MDS Alert

This approach works whether residents are cognitively impaired or not.

What might screaming, hitting,weeping, and refusing staff requests have in common?

The behaviors may all be serving the same underlying function for a particular resident, says Michael Partie, principal of Therapeutic Options in Newark, Del. And if you can figure out what that is, you're well on your way to coming up with an effective behavioral care plan.

Possibilities: Perhaps the person is "trying to control his environment or to make himself feel safe," Partie suggests. Or he may be trying to make people interact with him or go away when he becomes stressed or fatigued, he adds. "Even a person with serious cognitive impairments will try to order his world as best he can within his understanding of his world," Partie says.

To identify the motivation underlying certain behaviors, consider using an A-B-C assessment and charting format to identify patterns that may elude you otherwise. B stands for the behavior, which you observe and document when it occurs, Partie explains. You also record the antecedent (A) which is what happened immediately preceding the behavior.

Also note the consequence (C) of the behavior. For example, asks Partie, "did a lot of people come running? Did staff express concern or frustration? Did staff or other residents leave the person alone? Analyzing patterns of antecedents and consequences in relation to the person's behavior helps us understand how the behavior works for the person -- what purpose it serves," he says.

Also take a look at what Partie calls "contextual variables" or "setting events," which can help you  assemble the big picture. For example, "do the behaviors happen following stimulating activities or during transitions between environments or activities? Who is always present during these incidents? Who is never associated with these events?" Partie asks.

Identifying the ABCs and context of the person's behavior helps the interdisciplinary team develop strategies to support the resident and ease his distress.

Example: Suppose you notice that a person "gets surly and uncooperative following a big social activity," says Partie. "The behavior may indicate fatigue or over stimulation." The intervention in that case may be to alter the activity's duration or scheduling of care. 

Perhaps the person's blood sugar is low when he attends a late afternoon activity. And if the staff gives him something to eat during the activity, he may be "more biologically prepared to do a socially demanding task," Partie says. Or "perhaps the resident is someone who ruminates all day when he has an argument with his roommate in the morning. And then he explodes in a group activity later in the day."

Beware: Staff can unwittingly instigate or reinforce certain behavioral patterns. One real-world case where that happened involved an elderly resident with dementia and morbid obesity who had been a model in the World War II era, relays Dee Kostolich, RNC, CRNAC, CLNC, principal of D.R.Kostolich & Associates LLC in Massillon, Ohio.

The woman had a habit of soothing herself by eating chocolates. "The facility, in agreement with her POA, attempted to place her on a weight loss program that included appealing nutritious snacks," explains Kostolich. But when the resident demonstrated socially inappropriate behavior, the staff found that giving her chocolates quickly calmed her down. As a result, the woman's acting out escalated, Kostolich says.