Primary Care Resources - Behavioural Issues

Behavioural issues also known as responsive behaviours are generally characterized by challenging outbursts of aggression, agitation, repetitive or bizarre actions, shouting and/or disinhibited behaviours. They are generally associated with cognitive impairments due to complex mental health conditions and addictions (substance abuse), dementia or neurological conditions.

Why is it Important?

  • 15-40 % of Canadian seniors require mental health services and 5-10% of have severe psychiatric impairment that may require specialized services (1)
  • Approximately 30% of home care clients with a diagnosis of dementia exhibit some degree of behavioural symptoms (1)
  • Often presents as a crisis situation
  • The majority of older persons with responsive behaviours can be managed at home with specialized geriatric community supports and early recognition (2)

Common Causes

May be precipitated by variety of triggers (follow P.I.E.C.E.S. acronym):

Physical: pain, constipation, polypharmacy, infections; especially UTI and pneumonia
Intellectual: Review Brain and Behaviour
Emotional: depression, anxiety
Capacity: miss match between functional ability and expectations
Environmental: changes in living environment, relocation, admission to hospital
Social: change or stress/illness of caregiver

Key Considerations

  • The goal of care is to support the person and their family to remain in the community
  • Assess medical, neurological, medications, functional and psychiatric status: refer to Geriatric Psychiatry or Geriatrician services as necessary. Early symptoms are commonly “under recognized”
  • Early referral to community supports: Community Care Access Centre for home and family supports: Aging at Home, SMILE Program, Alzheimer’s First Link, etc.
  • Assess the impact of behavioural issues on the individual’s quality of life and signs of caregiver stress
  • Determine concerns (e.g.  fears) and expectations (hopes) of the person and family using the 3 question framework:
    1.  What are the main concerns and what has changed?
    2.  What are the RISKS and possible causes (Think P.I.E.C.E.S. TM)?
    3.  What is the action?
  • Continuity of health care providers, services and a case management approach supports both the individual and  the  family (1)
  • Identify conditions that may be responsive to medications and those which only respond to environmental or caregiving approaches. Utilize the Beers criteria for potentially inappropriate medication use in older adults

References

1. Dudgeon, S. & Reed, P. (2010). Older Adults Behaviour Support System. Retrieved Feb 19, 2014 from: 
    http://brainxchange.ca/Public/Resource-Centre-Topics-A-to-Z/Behavioural-Supports-Ontario.aspx

2. Family Caregiver Alliance. (2012). Retrieved Feb 18, 2014 from:
    http://www.caregiver.org

3. Puxty, J. & Rivard, M. (2009) Introduction to Behavioural and Psychological Symptoms of Dementia
    (BPSD): A Handbook for Family Physicians (2nd ed.) Retrieved Feb. 2014 from:
    www.sagelink.ca/bpsd_handbook

4. Mental Health Commission of Canada. (2014). Retrieved Feb. 18, 2014 from:
    http://www.mentalhealthcommission.ca/English