Dedicated to helping Activity Professionals with the daily operation of their department.
by Debbie Hommel, BA, CRA, ACC, Executive Director of DH Special Services.
Let Debbie answer your
Activity Questions
About Debbie

Debbie Hommel, BA, CRA, ACC,
is the Executive Director of DH
Special Services. She is a
Certified Activity Consultant on
State and National level, with
over twenty-seven years of
experience in providing direct
care and consultation to long
term care, medical day care,
assisted living, and ICF/MR
facilities throughout New Jersey,
New York, Maryland, and
Pennsylvania. She is an
experienced trainer and
workshop presenter, conducting
a variety of seminars throughout
the Tri-State area for the Activity
Professional, Administrator, and
allied healthcare professional.
Debbie Hommel is an active
member of Activity Professional
Associations on State and
National levels. She is ACC
certified through the NCCAP.
She is a founding member of
the New Jersey Activity
Professionals' Association,
serving terms as Vice President
and President. She received the
Weidner Lifetime Achievement
Award in 1994 and the
Monmouth & Ocean County
Activity Professionals Life
Achievement Award in 1999.
Providing Internet Resources
for Activity Professionals
in Long Term Care Settings

Copyright 2004-Present
The Activity Director's Office
All Rights Reserved

Understanding Behavioral Symptoms
by Debbie Hommel, ACC, CTRS

“She has a problem behavior” or “We need to call a psych consult in for his problem behavior”
are statements sometimes heard amongst health care professionals working in long term care
settings.  Caregivers are quick to cite the resident as a problem because of difficult or
“problematic” behavior.  In order to truly address the needs of residents or clients who may be
exhibiting behavioral symptoms, the caregiver needs to understand the dynamics of human
behavior as well as the undercurrents of dementing illnesses.  

Behavior is defined as the actions or reactions of a person in response to internal or external
stimuli.  This definition applies to all people, of any age or gender.  The very first lesson in
understanding negative behaviors is that all behaviors are driven and motivated by some
internal or external force.  It is common practice to put the elder in a different category and to
label the behavior “inappropriate”.  However, if we were to put ourselves in the elder’s shoes
and see the world through their eyes, the behavior is not as inappropriate as originally

The dilemma many residents/clients with memory impairments experience is that they see and
process the world differently.   Their perception of conversations, the environment and events
around them are altered and not always accurate.  However, even if their perceptions are not
accurate, their feelings associated with their perceptions are real.  An important lesson in
understanding challenging behaviors amongst the elderly is to view the behavior as a symptom
which is trying to communicate something rather than a problem that needs to be stopped.  

Behavior is provoked by a number of causes which can often be divided into two categories:
internal stimuli and external stimuli.  Examples of internal stimuli might be pain or hunger.  
Whereas external stimuli might be a noisy environment or being approached too abruptly.   
Although stimuli may be divided into two lists, the causes are often inter-connected.  For
example, a strange and unfamiliar environment is an external stimuli but it also provokes a
response of uneasiness which would be an internal stimuli.   
The easiest way to resolve negative behavioral symptoms is to identify the cause.  If the cause
can be identified, then it can be resolved.  

Unfortunately, determining the cause of behavior is not easy in many cases.  Elders with
memory loss often cannot articulate their unmet needs or discomforts.  In order to bridge this
barrier, the caregivers need to follow a consistent protocol to identify potential causes.  
Evaluating physical needs first is the standard approach.  Is the elder hungry, thirsty, in some
discomfort due to pain, needing to be re-positioned or changed?  The solution, in these cases,
would be to address the physical need.   Once the need is met or discomfort resolved, the
elder is often easily engaged in re-directed.

The second area to review for cause of behavior might be emotional needs.  Fear, anxiety,
anger, sadness, boredom and frustration are common emotions.  The elder with memory loss
may have difficulty coping or managing these emotions, causing them to be expressed in
inappropriate ways.  The caregiver needs to explore any emotional response and respond to it
as a valid emotion.  When an emotion is expressed (by any person, at any age), the emotion
has meaning and is valid to the person expressing it.  An inappropriate caregiver response
would be to minimize the expressed emotion and suggest the elder should not be feeling or
behaving the way they are.  Although offered in a way to comfort the elder, implying the
emotion is not important generally causes more frustration.

The third area to review for a cause of behavior would be environmental causes.  Too much
noise, bright lights, dim light, the hyper-activity of the nursing unit or unfamiliar surroundings
can contribute to over stimulation or stress.  Individuals with memory loss have difficulty
processing external cues and have a reduced ability to process multiple cues.  Sometimes
simply removing the elder from the stressful environment is a solution.  

One final area to evaluate for a potential cause of behavior is the caregiver. Inadvertently, the
caregiver causes negative responses or behaviors.  Approaching the elder too quickly,
presenting too many requests at once and not allowing time to process request can cause a
negative response.   The tone of voice, rate of speech, vocabulary use and non-verbal
messages can also contribute to the elder’s understanding or lack of understanding.  
Experienced caregivers learn quickly to approach the elder a particular way and to allow ample
time for processing and response.  

Assessing the causes of symptomatic behavior is a team approach requiring observational
skills and an empathetic touch.   Consistency and compassion allow the caregiver to better
understand why the elder may be acting out, responding negatively or seeking attention in a
particular situation.   If the caregivers share the belief that all behavior is purposeful, the team
will be empowered to address the needs that the elder is expressed.  
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