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Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond RedirectionPart IV

Margaret Hoberg MSN, GNP-BCSiobhan McMahon MSN MPH GNP-BCIn modules I and II and III we discussed dementia, its causes symptoms and typical progression. We also discussed how the effects of dementia often change behavioral expressions. Through the Need-driven Dementia-Compromised Behavior theory we were able to view behavioral symtpoms a bit differently. Instead of veiwing them as a problem, we learned to view them as a symptom, as a clue to what a person may be trying to tell us about his/ her emotional, social or physical health and needs.

We discussed a strategy to assess what might be causing the behavioral change and also how to describe the behavioral change in a way that will be helpful to assess/ evaluate it over time after various interventions and such.

1Learning ObjectivesExplain the effects of dementia on thinking, emotions and communicationUse a theory to help explain behavioral and communication changes associated with dementia and to guide interventionsRespond to behavioral changes with a calm, validating approachComprehensively assess verbal and nonverbal messages, including those that are associated with stressDevelop a plan whose non-pharmacological interventions reflect an understanding of and respect for the person and their preferences.Objectives

Module III of this presentation about dementia will focus on interventions to trial after you have completed your thorough assessment. 2Making a plan:Treat acute illness or exacerbation of chronic illness Manage dehydration, hunger, and thirst or wetnessManage painTrial scheduled Tylenol Remove offending medicationsAttend to patients sleep and eating patternsReplace poorly fitting hearing aids, eyeglasses, and denturesEnsure tailored activities are scheduledDevelop a structured schedule (predictability is helpful)Ensure 1:1 meaningful interactions at least 2x/day for 20 minutes (reminiscence, storytelling, reading)

3After thoroughly assessing and identifying interventions that may work , setting up a plan and communicating it to the whole team will be key. It will no doubt have a many different interventions for different times during the day.

Persons with dementia do well when there is structure and routine in their environments. So once effective and desired interventions are identified, develop a schedule so that all loved ones and caregivers are aware of and can support the scheduleDocumenting Target BehaviorsProblem-solving requiresgood documentation!Demanding? In what way?Disoriented? To time? Place? Or person?Delusional? What about? What did she say? Do?Agitated? What movements, words, actions indicate agitation?

Evaluating a plan It's important to document what happens in very specific terms. Generalizations are not helpful in better understanding what causes or precipitates behavior, whether catastrophic or confused. Describe the behavior!! Is the person-- demanding? In what way?-- disoriented? In what sphere? time, place, person, thing?-- delusional? What about? What did she say? Do?Specific description is needed to know what might be causing the problems.What was happening in the environment before the catastrophic response? Who was the patient interacting with? At what time of day? In order to find develop interventions to reduce the risk that behavioral symptoms occur, we MUST know what the triggers are!Evaluating the plan

Evaluate CareSleep patternsWeightFood & fluid intakeIncidents and outburstsHow often?How long?How severe?Medication useAnd finally there are a lot of things that can be monitored to evaluate whether these interventions are really being helpful to the person.* Sleep patterns: If stress is kept at a manageable level through out the day, they should be less restless during the night* Food intake/Weight: By simplifying the environment (like reducing noise and confusion during mealtimes and offering food that is understandable to the person), nutrition and hydration can be maintained* Incidents/Outbursts: The number of times the person experiences PLST behaviors should be reduced if caregivers are effectively managing daily routines to reduce stress* Medication use: Less medication should be needed if we substitute nursing care strategies and meaningful activities that calm, soothe, reassure, and occupy the person in meaningful ways so that the person is not concentrating on distressing thoughts and behaviors* Family's feedback: The calmer, more functional and engaged the person with dementia is, the greater the likelihood that family members will be satisfied with their loved ones care; ask them what their observations have been. What have they noticed that works? What have they noticed that doesnt work? EvaluationOnce you choose intervention, include it in the plan, implement it , evaluate and re-evaluate its effectiveness, discuss the situation with the person, their family and the interdisciplinary team then adjust the plan accordingly.

