NEWCASTLE CHALLENGING BEHAVIOUR SERVICE

Transcription

1 NEWCASTLE CHALLENGING BEHAVIOUR SERVICE Northumberland Tyne and Wear MH NHS Foundation Trust Ian A. James Clinical Psychologist Head of Newcastle OP Psychology & Challenging Behaviour Teams, Dementia Services Visiting Professor Northumbria University 1

2 Definition: Any behaviour, including apathy, that causes emotional distress within the carer or others in the environment. Mackenzie and James (2011)

3 Aggressive forms of CBs Hitting Kicking Grabbing Pushing Nipping Scratching Biting Spitting Choking Hair pulling Tripping Throwing objects Stick Prodding Stabbing Swearing Screaming Shouting Physical sexual assault Verbal sexual advances Acts of self harm Non-aggressive forms of CBs Repetitive noise Repetitive questions Making strange noises Constant requests for help Eating/drinking excessively Over-activity Pacing General agitation Following others/trailing Inappropriate exposure of parts of body Masturbating in public areas Urinating in inappropriate places Smearing Handling things inappropriately Dismantling objects Hoarding things Hiding items Falling intentionally Eating inappropriate substances Non-compliance

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5 Nervous System dizziness, fatigue, drowsiness, vertigo Restlessness Dry Mouth Fractures Wandering Incontinence Parkinsonism Depression Liver Toxicity Stroke Over 12 wk period 20% will improve. But 1% will be killed, 1.8% vascular events (50% severe) 6-10% gait disturbance Increased mortality Diabetes Weight Gain Sexual Dysfunction Constipation Tardive Dyskenisia Cognitive Decline Cardiotoxicity Anti-psychotic side-effects (Banerjee, 2009) 5

6 Treatment strategies Drug treatment for a physical/mental health cause Tranquilisation & sedation to reduce activity CB Psychological Preventative vs Intervention Environmental modification Care practices

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8 Stepped Care Model Step 4: Idiographic formula.on led interven.on: Specialist Individualised assessment, formula2on and interven2on (Specialist prac22oners and carers/care staff) Step 3: Protocol led interven.ons: high intensity Interven2ons tailored to specific presenta2ons and needs (Experienced prac22oners and carers/care staff) Step 2: Assessment and treatment of contextual issues: Low Intensity Thorough assessment and general good prac2ce in care environment (GP & carers/care staff) Step 1: Recogni.on Identification of difficulties, physical health & initial monitoring (GP & carers/care staff)

9 Cohen-Mansfield s TREA Verbal Agitation Need for social interaction? Need for stimulation? Boredom? Need for control? Try social interaction: real or taped Identify meaningful activities/physical exercise Offer choices; provide tasks that allow for control

10 Behavioral Interventions Note Overview (Bird & Cortina, 2012) Antecedents Behaviors Consequences

11 Imports key information on possible Antecedents from CPRS & Prompts further documentation of common antecedents in environment

12 Checklist - Causes ITEM MEAN FRUSTRATION 4.19 MEMORY DIFFICULTIES 4.02 ANGER 3.94 CONFUSION 3.94 FEAR 3.87 CARERS, RESIDENT BEHAVIOUR 3.82 DISLIKE OF CURRENT ENVIRONMENT 3.76 CARERS' BEHAVIOURS 3.70 INABILITY TO EXPRESS PHYSICAL NEEDS 3.65 LACK OF ACTIVITY IN ENVIRONMENT 3.65 DEPRESSION 3.63 OTHER PHYSICAL HEALTH CONDITION 3.61 SADNESS 3.56 BOREDOM 3.48 SOCIAL ISOLATION 3.48 PAIN (ARTHRITIC, DENTAL, SPINAL) 3.34

13 Checklist -Treatments ITEM MEAN GIVING CARERS MORE TRAINING IN C.B 4.67 COMMUNICATION 4.49 MORE TIME ON UNDERSTANDING THE CAUSE OF C.B 4.47 LEARNING MORE ABOUT PERSON'S B'GROUND 4.42 GREATER CONSISTENCY IN APPROACHES 4.36 USE CHECKLIST IN FUTURE CASES 4.36 REMINISCENCE REALITY ORIENTATION 4.14 PROVIDING 1:1 SUPPORT TIME 4.14 GIVING PERSON MORE CHOICE RE CARE 4.12 INCREASING LEVELS OF MEANINGFUL ACTIVITIES 4.04 MORE STAFF 4.02 INITIATING/INCREASING PAIN RELIEF 3.38 USING APPROPRIATELY TARGETED THERAPEUTIC LIES 3.37 ADDING/ALTERING MENTAL HEALTH MEDICATION 3.26

14 Environment, including carers CB Behaviour Belief & Emotions Surface Physical status Perceptual issues Personality Mental health Medication Neurology Metabolic features 14 Figure : Iceberg Analogy

15 Improve communication Provide personalised activity Consistent approach from staff Change in physical interpersonal interactions with client One-to-one time Promote independence Offer client choice (for example (clothing or activity) Provide explanation of action Ensure client is alert prior to commencing interventions Empathise Gain permission to enter personal space

16 Communication Use eye contact and face the person. Get attention by addressing by name - say who are and why there. Treat the person like an adult. Even though need to simplify what/how you say things, and repeat often, be careful not slip into condescension/disrespect. Speak in clear, simple language; use direct short sentences; call people and things by name. Avoid using pronouns (he, she, them, it). When giving directions, give them clearly and one step at a time. Praise and encourage often. Be willing to repeat and rephrase. If you do not get a response to a question, simplify it. Sometimes it is best to ask questions that are direct and require a yes/no response rather than open-ended (e.g. Would you like chicken for lunch? rather than What would you like for lunch? ). Be a good listener. Show with your body language and short affirmations ( Yes, I see ) you re interested. Be patient if this is not the first time you have heard this; to the client, this is the first time they are telling you. If you do not understand something, ask the client to point and gesture. Emotions speak louder than words. Pay attention to the feelings behind the words. Be your normal, warm, outgoing self!

17 Person with Dementia Carer Betsy tried to stack the dish-washer, but placed items in the wrong sections and failed to remove food from the surface of the plates Stan stopped her from loading the dish-washer, and shouted at her when she persisted. Betsy got angry and scratched Stan on the arm. When Betsy gets out of room, she is very distressed as she cannot remember what has happened, but is now feeling anxious and in need of reassurance Stan yelled at her and locked her in the spare room while he finished clearing up the kitchen. Stan feels tired, guilty and frustrated. Emotional Exchanges Interacting Triads (2007)

18 Key references WHELD project Jiska Cohen-Mansfield Clive Ballard Esme Moniz-Cook