Powys - Non Pharmacological Approaches

Managing Challenging Behaviour Non-pharmacological Approaches 1000Lives plus National Learning event May1st 2012 1

BPSD Defined as symptoms of disturbed perception, thought content, mood or behaviour that frequently occurs with dementia:      

Disinhibited behaviour Delusions and hallucinations Verbal and physical aggression Agitation Anxiety Depression/Apathy 2

Key messages Non-pharmacological options are recommended (NICE, 2006) as the firstline approach Unless a person is at risk to themselves or others If the approaches do not help the person and their symptoms are severe or distressing, medication may be necessary 3

Key messages Offer an early assessment to identify factors that might influence behaviour. Include:       

The person’s physical health Possible undetected pain or discomfort Side effects of medication Individual biography Psychosocial factors Physical environmental factors Behavioural and functional analysis, conducted by professionals with specific skills, in conjunction with carers and careworkers 4

Key messages Develop an individually tailored care plan to help carers and staff address the behaviour that challenges Recorded in the patients notes Regularly reviewed The importance of working with care home staff to change entrenched/inappropria attitudes and behaviours through training 5

Key messages For co-morbid agitation, consider interventions tailored to the person’s preferences, skills and abilities  Monitor response and adapt the care plan as needed  Consider options including; aromatherapy, multisensory stimulation, therapeutic use of music and dancing, exercise, animal assisted therapy, massage 6

Key messages For co-morbid emotional disorders – depression and /or anxiety:  Consider cognitive-behavioural therapy (possibly involving carers)  A range of tailored interventions, such as reminiscence therapy, multi-sensory stimulation, animal assisted therapy and exercise should be available.

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Key messages Health and social care staff should be trained to anticipate behaviour that challenges and how to manage violence, aggression and extreme agitation, including de-escalation techniques  Offer people with dementia and their carers the opportunity to discuss their experiences

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Managing risk Address environmental, and psychosocial factors that may increase the likelihood of behaviour that challenges:

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Prevention Guidance: Recognition of triggers and early signs Pain, dehydration, constipation, malnourishment, physical illness such as infection Stress, irritability, mood disturbance and suspiciousness Increased levels of distress Early signs may be noticed at certain times of the day, particularly during personal care

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Prevention Guidance: Person-centred care  Is the person being treated with dignity and respect?  Is there good communication between the person and staff? And is there consistency of approach?  Do you know about their history, lifestyle, culture and preferences?  Does the person have an opportunity for relationship with others?  Does the person have the opportunity for stimulation and enjoyment?  Has the person’s family or carer been consulted?  Does the person’s care plan reflect their communication needs and abilities? 11

Prevention Guidance: Physical environment If in a bed or a chair, is the person comfortable and free of pressure sores? Is the TV playing something they can relate to and enjoy? If the person is mobile, can they move around freely and have access to an outside space? Does the person have enough privacy? Is the layout and signposting friendly? 12

Watchful waiting A pro-active process over 4 weeks involving on-going assessment of contributing factors and simple non-drug treatments. It does not mean doing nothing! Watchful waiting is the safest and most effective therapeutic approach unless there is severe risk or extreme distress

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Watchful waiting Guidance Person-centred care Have the carers considered the person’s relationship with others? How are these supported? Do the carers help the person to feel socially confident and not alone? Are the person’s fears recognised and addressed? How is the person included in conversations and care? How are they shown respect, warmth and acceptance? 14

Watchful waiting Guidance: Consult with the family

It is essential to discuss the person’s symptoms and possible treatments with their family or carer They may be able to shed light on the reasons for their symptoms and ways to engage them in activities

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Watchful waiting Guidance: Soothing and creative therapies Evidence is poor and sample sizes small:  Aromatherapy and hand massage  Hairbrushing and manicures  Music, singing and movement; structured social interactions and meaningful activities  Art therapy  Animal assisted therapy  Multi-sensory stimulation  Reminiscence/Life-story 16

Specific interventions: Guidance There is good evidence for the value of specific psycho-social interventions delivered by a clinical psychologist or equivalent health professional. Appropriate approaches include the Antecedent Behaviour Consequence (ABC) approach to develop individualised intervention plans. These approaches are effective, but require specialist referral 17

Dem3/ Meds Mgt collaborative Non-pharmacological options are recommended (NICE, 2006) as the first-line approach* Evidence for non-pharmacological options is poor, but known anecdotally to be effective. Learning from the experiences of others is therefore a vital tool in disseminating good practice – already good examples in action Saves time, energy, good will and costs 18

Suggested key areas for sharing 1. Environmental improvements 2. Alternative therapies (NICE 2006) – ‘Aromatherapy, multisensory stimulation, therapeutic use of music and/or dancing, animal assisted therapy, massage’ 3. Reminiscence/Life story 4. Staff training courses 5. Activities (e.g. exercise gardening, cooking)/Refocusing roles 6. Behavioural analysis 19