Behavior Disturbance

Also Consider:  Delirium, Managing A Crisis,  Mood Change 

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Not eating or drinking

• Respiratory: New cough, abnormal lung sounds

• GI: Constipation, abdominal distention, pain or tenderness

• GU: New or worsened incontinence, pain with urination, blood in urine, bladder scan for urinary retention

• Neurologic  changes: consciousness/alertness, orientation, weakness

• Skin: bruising (including potential head trauma), rash, infection/cellulitis

• Fingerstick glucose (patients with diabetes)

• Unrelieved pain

• Alcohol intoxication or drug use

• Danger to self (injury, suicidal ideation) or others

• Events leading up to the behaviors (Triggers - See "Identifying Triggers & Implementing Interventions" below)

3. Take Action using SBAR Report:

• Immediately notify the medical staff & resident representative

  • Behaviors posing imminent danger to themself or others, OR associated with fever >100 or new onset abnormal neurological signs

• Notify medical staff & resident representative within the next 16 hours. 

  • Abrupt onset of significant change from usual behavior

• Notify medical staff on the next business day 

  • Worsening or progression of established behavioral patterns

• Notify medical staff at the next regular rounds 

  • Behavioral disturbances managed effectively with current interventions

  • Prolonged improvement in symptoms allowing for a gradual dose reduction of medication.

4. Implement Management Plan

• Increase monitoring/supervision (15 minute checks, 1:1 observation, etc), inviting assistance from patient’s family and friends

• Assess risk for unsafe wandering and falls

• Identify Triggers and implement Interventions: See below

• Remove items that may be used as weapons or otherwise cause harm to the patient or others

• Monitor vital signs every 8 hrs for 2-3 days

• Offer fluids frequently

• Place on Intake & Output monitoring

• Place on 24-hour report for 2-3 days

• Document symptoms and response to interventions each shift

• Obtain lab results (if ordered), and notify medical as appropriate of:

  • Significantly abnormal values in blood count or metabolic panel (refer to appropriate Situation)

  • WBC > 12,000 or neutrophils > 90%

• Care team meeting next business day to create or update the patient’s Behavior Management Plan

• Review status and plan of care with designated representative daily until behavioral disturbance is managed.

• Update advance directives, if appropriate.

Identifying Triggers & Implementing Interventions (credit: igec.uiowa.edu/ia-adapt)

STEP 1: IDENTIFY, ASSESS, AND TREAT CONTRIBUTING FACTORS

▪ Determine and document frequency, duration, intensity, and characteristics of each problem behavior

▪ Identify, assess, treat or eliminate ANTECEDENTS and TRIGGERS

Unmet physical needs?

▪ Pain

▪ Infection/illness

▪ Dehydration/nutrition

▪ Sleep disturbance

▪ Medication side effects

▪ Sensory deficits

▪ Constipation

▪ Incontinence/retention

Unmet psychological needs?

▪ Loneliness

▪ Boredom

▪ Apprehension, worry, fear

▪ Emotional discomfort

▪ Lack of enjoyable activities

▪ Lack of socialization

▪ Loss of intimacy

Environmental causes?

▪ Level/type of stimulation: noise, confusion, lighting

▪ Caregiver approaches

▪ Institutional routines, expectations

▪ Lack of cues, prompts to function & way-find

Psychiatric causes?

                ▪ Depression

                ▪ Anxiety

                ▪ Delirium

                ▪ Psychosis

                ▪ Other mental illness

STEP 2: SELECT AND APPLY NON-DRUG INTERVENTIONS

• Select interventions based on the TYPE of problem and ASSESSMENT of retained abilities, preferences, and resources

  • Cognitive level

  • Physical function level

  • Long-standing personality, life history, interests/abilities

  • Preferred personal routines and daily schedule

  • Personal/family/facility resources

• Train staff to use selected interventions appropriately/following best practice and evidence-based guidelines

• Tailor intervention to individualized needs, combining approaches and interventions to promote comfort & function

• Monitor outcomes using rating scales to quantify behaviors

Adjust caregiver approaches:

• Personal approach: cue, prompt, remind, distract (treats, activities); focus on person’s wishes, interests, concerns; use/avoid touch as indicated; avoid trying to reason, teach new routines, or ask to “try harder”

• Daily routines: simplify, sequence tasks; offer limited choices; use long-standing history & preferences to guide

• Communication style: simple words and phrases; speak clearly; wait for answers; make eye contact; monitor tone of voice/other nonverbal messages

• Unconditional positive regard: do not confront, challenge or “explain” misbeliefs (hallucinations, delusions, illusions); accept belief as “real” to the person; reassure, comfort, and distract

• Involvement/Engagement: tailor activities to increase involvement/reduce boredom; individualize social and leisure activities

Change the environment:

• Eliminate misleading stimuli: clutter, TV, radio, noise, people  talking; reflections in mirrors/dark windows; misunderstood pictures/decor

• Reduce environmental stress: caffeine; extra people; holiday decorations; public TV

• Adjust stimulation: reduce noise, activity, confusion if over- stimulated; increase activity/involvement if under- stimulated (bored)

• Enhance function: signs, cues, pictures to promote way-finding;increase lighting to reduce misinterpretation

• Involve in meaningful activities: personalized program of 1:1 and small group vs. large group

• Adapt the physical setting: secure outdoor areas; decorative tactile objects; home-like features; smaller, segmented recreational and dining areas; natural and bright light; spa-like bathing facilities; signage to promote way-finding

Use evidence-based interventions:

• • • • Agitated/Irritable: Calm, soothe, distract

        • • Individualized music

          • Aromatherapy (e.g., lavender oil)  

          • Simple Pleasures https://www.health.ny.gov/diseases/conditions/dementia/edge/interventions/simple/index.htm

          • Pet therapy

          • Physical exercise/outdoor activities

      • Resistant to care: Identify source of threat; change routines and approaches

      • Wandering/Restless/Bored: Engage, distract

        • • “Rest stations” in pacing path

          • Adapt environment to reduce exit-seeking

          • Physical exercise/outdoor activities

      • Disruptive vocalization: Distract, engage

        • • Individualized music; Nature sounds

          • Presence therapy: tapes of family

      • Apathetic/Withdrawn: Stimulate, engage

        • • Individualized music

      • Repetitive questions/mannerisms: Reassure, address underlying issue, distract

        • • Validation therapy/therapeutic lying

      • Depression/Anxiety: Reassure, engage

        • • Physical exercise

          • Pleasant activities

          • Cognitive stimulation therapy

          • Wheelchair biking

STEP 3: MONITOR OUTCOMES AND ADJUST COURSE AS NEEDED

• Quantify behavioral symptoms using rating scale(s)

• Assure adequate “dose” (intensity, duration, frequency) of interventions

• Provide/reinforce staff training and development activities to assure full understanding and cooperation in daily care

• Adapt/add interventions as needed to promote optimal outcomes

2025-04-26