SORKC: Behavior Analysis

Most in neuropsychology prefer a model developed by Dr. Fred Kanfer.  In his approach, behavior analysis involves filling in the terms in the behavioral equation:

1. S – Antecedent or prior pattern of stimulation. More recently these elements are seen as the contextual patterns of influence. It is what happens BEFORE the behavior of focus.
2. O – Organismic or biological state that may be influencing a pattern of behavior of concern. For example, changes in perception associated with dementia or recent changes in medication.
3. R – The response that is the focus of the analysis. The litmus test for a definition of a response is that it uses verbs and is sufficiently detailed that you could describe it to another person and they would immediately recognize the pattern.
4. K - The contingency between the response and the consequences that occur when the response occurs.  If every time the behavior occurs the consequence is attention and attention that is not being provided for alternative patterns that is a powerful contingency relationship.
5. C - The events that follow the behavior or the consequences of the behavior. This has major influence in perpetuating the pattern.

As in most problem solving 80% of the solution is in a precise definition of the problem.  The SORKC model provides a framework for doing just that. However, these methods must fit in a person-centered approach that avoids making a dementia patient an object. Between 70% and 80% of the challenging behaviors presented by dementia patients are product of a lower threshold for stress and the deficit in their ability to organize their response. With neurological decline comes a reduced capacity to cope with stress without our help.

Behavior is contextual and rarely the product of a single cause.  To try to explain behavior in terms of chemicals, stimuli or events subsequent to the behavior is a fool’s errand. All behavior is a product of multiple factors and our challenge is to isolate those factors. More often than not, that entails formulating a hypothesis with the elements of SORKC and then testing.

If the context of behavior is poorly defined any effort to resolve the problem becomes random trial and error. The first step is to define the antecedent conditions (S) associated with the behavior of focus. The question is what happened immediately before the problem behavior.  Who was involved?  What time of day? The more detail, the better.  The word trigger is often misused and leads to leaping to conclusions. Biological and cognitive events (O) must be considered. Has there been a change in medication? What was the patient’s likely perception of the antecedent events? Is there a urinary tract infection? The response (R) is the challenging behavior and the more descriptive and action oriented the language the better. After obtaining a good description of the response we must always ask this question: What is the alternative or preferred response. If the patient is hanging around the nurse’s station we have to ask what we want them to do as an alternative. So R must include BOTH the problem behavior and our preferred alternative.

All people, including dementia patients, are heavily influenced by the consequences of their behavior.  Otherwise we would all still be in trees. The relationship between the response and its consequences is K and the consequence is C. When all behavior is ignored and approaching the nurse’s station leads to attention that is a contingency (K) and that must change if we want the behavior to change.

We can never really manage the behavior of others.  We can all only manage the context.  We can change what happens before, what happens during and what happens after the behavior. We must understand the context fully. Because people are marvelously adaptable the behavior may then change unless biological factors, including neurological factors, prevent it.

Managing Behavior in Dementia Patients

All behavior is triggered by something. It does not come out of the blue. Therefore the first thing to consider is what happens before the behavior takes place. Some people find it valuable to keep a notebook in which to enter observations. The simplest way to make observations is to note in your notebook what happened before the behavior, describe the behavior that concerns you and then note what happens after the behavior. It may be that some change in the physical environment, that you may not even notice, causes confusion. It may be something you said or something someone else said that triggered the behavior. Once you know that, changing those antecedent conditions may suffice. It also may be that the behavior produces certain consequences and changing those consequences may suffice. However keep in mind that what works today, may not work tomorrow. Troubling behavior is often influenced by multiple factors and so the key is to be flexible. Your loved one will have good days and bad days and so will you. That is one reason why you’re behavioral notebook can be a valuable asset. You should keep it each and every day, not just when troubling behavior occurs, but also when it is not occurring. You may learn a lot from the conditions that are described in your notebook, on days in which few if any problem behaviors occur.

