What Environmental Changes Can Contribute To Changes In Behavior In A Patient With Dementia?

Flowers Dementia: Management of Behavior Problems
(Carlson DL, Fleming KC, Smith GE, Evans JM. Management of Dementia-Related Behavioral Disturbances: A Nonpharmacologic Arroyo)

Reproduced with permission from Mayo Dispensary Proceedings 1995; 70:1108-1115.
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Elderliness

The diagnosis of dementia is largely predicated on the presence of cognitive impairment. The syndrome of dementia, notwithstanding, includes a broad range of behavioral disturbances, sometimes referred to equally "noncognitive" bug. Many of these behaviors, however, result from the progressive inability to recall, reason and solve problems. Behavioral problems associated with dementia include agitation and aggression, resisting aid with cares, wandering, incontinence, sleep disturbances and emotional lability, among others. These behavioral disturbances are often frustrating,disruptive, and significantly impact on quality of life, caregiver stress, and the demand for institutionalization.These behaviors frequently go the primary focus of contacts between health care professionals, patients and their caregivers. Understanding the basis for these behaviors, recognizing the full range of management options and being aware of the resources available may assistance patients and their families through the course of this disease.

Excess Disability

Many behavioral disturbances in dementia are not directly related to progressive cognitive decline, only occur in excess of expectations given the illness severity and duration.Behavioral bug or functional impairments occurring out of proportion to the caste of cerebral impairment stand for a gap between actual and potential function. This extra behavioral or functional disturbance has been termed "backlog inability." Excess disability in dementia may be attributed to health, psychological, ecology or social factors.These added deficits, when recognized, may be eliminated, modified, or prevented.

Coexisting Illness

It is estimated that approximately 50% of patients with dementia take at to the lowest degree one co-existing medical disease. Approximately one-fourth of such patients will experience at least transient improvement of beliefs and noesis with handling 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 a concrete illness in patients with dementia.Pain, dehydration, infection, heart failure, infections, COPD, drug toxicity, constipation, hunger, fatigue, and head trauma are common diagnoses to consider.

Sensory Harm

Hearing and vision impairments can increase the sense of isolation experienced past demented patients. These sensory losses may contribute to misperceptions of the environment resulting in illusions or hallucinations and associated behavioral disruptions. Hearing aids or hand-held amplifiers may improve advice ability between patient and caregiver. Visual aids and eyeglasses can reduce some perceptual distortions. Astute caregivers can use adaptive equipment during times of greatest need (east.chiliad. assisting with training) if their use is otherwise resisted.

Role of Medications

Psychotropic medications used in the management of behavioral problems in dementia may paradoxically exacerbate these behaviors and can cause farther cognitive or functional impairments.This may lead to a roughshod cycle of increasing dosages based on increasing disturbances. In add-on, drug side effects tin result in anorexia, agitation, sedation and falls. Medications used to care for underlying nondementing medical weather can also outcome in secondary behavioral effects. These behaviors tin occur as directly furnishings of the medications used or from resultant changes in the subject's underlying health condition. Virtually any medication adjustment (improver, withdrawal or modify in dose) may take direct behavioral effects.

Psychiatric Illness

Anxiety

Feet is reported to affect up to xl percent of subjects with dementia. The prevalence increases with advancing historic period and is also higher amongst nursing home residents. In adults with established dementia, anxiety often manifests every bit excessive anticipatory business organization regarding upcoming events, or by behaviors such as wandering, screaming, or assailment. Various factors may play a role in the evolution of anxiety in demented patients, including medical affliction, depression, corruption, social losses, cognitive impairment, and functional refuse.

