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The Science and Art of Behavior Management

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The Science and Art of Behavior Management Powered By Docstoc
					                       The Science and Art
                     of Behavior Management




Kelly Trevino, PhD
                                   GRECC Audio Conference Series
Clinical Psychologist
                                                   July 29, 2010
VA Boston Healthcare System
          Acknowledgements
   Nurse Managers              Medical Staff
    ◦   Annette Couchenour       ◦ Dr. Juman Hijab
    ◦   Steve McGarry            ◦ Jack Earnshaw
    ◦   Connie Soule
    ◦   Mary Farren
                                Psychiatrists
                                 ◦ Dr. Mohit Chopra
   Nursing Director             ◦ Dr. Ronald Gurrera
    ◦ Ronald Molyneaux

   CLC Nursing Staff
Outline
   Background
   The 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
Background
   5.3 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 Restraints

   Psychotropic Medication
    ◦ Limited effectiveness10
    ◦ Negative side effects11,12

   Restraints13
    ◦ Higher rate of falls
    ◦ Negative psychological outcomes
THE SCIENCE
        The Science: Learning Behavior
        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 Behavior
        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 Behavior
Model
   Characteristics 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-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-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 Behavior
   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 Guidelines
   Basic principles
    ◦ Specificity
    ◦ Individualization
    ◦ Consistency: Implementation and documentation
   Behavior may increase initially
    ◦ Re-examine plan after 2-3 days
   Behaviors are not
    ◦   Voluntary or purposeful
    ◦   Rudeness
    ◦   Due to a “bad attitude”
    ◦   Attempt to make your job difficult
           Boston VA CLC



        THE ART
Behavior Management Team (BMT)
    BMT: Creation
 Recognition   of a problem
 Weekly interdisciplinary meetings
  ◦ Psychology, nursing, medicine
 Identified:
  ◦ Problem
  ◦ Goals
  ◦ Process
  ◦ Staff Training
  ◦ Documentation
        Staff Training: BMT
   What is the BMT                Outcome measures
    ◦ Explain why                   ◦   Frequency of behaviors
    ◦ Explain how                   ◦   Severity of behaviors
    ◦ Get feedback/ideas            ◦   Referrals to BMT
                                    ◦   Medications for behaviors
   BMT Documentation               ◦   Inpatient psych transfers
    ◦ Focus on BMT Shift Note       ◦   Code greens for behaviors
                                    ◦   Staff feedback on BMT
       Staff Training: Functional Analysis
 Prevalence of behaviors
 Difficulty of managing behaviors
 Define types of behaviors and correlates

 DON’T PANIC
 ABCs of behavior management
 Unmet needs

   Questions for describing context of behaviors
ABCs of Challenging Behavior

               Behavior
                 (B)




 Antecedents              Consequences
     (A)                      (C)
      Staff Training:
      Creating/Implementing Behavior
      Plans
 Basic principles
    ◦ Specificity
    ◦ Individualization
    ◦ Consistency: Implementation and documentation
   Behavior may increase initially
    ◦ Re-examine plan after 2-3 days
   Behaviors are not
    ◦   Voluntary or purposeful
    ◦   Rudeness
    ◦   Due to a “bad attitude”
    ◦   Attempt to make your job difficult
   Questions for identifying new ABCs
       Behavior Frequency/Severity




          Start Behavior Plan




Time
           The Art: Behavior Management
           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 Management
Team
   Inclusion 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 Management
        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 Plan
Primary 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 Note
Target 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 Note
Session Type: BMT Rounds
Time 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 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.

   Measures
    1. Demographic information: Age, gender, residential status
    2. 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
        Management
   Person-centered care
    ◦ Implement WITH the resident, not TO the resident
   Interdisciplinary
    ◦ Consider role of MD/PA
 Individualization
 Consistency
 Communication
    ◦ Team
    ◦ Ask/Talk to the resident
   Dementia-care skills
Lessons Learned:
Program Implementation
    Identify and include relevant stakeholders
     ◦ Facility specific
     ◦ All services
     ◦ All levels
    Union
     ◦ Include early
    Intervention-setting fit
     ◦ Resources
     ◦ Limitations
        Lessons Learned:
        Program 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
Questions
References
1.   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.
References
7. Burgio, L.D., Jones, L.T., Butler, F., & Engler, B.T. (1988). Behavior problems in an urban nursing home. J of
     Gerontol Nurs, 14, 31-34.
8. Brotons, M. & Pickett-Cooper, P. (1996). The effects of music therapy intervention on agitation behaviours
     of Alzheimer's disease patients. J Music Ther, 33 (1), 2-18.
9. Conely, L. & Campbell, L. (1991). The use of restraints in caring for the elderly: realities, consequences
    and alternatives. Nurs Pract, 16, 48-52.
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.
12. Kales, H.C., Valenstein, M., Kim, H.M., McCarthy, J.F., Ganoczy, D., Cunningham, F., & Blow, F.C. (2007).
    Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric
    medications. American Journal of Psychiatry, 164, 1568 – 76.
13. Cotter, V.T. (2005). Restraint free care in older adults with dementia. Keio J Med, 54, 80-84.
14. Cohen-Mansfield, J. (2001). Nonpharmacologic interventions for inappropriate behaviors in dementia.
    American Journal of Geriatric Psychiatry, 9, 361-381.
15. Tarpy, R.M. (1997). Contemporary Learning Theory and Research. McGraw Hill: Boston.
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.

References
 17. Teri, L., Huda, P., Gibbons, L., Young, H., van Leynseele, J. (2005) STAR: A dementia-specific
     training program for staff in assisted living residences. The Gerontologist, 45, 686-693.
 18. Lichtenberg, P.A., Kemp-Havican, J., MacNeill, S.E., & Schafer Johnson, A. (2005). Pilot study of
     behavioral treatment in dementia care units. The Gerontologist, 45, 406-410.
 19. Lawton, M.P., & Nahemow, L. Ecology and the aging process. (1973). In: The Psychology of Adult
     development and Aging, Eisdorfer L, Lawton MP. (eds). Washington DC, 619-674.
20.   Camberg, L., Woods, P., Ooi, W.L., Hurley, A., Volicer, L., Ashley, J., Odenheimer, G. & McIntyre, K.
      (1999). Evaluation of Simulated Presence: a personalized approach to enhance well-being in
      persons with Alzheimer's disease. J Am Geriatr Soc, 47(4), 446-52.
21.   Boyle, M., Bayles, K.A., Kim, E., Chapman, S.B., Zientz, J., Rackley, A., Mahendra, N., Hopper, T., &
      Cleary, S.J. (2006). Evidence-based practice recommendations for working with individuals with
      dementia: Simulated Presence Therapy. Journal of Medical Speech-Language Pathology, 14 (3), xiii-xxi.
22.   Volicer, L., Simard, J., Pupa, J., Medrek, R., & Riordan, M. (2007). Effects of continuous activity
      programming on behavioral symptoms of dementia. J American Medical Directors Association, 7(7),
      426-431.
 23. Algase, D., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K., & Beatty, E. (1996). Need-
     driven dementia-compromised behavior: an alternative view of disruptive behavior. Am J of
     Alzheimer’s Dis Other Demen, 11, 10-19.
 24. Cohen-Mansfield J. (2000). Nonpharmacological management of behavioral problems in persons
     with dementia: the TREA model. Alzheimer’s Care Quarterly, 1, 22-34.

				
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