Managing Challenging Behaviors in Dementia

Non-pharmacological Interventions

Teah Bayless, DOJuly 11, 2018

OBJECTIVES

Discuss dementia statistics, prevalence of behaviors in dementia, and its impact across the continuum of care Discuss

Identify behaviors that commonly occur in dementiaIdentify

Learn how to use the Snow Model as a framework to think systematically about an unwanted behavior and how to address it with the caregiverLearn

Apply nonpharmacological interventions to combat a particular behaviorApply

Appreciate when pharmacological interventions may need to be considered Appreciate

The Facts• 5.5 million Americans of all ages were living with

dementia in 2017.– 5.3 million were aged 65 and older

• In North Carolina, 160,000 people have a diagnosis of dementia. It is projected by 2025, that number will grow to 210,000.

• In 2017, the cost of providing care to people with a diagnosis of dementia was projected to be $259 billion dollars.

The Facts

• Caregivers: 18.2 billion hours of care valued at $230 billion dollars

• Community dwelling older adults with dementia rely on multiple unpaid caregivers - 30% have 3 vs 23% of their peers with no diagnosis of dementia

• 3 reasons caregivers provide care:– Desire to keep family member of friend at home (65%)– Proximity to person (42%)– Perceived obligation (38%)

Alzheimer’s Association. 2017 Alzheimer’s Disease Facts and Figures. Alzheimer’s Dementia 2017;13:325-373.

Food for Thought

• 8% of those with dementia do not receive help from family members or other informal care providers.

• Of this 8%, 40% live alone without caregiver support making it more difficult to ask for and receive informal care (or I would wager services available to them!)

• 90% of individuals with dementia will exhibit behavioral and psychosocial symptoms of dementia

Reminders

• Non-pharmacological interventions are the first line therapy for treatment

• Educating caregivers helps everyone

Implications of challenging behaviors

• Caregiver stress• Patient stress• Early placement in long term care facilities• Unnecessary ED visits and potentially, preventable

hospitalizations leading to increased health care costs• Potentially inappropriate anti-psychotic initiation• Misuse of medications • Risk for abuse or neglect by a caregiver

The Impact• Twice as many hospitalizations per year than other older

adults without a diagnosis of dementia– 538 stays per 1000 Medicare beneficiaries > 65 years old with

dementia compared to 266 per 1000 Medicare beneficiaries without diagnosis of dementia

• Hospitalizations are prolonged – 22.5 days on average vs 4.6 for older adult without dementia diagnosis

• 238 SNF stays per 1000 Medicare beneficiaries vs 73 per 1000 in peer group without dementia diagnosis

• 25% of Medicare beneficiaries with dementia have home health services at least one time per year in comparison to 10% of those in peer group who do not have the diagnosis.

Alzheimer’s Association. 2017 Alzheimer’s Disease Facts and Figures. Alzheimer's Dementia 2017;13:325-373.

Challenging Behaviors• Agitation• Elation• Irritability• Aberrant motor behaviors• Anxiety• Apathy• Depression

• Appetite changes• Aggression• Delusions• Hallucinations• Disinhibition• Sleep changes• Wandering• Repetition

Cerejeira, J, L. Lagarto, E.B. Mukaetova-Ladinska. "Behavioral and Psychological Symptoms in Dementia." Frontiers in Neurology 3 (2012): 73. PMC. Web .20 Jan. 2017.

Agitation

• Characterized by disruptive motor or vocal activity• Distressing for patients and affects quality of life• Interferes with care delivery in various settings• Can be used to describe behaviors ranging from

verbal complaints to significant aggression depending on care setting and informant– Be sure to clarify with the informant what the behavior is in a given

patient

How can we help with challenging behaviors?

• Describe the behavior: Use objective words• Categorize: Annoying, disruptive, dangerous, etc. • Ask: What happens? Where does it happen? Who is

involved? When does it happen? Are there known antecedents? Are there known consequences to date? Outcomes?

• Figure out what you know and what you don’t know• Take time to fill out all the pieces of the puzzle.• It might take a few visits (or a few phone calls!)

Who is/was this person? History, life pattern, and preferences

Patterns and Routines?How does this fit in with the rest of the day? Is this related to old personal habits or rituals? Stress threshold related?