Depression

Depression is common among demented patients, with somewhat higher rates amongst many non-AD dementias than in AD (e.g. vascular dementia, Huntington'due south illness, and Parkinsonism). Noradrenergic and serotonergic neurotransmitter deficits, in addition to frontal lobe and limbic structural changes, correlate with the occurence of low in Advertizement. Depressive symptoms reportedly occur in up to 50 percent of Advert, which is three to four times more frequent than in nondemented elderly patients. Low may nowadays as worsening cognitive impairment, social withdrawal, weight loss, behavioral disruption, and functional decline. Tearfulness, thoughts of worthlessness, and concerns nearly existence a burden are common. Depressed mood in demented patients may be more amenable to behavioral approaches such equally lark or changes in ecology stimuli. Although the rate of suicide is highest amongst the elderly, suicide is rare amidst patients with dementia.

Feelings of stress, discouragement, resignation, and frustration resulting from progressive losses are farther sources of excess inability in patients with dementia. Caregivers tin assistance to minimize this by structuring patient tasks in ways that reduce the likelihod of failure and increase the opportunity for success. One must keep in listen the ofttimes variable capacity of a patient to perform sure functions successfully.

Environment

Environmental factors such equally understimulation and overstimulation can lead to the development of undesirable behaviors. With nothing to do, a patient may become bored or restless and begin to wander or become involved in self-stimulating behaviors such as repeatedly yelling or calling out to caregivers. Multiple, simultaneous or unnecessary stimuli may be difficult to translate and tin can overwhelm the patient. Loud and repeatedly heard nursing dwelling buzzers may exist annoying and lead to agitation. Television shows may be misunderstood or mistaken for reality and cause demented subjects to become frightened or angry, resulting in cries of alarm or enraged beliefs. "Disembodied" voices coming from radios or overhead paging systems, or that result from whispering or laughing out of view, tin similarly contribute to confusion, suspiciousness, and agitation.

Lack of familiar cues or personal effects in the environment tin can event in greater confusion, fearfulness and agitation. Environments can be modified to compensate for sensory losses by reducing glare, increasing lighting, removing rugs and cords on the floor and using contrasting colors. A simple, consistent, and predictable environs provides a sense of familiarity and comfort for the patient. Conversely, an environs poorly adjusted to cerebral losses may cause the individual to misinterpret environs and events, and either acquit in socially inappropriate ways or withdraw.

Social Factors

In spite of progressive cognitive loss, older adults with dementia retain basic homo needs to belong, to be loved, and to feel useful. However, quality relationships and social groups appropriate to their need and level of functioning.are often unavailable or insufficient. Adapting normal household duties or "chores" to the patient's level of ability tin address the want to contribute and experience needed. Planned activities should promote a sense of success (by non exceeding the ability of the patient to perform without failure), and should correspond to individual interests, abilities, and reduced attending spans whenever possible. Promoting existing abilities serves to reinforce the familiar, provide reassurance through daily rituals, and contribute to a sense of competency.

Caregivers tin can contribute to backlog disability past a reinforcement structure that rewards dependent behavior (past more attention) and ignores contained behavior. Caregivers may foster dependence and loss of office if patients are non immune or encouraged to participate in personal cares appropriate to their abilities (e.yard. dressing a demented patient in order to salvage time). When patients with dementia do not continue to exercise even over-learned or habituated skills, these abilities can be lost. This may increase dependence on others prematurely, and reinforce a sense of helplessness and failure.

Behavior as Communication

Reconceptualization of beliefs in dementia involves the ability to see beliefs equally a means of advice. 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. The behaviors of individuals with dementia represent an attempt to express feelings and needs that cannot be adequately verbalized. In a young child, crying out is a ways of communicating hunger, hurting or fright is not considered a "behavior problem." A demented adult may have comparable limitations in language and reasoning, and have similar behavioral responses. Labelling of unwanted behaviors (and patients) equally "bad" or "difficult" often creates a gear up of expectations that foster a sense of futility or resignation. Withal, troublesome behaviors are rarely enacted purposefully or to exist manipulative, but arise from the disease procedure and the more primitive (or childlike) coping styles that result.

