BEHAVIOURAL APPROACHES BEHAVIOURAL APPROACHES IN DEMENTIAIN DEMENTIA:

PRIMING, TIMING, MIMING for Behavioural Care Plans

Dr. Lindy A. KilikNeuropsychology Service,

Geriatric Psychiatry ProgramProvidence Care-MHS

Learning ObjectivesLearning Objectives

To understand the current and future impact of dementiaTo review diagnostic criteria for dementia and identify dementia sub-typesTo review the cognitive, behavioural, perceptual and functional changes associated with dementiaTo identify nursing strategies for working with individuals who have a dementiaTo introduce the “Priming/Timing/Miming model of behavioural care plan development

Dementia DefinedDementia Defined

Dementia: DSMDementia: DSM--IV CriteriaIV Criteria

Memory LossOther cognitive impairments present (agnosia, aphasia, apraxia, loss of executive functioning)Decline from previous levels of abilityImpairment caused by each of the symptoms is of degree that is sufficient to interfere with patient's work/social lifeNo delirium

Oh Those Demographics!Oh Those Demographics!

BackgroundBackground

For industrialized nations:Populations are steadily aging• Age is a major risk factor for the development of dementia,

and so, concomitantly…

The number of individuals with dementia is rising

Schematic: 1950s demographicsSchematic: 1950s demographics

old

adults

young

Schematic: 2028 demographicsSchematic: 2028 demographics

old

adult

young

Increase in Population 65+ for Ontario

3237370

1543598993900

0500000

100000015000002000000250000030000003500000

1986 1992 1994 1998 1999 2000 2028

year

popu

latio

n

Ontario

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

2000 2004 2008 2012 2016 2020 2024 2028 65-69 70-74 75-79

80-84 85-89 90+

Dementia Projections 2000 - 2028

Dr. Leila Denmark, US Pediatrician, retired in 2002 at age 104

Dementia Prevalence RatesDementia Prevalence Rates(Canadian Study on Health & Aging Data)

0%

10%

20%

30%

40%

50%

60%

65-69 70-74 75-79 80-84 85-89 90+

Dementia Rates By 5 Year Age Groups

CSHA Dementia RatesCSHA Dementia Rates

AGEAGE Dementia RateDementia Rate

65-69 1.5%

70-74 3.4%

75-79 8.0%

80-84 16.2%

85-89 28.3%

90+ 51.8%

Types of DementiaTypes of Dementia

Causes of Reversible DementiasCauses of Reversible Dementias

B12 DeficiencyHyperthyroidismLithiumPhenytoinArsenic, LeadEncephalitisSevere AnemiaEtc., etc., etc.

Common Types of DementiaCommon Types of Dementia

Dementia TypeDementia Type How common is this type?How common is this type?

Alzheimer Disease 50-70%

Lewy Body Dementia 15%

Vascular Dementia 13%

Fronto-temporal dementia/Pick’s Disease

<10%

Alcohol Dementia 3%

Alzheimer’s disease is a brain disorder named for German physician AloisAlzheimer, who first described it in 1906.

DSMDSM--IV Diagnostic Criteria for IV Diagnostic Criteria for AlzheimerAlzheimer’’s Diseases Disease

Development of multiple cognitive deficits:memory impairmentother cognitive disturbance (aphasia, apraxia, agnosia, etc.)

Cognitive deficits cause significant impairment in social or occupational functioning, represent a declineGradual onset and continuous declining courseNot due to other CNS or medical conditions, delirium or an AXIS I Disorder

NINCDSNINCDS--ADRDA criteria: AlzheimerADRDA criteria: Alzheimer’’s s DiseaseDisease

Probable ADDementia established by clinical exam and documented by MMSE or Blessed scale, confirmed by further neuropsychological testsDeficits in 2 or more areas of cognitionProgressive worsening of memory & other cogNo disturbance of consciousnessOnset between age 40 and 90Absence of systemic disease or other brain diseases that could explain the cognitive changes

Probable AlzheimerProbable Alzheimer’’s Diseases Disease……22

Supported by:Progressive aphasia, apraxia, agnosiaImpaired activities of daily livingPositive family hxLab results: normal lumbar puncture, EEG, evidence of cerebral atrophy on CT/MRI

