Vocally Disruptive Behaviour

Preventing and managing vocally disruptive behaviour

The following scenario describes the recommended approach and responses to preventing and managing vocally disruptive behaviour. Below the flow chart you will find specific strategies to manage verbal disruption.

Unmet physical needs

People with dementia are unlikely to be able to communicate discomfort from:

  • Acute medical problems – pain, infection, unwell.
  • Incontinence, constipation or wanting to go to the toilet.
  • Awkward or uncomfortable positioning.
  • Sleep disturbances – often result in fatigue and may increase agitation and confusion.
  • Feeling too hot or too cold.
  • Sensory impairment.
  • Limited freedom of movement, eg restraint.

Psychological distress

Calling out may be the only way that the person is able to communicate sadness, frustration or distress. Vocal disruption may indicate:

  • Anxiety – the person may be seeking comfort.
  • Feelings of anger, frustration, resentment, hopelessness etc.

Environmental factors

  • Overstimulating environment – an environment that is cluttered and noisy will lead to agitation, irritability, stress and confusion not only for the person but also for carers and families. Unpleasant aromas can add to a person’s distress and agitation.
  • Lack of stimulation or social contact – Studies have shown that residents in aged care facilities lack social contact. One study found that 95 per cent of the time elderly patients have no contact with nursing staff (Armstrong, E. 1989). Often, the only contact patients have with staff is when they are providing specific and basic nursing care.
  • Repetitive behaviour can result from loneliness and boredom – the value of frequent personal attention by staff cannot be underestimated.
  • Not being able to see and watch what is going on around the person can contribute to a person’s sense of isolation, loneliness and fear.

What can we do about it?

Take a few minutes to close your eyes and identify the sounds and smells around you. Think about how they make you feel and then imagine them from the perspective of a person with dementia. How can you change the environment to improve the sounds and smells and make the environment more comfortable for people with dementia?

Look for possible underlying reasons behind the behaviour and deal with them. For example, if someone always starts yelling when you sit them in a certain chair, they may do so because they are uncomfortable, don’t like the people around them, can’t see what’s going on around them, can see too much of what’s going on around them etc. Interventions really depend on the cause.

Talk to other staff, family and friends to get a good picture of when the yelling occurs. Try to find out if there is any precipitating factor and work from there. Try one intervention and if that doesn’t work try another. But remember, there is always a reason.

Complete a behaviour chart over one or two weeks to identify a pattern to the behaviour and to identify activating events.

Some practical management strategies

Non-pharmaceutical strategies such as one to one social contact and communication-based activities related to the person’s past interests have been shown to significantly reduce verbal disruptive behaviours and agitation, resulting in an improved quality of life for the person with dementia.

  • distract the person by introducing other enjoyable activities.
  • avoid reminding the person that they have already asked the question; try distracting them instead.
  • use memory aids for people who can read, such as written labels on objects, notes for them to use as a memory prod and a whiteboard with the day’s activities/schedule.
  • try giving a different response or turning the question into a discussion.
  • try to understand why the person is repeating the question and respond to any underlying feelings.

Other strategies

Please refer to: the Ten Top Tips for dealing with people who have dementia, and; Communication strategies

  • Increase social contact and meaningful activity:
  • Establish formal activity periods outside of the mandatory nursing care routines. Contact should be one on one and involve verbal communication. Know and use the residents past skills and interests. For example, if the resident enjoyed housework encourage them to help fold the laundry or allow them to have a basket of towels and dusters in their room. Encourage a walk in the garden if this was an area of interest.
  • Use sensory techniques such as massage; provide visual cues through touch.
  • Encourage light exercise.
  • Encourage the family to create a video of family having conversation and reminiscing about special events, or a memory book of photographs and special memories to help with conversation.
  • reduce stressful stimuli or increase stimulation
  • communicate continually with the resident during the task at hand
  • alter the stimulation level according to need eg if overstimulated, place in a quieter environment; if under-stimulated, place in an area such as the lounge room.
  • Provide adequate meals/snacks/fluids to prevent hunger and thirst.
  • Initiate an individual toileting regime and change promptly after incontinent episodes.
  • Allow/encourage rest periods to prevent fatigue.
  • Provide frequent positioning changes/massage for people who are immobile.
  • Check environment and maximise cognitive capacity through orientation cues such as notes, signs, diagrams, calendars and personal items of significance.

References and recommended reading

Alzheimer's Association Australia (2000). Help Sheets for people with dementia and their families and carers. Alzheimer's Association Australia. [available online] http://www.alzheimers.com.au/.

Armstrong-Esther, C.A. Browne, K.D. & McAfee, J.G. (1994). Elderly patients: still sitting clean and quietly. Journal of Advanced Nursing, Vol.19., pp264-271.

Cohen-Mansfield, J. (2001). Nonpharmacological interventions for inappropriate behaviours in dementia. The American Journal of Geriatric Psychiatry, Vol.9:No.4., pp.361-376.

Keane, B. & Dixon, C. (1999). Caring for people with problem behaviours. 2nd Ed. Ausmed Publications, Australia.

Robinson, A. Spencer, B. & White, L. (1991). Understanding Difficult Behaviours: Some practical suggestions for coping with Alzheimer's Disease and related illnesses. Eastern Michigan University, USA.

Salmon, P. (1993). Interactions of nurses with elderly patients: relationship to nurses' attitudes and to formal activity periods. Journal of Advanced Nursing, Vol.18.. pp.14-19 Santo Pietro, M.J. & Ostuni, E. (1997). Successful communication with Alzheimer's Disease Patients - An In-service Manual. Boston:MA, Butterworth-Heinemann.

White, M.K. Kaas, M.J. & Richie, M.F. (1996). Vocally Disruptive Behaviour. Journal of Gerontological Nursing, Vol.22: No.11., pp.23-29.