Behavioural and Psychological Symptoms of Dementia (BPSD)

Behavioural and Psychological Symptoms of Dementia (BPSD)

Reducing Antipsychotic Prescribing for Behavioural and Psychological Symptoms of Dementia (BPSD)

Care Homes Good Practice Guidance

Table of Contents

Aim……………………………………………………………....................2

Background…………………………………………………….................3

SECTION 1 – Guidance for prescribers ………………………...........4

Step1: Explore and address potential biopsychosocial factors...4

Response to BPSD with antipsychotic treatment…………............4

Step 2: Factors to consider before starting an antipsychotic...... 4

Step 3: Starting antipsychotic treatment……………………............5

Step 4: Reviewing antipsychotic treatment…………………...........6

Step 5: If antipsychotic is continued, repeat step 4………...........7

Step 6: If antipsychotic is discontinued……………………............7

Recommended deprescribing protocol…………………….............9

SECTION 2– Information for care practitioners…………........…..11

SECTION 3 - Guidance for care practitioners…………….............12

SECTION 4 – Ideas for care practitioners…………………........…14

Appendix 1…………………………………………………..............…20

References………………………………………………….............….23

AIM:

This guidance has been produced to provide GPs, PCN pharmacists and care practitioners with a practical approach in the treatment of behavioural and psychological symptoms of dementia, including guidance on reviewing antipsychotics. This guideline aims to promote evidence based, cost effective prescribing and support adherence to up to date national guidelines (NICE guideline NG97).

BACKGROUND:

BPSD includes a wide range of symptoms including agitation, aggression, wandering, hoarding, shouting, depression, anxiety, distress during care, sleep disturbance, hallucinations, apathy, delusions, and psychosis. More than 90% of people with dementia will experience these symptoms as part of their illness over the years and the number, type and severity of these symptoms varies between patients. Patients may also experience multiple symptoms at the same time, making it very difficult to target specific symptoms.

There are several rating scales to assess the severity and presence of BPSD symptoms. Two rating scales were recommended by a study which analysed 29 scales (Tible et al., 2017). Among these scales, the neuropsychiatry inventory (NPI) and the behavioural pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) were rated as the best measures for the assessment of BPSD symptoms. One of these two scales can be found in the following link: BEHAVE-AD-1.pdf (dementiaresearch.org.au).

Management of BPSD includes non-pharmacological and pharmacological interventions. Choice of treatment must always be patient, and caregiver centred to with the aim of providing comfort for the patient and to help alleviate caregiver burden. Treating concomitant somatic diseases plays a crucial part in the treatment plan.

The NICE dementia guideline (NG-97), recommends non-pharmacological interventions as the first line approach and emphasises the importance of assessing medical conditions and pain, which often underpin the development of these symptoms of BPSD. It is important not to initiate pharmacological interventions until non-pharmacological options are explored.

Section 1 – Guidance for prescribers Responding to non-cognitive (behavioural and psychological) symptoms in dementia without antipsychotic treatment.

Step1: Explore and address potential biopsychosocial factors.

BPSD patients with acute symptoms must at first be assessed to exclude alternative causes such as physical health issues (pain/infection), environmental factors, psychosocial factors, and others.   Two potential methods can be used to explore these underline causes and one of them called PAIN approach is described below. Other method called ABC is described in appendix 1.

●(P) Physical factors: contributing physical health conditions including pain, acute infection, constipation, anxiety, depression, electrolyte imbalances, metabolic disorder, urinary retention, and others are managed properly.

● (A)Activity related: Personal care activities such as dressing and washing can cause agitation.

● (I)Iatrogenic/drug induced: Drugs with high anticholinergic effects have the potential to cause symptoms including confusion, agitation, and delirium. They can increase the risk of cognitive impairment, constipation, urinary retention, dry mouth/eyes, sedation, insomnia, photophobia, and falls.

● (I)Intrinsic to Dementia: There are certain symptoms of BPSD which are intrinsic to dementia. These include wandering, agitation, delusion, and others.