Wandering

Patients with dementia may very well wander for a variety of reasons including boredom, medication side effects or because they are looking for someone or something. They may be trying to fulfill a biological need like thirst, hunger or the need to use a toilet. Since people are built to move around, they may be walking, quite simply, because they need the exercise. So we should make time for regular exercise each and every day and not expect them to sit is in the same place or lie in bed for hours and hours. If you are concerned that they may wander away and harm themselves consider installing new locks that require a key. You may position the locks high or low since often dementia patients will not look beyond eye level. You may want to consider a barrier like a curtain or simply place a stop sign at the door. Some people have found that placing a black mat or even painting a black square on the front porch, may stop the patient, since it may appear like a hole. You can use child safe plastic covers over the door knob or if your loved one will not go out unless they have a coat, a purse or glasses you may want to put those away. Be sure to tell your neighbors about the risk of wondering and make sure they have your phone number then tell them call you immediately. If you can afford it consider a home security system that will respond to movement and sound an alarm. New digital devices that use global positioning systems can be a valuable backup enabling you to immediately locate your loved one. You may also want your relative to wear an ID bracelet.

Incontinence

As dementia progresses there may be a loss of bladder or bowel control. At times accidents may result from environmental factors, such as the patient not being able to remember the location of the bathroom, or they simply cannot get to the bathroom in time. While memory is impaired, the sense of dignity on such occasions is not. It can be a major source of humiliation. If an accident occurs your understanding and your reassurance will be needed. The best course is a plan that will allow you to avoid such circumstances. You can use signs marking the route to the bathroom and to indicate which of the doors is the door to the bathroom. Establish a routine for using the toilet. Try reminding the person, and assisting her to the bathroom every two hours. Carefully control fluid intake and limit fluid intake in the evening before bedtime. Keep in mind the risk of dehydration and avoid drinks with a diuretic effect like coffee, tea, Cola or beer. A commode, which can be obtained in a medical supply store, can be left in the bedroom at night to ensure easy access. Incontinence pads and products can be purchased at a pharmacy or at the supermarket. A urologist may be able to prescribe special products that can be of help. You should use easy to remove clothing with elastic waist bands or Velcro closures and clothes that are easily washable.

Agitation

Agitation refers to a range of behaviors associated with dementia including sleeplessness, irritability and verbal or physical aggression. Often these behaviors increase as the disease progresses from mild to more severe. The need for control continues, in spite of dementia, and often agitation is triggered when a person feels like control is being taken away. A good place to begin with your family member is to reduce the intake of caffeine, sugar and junk food. Reducing noise and clutter can be helpful and often, having too many people in the room, can be a triggering event. Unfamiliar things can be a trigger while familiar objects and photographs may offer a sense of security. A gentle touch, soothing music or going for a walk can often quell the agitation. Only speak in a reassuring tone of voice and beware of trying to restrain the person since this can result in panic and even more dramatic agitation. Be sure to keep dangerous objects well out of reach to avoid the risk of impulsive acts. Confrontation may actually increase anxiety, and, thus increased agitation. Acknowledge the frustration with loss of control. Often the best way to deal with agitation is distraction. Offer a snack or some kind of preferred activity. By encouraging as much independence as possible we reduce the likelihood of agitation as a product of diminished sense of control.

Sleeplessness and Sundowning

Disorientation, restlessness and agitation often get worse at the end of the day and may even continue throughout the night. Experts call this behavior pattern sundowning. It is caused by a combination of factors such as exhaustion from the days events, changes in the patient’s biological clock and resulting confusion between day and night. Often increasing daytime activities including physical exercise and discouraging inactivity and napping during the day, can be most helpful. It is useful to eliminate or restrict caffeine, sugar and junk foods too early in the day if at all. Plan smaller meals throughout the day and a very light meal, such as half of sandwich, before bedtime. Late afternoon and evening activities should be quiet and calm. However, structured and quiet activities such as a stroll outdoors, a simple card game or listening to music can be helpful. Turning on the lights well before Sunset and closing the curtains will minimize shadows and perhaps reduce confusion. At a minimum, keep a night light in the person’s room, in the hallway and in the bathroom. Block off stairways with gates and put away dangerous items. As a last resort, consider talking to the doctor about medication that would help your family member relax and sleep. We say as a last resort because sleeping pills and tranquilizers may solve one problem and create others. For example the patient sleeps at night but is more confused the next day.

