Dementia Conference 2014 Guildford & Waverley Clinical Commissioning Group Dr. Lia Ali Consultant Psychiatrist to G&W Virtual Ward

What do people with advanced dementia live with?

Aggression Physical aggression Verbal Aggression Aggressive resistance to care Agitation/Motor Wandering Restlessness Sleep disturbance Repetitive actions Screaming Apathy Withdrawn Lack of interest Amotivation Depression Sad Tearful Hopeless Guilty Anxiety Psychosis Hallucinations Delusions Misidentification Behavioural & Psychiatric Symptoms (BPSD)

Differing dementias Alzheimer’s disease Apathy, agitation, irritability, anxiety, depression, (delusions & hallucinations are less common) Vascular dementia Apathy, depression, delusions, emotional lability Corticobasal degeneration Depression Dementia with Lewy bodies & Dementia in Parkinson’s disease Visual hallucinations, delusions, depression, sleep disturbance (REM sleep-behaviour disorder) Progressive supranuclear palsy Apathy, disinhibition McKeith & Cummings 2005

Causes of BPSD Cognitive factors Biological factors Psychological factors Social factors - Neuroanatomy - Neurochemistry - Genetics Physical factors

Causes of BPSD Cognitive factors Biological factors Psychological factors Social factors Physical factors - Amnesia - Agnosia - Apraxia - Aphasia - Visuoperceptual - Executive function

Causes of BPSD Cognitive factors Biological factors Psychological factors Social factors Physical factors - Illness - Delirium - Pain - Medication - Fatigue - Constipation - Basic needs (dietary, toiletry)

Causes of BPSD Cognitive factors Biological factors Psychological factors Social factors - Social network - Family relationshipsSocial interactions (caregivers, residents) Physical factors

Causes of BPSD Cognitive factors Biological factors Psychological factors Social factors - Premorbid personality - Previous mental health - Previous trauma/losses - Adjustment - Lifelong coping strategies Physical factors

Causes of BPSD Cognitive factors Psychological factors Social factors Physical factors Environment Biological factors

Prevalence of BPSD varies at different stages of the disease process Earlier: Depression Anxiety Psychosis Later: Agitation Wandering Apathy Behavioural disturbance Cognition Severity Time BPSD: persistent throughout disease course Lovheim et al., (2008)

ABC chart ABC Chart for Mr X Please record ALL incidents of aggressive or inappropriate behaviour as this will help us to devise the most effective strategies for managing his behaviour. Antecedents Antecedents consist of both the setting conditions (which increase the likelihood of a behaviour occurring) and the immediate triggers to the behaviour. Setting conditions  How was the person feeling before the behaviour? e.g. feeling low in mood, tired, ill, in pain, bored, etc. Triggers  What was happening before the incident? e.g. he was being washed, being asked to transfer out of bed, being asked what he wanted for lunch, pad was being changed, he was being asked something, etc.  Where did it happen? e.g. in the person’s room, in the community, etc.  Who was involved? Behaviour  Give as full a description as possible of what the person was doing, including physical aspects (e.g. hitting, throwing, being sexually disinhibited) and verbal aspects (e.g. shouting, swearing).  Record what the person actually said.  How long did the behaviour last for?  How severe or intense was the behaviour? Consequences  What happened as a result of the behaviour?  What did you do to try and manage the behaviour?  How well did that work?  What was the behaviour of the person like after the incident? SETTING CONDITIONSTRIGGERS Mr X reported that he had been feeling tired as he hadn’t slept well last night due to pain, and was continuing to experience pain. Mr X was being washed and having his pad changed in his bedroom by myself and another HCA, Jon. Mr X became angry, shouted that he wanted us to go, swore at us and then threw a cloth at us. He remained agitated for 10 minutes. We stopped the activity and gave Mr X time to calm down. We then explained why we needed to wash him. We explained that he should tell us when the pain was too much for him and we would stop for a break. He calmed down and agreed to be washed. We explained what we would be doing at each step and checked his pain levels during it, stopping for a break when it was too much.

Management – other non-pharmacological Treat the underlying cause Aromatherapy (Ballard, lemon balm) Multisensory stimulation Therapeutic use of music and/or dancing Animal-assisted therapy Massage Signage

The evidence suggests for Agitation in AD If you have to prescribe a drug…. Risperidone 0.5mg bd for 6/52 Less evidence for alternative antipsychotics Quetiapine – evidence of non-efficacy Cholinesterase inhibitors and memantine – not effective acutely or in prophylaxis

So in conclusion – courtesy of Prof Howard What to do Cholinesterase inhibitors and, to a lesser extent, memantine offer modest symptomatic benefits for cognitive symptoms at all stages Try to avoid drug treatments for behavioural symptoms and only use the licensed agent What not to do Don’t raise unrealistic expectations about the impact of symptomatic cognitive treatment Benzodiazepines generally make people with dementia worse The fewer psychotropics the better

Want to know more? IMPARTS Course Mental health skills for non-mental health professionals distressed patients; confusion/dementia; substance misuse; medically unexplained symptoms; managing conflict. 29/01/2014 and 26/02/2014 with additional e-learning MSc in Advanced Care in Dementia