Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond Redirection Part II Margaret Hoberg MSN, GNP

1. Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond Redirection Part II Margaret Hoberg MSN, GNP-BC Siobhan McMahon MSN MPH GNP-BC

2. Objectives Learning Objectives • Explain the effects of dementia on thinking, emotions and communication • Use a theory to help explain behavioral and communication changes associated with dementia and to guide interventions • Respond to behavioral changes with a calm, validating approach • Comprehensively assess verbal and nonverbal messages, including those that are associated with stress • Develop a plan whose non-pharmacological interventions reflect an understanding of and respect for the person and their preferences.

3. Effects of Dementia

4. As many as 80%–90% of patients with dementia develop at least one behavioral or psychological symptom during the illness • Behavior changes are time consuming, increase environmental stress and caregiver stress • Behavioral symptoms of dementia often trigger relocation (NH)

5. Behavioral symptoms of dementia: Good News • Non pharmacological individualized approach to assessment and management minimizes behavioral symptoms of dementia and can prevent catastrophic events (e.g. extreme fear, falls, ER visits, hospital visits). These are considered first line. • A person with dementia still expresses what their basic needs and feelings are, but in new and different ways (verbal, non-verbal and behavioral).

6. Behavioral symptoms of dementia: Bad News • There is no magic solution or cure for behavioral symptoms of dementia. • Psychotropic medications that are often used for behavioral symptoms of dementia, such as benzodiazipines or anti-psychotic medications, are not FDA approved for these indications; the have minimal efficacy; and they have significant/ severe side effects • Delirium is under-recognized and often missed • Comprehensive assessments are not always done in the face of behavioral changes (Kovach, 2006). • Uni-dimensional treatment initiated without comprehensive assessment may trigger a cascade of problems.

7. Behavioral symptoms: Words such as Agitation & Anxiety are general descriptors; not specific enough to treat. Agitation can lead to or be related to DEPRESSION!!

8. Psychological Changes • Depression • Paranoia • Delusions • Hallucinations • Anxiety

9. Theories that explain changing communications and behaviors Need-driven Dementia-Compromised Behavior Theory • Explains factors that produce behavioral symptoms • Explains the mechanisms of interventions that effectively treat behavioral symptoms

10. Need-driven Dementia-Compromised Behavior Theory Changes the negative view of behavioral view of symptoms as disruptive and inappropriate Instead it conceptualizes behaviors as indicating unmet needs that, if responded to well, will increase quality of life.

11. Need-driven Dementia-Compromised Behavior Theory • Background Factors such as health, functional factors, psychosocial factors (including personality) • Proximal or immediate Factors : physical needs, emotions, social environment, physical environment.

12. Need-driven Dementia-Compromised Behavior Theory Background factors (e.g., arthritis, heart failure, need for assistance) Behavioral symptoms Immediate factors (e.g., warmth, noise, pain)

13. Caregiver training Communication techniques that are respectful & re-assuring; not confrontational Not over-reacting to behaviors Avoid Restraints Develop individualized routines Avoid high risk medications Prevention

14. Assessment: Investigating the details of common descriptions. • He is causing chaos in the dining room • She is ‘anxious’, she needs ativan • She is combative • She bit her caregiver • We cannot seem to calm her down • He is out of control • We called the police to help contain him • Help! we need something to calm her down

15. Assessing the situation History of behavior pattern • Type • Antecedents • Frequency • Duration • Intensity • Keep a behavior log or use behavior tools (e.g. Cohen Mansfield)

16. Assessing the situation History: Take a step back to consider Include details detailing history, physical, social and environmental factors? • Is this an atypical presentation of an acute illness or exacerbation of chronic illness? • Is pain playing a role ?U • What physical needs might the patient have ? • Is the patient bored? • Is there Environmental stress? • How is the Caregiver doing?

17. Review individual history PMH (which diagnoses are associated with pain? ) Social /Life History Traits Habits Past work Hobbies Difficulties Recent life stresses (e.g. death of a loved one) ROS (multiple sources) Assessing the situation

18. Is the situation being aggravated by medication? New medications? CNS effects/side effects? (e.g. benzodiazipines, meds for Parkinson’s & restless legs) Anticholinergics Home remedies ETOH Assessing the situation

19. Assessing the situation Physical exam • Functional status • Screen for malnutrition • Screen for sensory impairment (eye glasses, mouth, hearing) • Screen for infection • Mental status (screen for delirium, depression) • Body systems • Individualized diagnostic tests

20. Assessment • Consider the whole person and their history • Get the perspectives of all—known history, family nurses, • CNA’s, activity therapists, rehabilitation, social services

21. Diagnosis Acute Illness? Chronic illness exacerbation? Medication side effect ? Pain? Unmet Physical need? Boredom? Environmental stress? Dementia progression? Identifying the triggers

22. Lillian • 85 year old with AD and VD: moderate stage. • Living at AL. • Has a lot of ‘agitation’ • More specifically, she has bad dreams, tends to wander, hits others at times, repeats statements, and refuses personal cares. • Staff say that she often seems to be sitting idle. • Her medical history includes heart disease, HTN, OA with pain

23. Need-driven Dementia-Compromised Behavior Theory: Lillian Background factors Heart disease Mixed vascular/Alzheimer’s dementia in moderate stage Osteoarthritis Behavioral symptoms Hitting others Refusing help Repeating statements Proximal factors Boredom, Pain not controlled Increased confusion Caregiver stress