● (N) Noise and other environmental causes: Noise and other environmental factors such as new admission to care home, light, unknow carer and unfamiliar environment can cause BPSD symptoms.

● Expression of distress and unmet needs: Make use of life history, direct observation of care and data collection (e.g., sleep, pain, and antecedent, behaviour & consequence (ABC) charts to understand what the unmet needs might be and to inform treatment changes) (Brechin et al.,2013).

Non-pharmacological options must be the first line of treatment.

Response to BPSD with antipsychotic treatment:

·Antipsychotics must not be used routinely to treat agitation and aggression in people with dementia. Long term treatment (≥12 months) with antipsychotics carries cumulative risks of increased mortality, cognitive decline, falls and other adverse effects.

· If a decision is made to commence an antipsychotic drug, refer to step 2 onwards, for best practice guidelines on safe prescribing and review.

· If reviewing a patient who has already been prescribed an antipsychotic, refer to step 4 onwards.

Step 2: Factors to consider before starting an antipsychotic

● Antipsychotics must be only offered to people with dementia who are

     a) at risk of harming themselves or others

     b) experiencing agitation, hallucinations or delusions that are causing them severe distress (NICE, 2018).

● Ensure potential biopsychosocial factors are explored and non-pharmacological interventions are already used for long enough (at least 4 weeks) where applicable.

● There should be clearly documented evidence in the care notes/ behavioural charts to demonstrate that there is a sufficient need for an antipsychotic to be prescribed.

● Consider risk factors for cerebrovascular disease e.g., previous history of stroke or transient ischaemic attack (TIA), hypertension, diabetes, smoker and, atrial fibrillation.

● Discuss the potential benefits and harms with the person/family members and care practitioners. The NICE decision aid can be used to support this discussion. NG97 Patient decision aid on antipsychotic medicines for treating agitation, aggression and distress in people living with dementia (nice.org.uk)

● Check for potential drug interactions and side effects (e.g., drowsiness and, confusion) including cumulative side effects in combination with other medication.

● For people with dementia with Lewy bodies or Parkinson’s Disease dementia, antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions (NG,97). Seek specialist advice.

Step 3: Starting antipsychotic treatment.

● Start on a low dose.

● Monitor response to treatment, symptoms, and side effects.

● Non-pharmacological approaches must continue while the person is prescribed an antipsychotic.

● Use the lowest effective dose for the shortest possible time.

● Although risperidone and haloperidol are the only antipsychotics licensed for non-cognitive symptoms in dementia most recent studies show that there are no significant differences across measures of effectiveness and safety among aripiprazole, olanzapine, quetiapine, and risperidone. Due to this treatment plan should be individualised and patient centred.

·       Risperidone –Recommended starting dose 0.25mg twice daily, increased in steps of 0.25mg twice daily on alternate days, adjusted according to response. The usual dose is 0.5mg twice daily. Maximum recommended dose 1mg twice daily.

·       Olanzapine - Usual dose range 2.5mg- 10mg per day.

·       Quetiapine – Usual dose range 12.5mg-300mg daily. Could be considered first choice for patients with Parkinson’s Disease or Lewy Body Dementia due to lower risk of movement disorders.

·       Aripiprazole- Usual dose range 5-15 mg daily. Could be considered as second choice for patients with Parkinson’s Disease or Lewy Body Dementia where quetiapine is ineffective or contraindicated.

·       Haloperidol – licensed for treatment of persistent aggression and psychotic symptoms in moderate to severe Alzheimer’s disease and vascular dementia. Recommended dose 0.5 to 5mg/ day orally, as a single dose or in 2 divided doses, dose adjusted according to response at intervals of 1-3 days.

·       Amisulpride – Usual dose range 25-50mg per day. This should be only considered where all other antipsychotic options have been ineffective or contraindicated.

● When antipsychotics are initiated, baseline measurements should be taken in secondary care. Regular monitoring may subsequently be done in primary care on specialists’ advice or depending on person’s care plan. This may include physical Health monitoring mentioned in table 2.

STEP 4: REVIEWING ANTIPSYCHOTIC TREATMENT.

