The management of challenging behaviour in people with dementia Dr G Theodoulou Consultant Older Adult Psychiatrist 7.9.16

Who am I?

Dementia Decline in two cognitive domains Impairment of ADLS Brain disease Six months duration Not easily reversible

Mind your language! Dementia sufferer Demented Senile or senile dementia Burden e.g. people are a burden or cause burden Victim Plague Epidemic Enemy of humanity Living death e.g. dementia is a living death

Person with dementia ‘Person centred care’- Kitwood 1997 Uniqueness of every individual’s experience of dementia

Behaviour that challenges ………..a manifestation of distress in the person with dementia or of distress in the carer…… Bird and Moniz-Cook 2008

What are the behaviours that challenge? Perceived aggression Agitation or restlessness; screaming Anxiety Depression Psychosis, delusions, hallucinations Repetitive vocalisation, cursing and swearing Sleep disturbance Shadowing (following the carer closely) Sundowning Travelling alone causing concern Non-specific behaviour disturbance e.g. hoarding, putting food in wardrobe

Newcastle model framework (James 2011)

Mental health, care home in-reach MH nurses Intensive input Smaller caseload (cf OACMHT) Use Newcastle model Use medication Consultant OA psych support Available in south Worcestershire Access via OACMHT

Medication for challenging behaviour Acetylcholinesterase inhibitors Memantine Benzodiazepines Antipsychotics Antidepressants Miscellaneous Consider capacity to consent, best interest decision + LPA for H&W

Acetylcholinesterase inhibitors Donepezil, Galantamine and Rivastigmine AD and DLB/PDD only May alleviate agitation May cause agitation May reduce psychosis Specialist initiation

Memantine Licensed for AD only NMDA receptor antagonist Reduces agitation Reduces psychosis Specialist initiation Can take up to 3 months for +ve effects

Benzodiazepines For rapid tranquilisation Lorazepam best Avoid diazepam- active long half life metabolite IMO- first line when there is severe distress or behaviour that puts PWD in harms way 0.25mg -0.5mg prn, Max 1.5mg/24hrs

Antipsychotics in dementia(1) Best avoided unless distressing psychosis, general severe distress or harmful behaviour Do more harm than good Only 10% gain benefit Increase risk of stroke, infection, DVT, MI, arrhythmia, constipation, dehydration, early death Before prescribing should try to evidence psycho-social intervention ineffective or not practicable

Antipsychotics (2) Risperidone 0.25mg to 1mg/24hrs Olanzapine 2.5mg to 5mg/24hrs Aripiprazole 2.5mg to 10mg/24hrs

Antidepressants in dementia High rate of depression in all dementias Best evidence for mirtazapine Mirtazapine 15-45mg/24hrs Sertraline 25-150mg/24hrs Venlafaxine 37.5-150mg/24hrs

Others Carbamazepine Pregabalin Melatonin Zopiclone Trazadone

….so in conclusion, the last professional a PWD and challenging behaviour needs to see is a psychiatrist!