Behaviour and Psychological Symptoms of Dementia (BPSD)

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1 Behaviour and Psychological Symptoms of Dementia (BPSD) Background information Brain functions Dysfunction and effect on behaviour Model of interpreting behaviour Helping manage the behaviours

2 BACKGROUND INFORMATION BPSD are evident in all dementias. Most severe in moderate stage of dementia. Dementia is an organic condition where there is irreversible loss of cognitive capacity and memory. Overtime this causes functional losses socially, physically and emotionally. Consciousness is not clouded

3 Background Information Over 60 different diseases processes cause Dementia Most common Alzheimers Disease, Vascular Dementia, Frontotemporal Dementias ( Semantic variant, behavioural variant) - Disease of the cortex predominantly but in advanced dementia all structures of the brain are affected

4 An increasing problem Presently in Australia approximately 250,000 people have a diagnosis of dementia. By 2050, the total number will exceed 1,130,000 - in excess of a fourfold increase since % of people admitted to nursing homes will have dementia. Over 80% will have BPSD

5 Brain functions 1.The outer part of brain - Cerebral cortex (Cerebrum): Responsible for higher brain function such as thinking and behaviour. - divided into two hemispheres - each hemisphere is divided into lobes frontal lobes parietal lobes temporal lobes occipital lobe

6 Anatomy of the brain

7 Functions of the Frontal Lobe The ability to concentrate and attend. Judgment, reasoning, inhibition/impulse control Personality and emotional traits. Motor Cortex (Brodman's): voluntary motor activity. Storage of motor patterns and voluntary activities. Language: motor speech

8 Damage to Frontal Lobe Impairment of recent memory, Inattentiveness, inability to concentrate, Difficulty in learning new information. Lack of inhibition (inappropriate social and/or sexual behaviour). Inability to plan and organise and initiate action Perseveration inability to stop action (repetitive) Inability to start an action Loss of empathy

9 Function of Temporal Lobe Function Symptoms of damage Expressed behaviour. Agitation, irritability, childish behaviour. Language: Receptive speech. Memory: Information retrieval. Receptive/ sensory aphasia. Forgets names, people, events

10 Parietal Lobe Functions Processing of sensory input, sensory discrimination. Body orientation. Damage causes Inability to discriminate between sensory stimuli (temperature, pain) Difficulty with speech (dysphasia) Inability to locate and recognise parts of the body, people, objects (agnosia) (use of knife and fork) Severe Injury: Inability to recognize self. Visual spatial disorientation within the environment (lost in corridor) Difficulty with learned patterns of movement - Inability to write, put clothes on in right order, use appliances.

11 Occipital Lobe Function Primary visual reception area. Primary visual association area: Allows for visual interpretation. Damage causes Loss of perception and visual interpretation linked with parietal lobe Depth perception

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13 Behavioural and Psychological Symptoms of Dementia Frequent, troubling emotional states accompanied by behaviours that distress the person and others. Apathy Aggression (Defensive/protective response) Pacing Intrusive wandering Impulsive behaviour Resistance to care Vocalisation Shadowing

14 Associated psychological experience Fight/flight response Threat and Fear seeking to survive Vocalisation Loneliness, boredom, pain Seeking affiliation, sense of worth Wandering Lost, seeking familiarity, seeking security, seeking meaningful activity

15 Models to explain BPSD Behaviour is meaningful communication about the person s living experience in the present moment. (embarrassed at soiled clothing - trying to get rid of faeces -faecal smearing ) Behaviour is an expression of an unmet need ( I need you to stop hurting me) Behaviour is a catastrophic stress response (I hurt, I m bombarded with stimuli and I can t keep pace)

16 Person centred model TO UNDERSTAND THE PERSON S BEHAVIOUR YOU MUST UNDERSTAND THE SITUATION FROM THEIR VIEWPOINT. If you determine the reason for behaviour from your viewpoint you ll probably be wrong. Understanding the reason for a behaviour comes through empathic resonance with the person s subjective world.