If the patient is under regular review by secondary care, responsibility for reviewing/reducing/stopping the antipsychotic would remain with secondary care.

● For patients who are not under review by secondary care (i.e., antipsychotic initiated in primary care, patients who have been discharged from secondary care):

·       Review every 6 weeks or as suggested by need.

·       Monitor response to treatment, symptoms, and side effects.

·       Unless there is severe risk or extreme distress, the recommended default management is to discontinue the antipsychotic with monitoring, ongoing assessment of contributing factors and continuation of non-drug treatments, based around the person’s needs, abilities, and interests.

Refer to the following guidance to support with dose reduction: · Table 1- Suggested tapering protocol for reducing and stopping antipsychotics · Recommended deprescribing protocol.

STEP 5: IF ANTIPSYCHOTIC IS CONTINUED, REPEAT STEP 4

The specialist should conduct health check at baseline, 3 months, and 6 months after prescribing a new antipsychotic. The GP should conduct a health check at least annually unless abnormality of physical health emerges. These physical health monitoring details are described in table 2.

STEP 6: IF ANTIPSYCHOTIC IS DISCONTINUED

     ● Non-pharmacological treatments in managing behavioural symptoms, based on the person’s needs, abilities and interests should continue after the antipsychotic has been stopped.

     ● It must be noted that antipsychotics can be withdrawn without significant detrimental effects on behaviour in around 50% - 70% of people living with dementia (NG 97).

    TABLE 1- SUGGESTED TAPERING PROTOCOL FOR REDUCING AND STOPPING ANTIPSYCHOTICS USED FOR BPSD: THE FOLLOWING IS A TAPERING GUIDE FOR THE MOST USED ANTIPSYCHOTICS FOR BPSD. INDIVIDUAL PATIENT CIRCUMSTANCES MAY NEED TO BE TAKEN INTO CONSIDERATION IN DOSE REDUCTION.

Antipsychotic

Usual dose range in dementia (oral)

Suggested regime for reduction/discontinuation (generally reduce over 2-4 weeks and ideally 4 weeks)

Amisulpride

25-50mg/day

●Reduce by 12.5-25mg every 1-2 weeks, then stop.

Aripiprazole

5-15mg/day

●Reduce by 5mg every 1–2 weeks (depending on dose), then stop

Haloperidol

0.5mg-5mg/day

●Reduce by 0.25–0.5mg every 1–2 weeks (depending on dose) then stop.

Olanzapine

2.5mg- 10mg/day

●Reduce by 2.5mg every 1–2 weeks (depending on dose) then stop.

Quetiapine

12.5mg-300mg/day

·For doses 12.5–100mg/day, reduce by 12.5–25mg every 1–2 weeks (depending on dose) then stop.

·For doses >100–300mg/day, reduce by 25–50mg every 1–2 weeks (depending on dose) then stop.

·If dose is 300mg/day, reduce to 150–200mg/day for 1 week then by 50mg per week.

Risperidone

0.25mg-2mg/day

●Reduce by 0.25–0.5mg every 1–2 weeks (depending on dose) then stop.

(Adapted from the Maudsley Prescribing Guideline, 2021).

TABLE 2- SUGGESTED PHYSICAL HEALTH MONITORING IN ADULTS PRESCRIBED AN ANTIPSYCHOTIC FOR BPSD:

Antipsychotics

Amisulpride, Aripirpazole, Haloperidol, Olanzapine, Quetiapine and Risperidone

Blood & Lipid profiles

ANNUAL: if fasting samples for lipid profile are impractical then non-fasting samples are satisfactory for most measurements except low-density lipoprotein (LDL) and triglycerides (TG). Follow NICE NG238 Overview | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE (updated December, 2023). Use QRISK 3 for assessing CVD risk for primary prevention and NICE CG71 Overview | Familial hypercholesterolaemia: identification and management | Guidance | NICE (updated 2019). Provide advice on lifestyle modification for prevention of CVD.

