behavioural and psychological symptoms of …...cursing, apathy, repetitive questioning and...

Behavioural and Psychological Symptoms of Dementia (BPSD) Resource Guide for Staff in LTC and CCC

of 23

Bridges to Care Resource Guide: BPSD

BPSD Resource Guide for Staff in LTC and CCC 1.0 Background

Key Concepts:

Behavioural and psychological symptoms in dementia (BPSD) suggest that symptoms can occur at any stage along the progression of dementia and at certain stages virtually all individuals demonstrate some form of BPSD (Reisberg et al., 1989).

BPSDs are associated with caregiver burden and often result in premature institutionalization of the individual with dementia.

BPSD has been described as very common and very significant for individuals with a diagnosis of dementia and they are associated with caregiver burden and often result in premature institutionalization of the individual with dementia (IPA, 2002a). The literature suggests that the most intrusive and difficult BPSD to cope with include: psychological symptoms (delusions, hallucinations, misidentifications, depression, sleeplessness and anxiety) and the behavioural symptoms of physical aggression, wandering and restlessness (IPA, 2002a). Symptoms that are described as moderately common and distressing include: agitation, culturally inappropriate behaviour, sexual disinhibition, pacing and screaming (IPA, 2002a). Common and upsetting behaviours that have been described as more manageable and less likely to result in institutionalization include: crying, cursing, apathy, repetitive questioning and shadowing (stalking) (IPA, 2002a). Understanding the normal functions of the brain and their impact on function and behaviour provides an insight as to why the person with dementia (with damage to certain parts of the brain) might react, interpret and act differently.

“Their reality is not our reality.” Using a structural/functional approach links the common functional, emotional and behavioural changes seen in dementia to the changes within affected regions of the brain. This approach can also provide insights into possibilities of predicting behaviours and therefore exploring appropriate care strategies to prevent or mitigate the negative consequences of these behaviours for the individual, his or her family and others. Appendix 1 includes information sheets regarding the 7 A’s of dementia, including: 1. Anosognosia – lack of insight into one’s deficits or illness attributable to temporo-parietal pathology.

of 23 Bridges to Care Resource Guide: BPSD

2. Amnesia – loss of short-term and long-term memory due to pathology in the hippocampus and/or the temporal lobe. Short-term memory loss causes difficulty learning new information; long-term memory loss causes difficulty recalling previously learned information and occurs in reverse order to the memory storage process (i.e. loss progresses from most recent to most remote). 3. Aphasia – loss of language expression or comprehension. In expressive aphasia (due to damage of Broca’s area of the frontal lobe), the individual may be able to comprehend speech, but is unable to express him or herself. In contrast, a person with receptive aphasia (due to damage of Wernicke’s area of the temporal/parietal lobe) may be able to express him or herself, but has impaired comprehension. 4. Agnosia – loss of ability to recognize people (including self), objects, or sounds despite intact sensory modalities of vision, touch, and hearing. The damaged area is the parietal lobe. 5. Apraxia – an inability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform them, due to impaired motor planning and sequencing processes controlled by the parietal lobe. 6. Altered perceptions - altered depth perception, visual distortions, and altered tactile perception are commonly seen in dementia due to damage to the parietal lobe. 7. Apathy – an inability to initiate activities or conversation due to damage in the frontal lobe. Notes:


2.0 Importance of BPSD

Key Concepts: BPSD are prevalent and persistent; they contribute to cognitive and

functional decline, significant suffering, poorer quality of life for the residents and caregivers, and a reciprocal cycle of resident-staff abuse, as well as increased staff turnover (Barucha et al, 2008).

Especially challenging to staff include: pacing and wondering, restlessness and agitation, trying to get to a different place, grabbing onto people, constant requests for attention and help, complaining and ‘whining’, repetitive sentences and questions, cursing and verbal aggression, making strange noises and screaming.

Resistance to care is a very common BPSD (Puxty et al, 2009).

