Using Communication to Manage Challenging Behaviors

Welcome to the educational program Using Communication to Manage Challenging Behaviors. This program will help you to understand the changes in communication associated with Alzheimer’s disease and how good communication skills are critical for good caregiving. You will also learn how to use good communication skills to help manage challenging behaviors and about care recipient abuse and how to prevent it.

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This is Lesson 12 of The Alzheimer’s Caregiver. You may view the topics in order as presented, or click on any topic listed in the main menu to be taken to that section.

We hope that you enjoy this program and find it useful in helping both yourself and those you care for. There are no easy answers when it comes to the care of another, as every situation and person is different. In addition, every caregiver comes with different experiences, skills and attitudes about caregiving. Our hope is to offer you useful information and guidelines for caring for someone with dementia, but these guidelines will need to be adjusted to suit your own individual needs. Remember that your life experiences, your compassion and your inventiveness will go a long way toward enabling you to provide quality care.

Let’s get started.

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Communication Changes

For those with Alzheimer’s disease, the capacity to understand language and to express thoughts, emotions and needs becomes more difficult as the disease progresses. They may not be able to understand what you are saying or only be able to grasp part of it. They may have difficulty finding a word and say a related word instead of the one that is forgotten. They may even talk fluently but not make any sense, or repeat the same phrase or word without meaning or purpose. They also lose their reading and writing skills.

Because of memory loss, those with dementia may not be able to talk about recent events or people they have recently met.  Distant memories typically remain intact until the later stages, but eventually, even old memories and family members may be forgotten.  Therefore it may be difficult for them to respond to questions such as, who is this, where are you, or what did you do last week?

Memory loss also shortens the attention span, so they may forget the purpose of an interaction or lose interest while it is happening.

Lastly, they lose conversational social skills and so may respond inappropriately by interrupting or ignoring other speakers.

Case Study 1

Let’s look at a case study with Robert and his caregiver, Mary. They are in the bathroom and Robert is displaying some challenging behaviors concerning his showering.

What could Mary have done to prevent this difficult behavior?

    • A) Mary should have faced Robert, gotten his attention and made sure he understood the instructions
    • B) Mary should not have tried to force Robert to take off his robe.
    • C) Mary should have tried to find out why Robert did not want to shower, and address any issues.
    • D) Mary should have shown a relaxed attitude and used a calming tone of voice and body language.
    • E) All of the above.

Answers:

Choice A: “Mary should have faced Robert, gotten his attention, and made sure he understood the instructions” is an excellent choice.

When communicating, you should make sure that the person is paying attention to you. To get someone’s full attention, face the person and maintain eye contact while speaking and when listening. When communicating, always try to be at the individual’s eye level. If the person is standing, you should be standing, if the person is sitting, you should be sitting.Try to stay in one place, so that it is easier for the person to follow you. Watch as well as listen, for people with dementia sometimes pretend to understand in order to hide their confusion. Even if they say that they understand what is being said, watch them to see if they demonstrate understanding. Remember that good communication is a two-way exchange.

Choice B: Mary should have faced Robert, gotten his attention, and made sure he understood the instructions” is an excellent choice.

One of the goals of communication is to build a caring, trusting relationship between the caregiver and care recipient, so that caregiving is made easier and more rewarding. In order to achieve this, caregivers should try to avoid forcing those with dementia to do things or treating them as if their feelings do not matter. Trying to force them to perform an activity often results in unwanted behavior.Caregivers should also avoid pointing out errors, arguing, criticizing, scolding, or embarrassing someone with dementia.

Choice C: “Mary should have tried to find out why Robert did not want to shower and address any issues”could also be a reason.

When challenging behaviors arise, try to find out the reason for the behavior.Then look for productive solutions that involve the whole care team, including the person with dementia.

Remember that the disease is causing the change in personality and loss of abilities. Use a non-judgmental approach and try not to judge or blame the person for negative behaviors and challenging situations.Mary should have been sensitive to the early signs of Robert’s challenging behavior and backed off, or diverted his attention with the use of distraction.

Choice D: “Mary should have shown a relaxedattitude and used a calming tone of voice and body language”is also a good answer.

Your tone of voice and emotional tone can convey more than words, particularly during the later stages of the disease when people have limited word understanding.

Remember that words are not the only form of communication and that you can use non-verbal forms of communication, such as facial expressions, tone of voice and body language, to convey how you feel, especially when the person is having a difficult time. A smile, a gentle touch, and a kind voice can express so much more than words. Try to show a positive, relaxed attitude and pose things in a positive way.