Caregivers tin waste a tremendous amount of attempt attempting to "teach" new information to patients who cannot learn, arguing well-nigh realities that differ, or "reasoning" with patients who can no longer reason. It is essential that behaviors be recognized as a form of communication, rather than as random, unpredictable, or meaningless events. Caregivers who learn what to expect as the disease progresses can conceptualize the limitations to come and their behavioral furnishings. Management of trouble behaviors can and so shift in focus from trying to change the patient to modifying causative or exacerbating factors.

Examples of Behavior Problems *click for a list of symptoms & behaviors*

Wandering

Often considered to be a behavior problem, wandering is divers as moving virtually in an apparently aimless or disoriented manner. As a ways of communication, wandering may signal boredom, the demand to leave a stressful situation, or a search for something familiar and comforting. In this context, wandering may be considered functionally adaptive, rather than maladaptive. Wandering may reflect lifelong patterns of coping with stress, the demand to keep busy, or a search for security. Even so, wandering may also reflect the need to detect the bathroom, a person, or a lost object, or represent efforts to "get domicile" or "become to work".

Interventions to manage wandering should be guided by asking what the beliefs may exist communicating about by patterns or nowadays needs. The answer may differ from solar day to day for some patients, and their full general mood may provide the key to interpreting the behavior. Sometimes, however, no answer is apparent. As long as patient safe is not compromised, wandering might exist allowed to occur. The associated benefits of practice and tension release from unrestricted wandering should be considered likewise. Caregivers might attempt to reduce wandering by providing meaningful activities and familiar objects, or planning regular exercise. When wandering becomes a rubber effect, more restrictive ecology adaptations may be needed. In institutional settings, alarm systems, stop signs, concealed or camouflaged doors and door knobs, and locks placed in unfamiliar places can be useful. A secured indoor or outdoor circular path tin can reduce concerns virtually escape or intrusiveness, although an identification bracelet or necklace and an updated photograph of the patient are recommended.

Agitation

Agitation occurs in more than one-half of customs-dwelling patients with dementia, and affects upwardly to 70 percent of nursing home residents. Agitation may be a behavioral manifestation of anxiety, simply may also be a concluding common pathway of expression for myriad symptoms in a dementia patient with progressively limited responses. The neurobiologic footing for these behaviors is unclear, but is thought to involve serotonin depletion. Some authors have suggested that agitated and ambitious behaviors go more common with increasing severity of dementia, while others have plant no such correlation. Still, these behaviors are fundamental in determining the demand for nursing dwelling house placement, regardless of the severity of cognitive damage. Dementia patients with uncontrolled agitation or wandering are more than hard to intendance for than subjects without behavioral disruptions. As a effect, they receive more psychoactive drugs, and are institutionalized sooner.

Repeated questioning, threatening verbalizations or gestures, resisting cares (e.yard. bathing), excess motor activity and numerous other behaviors are collectively referred to equally "agitation". Yet these behaviors may take different antecedents or triggers, and may be communicating unlike needs. Agitation may exist a ways of communicating pain or discomfort, a reaction to tasks which exceed capabilities, or a response to a threatening environment.Physical aggression often occurs as a defensive response to unwanted touch or every bit a reaction to a perceived threat, rather than as a manifestation of acrimony. Similarly, screaming is related to aggressive behaviors and may ascend as a response to social isolation. Because the basic bulletin is distress, intervention is necessary. Potential antecedents of the beliefs should be addressed. Reducing excess noise and stimulation, providing meaningful activity, and simplifying or structuring a routine to provide familiarity are effective strategies.

The antecedent to agitated behavior may be an impatient and irritable caregiver who is trying to get the patient to complete a task, and is meeting resistance. In situations like this, it is all-time that the caregiver back off and return later, recognizing that 1's affect can touch patient beliefs. Some behaviors, at first just a nuisance, may go annoying or irritating (e.g. repetitive questioning, pacing). Patient and caregiver agendas may differ significantly, causing conflict when the demand to be in control may be an event for both individuals. In these instances, it may be best for caregivers to "choose their battles," and avert potential conflict if the result of little importance. Patience, reassurance and increased tolerance may be the all-time initial strategy. It may be useful to remind caregivers that the demented patient is not trying to beal or manipulate them. Furthermore, scolding the patient for repeated questions may only serve to highlight the cerebral loss and sense of failure, precipitating fearfulness, suspicion, anxiety or acrimony.