Blood Pressure/Pulse

ANNUAL - Blood pressure target <140/90 mmHg in adults with hypertension aged under 80, <150/90 mmHg in adults with hypertension aged 80 and over (NICE NG136 Overview | Hypertension in adults: diagnosis and management | Guidance | NICE , 2019). Refer to appropriate clinician for investigation/management if indicated.

ECG

Perform an ECG to monitor for QTc prolongation if there are cardiovascular risk factors, including a strong family history of CVD or if new medicines or changes to physical health have increased the risk of QTc prolongation. Once stabilised on high-dose treatment, perform ECG every 12 months or sooner if clinically indicated.

Fasting blood glucose & Hba1c

ANNUAL - If fasting blood glucose (FBG) is impractical then random blood glucose (RBG) can be measured and interpreted accordingly. People with FBG of 5.5-6.9mmol/L or HbA1c 42–47mmol/mol (6.0%–6.4%) are at high risk of diabetes and should be supported to change their diet and lifestyle. Follow Public Health Guideline PH38: Overview | Type 2 diabetes: prevention in people at high risk | Guidance | NICE , Updated 2017)

Full Blood Count (FBC)

ANNUAL - Stop suspect drug if neutrophils <1.5 x 109 and refer to medical specialist if <0.5 x 109. Note: high frequency of benign ethnic neutropenia in some ethnic groups.

Liver Function Tests

Annual

Prolactin level

A prolactin level is useful at baseline as it can be repeated if sexual or reproductive system abnormalities are reported. Drugs reported to cause raised prolactin: amisulpride, sulpiride, risperidone, and first-generation antipsychotics. Aripiprazole, olanzapine, and quetiapine have minimal effect on prolactin levels. Refer to psychiatrist if antipsychotic induced hyperprolactinaemia: Men 0–424 mIU/L (0 -20 ng/ml) and Women 0–530 mIU/L (0 – 25ng/ml).

Renal Function

(U&Es & eGFR)

ANNUAL – Presence of chronic kidney disease increases risk of CVD. Monitor Urea and Electrolytes (U&Es) and eGFR.

Weight (BMI/ Waist circumference)

ANNUAL - Target BMI is 18.5-24.9 kg/m2 (18.5-22.9 kg/m2 in South Asian or Chinese). Waist measurement is a predictive factor for cardiovascular risk. A healthy waist measurement (reflecting low coronary risk) is below 37 inches/94 cm for men and 32 inches/80 cm for women. The greatest health risks are associated with waist measurements greater than 40 inches/102 cm for men and 35 inches/88 cm for women. Weight gain of >5kg over 3 months and/or high BMI over target require action (medication review/lifestyle advice). Ideally this should be plotted on a chart; if more than one recorded weight is available, Eclipse Live can be used to populate a graph.

Adapted from guidance-on-choice-and-selection-of-antipsychotics-in-the-management-of-psychosis-and-schizophrenia-in-adults-v21-internet-version.pdf (hpft.nhs.uk) & HPFT physical health policy V 6.1. Reproduced from the GP Guide for Physical Health Monitoring in Adults Prescribed an Antipsychotic for Serious Mental Health Illness (SMI), October 2020, Herts Valley CCG.

  RECOMMENDED DEPRESCRIBING PROTOCOL:

● Deprescribing is recommended if a patient with BPSD has been taking antipsychotic treatment for more than 6 weeks and either symptoms are controlled or there is no response to treatment.

● Review at every stage of dose reduction to evaluate patient response. Expected benefits may include improved alertness, reduction of weight loss, or weight gain (e.g with olanzapine), reduced number of falls and extrapyramidal side effects.

● Abrupt discontinuation of antipsychotics can result in adverse withdrawal effects (especially after prolonged use). Withdrawal effects can include psychosis, hallucinations, delusions, aggression, agitation, nausea, vomiting, sweating, insomnia, headache, restlessness, and anxiety.

● If a very high dose was recommended by a specialist, seek their advice before making any changes.

● In some cases, it may be necessary to withdraw the drug more slowly, particularly if symptoms reappear or withdrawal symptoms occur.

·         Implement small decreases in dose (ensure dose reduction is possible with strengths available), one step down at a time.

