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									ROYAL ADELAIDE HOSPITAL
Glenside Campus Mental Health Services for Older People

RECOGNISING DEPRESSION IN LATER LIFE & UNDERSTANDING BEHAVIOURS OF CONCERN IN DEMENTIA

Stephen Merrett CMHN
Country Services Coordinator Country Liaison Service July 2003

1. Recognising Depression
 Depression, followed by dementia are the two largest causes of disability burden in Australia (ahead of diabetes, asthma and osteoarthritis)
Source: The Dementia Epidemic: Economic Impact and Positive Solutions for Australia. Access Economics March 2003 © Alzheimer’s Australia, 2003

Prevalence Community Nursing Homes Hospitalised > 65 Seen in outpatients (GP) 10% - 15% 30% - 40% 10% - 45% 13% - 40%

 70% of suicides follow an episode of depression.  Up to 75 percent older adults who die by suicide have visited a GP within a month of their suicide  Increased mortality rate of 2 – 4 times over non-depressed older people.
From ‘Evidenced based medicine in dementia and old age depression” Lundbeck

NB: There is a tendency to assume that depression is a part of ageing and to misinterpret some of the symptoms of depression (eg. changes in: sleep, appetite, interests and energy) to be a part of normal ageing.

DEFINITION
A pervasive and persistent change in mood characterised by depressed mood and loss of interest or pleasure in life.

KEY FEATURES
            
Depressed mood Loss of interest Loss of energy Reduced concentration Reduced self esteem Guilt Pessimism Tendency to underestimate cognitive functioning Altered sleep Decreased appetite Irritable and/or easily frustrated Self harm/suicide Psychotic features

SCREENS
Possible use of Depression Scales eg.  Geriatric Depression Scale Exclude Dementia.  Mini Mental State Examination

2

TESTS
Exclude physical causes.  Biochem  CBP  B12 & Folate  Thyroid studies  Chest Xray

VULNERABILTY
       
History of depression Social isolation Chronic health problems  Cancer – up to 25%  Dementia – up to 40% Following acute health problems  Stroke – 10% to 27%  Heart Attack – 40% to 65% Chronic pain Losses Prolonged stress Some medications

HOW DOES A DEPRESSED PERSON LOOK AND ACT?
            
Poor eye contact Sad face, no smiles, mouth turned down, or blank expression. Some may hide their sadness. May act as if irritable May look untidy, unshaven or not made up Talk and move slowly (or be very agitated and restless) Cry, call out Ask for help Act distressed and fearful Say they want to die, complain or being worthless, helpless, hopeless. Say they feel guilty Complain about pain or illness Complain about poor memory or concentration In very severe cases they may lose touch with reality (seeing or hearing things which are not there or having beliefs which are not based in reality)

MANAGEMENT
    
Medical assessment Supportive psychotherapy Exploration of family and social circumstances Management of anxiety Medication

3

ALERTS
   
Self harm Psychotic features Marked weight loss/ refusal of sustenance MAD & BLUE Male Alcohol Depressed & Bereaved Lonely Unwell Elderly

TREATMENTS
Antidepressant medications are successful in treating the vast majority of older people who develop a depressive disorder. Antidepressants are not addictive.

MEDICATIONS ARE NOT THE ENTIRE ANSWER
Social support to reduce isolation:  referral to day centres or other appropriate agencies  in home care support services  visiting nursing services  pet therapy  social support visits  volunteer jobs as indicated Psychotherapy:  supportive psychotherapy  cognitive- behavioural therapy  interpersonal therapy  group therapy or family counselling  substance abuse interventions as indicated  bereavement counselling and services as needed Health promotion and maintenance:  good nutrition  light physical exercise  attention to chronic medical conditions  establish a regular daily routine What can you do?  Listen  Use clear, uncomplicated communication and allow time for responses.  Ask simple questions that only need a brief response.  Be non-judgmental in your approach.  Is there evidence of suicidal thoughts or plans?  Notify your supervisor/GP  Make the environment safe.

