Dementia Conference 2014Guildford & Waverley Clinical Commissioning Group

Dr. Lia AliConsultant Psychiatrist to G&W Virtual Ward

What do people with advanced dementia live with?

Aggression• Physical aggression

• Verbal Aggression• Aggressive resistance to care

Agitation/Motor• Wandering• Restlessness• Sleep disturbance• Repetitive actions• Screaming

Apathy• Withdrawn• Lack of interest• Amotivation

Depression• Sad • Tearful• Hopeless• Guilty• Anxiety

Psychosis• Hallucinations

• Delusions• Misidentification

Behavioural & Psychiatric Symptoms (BPSD)

Differing dementias

Alzheimer’s diseaseApathy, agitation, irritability, anxiety, depression, (delusions & hallucinations are less common)

Vascular dementiaApathy, depression, delusions, emotional lability

Corticobasal degenerationDepression

Dementia with Lewy bodies & Dementia in Parkinson’s diseaseVisual hallucinations, delusions, depression, sleep disturbance (REM sleep-behaviour disorder)

Progressive supranuclear palsyApathy, disinhibition

McKeith & Cummings 2005

Causes of BPSD

Cognitivefactors

Biologicalfactors

Psychologicalfactors

Socialfactors

- Neuroanatomy- Neurochemistry- Genetics

Physicalfactors

Causes of BPSD

Cognitivefactors

Biologicalfactors

Psychologicalfactors

Socialfactors

Physicalfactors

- Amnesia- Agnosia- Apraxia- Aphasia- Visuoperceptual- Executive

function

Causes of BPSD

Cognitivefactors

Biologicalfactors

Psychologicalfactors

Socialfactors

Physicalfactors

- Illness- Delirium- Pain- Medication- Fatigue- Constipation- Basic needs

(dietary, toiletry)

Causes of BPSD

Cognitivefactors

Biologicalfactors

Psychologicalfactors

Socialfactors

- Social network- Family

relationshipsSocial interactions (caregivers, residents)

Physicalfactors

Causes of BPSD

Cognitivefactors

Biologicalfactors

Psychologicalfactors

Socialfactors

- Premorbid personality- Previous

mental health- Previous

trauma/losses- Adjustment- Lifelong

coping strategies

Physicalfactors

Causes of BPSD

Cognitivefactors

Psychologicalfactors

Socialfactors

Physicalfactors

EnvironmentBiological

factors

• Prevalence of BPSD varies at different stages of the disease process

Earlier:• Depression• Anxiety• Psychosis

Later:• Agitation• Wanderin

g• Apathy

Behavioural disturbance

Cognition

Sev

erity

Time

BPSD: persistent throughout disease course

Passiveness

Lovheim et al., (2008)

ABC chartABC Chart for Mr X

Please record ALL incidents of aggressive or inappropriate behaviour as this will help us to devise the most effective strategies for managing his behaviour.

AntecedentsAntecedents consist of both the setting conditions (which increase the likelihood of a behaviour occurring) and the immediate triggers to the behaviour.Setting conditionsHow was the person feeling before the behaviour? e.g. feeling low in mood, tired, ill, in pain, bored, etc.TriggersWhat was happening before the incident? e.g. he was being washed, being asked to transfer out of bed, being asked what he wanted for lunch, pad was being changed, he was being asked something, etc.Where did it happen? e.g. in the person’s room, in the community, etc.Who was involved?

BehaviourGive as full a description as possible of what the person was doing, including physical aspects (e.g. hitting, throwing, being sexually disinhibited) and verbal aspects (e.g. shouting, swearing). Record what the person actually said.How long did the behaviour last for?How severe or intense was the behaviour?

ConsequencesWhat happened as a result of the behaviour?What did you do to try and manage the behaviour?How well did that work?What was the behaviour of the person like after the incident?

SETTING CONDITIONS TRIGGERS

Mr X reported that he had been feeling tired as he hadn’t slept well last night due to pain, and was continuing to experience pain.

Mr X was being washed and having his pad changed in his bedroom by myself and another HCA, Jon.

Mr X became angry, shouted that he wanted us to go, swore at us and then threw a cloth at us. He remained agitated for 10 minutes.

We stopped the activity and gave Mr X time to calm down. We then explained why we needed to wash him. We explained that he should tell us when the pain was too much for him and we would stop for a break. He calmed down and agreed to be washed. We explained what we would be doing at each step and checked his pain levels during it, stopping for a break when it was too much.

Management – other non-pharmacological

Treat the underlying cause

Aromatherapy (Ballard, lemon balm)

Multisensory stimulation

Therapeutic use of music and/or dancing

Animal-assisted therapy

Massage

Signage

The evidence suggests for Agitation in AD

If you have to prescribe a drug….

Risperidone 0.5mg bd for 6/52

Less evidence for alternative antipsychotics

Quetiapine – evidence of non-efficacy

Cholinesterase inhibitors and memantine – not effective acutely or in prophylaxis

So in conclusion – courtesy of Prof HowardWhat to do

Cholinesterase inhibitors and, to a lesser extent, memantine offer modest symptomatic benefits for cognitive symptoms at all stages

Try to avoid drug treatments for behavioural symptoms and only use the licensed agent

What not to do

Don’t raise unrealistic expectations about the impact of symptomatic cognitive treatment

Benzodiazepines generally make people with dementia worse

The fewer psychotropics the better

Want to know more?IMPARTS Course

Mental health skills for non-mental health professionalsdistressed patients; confusion/dementia; substance misuse; medically unexplained symptoms; managing conflict.29/01/2014 and 26/02/2014 with additional e-learning

Lia.ali@kcl.ac.uk

MSc in Advanced Care in Dementiamscacid@kcl.ac.uk