·         Where the antipsychotic is given more than once daily, decrease only one dose to start with, choosing the dose where the patient is likely to be least affected.

·         Allow sufficient time for the patient to adapt to the new dose (usually 1-2 weeks) before considering the next small reduction in dose.

·         When the lowest daily dose has been achieved, then administer on alternate days before stopping completely.

● For those with worsening of symptoms, the first four weeks are the most challenging. Monitoring, ongoing assessment of contributing factors and non-pharmacological treatments may prevent the need to restart antipsychotics.

● The risk of recurrence of symptoms after discontinuation may be more likely if:

·         Previous discontinuation has caused symptoms to return.

·         The person currently has severe symptoms.

SECTION 2– INFORMATION FOR CARE PRACTITIONERS ANTIPSYCHOTIC MEDICINES FOR TREATING NON-COGNITIVE (BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS) IN DEMENTIA

Antipsychotic medicines are sometimes used to treat behavioural and psychological symptoms in dementia. Only risperidone and haloperidol have a licence to treat these sorts of problems in people living with dementia. Other antipsychotics, including olanzapine, aripiprazole, and quetiapine, are often prescribed to treat these behavioural symptoms but are not licensed for this use.

The most common side effects of antipsychotics are:

·       Feeling sleepy or less alert (although some people have difficulty falling or staying asleep)

·       Headache

·       Changes in appetite and weight gain

·       Symptoms like those of Parkinson’s disease. These may include slowness or difficulty in moving, a sensation of stiffness or tightness of the muscles (making the person’s movements jerky), and sometimes even a sensation of movement ‘freezing up’ and then restarting. The person may develop a slow shuffling walk, a tremor, increased saliva or drooling, and a loss of expression on the face.7

Not everyone will get these, but many people will. The higher the dose of antipsychotic and the longer the person takes it, the more likely they are to get these side effects (NG 97). There are also other less common side effects (refer to the medicine’s patient information leaflet for a full list of side effects). The most serious side effects include an increased risk of stroke.

Because of these side effects, it is important that non-pharmacological treatments
(e.g., music, aromatherapy, activities that are person-centred) are used as a first line option. It may be necessary in some cases for a person to be prescribed an antipsychotic, for example when a person is at risk of harming themselves or others, or if they are severely distressed. In these cases, non-drug measures must continue alongside the antipsychotic. Where antipsychotics are prescribed for behavioural symptoms in dementia, these medicines must be reviewed regularly, with the prescriber, to see if the dose can be reduced or if the medication can be stopped.    Refer to section 3 and 4 for further guidance.

SECTION 3 - GUIDANCE FOR CARE PRACTITIONERS RESPONDING TO NON-COGNITIVE (BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS) IN DEMENTIA.

Initial presentation of symptoms: Use non-pharmacological measures.

Identify what the behavioural symptom is.

Identify and address cause of behaviour(s).

The reason for the behaviour could be due to an unmet need.

If the cause of the behaviour is due to a physical factor e.g., infection, pain, constipation:

·       Liaise with the GP to treat accordingly. Sleep charts, pain charts, bowel charts may help to understand what the unmet need might be and could help to guide treatment.

·       If the cause of the behaviour is due to other factors e.g., environmental, lack of understanding about the person:

·       Use person-centred, non-drug measures (see section 4 for ideas). Record this in the care plan.

·       It is important to recognise that behaviours such as walking about or sundowning could be a sign that the person has an unmet need. The person may be trying to communicate rather than behaving a certain way.

● Simple adjustments to social interactions and the environment can make a difference.

● Set up a system for monitoring and documenting behaviour and outcomes of non-pharmacological measures (e.g., using ABC charts). Record trigger, description of the behaviour, what actions were taken to support the person, outcome. You may need to try several different things over the course of a few weeks before you see improvement. Clear documentation will help to identify what is working and what is not working.

● Be patient. Remember, behavioural symptoms of dementia often disappear over 4-6 weeks without the need for medication.

●If above options have not worked, liaise with the GP.