Bathing

People with dementia often forget essential grooming activities. As children we are taught that certain activities are highly private, are to be undressed and cleaned, even by another family member, can be embarrassing and humiliating. As a result bathing is often a source of major distress. Begin by recalling your family members historical hygiene routine. Did they take baths or showers? Were they in the morning or at night? Did she have her hair washed at a salon or did she do it herself? Was their favorite scent, lotion or talcum powder that was always used. To the extent possible adopt the past bathing routines, because the familiarity will be calming. If your loved one has always been modest accommodate by making sure doors and curtains are closed. Whether in the shower or the bath keep a towel over the front of the body, lifting it to wash as needed. Always have towels and a robe nearby and ready immediately when they get out of the shower or tub. Notice the environment including room temperature and water temperatures. Older adults are more sensitive to both heat and cold. Nonslip floor bath mats, grab bars and bath or shower seats can be most helpful. If possible install a hand-held shower to give more control to you and the patient. Older people are often afraid of falling so help them feel secure. Never leave a person with dementia unattended in the bath or shower. Have all the things you’ll need laid out beforehand. If you draw the bath water first you can reassure the patient by pouring a cup over the hands before they step in. If the tub or shower is consistently traumatic a towel bath maybe considered. This uses a large bath towel and washcloths dampened in a plastic bag of warm water and no rinse soap.

Quality of Life in Long Term Care

The overriding goal in long term care should be to improve the quality of life for residents and a major feature of quality living is psychological well-being. There are two sets of factors that must work hand-in-hand to produce psychological well-being. One is the quality of care provided. These are the processes of care that are the focus of most quality programs. Another set of factors, however, too often ignored are the quality-of-life factors that take into account what the residents actually bring to the equation. For example, coping patterns help residents preserve their individuality and spite of declining health. We will apply a developmental theory called selective optimization and compensation and discuss how a greater understanding of how older people adapt to the changes of aging can serve to refine quality of care strategies. Research in Positive Psychology suggests at least 16 specific factors that seem to influence a resident’s is subjective sense of well-being.

Quality Care and Quality of Life

In many cases quality care patterns have a direct impact on resident quality of living. A safe and timely pattern of care with can lead to a sense of security. Technically proficient healthcare can lead to optimal health and increased levels of functioning. Personal attention and individualized care programs that engage the individual in their own care lead to a sense of autonomy and self-determination. Patterns of care which are respectful of individual needs and values into affirm personhood and reinforce the continuity of the self concept. A higher-quality life comes from recognition by caregivers of individuality as does respect by caregivers to the right to privacy. Even for dementia patients there needs to be continuity with the past and respect for the continuation of social roles important to the individual earlier in life. People are not constituted in a way that allows them to lie in bed hour after hour, day after day, week after week, month after month as the months turn into years. An environment must provide opportunities for activities appropriate to age and skills no matter what the disability.

Preservation of the Self

Sheldon Tobin in his book Preservation of the Self in the Oldest Years points out that those who design and long-term care must take into account the way older people, particularly those over the age of 85, strive to cope with the stress of changes that threaten their sense of self. He divides the coping methods into two classes: rational coping techniques in less than rational coping techniques. The preservation of the sense of self is served by ensuring residents are involved in affirming meaningful activities. They need to have at least a measure of control over daily activities and over social interactions. In too many nursing homes neither of these is the case. He points out that successful coping with the challenges of advanced age involves a contraction of one’s personal space, sense of time and the numbers of people with whom one has significant relationships. However contraction cannot mean elimination and providers of care in LTC must realize this. For example, a couple may have traveled widely and sailed all along the East Coast in earlier years but now must confine their travel to radius 60 miles from their assisted living facility. But travel they can. At the age of 30 that are decades of future ahead at the age of 85 the future is a matter of years at best. In earlier years a person may associate with hundreds or even thousands of people but in the older years associations may be restricted to family and only the closest of friends. Such constrictions are appropriate ways to cope. However, Tobin also points out that are less rational coping techniques. The older person may deny reality completely. Is as an example they may continue to believe in their driving ability well beyond the point at which they should recognize this limitation. Under stress the older person may become more aggressive because this gives them the illusion of continued control. When that is the case punishment of the aggression only leads to more aggression. The older person may blame others for things other than admit to themselves that they are vulnerable. There’s no better example of this in the dementia patient who blames thievery by staff for items they have misplaced or lost. In short older people will go to great lengths to protect their sense of self.