Behavioral interventions in memory care are designed to better address the complicated behavioral challenges that result from memory loss. Although this is not a new solution, stakeholders have historically been hesitant to implement behavioral interventions due to a lack of specialists in this field. They have instead focused on the easier alternative of pharmacological solutions like anti-psychotics. However, stakeholders should use a behavior-first approach to avoid negative outcomes and prevent escalating patients to higher levels of care.

Behavioral interventions in memory care focus on helping caregivers understand how dementia affects brain function, so that they can adjust how they interact with people with dementia. The goal is to understand and modify the underlying trigger for the behavior, rather than trying to control the behavior itself.

Examples of behavioral challenges:

• aggression and anger
• anxiety and agitation
• depression
• hallucinations
• confusion
• suspicions and delusions
• wandering
• sleep issues and sundowning
• repetition

Examples of behavioral interventions:

• speaking with either a professional therapist or a caregiver trained in behavioral health issues for memory care patients
• using familiar touch, sound, sight, taste, and smell to soothe anxiety or confusion
• using creative solutions to prevent common issues like incontinence or exit seeking
• electro convulsion therapy for treatment of depression

Many stakeholders agree that one of the most challenging aspects of memory care is dealing with the behavioral changes that come with memory loss. However, there is less agreement on how to best deal with these changes.

Behavioral challenges associated to memory loss are expected but challenging to manage. A normal consequence of dementia is the deterioration of the brain over time and subsequent changes to behavior. Patients eventually lose their ability to respond to their environment, converse with others, maintain socially expected norms of behavior, and control their movements. Although expected, these changes manifest in unique and often challenging ways that can cause problems in care centers—especially for understaffed care centers.

There is no easy, one-size-fits-all approach to managing behavior. Historically, providers have been slow to adopt behavioral interventions for patients with dementia due to the lack of, and cost, of behavioral health clinicians. Behavioral interventions for non-specialists can also be difficult to implement effectively without proper training. It often takes more time, and can cost more upfront, to identify the behavioral interventions needed for each patient than to use a pharmacologic interventions like anti-psychotics. When individuals’ behaviors are not properly managed, however, they typically end up in higher, more expensive levels of care.

1. Behavioral interventions prevent escalation to higher levels of care

To address the challenging behaviors related to memory loss, stakeholders should work to incorporate behavioral health into the broader care team as early as possible. When care centers and caregivers do not have adequate resources to support behavioral health concerns in dementia patients, they often find hospitalization the only option. This is particularly true in the later stages of the disease’s progression. People with dementia experience more than three times the hospitalization rate of older adults without cognitive impairment. However, once escalated to the hospital patients’ symptoms often worsen due to the confusion and the added stress of the new surroundings. Delirium develops in more than 50% of hospitalized patients with dementia. Not only does delirium increase morbidity and mortality, but it also creates additional costs to the health care system.

2. Behavioral interventions should precede pharmacological interventions

Most memory care patients who are in the later stages of the disease are already taking numerous prescriptions, and the additional medications used to treat difficult behaviors can easily lead to adverse drug effects and hospitalization. Additionally, a behavior-first approach prevents escalating patients to higher levels of care: studies show that when patients with memory loss go to the hospital, they often deteriorate more quickly, become more confused, and die quicker than those who are not placed under this additional mental stress.

There are three ways the healthcare industry can implement behavioral interventions for challenging behavior related to memory loss:

Although regulatory changes to incentivize and pay providers to implement more behavioral interventions for memory care patients, there are important reasons to implement them despite the up-front time and cost. Below are the headwinds and tailwinds for behavioral interventions:

Tailwinds

• Prevention of delirium and deterioration from the stress of hospital stay is a clinical and financial priority because it exacerbates health complications.
• Minimizes the use of pharmaceutical interventions which could lead to adverse drug effects and hospitalization.
• Helps prevent evictions from nursing homes. Although illegal, this can happen if facilities are ill-equipped to care for dementia patients.

Headwinds

• The cost per hour of a geriatric psychiatrists is expensive (upfront cost is high).
• There are not enough clinically-trained behavioral health workers to meet one-on-one with all the memory care patients who need them.
• There are regulatory barriers to implementing some behavioral health techniques, especially around restraining patients.
• Behavioral interventions require a lot of creativity and knowledge to determine what is best for each patient—there isn’t a one size fits all approach.

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