Severe Behaviour Response Teams (SBRTs) are addressing the underlying causes of behavioural and psychological signs of distress in people living with dementia.

The Federal Government launched the pioneering initiative in November 2015. Almost a year later, the SBRTs, a mobile multidisciplinary workforce of nurse practitioners, nurses, allied health and specialist staff, have responded to about 400 referrals nation-wide.

Under the unique program, SBRTs work to treat the severe and very severe Behavioural and Psychological Symptoms of Dementia (BPSD), such as physical and verbal aggression, agitation, anxiety and wandering through to delusions, hallucinations, apathy and depression.

The teams also assist nursing and other care staff to resolve the issues and to develop a care plan to manage the behaviours while providing follow-up support.

Dementia Support Australia (DSA), a consortium led by HammondCare, runs the SBRTs and the Dementia Behaviour Management Advisory Service (DBMAS). All referrals to SBRTs are made through DBMAS, which then decides whether DBMAS or the SBRTs will provide the best response.

The SBRTs, which have offices in all states and territories across the nation, travel to Commonwealth Residential Aged Care Facilities within 48 hours of the SBRT receiving the referral.

Associate Professor Colm Cunningham, Director of the Dementia Centre at HammondCare and a nurse registered in the United Kingdom, says despite the teams being labelled as ‘flying squads’, the SBRTs are not an emergency service but instead provide a fast-paced response.

“Within four hours of referral from DBMAS, an SBRT consultant is triaged and within 48 hours we’re out there on the ground,” he says.

“It’s a national service going anywhere in Australia and there are teams populated right across the country or travelling to anywhere in the country.

“The other thing that is slightly different from the DBMAS is that we can work with people for longer.

“DBMAS is meant to be a short-term response in these contexts and we recognise there’s a lot of complexity if somebody has got to the point of being classed as needing an SBRT approach, so we could be working with somebody for up to six months.”

Understanding the person with dementia

Assoc Professor Cunningham says getting to know the person with dementia - their individual situation and story, is often pivotal to understanding a challenging behaviour.

Uncovering what causes the person’s behavioural changes and then addressing those factors instead of the actual behaviour, is more likely to alleviate distress and enhance the person’s quality of life, he adds.

In one case, an SBRT helped a woman who became distressed each time she was assisted to shower.

“What was picked up by the consultant was that while she was being showered, she was talking about water,” Assoc Professor Cunningham says.

“Now the staff were missing this because they were orientated to the task, they were focused on the fact that her personal care was the primary objective and that it was a heated situation.”

When speaking to the patient’s family, the consultant discovered the woman was passionate about conserving water, and had once regularly used the water from washing her dishes or showering to water her plants.

“You can imagine the distress of standing in a free-flowing shower, so it was about understanding her values and what distressed her,” Assoc Professor Cunningham says.

“The changes that were made were simple. Firstly, it’s important staff listen and watch. Staff should be allowed and supported to have the time to do that.

“It should be seen as an important use of their time. If they are seen as lazy doing that, then we’ve got a problem.

“Then, when they went to this person to have a shower, they talked about water conservation, so they immediately engaged with her values, so she knew these people who were coming to assist her, cared about the things that she cared about.

“When she got to the shower, they had adapted it and there were water conservation signs around the shower cubicle, so as she was being showered the message was clear that water mattered to everybody.

“Her behaviours didn’t go away completely but they were significantly reduced.”

Assoc Professor Cunningham says if staff better understand a person with dementia, they are more likely to change their approach to that person.

“It won’t probably be about one element of that, it won’t necessarily be about the signs in the shower, but it will be about the whole package.”

Wandering

One of the main behaviours SBRTs have been called to manage is people with dementia regularly experiencing anxiety or wandering in the afternoon and evening.

“If you start to look at the practice that’s happening, you may find, unintentionally, staff have been talking about what they’re going to do later in the day - they need to pick up the kids from school or get to Coles to do the shopping,” Assoc Professor Cunningham says.

“A person with dementia doesn’t have the filter on their ears that the staff are talking about themselves, and they are getting information in.

“Why wouldn’t I, if I have dementia and am dependent on my long-term memory, become agitated about leaving to pick up my kids because that memory and that responsibility has quite readily been stimulated unintentionally?

“One of the things we might basically help the team learn is that if they’re talking about their personal life, that might be for the staffroom.”

Physical environments and regimented care can also exacerbate symptoms of dementia, including BPSD.

Assoc Professor Cunningham says loud, busy environments can prompt many people living with dementia to seek quiet places.

“But if you cannot get away, if you cannot find the garden or if the doors are locked then that is going to agitate you,” he says.

“That wandering behaviour may well be for reasonable reasons of trying to find a space, or trying to get away from things, and if the doors to the garden are locked, then there’s going to be predictable problems.”

Pain management

Early SBRT data shows ineffective pain management is sparking challenging behaviour in up to 60 per cent of referral cases.

In one case, an SBRT was sent to assist with a female patient who was punching people.

“When the consultant actually stood back and watched the situation, she noticed that when people passed from the right, the woman didn’t punch them but when they passed her from the left, she punched out straight away,” Assoc Professor Cunningham says.

“The reason for that was that she would hear somebody coming and she would turn her head to the left, and there was something wrong with her neck, so as she turned, she got a jabbing pain in her neck. She associated that pain with the person that was coming and she punched out.

“When that was picked up, which takes time, she went on pain relief…and that behaviour was completely gone.”

Admission

Challenging behaviours in the early stages of admission, particularly in the first 6-12 weeks, are also prompting a large number of referrals to the SBRTs.

Assoc Professor Cunningham says it may be an issue of staff not being well prepared or supported for new residents.

“It’s a traumatic event for the person and the staff actually need to not just see it as business as usual,” he says.

“The staffing model needs to allow staff to have the time to get to know that person and to adjust to their needs.

“When you actually look at the amount of time we spend reacting to the behaviour, if we’d re-directed that energy into getting to know the person in transition we might not get some of these behaviours.”

To access SBRTs, referrals must be made via the 24-hour DBMAS helpline on 1800 699 799.