Possible AlzheimerPossible Alzheimer’’s Diseases Disease

Fits probable profile but…Variations in onset, presentation or clinical courseMay be made in the presence of a second systemic or brain disorder sufficient to cause a dementia which is not considered to be the single cause of the dementia

Healthy & Alzheimer BrainHealthy & Alzheimer Brain

Alzheimer PlaquesAlzheimer Plaques

Alzheimer TanglesAlzheimer Tangles

Vascular Dementia: Vascular Dementia: NINDSNINDS--AIREN criteriaAIREN criteria

Meets criteria for a dementiaEvidence of cerebro-vascular disease (CVD)

Focal signs on neurologic examEvidence of CVD on imaging: multiple large-vessel infarct or a single strategically placed infarct & multiple basal ganglia and white matter lacunes/extensive periventricular white matter lesions

Relationship between the dementia and CVDWithin 3 months following a stroke and/or abrupt deterioration and/or fluctuating, stepwise progression of cognitive deficits

Vascular dementiaVascular dementia……22

Clinical features of Probable VaDEarly gait disturbanceHistory of unsteadiness and frequent fallsEarly urinary frequency, urgency, other not explained by urologic diseasePseudobulbar palsyPersonality and mood changesOther subcortical deficits (e.g., psychomotor retardation)

LEWY BODY DEMENTIALEWY BODY DEMENTIA

Probable LBDMemory may be relatively spared as compared to attention, fronto-subcortical skills and visuo-spatial abilityTWO of• Fluctuating cognition with pronounced variations in

alertness and attention• Recurrent visual hallucinations• Spontaneous motor features of Parkinsonims

LBD continuedLBD continued

Supported by:Repeated fallsSyncope or transient loss of consciousnessNeuroleptic hypersensitivityDystematized delusionsHallucinations in other modalities

Areas of ChangeAreas of Change

Perceptual AbilitiesPerceptual Abilities……11

Visionision:loss of depth perception, poorer colour vision, tunnel vision

Decreased hearinghearing

Reduced sense of touchsense of touch

Perceptual AbilitiesPerceptual Abilities……22

Sense of balance balance (where the body is in space)

Confusing right and leftConfusing right and left

Hallucinations Hallucinations (hearing voices or seeing shadows causes fear and suspiciousness

Cognitive…1Disoriented (to person, place, date, time)

Impaired attention / more distractible

Poor recent memory / limited ability to learnearn new information

Language problemsproblems: understanding/ expressing languagenaming objectsword-findingvague speech

CognitiveCognitive……22

Slowed speed of taking in information / overload

Lack of insight / self-awareness

Reduced problem solving and reasoning

Delusions: esp. paranoid thinking

Emotional ChangesEmotional Changes……11

Emotional blunting (emotionally "flat")Emotional lability= emotions may rapidly shift from one extreme to anotherIrritabilityEmotional memory may remain strong when other types of memory fail (what you feel in your gut)

Functional ActivitiesFunctional Activities

Managing financesManaging finances: making financial decisions, paying bills, making change

Dressing, grooming and hygieneDressing, grooming and hygiene skills may decline

Reduced ability to know how to use common know how to use common objectsobjects: keys, comb, fork, razor

Inability to do multiInability to do multi--step activitiesstep activities: e.g., Cooking

A Word About A Word About BehaviourBehaviour

BehaviouralBehavioural ChangesChanges……11

DisinhibitionDisinhibition and impulsivenessimpulsiveness (mental brakes)

Inappropriate social behaviourInappropriate social behaviourloss of social skills, sexually inappropriatesexually inappropriate behaviour

Perseveration Perseveration (getting stuck, repeating something (getting stuck, repeating something –– a word or an action)a word or an action)

BehaviouralBehavioural Changes...2Changes...2

Irregular sleep and wake cycleIrregular sleep and wake cycle

Restlessness, agitatedRestlessness, agitated behaviour

Wandering / Getting lost Wandering / Getting lost

Vacant lookVacant look

General Nursing StrategiesGeneral Nursing Strategies

General General BehaviouralBehavioural StrategiesStrategies……11

Approaching the person / establish rapportApproach from the frontIdentify yourselfBody language / non-verbalsEye contactLevel the playing fieldMove slowly

General General BehaviouralBehavioural StrategiesStrategies……22

Engaging the person in conversationSpeak slowly Use simple statements/questions

(yes/no instead of multiple choice or open-endedAllow time to process your question & form a responseRepeat / rephrase your question when neededTalk about something pleasantUse humour (with caution – can be taken literally!)

