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B. Heath Gordon, Ph.D.1,2,3 11.08.13 1. G.V. (Sonny) Montgomery VAMC 2. UMMC School of Medicine, Division of Geriatrics 3. Private Practice, Jackson, MS None Upon completion of this 1-hour learning activity, attendants should be able to: 1. Identify the primary types and causes of dementing illnesses 2. Describe the cognitive and behavioral features of different dementing illnesses 3. Identify a behavioral model and techniques for managing challenging behaviors in loved ones with dementia Multiple cognitive deficits: Memory Impaired ability to learn new things or recall old information Plus (one or more of the following): Language disturbance Difficulty performing motor activities (w/ intact motor ability) Failure to recognize or identify objects (w/ intact senses) Impaired planning, organizing, sequencing, or abstracting ability Symptom must interfere with daily life Represents a decline from a higher level of functioning Does not occur exclusively during an episode of delirium Not better accounted for by another mental health condition Major and Mild Neurocogitive Disorders (NCDs) Evidence in cognitive decline in one or more areas based on 1. 2. Self-report or an informant, AND Clinical assessment Subtypes of NCD are specified E.g., Probable major neurocognitive disorder due to Alzheimer disease, with behavioral disturbance, moderate Greater alignment with consensus criteria E.g., Probable vs. Possible Alzheimer disease Progressive disease Metabolic disorders Vascular disease Endocrine disorders Trauma Epileptic disorders Tumors Toxic reactions Substance-induced Anoxia Infection Vitamin deficiency Alzheimer disease (DAT) Vascular dementia (VaD) Dementia with Lewy bodies (DLB) Frontotemporal lobar dementia (FTD) Parkinson’s disease Substance-induced Huntington’s disease persisting dementia Multiple sclerosis HIV-related dementia Pick’s disease Dementia pugilistica Hydrocephalus Multiple etiologies Creutzfeld-Jacob disease Memory impairment: Learning & Recall One or more impairments in the following: Speech and/or understanding language = aphasia Skilled movement = apraxia Object recognition = agnosia Judgment, planning, switching tasks, etc. = executive functioning Cognitive deficits represent a significant decline Gradual start and decline in cognition (vs. sudden) Deficits cause significant impairment in social or occupational functioning Generally a gradual onset with initial difficulty remembering recent events (perhaps mood changes) that becomes global and affects longterm memory Accounts for ~60-80% of all dementing illnesses Due to neuronal atrophy, synapse loss, abnormal accumulation of neuritic plaques and neurofibrillary tangles Memory impairment: Learning or Recall One or more impairments in the following: Speech and/or understanding language Skilled movement Object recognition Judgment, planning, switching tasks, etc (executive functioning) Cognitive deficits represent a significant decline Focal neurological signs and symptoms or lab evidence indicative of cerebrovascular disease Deficits cause significant impairment in social or occupational functioning and are a significant decline Generally an abrupt onset of cognitive deficits and step-wise pattern of decline Multiple injuries to the brain due to inadequate blood supply Where injury occurs determine type of cognitive deficits Impairment in memory memory retrieval > new learning Deficits in attention/concentration Impairment in judgment Personality and mood changes Stroke A ≠ Stroke B Motor cortex Motor function, fine motor coordination Premotor cortex Frontal eye fields, motor planning Prefrontal cortex “Executive functions” Planning, organizing, monitoring, inhibiting Motor speech area Dysexecutive syndrome Poor problem-solving, reasoning, sequencing, maintaining behaviors (perseverative) Poor motivation Poor insight and judgment Slow learning, environmental dependence, poor memory attention, forgetting temporal sequence of events Blunted and apathetic affect but anger when aroused Emotionally dysregulated Behaviorally disinhibited Impulsive Poor smell discrimination Pseudopsychopathic syndrome Disorganized Lack of social graces Poor appreciation for feelings of others or negative aspects of behavior Associated with anterior cingulate Akinetic and apathetic with bilateral damage Little initiation of movement or speech Lack of interest and indifference Emotional blunting Memory impairment (amnesia with confabulation) Incontinence Lower extremity weakness Memory impairment: Learning & Recall One or more impairments in the following: Speech and/or understanding language Skilled movement Object recognition Judgment, planning, switching tasks, etc (executive functioning) Cognitive deficits represent a significant decline Evidence from medical exam of related illness Deficits cause significant impairment in social or occupational functioning Associated with abnormal structures called Lewy Bodies in the brain Gradual start and progression of cognitive decline Fluctuating cognition and variability in alertness/attention Abrupt confusion Memory deficits (memory retrieval more than learning new information) Parkinsonism Bradykinesia (loss of spontaneous movement) Rigidity (muscle stiffness) Tremor Shuffling gait Visual hallucinations (well-formed, detailed, recurrent) Frequent falls Memory impairment: Learning & Recall One or more impairments in the following: Speech and/or understanding language Skilled movement Object recognition Judgment, planning, switching tasks, etc (executive functioning) Cognitive deficits represent a significant decline Evidence from medical exam of related illness Deficits cause significant impairment in social or occupational functioning Loss of brain tissue in frontal and temporal lobes Associated with abnormal structures in the brain (Pick’s Bodies) Gradual start and progression of cognitive decline: Behavioral & personality changes are significant loss of personal (hygiene) and social (tact) awareness Disinhibited and impulsive Loss of initiative, indecision, lack of spontaneity Impairment in speech and/or understanding language Object recognition impairment Impairment in skilled movement Models for Understanding Behavior Different types of disruptive behavior/agitation Mixing three models Matching Interventions to Disruptive Behaviors Based on environmental links Individualized to ability and preference Behavioral Disturbances: Behaviors we don’t want to see but are present. Physically Aggressive Hitting Kicking Biting Physically Non-Aggressive Pacing Inappropriate disrobing Verbal Aggression Cursing Screaming Threatening Verbally Non-Aggressive Crying Repeated Questions Constant Requests Behavioral Deficits: Behaviors we do want to see but are not present. Decreased social skills Apathy/Decreased display of emotion Physical dependency/ADL limitations greater than indicated by illness/disease Unable to interact with their surroundings Behaviors Rated by Dimension VERBAL/VOCAL VERBALLY NONAGGRESSIVE -complaining -negativism -repetitive questions -constant, unwarranted requests for attention NONAGGRESSIVE VERBALLY AGGRESSIVE -cursing and verbal aggression -making strange noises -verbal sexual advances -screaming AGGRESSIVE PHYSICALLY NONAGGRESSIVE -repetitious mannerisms -inappropriate robbing and disrobing -eating inappropriate substances -handling things inappropriately -pacing, aimless wandering -intentional falling -general restlessness -hoarding things -hiding things PHYSICAL PHYSICALLY AGGRESSIVE -physical sexual advances -hurting self or others -throwing things -tearing things -grabbing -pushing -spitting -kicking and hitting -biting (Cohen-Mansfield, 2000) Role of Individual Qualities Personal History, Habits, Preferences Personality Style Neurological/Brain structure and chemistry Mental & Physical Abilities, Deficits Role of Environmental Qualities INTERNAL NEEDS: Physical Emotional EXTERNAL DEMANDS: Physical Surroundings Social Surroundings A connection occurs between antecedents, behavior, and consequences Disruptive behavior is learned through reinforcement from others Goal: reinforce positive, appropriate behavior and do not reinforce negative, disruptive behavior Based on Cohen-Mansfield, 2000 Unmet Needs Model Life long habits & Personality Environment Physical Psychosocial Unmet needs and Direct effects of dementia Need-Driven Behavior Current abilities Physical & Mental Person Environment Fit Model Learning Behavior Model All models focus on the reason or cause for the behavior. Need to understand behavior before you act Does not decrease the person’s ability to interact, which is already difficult. Focuses on psychosocial interventions, and does not have the drawbacks of medication. Side effects Drug interactions Limited value (does not increase positive behavior) All behavior has meaning Behavior is a way of communicating Behavior can be a demonstration of a person’s abilities, disabilities, and challenges they face Understanding the reason or cause is the best way to manage disruptive behaviors Try psychosocial approaches before medications Interventions must be person-centered “A” Antecedents “B” Behavior “C” Consequences The ABCs of Behavioral Management A = Antecedent B = Behavior C = Consequence Antecedent: what happens before the behavior Consequence: what happens after the behavior (Burgio & Stevens) To identify the Antecedents and Consequences, ask the ‘W’ questions What Why When Where Who (Burgio & Stevens) Time & Date: Behavior: List & Describe: With whom? Number of people: Where?: Trigger Event(s): Interventions Tried: List & Describe: End Result(s): Effective?: Why do behavioral disturbances occur? Internal factors Memory loss Sensory changes Loss of communication skill Pain/discomfort (Burgio & Stevens) Why do behavioral disturbances occur? External factors Over stimulation Lack of stimulation Lack of activity Too many demands (Burgio & Stevens) Why do behavioral disturbances occur? Caregiving situations Factors in the caregiving routine can often cause the residents to react with a behavioral disturbance. These factors include Too much information Speaking too quickly Touching without warning (Burgio & Stevens) Why do behavioral disturbances occur? Verbal Pointing out reality is not useful with a resident who is confused or disoriented because of dementia The resident with dementia cannot remember the correct information Frequently reminding a resident of correct information gives a negative message (Burgio & Stevens) Why do behavioral disturbances occur? Nonverbal The nonverbal message, or your body language, emphasizes what you are saying to the resident Body language also gives an emotional message by showing how you feel about the resident Remember: Even though residents with dementia have trouble understanding what you are saying or doing, they still can receive the emotional message. (Burgio & Stevens) Yelling and Screaming: Difficult symptoms because they disturb others May be a means for getting attention May be a response to over or under stimulation, fear, pain, hunger, feeling overwhelmed or depression Resisting Care: Can result from fear, feelings of powerlessness or misunderstanding, or if the resident feels rushed or treated roughly Many times the person with cognitive loss is aware at some level of his/her loss of skills; the refusal may be the only way the person can have control and reduce feelings of powerlessness Verbal Aggression: Includes arguing, cursing, threatening, swearing, or accusing May be the result of a loss of impulse control Anything that increases stress may cause this behavior Verbal aggression may be a cry for help May be a response to fear, pain, hunger, feeling overwhelmed or depression 1. Identify yourself by name 2. Address Patient by name 3. Speak slowly and allow time to communicate 4. Give one-step instructions 5. Phrase questions in a simple multiple-choice format 6. Use positive statements whenever possible 7. Avoid negative statements Effective communication involves positive choice of words Don’t assume that the other person knows what you think or feel Avoid blaming or over-generalizing “you are trying to be difficult” “you always . . . “ “you never . . . “ Effective communication involves active listening. Sit or stand to face the person at a slight angle, to connect but allow personal space. Avoid mind reading or judging what the other person is thinking or feeling BEFORE you listen “you don’t want to hear what I say” “you are trying to be difficult” “you don’t care” Effective communication involves understanding Repeat what you heard make sure you heard what was said correctly: “I heard you saying X, is that correct?” gives the other person the opportunity to correct miscommunication Restate what the person’s actions say Accept what feelings the person has Positive Reinforcement Planned Ignoring Distraction & Diversion Replacing Disruptive Behaviors When Patients are behaving in a manner that is appropriate, reward them. Give them attention for these good behaviors Remember: Reward behaviors you want to continue Ignore behaviors you want to end or not re-occur Ways to give positive reinforcement Attention Praise and Appreciation Acknowledgement Comfort Positive reinforcement can be used to change the C, Consequences. Positive reinforcement is a consequence When a behavior is followed by a positive reinforcer, the behavior is likely to occur again Therefore, only use positive reinforcement for behaviors you want to re-occur. Don’t reinforce behavioral disturbances. Rules for reinforcing behavior: 1. Give reinforcement immediately following the desired behavior 2. Reinforcement should be given each time the desired behavior occurs 3. Make sure that the reinforcer is meaningful and personal to the Patient. 4. Patient should not get the reinforcer unless the desired behavior occurs 5. The reinforcer should be short-term. There are a variety of tools to assist in managing behaviors to change the As & Cs Behavior management skills such as positive reinforcement, planned ignoring, distraction/diversion, and replacing behaviors can be used to decrease disruptive behaviors