BEHAVIOURAL APPROACHES BEHAVIOURAL APPROACHES IN DEMENTIAIN DEMENTIA:
PRIMING, TIMING, MIMING for Behavioural Care Plans
Dr. Lindy A. KilikNeuropsychology Service,
Geriatric Psychiatry ProgramProvidence Care-MHS
Learning ObjectivesLearning Objectives
To understand the current and future impact of dementiaTo review diagnostic criteria for dementia and identify dementia sub-typesTo review the cognitive, behavioural, perceptual and functional changes associated with dementiaTo identify nursing strategies for working with individuals who have a dementiaTo introduce the “Priming/Timing/Miming model of behavioural care plan development
Dementia DefinedDementia Defined
Dementia: DSMDementia: DSM--IV CriteriaIV Criteria
Memory LossOther cognitive impairments present (agnosia, aphasia, apraxia, loss of executive functioning)Decline from previous levels of abilityImpairment caused by each of the symptoms is of degree that is sufficient to interfere with patient's work/social lifeNo delirium
Oh Those Demographics!Oh Those Demographics!
BackgroundBackground
For industrialized nations:Populations are steadily aging• Age is a major risk factor for the development of dementia,
and so, concomitantly…
The number of individuals with dementia is rising
Schematic: 1950s demographicsSchematic: 1950s demographics
old
adults
young
Schematic: 2028 demographicsSchematic: 2028 demographics
old
adult
young
Increase in Population 65+ for Ontario
3237370
1543598993900
0500000
100000015000002000000250000030000003500000
1986 1992 1994 1998 1999 2000 2028
year
popu
latio
n
Ontario
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
2000 2004 2008 2012 2016 2020 2024 2028 65-69 70-74 75-79
80-84 85-89 90+
Dementia Projections 2000 - 2028
Dr. Leila Denmark, US Pediatrician, retired in 2002 at age 104
Dementia Prevalence RatesDementia Prevalence Rates(Canadian Study on Health & Aging Data)
0%
10%
20%
30%
40%
50%
60%
65-69 70-74 75-79 80-84 85-89 90+
Dementia Rates By 5 Year Age Groups
CSHA Dementia RatesCSHA Dementia Rates
AGEAGE Dementia RateDementia Rate
65-69 1.5%
70-74 3.4%
75-79 8.0%
80-84 16.2%
85-89 28.3%
90+ 51.8%
Types of DementiaTypes of Dementia
Causes of Reversible DementiasCauses of Reversible Dementias
B12 DeficiencyHyperthyroidismLithiumPhenytoinArsenic, LeadEncephalitisSevere AnemiaEtc., etc., etc.
Common Types of DementiaCommon Types of Dementia
Dementia TypeDementia Type How common is this type?How common is this type?
Alzheimer Disease 50-70%
Lewy Body Dementia 15%
Vascular Dementia 13%
Fronto-temporal dementia/Pick’s Disease
<10%
Alcohol Dementia 3%
Alzheimer’s disease is a brain disorder named for German physician AloisAlzheimer, who first described it in 1906.
DSMDSM--IV Diagnostic Criteria for IV Diagnostic Criteria for AlzheimerAlzheimer’’s Diseases Disease
Development of multiple cognitive deficits:memory impairmentother cognitive disturbance (aphasia, apraxia, agnosia, etc.)
