Dr Tony Jones, DBMAS Alzheimers Australia ACT: Effectively Managing BPSD and Challenging Behaviours

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Tony Jones, Senior Clinical Consultant, DBMAS, Alzheimer's Australia ACT delivered this presentation at the 2014 National Dementia Congress. The event examined dementia case studies and the latest innovations from across the whole dementia pathway, from diagnosis to end of life, focusing on the theme of "Making Dementia Care Transformation Happen Today. For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/dementiacongress2014

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Dr Tony Jones, DBMAS Alzheimers Australia ACT: Effectively Managing BPSD and Challenging Behaviours

  1. 1. ACT Dementia Behaviour Management Advisory Services (DBMAS) Supporting workers • Advice • Information • Referral Managing Behavioural and Psychological Symptoms of Dementia 5th Annual National Dementia Congress. 20th & 21st February 2014. Novotel Melbourne, Australia Tony Schumacher Jones PhD. Alzheimer’s Australia ACT Helping Australians with dementia, and their carers
  2. 2. Partner logo here Managing Behavioural and Psychological Symptoms of Dementia • • • • • • • Introduction Defining BPSD BPSD – Conceptual Problems Alternatives to BPSD Praxis Implications for Practice Summary Helping Australians with dementia, and their carers
  3. 3. Partner logo here Managing Behavioural and Psychological Symptoms of Dementia • • • • • • • Introduction Defining BPSD BPSD – Conceptual Problems Alternatives to BPSD Praxis Implications for Practice Summary Helping Australians with dementia, and their carers
  4. 4. Partner logo here Introduction • The ubiquitous nature of behaviour changes in dementia • A behavioural element and a psychological element • Types of behaviours typically seen • Types of behaviours typically indicated in referral to DBMAS • Central themes in dementia presentations cognitive decline –behaviour changes - psychiatric pathology medically compromised - symptom cluster – social impairment Helping Australians with dementia, and their carers
  5. 5. Partner logo here Managing Behavioural and Psychological Symptoms of Dementia • • • • • • • Introduction Defining BPSD BPSD – Conceptual Problems Alternatives to BPSD Praxis Implications for Practice Summary Helping Australians with dementia, and their carers
  6. 6. Partner logo here Defining BPSD • challenging behaviours, changed behaviours, difficult behaviours, behaviours of concern, neuropsychiatric symptoms, or BPSDs? • terms reflect one’s relationship to the person with dementia • diagnosis, definition or description? • BPSD is not a diagnostic entity but is instead a term that describes a clinical dimension of dementia [Lawlor 2004]. • what do we expect from a descriptive term? – explanation of behavioural displays - causes of behavioural displays - a pointer to an effective response - a differential diagnosis - all of the above - something else Helping Australians with dementia, and their carers
  7. 7. Partner logo here Defining BPSD any behaviour associated with the dementing illness which causes distress or danger to the person with dementia or others, or is a manifestation of distress [Bird et al 1998]. an umbrella term for a heterogeneous group of non-cognitive symptoms (psychosis, depression, agitation, aggression and disinhibition) that are almost ubiquitous in dementia [Brodaty 2003]. symptoms of disturbed perception, thought content, mood or behaviour that frequently occur in patients with dementia’[Finkel & Burns 1999]. [BPSDs]….are typically identified by observation of the person with dementia and only considered challenging when they impact on other people or cause harm to the person with dementia [DCRC 2012]. Helping Australians with dementia, and their carers
  8. 8. Partner logo here Managing Behavioural and Psychological Symptoms of Dementia • • • • • • • Introduction Defining BPSD BPSD – Conceptual Problems Alternatives to BPSD Praxis Implications for Practice Summary Helping Australians with dementia, and their carers
  9. 9. Partner logo here BPSD – Conceptual Problems • Categorical broadness – any behaviour [any behaviour at all?] …. associated with [not caused by or derivative of but simply associated with – false positives] ….causes distress [threshold problems – how much distress triggers a case in a tired carer?]… impact on other people [who decides?] • Categorical vagueness – an umbrella term for a heterogeneous [different – unrelated] group of non-cognitive symptoms…..frequently [but not always] occurring in patients with dementia…. [vagueness undermines validity] • Subjectivity – identified by observation [who observes, whose judgement?]….cause(es) harm to the person with dementia [who decides? What about QOL - false negatives?] Helping Australians with dementia, and their carers
  10. 10. Partner logo here BPSD – Conceptual Problems • Medicalization of dementia – is dementia only (or even mostly) a medical problem? dementia ….a clinical syndrome that expresses itself in three areas: cognitive deficits, psychiatric and behavioral disturbances, and difficulties in carrying out daily functions [De Dynet al 2005] – grief, loss, identity, roles, relationships? • No information as to the causes of behavioural displays • No requirement to forebear • The stickiness of psychiatric labels - whose interests are served • Behavioural identity and behavioural ownership • Lack of solution focus Helping Australians with dementia, and their carers
  11. 11. Partner logo here Managing Behavioural and Psychological Symptoms of Dementia • • • • • • • Introduction Defining BPSD BPSD – Conceptual Problems Alternatives to BPSD Praxis Implications for Practice Summary Helping Australians with dementia, and their carers
  12. 12. Partner logo here Alternatives to BPSD - Assumptions • • • • • • • all behaviour is a response to some type of stimulus – internal/external all behaviour is a form of communication – distress/wellbeing when confronted with changes in behaviour we ask – what is going on for the person – internally/externally – we make no other assumptions challenging behaviours emerge when some need (internal/external) is not being met needs can emerge within any aspect of the person – biological, psychological, social identifying needs does not presuppose individual pathology – everything is on the table the challenge is – to know the person – to know the environment – to know yourself – to know the inter-relationships – assume nothing Helping Australians with dementia, and their carers
