Non-Pharmacologic Management Table

Behavior Agitation
Common Patient or Event-Related Factors	Non-Pharmacologic Intervention	References
Physical illness Examples: Pain Infection Fatigue Constipation	Assess and manage pain (and avoid restraints) Assess and manage other illness Hand massage Slow-stroke back massage	Cohen-Mansfield & Werner, 1995 Snyder, Egan &Burns 1995a Fraser and Kerr, 1995
Medication	Assess, monitor, reduce/change as indicated
Environmental stress Examples: Unfamiliar caregivers New schedules Excess stimulation, noise Being alone Involved in ADL-bathing, toileting Restraints	Music Therapy Calming music Favorite music Structured care unit activities, e.g. predictable routines, continuity of care, low-noise, limit crowding	Tabloski, McKinnon-Howe & Remington, 1995 Casby & Holm, 1994 Swanson, Maas & Buckwalter, 1993
Expectations of patient too great, patient being “quizzed” too often	Caregiver/Staff education-avoid persistent testing of memory, simplify questions.	Maxfield, Lewis & Cannon, 1996
Bored, restless	Increased activities, individualized Example: Animal-assisted therapy	Zisselman, Rovner, Shmuely & Ferrie, 1996

Behavior
*Depression

Common Patient or Event-Related Factors

Non-Pharmacologic Intervention

References

Personal losses and fear of advancement of disease:

Perceived cognitive changes, loss/alteration of usual interpersonal relationships, developing functional disability

Reminiscence Therapy

Validation Therapy

Clinical Practice Guideline

Rentz, 1995

Bleathman&Morton, 1992
Kelly & Vanderslott, 1995

Depression Guidleine Panel, 1993

*(The degree of complication of a patient's clinical course due to depression varies by stage of illness; depression is usually a more significant complication early in disease course.)

Behavior Inappropriate or impulsive sexual behavior
Common Patient or Event-Related Factors	Non-Pharmacologic Intervention	References
Dementia-related decreased judgment and lack of social awareness	Do not overreact or confront; respond calmly and firmly; distract and redirect
Misinterpreting caregiver's interaction as having sexual overtones	Educate caregivers Do not give mixed sexual message (double entendres and innuendos - even in jest); avoid nonverbal messages; distract while performing personal care or bathing	Ballard & Poer, 1993 Ballard, 1996
Uncomfortable-too warm, clothing too tight; need to void, genital irritation	Check room temperature; assist with comfortable weather-appropriate clothing; ensure that elimination needs are met; examine for groin rash, perineal skin problems, stool impaction
Need for attention, affection, intimacy	Increase or meet basic need for touch and warmth; model appropriate touch; offer soothing objects (such as dolls or stuffed animals); provide hand or back massage
Self-stimulating, reacting to what feels good	Offer privacy; remove from inappropriate place

Behavior Incontinence
Common Patient or Event-Related Factors	Non-Pharmacologic Intervention	References
Infection, prostrate problem; chronic illness; medication side-effect; stress or urge incontinence	Evaluate medically	Skelly, Flint, 1995
Dependency created by socialized reinforcement	Provide increased attention for continence rather than incontinence; allow independence whenever possible, even if time consuming
Cannot express toileting need	Institute toileting schedule, e.g. prompted voiding q 2 hours “Visible toilet” toilet to center of room Reduce diuretics and bedtime liquids	Eustice, Roe, Paterson, 2000 Skelly, Flint, 1995 Harr 1995, ch 2
Task overwhelming	Simplify; use step by step instructions; establish a routine
Impaired mobility	Evaluate medically; treat associated pain (include physiotherapy); Bedside commode Reduce diuretics where possible

