Managing challenging behaviours
Aims: Explore a selected psychosocial approach that may help to reduce the use of medication The positive and negative aspects of using the Newcastle model Look at how Newcastle model can be used in conjunction with Kitwood s model Implications for practice
Behavioural and Psychological Symptoms of Dementia (BPSD) behaviour that puts the person, or those around them (such as their carers) at risk of harm, or leads to a poorer quality of life NHS (2015) Approximate ly 90% of those diagnosed with dementia, will at some point experience one BPSD Around 1/3 display increasing aggression. There are various ways of looking at behaviours that challenge (BPSD). More recent thinking is that it is not just a result of organic changes in the brain
The Iceberg Analogy Behaviour is only the tip of the Iceberg. Numerous underlying elements. Behaviour Emotions & Beliefs Personality & History Social Network Perceptual Issues Environment Coping Skills Medication Physical Health Adapted from: The Motivation Iceberg 2009.
D = P + B + H + NF + SP
Kitwood also suggests that all human beings have the five following fundamental psychological needs: Comfort - the provision of warmth and strength Attachment - the forming of specific bonds or attachments Inclusion - being part of a group Occupation - being involved in the process of life Identity - having a sense and feeling of who one is
What happens if these needs are not met? These human needs drive our behaviour. BPSD occurs when our needs are not met as a way of communicating our feelings or needs
The Newcastle Model of understanding Challenging Behaviour Model which looks at unmet need to understand Challenging Behavior The model asks you to find out two types of information for the person you are working with: Finding out about the person - information about the person s life story, their personality, how they coped with stressors, their cognitive functioning, physical and mental health and the environment they are currently in. Finding out about the Challenging Behaviour - Detailed and comprehensive information about the challenging behaviour episode-what happened before the episode, what time did it occur, who was present, what did the person say, how did they look, how was the situation resolved?
Newcastle Model
The good, the bad... And reality! Positive factors for the use of the Newcastle model: Informs care planning based on the person s needs (biopsychosocial). Allows care staff to gain a better insight into the PWD builds therapeutic relationships. Involves the PWD, their family/carer in the process. Helps to maintain the personhood of the individual, providing a better quality of life. Stepping away from the medical model and reduces the need for medication in some cases.
The barriers to the Newcastle Model. Time consuming Staffing levels and attitudes. Additional work load. Lack of training/confidence to implement the model (literacy or documentation skills). Inconsistent documentation not giving clarity or quality of events, which in turn fails to address the underlying issues.
Kitwood s model of psychological needs, together with the Newcastle Model. Reduce agitation and distress COMFORT Working in partnership with the PWD and others INCLUSION Helps to build connections/therapeutic relationships ATTACHMENT Gaining knowledge of PWD through life history reinforces IDENTITY Finding out the person s interests, hobbies and lifestyle OCCUPATION Achieving all of these elements strengthens individuality and personhood LOVE Kitwood (1997) Dementia Reconsidered.
good lines of communication Management of CB or BPSD Consistency Positive Reinforcement Modelling staff attitude is central in managing challenging behaviour it s about knowing your patients Pro-active rather than reactive approach invest in good staff
Common example... Although every patient requires an individual approach to understand and manage their CB, there are some situations where we can use some standard approaches to help us in the first instance
Aggressive / agitated and physically threatening to others Preventing aggression from happening in the first place is always the best option. Some initial questions: Have you monitored this behaviour to understand it s frequency, triggers and consequences? What is the unmet need? boredom, fear, lack of information, etc Have we supported the person to express their unmet needs? Therapeutic activities, ask to voice their concerns Is there anything the staff team can do to prevent incidents? E.g. Therapeutic observations, doing activities at particular times of day, separating particular residents, frequency of personal care, adapting environment
Acetylcholinesterase inhibitors. Medication as intervention. Atypical anti-psychotics (Risperidone, Olanzapine, Quetiapine) Risk of overuse. Side effects of anti-psychotic medication can include lethargy, stooped posture and abnormal gait, urinary tract infections and drowsiness which may affect nutritional intake. Out of 180,000 PWD prescribed such medication, only 36,000 are thought to derive any therapeutic effect. This highlights that there is a role for prescribed medication to alleviate BPSD. Although in contrast 1,800 deaths per year may be attributed to the use of anti-psychotic medication in dementia due to factors such as Cerebrovascular adverse events.
Implications for practice/summary An audit completed in 2012 reports that alternative approaches have seen a reduction of anti-psychotic medication in dementia. From 2008 2011 there was a 51.8% reduction in the prescription of such medication for PWD. This suggests that the use of non-pharmacological approaches is effective to prevent/manage BPSD. The Newcastle model reflects the principles of person centered and relationship centered dementia care as everyone can be involved. Helps to maintain quality of life for the PWD, rather than relying on the chemical kosh which does not address underlying causes. This approach helps to build and strengthen relationships, ensuring the PWD is perceived as a person rather than a patient/resident.
Conclusion Whilst medication does play a role in reducing BPSD, it is worth considering the use of more interpersonal approaches in dementia care. Reduces the potential of harmful side effects. Promotes the desired relationship centered care approach and improves quality of life for the PWD.
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