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Managing
Behavioral Difficulties Associated with Dementia
Part
1
Management
of behavior problems associated with dementia begins with
understanding potential causes of behavior disturbance in persons
with dementing illnesses. While
generic recommendations are helpful for some residents in some
situations (i.e. “when the resident becomes agitated, guide the
resident to a quiet location”), caregivers can easily become
discouraged when it appears that these techniques work only
inconsistently for a given resident or when these interventions work
with some individuals, but not with others.
Often recommendations are contradictory (i.e. “use
distraction”/“provide a quiet soothing environment”), leading
to inconsistency in caregiver response to inappropriate behaviors
and lack of effectiveness of the interventions.
Effective interventions must, therefore, begin with
examination of potential causes of behavioral disturbances followed
by selection of interventions that are consistent with likely causes
of the resident’s behavioral disturbance.
Analysis
of the potential causes of behavioral disturbance is complex,
particularly since different causes interact in contributing to the
problem behavior, as shown in the chart below.
Physical
Illness
Approximately
50% of patients with dementia have at least one co-existing medical
illness. Approximately ¼ of such patients will experience at least
transient improvement of behavior and cognition with treatment of
the underlying disorder. In many cases, this improvement is
sustained. A behavioral
disturbance, a sudden decline in functional status, or the worsening
of confusion may be the initial manifestation of physical illness in
patients with dementia. Pain,
dehydration, infection, heart failure, infections, COPD, drug
toxicity, constipation, hunger, fatigue, and head trauma should be
considered as possible causes of behavioral disturbance.
Auditory
and visual impairments can increase the sense of isolation
experienced by dementia patients and can contribute to
misperceptions of the environment, leading to illusions or
hallucinations. In
these cases, hearing aids or hand-held amplifiers, visual aids, and
eyeglasses can help.
Cognitive
Functioning
In
Alzheimer’s Dementia and related diseases, specific personality
changes and behavior problems are commonly associated with
particular stages of the disease process (please see “Dementia and
Behavior” in ACT’s November, December 2000 newsletter located in
the archives). For
example, depression is commonly associated with early stages of
dementia, while dependency and anger are typical of middle stages of
dementia. Forty percent of individuals in Stage 5 of dementia
experience suspicion that caregivers or others are taking or hiding
objects from them, while persons in Stage 6 of the dementia problems
exhibit activity disturbances, such as verbal repetitive behavior,
pacing wandering, or moving or hiding objects.
25% of patients in Stage 6 exhibit threatening or aggressive
behavior. Situations
that lead to increased confusion can result in exacerbation of
behavioral problems.
Emotional
Problems
Depression
is common among patients with dementia and may present as worsening
cognitive impairment, weight loss, behavioral disruption, functional
decline, or irritability. Anxiety is reported to affect up to 40% of patients with
dementia and is higher among nursing home residents.
Anxiety often manifests as anticipatory concern regarding
upcoming events or by behaviors such as verbally repetitive
behaviors, wandering, screaming, or aggression.
Communication
Impairment
Behavior
problems can often be viewed as a means of communication.
In dementia, reasoning and language skills are gradually lost
and communication becomes more overtly behavioral.
Even when speech is intact, it is often limited by
difficulties in forming and expressing the desired thoughts
correctly. Just as
limited ability to express needs and wants in young children is
associated with tantrums and crying out typical of “the terrible
two’s”, comparable limitations in language and reasoning occur
in individuals with dementia, leading to similar behavioral
responses. Rather than
trying to teach (i.e., scold) or reason with patients who can no
longer reason, caregivers should recognize that these behaviors
serve a communication function.
Rather than trying to change the patient, caregivers should
try to identify and change other causative or exacerbating factors.
Task-Related
Causes
Tasks
that are too complicated or involve too many steps can lead to
increased confusion, feelings of stress, discouragement, resignation
and frustration. It is
important to remember that even simple, personal care tasks involve
a large number of steps and involve coordinated motor movements that
may be lost as part of the disease process.
Caregivers can help minimize confusion and resulting
agitation by structuring patient tasks in ways that reduce the
likelihood of failure and increase the opportunity for success.
Environmental
Causes
A
careful balance must be achieved between understimulation and
overstimulation of patients with dementia.
