Helping Australians with dementia, and their carers

Dementia Behaviour Management

Advisory Services

Helping Australians with dementia, and their carers

DBMAS Target Group

Severe and persistent

Behavioural and

Psychological

Symptoms of

Dementia

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Brain StemControls heart rate

and rate of breathing

Temporal LobeHearing

Memory of hearing and Vision

Broca’s

AreaMotor

control of

speech

Frontal LobeMotor control of voluntary muscles

Personality

Concentration, organization

Problem solving

Motor StripSensory Strip

Parietal LobeSensory areas of touch,

pain, temperature.

Understanding speech,

language.

Express thoughts

Wernicke’s AreaInterpreting speech

Occipital

LobeVisual recognition

Focus the eye

CerebellumBalance

Coordinating

muscle movement

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Cross Section

Normal Brain

Cross Section

Brain with

Alzheimer’s Disease

- enlarged ventricles

Normal Neurone

Abnormal Neurones

Inside are neurofibres

in paired helix

MMSE deficits:

•Relies on literacy

•Education

•Cultural background

•Emphasis on orientation

•Poor sensitivity for frontal lobe deficits

Imprecise or inaccurate language translation

Limitations of the MMSE

RUDAS: Rowland Universal Dementia

Assessment

Scale

A Multicultural

Mini Mental Status

Examination

MCMMSE

• 6 items

• 12 domains (Memory, Learning, Praxis,

Judgment, Planning, Attention, Gnosis,

Language, Visuo-spatial/Construction,

Perseveration, Initiation, Orientation)

• 10 mins

MCMMSE12 domains:

Memory, Learning,

Praxis, Judgment,

Planning, Attention,

Gnosis, Language,

Visuo-spatial

Construction,

Perseveration,

Initiation, Orientation

Africa

Middle East

Central/Sth America

Asia

Europe

U.S.A. United Kingdom

Australia

Country of Birth

of Pilot Participants

50%

English

speaking

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Item/Domain

Matching

1. 4 Item Grocery List

2. Identify Body Parts

3. Hand/Fist Alternating

4. Cube Drawing

5. Crossing the Road

6. Animal Naming

2. (R) Parietal / Frontal Lobes:

Memory, Praxis, Judgement, Planning, Attention, Gnosis, Language, Visuo-spacial construction, Perseveration, Initiation, Orientation

1. Frontal / Temporal Lobes:

Memory, learning, attention, Language,perseveration

3. Parietal Lobes:

Learning, Praxis, Judgement, Planning, Attention, Visuo-spacial construction, Perseveration, Initiation,

4. Frontal / (R) parietal Lobes:

Learning, Praxis, Planning, Attention, , Visuo-spacial construction, Perseveration, Initiation,

6. (L) Parietal / Frontal medial Lobes

Memory, Judgement, Attention, Gnosis, Language, Perseveration, Initiation,

5. Frontal Lobe:

Memory, Judgement, Planning, Attention, Gnosis, Language, Visuo-spacial,construction, Perseveration, Initiation, Orientation

Helping Australians with dementia, and their carers

Cube Examples

RUDAS

Highlights

the cognitive domains

Functional Abilities and Disabilities

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MMSE:

as a Management Tool

RUDAS:

as a

Behaviour Management Tool

why not???

What should our set of Guidelines look

like?

12 DOMAINS 6 ITEMS MANAGEMENT

STRATEGIES

COMMENTS &

SUGGESTIONS

Item1 4 item grocery list Item 2 Identify Body Parts Item 3 Hand/Fist Alternating Item 4 Cube Drawing Item 5 Crossing the Road Item 6 Animal Naming

1.

Research project!

Helping Australians with dementia, and their carers

Helping Australians with dementia, and their carers

Helping Australians with dementia, and their carers

Helping Australians with dementia, and their carers

Part of an Holistic Assessment

• The Behaviour Response Flow Chart

• Describe the behaviour

• A: antecedents

• Is the behaviour consistent with the type of

dementia?

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How to implement the Toolkit

• Conduct the RUDAS test

• Review ‘Problems” to see which match with the

description of the person’s behaviour.

• Review the ‘Suggested Strategies”

• Choose which ones apply to this event or

circumstance

• Personalize them, then add to the care plan

Elizabeth Brandis CNS

•German woman

•Living alone and in squalor

•Self care deficit

•Risk taking behaviour:

Lighting fires in house

History of disinhibition

Allowing unknown males into her home

Taking explicit photos

•75 years old

•Bizarre ‘eccentric’ behaviour

•Family conflict

•Unaware of true nature of situation

•No history of psychiatric illness

•No diagnosis of dementia

Zilla’s Story

2001: ACAT and Neuropsychology assessments

Fronto-temporal dementia, services refused;

nil further contact with health services until…

2003: ACAT assessment initiated by family

MMSE 28/30, services refused

shortly followed by…

2003: Hospital admission confusion and agitation;

one month later…

Hospital admission confusion & UTI.

