IN YOUR FACE !!! IN YOUR FACE !!!

CHALLENGING BEHAVIOURS IN CHALLENGING BEHAVIOURS IN OLDER ADULTS WITH DEMENTIAOLDER ADULTS WITH DEMENTIA

Dr E C KomockiDr E C KomockiConsultant in Old Age PsychiatryConsultant in Old Age Psychiatry

DEFINITIONSDEFINITIONS DescriptiveDescriptive Tends to requires two people!Tends to requires two people! Socially constructedSocially constructed The “Weed” analogyThe “Weed” analogy No diagnostic or aetiological significanceNo diagnostic or aetiological significance Not necessarily a psychiatric conditionNot necessarily a psychiatric condition ““The Scab Lady”The Scab Lady”

THE COMMON CHALLENGING THE COMMON CHALLENGING BEHAVIOURSBEHAVIOURS

AgitationAgitation Emotional & motor components – Emotional & motor components – “Sundowning”“Sundowning” Wandering, restlessness and pacingWandering, restlessness and pacing ““The Long Haul”The Long Haul” Shouting and screamingShouting and screaming Sexual disinhibitionSexual disinhibition InterferingInterfering Aggression & resistivenessAggression & resistiveness “ “The Enucleator”The Enucleator”

TOP 10 EREWASH AGITATORSTOP 10 EREWASH AGITATORS

ConstipationConstipation InfectionInfection Affective DisorderAffective Disorder Sensory Sensory

ImpairmentsImpairments

““My Mum”My Mum” PainPain Other PatientsOther Patients

““Shouters”Shouters”

SSRI’sSSRI’s

“ “Fluoxetine”Fluoxetine” Inconsiderate StaffInconsiderate Staff

““Non-verbal Non-verbal communication communication workshop”workshop”

PsychosisPsychosis StereotypingStereotyping

““Enforced Bingo”Enforced Bingo”

ASSESSMENTASSESSMENT

Rule out physical disordersRule out physical disorders Rule out functional psychiatric disordersRule out functional psychiatric disorders Assess psycho-social stressorsAssess psycho-social stressors Assess riskAssess risk Patient, other patients and staffPatient, other patients and staff Correct and accurate descriptionCorrect and accurate description

“ “The Burma Railway Man”The Burma Railway Man” Measure and recordMeasure and record

ABCABC “ “ Antecedents, Behaviour, Consequences”Antecedents, Behaviour, Consequences” Pavlov’s classical conditioningPavlov’s classical conditioning

“ “CS plus associated UCS produces a response”CS plus associated UCS produces a response” Skinner’s operant conditioningSkinner’s operant conditioning

“ “Alteration of the frequency of a piece of Alteration of the frequency of a piece of spontaneous behaviour by reward or spontaneous behaviour by reward or punishment”punishment”

Simple to organise and recordSimple to organise and record Allows generation of a “Behavioural Hypothesis”Allows generation of a “Behavioural Hypothesis”

TREATMENT - SOCIALTREATMENT - SOCIAL

Improved environmentsImproved environments New architecture, wander loops and New architecture, wander loops and

orientating stimuliorientating stimuli Reduce isolationReduce isolation De-escalation of over-arousalDe-escalation of over-arousal ““Time-out”, distraction and individual Time-out”, distraction and individual

supportsupport Carer consistencyCarer consistency Care homes and wardsCare homes and wards

TREATMENTS – PSYCHOLOGICAL TREATMENTS – PSYCHOLOGICAL

Carer educationCarer education Routines with individualityRoutines with individuality

“ “Xbox 360”Xbox 360” Communication – Validation or reality orientationCommunication – Validation or reality orientation

“ “Where’s Eric?”Where’s Eric?” Symptom-focussed programmesSymptom-focussed programmes

“ “The Water Pistol”The Water Pistol” Avoidance of “Malignant Social Psychology”Avoidance of “Malignant Social Psychology”

MALIGNANT SOCIAL MALIGNANT SOCIAL PSYCHOLOGYPSYCHOLOGY

• TreacheryTreachery• DisempowermentDisempowerment• InfantilisationInfantilisation• IntimidationIntimidation• LabellingLabelling• StigmatisationStigmatisation• OutpacingOutpacing• InvalidationInvalidation