General General BehaviouralBehavioural StrategiesStrategies……33

Watch the person’s non-verbals:If they can’t use language• They may act out what they are trying to tell you

Signs of agitation:• Clenched fists/slapping motions/rigid posture• Starting to stand up• moving back and forth in a restless fashion, pacing

Something to keep in mindSomething to keep in mind……

The person with dementia has been a The person with dementia has been a PERSON much longer than they have had PERSON much longer than they have had dementia. dementia.

ThereThere’’s a whole lot more to that individual s a whole lot more to that individual than the disease!than the disease!

Priming, Timing and Miming –A Heuristic for Planning BehaviouralApproaches in Dementia (© Kilik, 2006)

Behavioural Challenges in Dementia

Identified in the literature as: BPSD- “Behaviouraland Psychological Symptoms in Dementia”

Typical BPSD identified in dementia:Aggression (25-60%), Restlessness (20-45%), Visual Hallucinations (5-25%) Auditory Hallucinations (5-10%), Delusions (20%)

BPSD rates…

At least one of the traditional BPSD symptoms seen in over 80% of institutionalized patients with dementia

40-50% of BPSD resolve within 3 months

Consensus Guidelines

CAN Family Physician, Feb. 2006“Optimal treatment of behavioural disturbances in patients with dementia involves nonpharmacologicapproaches and using medications with demonstrated efficacy.”

“All guidelines stress that initial interventions should be nonpharmacologic. Generally, this means beginning with environmental and behaviouralmodifications.”

CAN Family Physician,Feb 2006

Pharmacologic treatment should target only those symptoms or behaviours that respond to medication. This approach minimizes unnecessary medication use and reduces adverse outcomes.

Behavioural Challenges in Dementia

Typical BPSD identified in dementia:Aggression (25-60%), Restlessness (20-45%), Visual Hallucinations (5-25%) Auditory Hallucinations (5-10%), Delusions (20%)

40-50% of BPSD resolve within 3 months

AGGRESSION IN DEMENTIAAGGRESSION IN DEMENTIA

80% of AGGRESSIVE BEHAVIOURis actually

DEFENSIVE BEHAVIOUR!!

Most behavioural challenges for inpatients occur…

In the “WHISPER ZONE”

In close proximity to patient

Involve physical contact

Involve personal (intimate) care

Whisper-zone care activities

BathingOral HygieneGroomingToileting Dressing

EatingTransfersAmbulationSleepAgitated/Aggressive behaviours

PRIMING, TIMING, & MIMING

A way to make sense of the vast literature on behavioural intervention strategies and approaches in dementia

Provides a quick and easy way to develop an individualized behavioural approach for a particular client with dementia.

PRIMING

What LEVEL of ASSISTANCE is required?Independentset-up/minimalModerateMaximal/totally dependent

How many PERSONS are required?

PRIMING

Do you have a predictable routinepredictable routine (or string of events) that signalssignals the activity to the client?

Are there familiar objects, scents, people, etc. you can involve in the activity to help the client understand the purpose and also to communicate that it is safe?

TIMING

What time of day do you engage in the activity?When did the client usually do this activity in the past?

What is the best time of day for the client?

TIMING

Are you pacing the activity at a rate that the patient can comprehend?

Are you speaking and moving slowly enough that the client can understand the process and participate

MIMING

Generally there is a greater chance of communicating something if it is presented in more than one modality at a time: Say it and slowly demonstrate it at the same time

Non-verbal communication makes up for over 90% of the message (tone of voice, rate of speech, facial expression, body language) . Use all of these modes as well as the words!

SUMMARY

“PRIMING, TIMING, MIMING” represents a heuristic that easily leads you to incorporate a number of tried and true behaviouraltechniques into your approach with clients

This framework is based on knowledge about an individual’s patterns, preferences and routines – it works because it’s personalized!

The strategies minimize confusion, anxiety/fear, agitation, catastrophic reactions & physical aggression.

The Priming, Timing, Miming Behavioural Care Plan©

A way to quickly capture all of the information within the “Priming, Timing, Miming©” model into an easy-to-follow care plan documentA single, double-sided sheet Includes

Goals for admission-dischargeIndividualized care approaches

CASE EXAMPLES