Sa Dbmas Reboc Guide 2012

ReBOC
Reducing Behaviours Of Concern

A Hands On Guide
A resource to assist those caring
for people living with dementia
Dementia Behaviour Management Advisory Services

Helping Australians with dementia, and their carers | www.dbmas.org.au
(C) 2012 Alzheimers Australia SA Inc

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behalf of Alzheimers Australia SA Inc pursuant to Part VA of the Copyright Act 1968
(the Act).
The material in this communication is subject to copyright under the Act. It is
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professionals with due reference.
Any further copying or communication of this material outside of these parameters
is the subject of copyright protection under the Act. Please contact: Chief Executive,
Alzheimers Australia SA Inc, 27 Conyngham Street, Glenside SA 5065.
The Australian Government funds the South Australian Dementia Behaviour
Management Advisory Services (SA DBMAS) which is one of eight centres nationally
that provides information, advice and support to improve the quality of life of people
with dementia and their carers where the behaviour of the person with dementia
impacts on their care.
The Australian Government is committed to improving the health of all Australians,
ensuring they have access to high quality health services and supportive care services.
Through the Dementia Initiative, the Australian Government aims to strengthen the
capacity of the health and aged care sectors to provide appropriate evidence-based
prevention and early intervention, assessment, treatment and care for people
with dementia.
Authors: Tim Wallace, Rajiv Chand, Elisabeth Buck, Pam Riley, Gina Murphy, Helen
Brauer, Susan McAuliffe, Jane Doolette and Elizabeth McGrath.
Commonwealth of Australia as represented by the Australian Government
Department of Health and Ageing 2012
Copyright in the product sample templates, Commonwealth logo, photographs and
graphic layouts reproduced from the Graphic Design Standards Manual for DBMAS
is owned by the Commonwealth of Australia and published with the permission of the
Commonwealth of Australia on the condition reproduction occurs for non-commercial
use and promotes or benefits selected Commonwealth approved dementia initiatives
and programs. All commercial and other rights are reserved.
Important notice: this work may not be a Commonwealth publication or product The
views expressed in this work are the views of its author(s) and not necessarily those
of the Commonwealth of Australia. Despite any permitted use of the Graphic Design
Standards Manual for DBMAS copyright material, the reader needs to be aware that
the information contained in this work is not necessarily endorsed, and its contents
may not have been approved or reviewed, by the Australian Government Department
of Health and Ageing.
ISBN: 978-0-9872055-0-6
Publisher: Alzheimers Australia SA Inc, 27 Conyngham St, Glenside SA 5065
Design and Print: Kwik Kopy Norwood
This section
will help you to...
01
Risk Assessment
Quickly identify whether the behaviours are creating

an emergency situation
Make an informed decision about what immediate
actions to take
02
Behaviours
of Concern
Understand the relationship between the brain,

cognition and behaviour
Identify and objectively describe behaviours of concern
Establish a baseline measurement for a behaviour
03
Delirium Screen
Identify and address behaviours related to delirium
Assessment
Undertake a comprehensive review of factors

contributing to the behaviours
Gain a better understanding of the emotional
status of the person with the behaviours
Introduction
The content of this guide draws on currently
accepted knowledge of the behavioural and
psychological symptoms of dementia (BPSD), and
promotes evidence based practice in dementia
care to maximise the quality of life for people living
with dementia and their carers. This guide aims to
enhance communication and interactions between
carers, the person with dementia and their family
members, and improve the occupational health
and safety of people who provide care. There are
a number of terms used to refer to the behavioural
symptoms of dementia including: behaviours
of concern (BOC); challenging behaviours; and
BPSD. Throughout this guide we refer to these as
behaviours of concern, but other terms are used
interchangeably. We have also used the word people
/ person to describe those living with dementia
with behaviours of concern, and the word carer to
describe those who are providing care and support
for the person with dementia.
How to use this guide

This guide has been designed to be used in
conjunction with your organisational procedures,
starting with a risk assessment of the behaviours of
concern. After the risk assessment, you sequentially
step through the other sections of the guide. If the
behaviours of concern are resolved, then you do not
need to continue with the steps. If at any point in
time you are unsure of how to complete one of the
steps, consult the relevant section of this guide as
it will provide you with some useful suggestions to
try. If you require further help with the behaviour of
a person you are caring for, please call DBMAS on
1800 699 799 for assistance.
04
05
Management
Strategies
Understand the guiding principles for behaviour

management
Match psychosocial therapy approaches to the
emotional needs underpinning the behaviours
Understand the guiding principles for the
pharmacological management of behaviours of concern
01
Risk
Assessment
Risk Assessment
ReBOC
Risk assessment
There are some behaviours which give rise to dangerous situations for the person experiencing the behaviour or for others in the immediate vicinity.
The first step is to manage the immediate risk. Once the immediate risk has been resolved, continue to follow this guide.
Risk
Verbal Presentation
any of the following
Physical Presentation
any of the following
Immediate Actions
02
Raised voice / angry tone

Threatening language
Remove self and others (if safe to do so) from the situation
Brandishing weapons / raised

fists / fighting posture
And
Emergency
Assess the impact on safety: Is anyone at risk?

