1. Management of Challenging Behaviour in Primary Care Daniel Collerton and Karen Franks Gateshead Older People’s Mental Health Service

2. Levels of Challenging Behaviour ChallengingBehaviourService Workbook Mental Health Services Non Specialist Services

3. Character of challenging behaviours Reflects the capability of the setting to manage behaviour – poorer settings generate more challenge Reflects the capability of the setting to manage behaviour – poorer settings generate more challenge Not related to severity of dementia Not related to severity of dementia Stressful and burdensome to carers Stressful and burdensome to carers Purposeful Purposeful Limited potential to respond to interventions Limited potential to respond to interventions Usually transitory Usually transitory

4. Principles Who, what, why, when? Who, what, why, when? Why is this a problem? Why is this a problem? Always consider non-pharmacological management first Always consider non-pharmacological management first Always consider physical illness, esp. delirium and pain Always consider physical illness, esp. delirium and pain

5. Management guidelines Talk to the person whose behaviour is causing concern Talk to the person whose behaviour is causing concern Identify purpose of behaviour Identify purpose of behaviour Identify and intervene in contributory factors Identify and intervene in contributory factors Support carers Support carers Balance risks Balance risks Be mindful of legal frameworks Be mindful of legal frameworks Aim for tolerable behaviour Aim for tolerable behaviour Review and refer Review and refer

6. What is the behaviour that challenges you? Mild- moderate behaviour: e.g. wandering, night-time disturbance, depression, apathy, repetitive questioning, shadowing, verbal aggression, mild sexual disinhibition. Severe- extreme behaviour: e.g. severe depression, psychosis, severe agitation, screaming, physical violence, suicidal behaviour, severe sexual disinhibition. Is the person with dementia, or another person at immediate and serious risk because of the behaviour? YES Seek specialist advice; consider transfer of the person to a safer setting depending on need, psychiatric or general hospital admission, respite care. Contact Mental Health Service for advice NO Is detail known about the behaviour? NO Describe exactly what the behaviour is, when, where and with whom the behaviour occurs. Detailed documentation is very useful. Have you used an assessment tool? Examples include ABC records, behavioural charts YESYES Use the information… To work through the challenging behaviour workbook. Gather more information… At each stage you may need to gather further information about the person, then go back and use it. Identify reasons for the behaviour… …make a plan… …and put the plan into action Review the situation… Has your plan worked? YES Well done! Continue to review the situation to ensure continuation of helpful strategies. NO Has the behaviour improved but not disappeared? If so is it now manageable? If not, do you need help from someone else? People who may be able to help include… Whose problem is it anyway? Could the person’s behaviour be due to the environment? Could procedures or routines be made more flexible to suit the persons’ needs? Was onset quite sudden? If so this could be due to physical illness, take a urine specimen if possible and arrange medical review

7. Specialist advice Mental health services Mental health services Challenging Behaviour Teams Challenging Behaviour Teams

8. Principles with Medication Keep it simple Keep it simple Start low, go slow Start low, go slow Think about what you are trying to achieve Think about what you are trying to achieve Monitor effects Monitor effects Encourage effective recording Encourage effective recording Consider change in timings before increase in dose Consider change in timings before increase in dose Can this setting cope with ‘prn’ meds? Can this setting cope with ‘prn’ meds?

9. Suggested Starting Dosages Lorazepam 0.5mg Lorazepam 0.5mg Clomethiazole 192mg Clomethiazole 192mg Trazodone 25 – 50mg Trazodone 25 – 50mg Sodium Valproate 100mg bd Sodium Valproate 100mg bd SSRIs SSRIs Mirtazapine 15mg nocte Mirtazapine 15mg nocte Cholinesterase inhibitors – incl patch Cholinesterase inhibitors – incl patch (Memantine) (Memantine)

10. Antipsychotics Should not be first line Should not be first line Probably should be started only with secondary care opinion/advice Probably should be started only with secondary care opinion/advice Keep under review Keep under review Many do not benefit, some do Many do not benefit, some do Always a risk benefit decision Always a risk benefit decision Keep for some psychotic symptoms and severe aggression Keep for some psychotic symptoms and severe aggression Some people may need to stay on Some people may need to stay on

11. Antipsychotics - Dosage Risperidone 0.5mg Risperidone 0.5mg Quetiapine 25mg Quetiapine 25mg Amisulpiride 25 – 50 mg Amisulpiride 25 – 50 mg Olanzapine 2.5mg Olanzapine 2.5mg

12. Questions? Scenarios?

13. Further reading The use of antipsychotic medication for people with dementia. Sube Banerjee, Department of Health (2009) The use of antipsychotic medication for people with dementia. Sube Banerjee, Department of Health (2009) Dementia: Supporting people with dementia and their carers in health and social care National Institute for Health and Clinical Excellence (2006) Dementia: Supporting people with dementia and their carers in health and social care National Institute for Health and Clinical Excellence (2006)