A Systematic, Evidence-Based Approach to Managing Challenging Behavior in Nursing Homes

by Steven Levenson, MD, CMD
Multi-Facility Medical Director, Baltimore, MD
Chair, Caring's Editorial Board

A majority of nursing home patients exhibit abnormal or problematic behaviors. Therefore, every nursing home should have a systematic, evidence-based approach to evaluate and address these common challenges. Yet, often, effective care is hampered by fear, myth, or misunderstanding.

This Special Report offers a systematic approach to evaluating and managing challenging behaviors in nursing home residents and patients. It incorporates the efforts of a statewide work group in Arkansas to develop process indicators and facility guidance on the topic (see box below).

Behavior is the primary means by which we express, or seek to satisfy, a need or desire. It is often influenced by physiological function and medical illnesses. An individual's problematic behavior--unlike many other symptoms--may affect other people, particularly in group settings, even if the behavior is not experienced as "problematic" for the person who displays it.

Behaviors always have underlying causes, some of which may be physical abnormalities or conditions that respond to various medications or non-medical interventions. But behavior is not a disease, and shouldn't be turned routinely into a medical event.

General Recognition & Documentation

One key issue is how we decide that a behavior is a problem that requires an intervention. A nursing facility resident's behavior generally comes to the staff's attention in one of three ways:

1. The resident has a diagnosis of a psychiatric or organic mental disorder.
2. The resident takes a psychoactive medication.
3. The resident says or does something that concerns someone (a "target behavior").

Many nursing home staff and practitioners react rapidly to a target behavior (the "symptom"), quickly assume or conclude that it is problematic, and hastily institute an intervention--often, a psychiatric consultation or a psychoactive medication.

However, relatively few situations, short of uncontrolled violence, require this rapid-fire approach. The rest need proper problem definition and cause identification--that is, what is the issue, why is it problematic instead of tolerable or expected, and what are its causes?

An effective approach typically requires "three dimensional" observation and description (done over time and in depth) instead of two-dimensional (isolated and superficial).

Thus, nursing facility staff at least should be able to recognize, describe, and document these behaviors and--with the help of appropriate practitioners--analyze and address specific underlying causes.

Once they identify a target behavior or a situation in which someone has a psychiatric diagnosis or is receiving a psychoactive medication, facility staff should describe the behavior's characteristics--that is, its nature, scope, severity, duration, frequency, and consequences, including its impact on other individuals (see box below).

Staff should be able to show that they use a consistent tool to measure and document behaviors, such as relevant behavioral documentation scales. For example, instead of saying that a resident is "agitated during the day," it is more appropriate to describe the situation as "several times weekly, in the early evening, after the resident has eaten, she becomes more restless and resists staff attempts to prepare her for bedtime," and provide descriptions of measures that address the situation successfully or that don't seem to work.

Specific Situations

Nursing home staff and practitioners may encounter challenging behaviors in several situations:

1. During a new patient evaluation.
2. When observing an acute or subacute change or slow decline in behavior and function.
3. When monitoring therapeutic interventions over time.

Such situations should be handled in a systematic way, incorporating the following steps:

New Patient Evaluation Upon admission, the staff should begin to observe and document an individual's behavior and evaluate the individual for high-risk behaviors--for example, elopement potential, aggressive behaviors, or behaviors that may represent dangerous situations for the resident or others.

Within 24 hours of admission of someone who has been identified as having a behavior problem or who enters the facility receiving treatment for a behavior problem or a psychiatric disorder, the staff should initiate an in-depth evaluation of behavior.

Change in behavior Upon identification of a significant change in usual behavior patterns, the staff should identify the nature, scope, and severity of behavior, and pinpoint urgent behaviors requiring prompt interventions--for example, changes in function or new-onset of delusions or paranoia.

Acute change-possible delirium Delirium is a medical emergency that presents as abrupt or rapid changes in function, behavior, attention, or level of consciousness. It requires prompt evaluation and intervention.

Staff should recognize situations that could represent delirium (for example, fluctuating level of consciousness) and factors that distinguish it from dementia (for example, abrupt onset).They should document a discussion of such situations with a health care practitioner within a few hours of identifying the behaviors.

Subacute change or a slow decline This refers to situations in which there is a more gradual change in behavior--for example, a recent increase in yelling or increasing agitation while being assisted with activities of daily living (ADLs). Staff should characterize such behaviors in detail, as a basis for identifying causes and interventions.

Monitoring of ongoing therapeutic interventions For individuals who are receiving psychoactive medications or other specific interventions, the staff should identify and periodically document the target behaviors that they are treating or trying to prevent.

Cause Identification

Once an abnormal or target behavior has been recognized, the staff should attempt to identify causes of problematic behavior or explain why identifying causes of behavior isn't feasible or indicated (for example, a terminal situation where knowing the cause would not change the management).