Decrease the environmental stimuli for the person displaying aggression
If behaviour persists or escalates then crisis management should be initiated.
Refer to your organisational procedures and contact emergency services as required.
Damaging property
Actual injuries to self or those
around them
If safe, attempt to diffuse the situation using non-pharmacological approaches

(refer to page 16 of psychosocial section)
Use short and simple communication techniques
Stop any interaction that infringes on their personal space
Threatening language
Screaming
Fidgeting / restlessness
And
High
Raised voice / angry tone
No verbal behaviours
Offer verbal reassurance (speak in a slow and low tone observe body language etc
refer to page 14)
Pacing back and forth /

walking in an urgent manner
Give the person space and time to calm down. Allow a minimum of five minutes
before attempting to reengage
No verbal presentation
ReBOC | www.dbmas.org.au
And / Or
Low
Fidgeting / restlessness
Calling out
Follow the steps in this manual
Pacing back and forth /

walking in an urgent manner
Contact DBMAS on 1800 699 799 for assistance if you would like some further help
No physical presentation
Dementia Behaviour Management Advisory Services 1800 699 799
Behaviours
of Concern
Behaviours of Concern
ReBOC
Behaviours of concern
What is dementia
Dementia is the term used to describe
the symptoms of a large group of
illnesses which cause a progressive
decline in a persons cognitive
functioning. It is a broad term which
describes a loss of memory, intellect,
reasoning, social skills and normal
emotional reactions that are often
reflected in a persons behaviour.
Dementia types
Dementia is caused by many disorders,
the most common of these are:
What are behaviours

of concern
A behaviour of concern is any behaviour
which causes stress, worry, risk of
or actual harm to the person, their
carers, staff, family members or those
around them. The behaviour deserves
consideration and investigation as it is an
obstacle to achieving the best quality of
life for the person with dementia and may
present as an occupational health and
safety concern for staff.
Alzheimers disease
Examples of behaviour
of concern
Vascular dementia
Verbal disruption
Parkinsons disease
Physical aggression
Dementia with Lewy Bodies
Repetitive actions or questions
Fronto-temporal dementia
Resistance to personal care
Huntingtons disease
Sexually inappropriate behaviour
Alcohol related dementia.
Refusal to accept services
Most people with dementia are older

but dementia is not a normal part of
ageing. The onset of symptoms is usually
gradual, with early signs of dementia
being quite subtle. Dementia has a
progressive nature.
Problems associated with eating
Important considerations
Behaviours of concern are common and are a consequence
of the brain changes
Behaviours may resolve on their own or escalate as the
disease progresses
Management strategies may only partially reduce
the behaviour frequency or impact.
Socially inappropriate behaviour

Wandering or intrusiveness
Sleep disturbance.
The brain and behaviour

The brain is the most complex organ in the human body and is responsible for all aspects of our behaviour. Researchers are still trying to understand in greater detail the
numerous structures that make up the brain, and their corresponding function.
The brain has four primary lobes and the limbic system. Each lobe has a number of sub-structures with different specialised functions. The primary functions of the four lobes
and the limbic system are described on this page in the colour coded boxes.
Dementia causes progressive damage to these brain regions, with the type and severity of the disease determining the degree of impairment to function and behaviour.
The brain does not exist in isolation, and it is important to understand the biological, psychological, and physical environment that provide the context for all behaviours.
The brain and behaviour

Frontal Lobe
Parietal Lobe
Temporal Lobe
Occipital Lobe
Limbic System
The frontal lobe is

responsible for higher
cognitive functions involving
planning, problem solving,
starting and stopping
actions and regulating
social behaviour.
The parietal lobe processes

and integrates tactile
information (touch, pressure,
temperature and pain) along
with information from the
occipital lobe, to create an
understanding of ourselves
and the world around us.
The temporal lobe plays

a vital function in learning
& memory, understanding
language, perception
and recognition.
The occipital lobe separately

encodes visual information
received by the retina in the
eyes into colour, orientation
and movement and passes
this information to the
temporal and parietal lobes.
The limbic system has a

primary role in processing
and regulating emotions,
memory and sexual arousal.
Damage to this
region causes
Inability to initiate activity
Repetitive behaviour
Inability to regulate mood
or emotional state
Rude and socially
inappropriate behaviour
Damage to this
region causes
Inability to locate and
recognise objects
Lack of coordination
Disorientation
Damage to this
region causes
Difficulties in
understanding speech,
recognising faces and
objects
Long and short term
memory loss
Increased aggression
Changes to interest in
sexual behaviour
Persistent talking.
Damage to this
region causes
Hallucinations
Blindness
Inability to see colour
or motion
Synesthesia (eg hearing
colours, tasting sounds).
Damage to this
region causes
Increased agitation
Uncontrolled emotions
Disturbed day/night cycle
Changes to sexual arousal.
Models for understanding behaviour

Four models may assist in understanding the causes for changed behaviour associated with dementia. It may be necessary to use more than one of these models to gain
greater insights into why the behaviour is occurring.
Unmet needs
ABC model
Theory
Theory
A person may exhibit behaviours when their needs are not met eg: hunger,
thirst, toilet, pain, fatigue, temperature, over/under stimulation, social
engagement. Maslows hierarchy of needs is one way of conceptualising the priority
of needs, with the needs fundamental to survival being the foundation for higher
order needs.
Antecedents > Behaviour > Consequences.

