Transcript Behaviour….. It’s All In Your Approach

Behaviour…..
It’s All In Your Approach
Alzheimer Conference 2008
Winnipeg, Manitoba
Joanne Collins
[email protected]
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Objectives
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Review the impact of Behavioural
and Psychological Symptoms of
Dementia (BPSD)
Introduce a framework to address
the complexity of BPSD
Highlight the significance of shared
team solution finding
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Behaviour…..
What are the behaviours you find
the most challenging when
providing care?
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What are the Canadian facts?
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Seniors age 85 and older are the fastest
growing age group and most likely to require
long term care facilities
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38% of all women and 24% of men age 85 and
older live in long term care facilities
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Over the next 30 years the number of long
term care beds is expected to triple
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Between 80% and 90% of seniors living in long
term care have some form of mental disorder.
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Recent Canadian study of 454 consecutive
Nursing Home admissions found:
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10% suffered from a mood disorder
2.4% were diagnosed with schizophrenia or
other psychiatric condition
More than two thirds had some form of
dementia
40% of residents suffering from dementia had
psychiatric conditions such as depression,
delusions or delirium
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Mental Illness is NOT a normal
consequence of aging!
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Depression: 14.7% - 20% in the community
LTC: 80-90 % of residents have mental health
issues
Alzheimer’s: 1 in 3 over 85 years old
Delirium: Up to 50% of older persons admitted
to acute care. 70% incidence in ICU
Suicide: The 1997 suicide rate for older
Canadian men nearly 2x that of the nation as a
whole.
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Mental Illness is NOT a normal
consequence of aging!
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Major Depression: 2 - 4%
Depressive Symptoms: 14 – 20%
Schizophrenia: 0.5%
Dementia: 8% rising to 34% in those >85yrs
Paranoid Thoughts: 10%
Anxiety Disorders: 19%
Alcohol Dependency: 1-3%, problem drinking 423%
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Behavioural and Psychological Symptoms of
Dementia (BPSD)
BPSD left untreated has been associated with
caregiver burnout, nursing home placement,
poor management of co-morbid conditions
and excess health care costs.
Steel, Cohen, Mansfield, Ballard
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Challenges of Challenging
Behaviour
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BPSD significantly impacts quality of life of
both the person and caregivers (Finkel SJ)
Caregivers consistently rate BPSD as the most
stressful aspect of caring (Jarriot PN)
Is the primary factor for deciding to
institutionalize (Steel C, Balestreri)
Approximately 50% of people with SDAT
experience psychosis, 90% behavioural issues,
7-10% severe (Rabins, Zimmer)
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The Reality for Older Adults
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Older adults have Medical, Social
and Physical needs that differ from
younger adults; 83% of those age
65 and older have one or more
chronic conditions, and 43% have
three or more conditions.
Wolf J.L et al Jama 2002 152 2269-2276
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Behavioural and Psychological
Symptoms
Are a:
 means of communicating needs and
desires,
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an expression of a person’s abilities,
disabilities and challenges
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All Behaviour Has Meaning!
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The issue for caregivers is to search
for meaning behind the behaviour
Acting on feelings that are
expressed is key
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Behavioural and Psychological
Symptoms
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Reflect a response to something negative,
frustrating or confusing in the person’s
physical or social environment – this can
be real or perceived.
Are self protective, defensive or
communication strategies in response to
unmet needs, which serve as important
ways in which people with dementia
express themselves
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BPSD can be Defined as….
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Verbally Aggressive – Verbally aggressive
and constant requests for attention
Verbally Non-Aggressive – Cursing, sexual
content
Physically Aggressive – pacing, undressing,
handling things, hiding things, wandering
Physically Non-Aggressive – spitting,
throwing things, sexual advances, hurting
self or others.
Has also been defined as challenging or disruptive
behaviour
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Behavioural and Psychological
Symptoms of Depression
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Places the reasons or “triggers,” for
behaviour outside, rather than inside the
person.
Recognizes that problems with social or
physical environment can be addressed or
changed.
Exemplify the person’s attempt to exert
control, protect or defend themselves in
their world as they know it.