“It is imperative that all persons with ADRD [Alzheimer’s and Related Dementias], regardless of where they are in the life course of the illness, have opportunities to live meaningful lives across the progression of the illness through active personal and community engagement.” (Alzheimer’s Society, 2006, p. 15)

BPSD can be viewed as an interaction of biological and psychological factors (McCracken et al., 2009). The importance of BPSD is related and put into context when consideration is given to the excess disability, increased hospitalization, premature institutionalization and suffering endured by the individuals and caregivers (McCracken et al., 2009). Allcroft and Loiselle (2005, Eds.) identify that there are a number of behaviours seen in association with dementia that especially challenge staff and caregivers in LTC settings; they include pacing and wondering, general restlessness and agitation, trying to get to a different place, grabbing onto people, constant requests for attention and help, complaining and ‘whining’, repetitive sentences and questions, cursing and verbal aggression, making strange noises and screaming. Unfortunately, resistance to care is a very common BPSD (Puxty et al., 2009). This BPSD can have significant impacts upon the activities such as bathing, dressing, toileting and eating. Caregivers are not always afforded the training to appropriately address BPSD in their residents. Informal and formal caregivers are often challenged by these changes in behaviour and mood, which may be misinterpreted as being volitional or intentional. Consequently, they may respond in ways that damage their relationship with the individual with dementia. As a result, situations can become stressful and uncomfortable for the resident and the staff or caregiver with potential for escalation of the behaviours and erosion of the relationship between the resident(s) and others.


There is a need to help informal and formal caregivers understand that these “challenging” behaviours are not wilful or intentional, but rather occur as a result of an “illness” or “malfunction” of the brain, and represent an individual’s adaptive response to a negative stimulus in their physical, social, or emotional environment. Appreciating the realities associated with BPSD is a foundation to more meaningfully interpret the behaviours of a person with dementia as responsive rather than willful, or purposeful and more likely to promote a therapeutic response. Notes:


3.0 Risk Factors Key Concepts:

There are multiple causes for BPSD both intrinsic and extrinsic to the individual.

BPSD, and potentially hospitalization, come about related to life events that have changed the resident’s social routine and environment.

Caregivers and the environment have the potential to both alleviate and aggravate BPSD through their interactions.

The reason for the appearance and presence of BPSD in individuals is not fully understood (Holmes, 2000) and likely involve multiple intrinsic and extrinsic factors. Some examples of common risk factors include: • Previous personality. Individuals who have previously demonstrated

suspicious, aggressive or controlling behaviours prior to the onset of their dementia are more likely to develop BPSD (IPA, 2002b).

• Changes in circadian rhythm are pronounced in individuals with Alzheimer’s Disease which can result in agitation during the day and restlessness at night.

• Change in social routine and environment are correlated with the emergence of BPSD and the need for hospital admission (Eriksson, 2000).

• Relocation has a significant impact upon individuals with dementia; the resultant effect can be depression, increased risk for mortality, agitation and disorientation for months post-relocation (Anthony et al., 1987).

• Individuals with a cognitive impairment are more susceptible to the effects of stressful life events (IPA, 2002b).

• Caregiver distress and/or poor interpersonal interactions between the individual and the caregiver can significantly contribute to BPSD.

• Modification of caregiver responses to BPSD had the potential to alleviate or even obviate BPSD (IPA 2002b; Ballard 2000; Haupt et al. 2000).

Notes:

of 23


4.0 Prevention Key Concepts:

Prevention strategies for BPSD should be examined prior to the onset, at the time of onset, and after significant events that impact resident’s function or participation within the LTC home.

Caregiver approach and attitudes have the potential to effect change when dealing with behaviours that are distressing to the individual resident, other residents, caregivers and family.

In preventing BPSD, the ideal environment for a resident with dementia is one that is non-stressful, constant and familiar.

When examining the factors discussed related to the risk for BPSD, there are some that are modifiable and others that are not. Prevention of BPSD seeks to identify risk factors that can be modified and should be considered prior to the emergence of BPSD, when symptoms may occur that interfere with the individual resident’s participation in activities and routines (escalation phase), and after the presence of BPSD (de-escalation phase). Preventing BPSD • Environmental Adaptations

o Physical: provision of safe and accessible areas for ambulation use of soft lighting and neutral colours music appropriate to the setting and resident population home-like furniture, decorations and opportunities for residents

to “personalize” their own space within the unit visual barriers at exits, (i.e. painting of a wall mural) provide opportunities for light exposure which can improve

circadian rhythm and ultimately sleep (IPA, 2002c)

o Temporal: consistent daily routine; changes in routine should be as gradual

as possible implementation of sleep hygiene program including: regular

timings, use of bedroom primarily for sleeping, regular timing of meals, reducing evening fluid intake, avoidance of caffeine, nicotine and alcohol, engaging in a bedtime ritual, minimizing light and noise at bedtime and throughout the night

provision of opportunities to participate in physical activity during the day which can improve circadian rhythm and ultimately sleep (IPA, 2002c)

of 23


• Regular assessments of sensory function; fear, anxiety and restlessness may be the result of a resident’s inability to hear or see.