The ABC model focuses on triggers (antecedents) that precede behaviours, with the
subsequent consequences reinforcing the behaviour.
Strategy
Problem solve to determine antecedents that may have triggered the persons
behaviour. Identifying the ABCs can help to target interventions aimed at reducing the
antecedents, or in some instances modifying the consequences.
Strategy
Attempt to understand which individual unmet needs are contributing to behaviours
and manage these needs prior to behaviours occurring.
cedent
C on
se
e
Ant
Esteem
nce
e
qu
Love / Belonging
Safety
Beha
v
i
o
ur
Physiological
Models for understanding behaviour

Progressively lowered stress threshold
Biomedical model
Theory
Theory
Dementia lowers a persons ability to deal with daily stress and increases the
susceptibility to environmental stressors.
Accumulated stressors such as noise, temperature and light can contribute to
behaviours of concern.
Pathological changes to the brain in dementia impair normal brain functions and
cause behavioural symptoms. Behaviours of concern are a part of dementia.
Strategy
Manage reversible causes of confusion and behaviour related to treatable biological
and physiological conditions.
Understand that treatment resistant behaviours are caused by the disease and not
an intentional or malicious act.
Strategy
Identify and remove cumulative stressors from the environment to reduce the
likelihood of stress related behaviours. Schedule rest breaks to allow the person to
cope with daily stress more effectively.
Normal
Progressively Lowered Stress Threshold
Alzheimers
03
1:
00
3: am
00
5: am
00
7: am
00
9: am
00
11 am
:0
0
1: am
00
3: pm
00
5: pm
00
7: pm
00
9: pm
0
11 0 pm
:0
0
pm
Cumulative stress
Delirium
Screen
Language
Time of day
Unexpected touch
Confusion
Fatigue
Pain
Memory
Language
Noisy
Thirst
Hunger
Stress threshold
Delirium Screen
ReBOC
Delirium screen
Delirium risk factors:

Infection
Pain
Dehydration
Multiple medications
Malnutrition
Electrolyte dysfunction
Sensory impairment
Hepatic or renal dysfunction
Sleep deprivation
Cardiovascular Disease
Immobility
Constipation/Diarrhoea
NO
1. Conduct baseline cognitive

function assessments
Is the persons cognition currently impaired?
Assess & manage risk factors

Screen cognitive function at regular intervals
YES
2. Determine any changes in

cognitive function
Differential diagnosis
Has this change occurred over hours or days?

Does the persons presentation fluctuate
over the day?
NO
For further information on delirium, please read Delirium Care

Pathways (Traynor & Britten, 2010)
YES
Assess for depression or dementia
YES
Consider the use of this pathway if the person is aged over

65 years or 45 years for Aboriginal or Torres Strait Island
Communitities.
Has the patient/client been identified as potenially suffering from delirium?
Adapt Care Plan
YES
3. Assess for Delirium

Confusion Assessment Method (CAM)
MMSE/Heidelberg Cognitive
Screen/Clockface/RUDAS
Medication review: Any changes in the
past weeks or months?
Organic Screen: CBE, biochemistry, U/E/C,
LFT, TFT, urine, C&S, chest x-ray
Physical examination and pain review
Is there a confirmed diagnosis of delirium?
Depression
Indwelling catheter
Physical restraint
Abnormal sodium
4. Consider sub-clinical delirium
Hospitalisation
History of delirium
Does the patient/client have some

symptons of delirium?
Refer to GP or specialist for treatment

Provide supportive care
NO
YES
Delirium, an acute confusional state, can compound the

confusion and exacerbate behaviours caused by dementia.
Delirium has numerous causes, with a wide range of risk
factors which are detailed here. People with multiple risk
factors are more likely to suffer from delirium. Treating the
delirium is critical as it presents a significant health risk and
can limit the effectiveness of any behaviour management
strategies. Follow this delirium screen flow-chart to identify
whether delirium is contributing to the behaviour changes.
Refer to Delirium Care Pathways

(Traynor & Britten, 2010).
NO
5. Monitor and respond to any sudden

changes in cognitive functioning by
repeating pathway.
11
04
Assessment
Assessment
ReBOC
High Stress
Establish a behaviour baseline

This section will guide you through some of the key
contexts that impact on behaviour.
Severity
It is important to measure and describe behaviours

as objectively as possible, using neutral language of
what was observed, and for measurement to be done
consistently both before and after any interventions or
management strategies. This will aid in developing an
appropriate plan of care, as well as helping to evaluate
the effectiveness of care. For assistance in measuring
behaviours contact DBMAS on 1800 699 799.
No Stress
Baseline questions
What is the specific behaviour to be reduced?
(describe what occurs step by step)
Who is the behaviour an issue to? (there may be more
than one person who is affected)
Never
Frequency
Constantly
How often is it the behaviour occurring? (frequency)

