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Understanding Dementia: Behaviour Disturbances - DementiaGuide.com
   
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Understanding Dementia

Behaviour Disturbances

Understanding Dementia is a short textbook for primary care physicians and other health care professionals. Chapter 10 discusses the approach to behavioural problems, including aggression, delusions, hallucinations, repetitive behaviour and wandering, the latter of which is also discussed in a case presentation.



Behavioural disturbances are common and distressing. After careful assessment of the problem behaviour an environmental precipitant can often be discovered and corrected. Otherwise medication is usually necessary.

Behavioural problems form an important part of the burden of Alzheimer's disease . While there is a range of what is called problem behaviour, and while this range is often dependent on the setting in which the behaviour occurs, there are a number of behaviours which typically are described as disturbed. Any consideration of management of behavioural and psychological symptoms in Alzheimer's disease must first deal with the fact that these behaviours can represent medical illnesses. Here again, the notion of staging is helpful. In general, most of the more difficult problem behaviours occur in the late stage of dementia (severe dementia or stage 6 on the Reisberg Global Deterioration Scale). In consequence, the notion of "stage congruence" becomes a hint as to whether altered behaviour represents presentation of an acute medical or surgical illness. Similarly, acuity of onset or acuity of worsening can also point to a medical precipitant. We have seen a wide range of medical problems (from metastatic breast cancer with humeral fracture to untreated fecal impaction to the flu) present as behavioural problems, even in patients with advanced dementia. The key to diagnosis in such cases then becomes the acuity of the problem. Such patients should be treated like any other patient with delirium (see Chapter 8).

In the approach to management of behavioural symptoms in dementia, the first step is to see whether a precipitant can be identified. Perhaps even more common than medical or surgical illnesses precipitating behavioural symptoms are changes in the environment; advanced dementia can be thought of as a predisposing variable and the environmental change a precipitating factor. Environmental changes include changes in the carer, the place of residence, the room (within an institution) or the routine (Table 10.1).

Rockwood & MacKnight, 2001. p.164

It is important to remember that agitation is often understandable as the adaptive response of someone with profound amnesia .

Although some people are born as good carers with great empathy, this single insight can be taught and underlies approaches such as reality orientation and validation therapy. Briefly, such approaches seek to understand the meaning of the agitated behaviour and to address the behaviour by addressing its meaning. For example, agitation can be greatly exacerbated by a particular caregiver, whose manner, inflection or characteristics may remind the patient of a difficult period or event. Our definitions do not do justice to the body of work underlying validation therapy and reality orientation, but the first can be thought of as an acceptance of the patient's worldview, erroneous as it may be, rather than provoking confrontation through constant correction. Reality orientation centres on a program of constant reorientation to person, place and time, through familiar objects, discussion of remembered events, and the generous use of signs, clocks, and calendars.

Some designs are very difficult for patients with dementia. Notoriously, the single long corridors with large windows at either end do not allow for wandering and exacerbate visuospatial problems. An institution with poor aesthetics, lacking display of individuality (paintings, posters, wall hangings) or life (plants, pets, visitors), containing rows of residents strapped in gerichairs is a bad place to visit, but a worse place to live. Patients with dementia are not completely without feeling, understanding or humanity and, considering such life circumstances, a certain degree of obstreperousness is understandable, and is remediable with institutional reform aimed at an improved living environment. On a less grand scale, having caregivers (family or staff) spend some time noting the pattern of problems can both be empowering for them (in the sense that once a pattern is identified it can be broken) and helpful from a diagnostic standpoint. In our experience, this recording of the pattern can be particularly helpful for patients in an acute care hospital, where an isolated episode in a patient labeled as having dementia can be presented as an ongoing problem. Unfortunately, acute care hospitals are habituated to sedate difficult patients, not to record patterns of behaviour. It is especially tragic, but not rare, to see a patient with a single episode of agitation trapped in a vicious cycle of drug-induced akathisia from inappropriate use of neuroleptics.

Often, sadly through apathy , institutional design, or intransigence, the environment cannot be readily addressed. To recapitulate and to emphasize: where environmental changes can be brought about, this is preferable. For example, wandering can virtually always be managed nonpharmacologically in an environment designed for patients who wander. Infants who call out are instinctively held; adults who call out are often reflexively sedated. Similarly, in the case of patients who are in institutions, educational interventions with the staff are often very helpful in alleviating behavioural problems, as often by redefining the problematic behaviour as acceptable as by changing it.

Where no precipitant can be found (or in any event changed) then pharmacologic management is commonly the next resort. A pragmatic approach to these instances is to group problems along two lines: those associated with disinhibition (e.g. aggression, agitation, importuning) and those associated with formal thought disorders (e.g. hallucinations and delusions). While neuroleptics have often been used as a mainstay in treatment of both types of problems, it is often the case in the former instances that one can avoid neuroleptics, although newer data suggest that in agitation risperdol can be the drug of choice.
Nevertheless, there are not as much data as one would wish. What we are proposing are suggestions based on our own experience and that of our colleagues (see Table 10.2). These recommendations also are consistent with an American expert consensus panel struck on this topic. (Reference: Alexopoulos GS, Silver JM, Kahn DA, Frances A, Carpenter D. Treatment of agitation in older persons with dementia: the Expert Consensus Guideline. Postgraduate Medicine Special Report April 18, 1998).

Rockwood & MacKnight, 2001. p.167

Rockwood & MacKnight, 2001. p.171

Chapter 10: case 3
Mr T, a 69-year-old man, had been diagnosed with Alzheimer's disease four years earlier and had never had specific treatment for his problems. Six months ago he was institutionalized, an event which had proceeded without much reaction on his part. Over the last few months, however, he has become increasingly restless, and several times has been found wandering into the rooms of neighboring patients. In the last week he has become aggressive with staff members and also with visitors this taking place on a ward in which behavioural problems are common, and the staff are used to dealing with them. No environmental participant is evident. Particularly given the concern over his aggressive interaction with visitors, and his comment to some of them that they must be the ones who are stealing from him, a decision to begin neuroleptics is made.

Commentary
Given that the situation is not acute, that the aggression is stage congruent, that it occurs in the absence of a clear medical or environmental precipitant, and given especially the delusion that visitors are stealing from him, treatment with a neuroleptic is justified. The situation is not acute, and therefore the treatment of choice is risperidol, initiated in doses 0.25 mg b.i.d.

Within a few days Mr T's agitation is noted to be less. He still paces and still wanders into other people's rooms, but he is no longer upset when he is asked to withdraw.

Commentary
Mr T has shown good response to treatment. Of note, not all of his symptoms have subsided. For example, he is still wandering. Nevertheless, in a supportive environment, and one in which wandering is tolerated and which staff are skilled in how to deal with a wandering patient, treatment with low dose risperidol is effective.

At this point, it has been elected to continue treatment for three months with reassessment, and with a view to a trial withdrawal at six months. This approach is undertaken given the natural history of agitation in Alzheimer's disease, which eventually settles.



Taken from Understanding Dementia: A Primer of Diagnosis and Management
Kenneth Rockwood & Chris MacKnight, 2001
Chapter 10, pp 163-166, 167, 171, 177

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