• Supportive Caregiver Characteristics o An empathetic, patient, kind, caring, ‘warm’ attitude toward the resident o Efforts to understand the causality and meaning behind the behaviour o Unhurried and patient attitude o Flexible personality, routines are important but not at all cost o Adaptability and the ability to accept change in the resident o Maintenance of realistic expectations of the resident’s abilities o Tolerance for the presenting BPSD o Commitment to engage the resident in meaningful activities o Fostering a sense of individualism in the resident o Allowing the resident ‘control’ over aspects of care within capabilities

and/or fostering a ‘sense’ of control o Sense of genuine concern for the individual resident, well-being and

interests o Respect for the resident as an individual with emotions and feelings o Maintenance of a sense of humour o Absence of thoughts focused on the resident’s limitations o Foster emotional support structure

Responding to the Behavour(s): • Recognize and identify the Behaviour • Apply the 3 Question Template

1. What has changed? 2. What are the RISKS and possible causes? 3. What is the action?

• Set realistic goals for the resident, staff and family • Encourage progress through positive reinforcement • Continually evaluate and modify based upon resident, family and caregiver

needs Notes:


5.0 Making the Diagnosis If a member on the collaborative care team identifies a significant change in a resident’s condition due to behavioural and psychological symptoms of dementia, the resident’s physician should be notified to determine the permanency of the change. Initial identification of a change should be documented in the progress notes. The P.I.E.C.E.S. - Three Question Template is a useful tool to assist the collaborative care team in identifying BPSD in residents.

Three Question Template – P.I.E.C.E.S. Framework:

1. What has changed? 2. What are the RISKS and possible causes? 3. What is the action?

Seniors need time to interact and engage in meaningful ways; therefore there is a need to create slower paced environments. Understanding the experience of the family/caregiver is vital to ensuring meaningful input is received from the individual residents. The collaborative care team, including all members, is vital to ensuring the care plan is suitable and responsive to the resident’s needs. Engaging in collaborative care provides an opportunity to enhance communication among colleagues as well as to redefine the roles of health care professionals, and to bridge the gap across health care sectors. A network of collaborative interactions across health care sectors (e.g. service providers, patients, families, caregivers and community) is critical when engaging in collaborative care. Roles within the health community need to be seen as part of a health care team rather than independent of each other. Working together allows for a collaborative patient-centered care approach, which fosters the potential for improved patient care, access to health care, improved communication among health care providers and satisfaction of both patients and health professionals. In collaborative care, there is the potential for the overlapping of roles. When this is the case, the team should ensure there is a well-documented description of responsibilities to avoid role confusion. As a member of a collaborative team in health care, each member of the team should be aware of the roles and responsibilities of their own discipline (e.g., PSW, physician, nurse, etc.) to help them to work effectively with others in order to optimize resident care.

of 23 Bridges to Care Resource Toolkit: BPSD

The following is a list of decision aids and assessment tools commonly used and supported by best practice guidelines and the evidence in the literature. The processes and tools have been linked to members of the collaborative care team, and where reprint is enabled, the tool is located in the BPSD toolkit. Non-

Regulated Staff

Regulated Staff

Physicians

Identify changes in behaviour, communication or function within the past week

Order appropriate Investigations & Labs

Rule out drugs Rule out delirium using CAM Rule out Infection Rule out Pain Think 7A’s Review pre-morbid cognitive information

Consider MoCA to compare to previous scores

Consider Mini-Cog to compare to previous scores

Order appropriate Investigations & Labs

Think Depression Consider SIG E CAPS Consider Cornell Scale for Depression

Consider ADLs, IADLs Think Safety, Security, Sensory cues, Structure, Stability


6.0 Treatment “The evaluation and care of unmet needs is always the guiding principle of good (patient) care”. (Cohen-Mansfield and Mintzer, 2005) Key Concepts:

Non-pharmacological treatment should always be considered even when pharmacological treatment is indicated.

