2Prevalence of Dementia 71,000 People with dementia in Scotland 2,300 ↓ 65yrs3,258 Patients in Ayrshire on dementia registers (Sep. 2011)Number is expected to double over the next 25yrs
3Costs 1.7 billion per annum £ million cost of care & treatment services provided by NHS & Local GovernmentTaking into account the current numbers of patients with dementia and the predicted increase is it any wonder that a significant % of patients being admitted to general hospitals have a degree of cognitive impairment.One of the biggest challenges for staff is dealing with behaviours that challenge.
4Aims To explore and discuss what behaviours that challenge means. To identify the types most commonly seen in patients with dementia.To analyse why it happens and help to minimise it.To encourage a consistent strategy in the work place.
5What is behaviours that challenge It is when behaviour is displayed that is not understood or coped with, that crisis can arise. The problem is often seen as belonging to the client. However, many of the behaviours exhibited are a response to the relationship the client has with others, and /or a response to environmental changes.Challenging behaviour presents staff/carers with difficulties. It is often viewed in a negative light and the client is seen as disruptive.A lot of the time the displayed behaviour is seen as something that must be ‘controlled’ This view creates a hostile situation which could act as a catalyst to further behaviour difficulties.Try to avoid a confrontation.What is perceived to be challenging will differ between settings, with some staff being more tolerant than others. For this reason Behaviour that challenges is a social construct as opposed to a clinical disorder.
6Unmet needs It is widely recognised that most challenging behaviour in dementia is an attempt at communicating unmet needs.Physical needNeed for securityNeed for occupationSocial and Human contact needThe need to knowEgocentric needsSexual needs
7Physical needsChallenging behaviour may result from pain, which due to confusion & dysphasia may be poorly communicated.Dental & arthritic pain is often unrecognised and untreatedPrivacy, dignity and respect in care is often reduced for people with dementia , with staff assuming the person will not realise or complain.Poor care often results in annoyance and frustration, which are often triggers for challenging behaviour.
8Need for securityWe all need to feel safe, if people with dementia feel they are in a world devoid of familiarity or reassurance they will feel unsafe.Fear & Frustration is one of the main causes of challenging behaviour. Not knowing where you are, why you are there and surrounded by strangers may cause distress. The person may respond by wanting to go home.Night time can be worse, with shadows, loud noises & unfamiliar surroundings.
9The need for occupation To be engaged in occupation and have stimulation is fundamental to psychological well-being.What is the usual activity for people with dementia ? Inactivity. Doing nothing or sleeping, and when patients try to do something we often try to stop them.Over stimulation is another catalyst to challenging behaviour.
10The need for social and human contact Social contact is fundamental to well-being and has a proactive effect against psychological distress.But isolation is the Norm for people with dementia. We often fail to engage in meaningful conversation and deny them our presence. Perhaps this is one reason why people call out or follow others around.
11The need to know Humans are nosey by nature. Due to confusion and disorientation, people with dementia have an increased need to know and can constantly seek information.Curiosity and exploration may result in collecting things, fiddling with things and wandering. Trying to stop the person may result in frustration.We need to increase our understanding and instead of labelling behaviours as ‘disruptive’ reframe them in the context of the person seeking meaning or comfort,
12Egocentric needsWe all need to have self- respect, self-determination and control and a sense of ‘mine’When these are lost, feelings of frustration, anger, low self-esteem, embarrassment and despair may arise.Lack of respect, dignity and choice in care may result in the patient refusing to co-operate with care or wanting to leave the care setting
13Sexual needsSexual interest is not lost in old age. It may be experienced less frequently, but for many it remains a pleasurable activity.There is no age when sexual activity abruptly ends. Yet our cultural expectation is for older people to be asexual.When patients with dementia exhibit sexual needs our approach may be prejudiced by our own values and beliefs. Sexual disinhibition is a frequent problem for care staff.We must work within the premise that it is not the sexual need that is unacceptable, but the behaviour accompanying it that needs to be appropriately managed.We cannot deny a person sexual expression, but need to ensure their and others safety and dignity.
14What is Challenging Behaviour Hitting, Kicking, Grabbing, PushingNipping, Scratching, Biting, Spitting, Choking, Hair PullingTrippingThrowing ObjectsStabbingSwearingScreamingShoutingPhysical sexual assaultActs of self harmApathy, DepressionRepetitive Noise/questionsConstant requests for HelpEating/drinking excessivelyPacing, over-activityAgitation, following others/trailingInappropriate exposure of bodyMasturbation in public areasUrinating in inappropriate placesSmearingHoarding/hiding items.Falling intentionally.These are not specific to dementia, they can frequently be seen in the general population and are seen outside many pubs and nigh clubs at the weekend
15Behaviour that Challenges “For an action to be perceived as challenging a threshold needs to be passed, and this requires a judgment from carers. This is determined by the tolerance of the carer and care settings and as such is often applied inconsistently. What is acceptable in one setting maybe seen as intolerable by carers in a different setting. Hence challenging behaviour is seen as a social construct rather than a true clinical disorder”(James 2011)
16Always Ask Who is the Behaviour a Problem For ? Does it Really Matter ?Why ?What will Happen if it Continues?
17PreventionTry to learn what triggers the aggression & watch for danger signs.Try not to give orders, make requests of the person.Possibly reduce the demands on the person if you feel they are over - stressed.Calm the person down.Calm yourself down - if necessary remove yourself from the situation.Always leave yourself a way out.Could an outsider get the person to do the actionTalk to someone about how you feel.
