Managing behaviours that challenge in dementia

Charlotte Mallon, Janet Krska & Shivaun GammieViews and experiences of care home staff on managing behaviours that challenge in dementia: a national survey in England, Aging & Mental Health | 2019 Vol 23: no.6  p698-705

Aim: To determine the views of care home (CH) staff in relation to experiencing and managing behaviour that challenges (BtC) in dementia and their experiences of training.

Method: Cross-sectional survey using a self-report questionnaire, distributed to staff employed in a 20% sample of all registered dementia-specialist CHs in England, either by postal or direct distribution.

Results: Questionnaires were returned from 352 care staff (25%), representing 5% of all dementia-specialist CHs, half were CH without nursing. Respondents estimated caring for 14,585 residents, 9,361 with dementia and 5,258 with BtC. 30.2% of residents with dementia were estimated as being prescribed a medicine to control BtC. BtC reported as experienced by most respondents were: shouting (96.6%), verbal aggression (96.3%) and physical aggression (95.7%), with physical aggression viewed as most difficult to manage. Top behaviours experienced every shift were: wandering (77.8%), perseveration (68.2%) and restlessness (68.2%).

Approaches such as assessing residents, knowing them and treating them as individuals, identifying triggers, having time for them and using an appropriate style of communication, were viewed as key to managing BtC, rather than guideline-specific interventions such as massage, aromatherapy and animal-assisted therapy.

Only 38% agreed/strongly agreed medicines were useful to control BtC, which was related to the extent to which they were prescribed. Training was available, but variable in quality with on-line training being least useful and on-the job training most desirable.

Conclusion: BtC are commonly and frequently experienced by care staff, who consider individual approaches, having time and good communication are key to successful management.

Full detail at Aging & Mental Health

Reducing anxiety, agitation, and aggression in older people with dementia

Wendy Moyle et al. | Can lifelike baby dolls reduce symptoms of anxiety, agitation, or aggression for people with dementia in long-term care? Findings from a pilot randomised controlled trial | Aging & Mental Health | Published online: 24 November 2018

Abstract
Objectives: To compare a lifelike baby doll intervention for reducing anxiety, agitation, and aggression in older people with dementia in long-term care (LTC), with usual facility care; and explore the perceptions of care staff about doll therapy.

Method: Pilot, mixed-methods, parallel, randomised controlled trial, with follow-up semi-structured interviews. Thirty-five residents from five LTC facilities in Queensland, Australia were randomised to the lifelike baby doll intervention (three, 30-minute, individual, non-facilitated sessions per week) or usual care. Outcomes were changes in levels of anxiety, agitation, and aggression after the 3-week intervention, and short-term effects at week 1. Following intention-to-treat principles, repeated measure MANOVA was undertaken. Qualitative interviews involved five staff.

Results: The doll intervention did not significantly reduce residents’ anxiety, agitation, or aggression when compared to usual care at weeks 3 (primary outcome) and 1 (secondary outcome). However, there was a significant group-by-time interaction for the outcome of pleasure – the doll group showed a greater increase in displays of pleasure at week 3 compared to baseline than usual care. Staff perceived benefits for residents included emotional comfort, a calming effect, and providing a purposeful activity. Perceived limitations were that doll therapy may only be suitable for some individuals, some of the time, and the potential for residents to care for the doll at the expense of their health.

Conclusions: Doll therapy can provide some residents with enjoyment and purposeful engagement. Further research should focus on understanding the individual characteristics and circumstances in which residents most benefit.

Full abstract available here

Management of behavioral and psychological symptoms in people with Alzheimer’s disease

Kales, H. et al. | Management of behavioral and psychological symptoms in people with Alzheimer’s disease: an international Delphi consensus | Published online: August 2018

Objectives:
Behavioral and psychological symptoms of dementia (BPSD) are nearly universal in dementia, a condition occurring in more than 40 million people worldwide. BPSD present a considerable treatment challenge for prescribers and healthcare professionals. Our purpose was to prioritize existing and emerging treatments for BPSD in Alzheimer’s disease (AD) overall, as well as specifically for agitation and psychosis.

Design:
International Delphi consensus process. Two rounds of feedback were conducted, followed by an in-person meeting to ratify the outcome of the electronic process.

Settings:
2015 International Psychogeriatric Association meeting.

Participants:
Expert panel comprised of 11 international members with clinical and research expertise in BPSD management.

Results:
Consensus outcomes showed a clear preference for an escalating approach to the management of BPSD in AD commencing with the identification of underlying causes. For BPSD overall and for agitation, caregiver training, environmental adaptations, person-centered care, and tailored activities were identified as first-line approaches prior to any pharmacologic approaches. If pharmacologic strategies were needed, citalopram and analgesia were prioritized ahead of antipsychotics. In contrast, for psychosis, pharmacologic options, and in particular, risperidone, were prioritized following the assessment of underlying causes. Two tailored non-drug approaches (DICE and music therapy) were agreed upon as the most promising non-pharmacologic treatment approaches for BPSD overall and agitation, with dextromethorphan/quinidine as a promising potential pharmacologic candidate for agitation. Regarding future treatments for psychosis, the greatest priority was placed on pimavanserin.

