Download The effect of a lollipop on vocally disruptive behavior

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International Psychogeriatrics: page 1 of 4 doi:10.1017/S1041610214000866
CASE REPORT
The effect of a lollipop on vocally disruptive behavior in a
patient with frontotemporal dementia: a case-study
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W. F. Fick,1 J. P. van der Borgh,1 S. Jansen1 and R. T. C. M. Koopmans1,2
1
2
De Waalboog “Joachim en Anna”, Centre for Specialized Geriatric Care, Nijmegen, the Netherlands
Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre,
Nijmegen, the Netherlands
ABSTRACT
A problematic and disturbing behavior which can develop in people with dementia, is vocally disruptive
behavior (VDB). To date, the study of VDB is underdeveloped and with only a limited knowledge base.
Medications commonly used in VDB have limited benefits and specific risks in patients with dementia. This
report details the case of a patient with frontotemporal dementia with VDB, which responded very well by
providing a lollipop. Subsequently, we pose theory-based hypotheses in order to try to explain the beneficial
effect of this intervention. This may contribute to a better understanding of VDB and possible treatment
strategies.
Key words: young onset dementia, frontotemporal dementia, agitation, behavioral and psychological symptoms of dementia (BPSD)
Introduction
Frontotemporal lobar degeneration (FTLD) refers
to a heterogeneous group of clinical syndromes
associated with atrophy of the frontal and temporal
lobe. The behavioral variant of frontotemporal
dementia (FTD) is the most common subtype,
which predominantly presents with progressive
behavioral features (Neary et al., 1998). FTD is
presented by slow progressive loss of personal
and social awareness, disinhibition, mental rigidity,
stereotyped behavior, impulsivity and distractibility
(Neary et al., 1998). One of the problematic
behaviors which can develop from these features,
are repetitive and compulsive vocally disruptive
behaviors (VDB), such as screaming, shouting,
abusive language, perseveration and repetitive
inappropriate requests. The descriptions of these
behaviors are variable in type, intensity, causes and
consequences. Therefore definitions are debatable.
The prevalence of VDB varies between 10 to
40 percent in nursing home patients with dementia
in general (Cariaga et al., 1991; Whall et al., 1992;
Cohen-Mansfield et al., 2003). VDB can occur in a
variety of dementia types (Cohen-Mansfield et al.,
2003), and is possibly related to frontal or frontoCorrespondence should be addressed to: Dr. W. F. Fick, Eldery Care
Physician, De Waalboog “Joachim en Anna”, Centre for Specialized Geriatric
Care, Groesbeekseweg 327, 6523 PA Nijmegen, the Netherlands. Phone:
+31 243228264; Fax: +31 24 3230076. Email: [email protected].
Received 24 Sep 2013; revision requested 16 Dec 2013; revised version
received 20 Mar 2014; accepted 13 Apr 2014.
subcortical dysfunction (Nagaratnam et al., 2003).
Yet, it remains unclear whether or not the type of
dementia predicts the frequency and type of VDB
(von Gunten et al., 2008). There is no literature of
the association of VDB and FTD.
Despite the limited research on the occurrence
of VDB, it is important to realize the severity
and impact of the related behavior. Vocal activities
producing excessive noise have been found to cause
severe emotional distress for caregivers and other
residents (Whall et al., 1992). Moreover, nursing
staff expressed significantly more frustration,
anxiety and anger towards patients with VDB and
even distanced themselves from them (Draper et al.,
2000). Therefore, it is important to understand this
phenomenon and find solutions for the treatment
and alleviation. The management of VDB requires
a good understanding of the underlying factors that
may trigger the behavior. Unfortunately, aetiologies
and explanations for the occurrence of VDB still
need to be established. Yet, Lai (1999) and Von
Gunten et al. (2008) pose some comprehensive
theories in their literature review. First, VDB
has been hypothesized to be a consequence of
the neurological damage associated with dementia
syndromes such as Alzheimer’s disease, vascular
dementia or FTD. The degenerative changes
in frontal and temporal lobes lead to loss
of inhibition, which could be related to vocal
compulsivity (Nagaratnam et al., 2003). Second,
VDB has been hypothesized to be an expression
of physical discomfort or mental suffering (Cariaga
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W. F. Fick et al.
et al., 1991). Furthermore, patients with impaired
communication skills manifested VDB at a greater
frequency than those with preserved language
(Matteau et al., 2003). Third, the occurrence of
vocal activity could be related to sensory deprivation
and social isolation (McMinn and Draper, 2005).
