Dementia Conference 2014
Guildford & Waverley Clinical Commissioning Group
Dr. Lia Ali
Consultant Psychiatrist to G&W Virtual Ward
What do people with
advanced dementia
live with?
Behavioural & Psychiatric
Symptoms (BPSD)
Psychosis
• Hallucinations
• Delusions
• Misidentification
Aggression
• Physical aggression
• Verbal Aggression
• Aggressive resistance to care
Depression
• Sad
• Tearful
• Hopeless
• Guilty
• Anxiety
Apathy
• Withdrawn
• Lack of interest
• Amotivation
Agitation/Motor
• Wandering
• Restlessness
• Sleep disturbance
• Repetitive actions
• Screaming
Differing dementias
Alzheimer’s
disease
Apathy, agitation,
irritability, anxiety,
depression,
(delusions &
hallucinations are
less common)
Vascular dementia
Apathy, depression,
delusions, emotional
lability
Dementia with Lewy bodies & Dementia
in Parkinson’s disease
Visual hallucinations, delusions, depression,
sleep disturbance (REM sleep-behaviour
disorder)
McKeith & Cummings 2005
Corticobasal
degeneration
Depression
Progressive
supranuclear palsy
Apathy, disinhibition
Causes of BPSD
Cognitive
factors
Psychological
factors
Social
factors
Biological
factors
Physical
factors
- Neuroanatomy
- Neurochemistry
- Genetics
Causes of BPSD
Cognitive
factors
Psychological
factors
Social
factors
Biological
factors
Physical
factors
- Amnesia
- Agnosia
- Apraxia
- Aphasia
- Visuoperceptual
- Executive function
Causes of BPSD
Cognitive
factors
Psychological
factors
Social
factors
Biological
factors
Physical
factors
- Illness
- Delirium
- Pain
- Medication
- Fatigue
- Constipation
- Basic needs
(dietary, toiletry)
Causes of BPSD
Cognitive
factors
Psychological
factors
Social
factors
- Social network
- Family
relationshipsSocial
interactions
(caregivers, residents)
Biological
factors
Physical
factors
Causes of BPSD
Cognitive
factors
- Premorbid
personality
- Previous
mental health
- Previous
trauma/losses
- Adjustment
- Lifelong coping
strategies
Psychological
factors
Social
factors
Biological
factors
Physical
factors
Causes of BPSD
Cognitive
factors
Biological
Psychological
factorsEnvironmentfactors
Social
factors
Physical
factors
BPSD: persistent throughout disease course
• Prevalence of BPSD varies at different stages of the disease process
Lovheim et al.,
(2008)
Cognition
•Depression
•Anxiety
•Psychosis
Later:
Severity
Earlier:
•Agitation
Behavioural
disturbance
Time
•Wandering
•Apathy
ABC chart
ABC Chart for Mr X
Please record ALL incidents of aggressive or inappropriate behaviour as this will help us to devise the most effective
strategies for managing his behaviour.
Antecedents
Behaviour
Consequences
Antecedents consist of both the setting conditions (which increase the
likelihood of a behaviour occurring) and the immediate triggers to the
behaviour.
Setting conditions
How was the person feeling before the behaviour? e.g. feeling low in mood,
tired, ill, in pain, bored, etc.
Triggers
What was happening before the incident? e.g. he was being washed, being
asked to transfer out of bed, being asked what he wanted for lunch, pad was
being changed, he was being asked something, etc.
Where did it happen? e.g. in the person’s room, in the community, etc.
Who was involved?
Give as full a description as
possible of what the person was
doing, including physical aspects
(e.g. hitting, throwing, being sexually
disinhibited) and verbal aspects (e.g.
shouting, swearing).
Record what the person actually
said.
How long did the behaviour last
for?
How severe or intense was the
behaviour?
What happened as a result of the
behaviour?
What did you do to try and manage
the behaviour?
How well did that work?
What was the behaviour of the person
like after the incident?
Mr X became angry,
shouted that he wanted us
to go, swore at us and then
threw a cloth at us. He
remained agitated for 10
minutes.
We stopped the activity and
gave Mr X time to calm
down. We then explained
why we needed to wash him.
We explained that he should
tell us when the pain was too
much for him and we would
stop for a break. He calmed
down and agreed to be
washed. We explained what
we would be doing at each
step and checked his pain
levels during it, stopping for a
break when it was too much.
SETTING CONDITIONS
TRIGGERS
Mr X reported that he had
been feeling tired as he
hadn’t slept well last night
due to pain, and was
continuing to experience
pain.
Mr X was being washed and
having his pad changed in
his bedroom by myself and
another HCA, Jon.
Management – other non-pharmacological
Treat the underlying cause
Aromatherapy (Ballard, lemon balm)
Multisensory stimulation
Therapeutic use of music and/or dancing
Animal-assisted therapy
Massage
Signage
The evidence suggests for Agitation in AD
If you have to prescribe a drug….
Risperidone 0.5mg bd for 6/52
Less evidence for alternative antipsychotics
Quetiapine – evidence of non-efficacy
Cholinesterase inhibitors and memantine – not effective acutely or in
prophylaxis
So in conclusion – courtesy of Prof Howard
What to do
Cholinesterase inhibitors and, to a
lesser extent, memantine offer
modest symptomatic benefits for
cognitive symptoms at all stages
Try to avoid drug treatments for
behavioural symptoms and only
use the licensed agent
What not to do
Don’t raise unrealistic expectations
about the impact of symptomatic
cognitive treatment
Benzodiazepines generally make
people with dementia worse
The fewer psychotropics the better
Want to know more?
IMPARTS Course
Mental health skills for non-mental health professionals
distressed patients; confusion/dementia; substance misuse;
medically unexplained symptoms; managing conflict.
29/01/2014 and 26/02/2014 with additional e-learning
Lia.ali@kcl.ac.uk
MSc in Advanced Care in Dementia
mscacid@kcl.ac.uk