4

POINTS TO REMEMBER
   
Symptoms of other illnesses can be confused with depression e.g. under active thyroid, dementia, viruses, chronic fatigue. If depression is missed it can affect the person’s recovery from other illness. Links with people who have cancer, stroke, heart attack. Easy to confuse depression with grief as symptoms of depression are similar to those of grief.  Grief gradually lessens over time where as depression is ongoing.  In Grief there are still moments of pleasure and joy Hopelessness is closely correlated with suicide. Depression (and Dementia) are not normal parts of ageing. Depression is as treatable in older people as in any age group. Antidepressants are not addictive.

   

EARLY RECOGNITION IS VITAL
Unrecognised depression can lead to;  Delays in commencing treatment  Premature placement in residential care  Incorrect diagnosis of dementia  Needless suffering for the individual and their family  Increased carer stress  Increased mortality rate from physical health problems.  Death from suicide

People suffering from depression are more aware of the problem and more likely to complain about symptoms (Blackmun, 1998). The symptoms may be misinterpreted as indicating a dementia.

5

CLINICAL FEATURES OF DEMENTIA, DELIRIUM AND DEPRESSION
DEMENTIA DELIRIUM DEPRESSION

ONSET

Insidious Months/years Stable and progressive (unless vascular dementia – usually stepwise) Usually normal May be normal – usually impaired for time and place Impaired short term and sometimes remote memory Slowed Reduced alertness Perseverate Delusions are common

Acute Hours/days ?? weeks Fluctuates – worse at night Lucid periods

Gradual Weeks or months Usually worse in morning, improves as day goes on

DURATION

COURSE

ALERTNESS

Fluctuates Usually impaired for: Time Place Person Impaired short term memory

Normal Usually normal

ORIENTATION

MEMORY

Short term may be impaired Remote memory intact Usually slowed, preoccupied by sad and hopeless thoughts. Mood congruent delusions 20% have mood congruent hallucinations Flat, unresponsive or sad and fearful. May be irritable Early morning wakening

THOUGHTS

PERCEPTION

May be normal

Often paranoid and grandiose ? bizarre ideas and topics ? paranoid Visual and auditory hallucinations are common Delusions are common Irritable Aggressive Fearful Nocturnal confusion

EMOTIONS

SLEEP

Shallow, apathetic, labile ? irritable, careless Often disturbed Nocturnal wandering common Nocturnal confusion

OTHER FEATURES

-

Other physical disease may or may not be obvious

? past history of mood disorder

Source: Dementia Services Development Centre. Dementia Touches Everyone: A Guide for Trainers and Trainees in General Practice. University of Stirling, Scotland. (Minor modifications made to original table)

6

Geriatric Depression Scale (Short Form)
Client’s Name: Date: ______________ Instructions: Ask the client to choose the best answer for how they have felt over the past week.

No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Question
Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home, rather than going out and doing new things? Do you feel you have more problems with memory than most? Do you think it is wonderful to be alive? Do you feel pretty worthless the way you are now? Do you feel full of energy? Do you feel that your situation is hopeless? Do you think that most people are better off than you are?

Answer Score
YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO TOTAL

Scoring: Assign one point for each of these answers (in bold): 1. NO 4. YES 7. NO 10. YES 13. NO 2. YES 5. NO 8. YES 11. NO 14. YES 3. YES 6. YES 9. YES 12. YES 15. YES A score of 0 to 5 is normal. A score above 5 suggests depression. Source:
Yesavage J.A., Brink T.L., Rose T.L. et al. Development and validation of a geriatric depression screening scale: a preliminary report. J. Psychiatr. Res. 1983; 17:37-49.

7

2. Understanding behaviours of concern in Dementia
DEFINITIONS
DEMENTIA
The development of multiple cognitive deficits including memory impairment and one or more of the following,  Aphasia = loss of the ability to use/understand words  Apraxia = loss of the ability to execute or carry out learned (familiar) movements. E.G. dressing, driving, domestic skills.  Agnosia = a failure of recognition, visual, auditory or tactile. E.G. can’t recognize people, places or objects.  Disturbance in executive functioning = problem solving, planning skills, initiating behaviours, monitoring social appropriateness, etc.

