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Section 2
Assess Communication Behavior in Dementia

Question 2 | Test | Table of Contents

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In the last section, we discussed positive interaction techniques which can be used by the caregiver of an elderly person with Alzheimer’s.  Included in this section are four basic rules for positive interactions.  The four basic rules for positive interactions discussed in this section are stay pleasant, calm, and reassuring, help maintain self-esteem, use simple sentences, and use nonverbal clues.

In this section, we will discuss managing difficult behaviors.  This section will focus on analyzing behavior and managing behavior problems.  In order for the caregiver to continue with an ongoing assessment of the patient’s Alzheimer’s and associated behavior, the following five steps may be useful when analyzing behavior. 

These five steps regarding analyzing behavior are deciding if the behavior is a problem, what the problem really is, with whom the problem occurs, where the problem occurs, and when the problem occurs.  As you listen to each step for analyzing behavior, consider the approaches used to manage specific behaviors.  You might think of how you can adjust and apply the ideas to benefit your client.

5 Steps to Analyze Behavior

♦ Step #1 -  Is the Behavior a Problem?
First, the caregiver can decide if the behavior is a problem.  Some behaviors are not dangerous and can be easier to live with than to challenge.  The following questions can help a caregiver determine if the behavior is a problem.  As I list these questions, consider playing this section for the caregiver of your client.

  1. Is the behavior harmful to anyone?
  2. Does the behavior keep the client from doing other things that might satisfy him or her more, given the stage of Alzheimer’s?
  3. Does the behavior keep the caregiver from functioning?

If the behavior is not actually a problem, then a general approach could be for the caregiver to take a deep breath and remind themselves that they must pick their battles and redefine their idea of success regarding interactions with and the behavior of the client.  If the behavior is a problem, the caregiver can continue to analyze the problem, trying various approaches. 

♦ Step #2  What Is the Real Problem?
Second, the caregiver can decide what the problem really is.  Do you agree that several problems can have a root cause which, once eliminated or solved, fixes the other problems?  For example, Maria’s husband, Ralph, age 76, had been diagnosed as having a 97 percent chance of Alzheimer’s disease.  Ralph enjoyed spending time outside, but Maria hated it when Ralph went out.  Ralph would pace in the garden, subsequently trampling Maria’s flowers. 

Maria stated, "He doesn’t even seem like he’s aware that the flowers are there when he starts pacing."  Clearly, the basic problem was not that Ralph tramples the garden, but rather his pacing was the problem.  I stated to Maria, "Ralph’s pacing is not a problem in itself.  Can you find or create a different place for Ralph to pace?  A place away from the garden, perhaps." 

Other general approaches that can be used to decide what the problem really is include studying the problem and asking for someone else’s perspective.  Do you agree that sometimes the root problem cannot be discovered in more complex situations?  I have found that in cases regarding an undiscovered root problem, solutions can still be found by trying different approaches one by one.

♦ Step #3  With Whom Does the Problem Occur?
In addition to deciding if the behavior is a problem and deciding what the problem really is, the third step I use in analyzing behavior is to decide with whom the problem occurs.  Does the problem only occur with you, only when others are around, or only when other specific people are present?

♦ Step #4  Where Does the Problem Occur?
In the case of Herb’s wife, Esther, age 81, the fourth step implemented in analyzing behavior was to focus on where the problem occurred.  As you are well aware, the physical environment affects behavior in clients suffering from Alzheimer’s.  Esther used to love to garden, but through the progression of her Alzheimer’s, she began to dislike leaving the house.  Herb was concerned that Esther didn’t join him in the garden because was afraid to leave her alone in the house.  As you may already know, Esther was afraid of the outdoors because she felt exposed and unprotected there. 

Have you found that clients with Alzheimer’s commonly react this way to open areas?  With Esther, glare, low light, wind, and temperature differences contributed to her sense of being in a strange place.  I stated to Herb, "Esther cannot understand and adjust to an environment that is distressing her.  Whenever possible, try to change the environment to suit her."  As you listen to the environmental changes Herb utilized, decide if you can adapt them to allow the caregiver of your client to manage environmental problems. 

Herb stated, "So Esther could feel safer outside, I painted the edges of the door bright yellow.  I thought maybe she could see it more clearly that way.  Sometimes I could point to the door and reassure her that we weren’t far from home.  That didn’t work all the time, so I built an awning over the patio.  Now Esther stays there when I garden.  She likes it.  I think having a roof over her head makes her feel more comfortable." 

Think of your Esther.  How could he or she benefit from caregiver management of the environment? 

♦ Step #5  When Does the Problem Occur?
In addition to deciding if the behavior is a problem, what the problem really is, with whom the problem occurs, and where the problem occurs, the fifth step used in analyzing behavior is deciding when the problem occurs.  For example, Parker’s mother, Helen, age 79, used to be alert and happy in the morning and that’s when she would take her baths.  Suddenly, Helen began resisting and finally refused to bathe.  Parker noticed dark circles under Helen’s eyes, so he had her checked for illness.  Helen had no fever or other symptoms, so Parker decided to check on her more at night. 

Parker stated, "I stayed up, listening for any signs of her activity.  It was pretty late when I heard her in there fooling around.  Turns out she was rummaging through her drawers and closets all night, not sleeping.  That’s why she didn’t want to bathe in the morning.  She was too tired!" 

I stated to Parker, "You may consider assessing Helen’s routine and adjusting it to suit her better.  During the evenings, keep her routine consistent, don’t expect her to do anything difficult or stressful, and reassure her that everything is okay.  Soothing music and easy activities she enjoys may help Helen."  Do you agree that problems with clients may become worse if they have nothing to do?    How could analyzing behavior benefit the caregiver of your client? 

In this section, we discussed analyzing behavior.  In order for the caregiver to continue with an ongoing assessment of the patient’s dementia and associated behavior, the following five steps are useful when analyzing behavior. 

These five steps regarding analyzing behavior are deciding if the behavior is a problem, what the problem really is, with whom the problem occurs, where the problem occurs, and when the problem occurs.  Would playing this section in a session be beneficial for the care giver of a client of yours whose family member has been diagnosed with Alzheimer’s?

In the next section, we will discuss catastrophic reactions.  Three methods may benefit a caregiver regarding dealing with a client’s catastrophic reactions.  These three methods for dealing with catastrophic reactions are avoiding catastrophic reactions, preparing for catastrophic reactions, and managing catastrophic reactions.
Reviewed 2023

Peer-Reviewed Journal Article References:
Gather, J., & Vollmann, J. (2015). How to decide? Evaluating the will of a person with dementia in the light of current behavior, advance directive and legal representatives’ perspectives. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 28(1), 17–20.

Kuemmel, A., Haberstroh, J., & Pantel, J. (2014). CODEM instrument: Developing a tool to assess communication behavior in dementia. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 27(1), 23–31. 

Martin, K., Lang, F. R., Rupprecht, R., & Nömer, J. (2021). Dementia worry and the perception of personal risk: A longitudinal study. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 34(1), 23–30.

Maxfield, M., & Greenberg, J. (2021). Anticipated stigma and dementia-related anxiety in middle-aged and older adults. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 34(1), 13–22.

Maxfield, M., Cui, R., Roberts, J. R., & Fiske, A. (2021). Interest in dementia testing: Family history, dementia-related anxiety, and coping. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 34(1), 5–11

Robitaille, A., Garcia, L., & McIntosh, C. (2015). Joint trajectories of cognitive functioning and challenging behavior for persons living with dementia in long-term care. Psychology and Aging, 30(3), 712–726.

QUESTION 2
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