Behaviours of concern

1. Reduce risk:
   • Remove resident/s from danger
   • Remove potentially harmful objects if safe to do so
   • Reduce environmental noise and distractions & give the person space (stand back)
2. Review resident's behaviour support plan:
   • Where the behaviour is addressed by the plan, follow the plan of action
3. Verbal de-escalation:
   • Use a calm, gentle voice with a respectful tone and a slow, even speed
   • For non-English speaking residents assign a staff member who speaks the language or involve family / friends if appropriate;
   • Engage family, as appropriate, to identify unmet needs and support positive behaviours
   • Use eye contact consistent with the person's cultural needs
   • Use the resident's preferred name
   • Use simple sentences without patronising
   • Communication should promote the resident feeling valued and respected
   • Do not attempt to reason or argue

Perform & document assessment of the behaviour, including:

1. Description of the behaviour in clear, non-emotive terms.
2. A holistic assessment to identify the antecedent or activating event for the behaviour - this assessment should extend beyond the "observable" antecedent and involve assessment of the resident and their environment in collaboration with usual carers, GP, and family;
   **Behaviours are often a way for residents to communicate their unmet needs**
3. What was the consequence of the behaviour for the resident; what did staff do and how did the resident respond? Were others affected by the behaviour? What are the maintaining factors of the behaviour?
4. Use the below assessments to identify the function of the behaviour for the resident and use this understanding to
   guide development (or modification) of the individualised behaviour support plan.

P - PHYSICAL assessment (with GP)

1. Pain - assess using a cognition-appropriate tool, treat and address underlying cause.
2. Toileting needs - urinary retention, constipation.
3. Acute illness - e.g. infection, acute injury or wounds, post-ictal behaviour, hypoglycemia.
4. Delirium - perform Confusion Assessment Method (CAM).
5. Polypharmacy - community pharmacist review for potential interactions, dosage, adverse effects.
6. Hunger or thirst.

I - INTELLECTUAL assessment

1. Dementia related cognitive changes e.g. short-term memory loss, orientation, lack of insight.
2. Loss of ability to communicate needs effectively e.g. expressive or receptive aphasia.
3. Loss of ability to initiate, sequence and complete motor tasks or apraxia.

E - EMOTIONAL assessment

1. Are there neurovegetative signs of depression (recent changes in sleep, appetite or motivation) - perform Neuropsychiatric Inventory (NPI) and Cornell Scale for Depression in Dementia.
2. Does the behaviour seem driven by psychotic features e.g. false beliefs or hallucinations - perform NPI.
3. Assess for evidence of grief or loss e.g. loss of spouse, roles, home, independence.
4. History of treatment for mood, anxiety or psychotic disorders especially if specialist psychiatrist involved or past history of self-harm or suicide attempts?
5. Have there been thoughts of suicide or self-harm or acts of deliberate self-harm or attempts at suicide?

C - CAPABILITY assessment

1. Undertake a resident capability assessment - is there a change to usual abilities?
2. Is the resident receiving support to maximise capabilities?
3. Is the resident being provided meaningful activities?

E - ENVIRONMENTAL assessment (consider social and physical environment)

1. Assess physical environment at time of behaviour for evidence of over- or under-stimulation: noise, temperature, smell, number of people, restrictions to movement, people / staff present.
2. Has there been a recent change to environment or routine?
3. Assess social environment: social isolation, meaningful contact, invaded personal space, interactions of other residents & staff with resident at time of behaviour.

S - SOCIAL SELF (consider cultural, spiritual and life story)

1. Review persons life history - are there any contributors from their life-experience e.g. traumas?
2. Cultural contributors to behaviours? E.g. language barrier with secondary frustration.
3. Are resident's personal preferences being addressed?
4. Are family relationship's stable?
5. Are staff interactions with the resident undertaken with a supportive approach?

Develop (or review, and update where indicated, existing plan), document & implement an individualised behaviour support plan (in collaboration with the resident, their family, their restricted practices decision maker, staff and the GP) - ensure that the plan includes strategies and objectives and addresses the resident's human needs, including:

1. Physical, intellectual, emotional, cognitive, environmental and social needs including: any assessments or
   investigations required to further evaluate these needs; known triggers that precede behaviours.
2. An individualised behaviour support plan to prevent / target behaviours or symptoms.

Non-drug, person-centred care approaches should be the mainstay of a behaviour support plan, with strategies to:

1. Use a resident's preferences and life history to guide activities and avoid boredom.
2. Provide guidance to staff on:
   • Communication styles and interactions that avoid the aggressive behaviour
   • How to provide care in a manner that will prevent aggression e.g. individualised care based on understanding resident's preferences for daily cares such as preferred timing of cares, water temperature for bathing etc.
3. Avoid over- or under-stimulation and known triggers for behaviours (where clinically appropriate).
4. Use social interactions to engage residents and assist them to build meaningful relationships.

