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

2. 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.

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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 ( )
Urgent referrals to TOPS phoned through to local team
Ambulance if appropriate
Police if high risk aggression – they could use s136 in a public place if needed

9. Questions?

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