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Behavioral
Approaches to
Agitation in
Dementia
Erin L. Patel, Psy.D.
Clinical Psychologist
Alvin C. York VAMC
Tennessee Valley Healthcare System
March 19, 2013
▪ What is dementia?
▪ How does dementia impact communication and
behavior?
Goals and
Objectives:
▪ What is agitation? How else can it be described?
▪ What are the risks associated with pharmacological
management of agitation in patients with
dementia?
▪ What are non-pharmacological interventions for
agitation?
▪ What is the ABC approach to behaviors?
▪ What barriers exist in implementing non-
pharmacological approaches?
Dementia is brain failure
Dementia’s Impact
Frontal Lobes
The frontal lobes are located behind the forehead.
This area of the brain is associated with higher-level
thinking, such as problem solving, reasoning, and
some aspects of speech. It also contains the motor
cortex, which controls voluntary movement.
Temporal Lobes
The temporal lobes, above the ears, are involved in
hearing, identifying objects, understanding
language, and storing memories. They also play a
role in emotions.
The Limbic System
Parietal Lobes
The parietal lobes on the top of the head process
senses like touch, pain, temperature, pressure,
and spatial awareness. They are also associated
with voluntary movement, attention, language,
and some mathematical abilities.
The limbic system is a ring-shaped group of structures
involved in emotions, instincts, and memory formation.
Together with the brain stem, it manages essential
survival functions such as temperature, blood pressure,
heart rate, and blood sugar.
Occipital Lobes
The occipital lobes at the back of the brain interpret visual
information like color, light, shape, and movement.
Behavior as Communication
▪ Communication is impaired in dementia
▪ Expressive/ Receptive/ Global aphasia
▪ Actions speak louder than words- but not as clearly
▪ Behavior communicates needs and wants
▪ Behavior as poorly communicated needs
▪ How might a resident show…
▪ Pain?
▪ Being too cold or too hot?
▪ Fear?
▪ Boredom?
▪ Need for control?
▪ Being thirsty or hungry?
▪ Being overtired?
What is Agitation?
▪ Per the dictionary:
▪ To excite and often trouble the mind and feelings of: DISTURB
▪ What about behavior?
▪ Antonyms:
▪ Calm
▪ Quiet
▪ Settle
▪ Sooth
▪ Tranquilize (uh, oh!)
▪ Agitation in older adults can take many forms- what comes to mind?
How Common is Agitation and Other
Behavioral Problems in Dementia?
▪ It is estimated that roughly 90% of patients with dementia will exhibit agitation or other problematic
behaviors during the course of their illness
▪ Common complaints include hitting at others, yelling/cursing, wandering, disrobing, hoarding/stealing,
anxiety, sexualized behaviors or comments, reversed sleep/wake cycles, resisting care
▪ Distressing for patient and caregivers
▪ May put patient or others at risk of harm
▪ What should we do for behaviors that are seemingly harmless and just annoy?
▪ Psychotic symptoms may also be present
▪ Hallucinations
▪ Delusions
▪ Paranoia
▪ Delirium also occurs frequently in older adults, especially in those who are cognitively and medically
compromised
▪ PTSD
▪ Depression
▪ Anxiety
The Impact
of Co-Morbid
Conditions
▪ Psychotic Disorders
▪ Personality Disorders
▪ Medical conditions/treatments:
▪ COPD
▪ Parkinson’s Disease
▪ ALS
▪ Delirium
▪ Medical restraints
▪ Sleep
The Impact
of Other
Conditions
▪ Pain
▪ Infection
▪ Dehydration
▪ Past experiences
▪ Pre-morbid personality
▪ Medications are SECOND line treatment for
behavioral and psychological symptoms associated
with dementia
Pharmacological
Management of
Agitation in
Dementia
▪ Classes of medications often used:
▪ Antipsychotics
▪ Hypnotics
▪ Benzodiazepines
▪ Mood Stabilizers
▪ Antidepressants
▪ Cholinesterase Inhibitors
▪ What do medications treat?
▪ How do medicines change/improve behaviors?