BEHAVIOURS OF CONCERN – IN DEMENTIA
Any behaviour that causes stress, worry, risk of or actual harm to the person with dementia, care-staff, family members or those around them. Examples include:  Verbal and physical aggression  Resistance to personal care activities  Sexually inappropriate behaviours  Restlessness and agitation  Wandering or intrusiveness  Sleep disturbance

NB: The above are high profile behaviours that attract attention because of their
very nature. Behaviours of concern should also include:  Social withdrawal  Inactive and lethargic behaviours  Loss of motivation or interest  Sad and tearful  Worried and anxious

STAGES OF DEMENTIA
Dementia is a progressive disorder with changes in an individual’s ability to function in a cognitive and behavioural sense occurring over time.  Every person is different as is the rate and style of the decline  Cognition and functional abilities are not directly linked  Any sudden change in a persons functional or cognitive abilities may warrant investigation The actual changes in a person’s behaviour are related to the areas of the brain that are damaged and will vary depending on the cause of the dementia. Dividing dementia into stages does serve to identify how dementia impacts on a person’s behaviour over time.

8

SUSPECTED DEMENTIA
Memory Consistent, slight forgetfulness. Some recollection of events.

MILD DEMENTIA
Noticeable memory loss, especially for recent events. Interferes with everyday events. Confusion about time of day and year. Mistaken identity of place and becoming lost. Noticeable difficulty in recognizing familiar people. Difficulty in handling problems. Social judgement usually maintained.

MODERATE DEMENTIA
Substantial memory loss. Only well known information retained. New material rapidly lost.

SEVERE DEMENTIA
Severe memory loss. Only parts of long term memory retained.

Orientation to time, place and person

Usually accurate.

Substantial difficulty in recognizing time, place and person

May only recognize people

Judgement and problem solving

Slight impairment in problem solving

Substantial impairment in handling problems. Social judgement usually impaired. Increased difficulty in social interaction. May be uninterested or unwilling to attend functions. Communication difficulties become more apparent. May appear well enough to be taken to functions outside family home. Only simple tasks retained. Very restricted interests poorly sustained.

Unable to make judgements or to solve problems.

Community affairs

Slight impairment in social activities due to some communication difficulties.

Difficulties with initiating (word finding) or following a conversation. May be able to function independently at these activities. Appears normal to casual inspection.

Decreased ability to engage socially. Very limited ability to respond to social situations. Appears too ill to be taken to functions outside of family home.

Home and hobbies

Life at home, hobbies and intellectual interests slightly impaired.

Obvious of function at home. Experiences difficulty or unable to undertake or complete tasks. Experiences difficulty or is ineffective with complex tasks.

No significant function at home.

Personal care

Fully capable of self care.

May need prompting.

Requires assistance or prompting with dressing and hygiene.

Requires total assistance with personal care

Adaptation of Berg’s three stages of dementia (1988) in Aged and Community Care Service Department and Evaluation Reports August 1996

9

PROBLEM SOLVING PROCESS
The ReBOC: A Hands On Guide recommends the following problem solving approach.

investigate
Discuss - Observe Record - Identify

review
Observe - Communicate Measure - Record - Decide

P I E

action
Discuss – Choose - Plan Implement - Communicate

INVESTIGATE
Identify information about the behaviour of concern and assess the possible factors in the PIE which trigger the behaviour. DISCUSS and OBSERVE with other workers, health professionals and family members.  What part of the behaviour is concerning?  When does the behaviour occur?  Where does the behaviour occur?  Who is involved when it does occur?  What happens just prior, during and after the behaviour incident(s)?  Refer to the PIE and discuss with those involved possible triggers for this behaviour.  Charts are provided to assist with RECORDING this information (attached).  What strategies have been tried to deal with this behaviour and what was the effect?  How long has the behaviour occurred?

