Assessing and Understanding Behavioral Symptoms

The Principles of Environmental Design for People with

Dementia

Tuesday 29th November, 9:30am – 11:00am

Friday 2nd December, 10:30am – 12:00pm

Angela Raguz, General Manager – Residential Care

HammondCare

• Independent, Christian Charity formed in

1932

• Today, specialising in community and

residential services for people with dementia

and palliative care, rehabilitation and older

persons‟ mental health

• Specialising in dementia care since the

1990s

• The Dementia Centre: independent, best

practice advice and are part of aged-care

experts HammondCare‟s commitment to

promoting excellence in dementia care and

related areas.

• HammondCare cares for 2770 clients and

residents and employs 2775 staff.

• Philosophy driven model of residential care

© 2011 HammondCare

• What are behavioral and psychological

symptoms of dementia?

• What are the common triggers for behaviors in

people with dementia?

• Assessing and responding to behavioural and

psychological symptoms of dementia

Session Overview: Assessing and Understanding

Behavioral Symptoms

© 2011 HammondCare

“Symptoms of disturbed perception, thought content,

mood or behaviour that frequently occur in

patients with dementia.”

Finkel & Burns (1999) International Psychogeriatrics Association

Defining Behavioral and Psychological

Symptoms of Dementia (BPSD)

© 2011 HammondCare

Impact of brain damage

Temporal lobe

Memory

Limbic region

Sleep, appetite,

emotions

Other Definitions

“A behavior of concern is any behavior which causes

distress to the person with dementia or others, or is a

manifestation of distress”.

Bird , M et.al (2002) Psychosocial approaches to challenging behaviors in dementia: A controlled trial. Australian

Government Department of Health & Ageing.

© 2011 HammondCare

Temporal lobe

Memory

Limbic region

Sleep, appetite,

emotions

Other Definitions

“A behavior of concern is any behavior which causes

stress, worry, risk of or actual harm to the person with

dementia, care staff, family members or those around

them. It deserves consideration and investigation as it is

an obstacle to achieving the best quality of life for the

person with dementia and may present as an

occupational health and safety concern for staff….

© 2011 HammondCare

Temporal lobe

Memory

Limbic region

Sleep, appetite,

emotions

Other Definitions

“…examples include: verbal disruption, physical

aggression, repetitive actions of questions, resistance to

personal care, sexually inappropriate behavior, refusal

to accept services, problems associated with eating,

socially inappropriate behavior, wandering or

intrusiveness and sleep disturbance”.

Alzheimer‟s Australia National Dementia Advisory Service (2003)

© 2011 HammondCare

The Brain and Behaviors of Concern

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The Brain and BPSD

Area of Brain Damaged Common Effect on

Behaviour

Examples

Temporal lobe (verbal &

visual memory)

Unable to remember words

that are spoken, read, seen

or heard

Forgetting people and events

Forgetting recent memories

Dominant Parietal Lobe

(analytical & logical centre)

Unable to use language

(speech, writing, reading)

and unable to calculate

Difficulty expressing

themselves, naming common

objects, understanding what

is said, doing math/handling

money

Non-Dominant Parietal Lobe

(spatial location)

Unable to locate position of

self, others or objects in

space

Difficulty knowing how to get

someone, getting lost

© 2011 HammondCare

The Brain and BPSD

Area of Brain Damaged Common Effect on

Behaviour

Examples

Both Parietal Lobes

(Agnosia)

Unable to recognise things Unable to recognise

people, objects or

surroundings

Both Parietal Lobes

(Apraxia)

Unable to carry out

planned or learned

patterns of movement

Difficulty putting clothes

on in correct order, using

appliances, following

instructions

Frontal Lobe - Lateral

(executive centre –

planning & learning)

Unable to plan, organise or

learn new things

Difficulty dressing

appropriately, not aware of

the state of tidiness of the

house, shop without

money

© 2011 HammondCare

The Brain and BPSD

Area of Brain Damaged Common Effect on

Behaviour

Examples

Frontal Lobe – Medial (executive

centre – initiation &

perseveration)

Unable to start an

action OR

Unable to stop once

starting or saying

something

Appear apathetic or

unmotivated

OR

Repeat questions,

statements and actions

Frontal Lobe – Orbitobasal

(executive centre – regulation)

Unable to control social

behaviour

Easily distracted, wander,

talk over others

Limbic Region (connecting

system)

Unable to connect

behaviours, emotions

and memories. Also

vegetative functions

(sleeping and eating)

Angry responses,

accusations of stealing,

disruption to sleep/eating

patterns

© 2011 HammondCare

Rates of BPSD have been estimated at:

• 61%–88% of people with dementia in a community setting

• 29%–90% of residents of Australian nursing homes

• 95% of hospitalised patients in long term acute care

Brodaty, H. et. al. Behavioural and psychological symptoms of dementia: a seven-tiered model of service delivery

(2003) Medical Journal of Australia

Prevalence of BPSD in Australia

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• Unidentified pain or poor pain management

• Poor nutrition

• Dehydration

• Changes in the environment, combined with

impaired ability to communicate and perceive

Common Triggers for BPSD

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•The majority of studies have concluded that at least 55% of

people with dementia are in pain at any given time (Horgas & Tsai

1998)

• As many as 55% of people with chronic pain have some

level of cognitive impairment as a result of the pain (McCracken &

Iverson 2001). This can lead to further impairment in people with

dementia

Pain and BPSD

© 2011 HammondCare

Pain and BPSD

• Up to 84% of older adults experience some form of chronic

pain (Tsai & Chang 2004)

• People with dementia are likely to have the same

conditions that cause chronic pain as other older people (eg.

diabetes, heart disease, hypertension, arthritis,

osteoporosis, pulmonary conditions, dental decay, cancer,

depression etc.)

