This chapter of the Introduction to Behavioural and Psychological Symptoms of Dementia (BPSD): A Handbook for Family Physicians outlines the general approaches to the management of delirium in dementia. Delirium is a frequent complication of dementia. Left untreated, a delirium can lead to a variety of poor outcomes, including death.  16 pages.

Emerging Priorities in Aging

Conferences & Workshops - Aging Research & Innovation Forum • October 26, 2012 • Kingston, ON

On October 26, 2012, as part of our series of Aging, Research & Innovation Forums, over 100 educators, clinicians, students, caregivers and researchers from across Ontario attended the Emerging Priorities in Aging conference at Portsmouth Olympic Harbour Restaurant in Kingston to discuss ideas, projects and research about the care and welfare of older adults.

Aging, Research & Innovation Forums

September 15, 2011 • November 23, 2011 • February 16, 2012 • Kingston, ON

Through a series of consultations, the Centre for Studies in Aging & Health at Providence Care identified a desire to create networking opportunities in aging research and practice at Providence Care and Queen’s University. Beginning in September 2011, CSAH organized a series of Aging, Research & Innovation Forums, inviting researchers, physicians, geriatric specialists and health care planners.

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. Symptoms generally include observable behaviours that are inappropriate or excessive within the situation and disturbing, disruptive or potentially harmful to the resident or others. (4)

Why is it Important?

  • 80-90% of nursing home residents live with some form of mental illness and/or cognitive impairment with more than 2/3 diagnosed with some form of dementia (5)
  • Individuals may have more severe symptoms in LTC with severe behavioural disturbances (3)
  • 12-21% of residents exhibit psychotic symptoms as a result of disorders such as schizophrenia, delusional disorders, mood disorders and delirium (4)
  • Neurological and vascular conditions such as Parkinson‘s disease (PD) can contribute to cognitive impairment and result in responsive behaviours.• Challenging behaviours are a major source of distress both to the person experiencing them and those who experience them such as the caregiver and their family (5)
  • Prevalence and psychological symptoms include 44% global agitation, 24% verbal aggression and 14% physical aggression.(4) Responsive behaviours increase safety risks and disruption for individuals and others.
  • 47% of Registered Practical Nurses reported physical assault and 72% reporting emotional abuse (5)

Common Causes;

May be precipitated by variety of triggers (follow P.I.E.C.E.S.TM 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

  • Responsive behaviours are not willful or intentional and represent an individual’s adaptive response to a negative stimulus in their physical, social, or emotional environment.  Health care providers (HCP) need to determine and understand the causality and meaning behind the behaviour.
  • Residents should receive individualized, self-directed person centered care.  Responsive behaviours respond to appropriate and timely interventions (4)
  • A culture of caring philosophy using empathy includes principles of psychosocial rehabilitation to maximize quality of life and build on resident and family strength while fostering a “sense’ of control”.
  • Utilization of informed clinical decision making assessment and screening tools based on evidence based practice.
  • Ongoing evaluation and modifications based upon resident, family and caregiver needs (4)
  • Minimization of pharmacological interventions and use of the BEERS criteria for potentially inappropriate medication use in older adults. Identify conditions that only respond to environmental or caregiving approaches. (6)   
  • Use of the P.I.E.C.E.S.TM framework and 3 question template:  
    1. What has changed?
    2. What are the RISKS and possible causes?    
    3. What is the action?

References

  1. Abbott-McNeil, D., Barber, D., Murphy. & Puxty, J. (2009).  Behavioral & Psychological Symptoms of Dementia (BPSD) in Long Term Care.   Bridges to Care Guide, The Centre for Studies in Aging and Health.
    www.sagelink.ca/bpsd_toolkit_full_pdf

  2. Conn, D., Gibson, M., Hirst, S., Leung, S., MacCourt, P., McGilton, K., Mihic, L., Cory, K., Le Clair, K., McLeary, L., Powell, S.,& Roberts, E.  (2006).  National guidelines for senior’s mental health. The assessment and treatment of mental health issues in long term care home.  Retrieved Feb. 2014 from:
    http://www.ccsmh.ca/en/natlGuidelines/ltc.cfm

  3. Dudgeon, S. & Reed, P. (2010).  Older Adults Behavioural Support System. Retrieved Dec 6, 2018 from: 
    http://brainxchange.ca/Public/Files/BSO/Older-Adults-Behavioural-Support-System.aspx

  4. Mental Health Commission of Canada. (2014). Retrieved Jan. 13, 2014 from: 
    http://www.mentalhealthcommission.ca/English

  5. Shields, M. & Wilkins, K. (2009).  Factors related to on the job abuse of nurses by patients. Retrieved Feb. 2014 from: 
    http://www.statcan.gc.ca/pub/82-003-x/2009002/article/10835-eng.pdf

  6. The American Geriatrics Society.  (2012).  AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.  Retrieved Feb.2014 from: 
    http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf


This presentation summarizes the behavioural and psychological symptoms of dementia. Dr. Puxty uses cases to review brain function and behaviour, as well as an approach for collaborative care planning within a primary care setting. Both non-pharmacological and pharmacological treatments are explored. 42 Slides.

