Dementia: Managing Challenging Behaviours Associated with Dementia

Text adapted from "The patient with dementia" in Psychiatry in primary care by Kenneth Le Clair, Dallas Seitz and Julia Kirkham.  (CAMH, 2019). 

Health Promotion and Preventing Unnecessary Disability

• Identify and treat cardiovascular risk factors and optimize cardiovascular health. This is critical not only in vascular dementia, but also in Alzheimer’s and other dementias.
• Encourage the patient to keep active in mind and body.
• Educate the patient and caregivers about early signs of delirium and common changes, including psychosis and depression.

Managing Challenging Behaviours Associated with Dementia

In addition to experiencing cognitive changes, it is also common for people with dementia to develop behavioural and psychological symptoms of dementia (BPSD). BPSD affects between 40 and 80 percent of people with dementia, and is associated with increased caregiver burden and likelihood of being placed in a nursing home.

BPSD can emerge at any stage of dementia. It includes behaviours and psychological symptoms such as:

• agitation and restlessness
• anxiety
• apathy/failure to participate, withdrawing/crying
• defensive behaviour
• hearing and seeing things that do not exist
• hoarding and rummaging
• impulsivity
• inappropriate sexual behaviour
• intrusiveness
• resistance to care
• suspicion, accusing others
• vocal disruptiveness
• wandering.

Neuroimaging is also recommended to evaluate concomitant cerebrovascular disease because it may affect management.

Evaluating and Treating Behavioural and Psychological Symptoms

The ABC approach involves clear steps for obtaining an accurate description of the problem behaviour:

• What are the Antecedents to the behaviour?
• What exactly is the Behaviour? (Be more specific than “agitated” or “aggressive.”)
• What is the Consequence (caregiver’s response) of the behaviour?

After getting a clear description, the next step is to rule out potential reversible secondary causes of the behaviour. Evaluate delirium risk in a systematic and comprehensive way by using the three-question template on pages 231–233 (What has changed? What are the risks and causes? What is the action?). Delirium can present with behavioural disturbances in patients with dementia and should first be ruled out (see Figure 12.1 on page 222 for an algorithm for diagnosing delirium). Be aware of potential medical indications conditions, including pain, that can exacerbate behaviours, as well as unmet needs, constipation and environmental contributors.

Initiate non-pharmacological management for the specific behaviours. Provide education to caregivers, which can often decrease distress and negative responses to the behaviours. You may need to consider pharmacological treatments early if the behaviours endanger others or cause extreme distress.

To determine the impact of the behaviour and the risks associated with it, and to monitor response, use the four Ds approach:

• Is the behaviour Dangerous, Distressing, Disturbing relationships or jeopardizing independence due to the effects on the caregivers, and/or causing Disability (e.g., medical malnutrition, risk for falls)?

If the behaviour persists, optimize the treatment of the underlying dementia. This may include taking measures to prevent further cognitive decline as well as prescribing cognitive enhancers.

In Dementia:

• The Primary Care Practitioner Role 
• Screening & Assessment
  • Assessing dementia and cognitive impairment in the real world
  • Beyond cognition: Five areas to assess in dementia
• Diagnosis
  • Differentiating Types of Dementia
• Treatment
  • Managing Challenging Behaviours Associated with Dementia
  • Medications for Treating Behavioural and Psychological Symptoms
    
• Resources & References