Overview of Challenging Behaviors in VISN 6
Jorge Cortina, MD DFAPA
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“…associated with subjective distress,
functional impairment, or compromised
interactions with others or the environment “
◦ Tariot PN, Mack JL, Patterson MB et al. The behavior rating scale for dementia of the
consortium to establish a registry for Alzheimer's Disease. Am J Psychiatry
1995;152:1349-57.
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Behavioral Excess vs. Deficit
◦ Allen-Burge R, Stevens AB, Burgio LD. Effective behavioral intervention for
decreasing dementia related challenging behavior in nursing homes.
International J of Geri Psychiatry 1999;14:213-232
Dementia: wandering, aggression, etc.
 SMI:psychotic and/or inappropriate
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Delirium: wandering, psychosis, varying state
PTSD: flashbacks, anger, irritability
Brain injury: dis inhibition, explosive anger
Substance Abuse: testing limits, organized
Personality D/O: splitting, entitled,
manipulative
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Aggression (provoked or unprovoked)
◦ Physical-hitting, grabbing, pushing, biting,
scratching
◦ Verbal-cursing and abusive language
Hyperactivity
◦ Physical-pacing, shadowing, wandering,
repetitive body motions, rummaging or hoarding
◦ Verbal-incoherent verbalizations, screaming or
repetitive questions
Hypoactivity- social withdrawal, declining ADL’s
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Psychosis
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Wandering
◦ Delusions Bizarre vs. Non Bizarre vs. in context of
relationship
◦ Hallucinations vs. Illusions
◦ Hallucinations (auditory vs. visual)
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Mania
Exit seeking
Modeling
Self Stimulation
Antipsychotics side effect, Akathesia
 50-90%
of individuals with modsevere Dementia
◦ Allen-Burge R, Stevens AB, Burgio LD. Effective behavioral
intervention for decreasing dementia related challenging behavior
in nursing homes. International J of Geri Psychiatry 1999;14:213232
 64-83%
in US Nursing Homes
◦ Swearer JM, Drachman DA, O'Donnell BF, Mitchell AL. Troublesome and
disruptive behaviors in dementia. Relationships to diagnosis and disease
severity.J Am Geriatr Soc. 1988 Sep;36(9):784-90
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More Men= More Testosterone= More
Aggression?
Veterans
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Action Oriented
Fighters:“Trained to kill”
More PTSD
More SMI due to demographics of SMI
More Dementia due to PTSD, head trauma?
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Requires intensive assessment, ABC’s
Except for SMI and perhaps delirium,
antipsychotics are not indicated
Non pharmacological interventions
have been shown to be effective
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59% in VA NHCU Overall
66% among those who aged with Mental
Illness
69% among the Dementia pts
68% among those with both Dx
◦ McCarthy JF, Blow FC, Kales HC. Disruptive behaviors
in Veterans Affairs nursing home residents: how
different are residents with serious mental illness?
J Am Geriatr Soc. 2004 Dec;52(12):2031-8.
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16% verbal disruption overall
◦ 29% SMI vs. 22% Dem vs. 23% Both
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11% physical aggression overall
◦ 16% SMI vs. 19% vs. Dem vs.19% Both Dx
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54% inappropriate behavior overall
◦ 58% SMI vs. 61% Dem vs. 62% Both Dx
◦ McCarthy JF, Blow FC, Kales HC.Disruptive behaviors in Veterans Affairs
nursing home residents: how different are residents with serious mental
illness? J Am Geriatr Soc. 2004 Dec;52(12):2031-8.
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2777 veterans treated in CLC (59%=1638)
104 veterans with Dementia Tx Specialty
36 with Psychiatric Tx Specialty
◦ DSS Tx specialty report pulled 8/16/10
Percent of patients
Disease
with disease
Heart disease
72%
Diabetes
48%
Depression
44%
Heart failure
35%
Dementia
33%
Substance abuse
29%
Cancer
29%
Anxiety/Personality Disorder
24%
PTSD
21%
Schizophrenia
20%
Tom Edes. InnoVAtions in Non-Institutional Care. GEC Leads
Conference. New Orleans, LA. June 81, 2010
250
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150
100
50
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BEC
DUR
FAY
HAM
ASH
RIC
SLM
SBY
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Our veterans are like everyone else
◦ Prevalence is about 60% of CLC residents
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Prevalence of behaviors is nearly equal in SMI
vs. Dementia (except for verbally disruptive)
High prevalence of SMI and Dementia in HBPC
Need for increased capacity to manage across
settings