Doctor, do
something...understanding
behavioural problems in dementia
Andrew Wiens MD FRCPC
Head, Division of Geriatric Ps...
Disclosures
• No commercial disclosures
Components of Managing
Behaviour
1. Deal with urgent situations: make it safe
2. Assessment: Define target symptoms, recen...
AmygdalaThalamus
Hippocampus
Sensory and
association cortex
Delirium
Dementia,
developmental
delay, and other
neurologic d...
Video 1: Phineas Gage
Phineas Gage
0
10
20
30
40
50
60
%
Schneider Lanctot Devenand
Allain DeDeyn Katz
Street Porsteinsson DeDeyn
Placebo Power in Neuropsych...
Does the name Pavlov ring a bell?
Many behaviours unlikely to respond
to medications
• Purposeless, repetitive behaviour: motor and verbal
• Resistance to c...
Case of A
• 87 years old
• Calmly lying in bed
• Approached by staff for AM care
• When staff help remove blanket she scre...
Assess and reverse aggravating factors:
behaviour communicating an underlying need
Sensory
deprivation or
deficits
Correct...
Music Man
Case of B
• Bed bound, incontinent of urine and feces
• Is edentulous and only takes liquid diet
• Unable to communicate w...
Case of A
• 87 years old
• Calmly lying in bed
• Approached by staff for AM care
• When staff help remove blanket she scre...
Case of C
• 23 years old
• Calmly lying in bed
• Approached by staff for AM care
• When staff help remove blanket she scre...
Case of C
• 23 years old
• Calmly lying in bed at home
• Approached by staff for AM care
• When staff help remove blanket ...
Case of C
• 23 years old
• Calmly lying in bed at home
• Approached by intruders
• When staff help remove blanket she scre...
Case of C
• 23 years old
• Calmly lying in bed at home
• Approached by intruders
• She screams, hits, kicks, scratches, sp...
12 minutes with Dementia
Adapt to cognitive deficits: mismatch between
environment and ability to cope with situation
ActivitiesofDailyLiving
MMSE ...
Old Age Task Force of World Federation of Biological Psychiatry:
Livingston et al. Am J Psychiatry 2005: 1996-2021
Learnin...
Neurobehavioural Metaphors
• Anxiety: restlessness, hand-wringing, pressured pacing,
fidgeting, agitation
• Sadness: cryin...
AmygdalaThalamus
Hippocampus
Sensory and
association cortex
Stress
Personal
problems
Substance
use
Cognitive Distortions
• All-or-nothing thinking: Black and white thinking
• Overgeneralization: the event is part of a nev...
Change your reaction to the behaviour
• Ignore the behaviour
• Reframe the behaviour
• Educate caregivers how to do this
B...
Stress Inoculation
1. Prepare for stressful interaction
2. Confronting and handling the stressful event
3. Coping with fee...
Assess and reverse aggravating factors:
behaviour communicating an underlying need
Sensory
deprivation or
deficits
Correct...
What is That?
Conversations at The Royal: Behaviour Issues in Dementia
Conversations at The Royal: Behaviour Issues in Dementia
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Conversations at The Royal: Behaviour Issues in Dementia

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Dr. Andrew Wiens, Head, Division of Geriatric Psychiatry at The Royal, talks about behaviour issues in dementia at our monthly lecture series, Conversations.