Health Issues?Psychological, physical, emotional, spiritual, medical, psychiatric, sensory history and status

Other people and caregivers? Approach, words, actions, and reactions in public, personal, and intimate space?

Environment? What is going on all around? How do things look, sound, feel, smell, or taste?

Type & level of cognitive function?Memory, language, understanding, impulsiveness, logic, etc.

Developed by T. Snow, MS, OTR, FAOTA for Durham VA GRECC Conference on Managing Challenging Behaviors August 2010

The Snow Model: A Framework for Addressing Behaviors

How can we help with challenging behaviors?

• Brainstorm: Given all the pieces of the puzzle, what do you think is going on? How would you explain the behavior of this person?

• Formulate an action plan with the caregiver (and patient, if possible).

• What will you try? Why/how do you think it might help? How will you know if it works? Who will be doing what? When will it be implemented? How will it be monitored? When will the impact be evaluated?

Developed by T. Snow, MS, OTR, FAOTA for Durham VA GRECC Conference on Managing Challenging Behaviors August 2010

The Literature Search• Mostly geared to Nursing Home or similar

environments, but studies are out there regarding community dwelling older adults with dementia

• Evaluated the following:Reminiscence therapy Acupuncture Music therapy Simulated presence Aromatherapy Snoezelan TherapyValidation therapy Light therapy TENS Massage and touchAnimal assisted therapy ExerciseBehavior Management

Putting It All Together

• Think about a patient you have had.

• What was the situation?

• Use the Snow Model to devise a strategy for the patient and their caregiver to address the assigned behavior.

Failure To Launch: When Interventions Fail

• Medication intervention may be warranted• Discuss goals of care

– Plan ahead if possible, start discussions early, provide families with necessary information at the start of care

• Discuss risks vs benefits with caregiver or other interested parties before initiation

• Try to wean off medication or at least reduce to lowest effective dose

Final Thoughts• Five tips for the caregiver providing care you can

share:– Try not to take behaviors personally.– Remain patient and calm.– Don’t argue or try to convince someone.– Accept behavior as a reality of the disease and try to work

through it.– Explore pain as a trigger.

• Nonpharmacological interventions are first line therapy for behaviors associated with dementia.

• Involve the whole care team – including the patient!

Online Resources

http://www.alz.org/care/alzheimers-dementia-stages-behaviors.asphttps://www.caregiver.org/caregivers-guide-understanding-dementia-behaviorshttp://zarcrom.com/users/alzheimers/cg-d.html

References• Alves, Jorge, et al. “ Non-pharmalogical Cognitive Intervention for Aging and Dementia: Current

Perspectives.” World Journal of Clinical Cases. 2013 Nov 16; 1(8): 233-241.• Cerejeira, J., L. Lagarto, and E.B. Mukaetova-Ladinska. “Behavioral and Psychological Symptoms of

Dementia.” Frontiers in Neurology 3 (2012): 73. PMC. Web. 20 Jan. 2017.• Gitlin, Laura N. et al. “Tailored Activities to Manage Neuropsychiatric Behaviors in Persons With Dementia

and Reduce Caregiver Burden: A Randomized Pilot Study.” The American Journal of Geriatric Psychiatry , Volume 16 , Issue 3 , 229 – 239. Web 2 April 2017.

• Gitlin Laura N, Helen C. Kales, and Constantine Lyketsos. “Managing Behavioral Symptoms in Dementia Using Non-pharmalogical Approaches: An Overview.” JAMA. 2012 Nove 21: 308 (19): 2020-2029.

• Kansagara, Devan, MD, MDR and Maya E. O'Neil, PHD, et al. A Systematic Evidence Based Review of Nonpharmacological Interventions for Behavioral Symptoms of Dementia. Mar. 2011, www.hsrd.research.va.gov/publications/esp/Dementia-Nonpharm.pdf. Accessed 1 Apr. 2017.

• Snow, T. (2010). A Team Approach to Managing Challenging Behaviors [Powerpoint slides]. Retrieved from http://cgne.nursing.duke.edu/content/managing-challenging-behaviors-older-adults

• Thakur, Mugda E., et al. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. American Psychiatric Pub, 2015.