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19 References from Lynne Chenoweth UTS Algase, D. Beel-Bates, C., Beattie, L Wandering in long-term care Annals of Long- Term Care, 11:33-9. Algase, D., Beck, C., Kolanowski, A., Whal, A., Berent, S.K., Richards, K Needdriven compromised behaviour: an alternative view of disruptive behaviour. American Journal of Alzheimer s Disease, 11(6): Ballard, C. et al 2001 Quality of life for people with dementia living in residential and nursing home care: the impact of performance on activities of daily living, behavioural and psychological symptoms, language skills and sychotropic drugs. International Psychogeriatrics, 13: Cohen-Mansfield, j. & Werner, P.1998 The effects of an enhanced environment on nursing home residents who pace.. The Gerontologist, 38 (2): Cutler, L.J., Kane, R.A., Degenholtz, H.B., Miler, M,J. & Grant, L. (2006) Assessing and comparing physical environments for nursing home residents: Using new tools for greater research specificity. The Gerontologist, 46(1): Davies, S, Aveyard, B. & Norman, I.J. (2006) Person-centred dementia care. In S.N Redfern & F. Ross (Eds.) Nursing older people. (4th edn.) pp Edinburgh: Elsevier. Brodaty et al., 2003 Brodaty H, Draper BM and Low LF (2003) Behavioural and psychological symptoms of dementia: a seven-tiered model of service delivery. MJA. Vol. 178, pp Brooker, D. & Duce, L 2001 Well-being and activity in dementia. Aging & Mental Health, 4:

20 References from Lynne Chenoweth UTS Finkel, 1998; Finkel SI (1998) The signs of behavioural and psychological symptoms of dementia. Clinician. Vol. 16, No. 1, pp Fleming R., Forbes I, & Bennett K Adapting the Ward for people with dementia. Woodhead International, Sydney Hall, G & Buckwalter,K 1987 From almshouse to dedicated unit: Care of the institutionalised elderly with behavioural problems. Arch Psychaitric Nursing, 4:3-11. Hall,GR 1998 Testing the PLST Model with community-based caregivers. Doctoral Dissertation, Iowa City, USA.: Iowa University Kitwood, T. 1997a The experience of dementia. Aging & Mental Health, 1: Lai, C,& Arthur, D Wandering behaviour in people with dementia. Jouranal of Advanced Nursing, 44: Lawton, M.P Environment and other determinants of well-being in older people. The Gerontologist, 23: McKee et al 2004 Supporting successful ageing in residential homes.-the role of the physical environment. Psychology & Health, McIntyre 2003; Mallott et al 2001 Enhancement of the breakfast eating experience in a dementia care unit. Doctoral dissertation. University of Waterloo, Ontario, USA. Mansell J & Beadle-Brown J (2004): Person-centred planning or person-centred action? A response to the commentaries. Journal of Applied Research17: 31-

21 References from Lynne Chenoweth UTS Marshall, M Care settings and the care environment: In C. Cantley (Ed.) A handbook for dementia care. Open University Press: Buckingham, PP Moos R.H. & Lemke S Evaluating Residential Facilities. The Multiphase Environmental Assessment Procedure. Sage Publications United Kingdom Nay R, Scherer S, Pitcher A, Koch S, Browning M, Flicker L, et al. (2003) Responding to Behaviours of Concern Among People Living in Residential Aged Care. La Trobe University, Melbourne. Rowles, G.D. (Ed.) 1983 Ageing & Milieu. Environmental Perspectives. On Growing Old. New York: Academic Press. Specht, J, Hall, G Alzheimer s Demonstration Project: Building a seamless dementia-specific service delivery system for rural aged. Iowa City, USA: University of Iowa. Sloane P.D., Mitchell C.M., Weisman G., Zimmer S., et al 2002 The Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH): An Observational Instrument for Assessing the Physical Environment of Institutional Settings for Persons with Dementia. Journal of Gerontology Social Sciences. Vol. 57B, No Swanson, E., Maas, M.,Buckwalter, K 1994 Alzheimer s residents behavioural and cognitive measures: Special and traditional care unit comparisons. Clinical Nursing Research, 3: Volicer, L 1997 Goals of care in advanced dementia: cognitive, behavioural and emotional aspects. Journal of Alzheimer s disease, 12: Whall, A.L. & Kolanowski, A.M. (2004) Editorial: The need-driven dementia-compromised behaviour model-a framework for understanding the behavioural symptoms of dementia. Aging & Mental Health, 8(2):

22 OTHER REFERENCES Glase, D.L., Beck, CB., Kolanowski, A., Whall, A., Berent, S., Richards, K., Beattie, E. (1996) Need-driven dementiacompromised behaviour: An alternative view of disruptive behaviour American Journal of Alzheimer s Disease Nov/Dec Dettmore D, Kolanowski A, Boustani M, (2009) Aggression in Persons with Dementia: Use of Nursing Theory to Guide Clinical Practice Geriatric Nursing 30.1 (Jan 2009) Maslow, A., (1970) Motivation and Personality (2nd Ed) Harper and Rowe. USA Rizzo, M and Nawrot, M., (1988) Perception of Movement and Shape in Alzheimer s Disease Brain 121,