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

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


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



• Praxis


• Summary

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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



• Praxis


• Summary

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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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• Introduction

• Defining BPSD



• Praxis


• Summary

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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



• Praxis


• Summary

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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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• Introduction

• Defining BPSD



• Praxis


• Summary

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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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• Introduction

• Defining BPSD



• Praxis


• Summary

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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…..



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?



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.



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


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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


• Introduction

• Defining BPSD



• Praxis


• Summary

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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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THANK YOU

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[email protected] [email protected]

mailto:[email protected]

Health & Medicine

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