Behavioural crisis in dementia Dr Oliver Bashford Old Age Psychiatrist East Surrey Hospital Liaison Psychiatry team East Surrey Older Adult CMHT

Case example 83 year old lady diagnosed with mixed dementia three years earlier and no longer under secondary care. Living at home. Her husband brings her to clinic to say that he cannot cope with her any more. She frequently appears agitated and angry, has hit him on a few occasions and tried to leave the house the previous night. On assessment she has mixed dysphasia, unable to give any account of her symptoms and appears anxious and distressed.

Assessment of the behaviour Consider: Biological: PAIN, Delirium, Sensory deficits, medication changes, neurological symptoms Psychological: Past psychiatric history, premorbid personality, life history, past occupations, mood, anxiety, psychotic symptoms Social: Any change in care provision, dysfunctional family dynamics, changes in social network or daytime activities

Assessment of risk Ask for details of the behaviour ‘Hitting’ includes a wide range of behaviours - ?open hand/ fist/ targeted/ provoked/ understandable in context What happened when she tried to leave the house? Risk to others – to whom? Family/public/staff. How likely, how often, how harmful (consider firearms, children etc) Risk to self – physical decline, poor self care, safety awareness, loss of dignity, breakdown of placement Risk from others – abuse: financial, physical, emotional Carer Stress

Management Depends on severity Biological: Treat comorbidities, optimise sensory deficits, low threshold for analgesia. Citalopram (Delphi consensus), Mirtazapine, Trazodone. Risperidone licensed but increases stroke risk 3-fold, therefore should be BI discussion Avoid benzodiazepines (unless risk-benefit analysis is favourable)

Management Psychosocial: Psychoeducation of family Personalised choices of music, photos, films Day centre, community groups, positive interactions, animal therapy Sense of purpose and meaning – encourage to have a role Carer support Package of Care Positive risk taking

Delphi consensus, International psychogeriatrics, Vol 31 (1) Jan 2019, pp 83-90 Treatment of overall BPSD and agitation Thorough assessment and management of underlying causes Caregiver problem-solving/information/education Environmental adaptation/approaches Person-centred care Tailored activity programme Citalopram Treat pain/analgesia Risperidone

Who can you call? Family/friends Social services – assess for care package/ placement/ carer assessment/ telecare/ Alzheimer’s Society for referral to dementia navigator Duty staff at CMHT (01737 288930) Urgent referrals to TOPS email: rxx.topssabp@nhs.net; phoned through to local team Ambulance if appropriate Police if high risk aggression – they could use s136 in a public place if needed

Questions?

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