10

Please consider:  Is there risk of harm to the person with dementia or those around them?  If yes, tell your supervisor.  If it is an emergency, call the police or ambulance. This Investigate process will help IDENTIFY the information about the behaviour before starting on the Action phase.

ACTION
Plan and implement strategies based on the PIE, developed from information in the Investigate step. DISCUSS your findings from Investigate with other workers, health professionals and family members. CHOOSE appropriate strategies to trial. PLAN by considering the following aspects.  Who will perform the new strategies? To be successful in this approach, all people involved in the care need to perform the new strategies in a consistent manner.  When will the new plan start and how long will it be trialed?  How much reduction of the behaviour is realistic? Document this goal in the new plan.  How will the changed behaviour be measured and recorded? Use the charts provided in the appendix. IMPLEMENT the new plan. COMMUNICATE with others during the process, describing the outcome of the new strategies. Use a shared communication book / care plan or discuss at meetings or by phone. If there is an undesired effect from the strategies, contact your supervisor.

REVIEW
Assess if occurrence of the behaviour has been minimised or its impact reduced by the strategies implemented in the Action step. OBSERVE and COMMUNICATE with other workers, health professionals and family members the effect strategies have had on the behaviour of the person with dementia. Charts in the appendix will help identify the changes in behaviour. By using the same charts to MEASURE and RECORD behaviour as those that were used in the Investigate phase, any changes to behaviour will be evident. DECIDE:  Has the behaviour minimised to the desire level?  Is it still causing disturbance to the person with dementia or others? If it is, recommence the problem solving process, using other resources and health professionals. Other aspects to explore are:  Did all people involved in the new strategy, perform them in a consistent manner? If not, why not?  Did this contribute to the outcome? Was the strategy feasible?  Was everyone involved and informed?

11

PIE: HOW IT AFFECTS BEHAVIOUR PERSON

P
Each person is unique. Before developing dementia, people had many various experiences. These experiences can contribute to their behaviour. A knowledge about their previous experiences can help you develop strategies to reduce behaviours of concern. The checklists following each section give examples. The emotional and physical feelings of a person will be demonstrated in behaviours. Responding to feelings is explained in the strategies section of this guide. Physical and sensory impairments, illness and medication are all potential factors that may trigger behaviours of concern.

PERSON: CONTRIBUTING FACTORS CHECK LIST
                    Cultural background / values / language Social History Impact of changes to family or work roles Personality traits Tiredness / sleeping problems Hungry / thirsty Impact of feelings (frustration, sadness, anger, grief) Pain / discomfort Hearing problems / hearing impairment Eye problems / visual impairment Infections / new illness Physical movement problems Incontinence issues Poor dental health Blood pressure (high or low) Pre-existing illness Medication side effects and interactions Non-compliance with or incorrect medication dose Progression of dementia Effects of dementia (see Stages of dementia)

12

INTERACTION

I
Interaction between the person with dementia and others may result in:  misunderstanding  confusion  agitation Many of the changes to memory and intellect which occur reduce the ability of people with dementia to communicate fluently or accurately. Therefore the carer's approach, including verbal communication and body language, is a vital factor in minimising behaviours of concern.

INTERACTION: CONTRIBUTING FACTORS CHECK LIST
                 Poor verbal communication (speaking too fast, slurring words, mumbling) Language too complex (confusing) Language demeaning and condescending Not enough information and prompting given Poor eye contact Hostile or defensive tone in voice Hostile of defensive body language (gestures and stance) Inappropriate or misunderstood verbal or non-verbal cues Personal space invaded Task or activity demeaning Changes to routine or activities Social isolation or too much socialisation Minimal activity / overwhelming levels of activity Unfamiliar people / carers Cultural and religious influences not considered Preferred language not used Feelings of person with dementia not acknowledged

13

ENVIRONMENT

E
A person with dementia is especially sensitive to their ENVIRONMENT. Dementia affects the person's ability to interpret and make sense of their surroundings. Creating or maintaining an environment which provides appropriate cues for the person to interpret contributes to the person with dementia being successful in their activities. A familiar environment with limited sensory distraction will help reduce the likelihood of behaviours of concern developing.