What is the impact of the behaviour on:
Carer stress? (can vary from carer to carer)
Quality of life of the person with dementia?
Health and safety of involved parties?
Other aspects?
By answering these questions at baseline, you will be
able to map the behaviour impact. When evaluating the
effectiveness of any management strategies, you can
ask the same questions again to see if the changes to
frequency and severity have reduced the overall impact
of the behaviour.
When describing the behaviour, do not try to interpret the intent or motivation, only record
what was observable (see incident report example on page 15)
Behaviours are a major source of stress for carers
The perception of behaviour severity is influenced by carer stress levels and knowledge
about dementia related behaviours
Family and care staff are a good source of information about the person with dementia, their
history, personality, and preferences
The skills and knowledge of a variety of professional disciplines may be beneficial in
producing a positive outcome.
13
Assessment
All behaviours occur in a context, and within that context, the behaviour makes perfect sense to the person exhibiting it. The challenge of behaviour assessment is to
gain insight into the context of the behaviour of the person with dementia at that moment in time, and to unpick their reality one strand at a time until the behaviour
makes perfect sense to you.
CONTEXT
ROLE IN BEHAVIOUR
PEOPLE WITH DEMENTIA:
Physical Health
The body is the link between the brain and the environment.
Anything that adversely impacts the body can impact the brain
and therefore behaviour
Are more likely to be over 65, and have age related changes
to their physical health which may require medication
Social / Emotional
History
Cumulative memories and associated feelings will shape how

people perceive the world around them
Are reliant on their life experiences in understanding the present.

How they experience today is shaped by their related past
experiences
Medicines
Medicines frequently have therapeutic actions or side effects

which can impact on brain chemistry and alter mood or
perception
Are more likely to have a medication regimen that alters mood

or perception, and are more likely to be sensitive to its effects
Environment
The physical environment provides the sensory information

that the brain needs to understand the world
Have a diminished capacity to process sensory information

and are more likely to not understand the context of the physical
environment.
Communication
approach
Communication is 95% non-verbal, with non-verbal cues

conveying the emotional context and meaning to help inform
the appropriate response.
Often lose the verbal context of communication due to short term

memory loss, and rely heavily on the emotional context
of communication to guide their reactions
14
Incident Report Example

Please complete one sheet for each incident of behaviour
Date: 5th
January
Time: 5:35pm
Person reporting: Donna
(staff)
Others involved: Sarah
(staff) witness
Where did the incident occur?

Lounge room
What happened before the behaviour of concern? (Consider cumulative stressors / unmet needs)
Mrs A had just left the dining room during tea (barely touched her food). Mrs A was moving around the lounge room
rearranging the cushions and chairs. The television was on loudly and the curtains were drawn, making the room dark.
What happened during the behaviour incident? (Describe the behaviour incident objectively, including who was involved, where it occurred,
and what the person with dementia did)
Mrs A moved a cushion near Mr B. Mr B told Mrs A to bloody get out of it. Mrs A then proceeded to call Mr B a
useless bastard and kicked and punched at him. Sarah (staff) attempted to hold Mrs A to stop her hitting Mr B at
which point Mrs A bit Sarah on the arm.
What happened following the behaviour incident?
The locum GP was called. John (staff) separated Mr B and Mrs A. Mrs A continued to call out bloody murderers
and you are all crooks as she paced around the facility until the locum arrived. Mrs As behaviours were observed
from a distance and Donna (staff) offered her a warm drink and a snack but Mrs A refused this
What might have caused the behaviour to occur?
Mrs A may have been startled by Mr Bs response. Restraining Mrs A to prevent her from harming Mr B may have made
her more upset.
What strategies could you suggest or trial to help avoid the behaviour in the future?
Mrs A could have been diverted to get her to move away from the situation instead of using physical restraint.
Increased supervision and assistance for Mrs A to complete her meal and then be provided with purposeful activity
which may prevent the situation.
15
Medicines
All medicines have an increased potential to cause adverse effects in older people.
Various classes of drugs (eg beta-blockers, anticonvulsants, benzodiazepines, tricylic
antidepressants, corticosteroids, narcotics, fluoroquinolones, H2 receptor antagonists,
antiparkinsonian drugs, antihypertensives, and anticholinergics) can have a negative
impact on a persons emotional and / or cognitive state and this may be exacerbated
for someone with dementia. The net result of this emotional and cognitive change may
be an escalation of any behaviours of concern.
Inappropriate polypharmacy (the use of multiple medications) further increases
the risk of adverse drug events such as falls, confusion and functional decline.
Therefore, reviewing a persons current medication regimen is an important part of the
assessment process of managing behaviours.
To determine if a medication review is needed, consider

these points:
Is the person on five or more regular medications?
Is the person having more than twelve doses of medications per day?
Has the person had significant changes in their medication regimen during the last
three months?
If you answered yes to one or more of these points, organise a medication review by
speaking to your GP or pharmacist.
Useful resources
Service
Phone number
Website
Medicines Line
Quality Use of Medicines Program
Home Medicines Review (GP refers to pharmacist)
1300 633 424

