Transcript Need-driven Dementia-Compromised Behavior Theory

Interventions to Minimize Behavioral
Symptoms of Dementia:
Moving Beyond Redirection
Part II
Margaret Hoberg MSN, GNP-BC
Siobhan McMahon MSN MPH GNP-BC
Objectives
Learning Objectives
1.
Explain the effects of dementia on thinking, emotions and
communication
2.
Use a theory to help explain behavioral and communication
changes associated with dementia and to guide interventions
3.
Respond to behavioral changes with a calm, validating
approach
4.
Comprehensively assess verbal and nonverbal messages,
including those that are associated with stress
5.
Develop a plan whose non-pharmacological interventions reflect an
understanding of and respect for the person and their preferences.
Effects of Dementia
Memory
Understanding
Reasoning
Communication
Problem
solving
 As many as 80%–90% of patients with
dementia develop at least one behavioral or
psychological symptom during the illness
 Behavior changes are time consuming,
increase environmental stress and caregiver
stress
 Behavioral symptoms of dementia often trigger
relocation (NH)
Behavioral symptoms of dementia:
Good News
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Non pharmacological individualized approach to
assessment and management minimizes behavioral
symptoms of dementia and can prevent catastrophic
events (e.g. extreme fear, falls, ER visits, hospital visits).
These are considered first line.
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A person with dementia still expresses what their basic
needs and feelings are, but in new and different ways
(verbal, non-verbal and behavioral).
Behavioral symptoms of dementia: Bad News
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There is no magic solution or cure for behavioral symptoms of
dementia.
Psychotropic medications that are often used for behavioral
symptoms of dementia, such as benzodiazipines or anti-psychotic
medications, are not FDA approved for these indications; the
have minimal efficacy; and they have significant/ severe side
effects
Delirium is under-recognized and often missed
Comprehensive assessments are not always done in the face of
behavioral changes (Kovach, 2006).
Uni-dimensional treatment initiated without comprehensive
assessment may trigger a cascade of problems.
Behavioral symptoms: Words such as Agitation & Anxiety are
general descriptors; not specific enough to treat.
Agitation
Aggressive
Non Aggressive
Verbal
physical
Verbal
physical
bossy
restless
screaming
kicking
Not liking things
Repetitive
cursing
grabbing
Agitation can lead to or be related to DEPRESSION!!
Psychological Changes
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Depression
Paranoia
Delusions
Hallucinations
Anxiety
Theories that explain changing
communications and behaviors
Need-driven Dementia-Compromised Behavior
Theory
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Explains factors that produce behavioral symptoms
Explains the mechanisms of interventions that
effectively treat behavioral symptoms
Need-driven Dementia-Compromised
Behavior Theory
Changes the negative view of behavioral view of
symptoms as disruptive and inappropriate
Instead it conceptualizes behaviors as indicating
unmet needs that, if responded to well, will
increase quality of life.
Need-driven Dementia-Compromised
Behavior Theory
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Background Factors such as health, functional
factors, psychosocial factors (including
personality)
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Proximal or immediate Factors : physical
needs, emotions, social environment, physical
environment.
Need-driven Dementia-Compromised
Behavior Theory
Background
factors (e.g.,
arthritis, heart
failure, need for
assistance)
Immediate
factors (e.g.,
warmth,
noise, pain)
Behavioral
symptoms
Prevention
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Caregiver training
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Communication techniques
that are respectful & reassuring; not confrontational
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Not over-reacting to behaviors
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Avoid Restraints
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Develop individualized
routines
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Avoid high risk medications
Assessment: Investigating the details of
common descriptions.
 He is causing chaos in the dining room
 She is ‘anxious’, she needs ativan
 She is combative
 She bit her caregiver
 We cannot seem to calm her down
 He is out of control
 We called the police to help contain him
 Help! we need something to calm her down
Assessing the situation
History of behavior pattern
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Type
Antecedents
Frequency
Duration
Intensity
Keep a behavior log or use behavior tools (e.g. Cohen
Mansfield)
Assessing the situation
History: Take a step back to consider
Include details detailing history, physical, social
and environmental factors?
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Is this an atypical presentation of an acute illness
or exacerbation of chronic illness?
Is pain playing a role ?U
What physical needs might the patient have ?
Is the patient bored?
Is there Environmental stress?
How is the Caregiver doing?
Assessing the situation
Review individual history
1. PMH (which diagnoses are
associated with pain? )
2.
Social /Life History
Traits
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Habits
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Past work
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Hobbies
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Difficulties
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Recent life stresses (e.g.
death of a loved one)
3.
ROS (multiple sources)
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Assessing the situation
Is the situation being
aggravated by
medication?
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New medications?
CNS effects/side effects?
(e.g. benzodiazipines, meds
for Parkinson’s & restless
legs)
Anticholinergics
Home remedies
ETOH
Assessing the situation
Physical exam
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Functional status
Screen for malnutrition
Screen for sensory impairment (eye glasses, mouth,
hearing)
Screen for infection
Mental status (screen for delirium, depression)
Body systems
Individualized diagnostic tests
Assessment
•Consider the whole person and their history
•Get the perspectives of all—known history, family nurses,
CNA’s, activity therapists, rehabilitation, social services
Identifying the triggers
Diagnosis
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Acute Illness?
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Chronic illness
exacerbation?
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Medication side effect ?
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Pain?
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Unmet Physical need?
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Boredom?
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Environmental stress?
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Dementia progression?
Lillian
 85 year old with AD and VD: moderate stage.
 Living at AL.
 Has a lot of ‘agitation’
 More specifically, she has bad dreams, tends to
wander, hits others at times, repeats statements,
and refuses personal cares.
 Staff say that she often seems to be sitting idle.
 Her medical history includes heart disease, HTN, OA
with pain
Need-driven Dementia-Compromised Behavior
Theory: Lillian
Background factors
Heart disease
Mixed vascular/Alzheimer’s
dementia in moderate stage
Osteoarthritis
Proximal factors
Boredom,
Pain not controlled
Increased confusion
Caregiver stress
Behavioral
symptoms
Hitting others
Refusing help
Repeating statements