Risk versus Benefit Analysis of Pharmacotherapy
(specifically antipsychotics) for Agitation in Dementia
Risks
DEATH!
Falls
Sedation
Extrapyramidal
symptoms
Restlessness
Social withdrawal
Reduced quality of
life
Pneumonia
Benefits
Accelerated
cognitive decline
Quick acting
Reciprocal
reactions
Mild/short term benefits
for aggression and
psychosis
Delirium
Hospitalization
Cerebrovascular
impacts
Metabolic effects
Cardiovascular
effects
Sedation
Requires less staff time
▪ Omnibus Budget Reconciliation Act (OBRA)- 1987- Guidelines: states that patients who reside in
nursing homes must be free from excessive physical and chemical restraints
▪ FDA- Public Health Advisory- 4/11/2005-
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/D
rugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm053171.htm
▪ National Institute of Mental Health- Press Release- 10/11/2006
▪ According to the Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE-AD) study (n=421),
antipsychotic medications (Zyprexa, Seroquel, and Risperdal) were no more effective than placebo when
adverse side effects are considered
▪ FDA Alert- 6/16/2008- Warning regarding Conventional Antipsychotics-
http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/uc
m124830.htm
▪ The New York Times- 1/11/2010, “Overmedication in the Nursing Home”
▪ 71% of Medicaid NH residents in FL on psychoactive medications within 3 months of admission
▪ “Beers consensus criteria for safe medication use in the elderly recommend avoiding antipsychotics
to treat neuropsychiatric symptoms of dementia “unless nonpharmacological options have failed and
[the] patient is [a] threat to self or others.”” (Steinberg & Lyketsos, 2012)
Risk versus Benefit Analysis of Use of Restraints
Risks
Increased rate of falls and injuries
Negative psychological outcomes
Death:
Asphyxiation
Strangulation
Cardiac Arrest
Functional Decline
Incontinence
Pressure Ulcers
Regressive Behaviors
Benefits
Keeps the resident in one location and
unable to move extremities
Staff may believe that this practice will
keep the person safe
▪ Risks associated with antipsychotic medications
▪ Falls
▪ Death
▪ Reduced quality of life
Why Use NonPharmacological
Techniques?
How is this related to the concepts
of cultural transformation in long
term care?
▪ Initiatives to reduce the use of antipsychotic
medications in nursing home patients
▪ Cultural transformation efforts to make the
environment “home-like” and reduce the use of
medications
▪ Promotion of quality of life
▪ Shift away from the medical model of nursing home
care
▪ What would you want for your family member? For
yourself?
What are “Non-Pharmacological”
Techniques?
“Non-pharmacological” techniques consist of individualized behavioral interventions,
as well as good care practices to prevent or reduce problematic behaviors
Behavioral Interventions:
Redirection
Distraction
Offering snack or activity
Validation
Respond to emotions
Soothing or comfort
Orient
Explain procedures
Incorporate history, occupation, interests, etc.
Others (be specific and individualized)
How about environmental modifications and care practices?
▪ Use active listening skills
▪ Be mindful of non-verbal cues
▪ Offer choices
▪ Set appropriate boundaries
▪ Provide praise, compliments, and acknowledgment
▪ Offer positive social attention on a daily basis
▪ Engage the resident in cooperative problem solving
▪ Actively involve the resident in MEANINGFUL instrumental, leisure, productive, and social activities
▪ Environmental Modifications: reduce noise, good lighting, clean and clutter free, pleasant sights and
smells
▪ Interprofessional care
Other non-pharmacological approaches*:
▪ Light therapy
▪ Validation
▪ Animal therapy
▪ TENS
▪ Exercise
▪ Acupuncture
▪ Music therapy
▪ Simulated Presence therapy
▪ Aromatherapy
▪ Reminiscence
▪ Sensory stimulation
▪ Massage
▪ Snoezelen
* These techniques have few studies supporting their efficacy, but may prove beneficial and can be used as part of an
individualized approach
Non-pharmacological Interventions for Delirium,
Depression, Anxiety, Sleep Problems, etc.
