Challenging behaviour in dementia care: a novel framework for translating knowledge to practice
Authors: James Ian A. , Reichelt Katharina , Moniz-Cook Esme , Lee Katy 
Published: October 2020

Abstract
This article provides guidance on the management of challenging behaviours (CBs) in dementia care, and introduces concepts from positive behavioural support not usually applied to dementia. While the use of formulations has received a lot of attention in recent years, the mechanisms of how to apply the formulation-led interventions requires more consideration. In order to assist caregivers to deliver effective interventions we need to have a better understanding of the CBs we are attempting to manage, and also produce management strategies with clearer goals. Ideally we would also want caregivers to be able to describe the skills they employ in a coherent manner in order to facilitate self-reflection and to be able to pass on their skills to junior colleagues. This paper attempts to fulfil these needs by integrating two new models with philosophies already used in dementia care. In terms of new concepts, the first is the Arousal Cycle, which gives caregivers an awareness of the five phases of a typical CB (wellbeing, trigger, escalation, CB, and recovery phase). In relation to the second, the Traffic Light analogy examines CBs in terms of four management stages: primary prevention, secondary prevention, reactive strategies, and calming strategies. It is proposed that we distinguish between these stages when composing our formulations and care plans, and thereby produce better targeted interventions. By the end of the paper the reader will have been presented with material integrating concepts from the fields of dementia and intellectual impairment, and been introduced to new ways of managing CBs.

Key learning aims
After reading this article people will:

(1)
Be provided with more specific guidance regarding the management of challenging behaviour (CB) in dementia; such guidance was not provided by the update of the NICE guidelines for dementia (2018).

(2)
Appreciate that the unmet needs perspective helps us both to understand why CB occur and to select appropriate management strategies.

(3)
Have an increased awareness and knowledge of new models from outside of the field of dementia. For example, through the use of the ‘arousal cycle’ people can recognise that a CB should more realistically be seen as having different phases (beginning, middle, end) rather than being perceived as a single action.

(4)
Be introduced to the traffic light conceptualisation which provides a useful way for guiding management strategies.

(5)
Be aware of when best to use resource-intensive formulations.

(6)
Recognise that in addition to conceptualising the person in relation to the CB, it is helpful to conceptualise the structural elements of the behaviour too.

(7)
Appreciate the need to help caregivers to recognise their existing skills, and to give carers the means to be able to articulate these abilities. Many care home staff currently work intuitively in the way they deliver care; as such we think they require practical frameworks and protocols to help them better elucidate what they do.