Choice E: For this question, the answer E, “all of the above,” is the best choice.

Mary should have stayed calm and displayed a relaxed, respectful manner while trying to find out why Robert was reluctant to shower, rather than forcing him to do things in order to stay on a schedule.

 

Case Study 2

Now, let’s look at one way Mary could have better handled Robert’s challenging behavior.

As you can see, with a little patience and understanding Mary was able to get Robert to take his shower. Of course some days are going to be harder than others for both the caregiver and the person with dementia, but always try to remain calm and don’t take challenging behaviors personally.

Using Communication to Help Manage Challenging Behaviors

Communication is a key strategy for managing challenging behaviors such as agitation, hostility, aggression, or combativeness. Let’s go over  some of the communication skills that caregivers can use to manage challenging behaviors.

First and foremost, always remain calm. This includes maintaining a pleasant facial expression and using reassuring body language.

Make sure that you have the individual’s attention before talking. This can be done by positioning yourself at the person’s eye level and maintaining eye contact while talking and listening. Offer reassurance rather than criticism and avoid invalidating emotions or arguing with, criticizing, scolding, or embarrassing the person.

One way to help avoid challenging behaviors is to use empathy and validation. If the person is agitated, upset, or sad, use empathetic phrases such as, “I understand you are upset,” or, “I’m sorry you are feeling sad,” to provide comfort rather than dismissing or criticizing the feelings. Remember that trying to reason with someone with dementia is often frustrating and futile, especially in the later stages of the disease.

Instead, if something is causing the person to become stressed, try to remove the trigger for the behavior, or remove the person from the stressful situation, as it is usually not worth continuing an activity or discussion that is going to result in an outburst or potential harm.

If removing the person is not an option then try redirecting or distracting the person. Try to find things that work to refocus the person’s attention onto safer, calmer topics or activities.  This may take some trial and error, so try to be patient and flexible. Some examples of distractions include discussing a favorite topic, interest or activity that the person enjoys, like going for walks, listening to music and playing games. Try turning on an enjoyable television show, or offer snack food. You might also consider involving another person, who may be able to help calm or redirect the person.  If there is no risk of harm to the person or to others, you can also try giving the person some time alone to regain control.

All behavior has meaning, and your ultimate goal is to discover the meaning of the behavior, so that you can help the person with dementia feel safe and comfortable. You need to know if the person is in pain, sick, hungry, thirsty, cold, hot, incontinent, or constipated, often without them telling you. In order to do this, you will have to become aware of sources of stress within the person’s daily environment, which can include such things as other people, room temperature, lighting, or objects.

Tips for Building Relationships

Having a caring, trusting relationship with the person you care for can make it easier for you to resolve challenging behaviors that may arise. The following are some tips for building relationships.

Try to provide regular, undivided attention, especially when speaking to the person. Although this requires a commitment of time and effort, it is important to provide regular, meaningful attention to create a sense of security and stability in the person’s life. Share in activities that you both enjoy. This can include such social situations as watching television,  playing games, sharing meals, and helping with hobbies, such as collecting things. Try to show that you value the person. Feeling valued and needed is important for self-esteem. Include the individual in meaningful activities such as housework, preparing meals, and having celebrations. Remember that body language is as useful for communication as words, so try using appropriate touch. A gentle, reassuring touch on the arm, hand or shoulder is one way to show support and comfort.

Lastly, do your best to preserve the person’s dignity and self-esteem. Never ridicule people because they cannot perform a task or become difficult. Remember that a person’s ability to function can fluctuate day to day, which means that you must adjust your behavior according to each situation.

Ideas for Sharing Activities

Sharing in meaningful activities can help build and maintain relationships between caregivers and care recipients.  Activities also provide opportunities for people to practice their communication skills. Let’s take a look at some ideas for sharing activities.

One activity is listening to music and singing together. Music taps different areas of the brain than verbal language, and because it is familiar to the person, it may evoke emotions in ways verbal language cannot.

You can also encourage conversation by focusing on a conversation piece, such as artwork, flowers, a stuffed animal, personal photo, or story.

Using pleasant smells, tastes, and textures as forms of communication is often overlooked, but  can be very productive. Odors, such as baking bread, can evoke pleasant memories or provide information about an upcoming meal, which can be used as a topic for conversation. Tastes can show caring when a special or favorite food is prepared. Finally, using textures, such as suede, or the bark from a tree, can stimulate the senses and provide a topic for conversation.

Exercising together is also great for both of you, but only do as much as the person is capable of doing.  For example, go for walks, do chair exercises, or go someplace where you can do water aerobics. Exercising in the water creates less friction on the joints and provides great sensory stimuli.