With nothing to do, patients can become bored or restless,
increasing wandering and self-stimulating behaviors such as
repeatedly yelling or calling out to caregivers.
On the other hand, multiple, simultaneous, or chaotic stimuli
can increase confusion and overwhelm the patient, leading to
agitated behavior. Television
programs are often designed to be emotionally provocative and can be
misunderstood or mistaken for reality, causing patients with
dementia to become frightened, angry, or emotionally aroused. Lack of familiar cues or personal items in the environment,
as well as large, open spaces, can result in greater confusion,
fear, and agitation. For
individuals with visual impairment, poor lighting and glare can lead
to visual illusions, while environments can be modified to
compensate for sensory losses through increased lighting and use of
contrasting colors. Simple,
consistent, and predictable environments provide a sense of
familiarity and comfort for individuals with dementia.
The
first step toward developing an effective behavior management plan
is to consider various potential causes of the problem behavior for
that patient. In the
next newsletter, specific intervention strategies related to these
causes will be presented.
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ACT,
Inc. Adds Nurse Practitioners to the Mental Health Service Spectrum
In
the first quarter of 2002, ACT made a major decision to add Nurse
Practitioners to our employed service provider profile.
This addition of Nurse Practitioners to our practice profile
is key in ACT’s efforts to maintain high quality, timely and
cost-effective psychiatric care to our served facilities across
North Carolina.
As
we prepared to make this change, we contacted by telephone and/ or
personally visited over 30% of our contracted facilities.
We were encouraged both to hear the familiarity and previous
satisfaction our facilities have had with NPs and to receive the
trust our facilities maintain with us- that ACT continues to review
the most appropriate model of mental health care for our North
Carolina community.
What
is a Nurse Practitioner?
A
Nurse Practitioner is an individual that has graduated from a Nurse
Practitioner Program. To
work as an NP in North Carolina, one must be licensed by the State
Board of Nursing and must follow Physician collaboration
requirements.
ACT
hires Nurse Practitioners who have, at minimum, successfully earned
a Master of Science in Nursing degree, earned state licensure as an
NP and who have been certified by an NP by a recognized national
certifying body. ACT’s
Nurse Practitioners have formal supervisory arrangements with
ACT’s Medical Director mandating review and signature for 100% of
documented NP sessions for six months, regular face-to-face
supervision, immediate accessibility by phone and other like
supports. We maintain
copies of these arrangements at each contracted site along with
Nurse Practitioner Protocols outlining Prescription privileges and
other NP responsibilities. Protocols
are set during NP training and orientation and are revised as needed
during the ongoing relationship of employed Nurse Practitioners and
ACT’s Medical Director.
What
limitations do Nurse Practitioners have in providing for Psychiatric
Needs of Patients?
NPs
can obtain DEA numbers and can prescribe most medications.
Many insurance companies, including Medicare and Medicaid,
reimburse NPs for services. Limitations
to their practice include the necessity of supervision by ACT’s
Medical Director and any other limitations created through our
Medical Director’s individualized Nurse Practitioner Protocols
located at each facility site.
How
will patients and facilities be impacted by this change?
Many
individuals will note no change other than the increased
availability of their assigned psychiatrist to meet their needs.
Other
facilities will be contacted regarding a transfer of psychiatric
care to one our employed Nurse Practitioners.
These facilities will receive Nurse Practitioner copies of
licensure, professional liability, supervisory arrangements and
nurse practitioner protocols to maintain on-site.
These facilities will also benefit from increased access to
care. In addition,
these facilities will benefit from the extra attention received
during a Nurse Practitioner’s immediate collaboration with ACT’s
Medical Director on client issues the NP would like to discuss.
Happy
Birthday!!
Dr. Gretchen J Belovicz
March 9
Dr. Christopher S. Norris
March 11
Dr. Barry A Moore
March 21
Dr. Jeffrey L Crawford
March 22
Happy
ACT Anniversary!!!
Dr. Bryan Patterson- four
years of service March 1
Erinn L Moore- four years
service on March 1
Dr. Jeffrey Crawford- two
years of service April 10
Dr. Craig Iversen- two
years
of service on April 13
Leslie B. Heller- one year
of
service on April 16
A
Warm Welcome to New ACT Members!
Michael F. Lefaive,
Nurse
Practitioner
Cynthia
Edens, Administrative
Assistant
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