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

2. Who am I?

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

4. 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

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

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

7. 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

8. Newcastle model framework (James 2011)

9. 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

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

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

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

13. 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

14. 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

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

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

17. Others
Carbamazepine
Pregabalin
Melatonin
Zopiclone
Trazadone

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