There are interrelationships between everything that exists (Pearce, 2007).
This is a concept that the Crisis Prevention Institute’s Nonviolent Crisis Intervention® training program refers to as the Integrated Experience (2005).
This concept, that staff behaviors and attitudes have an effect on a client’s behaviors and attitudes, and vice versa, is ever-present in caregiver interactions with those they serve—especially when working with individuals who have Alzheimer’s disease and dementia. Given that a larger segment of the population is aging and, logically, a larger percentage of adults is likely to acquire these conditions, staff will need to be prepared for this increase in service needs.
Although medical advances—such as better pharmacological options and earlier diagnostic techniques—have allowed many to slow the progression of the disease, unlike other behavioral conditions that may improve over time, dementia and Alzheimer’s disease are considered degenerative.
As the disease advances over time and symptoms worsen, caregivers have an increasing responsibility to foster a connection with those they serve. Understanding the Precipitating Factors of a person with Alzheimer’s disease or dementia may help caregivers prevent disruptive situations, allowing the caregiver to build rapport.
In the Nonviolent Crisis Intervention® training program, a Precipitating Factor is defined as an internal or external cause of behavior over which a care provider has little or no control. The effects of dementia and Alzheimer’s disease are themselves important physiological Precipitating Factors that staff need to understand as they prepare to care for these individuals.
Doctors typically come to a diagnosis of Alzheimer’s by ruling out other potential disorders through the process of elimination. Even though a diagnosis of Alzheimer’s disease is made, each person may manifest a different array of behaviors and symptoms. As such, individualized care is essential to ensure a person’s unique needs are met.
According to the Mayo Clinic (2002), Alzheimer’s disease affects the brain by destroying neurons. This normally happens in the hippocampus first, followed by the frontal, parietal, and temporal lobes of the cerebral cortex. This destruction of brain tissue often results in memory loss, disorientation, and the loss of spatial memory. Similar conditions to Alzheimer’s disease include Dementia and Mild Cognitive Impairment—both of which may be precursors to Alzheimer’s disease, according to recent studies. (See also: Major Neurocognitive Disorder
Because of the way Alzheimer’s disease affects an individual’s brain, working with this population requires compassionate caregivers who are educated about the psychopathology of Alzheimer’s disease and dementia. People with Alzheimer’s disease and dementia are unique individuals with personal preferences that must be respected (Kuhn, 2003).
It is important to accurately (and continually) assess how the disease has affected each individual, and alter the care provided to the individual, based upon that assessment. An ongoing assessment of each individual’s environment is also necessary to locate the sources of stress or perceived danger.
To help identify and mitigate the effects of these possible hazards, the Australia Government Department of Health and Ageing (2004) proposed that staff consider a number of environmental factors as alternatives to physical, chemical, and mechanical restraint. Some of these factors include: improved lighting, non-slip flooring, lowered bed height to suit individual needs, and appropriate mobility aids close at hand (railings on the wall, trapeze to enhance mobility in bed). (See also: How to Manage Alzheimer's Behavior Without Drugs
Examining the Precipitating Factors for an individual with Alzheimer’s disease or dementia is far more than an inventory of symptoms.
Each person has a lifetime of experiences, relationships, and hardships, and it is important to understand that seemingly simple things really matter.
A person may have a simple, everyday routine he has followed for years, which is no longer possible because of physical limitations, organizational policy, or changes to that routine. Having someone to assist in what may seem like a mundane task could help address a potential Precipitating Factor.
Before coming to an assisted living residence, a hypothetical resident walked out to his mailbox at 11 a.m. every morning and read the mail before having lunch. At the facility, the person is often frustrated as his mail is delivered to his room every morning and he can no longer follow his usual routine of walking out to get the mail. A staff member recognizes that the resident is continually uninterested in eating lunch and finds out through a family member about the usual 11 o’clock routine. To help re-establish the resident’s mailbox routine, the staff member sets up a mailbox at the nurse’s station where the resident is able to walk to pick up his mail. (See also: Life Story Questionnaire
According to Kuhn (2003), loneliness may also be a common emotion among those with Alzheimer’s disease—and thus, may be another Precipitating Factor.
Kuhn states that people need a sense of community—a sense of belonging to a group with whom one shares a common bond. Some facilities use volunteers to put together hobby groups—knitting, painting, music, bingo, etc. Facilities offering a wide range of activities allow individuals with Alzheimer’s disease or dementia a chance to stay physically, socially, and emotionally active within their home and within their community.
