Screaming and Wailing in Dementia Patients _Part II_

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					Screaming and Wailing
in Dementia Patients (Part II)
Screaming is a behavioural problem that indicates great distress in patients which can also
be very disturbing and a considerable source of stress, not only for the other patients but
also for caregivers. After exploring its possible causes in Part I, this article addresses the
principles and examples of therapeutic approaches and interventions, with particular
emphasis on nonpharmacologic approaches.

by Bernard Groulx, MD, FRCPC

                                                                            Theoretical Framework
                                    I  hesitated a long time before
                                       writing Part II. It was far easier
                                    for me to ask myself questions
                                                                            No one has been able to explain
                                                                            how to analyze behavioural disor-
                                    about the causes of screaming and       ders as clearly as Dr. Jiska Cohen-
                                    wailing that we do not understand       Mansfield. Dr. Mansfield’s many
                                    in dementia patients than it was to     publications place unsatisfied
                                    find the answers. I had already         needs at the core of the dynamic
                                    discovered that studies and             surrounding behavioural prob-
                                    research on this specific type of       lems, screaming and wailing
                                    behaviour are very rare and, con-       being one example (Figure 1).
                                    sequently, scientific documenta-        The source and causes of dissatis-
                                    tion is minimal. In addition, I         faction are found in the patient’s
                                    thought then—and still do—that          personality, current physical and
Dr. Groulx is Chief Psychiatrist,   seeking the causes was fundamen-        mental condition, and environ-
Ste-Anne-de-Bellevue Hospital       tally the best way to answer this       ment. In advanced dementia, the
and Associate Professor, McGill     behavioural problem.                    unsatisfied need will be expressed
University, Montreal, Quebec.
                                        There are, however, some ther-      in one of the following ways:
                                    apeutic approach principles that        • a behavioural problem that will
                                    are important to remember and,             satisfy the need;
                                    no doubt, examples to be given. It      • a behavioural problem that will
                                    should also be remembered that             communicate the need;
                                    we are discussing patients with         • a behavioural problem that
                                    moderately severe to severe                results from frustration or
                                    dementia who are, by definition,           other negative effects that
                                    unable to explain why they are             interact with the lowering of
                                    screaming.                                 inhibitions.

                                                       The Canadian Alzheimer Disease Review • January 2005 • 7
 Figure 1
                                                                              getting dressed. A good way to
 Theoretical Framework                                                        remember to think about pain in
                                                                              our patients is to enter it on the
                                                       Screaming              chart as a fifth vital sign. In other
            Habits and
            personality                               satisfies the           words, when vital signs are noted,
                                                         needs                we should automatically include
                                                                              signs of possible pain (facial
                                                                              expression, positioning of the
        Current condition                              Screaming              limbs, etc.) We must also remem-
            Physical                                 communicates
                                                         needs                ber another pain that can be pres-
                                                                              ent more often than thought—
                                                                                 Mental pain and depression. It
            Environment                             Screaming is due
              Physical                                                        is surprising, at least in my expe-
                                                    to frustration and
            Psychosocial                             negative affects         rience, just how rarely we think of
                                                                              screaming as an expression of
                                                                              depression or of a major affective
                                                                              disorder. It is true that screaming
  Let us see how the theory             more common and will lead to          is often nerve-racking for every-
applies to screaming.                   deep feelings of loneliness and       body and disturbing to the other
                                        boredom in many patients. In this     patients and the staff. The label
Screaming Fills a Need                  instance, screaming may of            “behavioural disorder” comes
By its very nature, dementia            course satisfy the need but, to be    quickly to mind and, if medica-
means that the patient’s world          honest, it is more logical to think   tion is used, it will invariably be a
shrinks and becomes increasingly        that it is a means of communica-      neuroleptic. As will be covered
empty. To this can be added sen-        ting the feeling of loneliness.       later, I have had far more success
sory deficits (loss of sight or, even                                         with antidepressants than any
more, loss of hearing). A patient       Screaming                             other type of medication in these
may possibly feel the need to fill      Communicates a Need                   patients.
his world with noise, which we          Physical pain. I know I will be          Loneliness and/or deep anxi-
interpret as screaming. That is the     told that it is self-evident that     ety. Dementia, with its inherent
only explanation I can find for the     everyone thinks of pain when          confusion, disorientation, etc., can
fact that, on several occasions, we     someone screams, but unfortu-         bring with it deep feelings of
have been able to stop screaming        nately this is not the case.          loneliness or anxiety at having
and wailing by correcting these         Dementia patients do not often do     been abandoned, even though
deficits. A hearing aid and/or          it “habitually.” As a clinician,      many people may be around.
improved corrective lenses can          therefore, this has to be kept in     Screaming can then be understood
therefore sometimes help stop           mind constantly. Particular atten-    as a call for help. Many therapeu-
screaming.                              tion should be paid to arthritic      tic approaches can be used to
   The mental or spiritual void, if     pain, which will make its presence    meet this feeling of loneliness; I
I may use this expression, is even      felt during hygiene care or when      will just mention a few of them.

