Using the Johns Hopkins 5-D Approach to Behavioral Problems in Dementia

De-Mystifying Behavioral Challenges

By Guest author Ann s. Morrison PhD, RN

Johns Hopkins Memory Disorders and Treatment Center

Baltimore, Maryland

Accurately and completely describing and defining behavioral problems is the most important step in identifying effective solutions.  Patients are unique and the solutions to their problems are often just as unique.  Use a systematic approach to assessing behavioral problems

Think of behavioral problems occurring in concert with one another.  Try to identify the relationships and effects that behavioral problems have upon each other.  For instance, irritability can grow into aggression if one forces a task upon a person with dementia.

Using a systematic dementia specific approach to evaluating behavioral problems can help caregivers to find multiple solutions to behavioral issues.  At Johns Hopkins we developed the 5-D approach to dementia care.  We use the 5-D system to generate solutions to behavioral problems.

1. Describe and define problem

a. who, what, when, where, antecedents

2. Decode behavior and think of all the issues that may be contributing to the problem

a. Problems of thinking and memory

amnesia, agnosia, apraxia, aphasia

b. Psychiatric Problems

depression, agitation, apathy, delusions

c. Physical Medical Problems

pain, fatigue, medication side effects, infection, vision and hearing loss, stroke/infarct

d. Environmental Problems

noise, distractions, heat or cold, too much stimulation

e. Caregiver Approach

hurried, angry, arguing, excess demand,  inappropriate assessment of problems

f.  Ineffective Plan of Care

poor scheduling, lack of routine, changes (of caregiver, location, foods), failure to consider preferences

3. Devise a plan

Try to identify all the possible reasons that may contribute to the behavioral problem.  For instance, a person who refuses to change clothes may have:  apraxia (uncoordination),  depression (makes people less interested in appearance), arthritis pain (hurts to move), feels cold (room too cold), being hurried along (creates stress) and cooperates poorly in the morning (wait till afternoon to change).

Try the most logical things first to solve behavioral issues.  Use resources such as this website (fill in here and any usual thing you recommend) for potential solutions to behavioral issues.

4. Do the plan

Set a goal of reducing the problem first.  Changes to care must be consistent.  Each care provider needs to approach the problem in the same manner in order to create a new behavior.

5. Determine effectiveness, re-design plan

Assume that you may have to refine and sometimes re-design your plan of care.  This is a process.  A little improvement is a worthy goal.  Figure out what part of the plan worked and keep that piece.  Try to add other strategies to the plan over time

A reduction in behavioral problems is considered success.  At times we aren’t able to reduce or eliminate problem behaviors.  In that case, we need to learn to change the way we view the situation.  Dementia is the culprit causing the issues.  Being flexible and accepting changes is a way to tolerate challenging behaviors.  Even the most difficult behavioral issues won’t last forever.  As the dementia progresses the behavioral response changes.  Agitated, irritable care recipients become more docile over time as the brain continues to change.  All things will pass.  We need to hang in there long enough to see the other side.

Practical Dementia Care. (1999) Rabins, P., Lyketsos, C., Steele, C.  Oxford University Press