ENVIRONMENT: CONTRIBUTING FACTORS CHECK LIST
               Unfamiliar surroundings Too much noise (TV or radio left on, engine sounds and building sounds) Competing noise Too much clutter and dangerous obstructions Visual distractions (patterned carpet) Poor lighting (glare from reflective surfaces, confusing shadows or shapes) Décor and fittings confusing Lack of visual prompts (eg not obvious where toilet is located) Visual prompts that cue unwanted behaviour (eg coats or hats hung by the door which cue people to go out) Unsafe environment Uncomfortable temperature (hot / cold) Lack of personal belongings Culturally inappropriate environment Lack of privacy and personal space Environment not sensitive to perceptual changes of dementia

14

GENERAL STRATEGIES
Strategies for responding to behaviours of concern should be tailored to individual needs to minimise or stop their occurrence. Sometimes there is not one solution but rather a process of trial and error, requiring another process of Investigate, Action and Review. A range of factors which contribute to behaviours of concern is suggested in the PIE:  Person with dementia  Interaction  Environment Family carers know the person with dementia well. Although they may not be experiencing behaviours which bother them they can provide important information to assist you to reduce the problem.

CONTINUE WITH PROBLEM SOLVING PROCESS Investigate
Investigate and charted the behaviour of concern.

Action
Taken these findings into consideration and decided on an action plan. The following pages provide a brief list of general strategies for common behaviours of concern which you could try in you action plan. It is recommended that you also refer to the list of books and resources in the ReBOC Guide (and other sources) for further assistance and a more detailed explanation of behaviours and strategies.

Review
Reviewed the outcomes of the action plan. The outcome of the review will determine what your next step will be. When dealing with a behaviour of concern always keep in mind that the person with dementia cannot help their behaviour and they are not intentionally being manipulative or difficult.

15

SOME GENERAL STRATEGIES
BEHAVIOURS OF CONCERN Verbal disruption
Eg screaming, strange noises, complaining

GENERAL STRATEGIES
   Check that the person is comfortable: eg not in pain or discomfort Give reassurance: eg verbally say who you are, why you are there and what you are doing Minimise noise and over stimulation: eg turn down radio, limit the number of people present Distract by involving in an activity which they like and are capable of undertaking: eg drying dishes, playing cards, reminiscing Check safety and risk of harm: eg remove self and others from a dangerous situation Allow time for the person to settle down, observe and monitor the situation Keep the person informed: eg who you are, where the carer is Try not to reason with the person as they may not be able to comprehend what is happening Keep in mind communication techniques to avoid further confusion: eg speak in calm manner, ensure that short, simple sentences and questions are used Give reassurance: eg stay with the person, verbally reassure and empathise with the emotion expressed Try changing the topic and divert their attention: eg "Let's make a cup of tea together" Divert the person with an activity which they enjoy: eg listening to music, watching TV, playing cards, gardening Keep a calm voice when responding to repeated questions and avoid asking questions that make it necessary for the person to rely on their memory Keep routine as familiar as possible for the person: eg showering at a certain time of day Provide a couple of options about how tasks may be completed: eg wearing a red dress or blue dress Break down and simplify tasks: eg place clothes to be worn in dressing order Encourage person to maintain their independence and provide prompts when required to initiate task: eg place flannel in hand to prompt washing Consider all the possible reasons for this behaviour: eg sexually related or the need to go to the toilet, discomfort, pain Reinforce who you are and why you are there. Considering wearing a uniform and name badge Try to gently discourage the behaviour: eg distract or redirect the person to another activity Consider other ways in which the person can receive physical contact: eg massage, holding hands Allow the person some 'time out' to meet this perceived or real sexual need: eg give the person privacy


   

Physical aggression
Eg hitting, hurting self or others, throwing things

 Repetitive actions / questions
Eg repeating the same sentence, question or action   


