Managing Challenging Behaviours in Dementia: Part 1

1. South West Dementia Partnership Behaviours that challenge us: part 1

2. Welcome • Introductions • Group Agreement • What will be achieved from this session?

3. Main Talking Points • Key theoretical issues and background when considering behaviours that challenge us. • Generalised solutions and tools to help when supporting someone with dementia and minimising distressful behaviours and situations.

4. Defining behaviours that challenge us • Angry (aggressive) behaviour. • Excessive walking (wandering behaviour). • Repetitive behaviours. • Vocally disruptive behaviours • Sexual expressive behaviours • Identify examples of these

5. A bio-psychosocial approach • a person’s behaviour is the result of the interactions between: • biological aspects, • psychological and • social environment. • taking an ‘inquiring’ approach to discovering helpful approaches.

6. Physical needs and physical health • Maslow’s (1943) ‘hierarchy of needs’ is often portrayed in the shape of a pyramid, with the most fundamental level of needs at the bottom. This first layer is sometimes referred to as ‘physical’ or ‘physiological’. • Air, water, and food are requirements for survival in all animals, including humans.

8. Essential physical needs Powell J (2007) Difficulties in understanding With permission When a person has dementia their ability to meet these needs becomes increasingly dependent on the support of others. Maintaining a person’s essential physical needs requires a high degree of observation and imagination on the part of those providing support.

9. Psychological & Social Needs

10. Malignant Social Psychology • Disempowerment • Objectification • Invalidation. • Infantilisation • Impact of interpersonal interactions: What happens within an interaction has an enormous effect on how a person feels.

11. Changes to information processing and emotional responses • Influence of Personality People with dementia retain the essence of their personality however personality traits may become exaggerated. • Neurological Impairment • Changes to information processing and emotional responses • Feeling + Thinking = Behaviour • Or • (Amygdala + Frontal Lobe= Behaviour)

13. Delirium, hallucinations and delusions • National Institute for Health and Clinical Excellence describes delirium as a ‘disturbance of consciousness or perception and confusion’. • A hallucination is an experience of any of the 5 senses that appears to the person experiencing it as real, but that reality is not shared by others. • A delusion is a belief that a person holds, despite evidence to the contrary, and is resistant to all reason.

14. Impact of the environment : Considering the impact of the environment and noise (Powell 2007) With permission

15. Verbal communication • Lighting/Heating • Lack of signs • Poor layout of a room which does not allow for moving around • Number of people in a room • Changes in routine, rushing. • Lack of ‘comfort cues’

16. General ways of helping • Communication • Life history • Environment • Observation tools • Validation Therapy • Working with families and friends - Relational approach • Medication

17. Communication • Upholding a person’s well being. This can be done by: • Connecting with the person at any opportunity and when engaging in any care tasks. • Talking to the person in a way that is appropriate for their age and status. • Talking calmly and with empathy when a person with dementia is having difficulties.

18. Life history • In workbook 1 (chapter 7) and workbook 2 (chapter 5) the importance of life history work was discussed. Finding out about a person may need exploring in an ongoing way rather than a ‘task’ to be completed in a ‘session’. • Some of the ideas as to what to include can be to use specific formats. For example the ‘Clipper Questionnaire’ by purchasing Jennie Powell (2007) Care to Communicate or gathering information using headers from a variety of sources for example the Alzheimer’s Society ‘This is Me’ format.

19. Environment • When thinking about having a positive environment for a person it is essential to consider a variety of factors: • What are the person’s past wishes and preferences regarding spending time in company? • What is the person’s present response to being with others? • Are individual comfort cues available for the person such as favourite pieces of furniture/blankets? • .

20. Environment • What objects are available to touch/hold that might be engaging /comforting • What is the background noise and how is the person responding to this? • Are there opportunities for the person to move around should they wish? • Are there clear signs to direct the person to the toilet? • Is there the opportunity for the person to access food and/or drinks?

21. Observation tools • There are various different observational tools with the most recognised being Dementia Care Mapping (DCM) and SOFI (Short Observational Framework for Inspection). • DCM is an observational tool which provides a format for observing and recording life through the eyes of a person with dementia. • Also a new Person, Interaction, Environment (PIE) observational method is being piloted for use in general hospital wards.

22. Validation Therapy • In the 1960s Naomi Feil, developed an approach which she named ‘validation therapy’ • Using validation is to hold less regard for the content of a person’s speech for example the facts of what is said, and instead to link with how a person may feel through a person’s tone of voice and their body language. • This is widely used today in the field of dementia

23. Working with families and friends - Relational approach • When a person has dementia it has an effect on all members of the person’s family and friends. • Working closely with a person’s relatives and friends is therefore vital. • Sometimes this is described as a ‘Relational Approach’. • Identify ways to engage positively with a person’s relatives and friends

24. MedicationAnti-Psychotics • There has been much focus on how and when anti psychotic medication for people with dementia is used. Several studies have highlighted concern and indicated significant risks relating to their use. • There have been many non pharmacological interventions described throughout this workbook. You will remember that anti psychotic medication should be used only once all other non pharmacological interventions have been considered.

25. MedicationAnti-Psychotics • Antipsychotics such as Haloperidol, Olanzapine and Risperidone should only be considered once all other possible approaches have been tried. • Identify the risks and assess against the benefits. • Start with a low dose. • Set a review date.

26. Medication: Acetylcholinesterase (AchE) Medication and Memantine • These medications do not ‘cure’ dementia but in certain cases can help to slow down the rate of progression of the illness. • In March 2011 the review and re-appraisal of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease resulted in a change in the guidance.

27. Medication: Acetylcholinesterase (AchE) Medication and Memantine • Donepezil, galantamine and rivastigmine are recommended as options for managing mild as well as moderate Alzheimer’s disease, and • Memantine is recommended as an option for managing moderate Alzheimer’s disease for people who cannot take donepezil, galantamine or rivastigmine and as an option for the later stages of Alzheimer’s disease

29. Main Talking Points re-visited: Any questions? • Key theoretical issues and background when considering behaviours that challenge us. • Generalised solutions and tools to help when supporting someone with dementia and minimising distressful behaviours and situations.