Trina's Notes

De-escalate changed behaviour or aggression in a person with dementia by being curious, open, and calm. Step into their reality, validate their emotion, gain their trust, and re-direct their attention.

Picture this:

It’s 1 am in the emergency department. Beeps from the cardiac monitors can be heard intermittently. Suddenly, you hear George from bed 35 yelling, “Get me out! Get me out! I want to get out of here!” How would you respond to this?

I would have been a bit scared. Certainly if George manages to get out of the ED trolley, he would be towering over me. There have already been instances in the past where my colleagues have been hurt. Some have been punched, others have been bitten. I would not want that to happen to me.

To de-escalate the situation, I would have tried to talk calmly by lowering my voice. I learned that from the book, “Never Split the Difference” by Chris Voss. Trying to use your FM DJ voice usually helps calm a stressful situation. I would try to re-orient George to where he was, what day it was, and why he was in ED. George calms down for a few moments.

Fast-forward a few minutes later, the same thing happens. We use the same tactic. Re-orient George to time, place, and person. That’s what we’ve always been taught. However, this time, George would continue on. Yelling and swearing, he tries to get his legs over the siderails. He would use all his might to get over it. What happens next?

Before George gets hurt from falling off the trolley, the staff assist button is pressed. The rest of the crew arrives. George gets sedated and falls asleep.

Was this a good outcome?

The De-Esc VR Training

Yesterday, I was among the lucky few to attend the first session of Dementia Australia‘s De-Esc VR Training at my workplace. This session focused on how to de-escalate behavioural emergency using a person-centered approach. In this workshop, we were immersed in a virtual reality scenario of a patient exhibiting a changed behaviour. How you respond to the situation would dictate the outcome of the scenario. Applying the same tactic above did not end well for me. The avatar I was playing ended up getting shoved into the ground.

Going back into the VR simulation again and tweaking my responses, here are the things that I did learn:

1. You need to be in control of yourself. Be confident, calm, and collected. Do not show fear, anxiety, or excitement. To help you get into that zone, try relaxation techniques like box breathing. Inhale slowly for 4 seconds. Hold your breath for 4 seconds. Exhale slowly for 4 seconds. Hold your breath for another 4 seconds. Then repeat until you feel calm. Use a low and calm voice. Make sure that your posture is open and relaxed.
2. You need to control the space. Know where your exits are. Scan the space to make sure others are also safe. Keep the space well-lit. Reduce stimulation by minimising noise and distraction. Have enough space between you and the person exhibiting changed behaviour.
3. You need to focus on the person. Be curious. Identify the stress trigger for the changed behaviour. Listen closely to what their saying. This will arm you with clues on how you can step into their reality. Hear them out and respond to their emotions.

Stepping into their reality

People living with dementia are “trapped” in their own reality. Arguing with their version of reality will only make the situation worse. This will only result in conflict, distrust, and further escalation of the changed behaviour. Stepping into their reality build rapport and fosters trust.

How then do you step into their reality?

Having a good knowledge of the person is essential. Know what their likes and dislikes. This can be tricky in the Emergency Department where you have just met the person and you barely know anything about them. Hence, a great tool that is recently being introduced in my workplace is the sunflower tool. Developed by the New South Wales Agency for Clinical Innovation, it provides a snapshot of the person’s preferences, likes, and dislikes. This personalised information can be used to connect with the person and help divert their attention from the problem. Posting this tool on the bedside would make it accessible to everyone caring for a person with dementia. It will help them connect with the person and de-escalate a behavioural emergency.

The highlight of the De-Esc VR training for me was how they modelled this approach in the scenario. Firstly, the responder approached in a calm manner. She made sure that the room was well lit. Then, she made sure that there was a ample open space between her and the person exhibiting a changed behaviour. Then, she engaged with the person by responding to their emotion. She then connected with the person by stepping into their reality. She asked him about things related to his current reality. She redirected his attention away from the problem by focusing on something else that he liked. This directly led to the de-escalation of the situation.

I have yet to try them in my own practice. Have you ever tried a person-centered approach to de-escalating a behavioural emergency? What worked well for you? What didn’t? Let me know in the comments below.