13 32 54 or 1800 555 254
1800 052 222
www.nps.org.au
www.dva.gov.au
www.commcarelink.health.gov.au
Medicines specifically intended for managing behaviours of concern can
at times worsen the behaviour they are intended to treat
16
Medication reviews should always be done in accordance with

organisational procedures.
Physical Health
It is important to assess a persons physical health status as any health issues can contribute to behavioural disturbances, often in seemingly unrelated ways.
People with dementia are particularly vulnerable to issues with their physical health as they are:
more likely to have age related changes to their health,
less likely to be able to manage their physical health independently, and
less likely to be able to understand and / or communicate their physical health concerns
Assessment of physical health needs to be a comprehensive and holistic screen. Any less than optimal health issues identified should be addressed in conjunction with an
appropriate specialist. Whilst the list below is not exhaustive, please consider how these and other physical health factors present may be impacting on the behaviour.
Bladder & Bowel: incontinence, constipation, diarrhoea, frequency, colour,

odour, infection
Medical history: Chronic and acute issues

Skin integrity: rashes, bruising, redness, swelling, unusual colour
Nutrition / hydration: adequate oral intake, weight gain or loss, inability to eat or
drink independently
Wound: skin tears, ulcers, wound discharge, odour

Pain / discomfort: fidgeting, restlessness; guarding a joint / limb, grimacing, calling
out, groaning
Swallowing / eating: history of choking or aspiration, pocketing of food in cheeks,

excessive chewing
Speech problems: inability to communicate needs
Oral and dental: gum disease, dental decay, ill fitting dentures, bad breath
Sleep: insomnia, daytime napping, nightmares, sleep apnoea
Mobility: recent falls, use of mobility aids, abnormal gait, ill-fitting shoes
Sensory: alterations in vision, hearing, touch, taste and smell.
17
Environment
The combination of the building, floor-plan, fittings and fixtures, furniture, lighting, ventilation, open space, building materials, flooring, acoustics, and more, forms the
environment. The environment can be considered as a passive carer and it plays a critical role in ensuring peoples quality of life is maximised.
A review of the literature on designing physical environments for people with dementia found evidence supporting a number of design considerations (Hammond et al, 2008).
When considering the environments role in the behaviours of concern, the following points are desirable in relieving the behaviours. The environment should:
Be small in size
Have single rooms big enough for a reasonable amount of personal belongings;
Be domestic and home like;
Provide good signage and multiple cues where possible; eg. sight, smell, sound;
Have scope for ordinary activities (unit kitchens, washing lines, garden sheds);
Use objects rather than colour for orientation;
Include unobtrusive safety features;
Enhance visual access, i.e. ensure that the resident can see what they need to see
from wherever they spend most of their time; and
Have rooms for different functions with furniture and fittings familiar to the age and
generation of the residents;
Control stimuli, especially noise.
Provide a safe outside space;
Useful resources
Service
Publisher
Contact
The use of environmental assessment tools for

the evaluation of Australian residential facilities
for people with dementia
Dementia Collaborative Research Centre
www.dementia.unsw.edu.au
Design for People with Dementia: Audit Tool
Dementia Services Development Centre,

University of Stirling
www.dementiashop.co.uk
Dementia-friendly environments: a guide for

residential and respite care
Department of Health, Victorian State Government
www.health.vic.gov.au/dementia
Gardens That Care
DBMAS South Australia
1800 699 799
18
Social / Emotional History

Elements of a persons social history can help explain behavioural disturbance. Vivid memories of traumatic past experiences may be triggered during every day activities, and
the person may have trouble distinguishing between their memories and the current situation.
When you consider the persons behaviour, think about the role that the following elements play:
Cultural Background customs, traditions, language.
Sexuality desires, instincts, preferences, feelings, beliefs.
Life History personal memories, accomplishments, interests.
Interests and hobbies sports, crafts, music, cooking, gardening.
Personality introverted and quiet, loud and gregarious, sense of humour.
Extraordinary life events positive and negative events, war, trauma,

births, deaths.
Spirituality religious beliefs, personal experiences.

Values and beliefs ability to trust others, acceptance of support, moral framework,
respect for others.
Habits and routines early riser, late to bed, breakfast in bed, eating meals outside /
in front of the television, showering.
Social connections and support networks roles within the community, homes
Useful resources
Service
Publisher
Website
Personal Life History booklet
Alzheimers Australia SA
www.fightdementia.org.au
This is Me Life Story Book
Alzheimers Australia Tasmania
19
Communication Approach
Behaviours of concern often occur between the person with dementia and their
carers. Carers in their interactions provide a set of contextual cues and prompts that
influence the person with dementias behavioural response. Identifying and modifying
any aspects of the carers communication style that contribute to the behaviour will
improve the outcome.
For example, a carer who is stressed because the person they are caring for is
repeatedly asking what the time is, will tell the person the time, but will convey their
frustration at the person with dementia by using a firmer tone of voice and perhaps
clenching their fists. The person with dementia will then respond to the actions and
expressed emotion of the carer, instead of the words.
When thinking about the way that carers communicate and interact with the person
with dementia, consider both the verbal and non-verbal aspects.
Non-verbal communication ignoring the words, what message is being conveyed by:
Body language posture (leaning towards the speaker) and gestures
(arm and hand movements)
Facial expression eyebrows (raised or furrowed), jaw (clenched or relaxed) mouth
(smile or frown)
Tone of voice inflection, pitch (low or high), volume (loud or quiet)
Pace of speech fast (excitement / anger) or slow (calm / disengaged)
Eye contact insufficient (disinterested) or intense (threatening)
Approach threatening (startle reaction or the person pulling away) or non
threatening
Verbal communication ignoring the delivery, what message is being conveyed by:
Message complexity the number and complexity of ideas communicated
Word complexity complicated jargon / over-simplification
Useful resources
Service
Publisher
Website
Dementia Education Online
NSW/ACT Dementia Training Study Centre
dementia.uow.edu.au
Help Sheets
Alzheimers Australia
One of the most challenging aspects of caring for a person with dementia
is learning to develop new approaches to communicating
20
Consider both verbel and non-verbel communication when interacting

