Changes in the brain in advanced stages of HIV infection can produce behavioral changes that are challenging to manage. Hyperactivity, impulsiveness, anger/agitation, manipulation and general forgetfulness are among some of the behaviors persons with HIV may exhibit. It is important to keep in mind that these behaviors are generally not personal attacks against caregivers. Disinhibition may occur along with cognitive changes. The ability to distinguish inappropriate from appropriate behavior is lost, and the person says or does whatever is on his/her mind, lacking the awareness of how it is perceived by others. For example, Monique reaches across the table and takes John's dessert off the plate and proceeds to eat it without realizing that this is inappropriate. Manipulative behaviors can have an impact on caregivers. A client may ask several people the same question not acknowledging the repetitiveness because of impaired memory. In contrast, the client may purposefully engage in manipulative behaviors by going from one person to the next in an attempt to have a desire fulfilled. Misrepresenting what one staff member said may manipulate another staff member to provide the desired effect. For example, some days John approaches the social worker and asks for a cigarette after being told by the nurse that he was not allowed to smoke at this time. John explains to the social worker that the nurse said it was OK for him to smoke. He asks if the social worker would give him a cigarette because the nurse is too busy.

This graphic may help you determine the influencing factors which may contribute toward behaviors that are difficult to manage. After identifying "triggers" to certain behavior(s), strategies can be implemented to modify and/or eliminate undesirable reactions.(Perez, Proffitt, Calkins, 2001)

1. IDENTIFY THE PROBLEM
a. Terrel exhibits verbal outbursts of anger.

2. RECORD THE BEHAVIOR
a. Monitor the who, what, when, why of the situation.
b. Record on the tracking form the circumstances revolving around each episode of behavior.
c. Try to find a pattern - Terrel displays agitated behaviors one hour after breakfast.

3. LEARN ABOUT PREVIOUS HISTORY
a. Gather information from family about past patterns of behavior. - Terrel's mother said the he was never a "morning person". His best time of day was early evening.

4. ESTABLISH AN INTERVENTION STRATEGY
a. Meet with the group of people responsible for Terrel's care.

5. PUT THE STRATEGY TO WORK
a. Decide which strategy will work the best, discuss the strategy with staff/caregivers, and implement it.
b. Allow Terrel to lie down for 1 hour after breakfast and hold conversation to a minimum.

6. RE-ASSESS
a. If your plan is not producing the desired outcome, begin the tracking process again. Terrel still exhibits angry behaviors even after a rest in the morning.

The following is a behavior tracking form to monitor and log each behavior that is being observed.

Other effective strategies to help manage challenging behaviors:

• Develop a written contract ("This is what I expect from you and this is what I will provide to you"). Each party will sign it and adhere to it.
• Daily memory book (a log of important care issues to refer to when needed).
• Help the individual identify triggers that elicit undesirable behaviors.

Whether the behaviors are a result of HIV infection, depression, mental illness, drug or alcohol abuse or a reaction to medications, it is important to realize that individuals with these issues may exhibit inappropriate behaviors directed toward caregivers and others. Providing caregivers with insight into the nature of these behaviors can provide effective coping strategies.