Cognitive deficits cause significant impairment in social or occupational functioning, represent a declineGradual onset and continuous declining courseNot due to other CNS or medical conditions, delirium or an AXIS I Disorder
NINCDSNINCDS--ADRDA criteria: AlzheimerADRDA criteria: Alzheimer’’s s DiseaseDisease
Probable ADDementia established by clinical exam and documented by MMSE or Blessed scale, confirmed by further neuropsychological testsDeficits in 2 or more areas of cognitionProgressive worsening of memory & other cogNo disturbance of consciousnessOnset between age 40 and 90Absence of systemic disease or other brain diseases that could explain the cognitive changes
Probable AlzheimerProbable Alzheimer’’s Diseases Disease……22
Supported by:Progressive aphasia, apraxia, agnosiaImpaired activities of daily livingPositive family hxLab results: normal lumbar puncture, EEG, evidence of cerebral atrophy on CT/MRI
Possible AlzheimerPossible Alzheimer’’s Diseases Disease
Fits probable profile but…Variations in onset, presentation or clinical courseMay be made in the presence of a second systemic or brain disorder sufficient to cause a dementia which is not considered to be the single cause of the dementia
Healthy & Alzheimer BrainHealthy & Alzheimer Brain
Alzheimer PlaquesAlzheimer Plaques
Alzheimer TanglesAlzheimer Tangles
Vascular Dementia: Vascular Dementia: NINDSNINDS--AIREN criteriaAIREN criteria
Meets criteria for a dementiaEvidence of cerebro-vascular disease (CVD)
Focal signs on neurologic examEvidence of CVD on imaging: multiple large-vessel infarct or a single strategically placed infarct & multiple basal ganglia and white matter lacunes/extensive periventricular white matter lesions
Relationship between the dementia and CVDWithin 3 months following a stroke and/or abrupt deterioration and/or fluctuating, stepwise progression of cognitive deficits
Vascular dementiaVascular dementia……22
Clinical features of Probable VaDEarly gait disturbanceHistory of unsteadiness and frequent fallsEarly urinary frequency, urgency, other not explained by urologic diseasePseudobulbar palsyPersonality and mood changesOther subcortical deficits (e.g., psychomotor retardation)
LEWY BODY DEMENTIALEWY BODY DEMENTIA
Probable LBDMemory may be relatively spared as compared to attention, fronto-subcortical skills and visuo-spatial abilityTWO of• Fluctuating cognition with pronounced variations in
alertness and attention• Recurrent visual hallucinations• Spontaneous motor features of Parkinsonims
LBD continuedLBD continued
Supported by:Repeated fallsSyncope or transient loss of consciousnessNeuroleptic hypersensitivityDystematized delusionsHallucinations in other modalities
Areas of ChangeAreas of Change
Perceptual AbilitiesPerceptual Abilities……11
Visionision:loss of depth perception, poorer colour vision, tunnel vision
Decreased hearinghearing
Reduced sense of touchsense of touch
Perceptual AbilitiesPerceptual Abilities……22
Sense of balance balance (where the body is in space)
Confusing right and leftConfusing right and left
Hallucinations Hallucinations (hearing voices or seeing shadows causes fear and suspiciousness
Cognitive…1Disoriented (to person, place, date, time)
Impaired attention / more distractible
Poor recent memory / limited ability to learnearn new information
Language problemsproblems: understanding/ expressing languagenaming objectsword-findingvague speech
CognitiveCognitive……22
Slowed speed of taking in information / overload
Lack of insight / self-awareness
Reduced problem solving and reasoning
Delusions: esp. paranoid thinking
Emotional ChangesEmotional Changes……11
Emotional blunting (emotionally "flat")Emotional lability= emotions may rapidly shift from one extreme to anotherIrritabilityEmotional memory may remain strong when other types of memory fail (what you feel in your gut)
Functional ActivitiesFunctional Activities
Managing financesManaging finances: making financial decisions, paying bills, making change
Dressing, grooming and hygieneDressing, grooming and hygiene skills may decline
Reduced ability to know how to use common know how to use common objectsobjects: keys, comb, fork, razor
Inability to do multiInability to do multi--step activitiesstep activities: e.g., Cooking
A Word About A Word About BehaviourBehaviour
BehaviouralBehavioural ChangesChanges……11
DisinhibitionDisinhibition and impulsivenessimpulsiveness (mental brakes)
Inappropriate social behaviourInappropriate social behaviourloss of social skills, sexually inappropriatesexually inappropriate behaviour
Perseveration Perseveration (getting stuck, repeating something (getting stuck, repeating something –– a word or an action)a word or an action)
BehaviouralBehavioural Changes...2Changes...2
Irregular sleep and wake cycleIrregular sleep and wake cycle
Restlessness, agitatedRestlessness, agitated behaviour
Wandering / Getting lost Wandering / Getting lost
Vacant lookVacant look
General Nursing StrategiesGeneral Nursing Strategies
General General BehaviouralBehavioural StrategiesStrategies……11
Approaching the person / establish rapportApproach from the frontIdentify yourselfBody language / non-verbalsEye contactLevel the playing fieldMove slowly
General General BehaviouralBehavioural StrategiesStrategies……22
Engaging the person in conversationSpeak slowly Use simple statements/questions
(yes/no instead of multiple choice or open-endedAllow time to process your question & form a responseRepeat / rephrase your question when neededTalk about something pleasantUse humour (with caution – can be taken literally!)
