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Skip to 0 minutes and 7 secondsOwing to the ethical issues associated with the area, we have produced a four stage hierarchy of strategies about how to deal with people who are communicating with us in a confused and disorientated manner. We should first of all consider if it's possible for us to directly meet the person's need, which is associated with the incorrect beliefs. In the example, is it possible to let the person leave a dodgy hotel or to leave to go to work? Are these things safe? If we can anticipate and then support a person to meet their immediate needs, this should reduce any behaviours that challenge. In the case of Jack, the need he is expressing is a desire to go home.

Skip to 0 minutes and 49 secondsBut for Jack, this is not possible or would not be safe for him. So we can't directly meet Jack's need, and so we need to find other strategies or other ways of responding. We could think about how we could substitute or simulate the need in some way. To do this in Jack's case, we would need to consider why he's asking to go home. Does he miss his wife? Does he need support with something his wife would usually help him with? Talking to Jack about home and his family might help. Looking through family photographs would allow Jack to connect to people he recognises.

Skip to 1 minute and 30 secondsYou need to know the person, or get to know the person, as a one size fits all approach to understanding challenging behaviour doesn't work. Experience may tell you that these two first steps will not work or are not appropriate. A third stage is to consider distraction and redirection. If a person gets anxious at certain times of the day, we could anticipate this and use distraction to avoid a person becoming distressed. To do this, we would need to know something about the person's previous hobbies and interests. This is because we are required to successfully redirect their focus from their current belief and drive towards something else that will occupy their concentration and attention.

Skip to 2 minutes and 13 secondsThe last stage is to employ a non-confrontational approach, which can help to reduce aggression, anxiety, and other problem behaviours. So if we find that cuing memory or distraction does not work or adds to distress, we can consider the use of a therapeutic lie. In therapeutic lying, the intention is to reduce distress and keep a person safe rather than to deceive. We need to enter the world of the person with dementia, and perhaps go along with his belief, which we know is incorrect. Indeed, in some circumstances, it is necessary for us to give up being right and meet halfway in order to do things successfully.

Skip to 2 minutes and 56 secondsSo for example, in Jack's case, agreeing with him that he still has a problem with his leg allows us to suggest that he should stay in a care home until he's well enough to go home. This fits with his reality because he can see the bandage on his leg. In his moment of distress, he will need to be given reassurance that his situation will improve.

Meeting a person's needs - a 4 stage approach

If we are able to reduce the emotion in a situation, we are in a better position to assess what someone needs or wants. The next stage is then to ‘meet’ the person’s needs. In this animation, Ian describes a four stage hierarchy of strategies that can help us to do this.

He suggests we try each of these in order, depending on what is possible.

  1. directly meet the person’s need
  2. substitute or simulate the need
  3. distraction and redirection
  4. non-confrontational approach, e.g. go along with a person’s reality/therapeutic lie

We may choose to skip some of these steps if we know from experience that they do not work in a given situation, or with a particular person.

It is not always possible for us to meet a person’s needs. We may not interpret the situation correctly, we can have competing demands on our time, and it is likely that sometimes we will be tired and frustrated.

Getting support from family and friends whenever possible is really important. Speaking to other carers or getting some respite care can be really helpful. Your nearest carer organisation can direct you to what is available locally.

If you feel you need additional support, there are organisations that may be able to offer specialist advice and guidance. In the UK, you should ask your GP to refer you to a specialist in dealing with challenging behaviour.

Please refer to some of the links below for relevant support organisations.

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Dementia Care: Staying Connected and Living Well

Newcastle University

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