Every member of the collaborative care team has a role in the implementation and the monitoring of treatments.

All behaviour has meaning and is rooted in an individual’s needs; treatment should seek to address the underlying need, not the resultant behaviour.

6.1 Non-Pharmacological Treatment It is critical that all members of the collaborative care team have a common understanding and appreciation of the possible non-pharmacological options and alternatives. This increases the likelihood that the actions by each caregiver and the group will be consistent and supportive of the agreed care plan.

Treatment Summary Behavioural Therapy - Modeled after conditioning and learning theory.

- Antecedents, (undesired) behaviours and consequences (ABCs) are identified and explained to the patient.

- Charts and diaries are often used to detail the triggers and reinforcers of an undesired behaviour, and interventions are identified.

- Some evidence in “reduction of wandering, incontinence and other forms of stereotypical behaviours.”

Reality Orientation - Mainly a treatment for memory loss. - Achieved by using “reminders” (e.g. signposts and

notices) that reorient the patients by providing facts about themselves.

- Con: May depress mood by reminding patients of their memory loss.


Validation Therapy - Theory explains that “individuals with dementia may retreat into an inner reality that is strongly biased to emotion (over intellectualism) as a means to avoid stress, boredom and loneliness.”

- Treatment involves exploring the “meanings hidden behind confused speech and behaviour.”

- Improves mood, decreases negative affect, behavioural disturbance, helps patients develop insight into reality.

- Can be used in an individual or in a group setting. - Efficacy is debated.

Reminiscence Therapy - Treatment involves reliving past experiences that are significant and positive to the individual.

- Attempts to provide pleasure and cognitive stimulation.

- Can be used in an individual or in a group setting. - Evidence does not suggest significant efficacy.

Art Therapy - Attempts to provide meaningful stimulation, improve social interaction and levels of self-esteem through self-expression and allowing the individual to make decisions in their creations.

- Lacks empirical evidence as to efficacy.

Music Therapy - Treatment ranges from musical activities (e.g. singing or playing instruments) to merely listening to music.

- Some evidence that it improves mood, social interaction and memory, as well as decreasing abnormal vocalizations and agitation.

Activity Therapy - Treatment involves recreational activity such as dance, sport and drama.

- Reduces falls and improves mental health and sleep. - Some evidence that daytime exercise reduced

daytime agitation and night-time restlessness. Cognitive-Behavioural Therapy

- A form of psychotherapy. - Treatment involves specific instructions/manuals

aimed at restructuring the (erroneous) thoughts and reactions of individuals so as to eliminate or suppress undesired behaviours.

- Can be used in individual and group settings. - May be unusable in the severely demented.

Interpersonal Therapy - Treatment involves “conceptualizing the individual’s distress into four domains: interpersonal disputes; interpersonal/personality difficulties; bereavement; and transitions/life events.”

- Some studies show efficacy but relatively new in its application in dementia.

Adapted from Douglas et al. (2004)


6.2 Pharmacological Treatment In order to help health care professionals identify appropriate use of pharmacological treatments, the following questions have been developed as a part of the P.I.E.C.E.S. training. Three Questions for Detecting, Selecting and Monitoring the Use, Risk and Benefits of Psychotropics

1. Detect: When should a psychotropic be used or considered? 2. Select: How do I contribute to the selection of the right medication? 3. Effect: How do I monitor the response and side effects?

All members of the collaborative care team are responsible to communicate and assist the prescribing physician by providing pertinent information and identifying patients who may be candidates for pharmacological treatment. Furthermore, these individuals can assist in establishing a baseline frequency and intensity of symptoms that will require monitoring during treatment. When to use a Pharmacological Treatment of BPSD? Consider pharmacological treatment of BPSD when:

1. Behaviour is dangerous, distressing, disturbing, damaging to social relationships and persistent

AND 2. Has not responded to comprehensive non-pharmacological treatment plan including removal of possible offending drugs

OR 3. Requires emergency treatment to allow proper investigation of underlying problems

