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Behaviour…..It’s All In Your Approach

Alzheimer Conference 2008

Winnipeg, ManitobaJoanne Collinscollinjb@gov.ns.ca

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Objectives

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?

Seniors age 85 and older are the fastest growing age group and most likely to require long term care facilities

38% of all women and 24% of men age 85 and older live in long term care facilities

Over the next 30 years the number of long term care beds is expected to triple

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:

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!

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!

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 4-23%

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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

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

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,

an expression of a person’s abilities, disabilities and challenges

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All Behaviour Has Meaning!

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

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….

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

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/cognitive changes 7A’s

EmotionalCapabilitiesEnvironmentSocial

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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 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

Adjustment Difficulties Depression Anxiety Delusions and Hallucinations

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Capabilities Related to BPSD

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

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

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

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!)

Physical Aggression

Verbal Aggression Anxious Restless Sadness, crying,

anorexia Withdrawn,

apathetic

Sleep Disturbance Wandering with

agitation Vocally repetitious Delusions/hallucinations Sexually inappropriate

behaviour with agitation

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Pharmacological Interventions

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 toa 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!

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?

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?

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?

Hamilton, P & Baker, K Psychogeriatric Resource Consultant’s Ontario

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What we have learned….

Avoid labels Think atypical Understand causes, often multiple:

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

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