dr tony jones, dbmas alzheimers australia act: effectively managing bpsd and challenging behaviours
DESCRIPTION
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/dementiacongress2014TRANSCRIPT
Helping Australians with dementia, and their carers
Managing Behavioural and Psychological Symptoms of Dementia
Supporting workers • Advice • Information • Referral
ACT Dementia Behaviour Management
Advisory Services (DBMAS)
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
Managing Behavioural and Psychological
Symptoms of Dementia
• Introduction
• Defining BPSD
• BPSD – Conceptual Problems
• Alternatives to BPSD
• Praxis
• Implications for Practice
• Summary
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• Introduction
• Defining BPSD
• BPSD – Conceptual Problems
• Alternatives to BPSD
• Praxis
• Implications for Practice
• Summary
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Managing Behavioural and Psychological
Symptoms of Dementia
Helping Australians with dementia, and their carers
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
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• Introduction
• Defining BPSD
• BPSD – Conceptual Problems
• Alternatives to BPSD
• Praxis
• Implications for Practice
• Summary
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Managing Behavioural and Psychological
Symptoms of Dementia
Helping Australians with dementia, and their carers
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
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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].
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Helping Australians with dementia, and their carers
• Introduction
• Defining BPSD
• BPSD – Conceptual Problems
• Alternatives to BPSD
• Praxis
• Implications for Practice
• Summary
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Managing Behavioural and Psychological
Symptoms of Dementia
Helping Australians with dementia, and their carers
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?]
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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
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• Introduction
• Defining BPSD
• BPSD – Conceptual Problems
• Alternatives to BPSD
• Praxis
• Implications for Practice
• Summary
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Managing Behavioural and Psychological
Symptoms of Dementia
Helping Australians with dementia, and their carers
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
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Helping Australians with dementia, and their carers
• Introduction
• Defining BPSD
• BPSD – Conceptual Problems
• Alternatives to BPSD
• Praxis
• Implications for Practice
• Summary
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Managing Behavioural and Psychological
Symptoms of Dementia
Helping Australians with dementia, and their carers
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….
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Helping Australians with dementia, and their carers
• Introduction
• Defining BPSD
• BPSD – Conceptual Problems
• Alternatives to BPSD
• Praxis
• Implications for Practice
• Summary
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Managing Behavioural and Psychological
Symptoms of Dementia
Helping Australians with dementia, and their carers
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…..
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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 – how does the term BPSD enhance our understanding of the
reasons for this lady’s behaviour…..
We might ask – what are her needs…..what is she trying to tell us…..what is she
communicating…..what should our response be…..
Helping Australians with dementia, and their carers
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.
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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].
How does saying ‘this man displays BPSD’ help us understand the issues that
confront him…. or his 80 year old wife….or his children?
Helping Australians with dementia, and their carers
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.’
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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
Implications for Practice - 4
Think of presenting behaviours as impaired communication.
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Conceptualise the behavioural displays in terms of an underlying
mental, physical, emotional state.
If the person could speak what would they tell us?
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
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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
what is happening
to them, to feel safe
and secure
culture, interests,
supports, familiarity,
environment
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
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behaviour problem need response
fluctuating
cognitions,
confused/lucid,
nocturnal distress,
agitated/settled
Delirium
secondary to UTI
free from delirium,
pain relief, controlled
environment, infection
treated
antibiotic, pain relief,
push fluids, low
stimulus environment,
orientation to
time/place/person
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
• Introduction
• Defining BPSD
• BPSD – Conceptual Problems
• Alternatives to BPSD
• Praxis
• Implications for Practice
• Summary
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Managing Behavioural and Psychological
Symptoms of Dementia
Helping Australians with dementia, and their carers
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
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Helping Australians with dementia, and their carers
THANK YOU
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