IF AN ANTIPSYCHOTIC IS STARTED, CONTINUE NON-DRUG MEASURES

If an antipsychotic is started, for example, if non-drug measures have not worked, or if the antipsychotic has been prescribed for a person who is at risk of harming themselves or others, or severely distressed:

● Continue to monitor behaviour e.g., using behavioural charts.

● Monitor and document side effects. Liaise with GP if side effects occur (see section 2 for a list of common side effects. Note this list is not exhaustive).

● Continue person-centred, non-drug measures (see section 4 for ideas).

● Set up a system within the home to ensure that antipsychotics being used to treat these behavioural symptoms are reviewed with the GP every 6 weeks (or sooner).

IF ANTIPSYCHOTIC DOSE IS BEING REDUCED/ STOPPED, CONTINUE NON-PHARMACOLOGICAL MEASURES

● Continue person-centred, non-drug measures (see section 4 for ideas).

● Monitor behaviour at every stage of dose reduction and after the antipsychotic has been stopped e.g., using behavioural charts.

● Monitor for withdrawal symptoms. This is more likely if the person has been on the drug for a long time and the dose is reduced too quickly. Common withdrawal symptoms include nausea, vomiting, sweating, insomnia, headache, restlessness and anxiety. Liaise with the GP if withdrawal symptoms occur (it may be necessary to withdraw the drug more slowly), or if behavioural symptoms reappear during dose reduction.

● For those with worsening of symptoms, the first four weeks are the most challenging. Continue person-centred non-drug treatments which may prevent the need to restart antipsychotics.

● It is important to note that antipsychotics can be withdrawn without significant detrimental effects on behaviour in around 50-70% of people living with dementia (NG 97).

● Liaise with the GP if behavioural symptoms reappear after the antipsychotic drug has been stopped.

SECTION 4 – IDEAS FOR CARE PRACTITIONERS NON-DRUG MEASURES FOR MANAGING NON-COGNITIVE (BEHAVIOURAL AND PSYCHOLOGICAL) SYMPTOMS IN DEMENTIA

● Use a behavioural chart, for example an ABC chart, to record:

·       Antecedent: What triggered the behaviour (e.g., activities, settings, objects, individuals, thoughts, feelings)

·       Behaviour: What did the behaviour look like (give a clear description of the behaviour that occurred)

·       Consequence: What actions were taken to support the person and what was the outcome (include what approaches were taken to support the resident and how the person responded to these approaches. It is important to include what did not work as well as what did work).

● Clear records will help to identify and address patterns or triggers for behaviour and will help to identify how well a person with behavioural problems is responding to different situations and different approaches.

● You may need to try several different things over a few weeks before you see improvement. If distress or behaviours do not resolve with the advice given in the following table, consult with the GP.

NB: ABC chart is added in Appendix 1

POSSIBLE CAUSE: PHYSICAL HEALTH

Challenging behaviour may result from:

Ideas for staff

Pain

People with dementia are often not able to identify or may deny pain due to cognitive impairment.

Pain can be a major trigger for agitation and aggression and is one of the most common causes of behavioural.

symptoms in dementia.1

Think about potential cause of the pain.

Ask the person – keep questions simple.

Check for any pressure sores/ ulcers.

If the person is unable to verbalise pain

Use pain assessment tool – this can guide you to the cause of the pain, severity, when it occurs and what helps to make the pain better or worse.

Look for signs e.g., facial expressions, body language.

Observe pain response during personal care, tasks, and transfers.

Factors that could help to alleviate pain: distraction, relieving boredom, a calm, comfortable environment, social contact, treating anxiety and/ or depression.

If prescribed ‘When required (PRN)’ pain relief, ensure there is a PRN protocol which is person-centred. This will help to identify what signs and symptoms to look out for that might suggest a resident is in pain.

If requiring ‘PRN’ medicines regularly, liaise with the GP to decide whether the medicine should be prescribed regularly.

Infection

Refer to GP.

For assessment of UTI, refer to ‘To Dip Or Not To Dip’ pathway (refer to the section on UTIs and hydration on the webpage)

Hunger, thirst, dehydration

Is pain affecting ability to eat or drink e.g. dentures, painful teeth?