© 2011 HammondCare

• Over a quarter of a million hip fractures occur and are treated

in the United States annually

• In one study, up to 42% of older patients experienced severe to

very severe pain post-operatively. 76% of people with dementia

did not receive regular pain relief post-operatively and,

proportionally, received only one third of the pain relief provided

to older people without dementia

Morrison & Sui 2000 in Cunningham, C (2006) Managing pain in patients with dementia in hospital, Nursing Standard

Case Study – are people with dementia

missing out?

© 2011 HammondCare

“Health professionals need to investigate and treat the

actual cause of challenging behavior (/behaviour of

concern) in patients with dementia and not attribute it to

being a symptom of dementia. It [pain] is a symptom that

requires investigation so that the cause can be addressed”.

Cunningham, C (2006) Managing pain in patients with dementia in hospital, Nursing Standard

© 2011 HammondCare

Identifying Pain in People with Dementia

McClean 2000 in Cunningham, C (2006) Managing pain in patients

with dementia in hospital, Nursing Standard

© 2011 HammondCare

Identifying Pain in People with Dementia

• The Abbey Pain Scale (Abbey et al 2004)

• Acknowledged as one of the better tools for identifying

pain in people with dementia who have impaired

communication

• Link: http://www.apsoc.org.au/owner/files/piracf4.pdf

© 2011 HammondCare

Managing Pain in People with Dementia

• People with dementia who exhibit behaviors of concern as

a result of pain are often treated with anti-psychotic

medication (Elenchenny & Shah 2001). This can mask symptoms

related to pain, prevent effective treatment and may effect

recovery time (Kovach 1999).

© 2011 HammondCare

Managing Pain in People with Dementia

Cunningham, C (2006) Managing pain in patients with dementia in

hospital, Nursing Standard

© 2011 HammondCare

Nutrition and BPSD

• Food is an important part of the healing and recovery

process of patients with dementia in hospital

• Although people with dementia experience weight loss, it

is not a symptom of dementia. It occurs because the

person can forget to eat, may not be able to communicate,

may have difficultly recognising food or managing a knife

and fork, staff may not be aware of their eating needs etc.

Archibald, C (2006) Meeting the nutritional needs of patients with dementia in hospital, Nursing Standard

© 2011 HammondCare

Nutrition and BPSD

Staff should allow time to find out about:

• the person‟s likes and dislikes

• the person‟s eating routine

• the person‟s capabilities

Staff should be aware of:

• creating excess disability (does the person need to be fed by a

staff member or do they just require prompting? Feeding a person

may be more effective and faster but it can lower self esteem, lead

to loss of independence and carer burden when the patient is

discharged

Archibald, C (2006) Meeting the nutritional needs of

patients with dementia in hospital, Nursing Standard

© 2011 HammondCare

Dehydration and BPSD

• Dehydration is present in as many as 25% of older people

(Ferry 1999)

• Dehydration can contribute to delirium or chest and

urinary infections

• Older people with dementia may have reduced thirst

responses, communication problems or forget to drink

(Copeman 2000)

© 2011 HammondCare

Dehydration and BPSD

Staff should:

• Closely monitor the fluid intake and output of people with

dementia

• Prompt verbally or demonstrate

• Provide a choice of drinks and find out what drink the person

prefers

• Address fears of incontinence (place the bed near the toilet

area, consider analgesia to help relieve arthritic pain which

hinders mobility)

Archibald, C (2006) Promoting hydration in patients with

dementia in healthcare settings, Nursing Standard

© 2011 HammondCare

The Environment and BPSD

‘Oh Mr Porter’ clip.

What are the environmental factors creating excess

disability for Mr Porter?

How could the environment be improved?

© 2011 HammondCare

Other Factors that contribute to BPSD

• Medication (and polypharmacy)

• Depression

• Major changes in the person‟s life

• Grief and anxiety

• Physical, emotional, social and spiritual health

© 2011 HammondCare

„Unpicking‟ BPSD

• Discover what the trigger is

• Understand the emotions behind the behaviour

• What is the person trying to communicate?

• What is the meaning of the behaviour?

• Imagine yourself in their position and consider the

situation from their perspective

© 2011 HammondCare

The ABC Method

A Antecedents Who was present at the time or just before the event?

When and where did the behaviour occur?

What was the person doing immediately before the

behaviour occurred?