18Non Pharmacological Interventions Reality OrientationCognitive Stimulation TherapyReminiscence TherapyValidation Therapy.Psychomotor TherapyMulti-sensory TherapyMusic TherapyAroma therapyArt TherapyDoll Therapy (James 2005)Prevention V Intervention.Reality orientation – attempts to orientate the patient to here and now with cues such as clocks, callanders newspapers and/or discussion. There is debate around its efficacy it can remind people of their deficits can also lead to repeated confrontation.Cognitive Stimulation Therapy – themes cars trains cookery.Reminiscence Therapy – flexible, adaptable to situations and individuals using life story work/books/photo albums.Validation therapy- validates what the person says and avoid confrontation leads onto distraction.Psychomotor Therapy – physical activity – folding towels, sorting envelopes people tend to spend longer on tasks that mimic work – enhances well-being, increases self worth relieves boredom reduces agitation – rummage boxes.Multi-sensory Therapy – SonisAromatherapy- 2 main oils used in dementia lavender and lemon balm reduce agitation.Music Therapy – Can have a profound effect on peoples mood and levels of agitation and sense of well being but not all older patients like war time music be sensitive to emotions that it may evoke.Art Therapy – shown to improve self esteem and reduce agitation.Doll Therapy – Controversial approach can be seen as patronising and promoting infantilisation but some recent research has shown positive results in managing levels of agitation and aggression
19What does this mean in Practice Rummage Box’sSorting/Counting Coins.Hand Massage.Hair BrushingWalk around environmentStop Signs.Black matt/paint.Photo AlbumsBooks.Worry Bead’sTexture material bag.Sock BagPost Cards.Rainbow Ribbons.
20How to Avoid it Know your client. Avoid situations known to provoke the behaviourCreate a calm environmentRespect personal spaceBe flexible and sensitiveOffer reassurance, help to understand environment.Praise appropriate behaviourUtilise non-pharmacological interventions.Know your client.
21How To Manage Challenging Behaviour Decide whether to take action or notIf action is required, try to appreciate how the client feels and why.Divert the client’s attention onto something else.Speak calmly and try to defuse the situation.Offer reassurance and understanding.Utilise non-pharmacological interventions.Don’t get involved in the issue or try to ‘win’ the argumentNever penalise anyone for challenging behaviourRemember that some problems are never solved.If you can’t help, try to find someone who can.
22Key – Take One Step Back and Ask Does it really matter?Is it that Important?Who’s problem is it?
23ReferencesJames I, et al( 2005) The therapeutic use of dolls in dementia care. Journal of Dementia Care; 13: 3, 19-21James A. (2011) Understanding behaviour in dementia that challenges: a guide to assessment and treatment. London
24Antipsychotic Medication The UK Medicines Healthcare Products Regulatory Agency (MHRA) issued a clear warning against their use including a letter to all healthcare professionals stating: “Committee of Safety of Medicines has advised that risperidone or olanzapine should not be used for the treatment of behavioural symptoms of dementia. Although there is presently insufficient evidence to include other antipsychotics in these recommendations, prescribers should bear in mind that a risk of stroke cannot be excluded, pending the availability of further evidence. Studies to investigate this are being initiated. Patients with dementia who are currently treated with an atypical antipsychotic drug should have their treatment reviewed.” (2004).
25There is evidence that antipsychotic drugs have some modest beneficial treatment effects for specific behavioural symptoms over short term periods (6 – 12 weeks) of treatment however, they have little benefit over long periods of time (Schneider et al, 2006).
26Medication management For drug treatments the ‘3T’ approach is good practice:drug treatments should have a specific Target symptomthe starting dose should be low and then Titrated upwards anddrug treatments should be Time limited
27Care planning medication Formalise care planning and notes to include:3 ‘T’ approach, target symptoms, titrate, time limitedMonitoring of side effectsReview on daily basis by care home staff
28Does it work?In a published trial (Ballard et al 2008) showing that people with dementia resident in nursing homes and prescribed antipsychotics could have these drugs stopped with no increase in behavioural disturbance.
29Local perspectiveIn the Mental Welfare Commission’s review of dementia services (2009), 73% of people in care homes were taking one or more psychotropic medicines, with 33% taking antipsychotic medication. There was evidence of inappropriate and multiple prescribing and concerns that medication was not being regularly reviewed. It was recommended that the use of medication to manage challenging behaviour should be the last, and not the first resort
30ReferencesFaculty of the Psychiatry of Old Age Atypical antipsychotics and BPSD Prescribing update for Old Age Psychiatrists (2004)Care Commission & Mental Welfare Commission (2009). “Remember, I’m still me” – report on the quality of care for people with dementia living in care homes in Scotland.Committee on Safety of Medicines. Summary of clinical trial data on cerebrovascular adverse events (CVAEs) in randomized clinical trials of risperidone conducted in patients with dementia. London: Committee on Safety of Medicines, 2004.Schneider, L.S. Tariot, P.N., Dagerman, K.S., et al. CATIE-AD Study Group (2006). Effectiveness of atypical anti-psychotic drugs in patients with Alzheimer’s disease. New England Journal of Medicine, 355(15):1525–38Ballard C et al (2008). 'A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (the DART-AD trial)', PLoS Med 5:e76