The new onset of problematic behavior may require either urgent or non-urgent attention. As noted earlier, behavior should be evaluated urgently if there is a significant change in function, cognition, or level of consciousness, or if there is an abrupt onset of new agitation, restlessness, or dangerous behavior.

If behavior requiring urgent attention is identified, the staff should initiate promptly a search for causes (pain, infection, etc.) and rule out delirium. The search for causes in a non-urgent situation--for example, chronic recurrent behaviors--can be done more deliberately.

Staff may conclude that a behavior is problematic--that is, sufficiently risky or disruptive to warrant an intervention. It is important to identify the probable cause of a problematic behavior in order to manage it effectively. A sufficiently detailed assessment and analysis will often permit a targeted intervention that is likely to be successful.

The staff and a health care practitioner (HCP) should evaluate various categories of causes of problematic behaviors--for example, agitation could be due to delirium, psychosis, depression, anxiety, frustration, or may simply be a typical response in a person who is not cognitively impaired but has a lifelong habit of reacting to annoyances in that way.

With diligence, a probable cause can often be identified. If a cause is not readily apparent, staff should consider possible causes in roughly the following order:

New or old medications Upon recognition of problematic behavior, the staff should review medications in the patient's regimen that could be contributing to change in mental status or behavior--for example, cardiac antiarrhythmics or medications with anticholinergic activity. The consultant pharmacist should also help the staff on an ongoing basis to recognize medications that may be associated with changes in mental status or behavior. If high-risk or problematic medications are identified, an appropriate HCP should be notified.

Physical health Examples are medical illness with or without delirium, and fluid and electrolyte imbalance. If delirium or another medical cause is suspected or identified, staff should promptly notify a physician, and the physician should intervene promptly.

Psychiatric illness The staff and HCP should consider psychiatric illnesses that might be causing problematic behavior--for example, worsening of schizophrenia or recurrence of major depression.

Environment The staff should review and identify environmental factors that could be causing or contributing to problematic behavior--for example, not enough structured activity, space too large, too much noise, or another resident causing agitation. It is important to recognize that boredom is a form of anxiety that commonly results in agitation and is not an indication for drug treatment.

Task The staff should consider functional causes of problematic behavior--for example, a task is too complicated, involves too many steps, was not modified for increasing impairment, or is unfamiliar. Here, the solution may be as simple as helping the individual approach the task differently.

Interactions with others The staff should consider causes of problematic behavior related to interactions with others--for example, the caregiver may be too loud or seem threatening, or the resident may be unable to understand or make himself understood. Examples of relevant approaches might include changing a staff person's approach or separating two residents.

Drawing Conclusions

Having enough information about the nature, severity, scope, extent, and potential causes of an individual's challenging behavior is essential to addressing the behavior effectively. Otherwise, the approach is likely to be speculative and may result in interventions that exacerbate or don't correct the problem.

It should be possible to provide a rationale for the approach to most situations--for example, how the staff and practitioner distinguished between paranoia related to psychosis and a personality disorder with associated paranoia.

Sometimes, a challenging behavior may improve even if the underlying cause has not been identified. But if a behavior problem worsens within 48 hours after initiating an intervention or is not resolving within a week of doing so, a physician should be involved. A psychiatric consultation is not always necessary.

Overall Management: Steps

Staff should be trained to effectively manage challenging behaviors, and be able to show a basis for choosing specific interventions in specific situations, and that interventions are relevant to a resident's needs, problems, strengths, limitations, and goals. Following are key steps in the process:

Identify goals of treatment Before or soon after initiating interventions, staff should identify and document resident-specific goals for managing behaviors. The goals should be relevant to the individual's condition, prognosis, wishes, causes, etc. Examples of goals include: reduce the frequency of aggressive behaviors, stabilize mood, correct underlying causes and consequences of the problem behavior, reduce undesirable medication side effects, etc.

Include appropriate individuals For non-emergency or non-urgent problematic behavior, the staff should include appropriate individuals such as the family and direct care staff in setting goals and management strategies, in light of identified behaviors.

For urgent or emergency situations, which generally differ in nature and causes from long-term behavior management, the staff should at least inform the family of the situation, keeping in mind that in acute situations such as psychosis or delirium, family members generally are not in a position to judge the appropriateness of various proposed interventions.

Consult with an HCP When basic non-medical (environmental, psychosocial, etc.) interventions are not sufficient to address problematic behavior, the staff should consult with an appropriate HCP--for example, a trained or knowledgeable primary care physician or nurse practitioner, psychiatrist, or geropsychiatrist. As noted earlier, a psychiatrist is often helpful but is not essential for all situations. Many situations can be managed effectively by properly identifying causes and then following established protocols. Protocols should be used routinely, to ensure a consistent and valid approach.

Whoever assumes responsibility for recommending or prescribing treatment should explain or document the rationale for treatment selection, including the basis for medication recommendations--for example, an antipsychotic medication is indicated because the individual is delusional and displaying increasing paranoia that suggests psychosis.