• BanishmentBanishment• ObjectificationObjectification• IgnoringIgnoring• ImpositionImposition• WithholdingWithholding• AccusationAccusation• DisruptionDisruption• MockeryMockery• DisparagementDisparagement

Kitwood(1997)Kitwood(1997)

REVERSING THE PROCESSREVERSING THE PROCESS

““REMENTIA”REMENTIA”

TREATMENTS - BIOLOGICALTREATMENTS - BIOLOGICAL Treat physical and psychiatric disordersTreat physical and psychiatric disorders

50-70% dementia patients “depressed”50-70% dementia patients “depressed” Choose psychotropic medication with reference to symptoms, Choose psychotropic medication with reference to symptoms,

side-effects and contra-indicationsside-effects and contra-indications• Target appropriate symptoms and timingTarget appropriate symptoms and timing• Simplest regime possibleSimplest regime possible

““Start low, go slow”Start low, go slow”• Monitor and adjust accordinglyMonitor and adjust accordingly• Agree longer term plan Agree longer term plan No underlying neuropharmacological theory and very few No underlying neuropharmacological theory and very few

RCTsRCTs

““From A to Z”From A to Z”

SPECIFIC MEDICATIONSSPECIFIC MEDICATIONS

Atypical antipsychotics Atypical antipsychotics (Risperidone)(Risperidone) Side-effects, efficacy and administration Side-effects, efficacy and administration Typical antipsychotics Typical antipsychotics (Promazine, Haloperidol)(Promazine, Haloperidol) Efficacy and costEfficacy and cost Anti-depressants Anti-depressants (Trazadone & SSRIs)(Trazadone & SSRIs) Shouting and sexual disinhibitionShouting and sexual disinhibition Mood-stabilizers/antiepileptics Mood-stabilizers/antiepileptics (Carbamazepine)(Carbamazepine) Anxiolytics Anxiolytics (Lorazepam, Midazolam)(Lorazepam, Midazolam) Cholinesterase inhibitorsCholinesterase inhibitors MemantineMemantine

ALTERNATIVE THERAPIESALTERNATIVE THERAPIES

Art/Music therapyArt/Music therapy Scheduled activityScheduled activity AromatherapyAromatherapy

Lavender and lemonbalmLavender and lemonbalm Bright light therapyBright light therapy Animal assisted therapyAnimal assisted therapy Sensory TherapiesSensory Therapies

Snoezelen RoomsSnoezelen Rooms

THE DEBATETHE DEBATE NICE guidance “Dementia” (2006/11)NICE guidance “Dementia” (2006/11) ““Always a Last Resort” (2008)Always a Last Resort” (2008) ““Time For Action” (2009)Time For Action” (2009) National Dementia Strategy (2009)National Dementia Strategy (2009) ““The Right Prescription” (DAA 2011)The Right Prescription” (DAA 2011) ““What Have The Drugs Done To Dad” (Panorama - 2011)What Have The Drugs Done To Dad” (Panorama - 2011) ““Antipsychotics Make Alzheimers Patients Die” (Daily Mail - Antipsychotics Make Alzheimers Patients Die” (Daily Mail -

2011) 2011)

180,000 dementia patients given antipsychotics but only 15-180,000 dementia patients given antipsychotics but only 15-25% get some benefit25% get some benefit

““ALWAYS A LAST RESORT” ALWAYS A LAST RESORT”

DOH 2008DOH 2008

Psychiatrists, Care Home Staff, Pharmacists & Psychiatrists, Care Home Staff, Pharmacists & CarersCarers

Main findings –Main findings –• Challenging behaviour of complex aetiologyChallenging behaviour of complex aetiology• Care home staff unpreparedCare home staff unprepared• Antipsychotics use excessive and too prolongedAntipsychotics use excessive and too prolonged• Side effects can worsen dementia symptomsSide effects can worsen dementia symptoms• Their use CAN be appropriate – “severe & critical”Their use CAN be appropriate – “severe & critical”• Use alternative methods but need trainingUse alternative methods but need training

““ALWAYS A LAST RESORT”ALWAYS A LAST RESORT”