Conclusions:
This international consensus panel provided clear suggestions for potential refinement of current treatment criteria and prioritization of emerging therapies.

New dementia briefing suggests that behaviour that challenges can be a result of unmet needs

British Psychological Society |June 2018 | New dementia briefing suggests that behaviour that challenges can be a result of unmet needs 21 June 2018

The British Psychological Society  have recently published an evidence briefing which outlines the importance of having a psychological understanding of the complex causes of behaviour that challenges in dementia.

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The key messages of the briefing, prepared by the Society’s Dementia Advisory Group, include:

  • Behaviour that challenges can be a consequence of a person’s unmet needs
  • Non-pharmacological approaches are the first-line treatments
  • Service pathways for people living at home require different workforce skills and resources compared with those living in 24 hour care settingsThe evidence briefing can be read in full here 

The views of care home staff in relation to experiencing and managing behaviour that challenges in dementia

Aim: To determine the views of care home (CH) staff in relation to experiencing and managing behaviour that challenges (BtC) in dementia and their experiences of training.

Method: Cross-sectional survey using a self-report questionnaire, distributed to staff employed in a 20% sample of all registered dementia-specialist CHs in England, either by postal or direct distribution.

Results: Questionnaires were returned from 352 care staff (25%), representing 5% of all dementia-specialist CHs, half were CH without nursing. Respondents estimated caring for 14,585 residents, 9,361 with dementia and 5,258 with BtC. 30.2% of residents with dementia were estimated as being prescribed a medicine to control BtC. BtC reported as experienced by most respondents were: shouting (96.6%), verbal aggression (96.3%) and physical aggression (95.7%), with physical aggression viewed as most difficult to manage. Top behaviours experienced every shift were: wandering (77.8%), perseveration (68.2%) and restlessness (68.2%).

Approaches such as assessing residents, knowing them and treating them as individuals, identifying triggers, having time for them and using an appropriate style of communication, were viewed as key to managing BtC, rather than guideline-specific interventions such as massage, aromatherapy and animal-assisted therapy.

Only 38% agreed/strongly agreed medicines were useful to control BtC, which was related to the extent to which they were prescribed. Training was available, but variable in quality with on-line training being least useful and on-the job training most desirable.

Conclusion: BtC are commonly and frequently experienced by care staff, who consider individual approaches, having time and good communication are key to successful management.

Full reference:
Charlotte Mallon, Janet Krska & Shivaun Gammie | 2018 | Views and experiences of care home staff on managing behaviours that challenge in dementia: a national survey in England |  Aging & Mental Health |  Published online: 25 May 2018

Case managers improve outcomes for people with dementia and their carers

Review supports the role of professional case managers by showing improvements in patient behaviour and caregiver burden | BMC Health Services Research | via National Institute for Health Research

Using a case manager to coordinate health and social care improves the challenging behaviour of people with dementia and reduces the burden on caregivers. Quality of life of caregivers improves the most when case managers have a professional background in nursing.

This NIHR-funded review compared the effectiveness of standard community treatment and interventions with case managers overseeing the interventions for people living with dementia. It considered evidence from 14 trials in a number of countries, with different health systems and support. Care coordination is variable across the UK, but this is often not provided by a qualified professional, so they are not able to develop and update the care plan.

Though the review did not provide strong evidence of effectiveness regarding hospitalisation or death, it does highlight the benefits of having a care coordinator with a background in nursing for improving quality of life.

Further detail at National Institute for Health Research

Full reference: Backhouse, A et al. | The effectiveness of community-based coordinating interventions in dementia care: a meta-analysis and subgroup analysis of intervention components |BMC Health Services Research |  Volume 17 , 2017

 

Challenging behaviour, BPSD and stress and distress

Challenging behaviour, BPSD and stress and distress: Potato, Po-ta-toe? | Perry, W. | The Dementia Services Development Centre

In this article, Wendy Perry discusses the use of the term ‘challenging behaviour‘ in reference to people living with dementia. This, she explains, places the emphasis on the behaviour of the person without taking into account the bigger picture. Equally the use of Behavioural and Psychological Symptoms of Dementia (BPSD) makes it appear as though behaviour changes are a) a recognised symptom of dementia and b) unavoidable.

The Dementia Services Development Centre instead recommend using the term ‘stress and distress’, because most changes in behaviour are caused by heightened levels of stress for the person living with dementia.

Full blog: Challenging behaviour, BPSD and stress and distress: Potato, Po-ta-toe?