Managing Behavioral Symptoms of
Dementia in a Person Centered Care
Environment
Elizabeth Weingast , RN, MSN, GNP
VP Clinical Excellence
Orah Burack, MA Senior Research Associate
Jewish Home Lifecare
Type Contact Information for Presenter Here
What is Dementia?
Dementia is a general term for a decline in mental
ability severe enough to interfere with daily life.
Alzheimer’s 60-80% of dementias
Vascular Dementia
Dementia related to other diseases – Parkinson’s,
Huntington’s
Reversible causes – thyroid disease, vitamin B12
deficiency
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While symptoms of dementia can vary
greatly, at least two of the following core
mental functions must be significantly
impaired to be considered dementia:
·Memory
·Communication and language
·Ability to focus and pay attention
·Reasoning and judgment
·Visual perception
Stages of Alzheimer’s Dementia
Staged from 1 – 7 , no impairment to very
severe cognitive decline
Stage 3 “mild cognitive decline”
Stage 6 – common access point to nursing
home care
•Stage 6: Severe cognitive decline
(Moderately severe or mid-stage Alzheimer's
disease)
•Memory continues to worsen, personality changes may
take place and individuals need extensive help with daily
activities. At this stage, individuals may:
•Lose awareness of recent experiences as well as of
their surroundings
•Remember their own name but have difficulty with their
personal history
•Distinguish familiar and unfamiliar faces but have
trouble remembering the name of a spouse or caregiver
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•Need help dressing properly and may, without
supervision, make mistakes such as putting pajamas
over daytime clothes or shoes on the wrong feet
•Experience major changes in sleep patterns — sleeping
during the day and becoming restless at night
•Need help handling details of toileting Have
increasingly frequent trouble controlling their bladder or
bowels
•Experience major personality and behavioral changes,
including suspiciousness and delusions (such as
believing that their caregiver is an impostor)or
compulsive, repetitive behavior like hand-wringing or
tissue shredding
•Tend to wander or become lost
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CMS – approach to behavior management in nursing
homes
Rise in use of antipsychotics for control of behaviors
23-25% of nursing home residents prescribed antipsychotics
Often without diagnosis of psychosis
Atypical antipsychotics (Seroquel, Risperidal, Zyprexa) carry a black
box warning for people with dementia due to increased risk of
cardiovascular events, including stroke or heart attack.
No research supporting us of these medications for behavioral
symptoms of dementia
Goal to reduce use by 15% over six months in 2012
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CMS approach – Education and Survey Focus
•Person Centered Care
•Quality and Quantity of Staff
•Thorough Evaluation of New or Worsening Behaviors
•Individualized Approaches to Care
•Critical Thinking Related to Antipsychotic Drug Use
•Engagement of Resident and/or Representatives in
Decision Making
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Person Centered Care
Greenhouse Model
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Comfort First
Understanding Behavior as Communication
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Programming and Training
Modeling Communication
Personal Care approaches
Meaningful activities
Special Care Units – inconclusive outcomes
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Music and Memory
Everyone benefits from a calmer, more
supportive social environment.
Staff regain valuable time previously lost
to behavior management issues.
There is growing evidence that a
personalized music program gives
professionals one more tool in their effort
to reduce reliance on antipsychotic
medications
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http://www.youtube.com/watch?v=5FWn4JB2YLU&list=UUWSW0V
yPUvG8dfJc9VtFQRg
Alive Inside
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INTRODUCTION
Distressing behavioral symptoms often associated with
dementia are not uncommon in the LTC setting.
