1. IN YOUR FACE !!! CHALLENGING BEHAVIOURS IN OLDER ADULTS WITH DEMENTIA Dr E C Komocki Consultant in Old Age Psychiatry

2. DEFINITIONS Descriptive Descriptive Tends to requires two people! Tends to requires two people! Socially constructed Socially constructed The “Weed” analogy The “Weed” analogy No diagnostic or aetiological significance No diagnostic or aetiological significance Not necessarily a psychiatric condition Not necessarily a psychiatric condition “The Scab Lady” “The Scab Lady”

3. THE COMMON CHALLENGING BEHAVIOURS Agitation Agitation Emotional & motor components – “Sundowning” Emotional & motor components – “Sundowning” Wandering, restlessness and pacing Wandering, restlessness and pacing “The Long Haul” “The Long Haul” Shouting and screaming Shouting and screaming Sexual disinhibition Sexual disinhibition Interfering Interfering Aggression & resistiveness Aggression & resistiveness “The Enucleator” “The Enucleator”

4. TOP 10 EREWASH AGITATORS Constipation Constipation Infection Infection Affective Disorder Affective Disorder Sensory Impairments Sensory Impairments “My Mum” “My Mum” Pain Pain Other Patients Other Patients “Shouters” “Shouters” SSRI’s “Fluoxetine” Inconsiderate Staff “Non-verbal communication workshop” Psychosis Stereotyping “Enforced Bingo”

5. ASSESSMENT Rule out physical disorders Rule out physical disorders Rule out functional psychiatric disorders Rule out functional psychiatric disorders Assess psycho-social stressors Assess psycho-social stressors Assess risk Assess risk Patient, other patients and staff Patient, other patients and staff Correct and accurate description Correct and accurate description “The Burma Railway Man” “The Burma Railway Man” Measure and record Measure and record

6. ABC “ Antecedents, Behaviour, Consequences” “ Antecedents, Behaviour, Consequences” Pavlov’s classical conditioning Pavlov’s classical conditioning “CS plus associated UCS produces a response” “CS plus associated UCS produces a response” Skinner’s operant conditioning Skinner’s operant conditioning “Alteration of the frequency of a piece of spontaneous behaviour by reward or punishment” “Alteration of the frequency of a piece of spontaneous behaviour by reward or punishment” Simple to organise and record Simple to organise and record Allows generation of a “Behavioural Hypothesis” Allows generation of a “Behavioural Hypothesis”

7. TREATMENT - SOCIAL Improved environments Improved environments New architecture, wander loops and orientating stimuli New architecture, wander loops and orientating stimuli Reduce isolation Reduce isolation De-escalation of over-arousal De-escalation of over-arousal “Time-out”, distraction and individual support “Time-out”, distraction and individual support Carer consistency Carer consistency Care homes and wards Care homes and wards

8. TREATMENTS – PSYCHOLOGICAL  Carer education  Routines with individuality “Xbox 360” “Xbox 360”  Communication – Validation or reality orientation “Where’s Eric?” “Where’s Eric?”  Avoidance of “Malignant Social Psychology”

9. MALIGNANT SOCIAL PSYCHOLOGY Treachery Treachery Disempowerment Disempowerment Infantilisation Infantilisation Intimidation Intimidation Labelling Labelling Stigmatisation Stigmatisation Outpacing Outpacing Invalidation Invalidation Banishment Objectification Ignoring Imposition Withholding Accusation Disruption Mockery Disparagement Kitwood(1997)

10. REVERSING THE PROCESS “REMENTIA”

11. ALTERNATIVE THERAPIES Art/Music therapy Art/Music therapy Scheduled activity Scheduled activity Aromatherapy Aromatherapy Lavender and lemonbalm Lavender and lemonbalm Bright light therapy Bright light therapy Animal assisted therapy Animal assisted therapy Sensory Therapies Sensory Therapies Snoezelen Rooms Snoezelen Rooms

14. TREATMENTS - BIOLOGICAL  Treat physical and psychiatric disorders 50-70% dementia patients “depressed” 50-70% dementia patients “depressed”  Choose psychotropic medication with reference to symptoms, side-effects and contra-indications Target appropriate symptoms and timing Target appropriate symptoms and timing Simplest regime possible Simplest regime possible “Start low, go slow” “Start low, go slow” Monitor and adjust accordingly Monitor and adjust accordingly Agree longer term plan Agree longer term plan  No underlying neuropharmacological theory and very few RCTs “From A to Z” “From A to Z”

15. SPECIFIC MEDICATIONS Atypical antipsychotics (Risperidone) Atypical antipsychotics (Risperidone) Side-effects, efficacy and administration Side-effects, efficacy and administration Typical antipsychotics (Promazine, Haloperidol) Typical antipsychotics (Promazine, Haloperidol) Efficacy and cost Efficacy and cost Anti-depressants (Trazadone & SSRIs) Anti-depressants (Trazadone & SSRIs) Shouting and sexual disinhibition Shouting and sexual disinhibition Mood-stabilizers/antiepileptics (Carbamazepine) Mood-stabilizers/antiepileptics (Carbamazepine) Anxiolytics (Lorazepam, Midazolam) Anxiolytics (Lorazepam, Midazolam) Cholinesterase inhibitors Cholinesterase inhibitors Memantine Memantine

