IN YOUR FACE - Derby GP Specialty Training Programme

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IN YOUR FACE !!!
CHALLENGING BEHAVIOURS IN
OLDER ADULTS WITH DEMENTIA
Dr E C Komocki
Consultant in Old Age Psychiatry
DEFINITIONS
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Descriptive
Tends to requires two people!
Socially constructed
The “Weed” analogy
No diagnostic or aetiological significance
Not necessarily a psychiatric condition
“The Scab Lady”
THE COMMON CHALLENGING
BEHAVIOURS
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Agitation
Emotional & motor components – “Sundowning”
Wandering, restlessness and pacing
“The Long Haul”
Shouting and screaming
Sexual disinhibition
Interfering
Aggression & resistiveness
“The Enucleator”
TOP 10 EREWASH AGITATORS
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Constipation
Infection
Affective Disorder
Sensory
Impairments
“My Mum”
Pain
Other Patients
“Shouters”
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SSRI’s
“Fluoxetine”
Inconsiderate Staff
“Non-verbal
communication
workshop”
Psychosis
Stereotyping
“Enforced Bingo”
ASSESSMENT
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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
ABC
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“ 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”
TREATMENT - SOCIAL
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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
TREATMENTS – PSYCHOLOGICAL
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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”
MALIGNANT SOCIAL
PSYCHOLOGY
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Treachery
Disempowerment
Infantilisation
Intimidation
Labelling
Stigmatisation
Outpacing
Invalidation
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Banishment
Objectification
Ignoring
Imposition
Withholding
Accusation
Disruption
Mockery
Disparagement
Kitwood(1997)
REVERSING THE PROCESS
“REMENTIA”
TREATMENTS - BIOLOGICAL
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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”
SPECIFIC MEDICATIONS
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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
ALTERNATIVE THERAPIES
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Art/Music therapy
Scheduled activity
Aromatherapy
Lavender and lemonbalm
Bright light therapy
Animal assisted therapy
Sensory Therapies
Snoezelen Rooms
THE DEBATE
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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
“ALWAYS A LAST RESORT”
DOH 2008
Psychiatrists, Care Home Staff, Pharmacists &
Carers
Main findings –
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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
“ALWAYS A LAST RESORT”
RECOMMENDATIONS –
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Mandatory training for care home staff
Enhanced support from psychiatric services
Mental Capacity Act training
Protocols for antipsychotic prescribing
Audit
LOCAL ADVICE DISTRIBUTED (2008) ... To be
updated
USING ANTIPSYCHOTICS
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Detailed and accurate assessment
Trial of non-pharmacological interventions
“For the right reasons”
Psychosis, physical aggression and risk
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Pre-commencement assessments
Wt, glycaemic status, lipids and ECG
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Beware cerebrovascular risk factors
“Start low, go slow”
Time-limited with regular review
Psychoeducation for all involved
CONTROVERSIES
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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”
SUMMARY
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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!!!
REFERENCES
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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) 6504
KRISHNAMOORTHY 7 ANDERSON (2011) “Managing Challenging
behaviour in Older Adults with Dementia!” Prog Neuro & Psych June (15) 3

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