General General BehaviouralBehavioural StrategiesStrategies……33
Watch the person’s non-verbals:If they can’t use language• They may act out what they are trying to tell you
Signs of agitation:• Clenched fists/slapping motions/rigid posture• Starting to stand up• moving back and forth in a restless fashion, pacing
Something to keep in mindSomething to keep in mind……
The person with dementia has been a The person with dementia has been a PERSON much longer than they have had PERSON much longer than they have had dementia. dementia.
ThereThere’’s a whole lot more to that individual s a whole lot more to that individual than the disease!than the disease!
Priming, Timing and Miming –A Heuristic for Planning BehaviouralApproaches in Dementia (© Kilik, 2006)
Behavioural Challenges in Dementia
Identified in the literature as: BPSD- “Behaviouraland Psychological Symptoms in Dementia”
Typical BPSD identified in dementia:Aggression (25-60%), Restlessness (20-45%), Visual Hallucinations (5-25%) Auditory Hallucinations (5-10%), Delusions (20%)
BPSD rates…
At least one of the traditional BPSD symptoms seen in over 80% of institutionalized patients with dementia
40-50% of BPSD resolve within 3 months
Consensus Guidelines
CAN Family Physician, Feb. 2006“Optimal treatment of behavioural disturbances in patients with dementia involves nonpharmacologicapproaches and using medications with demonstrated efficacy.”
“All guidelines stress that initial interventions should be nonpharmacologic. Generally, this means beginning with environmental and behaviouralmodifications.”
CAN Family Physician,Feb 2006
Pharmacologic treatment should target only those symptoms or behaviours that respond to medication. This approach minimizes unnecessary medication use and reduces adverse outcomes.
Behavioural Challenges in Dementia
Typical BPSD identified in dementia:Aggression (25-60%), Restlessness (20-45%), Visual Hallucinations (5-25%) Auditory Hallucinations (5-10%), Delusions (20%)
40-50% of BPSD resolve within 3 months
AGGRESSION IN DEMENTIAAGGRESSION IN DEMENTIA
80% of AGGRESSIVE BEHAVIOURis actually
DEFENSIVE BEHAVIOUR!!
Most behavioural challenges for inpatients occur…
In the “WHISPER ZONE”
In close proximity to patient
Involve physical contact
Involve personal (intimate) care
Whisper-zone care activities
BathingOral HygieneGroomingToileting Dressing
EatingTransfersAmbulationSleepAgitated/Aggressive behaviours
PRIMING, TIMING, & MIMING
A way to make sense of the vast literature on behavioural intervention strategies and approaches in dementia
Provides a quick and easy way to develop an individualized behavioural approach for a particular client with dementia.
PRIMING
What LEVEL of ASSISTANCE is required?Independentset-up/minimalModerateMaximal/totally dependent
How many PERSONS are required?
PRIMING
Do you have a predictable routinepredictable routine (or string of events) that signalssignals the activity to the client?
Are there familiar objects, scents, people, etc. you can involve in the activity to help the client understand the purpose and also to communicate that it is safe?
TIMING
What time of day do you engage in the activity?When did the client usually do this activity in the past?
What is the best time of day for the client?
TIMING
Are you pacing the activity at a rate that the patient can comprehend?
Are you speaking and moving slowly enough that the client can understand the process and participate
MIMING
Generally there is a greater chance of communicating something if it is presented in more than one modality at a time: Say it and slowly demonstrate it at the same time
Non-verbal communication makes up for over 90% of the message (tone of voice, rate of speech, facial expression, body language) . Use all of these modes as well as the words!
SUMMARY
“PRIMING, TIMING, MIMING” represents a heuristic that easily leads you to incorporate a number of tried and true behaviouraltechniques into your approach with clients
This framework is based on knowledge about an individual’s patterns, preferences and routines – it works because it’s personalized!
The strategies minimize confusion, anxiety/fear, agitation, catastrophic reactions & physical aggression.
The Priming, Timing, Miming Behavioural Care Plan©
A way to quickly capture all of the information within the “Priming, Timing, Miming©” model into an easy-to-follow care plan documentA single, double-sided sheet Includes
Goals for admission-dischargeIndividualized care approaches
CASE EXAMPLES