Where restrictive practices are included in the Behaviour Support Plan:

1. They are used as a last resort.
2. They encompass the least restrictive practice possible.
3. Their use is necessary and proportional to the risk of harm.
4. They are used for the shortest time possible.
5. Ensure documentation of the name of the resident's restrictive practices decision maker and the type of restrictive practice to which the appointed decision maker relates.

Providers should ensure that legislated requirements are fulfilled in relation to use of restrictive practices, If you have not received training and support to implement a resident's behaviour support plan, discuss with your facility clinical care manager. Dementia Support Australia may support providers with education or clinical support.

Non-drug, person-centred care approaches include:

1. Non-drug strategies outlined in a resident's existing behaviour support plan.
2. Verbal de-escalation.
3. Distraction techniques.
4. Assess for and address resident's unmet needs:
   • Pain - assess using a cognition appropriate pain assessment tool
   • Hunger
   • Need to toilet
   • Lack of privacy
   • Lack of meaningful activity / boredom
   • Communication or social needs
5. Multi-component interventions tailored to the person's primary behaviours: therapeutic use of music or reminiscence therapy may assist with a wide array of behaviours; for anxiety / depression it may be
   of additional benefit to provide support and counselling; for agitation, consider additional use of massage or behavioural management interventions.
6. Montessori activities supporting independence through meaningful activities and environmental cueing.
7. Animal assisted therapy.

Dementia Support Australia may support providers with education or clinical support.

• Non-drug approaches should be the mainstay of management. Review prior history and determine whether there have been previously effective management strategies utilised - note: ALL residents with cognitive impairment / dementia should have a behaviour support plan established to prevent and manage acute behavioural disturbance; use of psychotropic medications to manage behaviours of concern is considered a restrictive practice - where used, ensure use is a last resort and that relevant legislative requirements are adhered to.
• Review existing medications for contributors to behaviours of concern: Anticholinergics (e.g. oxybutynin), ranitidine, promethazine, anti-epileptics, Levo-dopa, dopamine agonists, opioids, psychotropics, corticosteroids, antibiotics, antivirals.
• Where there are unmet needs contributing to the behaviours, ensure these are appropriately managed before consideration of use of specific pharmacological therapies for behaviours (e.g. treat pain, treat underlying depression, modify environmental contributors).
• Effectiveness of medications in behavioural symptoms of dementia is low and there is increased risk of mortality
  with psychotropic or sedative medications.
• If non-drug methods are exhausted in management of agitation or aggression and the symptoms are severe, dangerous and / or cause significant distress to the resident, consult resident and their restrictive practices substitute decision maker and the resident's GP to consider a short-term trial of:
  • Risperidone commence at 0.25mg orally twice daily, gradually increasing if needed by 0.25 mg every 2 or more days to maximum 2mg daily (divided into 2 doses)
    OR
  • Olanzapine 2.5mg orally daily. Where indicated, gradually increase by 2.5mg daily every 2 or more days to a maximum of 10mg daily (divided into 2 doses)

Note: specific populations where specialist input may be warranted include those with:

• Parkinson disease or Dementia with Lewy bodies - seek geriatrician or psycho-geriatrician input
• On a palliative pathway, where alternate approaches may be indicated - seek specialist palliative care input

Prior to commencement of psychotropic medications for behaviours of concern:

1. Obtain and document informed consent for the medication to be used (including discussion of risks and benefits relevant to the resident's individual circumstances) and for the use of the medication as a chemical restrictive practice from the relevant substitute decision makers; the name of the substitute decision maker and what they are authorised to consent for on behalf of the resident should be documented.
2. With GP, document a plan for:
   • Monitoring (for effect on behaviours and adverse effects) and
   • Review of ongoing requirement for the medication

• Dementia Support Australia
• HHS older persons mental health services or dementia outreach services
• Dementia Behaviour Management Advisory Service and Severe Behavioural Response Teams phone (24 hours a day): 1800 699 799
• Dementia Training Australia resources
• Supporting a restraint-free environment in residential aged care Aged Care Quality and Safety Commission
• Restrictive practices provider resources Aged Care Quality and Safety Commission

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8. Anstey KJ, Peters R. Dementia prevention. NHMRC partnership centre for dealing with cognitive and related functional decline in older people. Sydney: National Health and Medical Research Council (NHMRC); 2019. https://cdpc.sydney.edu.au/research/care-service-pathways/
9. McDermott O, Charlesworth G, Hogervorst E, Stoner C, Moniz-Cook E, Spector A, et al. Psychosocial interventions for people with dementia: a synthesis of systematic reviews. Aging Ment Health. 2019;23(4):393-403.
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11. Reus VI, Fochtmann LJ, Eyler AE, Hilty DM, Horvitz-Lennon M, Jibson MD, et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. Am J Psychiatry. 2016;173(5):543-6.
12. Watt JA, Goodarzi Z, Veroniki AA, Nincic V, Khan PA, Ghassemi M, et al. Comparative Efficacy of
    Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis. Ann Intern Med. 2019;171(9):633-42.
13. Psychotropic Expert Groups, Therapeutic Guidelines: Psychotropic. Melbourne: Therapeutic Guidelines Limited; 2021.