  

Resistance to personal care
Eg uncooperative with showering, dressing or toileting




Sexually inappropriate
Eg making verbal or physical sexual advances

   

16

BEHAVIOURS OF CONCERN Refusal to accept services
Eg refusing to be seen by health professional, denial of the need

GENERAL STRATEGIES
  Alter what is being explained using words which are believable but less threatening: eg instead of day care say 'going to work' or 'going to a social club' Try 'loving deceptions' which involves accepting and agreeing with the person's reality when they are upset: eg may not want to go to the doctor's appointment so suggest you go for a drive first Remember the person's memory loss as they will frequently forget what their wishes were: eg may have forgotten that they refused to go to the doctor Check that the problem is not related to the mouth: eg gum disease or ill-fitting dentures Consider a referral to a speech pathologist for swallowing problems or dentist for teeth and gum problems Keep food simple and appropriate: eg cold foods on a hot day, finger foods Initiate eating by placing utensils in their hands and limit cues if overeating: eg put food items away, serve one course at a time to avoid confusion Gently remove the person if in a public area and change activities Ignore the behaviour and involve the person in another activity Keep calm and respond in calm manner Inform (when appropriate) recipient of the behaviour that the person has an illness which cause this type of behaviour eg use of a small standard card with this information when written on it Ask the person where they are going and use this information to develop 'distracting' strategies Check if there is a pattern for the wandering: eg concern times of day, when they are upset or inactive Remove items which may trigger the desire to go out: eg coat, bag Reassure person frequently about where they are and why they should stay (note from carer or GP may help) Use of distraction techniques by involving the person in a task which they like doing Keep person active during the day: eg involve in activity, take for a walk Leave night light on during the night to increase visibility: eg ensure ease of access to the toilet Gently remind the person when it is time to wake or sleep: eg use a clock, show that it is either daylight or dark outside Reduce oral stimulants eg caffeinated drinks, alcoholic beverages and some medications


  

Swallowing / eating difficulties
Eg refusing to eat, forgetting to eat or overeating


  

Socially inappropriate
Eg cursing or verbal aggression (swearing, use of obscenity, unkind speech or criticism), undressing in public)


      

Wandering / intrusiveness
Eg pacing and aimless wandering, trying to get to a different place, disturbed a night

 Sleep disturbances
Eg waking during the night, sleeping during the day


Adapted from: ReBOC: A HANDS ON GUIDE

17

EXAMPLES OF BEHAVIOUR PROBLEMS AND MANAGEMENT STRATEGIES
BEHAVIOUR
WANDERING

POTENTIAL CAUSES OR ANTECEDENTS MANAGEMENT STRATEGIES
Stress: noise, clutter, Crowding. Lost - looking for someone or something familiar Restless, bored – no stimuli. Medication side effect. Lifelong pattern of being active or coping style. Needing to use the toilet Environmental stimuli - exit signs, people leaving. Reduce excess stimulation Provide familiar objects, signs, pictures. Offer to help find objects or place; reassure Provide meaningful activity. Monitor, reduce or discontinue medication Respond to underlying mood or motivation; provide safe area to move about (e.g. secured circular path). Institute toileting schedule (e.g., every 2 hours). Place signs or pictures on bathroom door Remove or camouflage environmental stimuli; ID or alarm bracelets Break task into small, successive steps Be patient, allow ample time, or try again later

DIFFICULTY WITH PERSONAL CARE TASKS
(e.g. resisting help with bathing, dressing, grooming)

Task too difficult or overwhelming Caregiver impatience, rushing

Cannot remember task Pain involved with movement Can't understand or follow caregiver instructions Fear of task - can't understand need for task or instructions Inertia, apraxia; difficulty initiating and completing out a task

Demonstrate action or task; allow subject to perform the parts of the task they are still able to do Treat underlying condition; consider pain medication or physiotherapy; modify or assist the movement needed Repeat request simply; give instructions (and allow their performance) one step at a time Reassure, comfort, distract from task with music, conversation. Ask subject to "help" you perform the task Set up task sequence by arranging materials (such as clothing) in the order to be used, then help them begin the task.