Important Basic Principles to Consider When Prescribing Medications for BPSD:

Correct or optimize treatment for underlying diagnosable medical conditions

Remove drugs that may be contributing to the BPSD Use one drug at a time Start low, go slow but optimize the dose and duration of treatment Choose drugs that won’t worsen dementia Check for potential drug-drug interactions


Behaviours NOT (usually) Responsive to Medication

Behaviours that may be Responsive to Medication

Aimless wandering Physical aggression Inappropriate urination/defecation Verbal aggression Inappropriate dressing/undressing Anxiety and restlessness

Annoying preservative activities Sadness, crying, anorexia, insomnia and other symptoms indicative of depression

Vocally repetitious behaviour Withdrawal and apathy Hiding/hoarding Sleep disturbance

Pushing wheelchair bound co-patient Wandering with agitation/aggression Eating inedibles Elation, pressured speech and hyperactivity (manic-like

symptoms) Tugging at/removal of restraints Persistent delusions and hallucinations

Sexually inappropriate behaviour with agitation Selecting the Right Medication The risks and severity of the presenting problems will help define the need for specific immediate interventions for those behaviours that may adversely affect the individual and/or caregiver. Classes of medications commonly used in BPSD

Antidepressants Anxiolytic (mostly SSRIs and other antidepressants) Antipsychotic medications Cognitive enhancers Mood stabilizers

Non-pharmacological interventions need to be continued during the implementation of pharmacological treatment. Notes:


7.0 Prognosis

Key Concepts:

The prognosis for BPSD is as variable as the course of dementia itself; flexibility is key for residents and staff within the LTC home.

Individualized, multidisciplinary interventions are helpful (Opie et al., 2002).

“If, when I come into the unit in the morning I see all the beds made, and the residents all dressed, I am concerned. But, if I see that not everything has been done, and that staff members are eating breakfast and joking with the residents, I know everything is just fine.” (Cohen-Mansfield and Bester, 2006)

• Flexibility is an essential ingredient in person-centred care (Cohen-

Mansfield and Bester, 2006) o With BPSD there needs to be adaptation to the individuals’ care

needs, preserved abilities or capabilities, habits, preferences and limitations (cognitive, sensory and/or physical)

• The potentially positive outcome for interventions, and ultimately the prognosis around BPSD is linked to the interventions themselves, the ability of staff to be flexible, work together and provide person-centred care.

• Non-pharmacological interventions linked to positive outcomes include: o behavioural techniques, staff training (e.g. P.I.E.C.E.S., U-FIRST) o environmental modifications o group programs (e.g. exercise, dancing) o light therapy o music therapy o social interaction and/or psychosocial activities o multimodal approaches o pet therapy o aroma therapy

Notes:


8.0 Resident and Family Education Key Concepts:

Be aware of the signs of caregiver stress. Seek to reduce caregiver stress. Link families and caregivers with information and organizations that will

enable and foster resident-centred care.

Caregiver Issues One of the major reasons for caregiver stress is the new and challenging demand on a caregiver’s time and energy. A caregiver may be spending an increasing portion of their day alone, seeing to the needs of their loved one, or even simultaneously juggling family and professional time with caregiving demands with no respite in sight. Here are some of the warning signs that this may indeed be an issue: 1. Excessive anxiety and tension 2. Debilitating depression 3. Persistent anger or guilt 4. Overreactions and emotional outbursts 5. A general feeling of exhaustion 6. Difficulty concentrating 7. Increasing isolation 8. Trouble sleeping 9. Increased health problems 10. Excessive use of medications, drugs or alcohol


Appendix 1: The 7 A’s of Dementia Anosognosia: No Knowledge of Illness or Disease

Deficits: • (Greek) a = no; nosos =illness/disease; gnosia

= knowledge of) • lack of insight into deficits or illness • person lives in the present, but accesses a life

of the past (when they were well) • unable to understand or perceive that they need

assistance • particularly likely if temporo-parietal pathology • behavioural and safety issues result

Associated Behaviours:

may unknowingly place self at risk in a number of domains, for example: o self-transferring or ambulating when not physically able o driving o doing finances

may not realize that they are in a hospital or long-term care home (they may think they are at home, at work, at school etc.)

