Behavioral Expressions in Dementia Patients
Dementia is characterized by a gradual and progressive decline in memory, thinking, and reasoning abilities. During the course of the disease, up to 90% of patients will exhibit behavioral and psychological symptoms of dementia (BPSD), which can include depression, apathy, disinhibition, delusions, hallucinations, aggression, irritability, agitation, anxiety, wandering, and sleep or appetite changes. BPSD are independently associated with poor outcomes, including patient and caregiver distress, increased hospitalizations, inappropriate medication use, and increased care costs.1
The challenges associated with BPSD account for 50% of nursing home admissions. In long term care facilities, 80% of dementia patients experience some degree of behavioral and psychological symptoms.2
Medication Overuse Concerns
Psychopharmacological medications should not be used to address BPSD without first assessing dementia patients for possible underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes of the behavioral symptom. While these medications may be effective when used appropriately to address significant specific underlying medical and psychiatric causes or new or worsening behavioral symptoms, these medications may be ineffective and are likely to cause harm when given without a clinical indication, at too high a dose, or for too long after symptoms have resolved, and if the medications are not monitored. With the exception of emergency use for acute dangerous behaviors, these medications should be used only after personalized approaches have been attempted and found to be ineffective.3
Avoid Negative Labeling
Negative labels or views of behavior symptoms describing a person as being disruptive, aggressive, or inappropriate often result in inappropriate labeling of the person as a "problem patient" or "behavior patient," which can increase the risk of overlooking acute illness, pain, or emotional, psychological, or physical needs that may trigger behavioral changes.4
Behavioral Expressions as Communication of Needs
Behavioral expressions rarely occur for no reason and should be assessed as an individual's attempt to communicate needs. For example, agitated behavioral expressions may arise from becoming overstimulated, environmental factors such as noise, inability to recognize surroundings or environment, the need to rest, pain, hunger, thirst, boredom, loneliness, unmet psychosocial needs, or an underlying medical condition.4
By evaluating behavioral expressions in terms of possible unmet needs, personalized approaches can be better implemented, inappropriate antipsychotic and other behavior medications are reduced, and quality of life is likely to be enhanced as more effective approaches, treatment, and communications with the dementia patient become more likely. Person-based, caregiver-based, and environmental-based factors can contribute to behavioral expressions (see Table 1).
Medication side effects and changes should be considered when there is a behavior change. Additionally, delirium due to medications, infections, metabolic/electrolyte disturbances, or dehydration should be ruled out.
Person-Centered Dementia Care
Learning more about an individual enables personal needs to be better anticipated and assists in more quickly identifying personalized approaches/interventions that may be the most meaningful and helpful. Better understanding a person's needs and typical response to unmet needs promotes personalized approaches that can be implemented more quickly and can often prevent a situation from turning into a catastrophic event, such as extreme fear, and the need for emergency department and hospital visits.3,4
Nonpharmacologic approaches that should be personalized based on the preferences and needs of an individual with dementia may include the following:1
• cognitive/emotion-oriented interventions (reminiscence therapy, simulated presence therapy, validation therapy);
• sensory stimulation interventions (acupuncture, aromatherapy, light therapy, massage/touch, music therapy);
• Snoezelen multisensory stimulation or transcutaneous electrical nerve stimulation;
• behavior management techniques; and
• other psychosocial interventions such as animal-assisted therapy and exercise.
Describing Behavioral Expressions
Avoid general terms such as "agitated" or "anxious" that may be interpreted differently among caregivers and change over time. Agitation may be manifested as verbal or nonverbal expressions such as cursing, yelling, grabbing, and striking out. Describing the details and possible consequences of resident behaviors helps to distinguish expressions such as restlessness or continual verbalization from potentially harmful actions such as kicking, biting, or striking out at others.
The frequency and intensity of these expressions can be assessed during the evaluation of various interventions. Other descriptors such as apathetic, repeating statements, questions, or gestures are also common. The more descriptive the terminology, the greater the likelihood of determining what may be causing the behavioral expression. For example, noting that the person is generally "violent," "agitated," or "aggressive" does not identify the specific behavior exhibited by a resident. Noting instead that the person responds in crowded, busy group activities by yelling or throwing furniture reflects not only a potential safety issue but should result in providing the resident with alternative activities to meet his or her needs.3
Assessing Pain and Depression
Depression is common in dementia patients, with up to 43% experiencing significant depressive symptoms at some stage. Untreated depression can lead to increased agitation, anxiety, irritability, and apathy. Both nonpharmacologic and pharmacologic interventions to help with depression should be considered. Additionally, serotonergic deficits seen in dementia may contribute to aggressive verbal and physical outbursts, sleep disturbance, depression, and psychosis.
• Use a calm voice.
• Offer no more than two choices.
• Avoid open-ended questions, and keep communication simple.
• Consider the person's nonverbal expressions as unmet needs and attend to those needs promptly.
• Create structured daily routines that are consistent and predictable.
• Keep the individual engaged with activities that match interests and capabilities.
• Use cueing strategies such as touch and verbal directions.
Interdisciplinary Care Team Approach
— Mark D. Coggins, PharmD, CGP, FASCP, is senior director of pharmacy services for skilled nursing centers operated by Diversicare in eight states, and is a director on the board of the American Society of Consultant Pharmacists. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.
Using Antipsychotic Medications
1. Target symptoms.
• Discuss the targeted symptoms with the patient and/or appropriate surrogate decision maker.
• Discuss the purposes and potential adverse effects of these medications, including FDA warnings regarding antipsychotic use in dementia.
3. Monitor for effectiveness and toxicity.
• Consider the use of standardized measures of agitation or behavioral symptoms in dementia, such as the Pittsburgh Agitation Scale or Cohen-Mansfield Agitation Inventory.
4. Consider tapering and discontinuing these medications when the target symptoms remit.
5. Monitor patients for evidence of relapse if and when the medication is decreased/discontinued.
2. Non-pharmacologic interventions for agitation and aggression in dementia. Agency for Health Care Research and Quality website. http://effectivehealthcare.ahrq.gov/ehc/products/559/1999/dementia-agitation-aggression-protocol-141113.pdf. Accessed December 2, 2014.
3. Department of Health and Human Services, Centers for Medicaid and Medicare Services. Revisions to State Operations Manual (SOM), Appendix PP – "Guidance to Surveyors for Long Term Care Facilities." http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R127SOMA.PDF. Revised November 26, 2014. Accessed December 4, 2014.
4. Dementia care: the quality chasm. CCAL — Advancing Person-Centered Living website. www.ccal.org/wp-content/uploads/DementiaCareTheQualityChasm_020413.pdf. Accessed December 2, 2014.