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Leading Age CEU Application
Title of Program: Behavioral Expressions: A New Approach to Behaviors in Dementia
Date of Program: November 12, 2015
Time/Duration of Program: 1hour webinar, 9:30-10:30 am, with one half hour Q&A to follow.
Instructor Qualifications: Cordula Dick-Muehlke, Ph.D., is a licensed clinical psychologist with 30 years of
experience in working with older adults. She received her doctorate in clinical psychology from Fuller
Graduate School of Psychology in 1993. Please see the attached curriculum vitae for more information.
Description of Course: Show how course directly relates to either the business operations or the care
of residents in the facility.
Recent research has shown that 7 out of 10 residents in residential care (e.g., assisted living, board and
care homes) are cognitively impaired.1 Of the 522,990 individuals in this study, 28% were cognitively
normal, 29% were mildly impaired, 23% moderately impaired, and 19% severely impaired. Similarly,
64% of Medicare beneficiaries living in a skilled nursing facility are cognitively impaired.2 A major and
worsening feature of dementia is the change in behavior that affected individuals experience.
Behavioral and psychological changes, predominantly apathy and depression, emerge in the prodromal
stage of dementia, known as mild cognitive impairment, and evolve to include symptoms such as
agitation, anxiety, aggressiveness and wandering as memory and thinking abilities decline. Behavioral
changes are a significant precipitant for placement, hence providers must be prepared to effectively
respond to these changes using non-pharmacological approaches that eliminate or minimize the use of
psychotropic medications. Rather than approaching behavioral changes in dementia as problems,
troublesome, or challenging, new approaches to dementia care conceptualize behaviors as expressions3,
emphasizing their communicative aspect and using tools such as the DICE approach4 to untangle their
meaning and respond appropriately. The course is designed to empower attendees with both
knowledge and tools to more effectively and compassionately respond to behaviors.
III. Objective of Course: What is the student expected to know upon completion of this course?
As a result of participating in this course, attendees will be able to
a. Identify at least two reasons why psychotropic medications should be a last option in
addressing dementia-related behavioral changes. See (4)(a)(i-iii) below.
b. Identify at least two possible medical, cognitive, psychological, and environmental triggers
(i.e., a total of eight) for dementia-related behaviors. See (5)(b)(i)(1)(a)(i-iv) below.
c. Apply the IDEA “response-finding” approach to identify the triggers and meaning of
behaviors. See (5)(b)(ii)(1-3) below.
IV. Teaching Methods: Explain the types of teaching methods to be used.
This presentation will include a lecture using PowerPoint slides, followed by an interactive discussion
about the development, progression, and symptoms of Alzheimer’s disease. A handout of the PPT
presentation will also be provided to all webinar participants.
V. Course Content: Hour-by-hour detail of course outline, including instructor for each segment.
Leading Age CEU Application
Presenter for entire session: Dr. Cordula Dick-Muehlke
Section I – Responding to Behavior Changes: A Major Challenge in Long-Term Care (10 minutes)
(1) Defining terms: dementia, mild cognitive impairment, Alzheimer’s disease
(2) Importance of building dementia care capacity in long-term care
a. 7 of 10 residents in assisted living are cognitively impaired1
i. Of the 522,990 individuals in the 2010 National Survey of Residential Care
Facilities, 28% were cognitively normal, 29% were mildly impaired, 23%
moderately impaired, and 19% severely impaired
ii. 64% of Medicare beneficiaries living in a skilled nursing facility are cognitively
impaired3
b. Behavioral changes as a significant precipitator for placement5 and are common among
long-term care residents
i. 38% of assisted living residents display behavioral symptoms6
ii. 74% of nursing home residents exhibit behavioral symptoms7
Section II – Evolution of Behavioral Changes across the Course of Dementia (15 minutes)
(3) Prevalence of behavioral changes in dementia
a. Ranges from 10%-76% depending on the behavior8,9
i. Not all individuals experience all behaviors
b. Typical course of behavioral changes in dementia10
i. Mild stage characterized by apathy and depression
ii. Moderate stage includes symptoms such as agitation, anxiety, aggressiveness,
