No more calling them “behaviors”: Dignifying our Language, Honoring the Person

Half of us do not eat breakfast.  Yet the number one driving force in every nursing home every day for getting people up is breakfast.  When asked how they would react to being awakened to eat a meal they don’t want, people say “mad” and “angry.” Someone inevitably says they would be “non-compliant” and administered a psychotropic drug! Yep.  Unfortunately, this is the norm and this is Unnecessary Drugs.  This is restraining a person for the convenience of staff and adherence to the “almighty schedule.”  This is non-compliance with many federal requirements to honor a person’s preferences and choices.  What we’ve called behaviors aren’t really at all. They are either coping skills to defend something one doesn’t want and/or unmet needs; is anyone else crabby when they are hungry or tired? I contend so called “behaviors” are also unmet preferences. It’s time people become so well-known and preferences so well-honored that drugs are truly unnecessary.

A recent CMS Memo QSO-25-14-NH announcing Appendix PP updates went into effect 4/28/25. One set of changes is the following:

Chemical Restraints/Unnecessary Psychotropic Medication: The regulations and guidance for the unnecessary use of psychotropics (F758) have been incorporated into F605. This change will help to streamline the survey process, increase consistency, and strengthen our message that facilities must prevent the unnecessary use of psychotropic medications.

The guidance regarding “convenience” has been revised to include situations when medications are used to cause symptoms consistent with sedation and/or require less effort by facility staff to meet the resident’s needs.

What do psychotropic drugs do to a person? Dr. Al Power says it makes people “calmatose.” Now, there’s a powerful word. He goes on to say psychotropics, “Make people quieter; they’re not complaining, they’re not talking, they’re not ‘bothering us’. Have we brought more happiness and well-being, or have we simply made them quieter?  And is that ‘quietude’ a prelude to a more serious drug complication?” (Dementia Beyond Drugs, 2010).  Whoa. Bring that to your quality assurance/performance improvement team and talk about it with your medical director.

Is the “calmatose” and “quietude” evidence of sedation that inevitably creates “convenience” and less effort needed by team members to meet peoples’ needs? Hard questions. To be honest, we were much more ahead of this over ten years ago. Hopefully you work in a team for which this is not an issue. If not, become a leader.

Another physician, Cheryl Phillips, MD of LeadingAge makes another great point: “How do we create a caringenvironment that better supports them rather than treating their symptoms with medication?” (HCPRO.com 2/2016).  Caring environment. We should use the word caring much more than the word care. Care is overused: medical care, clinical care, care plan, care center, dementia care, person-centered care. Life is much more than care and we inadvertently keep the concept of the life one is living down when we only talk about care. I propose we talk much more about the life people are actually living in this, their home (not a facility, not a care center and not a homelike environment).

For fun and to make a point, consider sprinkling the word caring around. We are a caring team. We take caringfor people seriously.

We’ve used psychotropics to “treat” what? Is it even fair to the person to call them “behaviors?” Another famous quote that has helped me learn and grow in my journey is this: “Behaviors are not problems, behaviors are messages.” Rose Marie Fagan, the founding executive director of the Pioneer Network was first an ombudsman and tells The Story of Ed. Ed lived in a nursing home and was apparently peeing in the plants. The team called her. She came. She met people including Ed, conversed with him for a while and eventually got around to asking, “So Ed, what is this about you peeing in the plants?” Ed’s reply? “It got you here, didn’t it?”

This story convinced me to refer to the person’s communication or message rather than behavior. It seems fair and appropriate. The term behavior ends up with a negative connotation which brings that negative connotation to the person themselves almost leading us to see the person as the behavior and as the problem. I once heard two older people speak at a conference in Canada. They both lived in a nursing home. They reminded us, “We are people with problems. We are not the problem.” So true.

Here is more thinking along those lines.

Behavior is communication: It is not the dementia that causes the behavior, it is the dementia which prevents the person from expressing the cause of their distress.

Anti-psychotics may remove the person’s only means of communication (and not be responsive to the underlying problem).

Care settings tend to want the person to conform to the needs of the setting, which means not only that the person’s needs may not be met adequately or in a timely manner, but that the setting itself may be causing the person’s distress. (HCPRO.com 2/2016)

Some refer to unmet needs instead of behaviors. Also good.

CaringKind brings another point.

“Behavior” suggests the person has control over their actions and can change if we tell them to.

“Distress” suggests we should seek the reason for the person’s discomfort and address it on their behalf (www.caringkindnyc.org).

Have you noticed that the terminology of distress has entered in? Personally, I think it matches what is going on. In fact, CMS has moved on from behavioral symptoms to instead “expressions or indications of distress” (CMS Appendix PP 11/24). This is good.

So, what words will you use instead of “behaviors” or “behavioral symptoms”?

What is the communication/message?

What are the unmet needs?

What do these expressions or indications of distress reference?

Next article we will keep going and bring up identifying stressors and what preferences might have to do with it….

Carmen Bowman, MHS, Regulator turned Educator of Edu-Catering: Catering Education for Compliance and Changing Institutional Culture is an activities/engagement/community life, regulatory compliance and culture change consultant.  She offers new or not-yet-qualified activity director consultation and personalized continuing education for professionals/teams/associations. At www.edu-catering.com join The Be Encouraged Blog, Become a Leader of Normal Life with the eResource GUARDIANS OF NORMAL LIFE: How Activity/ Recreation/ Engagement/Community Life Professionals can Save the World of LTC and share with your team the eBook Individualizing Medication Administration using Regulations. At the Edu-Catering YouTube channel, see the documentary that highlights changing institutional language Life Care Center of Casper Wyoming Culture Change Video 2023.