Check access to food and fluids.

Visual aids, such as pictorial menus or showing plates of the food on offer may help people to make choices.

Refer to Hertfordshire and West Essex Integrated Care board (HWEICB)    Malnutrition pathway download (hweclinicalguidance.nhs.uk) and other  fortifying food guideline download (hweclinicalguidance.nhs.uk).

Constipation

Monitor bowels (using bowel chart).

Sensory impairment e.g., eyesight

Check that there is enough light.

If the person wears glasses, make sure they are clean.

Poor eyesight/ hearing can lead to misunderstandings and misperceptions (the person can mistake what they see or hear for something else)

Be aware that reflections in mirrors could be misinterpreted as another person.

Remember that many people with sight loss will not pick up on visual communication e.g. facial expressions might be lost to them. Improve ways of verbal communication e.g. ask the person where you are most likely to be seen and heard, given their particular condition.

Three key principles:

1.    Make things bigger (such as using clocks and watches with large numbers).

2.    Make things brighter (by using good lighting).

3.    Make things bolder (use contrasting backgrounds).

Restlessness

Consider body language, facial expressions, gestures, general demeanour.

o If the person is pacing around, do they want to go for a walk?

o Are they fidgeting because they need to use the toilet?

Medication side effects

Liaise with GP.

POSSIBLE CAUSE: ENVIRONMENTAL FACTORS

Challenging behaviour may result from:

Ideas for staff

Over-stimulation

· Noise that is acceptable to care staff may be particularly distressing and disorientating, especially busy times of the day such as shift change-over and mealtimes.

o Consider quiet time.

o Consider change of scenery e.g. garden, another room.

o Tailor music/songs to what the individual prefers.

o Be alert to noise from other devices such as alarms, doorbells, telephones. Try to minimise these types of noises, which can be intrusive, especially at nighttime.

Under-stimulation

Use meaningful activities that are relevant to the person based on interests, hobbies, or previous work.

Frequent, short conversations (as little as 30 seconds has proven effective).

Use social areas to encourage interactions.

Some people relate better to pictures than words.

Consider music (tailored to what the individual likes). Music from the past can bring back good memories.

Just 60 minutes of pleasant activities each week improves behaviour and other symptoms.

Getting used to a new place.

May take up to 6 weeks for people to feel settled.

Use information from family and/ or previous care facility of what has helped in the past.

Familiar items e.g., personal belongings in room.

Consistency with people involved in the person’s care, particularly in the first few weeks.

Support the person to continue their preferred routine. (Routines help the person with dementia know what to expect).

When they wake up, for example, do they normally have the radio/TV on?

Confusion linked to

physical design of the home

Ensure there is good lighting.

Use of pictures and colours to find the way around (some people relate better to pictures than words).

Clear signage to toilets.

Reactions to uncomfortable temperatures

Check that the temperature is not too hot or too cold.

Possible cause: Lack of awareness of person’s beliefs and life-style preferences

Challenging behaviour may result from:

Ideas for staff

Lack of knowledge about the person and their beliefs and preferences

The more you know about the person with dementia, the more likely it will be to understand what they may be trying to communicate.

Consider the following:

o Life story.

o Personal likes and dislikes.

o Important relationships.

o Culture – promote respect for religious or cultural rules and customs. o Beliefs.

o Consider whether the person thinks they have work or care responsibilities.

e.g. that they need to go to work. Offer alternative meaningful activity which will be valued by the person. Acknowledge where the person is at - don’t argue or attempt to change their viewpoint.

o Promote work with family members to inform care and better understand the resident.

Possible cause: Lack of understanding of how the person sees and interprets their world

Challenging behaviour may result from:

Ideas for staff

Person unable to communicate their needs or requests are being ignored

Be proactive with checking person’s needs at frequent intervals.

Use short, simple sentences or statements or non-verbal gestures to indicate walking to the toilet etc.

Hearing and visual difficulties

Check for sensory impairment.

Find a suitable place to talk, with good lighting, away from noise and distraction.

If they have visual impairment on one side then approach from the other.