Recent studies have shown that the adage “use it or lose it” may be very applicable for people with Alzheimer’s disease and dementia. People with Alzheimer’s disease and dementia need more than a “clean, warm, and comfortable environment . . . [i]nactivity and low levels of engagement also contribute to loss of physical function, social isolation, behavioral symptoms, and poor quality of life” (Mor, Branco, Fleishman et al., 1995; Alessi, Yoon, Schnelle et al., 1999 in Alzheimer’s Society 2007).
Although Alzheimer’s disease is partially genetic, “complex leisure activities could offer seniors, even those at high risk for the disease, a better shot at delaying its onset” (Facklemann, 2005). Considering that studies also suggest that Alzheimer’s disease may impair the brain long before any symptoms are evident, engaging an individual as much as possible even after the onset of Alzheimer’s disease may be extremely helpful.
The Alzheimer’s Society in the UK reports that the uniqueness of every individual also means that staff should try to tailor activities to a person’s interests as much as possible. This can lead to increased engagement and potentially increased brain function, which may help slow the advancement of the disease.
Staff should also be aware of other Precipitating Factors related to medical conditions that may accompany the disease.
These include, but are not limited to: depression, anxiety, and/or sleep disorders. Each condition brings symptoms that may increase the neurological decline of Alzheimer’s disease, as well as several behaviors that staff may find disruptive. Pharmaceutical interactions and side effects from drugs used to treat other conditions should also be monitored closely, especially when these drugs are prescribed by specialists other than the individual’s primary physician.
Staff must be constantly mindful that behavior is often a form of communication. What may seem to be a behavioral issue may actually be a response to the discomfort or pain of a medical issue. It’s a good idea to schedule regular check-ups to rule out any health problems before assuming the deterioration is due to the Alzheimer’s disease and dementia.
Another important possible Precipitating Factor is that individuals with Alzheimer’s disease or dementia may feel more uncomfortable when others invade their personal space. Webb and Weber (2003), examined how declining physical abilities associated with aging—such as vision, hearing, and mobility—can affect a person’s perceived personal space. The study found that as a person’s sensory abilities declined, the person’s perceived personal space increased. In her book, Alzheimer’s Patients in the Nursing Home: How Well Do Caregivers Meet Their Needs?
, Michelson (2005) suggests giving an agitated resident more personal space until the resident is comfortable with a new staff member.
Staff should also recognize that personal space can extend to personal belongings. A person with Alzheimer’s disease may be especially protective of their personal items when they move into a residential setting.
Similar to the discussion on routines, many people can easily become frustrated when their items are not where the person thinks they belong. For instance, perhaps a resident liked to store spare batteries in a nightstand drawer. When she moved into a residential setting, the nightstands had no drawers and she had to keep spare batteries somewhere else. When needing new batteries, the resident may not remember where her batteries were and can easily become upset because the batteries were not where she felt they belonged.
According to Michelson, many frontline staff members are not provided enough information about the unique Precipitating Factors associated with Alzheimer’s disease and dementia (2005).
Downward restricted vision restricts the sight of the person with Alzheimer’s disease to one specific area. This is important information for staff to include in a care plan, as any staff approaching this resident from outside this range of vision may startle the individual, who then may become resistant to the staff’s request.
With Alzheimer’s disease in particular, the individual may not respond to a staff member speaking to them unless that staff member is in that person’s range of vision. Without this realization, the staff member may take or perceive the ignoring behavior as defiance and inadvertently escalate a confrontation. This confrontation can further lead to a power struggle—a conflict of wills between the resident and the staff member.
For an individual with Alzheimer’s disease or dementia who has a co-occurring hearing loss, the individual may have difficulty hearing staff who speak too quickly or quietly, or may just need more time to process the information.
Caregivers should avoid making demands; rather, rephrase the resident’s options in ways that make it clear that the resident has a choice. Caregivers may unknowingly take away an individual’s choices in a long-term care environment—by using statements such as, “You can’t do __” or “That’s not your room!”
A client may become frustrated if she feels she is not allowed to make choices for herself. Staff who are better able to present directives as a guided or shaped choice of options help the person continue to feel empowered to make her own decisions. Careful assessment of each individual is essential, though, as some clients may have difficulty with decision making, and presenting too many choices can lead to further frustration.
As the disease progresses, the person with Alzheimer’s disease or dementia may no longer remember the rules of the facility, or may be lost and confused. Without realizing this Precipitating Factor, the individual’s confusion and frustration can quickly turn to agitation if they perceive that staff is being confrontational.
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Although the stress and frustration caregivers experience may technically not be a Precipitating Factor—a caregiver does have control over this—showing signs of frustration and stress in the presence of a client will have an effect on the client’s behavior.
As mentioned above, this is referred to as the Integrated Experience in the Nonviolent Crisis Intervention® training program, which illuminates how staff behavior can affect client behavior. (See also: Compassion Fatigue.)
