Dementia care
history and discover that she has a history of depression and post-traumatic stress disorder following a motor vehicle accident that resulted in her experiencing anxiety when feeling out of control. They also discover Meera enjoys gardens and music from the 1970s and contemplate how they might incorporate this into her care plan.
Planning care to support the person with changed behaviours Person-centred non-pharmacological interventions are the foundational response to BPSD. When planning care to support a person’s changed behaviour, the most crucial issue is to address the identified contributing factors – hence the value of a thorough assessment. Being specific about the strategies that respond to contributing factors and communicating these clearly to all care providers through a straightforward care plan will promote a sustainable approach to the person’s care that reduces the risk of behaviours recurring. For instance, if the person regularly becomes agitated because of fatigue or boredom, providing clear guidance can pre-empt this by offering strategies to support the person to rest or using an individualised and easily implemented toolbox of meaningful activities. Modelling positive engagement and using respectful, kind language and tone, rather than telling the person what to do, will also help moderate behaviour and improve the experience of receiving care.9
The role of medications in changed behaviours When using medications to help support a person experiencing BPSD, the principle of a thorough assessment is just as important. Most commonly, medications have a specific role in treating contributing factors such as pain, infection and constipation. Psychotropic medications, such as antidepressants and antipsychotics, should primarily target symptoms of depression, anxiety, or psychosis – such as hallucinations and delusions. The prescriber should follow up on whether the medication relieves the target symptoms and whether it causes any side effects. If a prescription does not help, it should be discontinued. One of the potential problems in aged care contexts is the commencing of medications without adequate follow-up so that the person with dementia ‘collects’ medications. The more medications a person is prescribed, the more likely they are to experience
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Instead, a thorough assessment to identify contributing factors, with comprehensive implementation of non-pharmacological strategies, should be a priority.11
interactions between medicines and unwanted side effects. Some medications, for instance, can contribute to problems such as constipation and delirium. Seeking to keep prescribing targeted to symptoms, using the lowest dose possible, is a good approach. Psychotropic medications that target mood, alertness, behaviour, thinking, and perception are frequently prescribed for people with dementia to moderate agitation and aggressive behaviour. Risperidone is an antipsychotic medication currently licenced in the UK for persistent aggressive behaviour in Alzheimer’s disease when there is a risk of harm to the person or others when non-pharmacological strategies have been exhausted.10 Benzodiazepines, such as oxazepam, are also frequently used to reduce agitation, anxiety and aggressive behaviour or to treat sleep disturbance. Other antipsychotics, such as quetiapine, may be used with a similar purpose, although they are prescribed off- label. Some advocates strenuously oppose the use of these medications for people with dementia. Others, including some care providers, prescribers and families of people with dementia, see these medications as the quickest way to deal with complex problems and ease distress. The reality is somewhere between these responses. Research shows that psychotropic medications have a role in caring for people experiencing BPSD, although this role is modest, with limited efficacy. It is reasonable for doctors to cautiously prescribe psychotropics, following an axiom of ‘start low, go slow and monitor frequently.’ Further, using psychotropic medications to manage BPSD should not be the first line of treatment.
Case study 2: Planning care for Arthur Arthur is an 80-year-old man living with dementia with Lewy bodies. He experiences visual hallucinations. He loses his way in the care home and frequently walks into other residents’ rooms resulting in altercations. He has chronic back pain from working as a carpenter, a job he loved. Care staff work as a team to optimise the approach to Arthur’s care. Arthur can read large print, so the staff print out signs and put them up in corridors and on doors to help Arthur identify his room, the bathroom and other residents’ rooms. Staff adapt creative activities to align them with Arthur’s background as a carpenter, supporting him to experience the touch and smell of working with wood, allowing him to come and go from activities depending on his ability to engage with them. Arthur’s GP prescribes regular
paracetamol to provide background pain relief and asks care staff to keep pain charts to help determine if more analgesia is needed. The GP also commences a two-week trial of low-dose quetiapine, which is well- tolerated in Lewy body dementia, to see if this reduces Arthur’s visual hallucinations. Arthur becomes more settled and less
distressed by taking a focused, person- centred approach and integrating strategies to target contributing factors.
Capability building for the future Caring for people with dementia, many of whom will experience BPSD, is an essential part of aged care. Our community requires public policy that responds to the changing landscape caused by the increasing prevalence of dementia, with the development of innovative ways of supporting people with dementia and those who care for them. Quality care begins philosophical commitment to a compassionate person-centred approach that understands the person and their story, responding to their specific needs. The way forward is to foster the capability of care providers to comprehensively assess changed behaviours so that they can implement robust non-pharmacological strategies for people experiencing BPSD, supported by diligent, quality use of medications underpinned by continuing research.
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www.thecarehomeenvironment.com May 2023
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