1. IN YOUR FACE !!! CHALLENGING BEHAVIOURS IN OLDER ADULTS WITH DEMENTIA Dr E C Komocki Consultant in Old Age Psychiatry

2. DEFINITIONS • Descriptive • Tends to requires two people! • Socially constructed The “Weed” analogy • No diagnostic or aetiological significance • Not necessarily a psychiatric condition “The Scab Lady”

3. THE COMMON CHALLENGING BEHAVIOURS • Agitation Emotional & motor components – “Sundowning” • Wandering, restlessness and pacing “The Long Haul” • Shouting and screaming • Sexual disinhibition • Interfering • Aggression & resistiveness “The Enucleator”

4. Constipation Infection Affective Disorder Sensory Impairments “My Mum” Pain Other Patients “Shouters” SSRI’s “Fluoxetine” Inconsiderate Staff “Non-verbal communication workshop” Psychosis Stereotyping “Enforced Bingo” TOP 10 EREWASH AGITATORS

5. ASSESSMENT • Rule out physical disorders • Rule out functional psychiatric disorders • Assess psycho-social stressors • Assess risk Patient, other patients and staff • Correct and accurate description “The Burma Railway Man” • Measure and record

6. ABC • “ Antecedents, Behaviour, Consequences” • Pavlov’s classical conditioning “CS plus associated UCS produces a response” • Skinner’s operant conditioning “Alteration of the frequency of a piece of spontaneous behaviour by reward or punishment” • Simple to organise and record • Allows generation of a “Behavioural Hypothesis”

7. TREATMENT - SOCIAL • Improved environments New architecture, wander loops and orientating stimuli • Reduce isolation • De-escalation of over-arousal “Time-out”, distraction and individual support • Carer consistency Care homes and wards

8. TREATMENTS – PSYCHOLOGICAL • Carer education • Routines with individuality “Xbox 360” • Communication – Validation or reality orientation “Where’s Eric?” • Symptom-focussed programmes “The Water Pistol” • Avoidance of “Malignant Social Psychology”

9. Treachery Disempowerment Infantilisation Intimidation Labelling Stigmatisation Outpacing Invalidation Banishment Objectification Ignoring Imposition Withholding Accusation Disruption Mockery Disparagement Kitwood(1997) MALIGNANT SOCIAL PSYCHOLOGY

10. REVERSING THE PROCESS “REMENTIA”

11. TREATMENTS - BIOLOGICAL • Treat physical and psychiatric disorders 50-70% dementia patients “depressed” • Choose psychotropic medication with reference to symptoms, side-effects and contra-indications • Target appropriate symptoms and timing • Simplest regime possible “Start low, go slow” • Monitor and adjust accordingly • Agree longer term plan • No underlying neuropharmacological theory and very few RCTs “From A to Z”

12. SPECIFIC MEDICATIONS • Atypical antipsychotics (Risperidone) Side-effects, efficacy and administration • Typical antipsychotics (Promazine, Haloperidol) Efficacy and cost • Anti-depressants (Trazadone & SSRIs) Shouting and sexual disinhibition • Mood-stabilizers/antiepileptics(Carbamazepine) • Anxiolytics(Lorazepam, Midazolam) • Cholinesterase inhibitors • Memantine

13. ALTERNATIVE THERAPIES • Art/Music therapy • Scheduled activity • Aromatherapy Lavender and lemonbalm • Bright light therapy • Animal assisted therapy • Sensory Therapies Snoezelen Rooms

14. THE DEBATE NICE guidance “Dementia” (2006/11) “Always a Last Resort” (2008) “Time For Action” (2009) National Dementia Strategy (2009) “The Right Prescription” (DAA 2011) “What Have The Drugs Done To Dad” (Panorama - 2011) “Antipsychotics Make Alzheimers Patients Die” (Daily Mail - 2011) 180,000 dementia patients given antipsychotics but only 15-25% get some benefit

15. “ALWAYS A LAST RESORT” DOH 2008 Psychiatrists, Care Home Staff, Pharmacists & Carers Main findings – • Challenging behaviour of complex aetiology • Care home staff unprepared • Antipsychotics use excessive and too prolonged • Side effects can worsen dementia symptoms • Their use CAN be appropriate – “severe & critical” • Use alternative methods but need training

16. “ALWAYS A LAST RESORT” RECOMMENDATIONS – • Mandatory training for care home staff • Enhanced support from psychiatric services • Mental Capacity Act training • Protocols for antipsychotic prescribing • Audit LOCAL ADVICEDISTRIBUTED (2008) ... To be updated

17. USING ANTIPSYCHOTICS Detailed and accurate assessment Trial of non-pharmacological interventions “For the right reasons” Psychosis, physical aggression and risk Pre-commencement assessments Wt, glycaemic status, lipids and ECG Beware cerebrovascular risk factors “Start low, go slow” Time-limited with regular review Psychoeducation for all involved

18. CONTROVERSIES • Inappropriate emphasis – • Antipsychotics DO have their place • Too focused on antipsychotics • Resources to adopt recommendations • Medication – a “quick fix”? • Pre-testing difficulties • Unlicensed use of all except risperidone • International practice/opinions “The Hong Kong Physio”

19. SUMMARY • Challenging behaviours are a message • Many run their course and stop • Ensure accuracy of description • Beware physical disorders • Consider functional psychiatric disorders • ABC • Multi-dimensional treatments • Clarity of planned treatments • Don’t give up on the drugs!!!

20. REFERENCES • SKINNER (1938) “The Behaviour of Organisms” • COHEN-MANSFIELD (1986) J Am Geriatr Soc 34: 722-7 • KITWOOD (1997) “Dementia Reconsidered” • ALEXOPOPULOUS et al (1998) “Treatment of Agitation in Older Persons with Dementia” • YORSTON (1999) “Aged and Dangerous” BMJ 174: 193-5 • BALLARD et al (2001) “Dementia – Management of Behavioural and Psychological Symptoms” • XENIDITIS et al (2001) “Management of People with Challenging Behaviour” APT 7:2 – 109-16 • NICE Guidance CG42 (2006) • SMITH & MANCHIP (2010) “Antipsychotic Prescribing in Dementia” Geriatric Med June (40) 6 • MACKIN & THOMAS (2011) “Atypical Antipsychotic Drugs” BMJ (342) 650-4 • KRISHNAMOORTHY 7 ANDERSON (2011) “Managing Challenging behaviour in Older Adults with Dementia!” ProgNeuro & Psych June (15) 3