set behavioral goal◦Monitor over time◦Change as needed◦Discharge when goal met 2 consecutive

weeks

The Art: Behavior The Art: Behavior Management TeamManagement Team

Weekly meeting on each unit◦Learning circle◦“Rounding”◦Meet with floor staff and PA, then consult

nurse manager

Documentation◦BMT Management Plan◦BMT Shift Note◦BMT Weekly note

The Art: Behavior Management Team

BMT Management PlanBMT Management PlanPrimary BMT Member:Reason for Referral:Behavior 1:Goal:Frequency of behavior: Disruptiveness: Not at all A little Moderately Very much

Extremely

Type of Behavior: Verbal Physical Non-aggressive Physical Aggressive

 Psychology:Psychiatry:Recreation Therapy:Medical:Nursing:

BMT Shift NoteBMT Shift NoteTarget Behaviors (from BMT Management

Plan):1.Frequency of behavior this shift: Disruptiveness: Not at all A little Moderately Very much

Extremely

Times of behavior:Locations of behavior:Antecedents (what happened before):Interventions (what action was taken):Outcomes (Resident’s response to intervention):

 

BMT Weekly NoteBMT Weekly NoteSession Type: BMT RoundsTime spent discussing veteran:Review for week of:CONSULTATIONS:*******************************************************************Behavior: Goal:Frequency of behavior this week: Disruptiveness of behavior this week: Behavior frequency: Percent change from previous week: Disruptiveness:  Description of behavior:a. Times: b. Locations: c. Antecedents (what happened before):d. Interventions (what actions were taken): e. Outcomes (resident's responses to intervention):*******************************************************************NEW RECOMMENDATIONS (based on today’s BMT Rounds): CONTINUED RECOMMENDATIONS (based on previous BMT assessments):

BMT OutcomesBMT Outcomes Participants

◦ n=24; Residents of the VA Boston CLC◦ Age: M=74.75; SD=11.39◦ Gender: 95.8% Male◦ Residential Status: LTC (54.2%); Rehab (37.5%); Transitional

(8.3%).◦ Approved by the IRB of the VA Boston Healthcare System.

Measures1. Demographic information: Age, gender, residential status2. BMT Shift Notes a.) Frequency of behaviors: b.) Severity of Behaviors

Method

◦ Medical record review of residents treated in the first six months of BMT implementation (July 28, 2009-February 1, 2010)

Lessons Learned: Behavior Lessons Learned: Behavior ManagementManagementPerson-centered care

◦Implement WITH the resident, not TO the resident

Interdisciplinary◦Consider role of MD/PA

IndividualizationConsistencyCommunication

◦Team ◦Ask/Talk to the resident

Dementia-care skills

Lessons Learned: Lessons Learned: Program ImplementationProgram ImplementationIdentify and include relevant

stakeholders◦Facility specific◦All services◦All levels

Union◦Include early

Intervention-setting fit◦Resources◦Limitations

Lessons Learned: Lessons Learned: Program ImplementationProgram Implementation

Education◦First step to buy-in

Hands-on demonstration◦Don’t be afraid to make mistakes

Observe impact and make changes◦Be flexible

Sustainability◦Repeat education◦Leadership support

Policy

QuestionsQuestions

ReferencesReferences1. Alzheimer’s Association (2010). 2010 Alzheimer’s Disease Facts and Figures

(2010). Alzheimer’s & Dementia, vol.6. http://www.alz.org/alzheimers_disease_facts_figures.asp

2. Hebert, L.E., Scherr, P.A., Bienias, J.L., Bennett, D.A., & Evans, D.A. (2003). Alzheimer disease in the U.S. population: prevalence estimates using the 2000 census. Arch Neurol, 60, 1119-1122.

3. Office of the Assistant Deputy Under Secretary for Health (2004). Projections of the prevalence and incidence of dementias including Alzheimer’s disease for the total, enrolled, and patient veteran populations age 65 or over. http://www.index.va.gov/search/va/va_search.jsp?QT=dementia&SQ=url:http%3A%2F%2Fwww4.va.gov%2FHEALTHPOLICYPLANNING%2F

4. Kraus, N.A., & Altman, B.M. (1998). Characteristics of Nursing Home residents-1996. Agency for Health Care Policy and Research, MEPS Research Findings No. 5, AHCPR Pub No. 99-0006. http://www.meps.ahrq.gov/mepsweb/data_files/publications/rf5/rf5.shtml

5. Bartels D.J., Horn, S.D., Smout, R.J., Dums, A.R., Flaherty, E., Jones, J.K., Monane, M., Taler, G.A., & Voss, A.C. (2003). Agitation and depression in frail nursing home elderly patients with dementia: Treatment characteristics and service. Am J of Geriatr Psych, 11, 231-238.

6. Chan, D.C., Kasper, J.D., Black, B.S., & Rabins, P.V. (2003). Prevalence and correlates of behavioral and psychiatric symptoms in community-dwelling elders with dementia or mild cognitive impairment: the memory and medical care study. Int J of Geriatr Psyc,18, 174-182.

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10. Schneider, L.S., Dagerman, K., & Insel, P.S. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14:191–210.

11. Schneider, L.S., Dagerman, K.S., & Insel, P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294:1934–1943.

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16. Proctor, R., Burns, A., Powell, H.S., Tarrier, N., Faragher, B., Richardson, G., et al. (1999). Behavioural management in nursing and residential homes: A randomized controlled trial. Lancet, 354, 26-29.

 

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dementia-specific training program for staff in assisted living residences. The Gerontologist, 45, 686-693.

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