with a person with dementia
Management Strategies
ReBOC
05
Management
Strategies
Management Strategies
The comprehensive assessments undertaken thus far will give you a greater insight
into the reality of the person with behaviours of concern. From this perspective you
will be able to identify their current physiological and emotional needs, and match
interventions accordingly. Monitoring and evaluating the impact of an intervention is an
integral part of the process.
Physiological & emotional needs

Physiological needs affect emotional states, and will frequently present as behaviours
of concern.
Assess and address the physical needs with the guidelines in the assessment section.
If behaviours persist, the emotional needs of the person with dementia will need to be
addressed with psychosocial strategies to improve the wellbeing of the person.
Well-being
Calm / Happy / Pleasant
Emotional needs
continuum
Ill-being
Anxiety / Agitation /
Aggression
Safe / Secure
Comfort
Unsafe / Threatened
Oriented / Aware
Identity
Disoriented / Confused
Belonging / Attachment
Attachment
Isolated / Lonely
Meaningfully Engaged
Occupation
Over / Under stimulated
Involved / Connected
Inclusion
Ignored / Excluded
Emotions drive all behaviour and all behaviours have an underpinning emotional state.
If you can identify the underpinning emotional state that corresponds to the specific behaviour,
you can target care interventions to meet the emotional needs accordingly.
Choose approaches that best meet identified unmet physiological and
emotional needs
Strategies that take the person with dementias personal life history
into account will have the greatest chance of success
Monitoring and evaluating the impact of an intervention is an integral

part of the process
Management strategies can only partially compensate for the

progressive brain changes in dementia. Set realistic expectations
Pharmacological and psychosocial interventions may be used

independently or in combination
Interventions should focus on maximising well-being and minimising

ill-being.
22
Psychosocial Strategies
There are a broad range of psychosocial strategies of varying complexity available
for use in managing behaviours exhibited by people with dementia. They are most
effective when using an individualised approach, taking into account the persons
history including culture, family, interests and working life. It is beneficial if activities
are meaningful and relevant to the client. A regular routine, allowing for flexibility in
care is often beneficial for clients. A strategy that works one day may not work the
Validation therapy
next; however this does not mean that the strategy is ineffective and that it should not
be used again.
A brief overview of some of the more effective psychosocial strategies has been
provided below. For further information or assistance with implementing any
psychosocial strategies, please call DBMAS on 1800 699 799.
Exercise therapy
Validation therapy is a communication approach that
validates or accept the values, beliefs and reality of the
person with dementia - even if it has no perceived basis
in reality.
Validation therapy can reduce stress and frustration by
accepting the persons reality rather than attempting to
orient them.
Validation therapy relies on validation at a verbal and nonverbal communication level to be effective.
Multi sensory stimulation
Scheduled reassurance therapy (SRT)
Multi-sensory stimulation involves stimulating the primary

senses: sight, hearing, touch, taste and smell. Therapy
includes the use of lighting effects, tactile surfaces,
meditative music, smelling salts.
Multi-sensory stimulation can improve concentration,
alertness and wellbeing of the client.
Be aware that over stimulation can also lead to escalated
behavioural symptoms.
Exercise and physical therapy is the use of movement to

improve physical health and wellbeing.
Exercise has numerous health benefits including social
engagement, improved mobility, reduced risk of falls
and improved quality of life for participants. Examples of
exercises include dancing, tai chi and walking.
Consider physio review and GP review to ensure the
participant is safe to take part in exercise programs.
23
SRT involves brief 1 minute interactions every 30 minutes

consisting of positive social interactions where no nursing/
care tasks are performed.
SRT is replicated throughout the day to reduce agitation
/ anxiety and provide the client with companionship and
increased wellbeing.
Client may become agitated / anxious if the program is not
strictly adhered to. Consistency is the key to success.
Aromatherapy
Spirituality
Aromatherapy involves using essential oils to calm and
relax the client.
Lemon balm and lavender have been researched and
evidence exists for their calming properties mainly in
relation to the management of agitation.
Consult the clients GP and contact an accredited
aromatherapist to conduct sessions with clients as
there may be incompatabilities with existing medical
conditions.
Spirituality relates to the human spirit or soul as opposed