Behavior Resistance to personal care (e.g. resisting help with bathing, personal hygiene, dressing, or grooming)
Common Patient or Event-Related Factors	Non-Pharmacologic Intervention	References
Caregivers rushed	Adjust timing of baths, wounds care, dental hygiene, etc. to times of maximal staff availability
Physical or emotional discomfort	Treat physical condition as able, e.g. pain medication if necessary Adjust bath environment, e.g. temperature of room ,water, may need to void whirlpool for some patients Preserve modesty, privacy	Potts, Ritchie & Kass, 1996 Bossenmaier & McLachlan 1991 Sloane et al., 1995
Apraxia-patient cannot remember how to perform tasks Patient cannot understand or follow instructions Patient afraid of doing task	Simple set-up, cueing or demonstration of task, unhurried assistance, easy-on clothing One-step at a time directions in an unhurried tone Reassure, distract with music When necessary and possible you may need to defer task to a later time.	Vogelpohl, Beck, Heacock & Mercer, 1996
Unclear cause but clear agitation during personal care	*Snoezelen	Brown, Jones, Volicier-lookup ref RDL...

*Snoezelen therapy combines soft lighting, gentle music, tactile surfaces, and essential oils to stimulate the sense of older adults with dementia in a comfortable, safe environment.

Behavior Sleep Disturbance
Common Patient or Event-Related Factors	Non-Pharmacologic Intervention	References
Agitation... "sun-downing" when it occurs in the early evening	See Agitation table
Sleep interruption due to physical causes: pain and nocturia most common Urge to void Environment (temperature, noise)	Hand massage Slow-stroke back massage Treat pain (and avoid restraints) Ensure a clear, well-lit pathway to bathroom Adjust environment as needed	Snyder, Egan & Burns, 1995a Fraser and Kerr, 1995 Cohen-Mansfield & Werner, 1995
Altered sleep cycle due to age +/- disease	Bright Light therapy Safety precautions	Campbell et al, 1993 chapter 8 ref
Depression	Reminiscence Validation Therapy Clinical Practice Guideline	Rentz, 1995 Bleathman & Morton, 1992 Kelly & Vanderslott, 1995 Depression Guideline Panel, 1993
Medication effect (e.g. causing daytime sleep or nocturnal awakening)	Evaluate medically
Less need for sleep	Schedule later bedtime; allow activities or tasks that can safely be done at night; plan more daytime exercise
Darkness disorientating	Use night lights
Caffeine or alcohol effect	Reduce or eliminate alcohol; Limit caffeine after noon
Hunger	Provide nighttime snack
Urge to void	Ensure a clear, well-lit pathway to bathroom
Daytime sleeping	Eliminate or limit naps; provide activity and exercise instead; for naps, use recliner rather than bed
Fear of darkness; restless	Soft music massage, nightlight

Behavior Psychotic symptoms: Suspiciousness, paranoia, hallucinations
Common Patient or Event-Related Factors	Non-Pharmacologic Intervention	References
Physical illness	Medical evaluation (infection and medication effects are common)
Someone is really taking something from person	Check out validity of situation
Combined, disturbed sensory and cognitive abilities e.g. decreased hearing, decreased or altered vision or color perception.	Distraction Respond to resident's feeling... do not argue or correct perception	Carlson, Fleming, Smith & Evans 1995
Forgot where objects were placed	Offer to help find; have more than one of same object available (e.g. purse, wallet); have a list where objects should be placed; learn favorite hiding places
Misinterpreting who people are, suspicious of their intentions	Introduce self and role routinely; draw on old memory, connections; do not argue
Change in environment or routine	Reassure, familiarize; set and follow a routine as much as possible
Social isolation	Encourage and provide familiar social opportunities

Behavior Wandering
Common Patient or Event-Related Factors	Non-Pharmacologic Intervention	References
Past history of using physical activity to relieve stress	Provide secure walking path, exercise program	Holmberg, 1997
Restless, bored	Increase activities scheduled Individualize programs	Teri, 1992
Toileting need	Institute toileting schedule Signs or pictures on bathroom door "Visible toilet" toilet to center of room	Harr, 1995, ch 2
Stress, noise, activity level	Reduce excess stimulation
Lost-looking for someone or something familiar	Provide familiar objects, signs, pictures. Offer to help find objects or place: reassure
Medication side effect	Monitor, reduce or discontinue medication
Environmental stimuli - exit signs; people leaving	Remove or camouflage environmental stimuli; ID or alarm bracelets