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Conversations at The Royal: Behaviour Issues in Dementia

  1. 1. Doctor, do something...understanding behavioural problems in dementia Andrew Wiens MD FRCPC Head, Division of Geriatric Psychiatry April 24, 2014
  2. 2. Disclosures • No commercial disclosures
  3. 3. Components of Managing Behaviour 1. Deal with urgent situations: make it safe 2. Assessment: Define target symptoms, recent changes 3. Manage caregiver stress 4. Optimize medical and psychiatric conditions and improve sensory impairment: • Presume delirium until proven otherwise • Is there a psychiatric illness? 5. Non-pharmacological interventions • Assess and reverse aggravating factors • Adapt to cognitive deficits • Evaluate learning/behavioural causes 6. Pharmacotherapy: Identify neurobehavioural metaphors
  4. 4. AmygdalaThalamus Hippocampus Sensory and association cortex Delirium Dementia, developmental delay, and other neurologic disorders Psychiatric disorders
  5. 5. Video 1: Phineas Gage
  6. 6. Phineas Gage
  7. 7. 0 10 20 30 40 50 60 % Schneider Lanctot Devenand Allain DeDeyn Katz Street Porsteinsson DeDeyn Placebo Power in Neuropsychiatric Symptoms Trials
  8. 8. Does the name Pavlov ring a bell?
  9. 9. Many behaviours unlikely to respond to medications • Purposeless, repetitive behaviour: motor and verbal • Resistance to care • Sexually inappropriate behaviour • Inappropriate dressing/undressing • Wandering, Exit-seeking • Inappropriate urination/defecation • Annoying repetitive activities (perseveration) or vocalization • Hiding/hoarding • Eating inedible items • Tugging at/removal of restraints • Pushing wheelchair bound co-residents
  10. 10. Case of A • 87 years old • Calmly lying in bed • Approached by staff for AM care • When staff help remove blanket she screams, hits, kicks, scratches, spits • Has injured several staff • Staff call in sick when they hear she is assigned to them
  11. 11. Assess and reverse aggravating factors: behaviour communicating an underlying need Sensory deprivation or deficits Correct sensory deficits: hearing aids, glasses Sensory Stimulation: Snoezelen, Music, Aromatherapy Excessive stimulation Reduced stimulation: colours, sounds (TV, radio, voices), exits, number of visitors Boredom Structured activities and exercise Loneliness Interaction with people or animals Quality of care Psychoeducation; Hands-on training with reinforcement Reducing restraints Removal of restraints; restraints often worsen behaviour Light levels Brighter lights, high contrast tablecloths, napkins, etc. Adapted from Old Age Task Force of World Federation of Biological Psychiatry: Livingston et al. Am J Psychiatry 2005: 1996-2021
  12. 12. Music Man
  13. 13. Case of B • Bed bound, incontinent of urine and feces • Is edentulous and only takes liquid diet • Unable to communicate with caregivers • Requires total assistance for all activities • Does smile at sight of others • Often screams at night and does not easily go back to sleep: – Caregivers are exhausted and stressed – Others living with her complain of their difficulty sleeping and dealing with their daytime activities
  14. 14. Case of A • 87 years old • Calmly lying in bed • Approached by staff for AM care • When staff help remove blanket she screams, hits, kicks, scratches, spits • Has injured several staff • Staff call in sick when they hear she is assigned to them
  15. 15. Case of C • 23 years old • Calmly lying in bed • Approached by staff for AM care • When staff help remove blanket she screams, hits, kicks, scratches, spits • Has injured several staff • Staff call in sick when they hear she is assigned to them
  16. 16. Case of C • 23 years old • Calmly lying in bed at home • Approached by staff for AM care • When staff help remove blanket she screams, hits, kicks, scratches, spits • Has injured several staff • Staff call in sick when they hear she is assigned to them
  17. 17. Case of C • 23 years old • Calmly lying in bed at home • Approached by intruders • When staff help remove blanket she screams, hits, kicks, scratches, spits • Has injured several staff • Staff call in sick when they hear she is assigned to them