18

SUSPICIOUSNESS / PARANOIA

Forgot where objects were placed

Misinterpreting actions or words Misinterpreting who people are, suspicious of their intentions Change in environment or routine Misinterpreting environment Physical illness Social isolation Someone is really taking something from person Discomfort, pain

Offer to help find; have more than one of same object available (e.g. purse, wallet); have a list where objects should be placed; learn favourite hiding places Do not argue or try to reason; do not take personally; distract or change subject Introduce self and role routinely; draw on old memory, connections; do not argue Reassure, familiarize; set and follow a routine as much as possible Assess vision, hearing; modify environment as needed; explain misinterpretation simply; distract. Medical evaluation (infection or medication effects are common) Encourage familiar social opportunities Check out validity of situation Assess and manage sources of pain, constipation, infection, or full bladder; check clothing and equipment for comfort. Medical evaluation; eliminate caffeine and alcohol Schedule adequate rest; monitor activity schedule (too much? too little?) Reduce noise, stress; remove from situation; use TV sparingly; limit crowding (e.g. dining hallways just before meals) Control affect with patient: model calm with lower tone and slow rate; use support system and groups for outlet. Do not put in failure oriented situations or tasks (i.e. choose tasks and activities with a higher likelihood of success); understand losses reduce expectations accordingly Avoid persistent testing of person's memory; one question at a time; eliminate questions that require abstract thought, insight, or reasoning. Assess, monitor, and reduce medication where possible; monitor health concerns.

AGITATION
(e.g. sundowning, catastrophic reactions) Physical illness (e.g. urinary tract infection) Fatigue Overstimulation: noise, overhead paging, people, radio, TV, activities. Mirroring of care giver's affect Overextending capabilities resulting in failure; care giver expectations too high Subject is being "quizzed" (multiple questions or topics that exceed subject's abilities) Medication side effect

19

AGITATION – cont.

Subject is thwarted from desired activity (e.g. attempting to escape)

Lowered stress threshold Unfamiliar people or environment; change in schedule or routine Restless

INCONTINENCE

Infection, prostrate problem; chronic illness; medication sideeffect; stress or urge incontinence Difficulty in finding toilet Lack of privacy. Difficulty undressing Difficult to see toilet Impaired mobility

Redirect energy to similar activity, ask person to "help" with meaningful activity; have diversionary tactics for outbursts; choose your battles: assess whether the behaviour is merely irritating, rather than compromising patient safety or obstructing care. Simplify tasks, create calm; lower expectations and demands; avoid arguments and reprimands Be consistent; avoid changes, surprises; new experiences (e.g. trips, parties) may be threatening rather than fun; make change gradually Play calming music, massage, or meaningful activities; assign tasks that provide exercise. Evaluate medically Place appropriate signs, picture on door; ensure adequate lighting Provide for privacy Simplify clothing (e.g. easier fasteners, elastic waists) Contrasting colours on toilet and floor; use a less institutional, more homelike room and toilet design where possible Evaluate medically; treat associated pain (include physiotherapy); use a commode; reduce diuretics where possible Provide increased attention for continence rather than incontinence; allow independence whenever possible, even if time consuming. Schedule toileting (such as every 2 hours while awake); reduce diuretics and bedtime liquids where possible. Simplify; use step by step instructions; establish a routine.

