Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond Redirection Part IV

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

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.

Making a plan: • Treat acute illness or exacerbation of chronic illness • Manage dehydration, hunger, and thirst or wetness • Manage pain • Trial scheduled Tylenol • Remove offending medications • Attend to patient’s sleep and eating patterns • Replace poorly fitting hearing aids, eyeglasses, and dentures • Ensure tailored activities are scheduled • Develop a structured schedule (predictability is helpful) • Ensure 1:1 meaningful interactions at least 2x/day for 20 minutes (reminiscence, storytelling, reading)

Documenting Target Behaviors Problem-solving requiresgood documentation! • Demanding? In what way? • Disoriented? To time? Place? Or person? • Delusional? What about? What did she say? Do? • Agitated? What movements, words, actions indicate agitation?

Evaluate Care Sleep patterns Weight Food & fluid intake Incidents and outbursts How often? How long? How severe? Medication use Evaluating the plan

Evaluation • Once you choose intervention, include it in the plan, implement it , evaluate and re-evaluate its effectiveness, discuss the situation with the person, their family and the interdisciplinary team then adjust the plan accordingly.

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

Lillian • Plan: Initial interventions included referring husband to Alzheimer’s Association support group; Risperdal .25mg BID; Inderol; Ativan TID and prn; lortab scheduled. • Initial Evaluation: Falls, confusion, exit attempts, resistance to care, periods of apathy all continued. Functional status declined.

Need-driven Dementia-Compromised Behavior Theory: Lillian Behavioral symptoms Hitting others (risperdal; ativan; inderol) Refusing help Repeating statements Exiting attempts Apathy Background factors Heart disease Mixed vascular/Alzheimer’s dementia in moderate stage Osteoarthritis Proximal factors Boredom, Pain not controlled Increased confusion Caregiver stress (AA referral) Falls

Lillian Adjusting the Plan: • Treated for UTI, • Gradual Medication changes • Structured environment /tailored activities (including in cooking group; walks daily; encouraging to make day to day decisions; reminiscing, group music) • Several team-family meetings to develop plan Re-evaluation: • Falls stopped • Ambulatory with walker again • No more exiting or refusing cares. • Still wishes she could live with husband • Occasional anger with staff and husband • Occasional excessive worry about a health issue.

Ella • A 82 -year-old woman • propelling self in WC (use to walk), eating less, losing weight. • Late at night she tends to pace throughout the assisted living; often entering other residents rooms thereby interrupting their sleep. When approached she at times becomes angry and swears • She has stable Coronary Heart Disease and no other illnesses. • She is widowed, her daughters are close to her and call her daily. They visit every 1-2 weeks from Grand Rapids MN. • Gets assist of 1 with ADLs; able to express needs-- often nonverbally; • Her sleep is intermittent; sleeps a lot during the day and for a few hours during the night. • She loves spaghetti but needing more cueing to eat. • Nurses wonder if ambien or something for sleep would help to correct her sleep/wake cycle changes and make her more comfortable.

Additional assessment • Physical exam • Review History • Observe antecedents and consequences to behavior • Discuss with daughters • Observe caregiver responses

Need-driven Dementia-Compromised Behavior Theory: Ella Behavioral symptoms Pacing at night Anger with swearing at night Background factors CAD Widowed Osteoarthritis Strong family support Proximal factors Sleep wake cycle alteration

Ella Acute illness, pain, unmet physical social or emotional need ruled out; what will you recommend next : • Ambien 2.5mg po q HS or Ativan 1 mg po q HS prn • Refer for psychotherapy or psychiatry • Ignore night time behaviors • Use stepped re-direction to encourage patient to sleep instead of wander at night. • Design strategies to develop an activity plan during the day based on her preferences.

SUMMARY • Persons with dementia may express their basic needs and feelings in different ways (verbal, non-verbal and behavioral). • When a resident has different behaviors, think about the Need-driven Dementia-Compromised Behavior Theory and then begin assessing for • Background factors (medical illnesses , history) • Proximal factors (delirium / pain / environmental stress / Unmet physical, social or emotional needs) • Describe the behavior in specific terms instead of general terms to help monitor over time

SUMMARY • Non-pharmacological interventions are considered first line • Psychotropic medications, benzodiazipines , medications with anti-cholinergic properties, and hypnotic agents have dangerous side effects and limited efficacy. • Collaborate with caregivers, loved ones and other health care professionals to choose individualized interventions that reflect the resident’s preferences, past hobbies, personality.

SUMMARY Consider these non-pharmacological strategies as first line: • Activities that are tailored to patients preferences, cognitive status, and energy level (Simple pleasures, music, aromatherpy, walking, chair exercises) • Physical environments that minimize social and spatial crowding • Staff trained to be sensitive and to validate the non-verbal expression of emotion • Individualized schedules that use varied activities to correct arousal imbalance • Use verbal and non verbal communication that is positive including validation approaches • Think of redirection as “stepped redirection” (validate concerns, make a plan to investigate, invite to discuss, invite to help with …)

References Gitlein, L., Winter, L., Vause Earland, T., Herge, E.A., Chernett, N.L., Piersol, C.V., & Burke, J.P. (2009). The tailored activity program to reduce behavioral symptoms in individuals with dementia: feasibility, acceptablity, and replication potential. The Gerontologist, 49, 428-430. Kverno, K.S., Black, B.S., Nolan, M.T., Rabins, P.V. (2009). Research on treating neuropsychiatric symptoms of advanced dementia with non-pharmacological strategies 1998-2008: a systematic literature review. International Psychogeriatrics, 21, 825-843.. Kolanowski, A., Litaker, M., Buettner (2005). Efficacy of a theory-based activities for behavioral symptoms of dementia. Nursing Research, 54, 210-228. Kovach, C.R.; Kelber, S.T. Simpson, M., Wells, T.(2006). Behaviors of nursing home residents with dementia examining nurse responses, Journal of Gerontological Nursing, 13-21. Smith, M. (2005). Revised from K.C. Buckwalter and M. Smith (1993), “When You Forget That You Forgot: Recognizing and Managing Alzheimer’s Type Dementia,” The Geriatric Mental Health Training Series, for the John A. Hartford Center of Geriatric Nursing Excellence, College of Nursing, University of Iowa. Watson, N.M. (2005). Simple pleasures a new intervention transforms one long term care facility. American Journal of Nursing, 105, 53-55.

Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond Redirection Part IV