to the physical body. This includes traditional and
alternative beliefs.
Spiritual and religious beliefs and practices can be a
significant source of comfort for people and reduce anxiety
related to uncertainty and fear.
Spiritual beliefs and practices are often of significant
importance to people. Where possible allow people the
freedom to choose to engage with their individual spiritual
beliefs and practices.
Pet therapy
Music therapy
Pet therapy is the use of animals or pets to improve
well-being and quality of life in people with dementia
The use of visiting pet services or staff and family
members pets can reduce anxiety and stress and be
a useful diversional technique.
Animals and pets can be unpredictable. Pet therapy
should always be used under close supervision.
Consider the use of stuffed toys or robotic toy animals
as an alternative to real pets.
Music therapy is the use of music to improve well-being. It

can include listening to music, singing, humming, playing
instruments and swaying / tapping to the beat.
Music therapy can be effective in improving overall quality
of life, reducing a number of behaviours of concern. Using
familiar and favourite music is most successful.
Be sure to learn the likes and dislikes of the person with
dementia. Avoid over stimulation or triggering unpleasant
memories. A registered music therapist can help you
implement a music therapy program.
24
Bright light therapy
Reality orientation therapy
Bright light therapy involves exposure to natural sunlight

or full spectrum artificial light of 2500 lux brightness for
thirty minute periods in the morning and evening. This
helps to regulate a persons sleeping pattern.
Bright light therapy can be effective to reduce sleep
disturbance in people with dementia, including early
morning awakenings and daytime sleeping.
Bright light therapy should always be used within the
proper limits of intensity and time.
Spaced retrieval
Reality orientation therapy is the use of verbal and

environmental prompts (eg calendar clocks) to reorient a
person with dementia to the present.
Orienting a person with dementia to their current context
can assist with their independence and autonomy and
reduce agitation.
The person with dementias reality may not always be the
present. Open communication will allow the person with
dementia to let you know where they are at the moment.
Any signs of distress when using the above tools should
alert you to the fact that this is not the right time or place.
Doll therapy
Spaced retrieval is a training technique used to
assist individuals with impaired memory to retain
information for later recollection. It has been used
successfully with people at all stages of dementia.
The therapy involves beginning with a prompt
question for the target behavior and training the
client to recall the correct answer. When retrieval is
successful, the interval preceding the next recall test
is increased.
Spaced retrieval can improve client function and
independence by enhancing recall of key information
related to specific tasks or behaviours.
It is advised to engage a psychologist or specialist
trained in spaced retrieval to maximise the likelihood
of success.
Doll therapy is a diversional intervention that provides

people with dementia an opportunity to interact with
a life-like baby doll in a manner that is therapeutic
to them.
Doll therapy can reduce agitated behaviour and
improve quality of life for people with dementia through
an opportunity to express their emotions; meaningful
communication through interacting with and talking
about the baby doll; and a sense of role and purpose.
Doll therapy can be seen as age-inappropriate.
Organisational policies and guidelines should be used
in conjunction with staff training on doll therapy.
25
Simulated presence therapy
Dementia Friendly Environment
Simulated presence therapy is the use of pre-recorded

audio or video loops for playback to simulate and
stimulate a conversation between the person and
the recording.
Simulated presence therapy can provide meaningful
occupation and can be used to alleviate boredom or
prevent / reduce agitated behaviour.
If the person with dementia no longer recognises the
voices or people this could be upsetting for them.
Always assess for a positive reaction and do not
persist if the person becomes unsettled by the voices
or pictures. Do not use simulated presence therapy to
replace other activities that the person is interacting and
engaging with.
26
Dementia friendly environments are those that have been

modified or purposefully designed through the application
of design principles that consider the needs of people
with dementia.
Dementia related behaviours can be prevented by creating
physical and built environments that are: self orienting;
compensate for disability; engage the local community;
maximise independence; demonstrate care for staff; and
reinforce personal identity.
When creating dementia friendly environments remember
that homelike is different for each individual person
with dementia.
Pharmacological Strategies
Evidence for the efficacy of drugs is limited and the risk of adverse effects is
significant (including death with antipsychotics). Behaviours that respond poorly to
medication include disruptive vocalisations, shouting, wandering, pacing, repetition,
cognitive deficits, incontinence, voiding inappropriately, insomnia and withdrawal.
Psychotropic medicines have a modest effect on dementia related behaviours overall,
but medicines that specifically target depression or psychosis have greater efficacy.
Informed consent from the person or their guardian must be obtained prior to
medication commencement.
Classes of medicines used in behaviour management include antipsychotics,
benzodiazepines, anticholinesterases, N-methyl-D-aspartate (NMDA) antagonist,
anticonvulsants and antidepressants.
Medication review
Commencing medication
Monitor closely when starting medication or increasing the dose to ensure

the target behaviour improves and that adverse effects are tolerated
Review the need for continuing antipsychotic therapy within 3 months and
regularly after this. Withdrawing antipsychotic treatment may not worsen
behaviour, provided it is done gradually.
There should be specific monitoring of side effects such as drowsiness,
restlessness, limb stiffness, reduced mobility, abnormal involuntary
movements (e.g. tremor, abnormal mouth movements) and postural
hypotension (dizziness on standing)
Involving a medical specialist in prescribing and/or reviewing medications
is highly recommended.
Start any new medication at the lowest possible dose

