Back to accessibility links

Caring for Behavioural and Psychological Symptoms of Dementia Patients

Central Coast Local Health District
Project Added:
26 July 2011
Last updated:
7 October 2014

Caring for Behavioural and Psychological Symptoms of Dementia Patients

By Heather Lloyd ASET CNC, Wendy Ritchie RN and Liz Derwin CNS
Central Coast Local Health District


Following the closure of the dedicated Confused and Demented Elderly unit on the Central Coast, the Behavioural Assessment (BA) team was formed to address the gap identified between community, hospital and residential aged care facilities (RACF) in the management of residents with Behavioural and Psychological Symptoms of Dementia (BPSD).

The BA team changed the model of care to an In- and Out-reach service specialising in the management of the most difficult clients in the most appropriate environment. This means that they were not only able to see patients in the hospital it meant that they could see residents within RACF's and in their own home.


The service aims to:

  • Provide comprehensive specialist assessment with a person-centred focus
  • Acknowledge and embrace the individual's physical, emotional and psychosocial aspects of their life
  • Develop individualised management strategies to optimise choice and quality of life


The BA team

The BA team is comprised of nursing staff experienced in the management of patients with BPSD. It is supported by Geriatricians and the Geriatric Registrar, and works closely with Behavioral Assessment & Intervention Service (BASIS), RACF staff and Community Aged Care Services, General Practitioners, and hospital inpatient services.

Patient Assessment

The BA team provides a comprehensive specialist assessment with a person-centred focus. They consider:

  • the most optimum environment for the patient
  • whether a move is suitable and addresses the person's needs
  • will the person fit in with the other residents

Individual Behaviour Management Plan

The BA team develops an Individual Behaviour Management Plan. This document embraces the physical, emotional and psychosocial aspects of a person's life and helps create an environment that promotes the individual's physical social and cultural well being. This plan assists those caring for the most challenging of these residents within their own environment and are supported by other health professionals.

An Individual Behaviour Management Plan is developed through:

  • Person centred "Life Story Album"
  • Involvement of family and carers
  • Medical problems, past and current
  • Social history - including memorable moments
  • Physical capabilities - such as mobility, ability to carry out Activities of Daily Living, communication issues, spiritual beliefs, cultural needs, diet, continence, vision and hearing and their usual sleep pattern.

Life Story Album

The Life story album for someone with dementia helps to restore the identity of the person because the dementing illness robs us of the person we once knew.

Reminiscing reviews one's life and validates one's experiences. Long term memory is often relatively intact reminiscing is therefore achievable.

The involvement of family and carers is integral in gaining valuable life and social history information about unique characteristics and hobbies are all really important.

Involvement of the family and carers is integral in gaining valuable life and social history to assist in the development of these plans with achievable goals.

The BPSD is addressed through identifying:

  • Underlying cause
  • Triggers for behaviour
  • Changes to routine
  • Changes to the environment
  • Medication
  • Recent life events
  • Previous management strategies that have been successful

It is important to first rule out any infections including, urinary, respiratory and various forms of cellulitis. The primary focus is on non-pharmacological behaviour management strategies and should these fail the use of medication may be required.

Support for RACF Staff and Carers

The BA team provide hands-on support to the RACF and/or carer to help settle the person and give advice on how to implement the behaviour management plan. This support takes various forms such as:

  • Explaining the differences between different types of challenging behaviours
  • Explaining that resident's behaviour is a form of communication
  • Education to RACF staff to assist them to identify the possible triggers for the behaviours and brainstorm for strategies
  • Lead by example, mirroring best practice, in the hope that the carer will be able to implement the strategies
  • For the person with these behaviours going into RACF for the first time, the BA team would work closely with the facility, the new resident and carer to help the transition
  • Continuing to review the person, their behaviours and surroundings in order to identify any underlying cause related to their BPSD
  • Follow-up visits
  • Information on support services
  • Referral to other services.


Greater numbers of the population have access to intervention before reaching crisis point.

August 2009 - February 2010 August 2010 - February 2011
Referals accepted 142 159
Inpatient visits 256 302
Community visits 428 493
Admissions avoided 50 64
Admissions required 11 14

These results show the program is increasingly Bridging the Gap for the BPSD resident on the Central Coast.


ASET Clinical Coordinator
Central Coast Local Health District
Phone: 02 4320 3980

Search Projects

Browse Projects

Submit your local innovation
and improvement project