delusions and wandering
iii. Severe stage characterized by increasing passivity with an easing of behavioral
symptoms as person moves closer to the end of life
c. Behavioral and personality changes first emerge in MCI11,12
i. Most common symptoms include apathy, depression, anxiety, and irritability
d. Behavioral changes have multiple negative consequences13
i. Interfere with performing activities of daily living
ii. Increase risk of fall, injury, and mortality
iii. Increase overall, cost of care, requiring more physician visits, more medications,
frequent visits to the emerge room, and temporary hospitalizations
iv. Decrease quality of life for the individuals and caregivers
v. Increase caregiver stress and depression
Section III – Psychotropic Medications are NOT the Answer (15 minutes)
(4) Limitations of psychotropic medications
a. Currently, drugs effective for treating symptoms in mental health disorders (e.g.,
schizophrenia, mania, depression) are “borrowed” for use in dementia
i. Benzodiazepines (e.g., Xanax, Valium, Ativan, Halcion)14
1. Should never be used in dementia as they increase risk for falls, cause
confusion, and worsen cognitive impairment
ii. Antidepressants
1. Are no more effective than placebo for treating mild depression in
dementia and result in more side effects (e.g., increased risk for
falls)15,16
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iii. Antipsychotic medications (typical and atypical)
1. None are specifically approved by the FDA for the dementia
2. Multiple side effects include extrapyramidal symptoms, increased risk
for death, further cognitive impairment and neuroleptic sensitive
(specific to Dementia with Lewy bodies)17,18
3. Why antipsychotics don’t work in dementia
a. Psychosis in dementia is very different from psychosis in
schizophrenia
i. Delusions in schizophrenia are bizarre and complex, but
in dementia are simple and memory-dependent (e.g.,
someone stole my purse)
ii. Hallucinations are typically auditory (e.g., God speaking
to me) in schizophrenia vs. visual (e.g., seeing a
deceased parent) in dementia
4. Despite risks, use of antipsychotics is high in assisted living and skilled
nursing facilities1,19
5. Use of antipsychotics should be limited
a. Schneider et al.,20 who investigated the use of antipsychotics for
psychosis, agitation, or aggression, concluded, “Although the
atypical antipsychotic drugs were more effective than placebo,
adverse effects limited their overall effectiveness, and their use
may be restricted to AD patients who have few or no side
effects and for whom benefits can be discerned.”
b. If use is necessary do so only after trying non-pharmacological
strategies
i. Start with a low dose and titrate upwards slowly
ii. Use the lowest effective dose
iii. Withdraw after an appropriate period and observe for
relapse
Section IV – Person-Centered Non-Pharmacological Approaches to Address Behavioral Changes (25
minutes)
(5) First line response to behaviors should be person-centered and non-pharmacological (Note:
Case examples will be integrated into this part of the lecture.)
a. Starts with changing our language and attitude
i. The transition from thinking about behaviors as problems, troublesome and
challenging to viewing them as expressions, that is, communication
b. Involves using “respond-finding” rather than “problem-solving” approaches to translate
the language of the behavior
i. STOP decision-making tree
1. Stop before you act to consider the physical, cognitive, psychological,
and environmental factors
a. Avoid automatically “blaming” the behavior on the dementia
i. First rule out medical causes
1. Over a third of behaviors can be traced back to
unrecognized medical causes (e.g., constipation,
dehydration, medication interactions/side
effects/polypharmacy)21,22
Leading Age CEU Application
2. Watch for delirium, an acute confusional state
that can present as hyperactive, hypoactive, or
mixed
ii. Consider cognitive issues (e.g., difficulty comprehending
instructions or communicating needs, shortened
attention span, inability to recognize a caregiver )
iii. Consider psychological issues (e.g., depression, fear,
loneliness)
iv. Consider environmental issues (e.g., clutter, noise,
distractions)
b. Develop a response based on the underlying cause
c. Evaluate and adjust
ii. The IDEA “response-finding” approach
1. ID = Identify
a. Describe the behavior as if in a movie (e.g., who, when, where)
2. E = Educate
a. About the possible causes/triggers (as described immediately
for the STOP decision-making tree)
b. About the meaning
i. What is the person saying?