6Need-driven Dementia-Compromised Behavior Theory: Lillian Background factors Heart diseaseMixed vascular/Alzheimers dementia in moderate stage OsteoarthritisBehavioral symptomsHitting othersRefusing helpRepeating statementsProximal factors Boredom,Pain not controlledIncreased confusion

So going back to our case study Lillian. We had identified backgroud factors that may contribute to her current behaviors as Heart disease, mixed vascular and Alzheimers dementia, and osteoarthritis.

Proximal factors in her situation are boredom, pain that is not controlled and increased confusion.

Her expressions of stress and not feeling well are through changing behaviors. Some may label these as agitation or anxiety, but describing the specifics of hitting others, refusing assistance from others and repeating statements are more specific. These are actually the target behaviors that will be helpful to monitor over time and as you trial various interventions. 7LillianPlan: Initial interventions included referring husband to Alzheimers Association support group; Risperdal .25mg BID; Inderol; Ativan TID and prn; lortab scheduled.

Initial Evaluation: Falls, confusion, exit attempts, resistance to care, periods of apathy all continued. Functional status declined.Over the course of several months, Lillians plan evolved. It included

Upon evaluation she was found to be falling on a regular basis, have periods of hieghtened confusion, trying to exit her home and the facility, resisting assistance from others. At other times, she would sit in her room alone, not engaging in any activity or conversation. Her ability to complete her activities of daily living was diminishing. 8Need-driven Dementia-Compromised Behavior Theory: Lillian Background factors Heart diseaseMixed vascular/Alzheimers dementia in moderate stage OsteoarthritisBehavioral symptomsHitting others (risperdal; ativan; inderol)Refusing helpRepeating statementsExiting attemptsApathy

Proximal factors Boredom,Pain not controlledIncreased confusion Caregiver stress (AA referral)Falls

Placing the re-evaluation of lillians situation into the context of the need-driven dementia compromised behavioral theory, it is easy to see that there are now additional aggravating factors, falls and caregiver stress, and additional behaviors (exiting and apathy)

Thus, addiitonal assessment, planning and intervention trials are necessary. 9LillianAdjusting the Plan: Treated for UTI, Gradual Medication changes Structured environment /tailored activities (including in cooking group; walks daily; encouraging to make day to day decisions; reminiscing, group music)Several team-family meetings to develop planRe-evaluation:Falls stoppedAmbulatory with walker againNo more exiting or refusing cares.Still wishes she could live with husbandOccasional anger with staff and husbandOccasional excessive worry about a health issue.After meeting with the interdisciplinary team additional potential problems were identified and treated including treatment for a UTI.

When taking a close look at her medications and the bheaviors they were targeting (hitting others; resisting cares), it was clear they were not having an effect. The majority of medications cannot or should not be stopped abruptly, thus a plan was made to descrease one medication at a time, slowly. At first the ativan was slowly weaned over the course of a month. Second the inderol was changed to a beta blocker that did not cross the blood brain barrier. Finally after 2-3 months, her risperdal was decreased. With each change, target behavior frequency, intensity and duration were monitored on a daily basis.

In addition to medication changes and treatment for a UTI, staff and family developed new routines and activities for Lillian. They created a schedule for her. Each day she participated in 1-2 group activities and staff spent time with her 1:1. She liked to help in the kithchen, which they encouraged and assisted her with. Even if it was just stirring the batter for the muffins, staff gave her positive feedback and talked with her during the process. Other activities she enjoyed included the reminiscing group and live music when they had it. Over time she gained strength and became less apathetic. She actually started walking again so outdoor strolls became incorportated into her routine.

Upon re-valuation this time, lillian was having fewer target behaviors and seemed more active and engaged. Her husband was very pleased. It is not that all of her communication patterns and worries had dissipated; they hadnt. She still on occasion talked about going home and became excessively worried about a health problem (e.g. a rash on her arm). She also occasionally became angry with her husband or a staff member for reasons that were unclear. The difference with the updated plan of care and these behaviors was that they were less frequent, less intense and shorter lived. 10EllaA 82 -year-old woman propelling self in WC (use to walk), eating less, losing weight. Late at night she tends to pace throughout the assisted living; often entering other residents rooms thereby interrupting their sleep. When approached she at times becomes angry and swearsShe has stable Coronary Heart Disease and no other illnesses. She is widowed, her daughters are close to her and call her daily. They visit every 1-2 weeks from Grand Rapids MN. Gets assist of 1 with ADLs; able to express needs-- often nonverbally; Her sleep is intermittent; sleeps a lot during the day and for a few hours during the night. She loves spaghetti but needing more cueing to eat. Nurses wonder if ambien or something for sleep would help to correct her sleep/wake cycle changes and make her more comfortable. 11Additional assessmentPhysical examReview HistoryObserve antecedents and consequences to behaviorDiscuss with daughtersObserve caregiver responses