Vocal activity may provide a source of selfstimulation to compensate for the low sensory input
in nursing homes (Cariaga et al., 1991). Finally,
VDB is assumed to be a method used to gain
attention from staff and other residents. It may
be attributed to specific unmet needs, such as a
need to be fed, to be brought to the toilet or to be
taken out of bed. Together with increasing cognitive
decline the verbal behaviors become less textual and
less related to specific needs (Cohen-Mansfield and
Werner, 1997).
Examples of behavioral and environmental
strategies commonly used to manage VDB are
music therapy, positive reinforcement during quiet
periods, multi-sensory therapy, one-to-one social
interaction and treatment of underlying conditions
such as pain and physical discomfort (CohenMansfield and Werner, 1997; Lai, 1999; von
Gunten et al., 2008). Yet, most important is the
individualization of interventions for treating VDB,
where some interventions are probably better suited
to certain individuals than others (Cohen-Mansfield
et al., 2007).
Case report
We present here a case history of a male patient that
was admitted in 2009 on a Young Onset Dementia
Special Care unit of a nursing home at the age
of 63 year. His medical history mentioned gout,
a low-grade non-Hodgkin’s lymphoma and chronic
obstructive pulmonary disease that gives no current
complaints. He consumed 5–10 units of alcohol
per day during approximately 40 years. From
2007 onwards, he gradually developed agitated
behavior and aggression towards family, showed
a poor insight and awareness in his functional
deficits, developed aphasia and showed obsessive,
compulsive features. For instance, he destroyed
several printers at his workplace, because he thought
they didn’t function properly. Also, when his
grandchildren visited him, he desperately wanted
the same candy like them. These behavioral
changes led to high caregiver burden with a forced
institutionalization in 2009 on a psychiatric ward
as a result. Considering the current consensus
criteria for behavioral variant of FTD (Rascovsky
et al., 2011), he showed several core diagnostic
features to meet the criteria for possible behavioral
variant of FTD. The present symptoms were early
behavioral disinhibition, early loss of empathy, early
perseverative stereotyped behavior, hyperorality
and executive deficits with relative sparing of
memory and visuospatial functions. His Frontal
Assessment Battery (FAB) (Dubois et al., 2000)
was 14/18 and his Mini-Mental State Examination
(MMSE) 30/30. Differential diagnosis consisted of
an alcohol-induced persisting dementia (DSM-IV
291.2) and possible FTD. They advised to transfer
him to a rehabilitation ward of an alcohol clinic.
Subsequently, fluorodeoxyglucose positron
emission tomography (FDG-PET) showed
frontotemporal and cerebellar hypometabolism.
Tau protein level in cerebrospinal fluid was
442 ng/l (N < 350 ng/l). The abnormal FDG-PET
scan in the context of the patient’s clinical picture
and significant functional decline, eventually
supported a diagnosis of probable FTD (Rascovsky
et al, 2011). Brain-MRI was not available.
In October 2009 he was admitted to the general
observational unit of a nursing home, because the
caregivers were not able to provide home care.
In the first six weeks of admission he escaped
almost daily by various inventive manners, despite
the locked doors. He walked back home and was
aggressive to his wife and family. Given these
behavioral problems the psychologist advised a
structured day program consisting of daily visits
to the day-care center were activities were offered,
participation in walking activities a couple times
a week and all of this combined with moments
of rest in his own room. Furthermore, supportive
medication was started with 50 mg of trazodone.
After three months he cognitively declined, he
showed an increasing loss of interest, his ability
to speech limited (he answered all questions with
“okay”) and he got more and more disoriented
especially in recognizing people. His attempts to
escape disappeared. Furthermore, an increase of
disinhibition was noticed, which was expressed
by eating behavior, inappropriate helpfulness to
other clients, and constantly opening water valves.