may be unaware of consequences of behaviour on others, i.e. “how it makes other people feel”

may become angry with caregivers or resist care, including becoming physically aggressive (e.g. pushing away, slapping, or kicking)

Effective Care Strategies for Anosognosia: explain to family members and care givers that behaviours such as resistiveness,

anger, and aggression are not wilful or intentional use a non-confrontational approach to resistive or aggressive behaviours avoid punitive approaches that attempt to instil remorse, or belabour how the

person’s behaviour makes other people feel realize that negative interactions may provoke an angry or frustrated mood that

persists all day if required, caregivers should “step back” and regain their composure prior to

responding to the resistive or aggressive behaviours when re-approaching the individual, smile, use positive words and a friendly and

relaxed tone. This approach is crucial to the success of a second attempt if a caregiver needs to proceed with a task or activity


The 7 A’s of Dementia Amnesia: Loss of Memory Deficits:

• short-term memory loss: difficulty learning new information

• long-term memory loss: difficulty recalling previously learned information

• in dementia, long-term memory loss occurs in reverse order; i.e. the last thing learned is the first thing lost

• the individual with dementia lives in the present, but can only access information from the past. This dissonance can lead to fear and anxiety, resulting in a variety of responsive behaviours

• “The person’s reality is not our reality.”


an inability to remember what happened this morning or last week, but able to remember information from a long time ago (memory loss in reverse order)

becoming anxious, overwhelmed, or frustrated by too much new information accusing others of being imposters, withholding information, stealing, or not visiting becoming suddenly uncooperative with familiar tasks or activities refusing assistance with care repeating questions, comments or behaviours experiencing “Time Warp Delusions” - a past memory triggered by a present stimulus

that can potentially cause extreme emotional reactions or misinterpretation of events

Effective Care Strategies for Amnesia: use memory aides or reminders such as:

o keeping a diary or other visible written schedules for “bath days” o using a “signing book” for visitors o displaying pictures of loved ones, family and friends

repeat information without indicating that the information has been provided previously validate experiences of the past while redirecting the individual to more pleasant and

meaningful activities in the present create a “memory trail” to enable new learning by doing important tasks the same way,

every day. Routines are important rather than confronting them it may be helpful to offer to look for the missing items


The 7 A’s of Dementia Aphasia: Loss of Language Deficits:

• two types: o expressive aphasia (Broca’s area) o receptive aphasia (Wernicke’s area)

• a person with expressive aphasia may be able to comprehend speech, but is unable to express him or herself

• a person with receptive aphasia may be able to express him or herself, but cannot understand what is being said

• despite impairment in the person’s expressive and receptive language functions, he or she often remains responsive to non-verbal communications of others (e.g. facial expressions and gestures)


difficulty following conversations, especially more than one social withdrawal word substitution or using the wrong word which leads to inappropriate statements or

requests reversion to first language (even if not used for number of years)

Effective Care Strategies for Aphasia: suspect the presence of expressive and receptive aphasia maintain a high index of suspicion for pain, discomfort, or other symptoms that the

individual may not be able to express use positive, supportive non-verbal communication that conveys calmness, reassurance

and kindness, e.g. facial expressions, body postures, tone of voice, etc.


The 7 A’s of Dementia Agnosia: Loss of Recognition Deficits:

• loss of ability to recognize: o people (including self) o objects o sounds,

despite intact sensory modalities (vision, touch, hearing)

• three types of agnosia: o visual (objects, faces, words) o auditory (sounds) o somatosensory (objects via touch)

• faces, objects, sounds, etc are perceived, but not recognized due to a disconnection between senses and memory

• leads to altered behaviours, interactions, and interpretations of others, objects, or sounds


loss of recognition of people in the reverse order that they came into the person’s life (e.g. grandchildren are forgotten first)

a belief that they are much younger than their actual age causing them to become confused at having an “older” spouse, or adult children that are the same age as they are

delusions that a family member or care provider is an imposter “inappropriate” sexual behaviour resulting from deluded self-perception and

misidentification of others becoming disturbed by mirrors, especially when reflecting the person (and other

caregivers) in their most personal space (e.g. bedroom/bathroom). The individual may not recognize self or other caregivers, so the perception is of a stranger(s) watching them undress, bathe, or toilet

inappropriate use of objects, or forgetfulness of the purpose of the object (e.g. toothbrush, faucet, toilet)

defensive or protective reactions when care involves the use of “unfamiliar” objects (e.g. caregiver trying to brush teeth causes resistance)

impaired auditory recognition (e.g. a cat meowing may be thought to be a crying baby)

