Managing behaviours that challenge within English care homes: an exploration of current practices

Behaviour that challenges in people with dementia is complex and multifactorial; there is no single solution for its management. In 2009 the Department of Health in England called for a reduction in the use of antipsychotics for people with dementia. Instead, individualised non-pharmacological interventions were recommended first-line. The aim of this study was to explore how behaviour that challenges in people with dementia is managed by care homes in England, and how they are managed in practice.

The study used a mixed methods approach, incorporating five phases. Interviews were conducted with 41 care staff and managers from 11 care homes in South-East England, alongside observations of the care environment. Pilot interviews from this phase informed the design of a cross-sectional survey, distributed nationally (25.1% response rate). Three care homes participated in an ethnographic study of 12 residents and 17 care staff, involving 204 hours of participant observation. Exploring the use of medicines in each of the three homes sought to investigate the appropriateness of the medicines prescribed and the mechanisms of recording medicines administration. Finally, interviews with residents’ relatives provided an alternative perspective of managing behaviour that challenges in dementia.

The findings from this study suggest that there is no one way to manage behaviour that challenges in dementia. Care staff did not believe that one size fits all, and the management of these behaviours changes from day to day and from person to person. Varying strategies were used; however these were not those advocated by practice guidelines, instead involving predominantly distraction and emotional reassurance. The level of antipsychotic use was lower than anticipated, however there was extensive use of other medications which were found to be questionable, indicating that perhaps the problems of managing behaviour that challenges are still present. Finally, relatives of people with dementia have valuable experience and opinion which must not be overlooked by researchers, or care home managers and staff.

This thesis provides an important examination of the ways in which behaviours that challenge in people with dementia are managed by care homes in England. It provides a picture of how care is delivered to people with dementia in care homes, particularly during incidents of behaviour that challenges. It has established the ways in which people with dementia are cared for during these incidents, and has exposed that, rather than following current guidelines, knowing the resident, understanding causes of the behaviour, use of the care team and the use of the care environment play a vital role in enabling staff to manage these behaviours.