Transcript document

IN YOUR FACE
CHALLENGING
BEHAVIOURS IN OLDER
ADULTS WITH DEMENTIA
Dr E C Komocki
DEFINITIONS
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Descriptive
Requires two people!
Socially constructed
The “Weed” analogy
Variable over time and with experience
Racism and Aggression
No diagnostic or aetiological significance
Not necessarily psychiatric
“The Scab Lady”
THE CHALLENGING BEHAVIOURS
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Agitation
Emotional and motor components – “Sundowning”
Restlessness and pacing
Wandering
“The Long Haul”
Shouting and screaming
Sexual disinhibition
Aggression
“The Enucleator”
TOP EREWASH AGITATORS
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Constipation
Infection
Affective Disorder
Sensory Impairments
“My Mum”
Pain
Other Patients
“Shouters”
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SSRI’s
“Fluoxetine”
Inconsiderate Staff
“Non-verbal
communication
workshop”
Psychosis
Stereotyping
“Enforced Bingo”
ASSESSMENT
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Rule out physical disorders
Rule out functional psychiatric disorders
Assess psycho-social stressors
Assess risk
Patient, other patients and staff
Correct and accurate description
“The Burma Railway Man”
Measure and record
COHEN-MANSFIELD
AGITATION INVENTORY
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Rating scale assessing frequency of up to 29
“agitated behaviours”
Scale 1-7 for each behaviour
Swearing, kicking, biting, attention-seeking,
intentional falling, hoarding, disinhibition etc.
Theoretical max score = 203
Need training to administer
No aetiology determined
ABC
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“ Antecedents, Behaviour, Consequences”
Pavlov’s classical conditioning
“CS plus associated UCS produces a response”
Skinner’s operant conditioning
“Alteration of the frequency of a piece of
spontaneous behaviour by reward or punishment”
Simple to organise and record
Allows generation of a “Behavioural Hypothesis”
TREATMENT - SOCIAL
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Improved environments
New architecture, wander loops and
orientating stimuli
Reduce isolation
De-escalation of over-arousal
“Time-out” and seclusion
Carer consistency
Care homes and wards
TREATMENTS – PSYCHOLOGICAL
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Carer education
Routines with individuality
Communication – Validation or reality
“Where’s Eric?”
Symptom-focussed programmes
“The Water Pistol”
Tom Kitwood’s theory of Malignant Social
Psychology
MALIGNANT SOCIAL
PSYCHOLOGY
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Treachery
Disempowerment
Infantilisation
Intimidation
Labelling
Stigmatisation
Outpacing
Invalidation
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Banishment
Objectification
Ignoring
Imposition
Withholding
Accusation
Disruption
Mockery
Disparagement
Kitwood(1997)
REVERSING THE PROCESS
“REMENTIA”
Angiogenesis, dendritic rearborization &
synaptogenesis
TREATMENTS - BIOLOGICAL
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Treat physical and psychiatric disorders
80% dementia patients “depressed”
Choose psychotropic medication with
reference to symptoms, side-effects and
contra-indications
“The Resistive Man”
No underlying neuropharmacological theory
“From A to Z”
EFFECTIVE PRESCRIBING
Target appropriate symptoms
• Simplest regime possible
“Start low, go slow”
• Pharmacological psycho-education of carers
to enhance concordance
• Assess side effect acceptability
• Monitor and adjust accordingly
• Agree long term plan
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SPECIFIC MEDICATIONS
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Atypical antipsychotics (Risperidone)
Side-effects, efficacy and administration
Typical antipsychotics (Promazine)
Efficacy and cost
Anti-depressants (Trazadone & SSRIs)
Shouting and sexual disinhibition
Mood-stabilizers (Carbamazepine)
Anxiolytics
Cholinesterase inhibitors
“ALWAYS A LAST RESORT”
DOH 2008
Psychiatrists, Care Home Staff, Pharmacists &
Carers
Main findings –
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Challenging behaviour of complex aetiology
Care home staff unprepared
Antipsychotics use excessive and too prolonged
Acknowledges side effects can worsen dementia symps
Their use CAN be appropriate – “severe & critical”
Use alternative methods but need training
“ALWAYS A LAST RESORT”
RECOMMENDATIONS –
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Mandatory training for care home staff
Enhanced support from psychiatric services
Mental Capacity Act training
Protocols for antipsychotic prescribing
Audit
LOCAL ADVICE DISTRIBUTED (2008)
ALTERNATIVE THERAPIES
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Art/Music therapy
Scheduled activity
Aromatherapy
Lavender and lemonbalm
Bright light therapy
Sensory Therapies
Snoezelen Rooms
CONTROVERSIES
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Questionable validity
Medical problem?
Treatments – punishment or control?
Medication – a “quick fix”?
Physical restraints
“The Hong Kong Physio”
SUMMARY
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Ensure accuracy of description
Beware physical disorders
Consider functional psychiatric disorders
ABC
Multi-dimensional treatments
Clarity of planned treatments
Don’t give up on the drugs!!!
Challenging behaviours are a message
REFERENCES
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SKINNER (1938) “The Behaviour of Organisms”
COHEN-MANSFIELD (1986) J Am Geriatr Soc
34: 722-7
KITWOOD (1997) “Dementia Reconsidered”
ALEXOPOPULOUS et al (1998) “Treatment of
Agitation in Older Persons with Dementia”
YORSTON (1999) “Aged and Dangerous” BMJ
174: 193-5
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