Cause-Specific Management

Causes of problematic behaviors can often--but not always--be identified. When the cause of a problematic behavior is identified or suspected, staff should provide cause-specific management or indicate why it was not feasible or not appropriate for that individual (problem not amenable to treatment, previous adverse reaction to a medication, terminal condition, etc.).

Examples of cause-specific interventions include addressing delirium by correcting underlying fluid imbalance, psychosis with delusions by using antipsychotics, environmental issues by managing excessive noise or other aggressive residents, and so on. It is important to recognize that problematic behavior related to a personality disorder rarely responds to medications and only sometimes improves with non-medication interventions.

Other considerations in cause-specific management include the following:

Problematic behavior related to personality For problematic behavior not associated with psychosis or delirium, staff should try pertinent interventions, such as different approaches to bathing or feeding, involving the resident differently in his or her own care, etc.

Medication treatments If management of problematic behavior requires a medication, then the staff or HCP should identify the basis for a medication recommendation and selection. If a resident is receiving psychoactive medications or new ones are initiated, the staff should initiate a process to identify and characterize the behavior for which the medication is being used. They should also consult with an appropriate HCP who can provide the rationale for a specific medication, or for a specific dosage and duration of treatment.

Refusal of recommendations If staff and the HCP have identified a relevant intervention that the resident or a substitute decision maker refuses, staff should document this, including evidence that the resident or substitute decision maker was informed of the potential consequences associated with not rendering that treatment.

If another valid alternative intervention is available, staff should use it or identify the reason that it is not feasible or appropriate for that individual.

Staff should also document when they believe that refusal of a relevant alternative prevents them from managing a resident's problematic behavior effectively--for example, the family resists the use of any antipsychotic medications in someone who clearly has psychotic symptoms. Under those conditions, the staff may be unable to continue to provide care.

Monitoring

All residents exhibiting problematic behavior should be monitored regularly, and treatments should be adjusted as needed, in accordance with the following steps:

Review progress For long-term or intermittent problematic behavior, staff should monitor behavior at least quarterly--or more frequently, depending on the resident's response to the interventions. For urgent or emergency problematic behavior, staff should monitor the situation at least several times daily.

In conjunction with an HCP, staff should review periodically the progress of someone with problematic behavior and adjust interventions in accordance with goals.The target behavior should be described and documented--that is, whether the scope, severity, nature, and extent are improving, worsening, or remaining stable.

The staff should systematically consider whether and for how long to continue interventions--especially medications being used to manage problematic behaviors. Based on input of an HCP, staff should be able to explain the basis for long-term medication management of an individual with a history of problematic behavior. There should be evidence of efforts to taper long-term medications in accordance with good practice and OBRA guidelines, or appropriate documentation as to why such efforts were not indicated.

If a problematic behavior worsens within 48 hours or is not resolving within a week, then the staff should review current interventions with an HCP. The HCP should indicate the reason that a specific intervention is still warranted and consider the possibility that the cause was not identified correctly or that the current approach may not be addressing the problematic behavior effectively. The HCP, or someone who has spoken with the HCP, should document the basis for conclusions to maintain or change current interventions.

Seek and address complications of treatments Treatments for problematic behavior such as medications and restraints can have adverse consequence. Staff should monitor residents for significant complications of drugs and devices. These may include change in appetite, falling, gait problems, decline in function, exacerbation of behavioral problems, or onset of new symptoms. Such complications may occur within days of the initial use or addition of medications or devices or after weeks or months of longer-term use.

Consider and address adverse drug reactions (ADRs) Many medications in many categories can affect mental status and behavior, and psychotropic medications can affect other body functions, such as blood pressure, appetite, and urinary continence.

If a possible ADR is identified, staff should communicate with an HCP, who should address specific possible complications. The HCP or someone who has communicated directly with the HCP should document a clinically valid reason for not tapering or stopping potentially problematic medications--for example, why there was no other acceptable alternative available, why the benefit of the medication outweighs the risks of a current ADR, why the resident cannot tolerate alternatives, etc.

If the resident continues to have symptoms that could represent an ADR, it is not adequate to state that no changes were made "because the physician said so."

Conclusion

Challenging behavior is common among nursing home residents everywhere. Therefore, addressing challenging behavior should be considered a key aspect of care in nursing homes. Sometimes, managing these issues requires trial and error, but more often than not evidence-based approaches targeting underlying causes are effective and much better for the residents.

A systematic approach such as is outlined here, supplemented by relevant protocols and guidelines, is likely to make these situations more manageable and can markedly reduce the frequency of resident transfers for behavior problems. Because these principles are universally applicable and enduring, the current variability in approaches in nursing homes is probably unwarranted. Physicians and other health care providers must play a more constructive role in addressing causes of problematic behavior and reducing iatrogenic behavioral and functional disturbances.

The AMDA Altered Mental States and Dementia CPGs contain many useful details and references about appropriate processes related to the management of problematic behavior or behavior risks.

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