Online Coverage from the 150th Annual Meeting
of the American Psychiatric Association
May 18 - 21, 1997
© 1997 Medscape, Inc.

Behavioral Techniques for Reducing Agitation and Violence in Patients with Dementia

Speaker: Linda Teri, MD
Reporter: Catherine Birndorf, MD

Introduction

Are psychosocial treatments for violence and agitation important when working with dementia patients? Dr. Linda Teri, Professor in the Department of Psychiatry and Behavioral Science at the University of Washington School of Medicine, says "yes," emphatically. In a clear, thoughtful and practical fashion, Dr. Teri presents a non-pharmacologic, behavioral approach to treating agitation and aggression in patients with dementia. She notes that, in the absence of ideal pharmacotherapies for aggression, psychosocial interventions for agitation or violence are at least as important, if not more so, than pharmacologies alone. Dr. Teri makes understanding such psychosocial treatment as simple as A-B-C.

Environment as a Cause of Violence and Agitation

According to Dr. Teri, "patients engage in agitated and violent behavior in direct and indirect response to their environment." That environment encompasses both physical and interpersonal components. Understanding both the patient and the caregiver responses within this environment, and modifying the physical and interpersonal factors, can greatly reduce agitated and violent behavior.

For example, Dr. Teri emphasizes employing good communication skills to improve the interpersonal environment. In any interaction with the patient the caregiver should:

allow ample time for listening and responding;
communicate clearly both verbally and visually;
be at eye level with the patient while communicating; and
provide clues and suggestions, using language modified to meet patient's needs.

Minimizing both visual and auditory distractions can also greatly decrease potential agitation and violence. Dr. Teri suggests experimenting with lighting, removing unnecessary objects that clutter the visual environment, and making sure that background noises are kept to a minimum.

Why should caregivers go to this extra level of effort when there are already onerous demands on their time and attention? Which staff should be involved in behavioral therapy? All caregivers, both physicians and allied health professionals are essential to good patient care. Understanding the patients' problems, within the context of Dr. Teri's behavioral model, helps each caregiver more effectively solve problems, manage day to day difficulties, and prevent agitation and violent responses.

ABC's of Behavior Management

The ABC's of Behavior Management is the model Dr. Teri' used to guide caregivers in treating agitated and violent demented patients. 'A' is the antecedent: or the triggering event that precedes the problem behavior. 'B' is the behavior itself. 'C' is the consequence of the behavior which reinforces and maintains the behavior.

Dr. Teri illustrated her behavioral technique with an example of a loud, irritated caregiver trying desperately to feed a soon-to-be-agitated older demented woman in a room filled with people, resonant with loud noises, and the table with the patient's food is cluttered with other objects. By modifying the environment, both physically (removing clutter and engaging in feeding at a less crowded time ) and interpersonally (caregiver softening her voice and attitude), the patient evidenced less agitated behavior and was able to eat more calmly. Thus, the antecedent (caregiver's tone and stressful environment) was identified, and the problem behavior (agitation and potential violence) was consequently mitigated.

The process of modifying the environment to reduce the antecedents of violence is not always so simple, however. For those more difficult, or less obvious scenarios, Dr. Teri describes five steps to behavior analysis and management.

First, define and observe the problem behavior (B). What is this behavior, and when and where does it occur? Who does it happen around and where does it happen most?

Second, identify what happens before and after the problem (A and C). What might have triggered the behavior and what happened after the behavior? How did others react?

Third, plan your intervention, and if you can identify (A), that's even better, since prevention is the best intervention. For successful intervention, Dr. Teri suggests starting with small, achievable goals and trying to anticipate potential problems.

Fourth, implement the plan.

Fifth, evaluate and modify the plan so that strategies can be assessed and revised to fit the individual situation.

Application Examples

To illustrate how these strategies can be applied, consider the examples of catastrophic reactions and paranoia/suspicious behavior. Catastrophic reactions. Catastrophic reactions, or overexpressed responses to the environment, often have identifiable antecedents, such as asking the patient too many questions at once or criticizing the patient. Minimizing such stimulus cues, for example, by speaking more slowly or softly, can yield a less aggressive response.

Effective responses to catastrophic reactions would be to soothe and empathize with the patients, distract or redirect them, or remove them from the conflicting scene.

Paranoia. Common antecedents for paranoia/suspicious behavior include sensory deficits or over stimulation, unexpected changes in daily routines, or boredom. Minimizing stimulus cues in this case may include increasing the amount of light, providing reassurance, keeping changes to a minimum, and sticking to a daily routine.

Effective responses to paranoia/suspicious behaviors include redirecting or distracting the patient, and reassuring the patient, both verbally and with physical touch if appropriate.

Conclusion

Guiding caregivers in behavioral techniques can help them to better understand and treat their patients. Additionally, helping caregivers cope with the stress of their jobs is also important for improved patient care and better job satisfaction. Dr. Linda Teri's continued efforts to develop, implement and evaluate behavioral models in simple-to-understand terms provide the potential for non-pharmacologic treatment in the difficult arena of agitation and violence among patients with dementia.

References

Teri L, Logsdon R. Assessment and management of behavioral disturbances in Alzheimer's disease. Comprehensive Therapy 16(5) 36-42. 1990
Khachaturian ZS, Radebaugh TS. Alzheimer's disease: Cause(s), diagnosis treatment, and care. New York. CRC Press, Inc. 1996.