The 6 R’s of Managing Difficult Behavior (from The 36-Hour Day)

The Johns Hopkins Health Alert from Monday may be of interest to those dealing
with challenging behavior. It’s on “The 6 R’s of Managing Difficult Behavior,”
according to Dr. Peter Rabins and Nancy Mace, as discussed in their book The
36-Hour Day, which I highly recommend to anyone dealing with dementia.

The 6 R’s are:
* Restrict
* Reassess
* Reconsider
* Rechannel
* Reassure
* Review

You can sign up for these health alerts (they come to your email) here:


The 6 R’s of Managing Difficult Behavior
Johns Hopkins Health Alert: Memory
Dated 1/4/10

Restrict, Reassess, Reconsider, Rechannel, Reassure, Review

In their groundbreaking book on Alzheimer’s caregiving — The 36-Hour Day — Peter Rabins, M.D. (author of the Johns Hopkins Memory White Paper) and Nancy Mace discuss the six R’s of managing difficult behavior in people with dementia. Here they are…

People with dementia often exhibit behaviors that are frustrating, embarrassing, and sometimes even dangerous to the caregiver and others. These may include angry outbursts, agitation, aggression, wandering, vocalizations, hoarding or hiding things, and inappropriate sexual behavior.

For many caregivers, these difficult behaviors are the most challenging and exhausting aspect of caring for a person with dementia. Unfortunately, the available medications to treat Alzheimer’s disease have little effect on behavioral problems.

Here are Dr. Rabins’ six coping strategies:

Dementia Strategy 1 — Restrict. First, calmly attempt to get the person to stop the behavior, especially if the behavior is potentially dangerous.

Dementia Strategy 2 — Reassess. Consider what might have provoked the behavior. Could a physical problem (toothache, urinary tract infection, osteoarthritis) be behind the agitation or anger? Is a particular person or the noise level in the room triggering the negative reaction? Could the time of day and fatigue be contributing to the problem?

Dementia Strategy 3 — Reconsider. Put yourself in the dementia patient’s shoes. Try to imagine what it must be like to not understand what is happening to you or to be unable to accomplish a simple task. Consider how frustrating or upsetting the current situation or environment might be for a person with dementia.

Dementia Strategy 4 — Rechannel. Try to redirect the behavior to a safer, less disruptive activity. For example, if the person constantly disassembles household items, try finding simple unused devices, such as an old telephone or a fishing reel, that can be taken apart and put back together repeatedly. For someone who hoards or hides things, put away valuables and replace them with an array of inexpensive items.

Distraction often works well to curtail disruptive repetitive behaviors and restlessness. For example, try asking the person you’re caring for to “help” with simple tasks, such as holding spoons or potholders while you cook.

Dementia Strategy 5 — Reassure. The demented person’s brain injury and the resulting confusion and frustration can lead to anger, anxiety, and outright fear in certain situations. Calmly reassure the person that everything is okay and that you will continue to take care of him or her.

Dementia Strategy 6 — Review. After an unsettling experience with your loved one, take time to review how you managed the problem and what you might have done differently. Think about what may have triggered the problem, how it might have been avoided, and what you might try the next time a similar situation arises.

It also helps to create a patient-friendly environment. This might include soothing music in the background; pictures, words, or arrows to help orient the person in the house; or a secure place to sit outside or walk in the backyard.