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3. THE CHALLENGING BEHAVIOURS Agitation Emotional and motor components – “Sundowning” Restlessness and pacing Wandering “The Long Haul” Shouting and screaming Sexual disinhibition Aggression “The Enucleator”

4. TOP EREWASH AGITATORS 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”

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. COHEN-MANSFIELD AGITATION INVENTORY Rating scale assessing frequency of up to 29 “agitated behaviours” Scale 1-7 for each behaviour Swearing, kicking, biting, attention-seeking, intentional falling, hoarding, disinhibition etc. Theoretical max score = 203 Need training to administer No aetiology determined

7. 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”

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

9. TREATMENTS – PSYCHOLOGICAL Carer education Routines with individuality Communication – Validation or reality “Where’s Eric?” Symptom-focussed programmes “The Water Pistol” Tom Kitwood’s theory of Malignant Social Psychology

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

11. REVERSING THE PROCESS “REMENTIA” Angiogenesis, dendritic rearborization & synaptogenesis

12. TREATMENTS - BIOLOGICAL Treat physical and psychiatric disorders 80% dementia patients “depressed” Choose psychotropic medication with reference to symptoms, side-effects and contra-indications “The Resistive Man” No underlying neuropharmacological theory “From A to Z”

13. EFFECTIVE PRESCRIBING Target appropriate symptoms Simplest regime possible “Start low, go slow” Pharmacological psycho-education of carers to enhance concordance Assess side effect acceptability Monitor and adjust accordingly Agree long term plan

14. SPECIFIC MEDICATIONS Atypical antipsychotics (Risperidone) Side-effects, efficacy and administration Typical antipsychotics (Promazine) Efficacy and cost Anti-depressants (Trazadone & SSRIs) Shouting and sexual disinhibition Mood-stabilizers (Carbamazepine) Anxiolytics Cholinesterase inhibitors

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 Acknowledges side effects can worsen dementia symps 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 ADVICE DISTRIBUTED (2008)

17. ALTERNATIVE THERAPIES Art/Music therapy Scheduled activity Aromatherapy Lavender and lemonbalm Bright light therapy Sensory Therapies Snoezelen Rooms

20. CONTROVERSIES Questionable validity Medical problem? Treatments – punishment or control? Medication – a “quick fix”? Physical restraints “The Hong Kong Physio”

21. SUMMARY 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!!! Challenging behaviours are a message

22. 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

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