Daniel Collerton and
Karen Franks
Gateshead Older People’s Mental
Health Service

Tier 5 -7
Severe to
Extreme Behaviours
Screaming to Physical Violence
<10% of people with dementia
Tier 3-4
Mild to moderate behaviours
Wandering to verbal aggression
20 -30 % of people with dementia
Tier 1-2
No behaviours
60 – 70% of people with dementia

• Reflects the capability of the setting to manage behaviour – poorer settings generate more challenge
• Not related to severity of dementia
• Stressful and burdensome to carers
• Purposeful
• Limited potential to respond to interventions
• Usually transitory

• Who, what, why, when?
• Why is this a problem?
• Always consider non-pharmacological management first
• Always consider physical illness, esp. delirium and pain

• Talk to the person whose behaviour is causing concern
• Identify purpose of behaviour
• Identify and intervene in contributory factors
• Support carers
• Balance risks
• Be mindful of legal frameworks
• Aim for tolerable behaviour
• Review and refer

What is the behaviour that challenges you?
Mild- moderate behaviour: e.g. wandering, night-time disturbance, depression, apathy, repetitive questioning, shadowing, verbal aggression, mild sexual disinhibition.
Severe- extreme behaviour: e.g. severe depression, psychosis, severe agitation, screaming, physical violence, suicidal behaviour, severe sexual disinhibition.
Is the person with dementia, or another person at immediate and serious risk because of the behaviour?
Y
E
S
NO
Is detail known about the behaviour?
NO
Describe exactly what the behaviour is, when, where and with whom the behaviour occurs. Detailed documentation is very useful.
YES
Seek specialist advice ; consider transfer of the person to a safer setting depending on need, psychiatric or general hospital admission, respite care.
Contact Mental Health Service for advice
Was onset quite sudden? If so this could be due to physical illness , take a urine specimen if possible and arrange medical review
Use the information…
To work through the challenging behaviour workbook.
Gather more information…
At each stage you may need to gather further information about the person, then go back and use it.
Identify reasons for the behaviour…
…make a plan…
…and put the plan into action
Review the situation…
Has your plan worked?
Whose problem is it anyway?
Could the person’s behaviour be due to the environment? Could procedures or routines be made more flexible to suit the persons’ needs?

• Mental health services
• Challenging
Behaviour Teams

• Keep it simple
• Start low, go slow
• Think about what you are trying to achieve
• Monitor effects
• Encourage effective recording
• Consider change in timings before increase in dose
• Can this setting cope with ‘prn’ meds?

• Lorazepam 0.5mg
• Clomethiazole 192mg
• Trazodone 25 – 50mg
• Sodium Valproate 100mg bd
• SSRIs
• Mirtazapine 15mg nocte
• Cholinesterase inhibitors – incl patch
• (Memantine)

• Should not be first line
• Probably should be started only with secondary care opinion/advice
• Keep under review
• Many do not benefit, some do
• Always a risk benefit decision
• Keep for some psychotic symptoms and severe aggression
• Some people may need to stay on

• Risperidone 0.5mg
• Quetiapine 25mg
• Amisulpiride 25 – 50 mg
• Olanzapine 2.5mg

• The use of antipsychotic medication
for people with dementia. Sube
Banerjee, Department of Health (2009)
• Dementia: Supporting people with dementia and their carers in health
and social care National Institute for
Health and Clinical Excellence (2006)