Dependency created by socialized reinforcement

Can't express need Task overwhelming

20

SLEEP DISTURBANCE

Illness, pain, medication effect. Depression Less need for sleep Too hot, too cold Darkness disorientating Caffeine or alcohol effect Hunger Urge to void Fear of darkness; restless Normal age and disease related fragmentation of sleep Daytime sleeping

Evaluate medically Antidepressant (consider bedtime sedative) Schedule later bedtime; allow activities or tasks that can safely be done at night; plan more daytime exercise Adjust temperature Use night lights Reduce or eliminate alcohol; Limit caffeine after noon Provide nighttime snack Ensure a clear, well-lit pathway to bathroom Soft music massage, Nightlight Accept; plan for safety Eliminate or limit naps; provide activity and exercise instead; for naps, use recliner rather than bed. Do not overreact or confront; respond calmly and firmly; distract and redirect Do not give mixed sexual message (double entendres and innuendos - even in jest); avoid nonverbal messages; distract while performing personal care or bathing Check room temperature; assist with comfortable weatherappropriate clothing; ensure that elimination needs are met; examine for groin rash, perineal skin problems, stool impaction Increase or meet basic need for touch and warmth; model appropriate touch; offer soothing objects (such as dolls or stuffed animals); provide hand or back massage Offer privacy; remove from inappropriate place

INAPPROPRIATE OR IMPULSIVE SEXUAL BEHAVIOUR

Dementia-related decreased judgement and lack of social awareness Misinterpreting care giver's interaction

Uncomfortable- too warm, clothing too tight; need to void, genital irritation

Need for attention, affection, intimacy

Self-stimulating, reacting to what feels good

Behaviour Management Strategies From: http://www.mayo.edu/geriatrics-rst/behav.mgmt.html

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APPENDIX 1: BEHAVIOUR CHART SPECIFIC BEHAVIOUR CLIENT'S NAME This chart assists with the identification of the aspects of the concerning behaviour. For optimal use, invite all people involved in the care of the person to complete the chart each time a concerning behaviour occurs. Continue recording for 7 days where practical. This chart may also be used after new strategies have been trialed to clarify how the concerning behaviour has changed.
DATE
TIME OF BEHAVIOUR INCIDENT WHERE DID THE INCIDENT OCCUR AND WHO WAS PRESENT? WHAT WAS HAPPENING PRIOR, DURING AND AFTER THE INCIDENT? PRIOR WHAT DO YOU THINK WAS TRIGGERING THE BEHAVIOUR? REFER TO THE PIECONTRIBUTING FACTORS CHECKLIST STAFF/FAMILY MEMBER RECORDING

WHERE

WHO

DURING

AFTER

WHERE

PRIOR

WHO

DURING

AFTER

WHERE

PRIOR

WHO

DURING

AFTER

Adapted from: ReBOC: A HANDS ON GUIDE

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APPENDIX 2: 24 HOUR CHART
DAY /

SPECIFIC BEHAVIOUR CLIENT'S NAME
This chart helps to clarify when the behaviour is occurring, how often and the level of disruption. It is intended for use during the INVESTIGATE and REVIEW phases of the ReBOC Problem solving process. By using this chart both before and after strategies have been tried, any changes to behaviour will be clear. From the key choose the number 0-4 which indicates the level of behaviour for the incident you have just witnessed, and place it in the appropriate time box. Involve all people providing care for the person in the recording of behaviours. Continue this charting for a period of 7 days where practical. KEY 0 not disruptive 1 a little disruptive no intervention by staff / carer cooperative response to intervention, not disruptive to other people

DATE TIME  0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400

2 moderately disruptive not always cooperative, but can, be resolved with intervention, sometimes disruptive to others 3 very disruptive sometimes requires immediate intervention, interferes with others, their belongings, unsociable behaviour always requires immediate intervention, wakes others at night, disruptive to others during the day, requires attention from one or more staff or constant attention

1500 1600 1700 1800 1900 2000 2100 2200 2300

4 extremely disruptive

Adapted from ReBOC: A HANDS ON GUIDE

2400

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APPENDIX 3: ReBOC WORKSHEET BEHAVIOUR OF CONCERN INVESTIGATE ACTION REVIEW

Use this sheet to record the behaviours of concern, information gathered during the problem solving process, your actions and the out-come of our review.

investigate
Discuss - Observe Record - Identify

review
Observe - Communicate Measure - Record - Decide

P I E

action
Discuss – Choose - Plan Implement - Communicate

Adapted from: ReBOC: A HANDS ON GUIDE

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