RUDAS 14/30

discharged home…

Background Discovered

2003:Later referred to IDST:

Wholistic assessment, RUDAS 17/30

The item numbers highlighted

deficits in the cognitive domains of:

•Memory, (1,2,5,6)

•Learning, (1,3,4)

•Initiation, (2,3,4,5,6)

•Perseveration, (1,2,3,4,5,6)

•Judgement, (2,3,5,6)

Demonstrated as:

•Extremely disinhibited,

•significant self care deficits,

•at risk behaviour etc

True Deficits Revealed

RUDAS

Highlights

the cognitive domains

Functional Abilities and Disabilities

1. Provide information, advice and education to

family

2. Increase monitoring of supervision of

environmental situation and activities

3. Provide calendar, memos and visual cues

4. Provide simple prompts and guides for ADLs

5. Attend dementia specific day care

6. Discourage inappropriate visitors to her house

Zilla’s Initial Care Plan R/T Domains

7.Trial of residential respite in female only

facility

8.Intensive Behaviour Monitoring in facility

9. Provide staff advice and education

10. Remove camera and provide

distractions

11. Meditrak electronic locating device

issued

12. Accept permanent placement

13. ACAT referral for ACCR

What happened?

Background: Zilla’s Story 75 year old woman of German background Living alone and in squalor Reduced ability to self care Bizarre behaviour, labelled as ‘eccentric’ by

health care workers Risk taking behaviour: History of disinhibition Allowing unknown males into her home

for sex Taking explicit photos Lighting fires in house to attract help

Family conflict over mother’s care needs Family and health care workers unaware of

true nature of situation No history of psychiatric illness or

diagnosis of dementia

Assessment Process: Chronology & Results2001 ACAT and Neuropsychology assessments fronto-temporal dementia,

services refused; nil further contact with health services until…..2003 ACAT assessment initiated by family, MMSE 28/30, Zilla refused

services; shortly followed by…..2003 Hospital admission 1. confusion and agitation; one month later

Hospital admission 2. confusion and UTI, assessed by CNC/Psychogeriatrics RUDAS 14/30; stabilized and discharged …..

2003 Referral to Behaviour Management Team: Wholistic assessment, RUDAS 17/30 deficits highlighted in

cognitive domains of memory, learning, initiation, judgement and perseveration (see Figure 1);

disinhibited++, significant self care deficits, at risk, Family conflict over residential placement Dementia specific day centre trial – discontinued due to her

disinhibition Family trial Zilla’s care in their home – discontinued due to her

behaviours impacting on their ability to care Respite/trial of placement in dementia specific female only

residential aged care unit BMT provided intensive behaviour monitoring and modelling of

care strategies aimed at behaviours of concern Facility agreed to permanent placement and Zilla settled but not

without additional BMT nursing and DT input as she was still taking photos and eloping from N/H with fellow resident.

DiscussionThe RUDAS findings highlighted cognitive deficits for Zilla which were not

demonstrated in the MMSE imparted understanding to the family members informed education and counselling allowing the family

to overcome feelings of embarrassment and denial assisted in the creation of a set of guidelines for

informing care

References:Storey, Rowland, Conforti and Dickson. 2002 The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale. International Psychogeriatrics, 16:1, 13-31.

ConclusionThe clinician’s experiences using theRUDAS have demonstrated the utilityof the tool in formulating care planswith implications for education aboutthe impact of the dementia diseaseprocess on behaviour, and appropriatelong-term care for older people withdementia.Zilla settled well into residential carewith the stimulus of men and camerasremoved within a supported environment.

Zilla’s Care Plan Provide information, advice and education to family Increase monitoring and supervision of

environmental situation and activities Provide calendar, memos and visual cues Provide simple prompts and guides for ADLs Attend dementia specific day care Discourage inappropriate visitors to her house ACAT referral for ACCR Trial of residential respite in female only facility Intensive behaviour monitoring in facility Provide staff advice and education Remove camera and provide distractions Issue ‘Meditrak’ electronic locating device Permanent placement accepted

HYPOTHESIS: That a set of guidelines for informing care of people with dementia can be developed from the results of the RUDAS TOOL

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Review

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References

• Agostinelli B, Demers K, Garrigan D, Waszynski C (1994) Targeted Interventions Use of the Min-Mental State Exam.

Journal of Gerontological Nursing

• Bird M, Llewellyn-Jones R, Smithers H, Korten A. (2002) Psychosocial Approaches to Challenging Behaviour in

Dementia: A controlled trial. Department of Health and Ageing: Canberra.

• Department of Health (2006a) Guidelines for Working with People with Challenging Behaviours in Residential Aged

Care Facilities: Using appropriate interventions and minimising restraint. NSW DoH: Sydney.

• Department of Health and Ageing (2000) Psychogeriatric Care Units Program Operational Guidelines. DoHA:

Canberra.

• Folstein M, Folstein S, McHugh P (1975) Mini-Mental State A practical method for grading cognitive state of patients

for the clinician Journal of Psychiatric Research, 12: 189-198.

• Storey J, Rowland J, Conforti D, Dickson H (2004) The Rowland Universal Dementia Assessment Scale (RUDAS): a

multicultural cognitive assessment scale. Journal of International Psychogeriatrics 16:13-31

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