Download Unwanted Behaviors - Alzheimer`s Association

11/24/2013
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Rita C.Voth, LMSW
Shiloh Jiwanlal CNS, APRN
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Describe the road for the aggressive and
assaultive behaviors.
Identify approaches to manage aggressive
tendencies.
Identify the Caregivers’ grief reconciliation in
managing aggressive behaviors.
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Brain Function vs. Malfunction
Types of Dementia
Frontotemporal
Vascular
Lewy Body
Alzheimers
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Chronic slow brain death
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Dementia is Dementia
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Early-law of encoding
Unable to form new memories
Disorientation in an unfamiliar environment
Disorientation of time
Same questions repeated
Loses track of conversations
Less able to learn new things
Easily loses things
Unable to recall people whom they have recently met
Appointments are quickly forgotten
Experiences anxiety and stress
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Delirium
Depression
Dementia
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Sleep Disturbance- Bright Light therapy
Sexual Behaviors: Assess patient’s awareness
Delusional mistaken identity
Capacity to say no
Aware of risk
Inappropriate: form, context, frequency,
contributing factors, problem for whom
Participants competent?
ABC- method
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Mid stage- Law of Roll-Back memory
Early childhood remains
Loss of daily skills such as using kitchen appliances
Memory loss of events most recent such as last holiday
Decreased vocabulary and inability to find words
Inability to recognize relatives, family
Flashbacks
Self care skills
Change in personality
Believe they are younger
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Male vs. Female
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Naming aggression
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Pain, UTI, Dental, Pneumonia
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All behavior has meaning
A verbal or physical act of an explicit or perceived sexual
nature, which is unacceptable within the social context in
which it is carried out.- Stubbs, B.
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Sex talk, sexual acts, implied sexual acts
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Indecent exposure in public places
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Obscene sex language, public masturbation, touching others
breasts or genitals, inappropriate propositions to others
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Lack of usual sexual partner- skin hunger
Lack of privacy
Under stimulating environment
Misinterpretation of cues
Unfamiliar environments
Premorbid patterns
Alcohol and benzo – disinhibit
L-dopa can cause hyper sexuality in people with Parkinson's
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Men vs. Women
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Physical vs. Verbal
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Recruit compensatory network
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ABC
Activity focused care
Repeat, Reassure, Redirect
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Correct sensory impairment
Simplify
Structure
Multiple cueing
Repetition
Guiding and demonstration
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Relaxation Techniques/breathing exercises
Distraction techniques/soft ball, teddy, dolls
Reminiscence
Needs-led therapy
Snozelen therapy- cranial nerve therapy:
music, tactile
Social skills
Consistency
Light therapy- Circadian rhythm
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Bean bag juggling
 Washing Clothes- washboards
 MAKS- German (Graessel E, 2011)
Motor stimulation, practicing activities of
daily living
Cognitive stimulation (K-Kognitiv)
Spiritual element
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Culture
Age
Gender
Space
Time
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Reinforcement
Reducing choices
Optimal stimulation
Determine and use over-learned skills
Avoid new learning
Minimize anxiety
Using redirection
Patient’s present level of functioning
Minimize danger through environment change
Value what is here and now and not what has
been lost
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Life Story
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Premorbid personality
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Medical Evaluation
Head to Toe
Dental
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Records- DPOA; Living Will; Code Status
Life inventory- Personality/ interests/habits
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The person with dementia, significant caregivers
and family members are a resource when
gathering information for the initial assessment
and the on-going evaluation of care needs.
