Behaviour Management and BPSD
(Behavioural and Psychological Symptoms of Dementia)

Challenging behaviours are a common symptom of dementia and remain to be one of the biggest challenges to care, staff.

When poorly managed, these behaviours can have far-reaching effects, including distress for the client, disruptions to the lives and comfort of other clients, and added stress and workloads to healthcare workers. Research has shown that antipsychotic medicines (which may cause significant side effects) continue to be used ‘too often’ to manage
behavioural and psychological symptoms of dementia.

Appropriate behavioural management is not only essential to maintaining a high quality of life and comfort for all clients, but it is also directly tied to Standard 1, 7 and 8 of the Aged Care Quality Standards.

So, how can nurses use non-pharmacological interventions to prevent antipsychotic use for people with dementia?

Non-Pharmacological Treatment in Dementia Care

There have been a number of systematic reviews that showed Psychosocial Interventions for aged care residents with dementia can prevent the use of antipsychotic medicine. Often, behavioural and psychological symptoms of dementia such as agitation are treated with prescribed antipsychotic medicines. However, this can lead to frequent side effects including falls, sedation and cardiovascular issues.

Additionally, antipsychotic medicines have been associated with an increased risk of stroke, increased risk of mortality and confusion (Alzheimer’s Australia 2014).
Antipsychotic medications should also be time-limited as most BPSD symptoms show an intermittent course which does not support long-term treatment with antipsychotics.

Managing Behaviours: Person-Centred Approach

There are countless ways to handle challenging behaviours, however, approaching the situation methodically with an assessment tool like the ABC approach examines the behaviour from a person-centred perspective.
The aim of this type of approach is to help us understand the etiology of the behaviour and develop a suitable, consistent response for ongoing support.

ABC Approach to Behaviour Management

• A: Antecedents / Activating Event – What led to or caused the behaviour?
• B: Behaviour – What is the behaviour?
• C: Consequences – What is the result of the behaviour?
• D: Decide and Debrief – What will be done differently to disrupt the behaviour?

A. Antecedent or Activating Event

The antecedent or activating event looks at direct or indirect triggers of the behaviour; the why, what, when, where and who. These stimuli could include:
• Organic causes – e.g. health conditions, pain, fatigue, effects of medicine etc.
• Emotional state – e.g. happiness, anger etc.
• Cognitions – e.g. what the person may be thinking.
• Environmental factors – e.g. a noisy or unfamiliar environment.
• Social relationships – e.g. interactions with other people

Common Triggers directly associated with an unmet need

B. Behaviour

The challenging behaviour should be defined clearly. Types of BPSD commonly seen include:

• Wandering or absconding;
• Depression;
• Sundowning;
• Anxiety or agitation;
• Aggression;
• Disruptive or intrusive behaviour;
• Hallucinations or delusions;
• Socially inappropriate or disinhibited behaviour.

Note, that simply labelling the behaviour is not sufficient. You must be able to describe what was
observed. For example, did the client yell, cry, punch or use particular words?

C. Consequences

The consequences of the behaviour are the responses from everyone involved. These could include those of the staff, family members or other residents who were witnesses to the behaviours.
• Were they emotional and panicked in their response?
• Did they simply ignore the behaviour?
• Did they reprimand the client?
• Were their actions calm and respectful?

D. Decide and Debrief

The final and additional step to the ABC approach is to decide and debrief. Before jumping to the option of pharmacological therapy, this step allows the care team to come together, consider their findings and collaborate on the best way to manage the situation. Remember that in true client-directed care, the client themselves is part of the care team and should be involved in this process, or alternatively the client’s family or designated decisionmakers.
Decisions on what actions to take could involve:
• Using a calm, gentle manner when communicating with the person;
• Reducing the number of staff who interact with the person;
• Have a consistent routine;
• Offering more stimulating or distracting activities or exercises;
• Use short, clear statements;
• Stronger, more effective means of communication between staff about potential triggers;
• Removing certain stimuli from the environment, such as overly-bright lights or loud noises;
• Closely monitoring interactions between particular people;
• Addressing underlying emotions and referring to other healthcare services when necessary

In Conclusion

The ABC approach to behavioural management works best when the challenging behaviour is
clearly documented and understood. The first approach should always be non-pharmacological and should involve tweaking the personal and environmental elements that contributed to the event. The client’s regular medical prescriber may consider a medications review if the behaviours are still ongoing however please keep in mind many milder challenging behaviours tend to run a course and can resolve with time, so patience and support are often the best response in these cases

For Additional Resources
• The Dementia Behaviour Management Advisory Service (DBMAS)
• Communicating with Someone Who Has Dementia
• Purposeful Engagement and Activities for People with Dementia