Delirium
Correct sensory
deficits
Calm, predictable
environment
Depression
Anxiety
Sleep Problems
Active listening
Use music
Reflect emotion
Dim lights
Engage in pleasurable
events
Quiet environment at
Calm, predictable, and night
consistent
environment
Dim lights
Reassure
Bright light during the
day
Increase socialization
Orient
Explain procedures
Encourage paced
breathing
Engage in activities
during the day
Discourage caffeine
later in the day
Meet a person’s needs
before they are needs.
Behavioral Management in Practice
▪ Eden Alternative
▪ Dr. William Thomas
▪ http://www.edenalt.org/
▪ http://www.youtube.com/watch?v=ZKRMd-r2dN8
▪ Teepa Snow, Occupational Therapist
▪ http://www.teepasnow.com/teepa_snow_resources.html
▪ Use of time
▪ Hand over hand
▪ Becoming a detective
▪ Bathing without a Battle
▪ http://www.bathingwithoutabattle.unc.edu/index.html
THE ABC
APPROACH TO
MANAGING
BEHAVIORS
Clinical Application of
Learning Theory: Functional
Analysis
A= Antecedents
▪ Begin looking for any ANTECEDENTS to the behavior. Antecedents can
be viewed as predictors of the behavior- if we know when the behavior
will occur, then we can prevent it from even happening!
▪ What preceded the behavior?
▪ People- Who?
▪ Places- Where?
▪ Time of day- When?
▪ Activities taking place
B= Behaviors
▪ Determining the BEHAVIOR that needs to be assessed. Answers the
“what?”
▪ Describe the behavior:
▪ What does it look like? Provide details so that others would be able to recognize
the behavior.
▪ How long does it happen? (Duration)
▪ How often does it happen? (Frequency)
▪ How severe is this behavior? (Intensity)
C= Consequences
▪ CONSEQUENCES are not always negative; instead, they are what lead
to learning and maintain a problematic behavior.
▪ Reinforcement- anything given or taken away that INCREASES a
behavior. Person specific!
▪ Punishers- anything given or taken away that DECREASES a behavior.
Person specific!
▪ A consequence that starts a behavior may not be the consequence
that maintains it. Situation specific!
ABCs of Difficult or Challenging Behaviors
Behavior
(B)
Antecedents
(A)
Consequences
(C)
Evidence for Non-Pharmacological Techniques
▪ Department of Veterans Affairs- HSR&D- March 2011- systematic review of non-pharmacological
interventions for behavioral sx of dementia:
▪ Best evidence for systematic individualized interventions
▪ Cohen-Mansfield has demonstrated positive effects of behavioral interventions (2001)
▪ 2012- Cohen-Mansfield et al. demonstrated that Treatment Routes for Exploring Agitation (TREA)
interventions for unmet needs led to statistically significant declines in total agitation and significant
increases in pleasure and interest.
▪ Behavioral management, cognitive stimulation, and physical activities improved quality of life in
persons with dementia (Vernooij-Dassen et al., 2010)
▪ Livingston et al. (2005)
▪ Grade A evidence- caregiver education and support; Grade B evidence- music therapy, cognitive stimulation
therapy, Snoezelen, behavioral management, staff training/education
▪ “Only behavior management therapies, specific types of caregiver and residential care staff education, and
possibly cognitive stimulation appear to have lasting effectiveness for the management of dementia-associated
neuropsychiatric symptoms”
Barriers Associated with the Use of
Non-pharmacological Techniques
▪ MDs had more favorable attitudes towards pharmacological interventions (PIs) and
less knowledge of non-pharmacological interventions (NPHIs) as compared to PhDs
and NPs (Cohen-Mansfield, Jensen, Resnick, & Norris, 2012)- but still a strong desire
to utilize NPHIs before PIs
▪ Staff barriers (time, attitudes, education)
▪ System barriers (need for interprofessional care)
▪ Patient barriers (unwillingness to participate, sleeping)
▪ Fewer barriers associated with socialization versus games/crafts (Cohen-Mansfield,
Thein, Marx, & Dakheel-Ali, 2012)
Questions?