An increase in agitation and confusion late in the afternoon or early in the evening is often described every bit "sundowning". Fatigue and stress likely contribute to this syndrome, although it is a nonspecific occurence that may reflect a wide variety of causes, especially in the hospitalized patient. Lowering expectations and reducing stimulation, while increasing security and comfort as the day progresses is warranted. However, an abrupt change in behavior may represent an acute disease causing dyspnea, discomfort, or a state of delirium and consequent agitation (east.g. urinary infection, myocardial infarction, constipation). Medication side effects, drug withdrawal states, and cumulative toxicity may outcome in agitation (east.g. digoxin, anticholinergic drugs, benzodiazepines). Caffeine and alcohol should be avoided in demented patients due to unwanted behavioral furnishings. Poor slumber, sensory deprivation, and changes in the environment (frequent conditions for the hospitalized dementia patient) are other possible triggers for agitation.

Slumber problems

Changes in sleep patterns occur with normal crumbling. Less fourth dimension is spent in deeper levels of sleep and nighttime enkindling is mutual. Sleep is further disrupted in dementia, and may come up to resemble the sleep patterns establish in newborns and younger children. Daytime naps, difficulty falling asleep, frequent awakenings, and twenty-four hour period-dark reversal affect 45 to 69 % of patients with dementia, and can exist a major problem for caregivers. Concerns nigh nightime wandering, injury, and safety can severely touch on the sleep of caregivers, prompting institutionalization for some patients.

A number of measures tin be taken to improve sleep in demented patients. Daily exercise and scheduled activities can supercede afternoon naps and improve nightime sleep, only may increase agitation in those patients who become fatigued during the day. Mid-day remainder periods could be spent in a recliner (rather than a bed) to reduce daytime sleeping. Caffeine should be avoided tardily in the day, and limited to a unmarried morning dose. In agitated patients, caffeine should exist avoided entirely. Toileting before bedtime and limiting evening fluids may reduce nocturnal awakening to void. Delaying the time for bed an hour or and then may decrease early wakening in some patients. A calm reduction in evening activities and a reinforcing bedtime routine (warm milk, a snack, massage, soothing conversation or music) may facilitate slumber initiation. For some patients, allowing nightime wandering in a supervised setting may be less harmful than apply of a sleep-inducing amanuensis. The apply of a room monitor tin warn the caregiver when the patient is upwards and limit the need to be on the alert.

Many medications, including sedatives, anticholinergics, sympathomimetics, diuretics, and booze may exacerbate sleep disturbances. Benzodiazepines and anticholinergic drugs should be avoided as therapy for sleep disorders in dementia patients. These medications are associated with increased cerebral harm, medication tolerance, falls , and prolonged sedation. Small doses of trazodone or chloral hydrate may exist beneficial in some cases, as can the sedating side effects of neuroleptics or antidepressants (when used for treating other conditions). Finally, sleep disorders may exist related to underlying low or anxiety, which tin can answer to appropriate therapy.

Delusions and Hallucinations

Delusions are reported to occur in 30 to 57 percentage of patients with Advert, and may exist related to acetylcholine deficiency and relative dopaminergic preservation in the limbic arrangement. Late-life delusions are often associated with social isolation, hearing impairment, and cerbrovascular lesions, particularly those involving subcortical structures and the limbic organization. Delusions are most frequent in eye to after Advertising, merely can occur at any stage and may be the presenting manifestation of a degenerative dementia. Patients with delusions accept a more rapid reject in cognitive function than those without, although survival is apparently unaffected. Delusional patients have more behavioral disruptions than nondelusional subjects, with increased wandering, anxiety, aggression, and agitation. Every bit a result, institutionalization for beliefs problems is much more than common in demented patients with delusions than in nondelusional subjects (54% vs 15%).