Effective Care Strategies for Agnosia: remove or reverse mirrors mimic the use of an object (such as toothbrush or face cloth) prior to handing it to the

person or administering care provide reassurance that the person in the environment is a family member or a care

provider who is there appropriately


The 7 A’s of Dementia

Apraxia: Loss of Purposeful Movement

Deficits: • an inability to execute or carry out learned

purposeful movements, despite having the desire and the physical ability to perform the movements

• it results from impaired motor planning and sequencing processes

• an inability to plan, sequence and execute the steps of particular tasks

• an impairment in the ability to attend to or focus on a task


the tendency to shift from one task to another, especially when distracted dress apraxia: an inability to sequence the layering of clothing or a lack of coordination

for putting on an article of clothing difficulty with push-button items, remote controls, microwaves, touch-tone phones experiencing frustration or anger if tasks are too difficult, unfamiliar, or have multiple

steps and demands that may exceed capabilities apparent “refusal” to participate in care by saying ”no” to a suggested task or activity,

despite the fact that they may appear physically able. It may not mean he or she does not want to do it, but rather that the person does not remember how

Effective Care Strategies for Apraxia: explain to care providers the impact that apraxia may have on the observed behaviours set out clothes in the correct order, from top to bottom, to facilitate independent dressing provide step-by-step instructions while allowing the person to proceed independently

with each step, thereby preserving privacy and dignity minimize distractions that compete for attention whenever feasible, provide visual cueing by dressing at the same time as the person

with dementia (e.g. a spousal care provider setting out clothes in the morning or a staff member demonstrating putting on a coat to go outside)


The 7 A’s of Dementia Altered Perception

Deficits: • during the course of dementia, a person

may experience altered sensory perceptions such as:

o altered depth perception o visual distortions o altered tactile perception

• loss of depth perception impacts greatly on the ability to mobilize freely through the environment, and it changes the way the person walks and sits.

• visual distortions are common and may cause misperceptions of objects, causing fearful behaviours


verbal or physical resistance to bathing (water is perceived to be much deeper than it actually is; the individual may believe they are at risk of drowning)

jumping over dark thresholds (looks like a crevasse) or dark tiles in floor (looks like a hole)

avoiding dark flooring (appears as body of water or ditch) or flooring with bold patterns (appears as obstacles)

misinterpreting objects for people (clothing on a chair, pole lamps, etc.) misperceptions that people on TV are in the room, causing the person to talk to the TV

or perhaps become very distressed by it when sitting, the person may cautiously put a hand on the edge of the seat, brush the

edge of the seat with a lower leg, and then sit on the edge or even arm of the chair. Although the person may be encouraged to move to the middle, he or she may not be sure where the middle is or how far down, or how far over to go

when walking, the person takes a more stooped pose, feet slightly apart, shoulders hunched, and knees bent a bit. The person ignores the peripheral visual fields because there is only so much information the brain can handle. The person focuses only on what is directly in front, therefore looking either straight ahead or down (mostly down)

an inability to relate to space causing frequent bumping into objects and/or people Effective Care Strategies for Altered Perception: identify an individual’s perceptual difficulties and understand how they may cause the

behaviours seek to minimize misperception by appropriate lighting and use of colors problem-solve around how to maintain safety for the person and others


The 7 A’s of Dementia Apathy: Loss of Initiation

Deficits: • inability to initiate activities or conversation • often interpreted as a sign of depression • a loss only of the ability to initiate – usually

able to participate if engaged by caregiver


sits in front of a meal without touching it until a care provider initiates the activity spends most of the day in silence, chin on chest, without initiating conversation.

However, when approached and called by name, can lift head, make eye contact, smile, and possibly converse

Effective Care Strategies for Apathy: initiate an activity (e.g. eating) by using verbal cues or hand-over-hand

technique. This may be sufficient to enable the person to complete the task or activity independently.


behavioural and psychological symptoms of …...cursing, apathy, repetitive questioning and...

Documents