Trazodone dose was raised to 150 mg, and
further psychosocial interventions were applied
like provision of tactile stimulation and stimulus
reduction by bringing him more often to his
own room. Unfortunately, these measures did not
result in a positive effect. His behavioral problems
steadily increased, which also led to extended
social deprivation. He walked with his hands on
the walls until they bleed, he smeared with feces,
and he started to make repetitious noises and
vocalizations. At this time he was transferred from
the observational unit to a Young Onset Dementia
Special Care unit. We intensified the stimulus
reduction, which resulted in a small improvement of
his VDB. However, the VDB remained difficult to
Vocally disruptive behavior: a case-study
handle. It only decreased by bringing him to his own
room, which resulted in further social deprivation.
One of members of the nursing staff had the
idea of trying a lollipop to reduce the VDB.
She was inspired by the idea of calming a child
by using a pacifier. Surprisingly, this intervention
was effective. The VDB obviously decreased and
there was even a slight improvement in social
engagement. The reduction of VDB was recorded
by clinical observations. At the moments he used
the lollipop he relaxed, mostly sat down in a chair
and sometimes closed his eyes. Physically/motor
agitation decreased, his inner need to walk
diminished and he stopped making repetitious
noises and vocalizations. It took him about one hour
to finish the lollipop and he used eight lollipops
a day on average. After the lollipop was finished
the physically/motor agitation and VDB returned
almost immediately. In this way the lollipop was
daily effective during eight months, until six weeks
before he died. These last weeks of his life his
physical condition seriously decreased.
3
hypothesis might be in our view the most obvious
explanation of the effect of the lollipop on VDB.
Yet, we must note that the diagnosis of FTD in this
case is only mediocrely supported by the performed
diagnostic tools.
With this case report we want to emphasize the
benefits of creative thinking in overcoming the great
challenges in dementia care. In this patient, the use
of a lollipop was associated with a marked decrease
in VDB. We have posed various theories, which
could explain the effect of the lollipop. In this way
we want to build a knowledge base in order to
understand VDB and its treatments. However, we
also want to point at several potential disadvantages
of the lollipop that should be considered, such
as dental caries, the risk of choking and diabetec
hyperglycemia. The overall efficiency and safety of
using a lollipop need to be further established.
Conflict of interest
None.
Discussion
In this patient with probable FTD, the use
of a lollipop was associated with a reduction
of VDB. Using a lollipop involves multimodal
processes, such as oral motor functions, tasting
of sweetness, olfaction, and intake of sucrose. We
pose under various theory-based hypotheses, which
could explain the successful effect of the lollipop.
Okamoto et al. (2009) found that during tongue
movements and the act of tasting the (ventro)
lateral prefrontal cortex is significantly activated
. This area of the brain may play an important
role in response inhibition (Walther et al., 2010).
Subsequently, this theory suggests that tongue
movements and tasting may be involved in the
capacity to suppress inappropriate actions, such
as VDB. The effect of the lollipop can also be
contributed to the result of tasting sweetness and
absorption of sucrose. First of all, altered food
preference toward sweet foods is a prominent and
early feature in FTD (Miller et al., 1995). Ikeda et al.
(2002) hypothesise that changes in eating behaviors,
including preference toward sweet foods, reflect the
involvement of a common network of the frontal
lobe, temporal lobe, and the amygdala. Finally,
using a lollipop and being vocally active at the same
time requires dual-tasking. Dual tasking refers to
the ability to allocate attention between two tasks
performed simultaniously. Impaired dual-tasking is
increasingly recognized as a marker of executive
dysfunction and increased distractabilty, which is
frequently seen in FTD (Allali et al., 2007). This
Description of authors’ roles
S. Jansen tried out the intervention in this case and
contributed in the description of the case report.
W. F. Fick collected the literature and wrote the
paper. J.P. van der Borgh wrote the description of
the case and assisted with further writing of the
paper. R. Koopmans supervised the data collection
and writing of the paper.
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