3. A = Adapt
a. Adapt your behavior or communication to elicit a different way
of behaving from the person
b. Be person-centered
i. Use what you know about the person’s history,
interests, and preferences to develop a tailored,
effective response to the behavior
iii. Case examples using the IDEA approach
1. My husband is having an affair
2. She bit me and I was only trying to help her
3. I’ve got to leave now
Section V – Taking a Proactive, Not Just Reactive Approach to Behavioral Changes (10 minutes)
(6) What if we could create the ideal person-centered care environment in which behaviors were
least likely to occur?
a. A model of well-being in dementia to base care on developed by Dr. G. Allen Power3
comprised of the following domains
i. Identity
ii. Connectedness
iii. Security
iv. Autonomy
v. Meaning
vi. Growth
vii. Joy
b. A final challenge to the audience: If behavioral expressions are a way of people with
dementia communicating unmet needs in these domains, what can you do in your care
environments to proactively meet the needs and eliminate or reduce distressing
behavioral expressions?
Leading Age CEU Application
i. Implement key aspects of person-centered care, by creating a culture that23
1. Values the individual (i.e., affirming personhood despite disease or
disability)
2. Uses an individualized approach (i.e., integrating the person’s biography
and preferences into the care plan)
3. Considers the person’s perspective (e.g., in understanding and
responding to behaviors, providing activities well-suited to the
individual)
4. Offers a supportive social/psychological environment (e.g., using lifeaffirming communication strategies that take into consideration the
person’s changing abilities)
Section VI: Question & Answer/Dialogue with the Speaker (15 minutes)
V. Address and/or Geographic Area Where the Course Will Be Presented: Webinar
VI. Method of Course Evaluation by Participants (explain how participants will evaluate the course):
Evaluation form
VII. Method of Evaluating Participants: No evaluation of participants.
VIII. Types of Records to be Maintained and Address Where Records are maintained: Record of
attendance and evaluations are maintained at Aging Services of California, 1315 I Street, Suite 100,
Sacramento, CA 95814
1
Zimmerman, C., et al. (2014). Health Affairs, 33, 658-66
Alzheimer’s Association (2014). Alzheimer’s Disease Facts and Figures. Available online at
http://www.alz.org/downloads/facts_figures_2014.pdf
3
Power, G. A. (2014). Dementia beyond disease: Enhancing well-being. Baltimore: Health Professions Press.
4
Kales, H. C., et al. (2014). Journal of the American Geriatrics Society, 62, 762-69
5
Gaugler, J.E. (2009). Medical Care, 47, 191-98
6
Zimmerman, C., et al. (2014).Health Affairs, 33, 658-66
7
Selbaek, G., et al. (2007). International Journal of Geriatric Psychiatry, 22, 843-9
8
Gauthier et al. (2010). International Psychogeriatrics, 22, 346-372
9
Landes et al. (2005). Journal of Neuropsychiatry and Clinical Neuroscience, 17, 342-349
10
Jost et al. (1996). Journal of the American Geriatrics Society, 44, 1078-1081
11
Teng, E., et al. (2007). Dementia and Geriatric Cognitive Disorders, 24, 253-9
12
Apostolova, L. & Cummings, J. (2008). Dementia and Geriatric Cognitive Disorders, 25, 1597-612
13
As summarized in Kales, H. C., et al. (2014). Journal of the American Geriatrics Society, 62, 762-769
14
California Guidelines for Alzheimer’s Disease Management, 2008
15
Banerjee , S., et al. (2011). Lancet, 378, 403-11
16
Rosenberg , P. B., et al. (2010). American Journal of Psychiatry, 18, 136-145
17
Schneider, L., et al. (2005). Journal of the American Medical Association, 294, 1934-43
18
Vigen, et al. (2006). American Journal of Psychiatry, AiA, 1-9
19
Chen, Y., et al. (2010). Archives of Internal Medicine, 170, 89-95
20
Schneider et al. (2006). New England Journal of Medicine, 3555, 1525-38
21
Woo et al. (2003). Journal of Geriatric Psychiatry and Neurology, 16, 121-25
22
Hodgson et al. (2011). Alzheimer Disease and Associated Disorders, 25, 109-115
23
Booker, D. (2007). Person-centered dementia care: Making services better. London: Jessica Kingsley Publishers.
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