8 • The Canadian Alzheimer Disease Review • January 2005
Speaking to the patient is obvi-        “new family” of nursing staff, can      stimuli around them or their “life
ously the simplest way to meet          prevent patients from screaming.        space” is being encroached upon.
this need. But it is easy to think of      While transitional objects can       That can create a feeling of deep
that when the patient can talk to       be useful, pets have proved their       anxiety and cause them to scream.
us. When the patient is aphasic or      worth even more. Regular                The obvious action at that point is
confined within his dementia, the       zootherapy can be an excellent          to move the individual away from
patient will hardly ever communi-       solution, and we have obtained          the television, places where too
cate. We must remember this and         excellent results specifically with     many people pass by, etc. But, to
force ourselves to communicate          screaming patients by having per-       be honest, the opposite condition
with the patient on a regular basis.    manent “live-in” cats in certain        is usually the norm and very often
It should be mentioned that stud-       units. Sometimes, it is not the         the cause of the screaming and
ies, as well as common sense,           presence of “a” dog that reduces a      wailing is because the patient is
show that touching the patient (on      patient’s wailing, but that of          under-stimulated and bored. A
the hand, forearm, etc.) or mas-        “their” dog. Again, life-size pic-      radio or, even better, an audio-
saging the patient while talking        tures of a favourite dog can work       cassette with his favourite music
has far more impact. Even if it is      wonders. I have even seen a             can be useful. Television can have
tempting to want to isolate             patient who never stopped               the same effect, though I have
patients who scream practically         screaming, despite all the pharma-      seen TV aggravate screaming as
all the time and get them away          cologic approaches that were            many times as it has soothed the
from the other patients, the oppo-
site solution often gives the best      Dementia, with its inherent confusion, disorientation, etc., can
results. Placing them closer to the      bring with it deep feelings of loneliness or anxiety at having
nurses’ work station, where there         been abandoned, even though many people may be around.
is a lot of action and movement to              Screaming can then be understood as a call for help.
and fro can alleviate the feeling of
    On a clinical level, patients       tried, until the day one of his life-   patient. Caution is therefore
with advanced dementia often            size china sculptures that bore a       advised.
have emotional needs similar to         strong resemblance to a dog he             Familiar, uncomplicated and
those of young children. It is          once had was placed beside his          repetitive manual activities have
therefore not surprising that a         bed. Although it obviously did not      proved useful in many cases of
transitional object (a doll, a          move or show any signs of life,         behavioural disorder, including
stuffed animal, etc.) which,            the china dog nevertheless reas-        screaming. Folding towels or
because it is a symbol and the          sured the patient and he stopped        socks occupies the patient and
extension of someone who loves          screaming completely. Sometimes         may give him a feeling of being
and protects, can reassure a child      only sounds can have an effect,         useful and a sense of self-worth.
and can also have the same effect       and audiocassettes of the sea or        Just recently, large aprons with
for the patient lost in dementia. In    birdsong can prove useful.              multiple pockets that have to be
the same way, but more directly,            Frustration. Patients may be        buttoned or zipped have been
large pictures or posters on the        frustrated because they are over-       created for patients with slightly
wall of family members, or the          stimulated. There are too many          more advanced dementia. The

                                                           The Canadian Alzheimer Disease Review • January 2005 • 9
                                                                                       and       the      nonpharmacologic
 Table 1
                                                                                       approaches which, in the final
 Principles of a Nonpharmacologic Approach
                                                                                       analysis, are fairly effective, create a
 • Observation                                                                         paradox. We must give a specific
 • Assessment of past and present                                                      approach sufficient time to work
 • Identification of unsatisfied need(s)                                               and, at the same time, know when it
 • Adapt the intervention to the patient’s needs, personal characteristics,            fails so we can try other approaches.
 • Try several alternatives and assess the approach used
                                                                                       Pharmacologic Approach
                                                                                       At the risk of repeating myself,
patient will unbutton and rebut-               Disorientation. If we become            and certain exceptions aside,
ton the pockets, sometimes for              disoriented for a few seconds,             patients’ screaming or wailing is a
hours on end, thus filling the              minutes or even longer when we             symptom that is far too complex to
emptiness in his mind in a very             are in a strange city or woken sud-        resolve by simply using a pharma-
real way. For less severely affect-         denly, we all feel a frustration that      cological approach. The excep-
ed patients, magazines or cata-             can easily turn to painful anxiety.        tions, as indicated above, are pain
logues that they obviously won’t            Just imagine being in that state           or hidden medical problems, such
read, but will leaf through can             day after day, night after night. It       as chronic infection, gastrointesti-
have the same effect. On the                is hardly surprising that simple           nal problems, constipation, etc.
more active side, walks or even             disorientation can be a source of          Once these have been eliminated, I
regular light exercise have some-           screaming and crying. In addition          always try to see whether simply
times served as a channel for the           to everything mentioned above,             reducing tension or anxiety might
anxious energy that made them               we must obviously not forget the           be the solution. A trial with
scream, and the behaviour                   basics—large clocks, calendars,            lorazepam 0.5 mg, or oxazepam,
stopped. Finally, experiences               posters with the patient’s full            10 or 15 mg, once or twice daily
directly involving members of               name within view—and, obvious-             and/or at bedtime, tells us this fair-
the family have had a certain               ly, make it a habit to reorient            ly rapidly. These drugs can useful-
degree of success. Audio- or                patients who scream every time             ly be replaced by trazodone 25 mg.
videocassettes with members of              we interact with them.                        If this approach is unsuccess-
the family talking together and                So far, as in Part 1 of this article,   ful, my second alternative would
sometimes talking to the patient            we have followed the main princi-          be an antidepressant, as explained
have had worthwhile results. The            ples of a nonpharmacologic                 above. Citalopram with a target
best results have been obtained             approach (Table 1). The most diffi-        therapeutic dose of 20 mg/day or
with audiocassettes that play               cult of these principles is the last       venlafaxine, with a usual target
continuously for the time desired           one: patience. A patient’s continu-        dose of 75 mg/day, are two inter-
in which a member of the family             ous screaming and wailing is a             esting choices. There are others,
seems to have a “telephone con-             symptom that is so frustrating and         of course, but it is important to
versation” with the patient that            upsetting for everyone that we look        remember to avoid drugs that
contains questions, comments                for the speediest solution. As will be     have harmful side effects (anti-
and news, with all the appropri-            covered further on, this will not hap-     cholinergic effects, in particular)
ate pauses.                                 pen with a pharmacologic approach          in elderly dementia patients and

