Behaviour….. It’s All In Your Approach

Behaviour…..It’s All In Your Approach Alzheimer Conference 2008 Winnipeg, Manitoba Joanne Collins collinjb@gov.ns.ca

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

Behaviour….. What are the behaviours you find the most challenging when providing care?

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.

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

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.

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%

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

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)

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

Behavioural and Psychological Symptoms Are a: • means of communicating needs and desires, • an expression of a person’s abilities, disabilities and challenges

All Behaviour Has Meaning! • The issue for caregivers is to search for meaning behind the behaviour • Acting on feelings that are expressed is key

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

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

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.

P.I.E.C.E.S Framework to Understand and Address BPSD Complexity Physical Problem or Discomfort Intellectual/cognitive changes 7A’s Emotional Capabilities Environment Social

Physical Factors Related to BPSD The 5 D’s • Drugs and Alcohol • Delirium • Disease • Discomfort • Disability

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

Emotional Factors Related to BPSD • Adjustment Difficulties • Depression • Anxiety • Delusions and Hallucinations

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.

Environment and BPSD • Relocation, changes in the environment, routine • Environmental demands i.e schedules and expectations • Noise • Over-stimulation, Under-stimulation • Lighting, colour schemes

Social and Cultural Factors and BPSD • Life Story/History • Cultural Heritage • Social Networks • Life Accomplishments • Negative Social Interactions • Mountain Top Experiences • Relationship with Family

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

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

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 Top Ten Behaviours Responsive To Medication (Perhaps!)

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

Changing The Outcome of Agitated Behaviour Recognizing the Chain of Events leading to a crisis: • The person feels anxiousorfrightened. • As you approach the persons, personal space, how the person reacts will depend on what they are seeing and hearing. • Physical intervention is always to be avoided if at all possible Hamilton, P & Baker, K Psychogeriatric Resource Consultant’s Ontario

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

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

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

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

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

Thank You Coming together is a beginning. Keeping together is progress. Working together is success. Henry Ford

Behaviour….. It’s All In Your Approach