How to manage attention-seeking behavior in a resident?

Management of Attention-Seeking Behavior in Nursing Home Residents

Begin with a comprehensive medical and psychiatric assessment to rule out underlying treatable causes, then implement structured nonpharmacological behavioral interventions as first-line treatment, reserving pharmacological management only for cases with co-existing psychiatric conditions like depression or anxiety that persist despite behavioral approaches.

Initial Assessment Framework

All residents with attention-seeking or other behavioral symptoms require systematic evaluation for underlying medical and psychiatric causes before attributing behavior to personality or manipulation 1.

Medical Evaluation

• Check vital signs and evaluate for infections, dehydration, pain or discomfort, delirium, fecal impaction, and injury 1
• Assess for adverse medication effects, drug interactions, and substance withdrawal 1
• Evaluate for sensory deficits (vision, hearing) that may contribute to behavioral symptoms 1

Psychiatric Assessment

• Screen for depression, anxiety, sleep disorders, psychosis, and other neurological conditions 1
• Assess environmental, situational, social, and psychological factors contributing to the behavior 1
• Describe and quantify the specific behavioral symptoms (verbal, nonverbal, physical) rather than using vague terms 1

First-Line Treatment: Nonpharmacological Interventions

After medical conditions are assessed and treated, initial treatment should be nonpharmacological when there is no psychotic features and no immediate danger 1.

Behavioral Strategies

• Implement the "three R's" approach: Repeat simple instructions, Reassure the patient, and Redirect attention 2, 3
• Use behavioral theory treatments that reward appropriate behavior and minimize reinforcement of attention-seeking behaviors 1
• Maintain consistent daily routines to reduce confusion and provide predictable structure 2

Environmental Modifications

• Create a homelike physical environment with spontaneity generated by children, pets, and plants 1
• Reduce excess stimulation while ensuring adequate social contact 3
• Modify activities of daily living care to meet individual needs 1

Social and Activity Interventions

• Increase meaningful social activities such as sheltered workshops, volunteering, religious activities, or activities that maintain past roles 1
• Provide sensory therapy and activities therapy administered by trained professionals or trained nursing home staff 1
• Ensure regular social contact interventions to address underlying needs for interaction 1

Staffing and Culture Considerations

• Adequate staffing is essential to strengthen staff-resident relationships through permanent staff assignments 1
• Enable nursing assistants to participate in interdisciplinary care planning 1
• Foster a nursing home culture that respects resident choice, autonomy, and decision-making 1

Interdisciplinary Care Planning

Assessment and treatment must be interdisciplinary, with individualized care plans involving families and incorporating information from both staff and family members 1.

• Develop individualized care plans based on the specific triggers and patterns of attention-seeking behavior 1
• Provide caregiver education on effective communication techniques and behavioral management strategies 3
• Involve caregivers in implementing behavioral interventions to improve adherence 2

When to Refer to Mental Health Professionals

Residents being treated with nonpharmacological interventions who show minimal or no improvement in 30 days should be referred to a mental health professional 1.

• If qualified mental health professionals are unavailable, qualified primary healthcare providers may perform these services 1
• Education and training of mental health professionals and nursing home staff in recognition, assessment, treatment, and monitoring of behavioral symptoms is essential 1

Pharmacological Management (When Indicated)

For Co-existing Depression

• If depression is identified as an underlying cause, SSRIs are the most appropriate first-line pharmacological treatment 1
• Start with low doses and monitor for effectiveness at 4-6 weeks 3

For Co-existing Anxiety

• SSRIs (citalopram 10-40 mg daily or sertraline 25-200 mg daily) are preferred for anxiety associated with dementia 3
• Reserve benzodiazepines only for severe, acute episodes, using lowest dose for shortest duration (ideally less than 2 weeks) 3

Important Medication Cautions

• Avoid antipsychotics due to FDA black box warnings for increased mortality risk in dementia patients 3
• Avoid anticholinergic medications as they worsen cognition and increase confusion 3
• Pharmacological treatments used only for behavioral symptoms should be evaluated for tapering or discontinuation at 6 months after stabilization, then every 6 months thereafter 1

Common Pitfalls to Avoid

• Do not assume all attention-seeking behavior is manipulative; it may represent unmet needs, pain, or treatable psychiatric conditions 1
• Avoid inconsistent staff responses that inadvertently reinforce problematic behaviors 4
• Do not overlook the situation-specific nature of attention-seeking behavior—different contexts may trigger different responses 4
• Ensure adequate staffing levels, as inadequate staffing prevents effective behavioral interventions and relationship-building 1