10 • The Canadian Alzheimer Disease Review • January 2005
that, whichever antidepressant is                cologic. This means trying to                   best type of care to be given to
selected, it may easily take up to               understand what the patient may                 this type of patient:
six weeks to become effective at                 be experiencing or feeling, and                 • something can be done for
the therapeutic dose.                            trying (using a great deal of imag-                individuals with dementia;
   It is only as a third option, even            ination) to find a specific solution            • many factors can cause excess
though it is the first choice of                 for a specific patient. That is why                disability in individuals with
many clinicians, that I would try                the few solutions suggested in this                dementia;
neuroleptics. Atypical agents are                article represent only a tiny por-              • individuals with dementia have
obviously strongly recommended                   tion of those possible. The                        residual strength;
because we want to avoid anti-                   approach must always be based                   • the communication between
cholinergic and extrapyramidal                   on one or more specific needs that                 individuals with dementia and
side effects. For patients with                  have not been met for a given                      others is often difficult but it
advanced dementia, usual maxi-                   patient, in specific circumstances.                can be enhanced to improve
mum daily doses are risperidone                  The purpose of this article is                     the quality of interaction and
1 mg, olanzapine 5 mg, and queti-                therefore to stimulate clinicians’                 comprehension;
apine 100 mg to 150 mg.                          imagination and creativity so that              • the behaviour of individuals
                                                 they will make a effort to find the                with dementia represents
Conclusion                                       right solution for their patients                  meaningful feelings and needs,
It has not been easy to write on                 who are suffering. Faced with a                    even if they are not expressed
this subject, because the scientific             dementia patient who can only                      in conventional and under-
literature is sparse and the                     communicate by constantly                          standable ways; and
research even more so. Despite                   screaming and wailing, it is easy               • many aspects of the physical
the aid of pharmacological tools,                to feel discouraged and at a loss.                 and social environment affect
experience has shown that the first              We then have to remember the                       the functioning of individuals
approach should be nonpharma-                    main principles that underlie the                  with dementia.

Suggested reading:                                  non-pharmacological interventions              nisms. Semin Clin Neuropsychiatry
1. Groulx B. Screaming and Wailing in               among nursing home residents with              1996; 1:325-39.
   Dementia Patients (Part I). The                  dementia. Psychiatric Services 2002;        6. Burgio L. Interventions for behavioral
   Canadian Alzheimer Disease Review                53(11): 1397-401.                              complications of Alzheimer’s Disease:
   2004; 6(2):11-14.                             4. Cohen-Mansfield J, Billig N. Agitated          behavioral approaches. Int
2. Cohen-Mansfield J. Theoretical frame-            behaviors in the elderly: a conceptual         Psychogeriatr 1996; 8(supp.1):45-52.
   works for behavioral problems in demen-          review. J AM Geriatr Soc 1986; 34:711-21.   7. Cohen-Mansfield J, Werner P, Marx MS.
   tia. Alzheimer’s Care Quarterly, 1(4):8-21.   5. Cohen-Mansfield J, Deutsch L.                  Screaming in nursing home residents. J
3. Cameron J, Cohen-Mansfield J. Use of             Agitation: subtypes and their mecha-           AM Geriatr Soc 1990; 38:785-92.

                                                                      The Canadian Alzheimer Disease Review • January 2005 • 11