As people age, they experience many changes, including physical, psychological, social and environmental; every individual reacts to these changes differently (1).

Older adults who are no longer able to communicate their needs and desires effectively  may engage in responsive behaviours, also refered to as challenging behaviours (2). This type of behaviour can include feeling annoyed, wandering, not wanting care, use of foul language, hitting and throwing (2). In these situations, it is helpful to use simple words, move slowly through activities and remain patient (3).

Caring for someone experiencing episodes of responsive behaviour is challenging. As a caregiver, it is essiental to stay emotionally, mentally and physically healthy. Seeking the support of community services, family members and friends can help ease stress or burden brought on by caregiving (3). Sharing tasks, solving problems and savouring the humour along the caregiving journey with others will help maintain your health. Finally, staying educated on your friend or family member’s condition can help you understand their experience and allow you to provide the best care you can (3).

References

(1)  Hilger. Z. (2009). Behaviour and emotions of aging. Retrieved from http://www.familycaregiversonline.net/online-education/behavior-and-emotions-of-aging/

(2)  Ontario Behavioural Support System Project Team. (2010). Behaviours have meaning -The Ontario behavioral support system project. Retrieved from http://www.nelhin.on.ca/Page.aspx?id=12028

(3)   Robinson, L., Wayne, M. S., & Segal, J. (2018). Tips for Alzhemier’s caregivers. Retrieved from https://www.helpguide.org/articles/alzheimers-dementia-aging/tips-for-alzheimers-caregivers.htm

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

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?

  • Challenging behaviours are a major source of distress both to the person experiencing them and those who experience them such as the caregiver and their family.
      • 34% of nurses have experienced physical assault from a patient and 47% reported emotional abuse (3)
      • Lack of community support and caregiver burnout may result in crisis admissions to hospital (3)
  • Hospital discharge may be delayed for persons experiencing responsive behaviours resulting in longer LOS and an increase in ALC designation (creating further burden on all sectors of the health care system)
      • ALC patients occupied 15% of all acute care beds in Ontario and 44% half of clients were waiting for long-term care (2)
  • Increased risk of iatrogenesis (unintended and untoward consequence of well-intended healthcare interventions) and functional decline contributing to client/patient morbidity and mortality

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

  • Responsive behaviours are not willful or intentional and represent an individual’s adaptive response to a negative stimulus in their physical, social, or psychological environment.
  • Responsive behaviours respond to appropriate and timely interventions: remain calm, empathetic, good communication techniques,distraction, build on their strengths, understand the causality and meaning behind the behaviour
  • Preventing responsive behaviours should inform the plan of care by recognizing and appropriately responding to the behaviour(s):
      • Creating a culture of safety and adapting the environment and care to meet client’s unmet needs; promoting the least restrictive and supportive physical and social environments whenever possible (i.e. reduce clutter, creating safe and accessible areas for ambulation, promote psychological safety)
      • Providing person centered care: getting to know the person as an individual, their likes, dislikes and background, fostering a “sense “of control and a collaborative approach to care model including the family, a knowledgeable care team
      • Utilization of informed clinical decision making to improve safety and quality of care through minimization of pharmacological interventions and use of the Beers criteria for potentially inappropriate medication use in older adults.
  • Identify conditions that may be responsive to medications and those which only respond to environmental or caregiving approaches.Pharmacological strategies should be carefully monitored and reviewed, time-limited and always combined with non-pharmacological strategies.
  • Facilitate good communication.

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. Ontario Hospital Association, (2012). Alternative Level of Care. Retrieved Feb. 2014 from:
    http://www.oha.com/currentissues/issues/eralc/Pages/eralc.aspx

3. Shields, M. & Wilkins, K. (2009). Factors related to on the job abuse of nurses by patients.
    Retrieved Feb. 2014 from:
    http://www.statcan.gc.ca/pub/82-003-x/2009002/article/10835-eng.pdf

4. The American Geriatrics Society. (2012). AGS Beers Criteria for Potentially Inappropriate Medication Use
    in Older Adults. Retrieved Feb. 2014 from:
    http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf

This booklet provides a condensed version of the BPSD in LTC for caregivers to understand these “challenging” behaviours and promote a therapeutic response. Topics include risk factors, prevention, making the diagnosis, treatment ( including Pharmacological Treatment: P.I.E.C.E.S. Psychotropic Template chart), Quality Improvement, Resident and Family education along with template questions for P.I.E.C.E.S., U-First and U.R.A.F. 25 Pages.

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