12Need-driven Dementia-Compromised Behavior Theory: Ella Background factors CADWidowedOsteoarthritisStrong family supportBehavioral symptomsPacing at nightAnger with swearing at nightProximal factors Sleep wake cycle alteration

13EllaAcute illness, pain, unmet physical social or emotional need ruled out; what will you recommend next : Ambien 2.5mg po q HS or Ativan 1 mg po q HS prnRefer for psychotherapy or psychiatry Ignore night time behaviorsUse stepped re-direction to encourage patient to sleep instead of wander at night. Design strategies to develop an activity plan during the day based on her preferences.

14EllaAcute illness, pain, unmet physical social or emotional need ruled out; what will you recommend next : Ambien 2.5mg po q HS or Ativan 1 mg po q HS prnRefer for psychotherapy or psychiatry Ignore night time behaviorsUse stepped re-direction to encourage patient to sleep instead of wander at night. Design strategies to develop an activity plan during the day based on her preferences.

15SUMMARYPersons with dementia may express their basic needs and feelings in different ways (verbal, non-verbal and behavioral). When a resident has different behaviors, think about the Need-driven Dementia-Compromised Behavior Theory and then begin assessing for Background factors (medical illnesses , history)Proximal factors (delirium / pain / environmental stress / Unmet physical, social or emotional needs)Describe the behavior in specific terms instead of general terms to help monitor over time16SUMMARYNon-pharmacological interventions are considered first linePsychotropic medications, benzodiazipines , medications with anti-cholinergic properties, and hypnotic agents have dangerous side effects and limited efficacy.Collaborate with caregivers, loved ones and other health care professionals to choose individualized interventions that reflect the residents preferences, past hobbies, personality.

17SUMMARYConsider these non-pharmacological strategies as first line:Activities that are tailored to patients preferences, cognitive status, and energy level (Simple pleasures, music, aromatherpy, walking, chair exercises)Physical environments that minimize social and spatial crowdingStaff trained to be sensitive and to validate the non-verbal expression of emotionIndividualized schedules that use varied activities to correct arousal imbalanceUse verbal and non verbal communication that is positive including validation approachesThink of redirection as stepped redirection (validate concerns, make a plan to investigate, invite to discuss, invite to help with )

18ReferencesGitlein, L., Winter, L., Vause Earland, T., Herge, E.A., Chernett, N.L., Piersol, C.V., & Burke, J.P. (2009). The tailored activity program to reduce behavioral symptoms in individuals with dementia: feasibility, acceptablity, and replication potential. The Gerontologist, 49, 428-430.Kverno, K.S., Black, B.S., Nolan, M.T., Rabins, P.V. (2009). Research on treating neuropsychiatric symptoms of advanced dementia with non-pharmacological strategies 1998-2008: a systematic literature review. International Psychogeriatrics, 21, 825-843..Kolanowski, A., Litaker, M., Buettner (2005). Efficacy of a theory-based activities for behavioral symptoms of dementia. Nursing Research, 54, 210-228. Kovach, C.R.; Kelber, S.T. Simpson, M., Wells, T.(2006). Behaviors of nursing home residents with dementia examining nurse responses, Journal of Gerontological Nursing, 13-21.Smith, M. (2005). Revised from K.C. Buckwalter and M. Smith (1993), When You Forget That You Forgot: Recognizing and Managing Alzheimers Type Dementia, The Geriatric Mental Health Training Series, for the John A. Hartford Center of Geriatric Nursing Excellence, College of Nursing, University of Iowa.Watson, N.M. (2005). Simple pleasures a new intervention transforms one long term care facility. American Journal of Nursing, 105, 53-55.19