RECOMMENDATIONS –RECOMMENDATIONS –

• Mandatory training for care home staffMandatory training for care home staff• Enhanced support from psychiatric servicesEnhanced support from psychiatric services• Mental Capacity Act trainingMental Capacity Act training• Protocols for antipsychotic prescribingProtocols for antipsychotic prescribing• AuditAudit

LOCAL ADVICELOCAL ADVICE DISTRIBUTEDDISTRIBUTED (2008) ... To be (2008) ... To be updatedupdated

USING ANTIPSYCHOTICSUSING ANTIPSYCHOTICS Detailed and accurate assessmentDetailed and accurate assessment Trial of non-pharmacological interventionsTrial of non-pharmacological interventions ““For the right reasons”For the right reasons”

Psychosis, physical aggression and riskPsychosis, physical aggression and risk

Pre-commencement assessmentsPre-commencement assessments

Wt, glycaemic status, lipids and ECGWt, glycaemic status, lipids and ECG

Beware cerebrovascular risk factorsBeware cerebrovascular risk factors ““Start low, go slow”Start low, go slow” Time-limited with regular reviewTime-limited with regular review Psychoeducation for all involvedPsychoeducation for all involved

CONTROVERSIESCONTROVERSIES

Inappropriate emphasis –Inappropriate emphasis –• Antipsychotics DO have their placeAntipsychotics DO have their place• Too focused on antipsychoticsToo focused on antipsychotics

Resources to adopt recommendationsResources to adopt recommendations Medication – a “quick fix”?Medication – a “quick fix”? Pre-testing difficultiesPre-testing difficulties Unlicensed use of all except risperidoneUnlicensed use of all except risperidone International practice/opinionsInternational practice/opinions

““The Hong Kong Physio”The Hong Kong Physio”

SUMMARYSUMMARY Challenging behaviours are a messageChallenging behaviours are a message Many run their course and stopMany run their course and stop Ensure accuracy of descriptionEnsure accuracy of description Beware physical disordersBeware physical disorders Consider functional psychiatric disordersConsider functional psychiatric disorders ABCABC Multi-dimensional treatmentsMulti-dimensional treatments Clarity of planned treatmentsClarity of planned treatments Don’t give up on the drugs!!!Don’t give up on the drugs!!!

REFERENCESREFERENCES SKINNER (1938) “The Behaviour of Organisms”SKINNER (1938) “The Behaviour of Organisms” COHEN-MANSFIELD (1986) J Am Geriatr Soc 34: 722-7COHEN-MANSFIELD (1986) J Am Geriatr Soc 34: 722-7 KITWOOD (1997) “Dementia Reconsidered”KITWOOD (1997) “Dementia Reconsidered” ALEXOPOPULOUS et al (1998) “Treatment of Agitation in Older Persons ALEXOPOPULOUS et al (1998) “Treatment of Agitation in Older Persons

with Dementia”with Dementia” YORSTON (1999) “Aged and Dangerous” BMJ 174: 193-5YORSTON (1999) “Aged and Dangerous” BMJ 174: 193-5 BALLARD et al (2001) “Dementia – Management of Behavioural and BALLARD et al (2001) “Dementia – Management of Behavioural and

Psychological Symptoms”Psychological Symptoms” XENIDITIS et al (2001) “Management of People with Challenging Behaviour” XENIDITIS et al (2001) “Management of People with Challenging Behaviour”

APT 7:2 – 109-16APT 7:2 – 109-16 NICE Guidance CG42 (2006)NICE Guidance CG42 (2006) SMITH & MANCHIP (2010) “Antipsychotic Prescribing in Dementia” Geriatric SMITH & MANCHIP (2010) “Antipsychotic Prescribing in Dementia” Geriatric

Med June (40) 6Med June (40) 6 MACKIN & THOMAS (2011) “Atypical Antipsychotic Drugs” BMJ (342) 650-4MACKIN & THOMAS (2011) “Atypical Antipsychotic Drugs” BMJ (342) 650-4 KRISHNAMOORTHY 7 ANDERSON (2011) “Managing Challenging KRISHNAMOORTHY 7 ANDERSON (2011) “Managing Challenging

behaviour in Older Adults with Dementia!” Prog Neuro & Psych June (15) 3 behaviour in Older Adults with Dementia!” Prog Neuro & Psych June (15) 3