16. THE DEBATE NICE guidance “Dementia” (2006/11) NICE guidance “Dementia” (2006/11) “Always a Last Resort” (2008) “Always a Last Resort” (2008) “Time For Action” (2009) “Time For Action” (2009) National Dementia Strategy (2009) National Dementia Strategy (2009) “The Right Prescription” (DAA 2011) “The Right Prescription” (DAA 2011) “What Have The Drugs Done To Dad” (Panorama - 2011) “What Have The Drugs Done To Dad” (Panorama - 2011) “Antipsychotics Make Alzheimers Patients Die” (Daily Mail - 2011) “Antipsychotics Make Alzheimers Patients Die” (Daily Mail - 2011) 180,000 dementia patients given antipsychotics but only 15-25% get some benefit

17. USING ANTIPSYCHOTICS Detailed and accurate assessment Detailed and accurate assessment Trial of non-pharmacological interventions Trial of non-pharmacological interventions “For the right reasons” “For the right reasons” Psychosis, physical aggression and risk Psychosis, physical aggression and risk Pre-commencement assessments Pre-commencement assessments Wt, glycaemic status, lipids and ECG Wt, glycaemic status, lipids and ECG Beware cerebrovascular risk factors Beware cerebrovascular risk factors “Start low, go slow” “Start low, go slow” Time-limited with regular review Time-limited with regular review Psychoeducation for all involved Psychoeducation for all involved

18. CONTROVERSIES Inappropriate emphasis – Inappropriate emphasis – Antipsychotics DO have their place Antipsychotics DO have their place Too focused on antipsychotics Too focused on antipsychotics Resources to adopt recommendations Resources to adopt recommendations Medication – a “quick fix”? Medication – a “quick fix”? Pre-testing difficulties Pre-testing difficulties Unlicensed use of all except risperidone Unlicensed use of all except risperidone New worries over BZDs??? New worries over BZDs??? International practice/opinions International practice/opinions “The Hong Kong Physio” “The Hong Kong Physio”

19. SUMMARY Challenging behaviours are a message Challenging behaviours are a message Many run their course and stop Many run their course and stop Ensure accuracy of description Ensure accuracy of description Beware physical disorders Beware physical disorders Consider functional psychiatric disorders Consider functional psychiatric disorders ABC ABC Multi-dimensional treatments Multi-dimensional treatments Clarity of planned treatments Clarity of planned treatments Don’t give up on the drugs!!! Don’t give up on the drugs!!!

20. REFERENCES SKINNER (1938) “The Behaviour of Organisms” SKINNER (1938) “The Behaviour of Organisms” COHEN-MANSFIELD (1986) J Am Geriatr Soc 34: 722-7 COHEN-MANSFIELD (1986) J Am Geriatr Soc 34: 722-7 KITWOOD (1997) “Dementia Reconsidered” KITWOOD (1997) “Dementia Reconsidered” ALEXOPOPULOUS et al (1998) “Treatment of Agitation in Older Persons with Dementia” ALEXOPOPULOUS et al (1998) “Treatment of Agitation in Older Persons with Dementia” YORSTON (1999) “Aged and Dangerous” BMJ 174: 193-5 YORSTON (1999) “Aged and Dangerous” BMJ 174: 193-5 BALLARD et al (2001) “Dementia – Management of Behavioural and Psychological Symptoms” BALLARD et al (2001) “Dementia – Management of Behavioural and Psychological Symptoms” XENIDITIS et al (2001) “Management of People with Challenging Behaviour” APT 7:2 – 109-16 XENIDITIS et al (2001) “Management of People with Challenging Behaviour” APT 7:2 – 109-16 NICE Guidance CG42 (2006) NICE Guidance CG42 (2006) SMITH & MANCHIP (2010) “Antipsychotic Prescribing in Dementia” Geriatric Med June (40) 6 SMITH & MANCHIP (2010) “Antipsychotic Prescribing in Dementia” Geriatric Med June (40) 6 MACKIN & THOMAS (2011) “Atypical Antipsychotic Drugs” BMJ (342) 650- 4 MACKIN & THOMAS (2011) “Atypical Antipsychotic Drugs” BMJ (342) 650- 4 KRISHNAMOORTHY 7 ANDERSON (2011) “Managing Challenging behaviour in Older Adults with Dementia!” Prog Neuro & Psych June (15) 3 KRISHNAMOORTHY 7 ANDERSON (2011) “Managing Challenging behaviour in Older Adults with Dementia!” Prog Neuro & Psych June (15) 3