You can also go on outings together outside of the home or facility.  For example, take a day trip to the zoo, aquarium, museum, or park. Before making any outside plans, it’s best to evaluate how the person is functioning that day and how much stimulation might be manageable.

Care Recipient Abuse

Caregivers who take care of people with dementia day in and day out have a very difficult job.  Sometimes the frustrations, stresses, and fatigue can lead to verbal and physical abuse of those in their care. 

There are many types of abuse of varying degrees. Some types of abuse are obvious such as hitting, yelling, and swearing, while other types are more subtle. Sometimes caregivers become so frustrated, that they don’t even recognize that they are being abusive. 

Some of these more subtle forms of abuse include the use of ridicule or criticism. This can lead to a decrease in self-esteem and motivation.  Ignoring a person’s needs, providing poor care, or neglecting someone are all forms of abuse.  Isolating or secluding someone from others can be a form of abuse if done for reasons other than  the temporary protection from  harm to self or others. The use of punishment and retaliation cause  the loss of dignity.  Hurrying people with dementia or pressuring them to move at your pace can be also be considered abusive as it can cause distress and trigger challenging behaviors. 

Threatening and frightening people are not acceptable ways of motivating them.

Lastly, the use of restraints can be abusive and cause physical and psychological injuries.  For more information about restraints, see the link provided.

The Minnesota Department of Health has provided information to consumers on understanding the role of physical restraints in resident safety.

Preventing Care Recipient Abuse

It is normal to have negative feelings about someone with dementia sometimes, but acting on those feelings is never appropriate.  It is never okay to punish those with dementia under any circumstance for behaviors that seem intentional, as their difficult behaviors are rarely intentional. The reality is that they usually have little control over their negative reactions, even if they seemed in control just moments before. 

Here are some tips to help you prevent care recipient abuse. First, use good communication skills as a primary strategy. Using a calm emotional tone and being away of the person’s non-verbal language as well as your own will help you to stay in control of your behavior.

Because your perception of the situation is critical to how you handle it, you should always assume that the person is acting to the best of their abilities and communicating in the only ways they can. On the other hand, if you assume that the person is just being difficult, you will be more easily frustrated.

People with dementia are not children, though they may regress in their behavior and act like children. You should try to treat people as hey wish to be treated. Doing this takes enormous patience, so if you are feeling pressured, overworked, or frustrated, take a break before abusive behavior occurs.

Some ideas for coping include the use of relaxation techniques. Simple breathing and counting exercises can be quick and effective. You can also try spiritual activities that coincide with your beliefs such as meditation and prayer. Sometimes using humor can help you lighten a situation and relax as well. Remember to make time for yourself and participate in the relaxing, pleasant activities that you enjoy doing.

Talk to others about your feelings and seek support from family, friends, support groups, counselors, or therapists and other healthcare professionals.

Read up on issues that concern you such as caregiver stress and learn tips on how to manage it. Remember that there is no one right way, but there is a way that is right for you.

Summary

In summary, using good communication skills can help to prevent and resolve challenging behaviors. The basic principles of good communication include showing respect, patience, and flexibility. Approach caregiving as a collaborative, team effort in which the person with Alzheimer’s can still make valued contributions. Use a non-judgmental, open-minded approach to difficult situations through the use of empathy and validation. Keeping a positive attitude and a good sense of humor can help alleviate stress and help you to prevent doing abusive things that you normally would not do.

Some strategies for using communication to manage challenging behaviors include using a calm tone of voice and pleasant facial expressions and body language. Make sure that you have the person’s attention and keep it while speaking and listening. Remove any environmental triggers and avoid situations that may cause distress and lead to difficult behaviors.  If such triggers cannot be avoided, remove the person from the situation and give her or him time to calm down.  Or try distracting the person with something pleasant. This becomes much easier to do if you figure out the meaning behind the difficult behaviors and invest the time and energy to establish a caring, trusting relationship with the person.

Remember that care recipient abuse comes in many subtle forms including criticizing, scolding, pressuring, punishing, threatening, isolating, ignoring, neglecting, restraining, and assaulting the person. Your best bet for preventing abuse involves taking care of  yourself and properly managing caregiver stress.

  ← Previous Lesson (Guidelines for Improving Communication)

Next Lesson (Activity-Focused Dementia Care: Meaningful Activities)

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Written by: Linda R. Phillips, R.N., Ph.D., F.A.A.N. (UCLA School of Nursing)

Edited by: Mindy J. Kim-Miller, MD, PhD (University of Chicago School of Medicine)

 

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