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Environmental Assessment
Visual sweep
Color response
Windows/curtains
Favorite piece of furniture
Favorite personal item
Label directions
Music type response
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Room over stimulation vs. under stimulation
Mobility, activity, needs
Staff contact: trigger positive/negative
Mirrors/ clocks
Room temperature
Time line for activity completion
Food type/enjoyment- Progressive Dinner
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Sense of self
Where you begin
Where she/he ends
When to stop- Markers
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Acceptance
Care giving
Promises made
Looking back
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Emotional reconciliation
Readily available in home guidance
Grief Process
Changing role
Loss of support
Emotional Supportive groups
Problem Focused groups
Combined group with structured time
boundaries
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Person’s happiness
Comfort
Security
Quality of life
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Dodd, K Psychological and other non-pharmacological interventions in services for
people with learning disabilities and dementia
Advances in Mental Health and Learning Disabilities vol.4 issue 1, March 2010 pages
28-35
O’Neil et. A Systematic Evidence Review of Non-pharmacological Interventions for
Behavioral Symptoms of Dementia, Department of Veterans Affair, March 2011
Duedon A., et. Non-pharmacological management of behavioral symptoms in nursing
homes; International Journal of Geriatric Psychiatry, 24: 1386-1395 2009
Gitlin, L.N., et. Nonpharmacologic Management of Behavioral Symptoms in Dementia,
Journal of The American Medical Association, 308,19 November 12, 2012 pages 20202029
Hong, S., et. Maximizing a Nurturing Care Style for Persons with Dementia: A
Person-Centered Analysis, American Journal of Geriatric Psychiatry 21:10, October
2013 pages 987-998
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Meyer, R.T., et. Psychosocial interventions for reducing antipsychotic
medication in care home residents (Review) The Cochrane Library 2012, Issue
12 pages 1-43
Norton, M.J. et. Predictors of need-driven behaviors in nursing home
residents with dementia and associated certified nursing assistant burden,
Aging & Mental Health, 14,3 April 2010 pages 303-309
Nguyen Vi T, et. Preventing aggression in persons with dementia, Geriatrics
63,11, November 2008, pages 21-26
Kverno,K et. Research on treating neuropsychiatric symptoms of advanced
dementia with non-pharmacological strategies, 1998-2008: a systematic literature
review. International Psycho-geriatrics, 21:5 2009 pages 825-843
Okura, T et. Caregiver Burden and Neuropsychiatric Symptoms in Older Adults with
Cognitive Impairments: The Aging, Demographics and Memory Study (ADAMS) NIH
Public Access Author Manuscript, April 2012
Ozkan, B et. Pharmacotherapy for Inappropriate Sexual Behaviors in Dementia: A
Systematic review of Literature. American Journal of Alzheimer’s Disease & Other
Dementias, 23,4, 2008, pages 344-354
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5
The Global Deterioration Scale for Assessment of Primary Degenerative Dementia
The Global Deterioration Scale (GDS), developed by Dr. Barry Reisberg, provides caregivers an overview of the
stages of cognitive function for those suffering from a primary degenerative dementia such as Alzheimer's disease. It
is broken down into 7 different stages. Stages 1-3 are the pre-dementia stages. Stages 4-7 are the dementia stages.
Biginning in stage 5, an individual can no longer survive without assistance. Within the GDS, each stage is
numbered (1-7), given a short title (i.e., Forgetfulness, Early Confusional, etc. followed by a brief listing of the
characteristics for that stage. Caregivers can get a rough idea of where an individual is at in the disease process by
observing that individual's behavioral characteristics and comparing them to the GDS. For more specific
assessments, use the accompanying Brief Cognitive Rating Scale (BCRS) and the Functional Assessment Staging
(FAST) measures.
Level
1
No cognitive
decline
2
Very mild cognitive
decline
(Age Associated
Memory Impairment)
3
Mild cognitive
decline
(Mild Cognitive
Impairment)
4
Moderate cognitive
decline
(Mild Dementia)
Clinical Characteristics
No subjective complaints of memory deficit. No memory deficit evident on
clinical interview.
Subjective complaints of memory deficit, most frequently in following areas: (a)
forgetting where one has placed familiar objects; (b) forgetting names one
formerly knew well. No objective evidence of memory deficit on clinical
interview. No objective deficits in employment or social situations. Appropriate
concern with respect to symptomatology.