Ensure verbal communication is clear, loud enough (but not shouting as this might look aggressive), speaking slowly enough, talking into the good ear.

Difficulty in recognising everyday objects

Use alternative means to aid recognition e.g. holding object, by demonstrating use of object, for example, flushing a toilet.

Repetitive behaviour

e.g. repeating actions, words, gestures

If a person is repeating the same question or phrase, try to help by offering an answer to break the cycle e.g. if asked the time, tell them the time and also show them the time on a watch or clock.

When an action is repeated, e.g. packing a bag or folding clothes, this may be linked to a previous job or hobby. Try turning this into an activity.

Lack of inhibition

(disinhibition)

Behaving in a way that others might find embarrassing (for example, saying things that aren’t appropriate)

Use distraction techniques and alternative means of meeting needs.

Observe for time of day and notice triggers.

Experiencing delusions and visual hallucination symptoms

Take personal care tasks slowly and give repeated reassurance about intentions.

Acknowledge the delusion/ hallucination - don’t ignore it or try to prove to the person they are wrong.

If they are not concerned or anxious about it, then don’t dwell on it.

Ensure plenty of reassurance if the person is worried and ensure there are alternative activities to be involved in.

Liaise with GP.

Possible cause: Underlying emotional or mental health problems

Challenging behaviour may result from:

Ideas for staff

Undiagnosed depression and anxiety

Ensure resident has access to activities and actively encourage participation.

Promote active involvement of relatives in care.

Be aware of triggers for anxiety e.g. confined places.

Person may be searching for a loved one

Try to provide the person with a sense of control and safety and ask them about their loved ones. Try to avoid correcting what they say as it is much more important to focus on the person’s feelings rather than whether what they are saying is true.

Try using life story information and photos to reinforce sense of identity and enhance memories.

Experience of bereavement or effects

of traumatic events in their life

Enable safe expression of emotions. It might be more positive to enter and accept their reality rather than bring the person back to our reality. Acknowledge and empathise with their feelings.

Check with family what works.

Enable usual coping behaviours, e.g. safe walking.

Consider using dolls and pets.

Disorientation and memory problems

Try to make the most of the person’s strengths and remaining abilities.

Acknowledgement to Sussex Partnership NHS Foundation Trust- the above table is based on version 4 of the document ‘Reducing antipsychotics in people living with Dementia’ .Other references used: Social Care Institute for Excellence (SCIE) https://www.scie.org.uk/dementia/   Alzheimer’s Society https://www.alzheimers.org.uk/about -dementia

APPENDIX 1:

ABC stands for Antecedence, Behaviour and Consequence, and is an important way of reviewing how well a person with behavioural problems is responding to different situations. Completed ABC charts and / or diaries must be reviewed along with the person-centred care plan at regular intervals, including at medication review, to help decide what plan of actions to continue with.

Antecedence

Record the situation in which the problem behaviour occurred, for example.

             ¡ time of day, activities that were happening or about to happen.

             ¡ Was anything different to usual?

             ¡Any other clues to set the scene.

Behaviour

Record the actual behaviour.

               ¡ What happened? How long did it last for? How severe was it?

               ¡ Did anyone present do anything to try and manage it? If so, what?

Consequence

How did the behaviour settle? How did the person respond to attempts to manage the behaviour?

                 ¡ Important to include things that didn’t work. What worked well?

                 ¡ Were there any significant consequences, eg family member now refusing to visit, care staff injured, patient fell or hurt themselves?

                 ¡ Did anything else happen after the episode of behaviour?

Date and Time

Antecedent (What triggered or came before the behaviour?)

Describe the behaviour (include location and other aspects of the environment (eg, lighting, noise)

Consequence (What did you do, or what happened to the behaviour? How severe was it?)

Outcome

(What did the observed person do after the incident was over?)

Acknowledgement to Hertfordshire Partnership Foundation NHS Foundation Trust (HPFT)- the above information in appendix 1 and table is based on version 1 of the document ‘Guidelines for the pharmacological Management of Dementia’ (Butterworth,2020).

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