1. IN YOUR FACE CHALLENGING BEHAVIOURS IN OLDER ADULTS WITH DEMENTIA Dr E C Komocki

2. DEFINITIONS Descriptive Descriptive Requires two people! Requires two people! Socially constructed Socially constructed The “Weed” analogy The “Weed” analogy Variable over time and with experience Variable over time and with experience Racism and Aggression Racism and Aggression No diagnostic or aetiological significance No diagnostic or aetiological significance Not necessarily psychiatric Not necessarily psychiatric “The Scab Lady” “The Scab Lady”

3. THE CHALLENGING BEHAVIOURS Agitation Agitation Emotional and motor components – “Sundowning” Emotional and motor components – “Sundowning” Restlessness and pacing Restlessness and pacing Wandering Wandering “The Long Haul” “The Long Haul” Shouting and screaming Shouting and screaming Sexual disinhibition Sexual disinhibition Aggression Aggression “The Enucleator” “The Enucleator”

4. TOP 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. COHEN-MANSFIELD AGITATION INVENTORY Rating scale assessing frequency of up to 29 “agitated behaviours” Rating scale assessing frequency of up to 29 “agitated behaviours” Scale 1-7 for each behaviour Scale 1-7 for each behaviour Swearing, kicking, biting, attention-seeking, intentional falling, hoarding, disinhibition etc. Swearing, kicking, biting, attention-seeking, intentional falling, hoarding, disinhibition etc. Theoretical max score = 203 Theoretical max score = 203 Need training to administer Need training to administer No aetiology determined No aetiology determined

7. 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”

8. 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” and seclusion “Time-out” and seclusion Carer consistency Carer consistency Care homes and wards Care homes and wards

9. TREATMENTS – PSYCHOLOGICAL  Carer education  Routines with individuality  Communication – Validation or reality “Where’s Eric?” “Where’s Eric?”  Symptom-focussed programmes “The Water Pistol” “The Water Pistol”  Tom Kitwood’s theory of Malignant Social Psychology

10. 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)

11. REVERSING THE PROCESS “REMENTIA” Angiogenesis, dendritic rearborization & synaptogenesis

12. TREATMENTS - BIOLOGICAL Treat physical and psychiatric disorders Treat physical and psychiatric disorders 80% dementia patients “depressed” 80% dementia patients “depressed” Choose psychotropic medication with reference to symptoms, side-effects and contra-indications Choose psychotropic medication with reference to symptoms, side-effects and contra-indications “The Resistive Man” “The Resistive Man” No underlying neuropharmacological theory No underlying neuropharmacological theory “From A to Z” “From A to Z”

13. EFFECTIVE PRESCRIBING Target appropriate symptoms Target appropriate symptoms Simplest regime possible Simplest regime possible “Start low, go slow” “Start low, go slow” Pharmacological psycho-education of carers to enhance concordance Pharmacological psycho-education of carers to enhance concordance Assess side effect acceptability Assess side effect acceptability Monitor and adjust accordingly Monitor and adjust accordingly Agree long term plan Agree long term plan

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

15. “ALWAYS A LAST RESORT” DOH 2008 Psychiatrists, Care Home Staff, Pharmacists & Carers Main findings – Challenging behaviour of complex aetiology Challenging behaviour of complex aetiology Care home staff unprepared Care home staff unprepared Antipsychotics use excessive and too prolonged Antipsychotics use excessive and too prolonged Acknowledges side effects can worsen dementia symps Acknowledges side effects can worsen dementia symps Their use CAN be appropriate – “severe & critical” Their use CAN be appropriate – “severe & critical” Use alternative methods but need training Use alternative methods but need training

16. “ALWAYS A LAST RESORT” RECOMMENDATIONS – Mandatory training for care home staff Mandatory training for care home staff Enhanced support from psychiatric services Enhanced support from psychiatric services Mental Capacity Act training Mental Capacity Act training Protocols for antipsychotic prescribing Protocols for antipsychotic prescribing Audit Audit LOCAL ADVICE DISTRIBUTED (2008)

17. 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 Sensory Therapies Sensory Therapies Snoezelen Rooms Snoezelen Rooms

20. CONTROVERSIES Questionable validity Questionable validity Medical problem? Medical problem? Treatments – punishment or control? Treatments – punishment or control? Medication – a “quick fix”? Medication – a “quick fix”? Physical restraints Physical restraints “The Hong Kong Physio” “The Hong Kong Physio”

21. SUMMARY 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!!! Challenging behaviours are a message Challenging behaviours are a message

22. 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