Only start one new medication at a time if there has been no benefit after
2-3 weeks, the dose could be increased gradually
Any increase in dose should be small and made slowly
Use an antipsychotic only if aggression, agitation or psychotic symptoms
cause severe distress or an immediate risk of harm
Non-pharmacological interventions should continue to be used in
conjunction with any pharmacological therapy.
Only commence drug treatment for BPSD once physical causes have been addressed and the behaviours
have not responded to non-pharmacological strategies.
Side-effects and drug interactions need to be considered prior to prescribing
It may be necessary to wait several weeks before efficacy can be assessed
There should be careful monitoring and documenting of adverse effects and intended benefits
27
Additional Help / Resources

Useful resources
Service
Description
Contact
DBMAS
The Dementia Behaviour Management Advisory Services provide assistance to carers of

people with dementia who have behaviours of concern
The Dementia Collaborative Research Centre conducts dementia research with the primary
aim to translate research into practice
DOMS provides dementia assessment tools for health professionals
Lifeline is a volunteer based service which offers generalist counselling and is available
24 hours 7 days a week.
The National Dementia Helpline provides understanding and support for people with
dementia, their family and carers as well as details of the full range of services provided by
Alzheimers Australia. They also provide practical information and advice as well as up to
date written material about dementia
This number can provide information on a range of aged care services and supports
available nationally and in your local region. Coordination and advice can also be provided
to access respite services, counseling and emotional support for carers.
The National Continence Helpline is an information and referral telephone service for
people with incontinence and their carers.
Health Direct Australia is a 24 hour telephone triage information and advice service for
residents of the ACT, NSW, the NT, SA, Tasmania and WA.
Medicines Line providing consumers with information on prescription, over-the-counter and
complementary (herbal/natural/vitamin/mineral) medicines.
Poisons Information Centre provide emergency medical advice on what to do if someone
has swallowed or been exposed to a poison, whether by accident or intentionally.
The Aged Care Complaints Investigation Scheme investigates complaints and concerns
about Australian Government-subsidised aged care including residential (hostel or nursing
home) and community care.
The aim of the Dementia Training Study Centres is to improve the quality of care and
support provided to people living with dementia and their families through the development
and upskilling of the dementia care workforce and the transfer of knowledge into practice
1800 699 799
Dementia Collaborative Research Centre

Dementia Outcomes Measurement Suite
Life Line
National Dementia Helpline (Alzheimers
Australia)
Aged Care Information
Continence information line
Health Direct Australia
Medicines Line
Poisons Information Centre
Aged Care Complaints Investigation Scheme
Dementia Training Study Centres
28
www.dementia.unsw.edu.au
www.dementia-assessment.com.au
13 11 14
1800 100 500
1800 200 422
www.agedcareaustralia.gov.au
1800 330 066
1800 022 222
1300 633 424
131 126
1800 550 552
www.dtsc.com.au
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31

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ReBOC

Reducing Behaviours Of Concern

Dementia Behaviour Management Advisory Services

(C) 2012 Alzheimers Australia SA Inc

Quickly identify whether the behaviours are creating

Understand the relationship between the brain,

Identify and address behaviours related to delirium

Undertake a comprehensive review of factors

How to use this guide

Understand the guiding principles for behaviour

Raised voice / angry tone

Brandishing weapons / raised

Assess the impact on safety: Is anyone at risk?

If safe, attempt to diffuse the situation using non-pharmacological approaches

Stop any interaction that infringes on their personal space

Raised voice / angry tone

Pacing back and forth /

Follow the steps in this manual

Pacing back and forth /

Dementia Behaviour Management Advisory Services 1800 699 799

What are behaviours

Dementia with Lewy Bodies

Repetitive actions or questions

Resistance to personal care

Sexually inappropriate behaviour

Alcohol related dementia.

Refusal to accept services

Most people with dementia are older

Problems associated with eating

Socially inappropriate behaviour

Dementia Behaviour Management Advisory Services 1800 699 799

The brain and behaviour

Dementia Behaviour Management Advisory Services 1800 699 799

The brain and behaviour

The frontal lobe is

The parietal lobe processes

The temporal lobe plays

The occipital lobe separately

The limbic system has a

Dementia Behaviour Management Advisory Services 1800 699 799

Models for understanding behaviour

Antecedents > Behaviour > Consequences.

Dementia Behaviour Management Advisory Services 1800 699 799

Models for understanding behaviour

Progressively Lowered Stress Threshold

Dementia Behaviour Management Advisory Services 1800 699 799

Delirium risk factors:

Hepatic or renal dysfunction

1. Conduct baseline cognitive

Assess & manage risk factors

2. Determine any changes in

Has this change occurred over hours or days?

For further information on delirium, please read Delirium Care

Assess for depression or dementia

Consider the use of this pathway if the person is aged over

Has the patient/client been identified as potenially suffering from delirium?

Adapt Care Plan

3. Assess for Delirium

4. Consider sub-clinical delirium

Does the patient/client have some

Refer to GP or specialist for treatment

Delirium, an acute confusional state, can compound the

Refer to Delirium Care Pathways

5. Monitor and respond to any sudden