Maintaining objectivity can be difficult, especially for family members providing care for an older loved one. There may be years worth of emotional baggage and finding room to stow this baggage is not easy. Keeping in mind, again, that behavior is often a form of communication is a tremendous help to maintain objectivity even during the most trying moments. (See also: 10 Self-Care Tips for Dementia Caregivers.)
Also, many people with Alzheimer’s disease may feel as though they are a burden on those providing care to them—a feeling that can be another Precipitating Factor in and of itself. Staff awareness of their own paraverbals and nonverbal behavior can be proactive to this particular Precipitating Factor. If a staff member sighs noticeably at a request, rolls his eyes, or speaks with an impatient cadence, this could cause escalation in an individual who only wanted a drink of water but perhaps struggled with how to ask.
Beyond the symptoms associated with Alzheimer’s disease and dementia are a number of Precipitating Factors which may affect a person’s behavior. This article outlined a few of the more common Precipitating Factors which may come up, but careful assessment of each individual in care can allow many of these factors to become known, allowing staff to problem solve solutions before problems arise.
When caregivers are provided the training to better recognize and deal with these Precipitating Factors, they are better equipped to foster positive relationships with individuals in their care and better able to improve that person’s quality of life.
Alzheimer’s Society. (2007). Home from home: Quality of care for people with dementia living in care homes. London, UK: Author.
Australia Government Department on Health and Ageing. (2004). Decision-making tool: Responding to issues of restraint in aged care [Electronic version]. Publication Approval Number: 3436/JN8326. Canberra, Australia: Commonwealth of Australia. Retrieved on January 4, 2008 from health.gov.au/internet/wcms/publishing.nsf/Content/ageing-decisionrestraint.htm.
Blake, L. (2001). Geriatric populations: An ethics primer of American Psychiatric Association. Arlington, VA: American Psychiatric Association.
Crisis Prevention Institute, Inc. (2005). Instructor manual for the Nonviolent Crisis Intervention® training program. Brookfield, WI: Author.
Fackelmann, K. (2005). Minds in motion: Evidence mounts that keeping the brain fit could ward off Alzheimer’s [Electronic version]. USA Today, January 25, 2005. Retrieved on December 19, 2007 from USA Today.
Kuhn, D. (2003). Alzheimer’s early stages: First steps for family, friends, and caregivers. Alameda, CA: Hunter House, Inc.
Mayo Clinic Health Information. (2002). Mayo Clinic on Alzheimer’s disease: Practical answers on memory loss, aging, research, treatment, and caregiving. Rochester, MN: Author.
Michelson, U. (2005). Alzheimer’s patients in the nursing home: How well do caregivers meet their needs? Philadelphia, PA: Xlibris Corporation.
Pearce, N. (2007). Inside Alzheimer’s: How to hear and honor connections with a person who has dementia. Nashville, TN: Forrason Press.
US Census Bureau. (2008). Historical national population estimates: July 1, 1900 to July 1, 1999. Retrieved on January 3, 2008 from census.gov/popest/archives/1990s/popclockest.txt
US Census Bureau. (2008). US POPClock Projection. Retrieved on January 3, 2008 from US and World Population Clock.
Webb, J., & Weber, M. (2003). Influence of sensory abilities on the interpersonal distance of the elderly. Environment and Behavior, 35, 695–711.
Alzheimer's Disease Education and Referral Center (ADEAR)
P.O. Box 8250
Silver Spring, MD 20907-8250
225 North Michigan Avenue
Chicago, IL 60601-7633
Alzheimer’s Disease International
64 Great Suffolk Street
London SE1 0BL UK
Tel: +44 20 79810880
Alzheimer’s Society (UK)
58 St Katharine's Way
London E1W 1JX
Tel: +44 (0) 20 7423 3500
Alzheimer’s Society of Canada
20 Eglinton Ave. W., Ste. 1200
Toronto, ON M4R 1K8
John Douglas French Alzheimer's Foundation
11620 Wilshire Blvd.
Los Angeles, CA 90025
Family Caregiver Alliance
690 Market Street
San Francisco, CA 94104
American Health Assistance Foundation
22512 Gateway Center Drive
Clarksburg, MD 20871
C-Mac Informational Services/Caregiver News [for Alzheimer's Type Dementia Caregivers]
271 Cedar Lane
East Meadow, NY 11554-2720
National Family Caregiver Support Program Administration on Aging
Washington, D.C. 20201
Originally published in the Journal of Safe Management of Disruptive and Assaultive Behavior, March 2008. © 2008 CPI. Updated 2016. Certified Instructors, log in to read more JSM articles.