B Behaviour Is this new behaviour?

What form did it take? Who or what was the focus of the

behaviour?

What are the precise details?

How did others respond to the event?

C Consequences What were the consequences for the person?

Did the person calm down or become more agitated?

© 2011 HammondCare

Managing and Responding to BPSD

© 2011 HammondCare

The Special Care Program – Linden Cottage

• Purpose built for older people with

severe and persistent challenging

behaviours

• Weekly case conferencing

ensures development of

comprehensive, individualised care

strategies

• Use of psychotropic medications

has decreased and psychosocial

approaches are developed to

respond to each individual‟s unique

needs

© 2011 HammondCare

The Special Care Program – Linden Cottage

© 2011 HammondCare

Questions?

© 2011 HammondCare

The Principles of Environmental

Design for People with Dementia

© 2011 HammondCare

• What is the impact of dementia on a person‟s

ability to function in the built environment?

• What are the principles of environmental design

for people with dementia?

• How can we apply these principles?

Session Overview: The Principles of Environmental

Design for People with Dementia

© 2011 HammondCare

Impact of brain damage

Temporal lobe

Memory

Limbic region

Sleep, appetite,

emotions

Frontal Lobe

Planning, insight, learning,

interpretation, behaviour

Temporal lobe

Memory

Limbic region

Sleep, appetite,

emotions

Parietal Lobe

Seeing 3D; performing

patterns/routines e.g.

language, arithmetic,

everyday tasks

The Impact of Dementia

© 2011 HammondCare

Abilities and deficits

Reference: Frontier, Cognitive disorders Clinic Prince of Wales Hospital

Brain Function Alzheimer’s disease Frontal lobe

dementia

Vascular dementia Dementia with

Lewy bodies

Word Understanding Mild- mod n/a n/a n/a

Memory Severe Variable Variable Variable

Spatial relations Moderate n/a n/a Mild – mod

Numbers Variable n/a n/a n/a

Vision Variable n/a n/a Mild – severe

Problem solving Mild – mod Mod- severe Mild – severe Mild – severe

Behaviour control Variable Mild – severe Variable Variable

Movement & coordination n/a n/a n/a Mod –severe

The Impact of Dementia – by Type

© 2011 HammondCare

But..... People with dementia also age People with Dementia are also Ageing…

© 2011 HammondCare

Vision

• Acuity – 75% of people

over the age of 70 have

problems

• Reduction in the visual field

• Light Adaptation

• Colour - Contrast + Range

• Height

• Eye Muscle

Hearing

• Clutter

• Discomfort

• Auditory Distraction

Mobility

• Dangerous gradients

• Unstable surfaces

• Sensation in Feet

The Impact of Ageing

© 2011 HammondCare

Excess disability is when the person has more

disability than can be attributed to the impact of

dementia

Factors which may increase disability include

The physical or social environment

The person‟s health

How we are communicating with the person

The physical environment

Consider Excess Disability as well…

© 2011 HammondCare

Ageing

Dementia

Excess Disability

Many Barriers to Function

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“…the disabilities that people

experience are a result of the

relationship between what‟s happening

in the brain and their social and built

environment.”

Professor Mary Marshall

Dementia Services

Development Centre Sterling

© 2011 HammondCare

HammondCare & Design for Dementia

© 2011 HammondCare

• Creating „home‟, a space

of belonging

• An environment that cares

for people with dementia -

physically, emotionally and

spiritually

Philosophy Driven Design

© 2011 HammondCare

• Small

• Domestic and familiar

• Highlighting features for independence

• Reducing unwanted stimulation

• Good visual access

• Safe and Secure

• Planned Wandering

• Close to community

• Promoting autonomy and choice

Principles of Design for People with Dementia

© 2011 HammondCare

Small

© 2011 HammondCare

Domestic and Familiar

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Highlighting for Independence

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Reducing Unwanted Stimulation

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Reducing Unwanted Stimulation

© 2011 HammondCare

Good visual access

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Safe and secure

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Planned Wandering

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Close to Community

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Promoting Autonomy and Choice

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• Use of contrast

• Lighting

• Signage & cueing

Other Design Issues for People with Dementia

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How not to use Contrast…

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How not to use Contrast…

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How to use Contrast…

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How can we apply the principles of good

environmental design for people with dementia to

the acute context?

Applying the Principles

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• In small groups look at the following photos of a usual hospital

environment

• Discuss ways in which the environment could be changed

using the principles of good design for dementia or the use of

contrast, lighting and signage & cueing to improve the

environment and reduce confusion

• Take ten minutes to discuss and be prepared to share with the

group

Practical exercise

© 2011 HammondCare

• Small

• Domestic and familiar

• Highlighting features for independence

• Reducing unwanted stimulation

• Good visual access

• Safe and Secure

• Planned Wandering

• Close to community

• Promoting autonomy and choice

• Also…contrast, lighting, signage & cueing

Remember the Principles of Design…

© 2011 HammondCare

The Challenge of Home

© 2011 HammondCare

Questions?

© 2011 HammondCare

www.dementiacentre.com.au