Hallucinations and illusions occur in 10 to 28% of patients with Advertizing. Visual hallucinations are nigh common, frequently involving people or animals. Auditory hallucinations also occur, with symptoms ranging from sensations of vague noises to the hearing of voices. Olfactory hallucinations are uncommon. Underlying vision and hearing disorders may predispose to sensory hallucinations. In demented patients, a thorough examination of vision and hearing is therefore of import in order to remedy potential contributing factors. External stimuli (such every bit a television) tin can sometimes be misinterpreted by demented patients. Patients may either recognize hallucinations as false or consider them real. Before considering treatment, physicians must decide whether these symptoms are actually bothersome or harmful to the patient (e.g. resulting in anxiety, fright or agitation) or whether they are harmless and acceptable.

Caregiver Resources

Instruction about dementia and related behavioral problems tin can exist invaluable to family members of demented patients, as well as to community and institutional caregivers. The almost useful resource for family unit information, education and referral is the Alzheimer's Association. Caregiving classes, back up groups, and information and referral to tangible local resources are provided. Numerous books and pamphlets on practical caregiving strategies are also available . These resources can help see many of the substantial needs of family unit caregivers at little cost.

Home Intendance and Placement

n a growing number of communities, a number of alternatives to nursing home placement exist for the care of demented patients. In-home respite intendance, companionship and homemaking services provide supplemental resource for home-based care. Adult 24-hour interval care programs (peculiarly if dementia-specific ) tin can offering meaningful structured activities for patients. These can provide needed socialization, exercise and routine for the demented elderly patient, and allow a well-needed respite for caregivers. At least 1-third of community-based dementia patients may not have local caregivers. When safety concerns arise, or when an individual's social back up network becomes inadequate for their needs, placement outside of the abode may be necessary. Placement advisable to the needs of the patient tin avoid iatrogenic disability. Supervised assisted living environments, such as adult family foster intendance, "group homes" and community-based residential facilities offer home-like environments where patients can live at their highest functional level. When long term skilled nursing becomes necessary, dementia-specific care units are a valuable resources where available.In utilizing consistent and knowledgeable staff, these units tin be more conducive to behavior management strategies.

Counselling

Although counselling may provide some benefit in the very early stages of dementia, there is no demonstrated role for counselling in treating moderate and severe dementia. The unconditional positive regard present in these therapeutic relationships can create a transient sense of well-being, only memory loss and lack of insight make sustained changes in mood or behavior unlikely. In any event, nonprofessional companionship, involvement in appropriate activities, and music or recreational therapy may provide similar benefits to formal counselling provided past a therapist or psychiatrist.

Summary

Behavioral disturbances in dementia need not be unmanageable. Recognizing and responding to the causes of excess inability, agreement behaviors every bit a form of communication, and having knowledge of available resources for caregivers and patients provides the health care professional person with a broader range of management options. The examples of problem behaviors provided here illustrate a nonpharmacologic approach to behavior direction. Not all problem behaviors, however, can be tied to recognizable antecedents, nor do they ever communicate messages we tin can sympathise. In these cases, caregivers should be encouraged to be flexible and creative in problem-solving approaches. What did not work yesterday may piece of work today, and vice versa. When it becomes axiomatic that the patient with dementia is no longer able to solve bug (especially their own behavioral disruptions), physicians and caregivers can more appropriately focus behavior direction on strategies that modify underlying health, ecology and psycho-social factors. Advisable modifications may enhance part, minimize medication use, and assist caregivers in coping with beliefs problems. Information technology is essential that behavioral management stategies are tailored to the individual and continually adjusted or modified as the disease progresses and the needs change. Educational activity and supportive intendance throughout the grade of the dementing illness allow the patient and family unit to acquire how to cope with the progressive cognitive, behavioral, and functional losses.

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