Reducing and managing behaviour that challenges

Read about how to manage situations where a person’s behaviour changes.

There are many possible reasons for behaviour that challenges. Sometimes, the behaviour happens in phases and stops over time. It can often be managed by recognising and responding to the person’s needs. However, there may be times when changes in behaviour happen very suddenly, and you may need support from professionals.

Managing sudden changes in behaviour

Sudden changes in behaviour are often caused by a physical health problem such as constipation, pain or urinary tract infection – especially when the person seems to be more agitated, confused or distressed.

If you notice a sudden change, it’s always a good idea to ask the person’s GP to visit. They can check for any physical problems, and arrange any necessary tests such as blood or urine tests. Ask the doctor to review all medication the person is taking, including any non-prescription drugs.

If the GP rules out health problems as a cause, they may refer the person to a mental health team. Mental health conditions such as depression may also contribute to changes in behaviour. These can often be managed with medication or with non-drug approaches.

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Think of the person’s point of view

Always try to see things from the person’s perspective. People with dementia can sometimes find it hard to understand what’s going on around them. This can be confusing and frightening for them. You might not understand their behaviour, and this can be frustrating for you. But the behaviour will often have meaning for the person with dementia.

Think about what you know about the person and their life. For example, if you know someone used to work night shifts, it might explain why they want to stay awake or go out at night.

It’s likely that they’re trying to stop feeling distressed and to feel well again. The behaviour may be the best way for them to communicate what they want or to help themselves feel better.

Be aware of the person’s beliefs and thoughts and try not to argue with them. For example, if they believe they need to go and collect their children from school, don’t tell them they’re wrong. Instead ask them to tell you more about their children, or move their focus onto an activity.

Managing wellbeing

Always think about what you know about the person and what works best for them. The person is likely to respond to your behaviour and communication, so if you’re frustrated or angry it may make things worse. For example, if they are repeating questions, try to be patient and sensitive towards them. They may not know that they have repeated themselves and may notice if you seem impatient, which might distress them.

If the person behaves rudely, don’t attempt to argue or correct the behaviour. Offer them gentle reassurance, or try to distract their attention.
 
Other tips for managing the person’s wellbeing include:

  • Spend time with the person. This could be having a cup of tea and a chat with them. You could do an activity like playing a game or preparing food together, or keep close to them when you have tasks to carry out. For example, you could be ironing while the person listens to the radio. Being with the person can help them feel reassured and comforted. If you’re unable to meet, then phone or video calls can be a good way to spend time with the person too.
  • Think about how the person has coped with situations in the past. This may affect how they deal with things now. For example, a person who has always been anxious may become more anxious about things now that they have dementia.
  • Think about how they are feeling, what they are trying to express, and how you can support them emotionally. Even though a person with dementia may have problems with their memory, they still feel and respond to emotions. If they forget an event that happened earlier in the day, they may still feel the emotions of it later. It can help to respond directly to how the person is feeling (for example, by saying ‘I can see that this is difficult for you’).

Antipsychotic drugs

Antipsychotic drugs often used to be prescribed to people with dementia if they showed behaviour that challenges. However, most of these drugs have limited or no benefits for people with dementia, may not treat the cause of changes in behaviour and carry serious risks and side effects.

Antipsychotic drugs should only be prescribed by a doctor as a last resort if other treatments have been tried and didn’t work. They should only be used if the person’s behaviour is persistently causing them severe distress or putting them or others at risk of physical harm. Even then, they should be used alongside non-drug approaches based on the person’s needs.

If antipsychotics are used, the doctor should monitor how they’re affecting the person. Treatments should be reviewed after six or 12 weeks, or both. 

Steps for managing behaviour that challenges

It may be helpful to manage behaviours by looking at them in steps. A professional (such as a dementia specialist nurse or a dementia support worker) can help you to follow the steps below.

1. Identify the problem

  • Is it the behaviour of the person that is causing the problem?
  • Is the problem the reaction or attitudes of other people?
  • Is the person’s living situation or environment causing a problem?
  • What are the other factors? Is the person trying to communicate a need, for example that they are in pain, bored or thirsty?

2. Look at the situation

It can be helpful to keep a diary of the behaviour and the circumstances around it:

  • When and where does the behaviour happen?
  • Does the person always behave in the same way in the same place?
  • Does it always happen with the same person or in similar circumstances?
  • Who are the other people involved? For example, they may be visitors, a family member, or a friend.
  • Look for patterns in the behaviour. For example, is there a common theme to their questions?
  • Look for triggers for the behaviour. Recognising these may help you prevent the behaviour from happening again. For example, if someone behaves in a sexually inappropriate way when you help them to get changed, they might be misinterpreting your actions. Changing how you approach this situation could help.

3. Consider how the person is feeling when they behave this way

Respond to the emotions the person with dementia is showing. Do they seem to be:

  • tired, getting too much stimulation, scared, anxious or frustrated?
  • embarrassed, ignored, misunderstood, feeling patronised?
  • depressed or having delusions or hallucinations?
  • bored, under-stimulated, lacking in social contact?
  • in an environment that makes them feel uncomfortable – for example, is it too hot or cold?

4. Identify anything the person could be reacting to

Use what you know about the person to think about whether they could be reacting to:

  • their awareness that they can no longer do something they used to enjoy
  • something unpleasant happening
  • something they dislike or are scared of
  • change, for example a new carer or living environment
  • a memory
  • being provoked, or a conflict with someone’s personality.

5. Develop a strategy

Talk to the person with dementia and the people they spend time with to come up with a plan.

Start to make some changes and see whether they make a difference to the person’s behaviour. You will likely need to try different things and find what works. For example, you could change the way you talk to the person when you’re providing personal care or helping them do something. Also consider making changes to the environment. Focus on what is in the person’s best interests, and what particularly helps to support them as an individual.

It’s important to be consistent. If possible, make sure that everybody supporting the person uses the same strategy, especially in care homes and hospital settings where the person may be supported by different carers at different times.

6. Keep a record

The changes you make might not work every time. Try not to be disheartened if this happens. Sometimes an approach needs to be tried several times to see whether it is helpful, and if not, another approach can be considered.

It can be useful to keep a record of what works, even if it doesn’t work every time. You can then share this with others who might look after the person, such as family members or friends, or health or social care professionals. It can be added to the person’s care notes.

Reducing and managing aggressive behaviour

See further tips for managing aggressive behaviour.

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