  13. 13. Partner logo here Managing Behavioural and Psychological Symptoms of Dementia • • • • • • • Introduction Defining BPSD BPSD – Conceptual Problems Alternatives to BPSD Praxis Implications for Practice Summary Helping Australians with dementia, and their carers
  14. 14. Partner logo here Praxis ….what we do in the world is some informed synthesis of an understanding of the person [both general and particular] and informed, committed and purposeful action based on that understanding, directed toward certain [ethical] ends embracing qualities of human well being, flourishing, respect and acceptance…. The philosophers have only interpreted the world, in various ways; the point is to change it. (Marx 1845 Theses on Feurbach) But change it how…. and in what way… and guided by what purpose….and directed to what ends? Aristotle - informed, committed and purposeful (telos) action directed toward and guided by the virtues…. Helping Australians with dementia, and their carers
  15. 15. Partner logo here Managing Behavioural and Psychological Symptoms of Dementia • • • • • • • Introduction Defining BPSD BPSD – Conceptual Problems Alternatives to BPSD Praxis Implications for Practice Summary Helping Australians with dementia, and their carers
  16. 16. Partner logo here Implications for Practice - 1 A 78 year old lady referred to DBMAS – dx with dementia - refuses to shower – smells – is physically aggressive – hits staff – shouts obscenities….. A 78 year old Jewish lady referred to DBMAS – dx with dementia - refuses to shower – smells – is physically aggressive – hits staff – shouts obscenities….. We might ask – what are her needs…..what is she trying to tell us…..what is she communicating…..what should our response be….. We might ask – how does the term BPSD enhance our understanding of the reasons for this lady’s behaviour….. Helping Australians with dementia, and their carers
  17. 17. Partner logo here Implications for Practice - 2 An 82 yr old AWM with ATD – lives at home with 80 yr old wife-ref from hospital after head/back trauma – wears a brace; anger, resistance to care, refuses shower, tries to leave hospital, hits staff when putting brace on, STM problems -attention /concentration issues. Additional [not described on referral – why?] Family grief, previous family losses, burden of care, financial difficulties, role/relationship changes. How does saying ‘this man displays BPSD’ help us understand the issues that confront him…. or his 80 year old wife….or his children? As clinicians we need to look at the person across dimensions – biological, social, psychological – and not just in terms of BPSD [a collection of unhelpful behaviours]. Helping Australians with dementia, and their carers
  18. 18. Partner logo here Implications for Practice - 3 An 80 year old lady referred to DBMAS – dx with dementia - refuses all ADLs (showering, dressing, toileting) - verbally and physically aggressive - extremely vocally disruptive- disturbing other resident – assaulting staff – ‘marked BPSDs.’ DBMAS RN did a detailed assessment based on ‘what is the underlying problem that manifests as behaviour disturbances?’ That is – everything is on the table – nothing assumed. Problem was this lady had a previous stroke, hand contractures, and finger nails had grown into the palm of her hand. BPSD suggested a line of inquiry that took her away from the real problem. Helping Australians with dementia, and their carers
  19. 19. Partner logo here Implications for Practice - 4 Think of presenting behaviours as impaired communication. If the person could speak what would they tell us? Conceptualise the behavioural displays in terms of an underlying mental, physical, emotional state. What need is not being met that encourages the behaviour to emerge? List the possibilities and test the hypothesis across all dimensions of what it means to be a person Helping Australians with dementia, and their carers
  20. 20. Partner logo here behaviour problem need response calling out, pacing screaming, agitation, physical aggression with ADLs pain - due to ingrown fingernails to be pain free; to feel well wandering, pacing, intrusive, physical aggression when being re-directed confused, muddled, overwhelmed, forgetful, fearful due to dementia to make sense of culture, interests, what is happening supports, familiarity, to them, to feel safe environment and secure withdrawn, apathy, stays in room, verbal/physical aggression, not eating loss of meaning, family, house, pets; dependency, bored, lonely, strange environment, socially isolated to belong, have choice, control, meaningful activities, friends, intimacy, familiar belongings Helping Australians with dementia, and their carers
  21. 21. Partner logo here behaviour fluctuating cognitions, confused/lucid, nocturnal distress, agitated/settled problem Delirium secondary to UTI need free from delirium, pain relief, controlled environment, infection treated wandering, pacing, intrusive, physical aggression when being re-directed withdrawn, apathy, stays in room, verbal/physical aggression, not eating Helping Australians with dementia, and their carers response antibiotic, pain relief, push fluids, low stimulus environment, orientation to time/place/person
  22. 22. Partner logo here Managing Behavioural and Psychological Symptoms of Dementia • • • • • • • Introduction Defining BPSD BPSD – Conceptual Problems Alternatives to BPSD Praxis Implications for Practice Summary Helping Australians with dementia, and their carers
  23. 23. Partner logo here SUMMARY We employ descriptors that give us the best chance of: 1.Understanding why behaviours emerge – what is driving them 2.Making distinctions between different sorts of behaviours 3.Suggesting a practical response to the underlying drivers of behaviour 4.Give us some insight into the subjective world of the person with dementia Helping Australians with dementia, and their carers
  24. 24. Partner logo here THANK YOU tony.jones@alzheimers.org.au Bonzodogdoodaband@gmail.com Helping Australians with dementia, and their carers

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