Understanding Behaviour in Dementia that Challenges. Ian Andrew James
is angry at being prevented from leaving the setting when she is convinced her children need to be collected from school.
Drugs
Polypharmacy is a fact of life for many older people, with the average older person taking five or more different types of medication. While we are aware of the side-effects of much of the medication used, we are less certain of the effects of the interactions. This is somewhat of a concern when we already know some of the drugs commonly used are known to increase BC, such as: statins (agitation) and Parkinson’s medication (hypersexuality). Furthermore, there are also major concerns about the tranquillising and sedating effects of many of the drugs used to routinely treat BC (Banerjee 2009).
Physical difficulties and metabolic changes
Dementia is an age-related illness, and many older people experience declining physical health and age-related illnesses (arthritis, backache, cancer, toothache, constipation and chiropody ailments). It is important to note that many BCs are related to pain and physical discomfort, which is often worsened during carer interactions (such as toileting, transfers and washing procedures). The body’s organs also become less efficient with age, leading to a reduction in the body’s ability to metabolise chemicals, including food and drugs.
Perceptual deficits
Age-related changes with respect to the five senses can trigger difficulties, as sensory loss may disorientate people further. Reductions in sight and hearing may also cause people to seek reassurance, or motivate them to search their environment in order to gain their bearings. Hearing problems are often associated with shouting (Cohen-Mansfield 2000a).
Psychological
Premorbid personality
It is important to recognise that a person’s personality endures through the course of dementia; their individuality will be apparent in various ways and at different stages of the illness. People with severe dementia may still wish to express lifestyle preferences (relating, for example, to accommodation, religious practices, food and sexual orientation). While some personality changes are related to changes in brain pathology, others are associated with psychological factors – for example, someone with dementia may feel they are vulnerable, become more emotional and seek out more physical attention. Finding out how the person coped with difficulties in the past can be revealing. Current problems may be explained by someone being unable to use familiar methods of coping, such as managing stress by going out for a walk.
Mental health
Mental health problems are common and it is important to acknowledge their potential influence. Past difficulties may interact with current problems; for example, a person with long-standing social phobic tendencies who develops dementia and moves into residential care may feel very anxious in a busy communal room (James and Sabin 2002). Changes in brain pathology may result in psychotic symptoms such as visual hallucinations, paranoid ideations or delusions of theft. Resolved issues, such as affective problems, may re-emerge, and chronic problems become magnified (e.g. Asperger traits, James et al. 2006c).
Social
Environment and care practice
Environmental factors (light, noise levels, room-layout) are important influences on the well-being of older people owing to their levels of dependency. This is particularly the case for people with dementia who have difficulties with memory, problem-solving and orientation. We need to recognise the link between people’s level of well-being and the opportunities they have to engage in fulfilling personal relationships. It is also worth checking whether a person’s ‘challenging behaviour’ might be triggered by him being too hot, too cold, hungry or being exposed to excessive stimulation such as a loud television or radio (DSDC 2008).
Care practices
Owing to the need for people with dementia to receive various forms of physical and practical help with aspects of daily living, conflict may arise with those providing such assistance. Carers are required to be skilled, patient practitioners and to have excellent communication skills. Such an angelic demeanour is not always possible, especially when there are competing issues with respect to carers’ time. As such, in many BC situations the triggers for the problems can be traced to carers outpacing the person with dementia, being too rushed or abrupt, and unempathic. The relevance of good care practices cannot be over-emphasised because many challenging behaviours occur during practical face-to-face interactions between carers and clients.
The biopsychosocial factors presented above are believed to be common causes of problematic behaviours. Hence, when investigating the potential causes of a BC, one would routinely collect information about each of the above aspects. The next section presents tables outlining causal features for BC, resulting from an audit undertaken of the case work of a member of the NCBT (Makin 2009).
| Table 2.1 The common biopsychosocial causes of shouting | |
| Shouting – one needs to distinguish the various forms of shouting – shrieks, moans, repetitive words or sentences. Also one needs to determine frequency, timings and triggers | |
| BiologicalPain, resulting from joint/dental/problemsDiscomfort due to skin, bowel problems, including constipationFrontal lobe deficits leading to perseverative behavioursResponse to hallucinationsDrug induced restlessnessInfection induced confusionEffects of alcoholHunger/thirstTiredness reducing threshold for irritability | PsychologicalAnxiety/fearAnger and/or frustrationFeels threatenedLonelinessBoredomSelf-stimulate, particularly if deafOver/under stimulated |
| Social and environmentalRequest for toiletRequest for food or drinkRequests are being ignoredCommunication difficultiesRejecting carers’ approachesSignalling dislike of someone in the vicinityAttempt to annoy someone elseExcessive noise or silenceRecent change to environmentImmobile person sitting signalling discomfort – e.g. sitting in sunlight or in a draughtRejection of current surroundings | |
| Table 2.2 The common biopsychosocial causes of sexual disinhibition | |
| Sexual disinhibition | |
| BiologicalFrontal lobe deficits, resulting in disinhibitionParkinson’s medication resulting in hypersexualityExcess use of alcohol, resulting in disinhibitionHigh libido | PsychologicalBoredRestlessMisidentifying other people as one’s partnerBelieving one is young, and sexually availableMisinterpreting intimate personal care activities as a sexual advanceMethod of reducing stressDisinhibitionA reliable method to be removed from a fearful/unwanted situation |
| Social and environmentalLots of members of opposite sex in the environmentAvailability of bedroomsConfused members of the opposite sex making advancesLooking for companionshipLooking for comfortSeeing other people in their night-wear | |
| Table 2.3 The common biopsychosocial causes of aggression | |
| Aggression – one needs to observe such behaviours carefully as the label is very subjective. Many aggressive acts are the products of perceived threat and/or anxiety. Despite the destructive aspects, aggression indicates the person with dementia still feels things are worth fighting for. If she loses this self-belief, she may become depressed. | |
| BiologicalFrontal lobe deficitsHead injury leading to disinhibitionDrug induced restlessnessUnderlying physical conditionsInfectionEffects of excess use of alcoholParanoid delusions requiring someone to defend themselvesHallucinations requiring someone to defend themselvesPain reducing threshold of agitationFending-off contact due to bodily painTemperamentSensory deficits | PsychologicalRestlessFrustration at not being able to communicate wellFrustration at not being understoodPerson thinks her rights are being infringedPerson feels patronised (treated like a child)Person thinks she is being unnecessarily rushed and harriedPerson thinks not being listened toPerson feels embarrassed during personal care tasksPerson thinks her personal space is being invadedPerson thinks not being allowed to use her existing abilities and skillsCo-existent mental health problemsDisinhibition |
| Social and environmentalCultureMisidentifying other peopleMisperceiving other people’s intentionsInterpersonal over-stimulationA particular carer is not acceptable to her (e.g. due to age, gender, race or colour)Person does not like being touched by someone elseSetting is unacceptablePerson not being allowed to leave the buildingPerson made to feel incompetentPerson does not like the restrictive rules and regulations being imposedCaregivers providing inconsistent approachesOver-stimulation (noise, lights)Setting is too hot or coldWeather is very warm | |