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P.I.E.C.E.S Framework to Understand
and Address BPSD Complexity
Physical Problem or
Discomfort
Intellectual/cognitiv
e changes 7A’s
Emotional
Capabilities
Environment
Social
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Physical Factors
Related to BPSD
The 5 D’s
 Drugs and Alcohol
 Delirium
 Disease
 Discomfort
 Disability
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Intellectual Factors Related to BPSD
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The type of dementia, and deficits.
(Alzheimer Disease, Vascular Dementia,
Lewy Body, Mixed)
The 7 A’s
- Amnesia
- Aphasia
- Agnosia
- Apraxia
- Anosognosia
- Altered Perceptions
- Apathy
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Emotional Factors Related to BPSD
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Adjustment Difficulties
Depression
Anxiety
Delusions and Hallucinations
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Capabilities Related to BPSD
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Not utilized enough – results in boredom
and anger
Demands exceed capabilities – frustrations
and catastrophic reactions
The more impaired an individual is the more
the environment accounts for the
behaviour.
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Environment and BPSD
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Relocation, changes in the
environment, routine
Environmental demands i.e
schedules and expectations
Noise
Over-stimulation, Under-stimulation
Lighting, colour schemes
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Social and Cultural Factors and BPSD
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Life Story/History
Cultural Heritage
Social Networks
Life Accomplishments
Negative Social Interactions
Mountain Top Experiences
Relationship with Family
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The Clinical Level - Care Planning
Key is Understanding
 All behaviour has meaning
 What has changed, what is new?
 Think atypical with older people
 Usually more than one cause –
Remember PIECES
 Takes a team to assess complex
care situations
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Non-Pharmacological Interventions
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Derived from holistic person
centered assessment – think
PIECES
Correct the correctable, treat the
treatable and prevent the
preventable
Care Strategies developed and
understood by all team members
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Top Ten Behaviours Responsive To
Medication (Perhaps!)
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Physical
Aggression
Verbal Aggression
Anxious Restless
Sadness, crying,
anorexia
Withdrawn,
apathetic
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Sleep Disturbance
Wandering with
agitation
Vocally repetitious
Delusions/hallucinations
Sexually inappropriate
behaviour with agitation
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Pharmacological Interventions
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Clear indication with potential benefits
Expected time to respond
Risks associated with and without
treatment
Appropriate dose range
Monitoring for side effects and response
When to consider dose increase,
reduction and discontinuation
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Changing The Outcome
of Agitated Behaviour
Recognizing the Chain of Events leading to
a crisis:
1. The person feels anxious or
frightened.
2. As you approach the persons, personal
space, how the person reacts will
depend on what they are seeing and
hearing.
3. Physical intervention is always to be
avoided if at all possible
Hamilton, P & Baker, K Psychogeriatric Resource Consultant’s Ontario
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The person feels anxious or
frightened!
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Think about how the person is
feeling in the situation
Anticipate the possible response
These are the keys to Prevention and
Avoiding further Escalation.
Hamilton, P & Baker, K Psychogeriatric Resource Consultant’s Ontario
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As you approach the person,
what are they seeing?
Non-Verbal Interaction – Think About it
 Your approach sets the tone, think
about your body language.
Ask – what does this person see when
they look at me?
Use your body language to send the
message you want.
Ask – What do I want the person to
see when they look at me?
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Hamilton, P & Baker, K Psychogeriatric Resource Consultant’s Ontario
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As you speak to the person,
what are they hearing?
Verbal Interaction- Think About it!
Think about what you are saying and how
you are saying it.
Ask- What does the person hear when I
speak?
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Use your words and your voice to send
the message you want.
Ask – What do I want the person to hear
when I am speaking?
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Hamilton, P & Baker, K Psychogeriatric Resource Consultant’s Ontario
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What we have learned….
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Avoid labels
Think atypical
Understand causes, often multiple:
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Comprehensive holistic person centered
assessment
Team contribution to assessment and shared
solution finding
Pharmacological interventions play a role
What I say and do makes a difference
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Resources
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Canadian Coalition for Seniors
Mental Health, National Guidelines
www.ccsmh.ca
P.I.E.C.E.S Canada
www.piecescanada.com
Canadian Collaborative Mental
Health Initiative. Seniors Mental
Health Toolkit www.ccmhi.ca
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Thank You
Coming together is a beginning.
Keeping together is progress.
Working together is success.
Henry Ford
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