  18. 18. Case of C • 23 years old • Calmly lying in bed at home • Approached by intruders • She screams, hits, kicks, scratches, spits
  19. 19. 12 minutes with Dementia
  20. 20. Adapt to cognitive deficits: mismatch between environment and ability to cope with situation ActivitiesofDailyLiving MMSE 25 20 15 10 5 0 KEEP APPOINTMENTS TELEPHONE OBTAIN MEAL/SNACK TRAVEL ALONE USE HOME APPLIANCES FIND BELONGINGS SELECT CLOTHES DRESS GROOM MAINTAIN HOBBY DISPOSE LITTER CLEAR TABLE WALK EAT 30 Adapted from Galasko. Eur J Neurol. 1998;5(suppl 4):S9-S17; Galasko et al. Alzheimer Dis Assoc Disord. 1997;11(suppl 2):S33-S39. Mild AD Moderate AD Severe AD Bars show 25th to 75th %ile of patients losing independent performance. May eventually produce a behavioural change even in the face of normal levels of stimulation
  21. 21. Old Age Task Force of World Federation of Biological Psychiatry: Livingston et al. Am J Psychiatry 2005: 1996-2021 Learning/Behavioural: mostly case studies Behaviour Therapy (B): • Connection made between – Antecedents (triggers) – Behaviour, and – Consequences (reinforcement) • Behaviour excesses: Modify reinforcer • Behaviour deficits: Use reinforcer Cognitive Techniques: • Cognitive Stimulation (B) • Reality Orientation (D) • Reminiscence (D) • Life Review • Validation Therapy (D)
  22. 22. Neurobehavioural Metaphors • Anxiety: restlessness, hand-wringing, pressured pacing, fidgeting, agitation • Sadness: crying, anorexia, terminal insomnia, nihilism, guilt, screaming • Withdrawn: apathy, quiet negativity, anorexia, sulleness, uncooperation • Markedly bizarre or regressed behaviour from previous standards • Over-elation/Overly boisterous: verbal hostility, aggressiveness, argumentativeness • Delusions: ideas of reference, paranoia, persecuted, sensory • Hallucinations
  23. 23. AmygdalaThalamus Hippocampus Sensory and association cortex Stress Personal problems Substance use
  24. 24. Cognitive Distortions • All-or-nothing thinking: Black and white thinking • Overgeneralization: the event is part of a never-ending problem • Mental filter: dwelling on negatives • Discounting the positives: accomplishments don’t count • Jumping to conclusions – Mind-reading: others doing nothing/don’t care – Fortune-telling: predict things will turn out badly • Magnification/catastrophization or minimization • Should statements: “Musterbation”: I must, I should • Labelling • Personalization and blame Burns 1980, Feeling Good
  25. 25. Change your reaction to the behaviour • Ignore the behaviour • Reframe the behaviour • Educate caregivers how to do this Behaviour Misinterpretation Re-interpretation Asking repetitive question They can control this but they are trying to annoy me They cannot keep track of time Accusing caregiver of stealing They are paranoid and trying to embarrass me This is due to memory failure Hitting They’re cruel and just want to hurt me on purpose This is loss of control due to brain damage Rewilak D. Behaviour Management Strategies in Conn et al. Practical Psychiatry in the Long-Term Care Home 3rd Ed. 2007 Hogrefe & Huber
  26. 26. Stress Inoculation 1. Prepare for stressful interaction 2. Confronting and handling the stressful event 3. Coping with feelings of being overwhelmed 4. Evaluating coping efforts and rewarding oneself Rewilak D. Behaviour Management Strategies in Conn et al. Practical Psychiatry in the Long-Term Care Home 3rd Ed. 2007 Hogrefe & Huber
  27. 27. Assess and reverse aggravating factors: behaviour communicating an underlying need Sensory deprivation or deficits Correct sensory deficits: hearing aids, glasses Sensory Stimulation: Snoezelen, Music, Aromatherapy Excessive stimulation Reduced stimulation: colours, sounds (TV, radio, voices), exits, number of visitors Boredom Structured activities and exercise Loneliness Interaction with people or animals Quality of care Psychoeducation; Hands-on training with reinforcement Reducing restraints Removal of restraints; restraints often worsen behaviour Light levels Brighter lights, high contrast tablecloths, napkins, etc. Adapted from Old Age Task Force of World Federation of Biological Psychiatry: Livingston et al. Am J Psychiatry 2005: 1996-2021
  28. 28. What is That?

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