The MDS 3.0 categorizes these symptoms as:
 physical behavioral symptoms directed toward others
(e.g., pushing, hitting)
 verbal behavioral symptoms directed towards others
(e.g., screaming, cursing at others)
 behavioral symptoms not directed toward others (e.g.,
hurting self, pacing, making disruptive sounds)
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INTRODUCTION CON’T
Potential antecedents of these symptoms
 illness
 distress
 pain
 unrecognized need
 caregiving actions not understood by the elder
Culture change with its “person-centered approach to
care” provides a potential non-pharmacological approach
to reducing these symptoms
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INTRODUCTION CON’T
Different behavioral symptoms may have different causes; thus,
interventions could address those causes
 forceful behaviors such as kicking may be related to
caregiving assistance (e.g., bathing or feeding); elder may not
understand or find frightening
physical agitation (e.g., pacing) may be due to an inadequate
amount of stimulation in the environment
verbal agitation may be related to discomfort, pain, or
depression
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CULTURE CHANGE INTERVENTION
 Community Coordinators
 Education
 Organizational and Community Structure Changes
 Meaningful Activities and Resident Choice
 Family Involvement
 Reduced Floating
Consistent Staffing
 Environmental Changes
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RESEARCH QUESTION
What is the impact of a culture change intervention on the
following categories of behavioral symptoms:
 forceful behaviors
 physical agitation
verbal agitation
Hypothesis: elders receiving culture change intervention
compared to controls will have reduced behavioral
symptoms (can be addressed by a person-centered
approach to care )
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STUDY DESIGN
13 long term care comm across 3 campuses
 7 Culture change pilot communities
 6 Comparison communities
Longitudinal study - 2 time points
 Time 1 – 2003
 Time 2 – 2005
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COHEN MANSFIELD AGITATION
INVENTORY (CMAI)
 29 behavioral symptoms
 CNA rated frequency with which the elder manifested each behavior
during past two weeks
 each behavior rated on a 7 point scale
(1)“Never”
(2) “Less than once a week but still occurring”
(3) “Once or twice a week”
(4) “Several times a week”
(5) “Once or twice a day”
(6) “Several times a day”
(7) “A few times an hour”.
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CMAI – FORCEFUL BEHAVIORS
(12 ITEMS)
 Hitting, Kicking, Scratching
 Biting, Pushing, Grabbing
 Throwing things, Cursing & Verbal Aggression
 Spitting, Tearing things or Destroying Property
 Hurting self or others
 Screaming
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CMAI – PHYSICAL AGITATION (6 ITEMS)
 pacing and aimless wandering
 attempting to exit area inappropriately
 general restlessness
 inappropriate dressing and disrobing
 handling things inappropriately
 repetitious behaviors
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CMAI – VERBAL AGITATION (4 ITEMS)
 Complaining
 Constant requests for attention or help
 Repetitive sentences or questions
 Expressing a negative attitude
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MEASURES
 Behavioral Symptoms – Cohen Mansfield Agitation
Inventory (CMAI) – captures forceful behaviors, physical
agitation, and verbal agitation (CNA interviews)
 Cognitive Impairment – MDS2.0 Cognitive
Performance Scale (high score indicates greater severity)
 ADL Impairment – 4 ADL items from MDS2.0 (high score
indicates greater dependence)
 Number of Diagnoses - use MDS2.0 med record data
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STUDY PARTICIPANTS
N = 101
 65 (64%) female
 36 (36%) male
 58% White; 28% Black, and 14% Hispanic
 Age range = 63 to 105 years (M=83.65, SD=9.29).
 Length of stay on communities; Range= 4 months to 14
years (M=34 months, SD=29 months)
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ANALYSIS PLAN
• 2 (Group) X 2 (Time) ANOVA*
Time 1 Time 2
Culture Change
Comparison
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RESULTS
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PREVALENCE OF BEHAVIORAL SYMPTOMS
All
Time 1
Time 2
Forceful Behaviors
Physical Agitation
Verbal Agitation
49%
39%
52%
57%
44%
57%
Comparison
Forceful Behaviors
Physical Agitation
44%
32%
61%
37%
Verbally Agitation
Culture Change
Forceful Behaviors
36%
56%
54%
52%
Physical Agitation
Verbal Agitation
45%
68%
51%
58%
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Forceful Behaviors: Adjusted mean scores.
Significant Interaction. F(1,92)=5.40, p=.022.
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Physical Agitation: Adjusted mean scores.
Significant Interaction. F(1,89)=6.34, p=.014
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Verbal Agitation: Adjusted mean scores.
Interaction Approaching Significance. F(1,86)=3.62, p=.061
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Summary
 forceful behaviors and physical agitation increased over
time on comparison communities, but not on culture change
communities
 implementing a culture change model can be an effective
non-pharmacological approach to ameliorating behavioral
symptoms
future studies should examine changes in pharmacological
approaches when implementing culture change.
 unique study feature - the inclusion of elders with wide
ranging cognitive abilities, ranging from no cognitive
impairment to more severe impairment
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Possible Links between Culture Change &
Behavioral Symptoms
 physical agitation (related to inadequate stimulation in
environment) may have been affected by increasing selected
meaningful activities for elders
 forceful behavior (resistance to care) may have been affected
by increasing choice over when to participate in activities,
environmental changes (e.g. calmer atmosphere), more
consistent staffing
 verbal agitation (related to depressed affect) showed a trend;
may be related to quality of relationships; may need to further
enhance these culture change elements
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Handouts –
Questions to post to facility leadership
Are programs in place to ensure best
practice in care for residents with
behavioral symptoms of dementia?
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