Earliest clear-cut deficits. Manifestations in more than one of the following areas:
(a) patient may have gotten lost when traveling to an unfamiliar location; (b) coworkers become aware of patient's relatively poor performance; (c) word and
name finding deficit becomes evident to intimates; (d) patient may read a passage
or a book and retain relatively little material; (e) patient may demonstrate
decreased facility in remembering names upon introduction to new people; (f)
patient may have lost or misplaced an object of value; (g) concentration deficit
may be evident on clinical testing. Objective evidence of memory deficit obtained
only with an intensive interview. Decreased performance in demanding
employment and social settings. Denial begins to become manifest in patient.
Mild to moderate anxiety accompanies symptoms.
Clear-cut deficit on careful clinical interview. Deficit manifest in following areas:
(a) decreased knowledge of current and recent events; (b) may exhibit some
deficit in memory of ones personal history; (c) concentration deficit elicited on
serial subtractions; (d) decreased ability to travel, handle finances, etc. Frequently
no deficit in following areas: (a) orientation to time and place; (b) recognition of
familiar persons and faces; (c) ability to travel to familiar locations. Inability to
perform complex tasks. Denial is dominant defense mechanism. Flattening of
affect and withdrawal from challenging situations frequently occur.
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5
Moderately severe
cognitive decline
(Moderate Dementia)
6
Severe cognitive
decline
(Moderately Severe
Dementia)
7
Very severe cognitive
decline
(Severe Dementia)
Patient can no longer survive without some assistance. Patient is unable during
interview to recall a major relevant aspect of their current lives, e.g., an address or
telephone number of many years, the names of close family members (such as
grandchildren), the name of the high school or college from which they
graduated. Frequently some disorientation to time (date, day of week, season,
etc.) or to place. An educated person may have difficulty counting back from 40
by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major
facts regarding themselves and others. They invariably know their own names
and generally know their spouses' and children's names. They require no
assistance with toileting and eating, but may have some difficulty choosing the
proper clothing to wear.
May occasionally forget the name of the spouse upon whom they are entirely
dependent for survival. Will be largely unaware of all recent events and
experiences in their lives. Retain some knowledge of their past lives but this is
very sketchy. Generally unaware of their surroundings, the year, the season, etc.
May have difficulty counting from 10, both backward and, sometimes, forward.
Will require some assistance with activities of daily living, e.g., may become
incontinent, will require travel assistance but occasionally will be able to travel to
familiar locations. Diurnal rhythm frequently disturbed. Almost always recall
their own name. Frequently continue to be able to distinguish familiar from
unfamiliar persons in their environment. Personality and emotional changes
occur. These are quite variable and include: (a) delusional behavior, e.g., patients
may accuse their spouse of being an impostor, may talk to imaginary figures in
the environment, or to their own reflection in the mirror; (b) obsessive symptoms,
e.g., person may continually repeat simple cleaning activities; (c) anxiety
symptoms, agitation, and even previously nonexistent violent behavior may
occur; (d) cognitive abulla, i.e., loss of willpower because an individual cannot
carry a thought long enough to determine a purposeful course of action.
All verbal abilities are lost over the course of this stage. Frequently there is no
speech at all -only unintelligible utterances and rare emergence of seemingly
forgotten words and phrases. Incontinent of urine, requires assistance toileting
and feeding. Basic psychomotor skills, e.g., ability to walk, are lost with the
progression of this stage. The brain appears to no longer be able to tell the body
what to do. Generalized rigidity and developmental neurologic reflexes are
frequently present.
Reisberg, B., Ferris, S.H., de Leon, M.J., and Crook, T. The global deterioration scale for assessment of primary
degenerative dementia. American Journal of Psychiatry, 1982, 139: 1136-1139.
Copyright © 1983 by Barry Reisberg, M.D. Reproduced with permission.
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