Positive Intervention Strategies

When supporting older people who may become physically or verbally aggressive, we need to ensure we are designing and implementing individual Behaviour Intervention Strategies (BIS’s) based on positive and non-aversive interactions.

This means adopting approaches and techniques that value and respect the person. One of the best ways to achieve this is to ensure a full and comprehensive Life Story Book is completed with the person. By using this, in combination with the information gathered during the Pre-admission Dementia Assessment tool, members of the direct care team can ensure interventions are based on in-depth knowledge of the individuals they are assisting.

Under no circumstances should members of the direct care team consider medication as a first line treatment for problem behaviour. Techniques based on cognitive behaviour therapy and other psychotherapeutic treatments should always be explored as the first option. This can be accessed through the CPN’s, Consultant Psychiatrist or myself as Dementia Consultant.

It is important to remember that the most common behaviour challenge experienced by people with dementia is anxiety. Very often, if the underlying cause of anxiety is treated, much of the unproductive behaviour is reduced or removed altogether.

Another important consideration when aiming to alter or shape the behaviour of a particular individual is that a behaviour being removed must always be replaced with a more appropriate one. Failure to do this is likely to result in an empty being.

Your approach should therefore consist of two strategies:

1. Pro-active: We must always believe and accept that providing good quality care based on person centred strategies is the best way of reducing the risk of problem behaviour developing in the first place. 

We must therefore provide an environment conducive to meeting the everyday needs of people living in the house. We should provide person centred therapies which address issues relating to anxiety

and aggression and we must offer a choice of activity and lifestyle.

Managers leading services must encourage the development of Life Story Books which enable carers to see the person as a person with dementia and not a dementing person.

Whilst this approach is aimed at reducing problem behaviour, the very nature of dementia may mean we cannot prevent it altogether.

For this reason, we need to have in place a second strategy which we can call upon. This is referred to as

2. Reactive: If a reactive approach is necessary, members of the direct care team must ensure that:

ü      The Royal Collegeof Psychiatrists de-escalating tactics are instigated. This suggests that we stand with an open posture when interacting with an aggressive person; that we ensure the safety of ourselves, colleagues and other people living in the house; that we speak clearly and calmly, ensuring we maintain open communication at all times; that we stand at a 45 degree angle and not directly in front of the person; that we ask a person to put down any potential weapons such as walking sticks (do not ask the person to hand them over); that we maintain eye contact and that we allow the person time and space to calm down. 

ü      The person’s individual Behaviour Intervention Strategy (BIS) is implemented. This should include guidelines developed from knowledge gained through the completed Life Story Book, the pre-admission dementia assessment and any risk assessments that have been carried out (remember that risk assessments are not an exact science and that they must be reviewed on a regular basis).  For example, what are the person’s likes and dislikes? What works best with each person? Does he/she like to be left alone? Does he/she like company? Would a walk around the garden be effective, etc? Each BIS must describe the approach to be adopted; the language to be used; the reward to be offered and any distraction methods to be used. Remember that both consistency in approach and continuity of care is an essential ingredient of any reactive strategy.

ü      Get telephone guidance and support from the Dementia Consultant

ü      As a last resort, contact the GP and consider medication

The safety of all concerned is paramount and a thorough risk assessment complete with accurate guidelines will ensure best professional practice in this area.

Following the incident, a debriefing session should be held whereby:

1)    Discussions take place about possible triggers and what can be done to reduce the risk of a repeat incident

2)    The people involved are offered guidance, support and counselling. This includes the people living in the house, their relatives and members of the direct care team.

3)    A review of behaviour strategies is planned, carried out and documented and the entire incident is documented in full.

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