By Dr Tanya Davison MAPS, Deakin University, Dr Michael Bird MAPS, Greater Southern Area Health Service NSW, Professor Marita McCabe FAPS, Deakin University, Associate Professor David Mellor MAPS, Deakin University
Behaviours such as yelling, violence, repetitive questioning and sexual disinhibition occur frequently in dementia, although accurate prevalence data is difficult to ascertain due to multiple definitional and measurement problems. What is known is that these behaviours, often described as ‘agitated behaviours' or Behavioural and Psychological Symptoms of Dementia (BPSD) in the literature, are the most common cause of carer stress and the reason why many families decide to surrender care. Rates of these behaviours are consequently high in aged care settings. The nursing staff and attending physicians often find residents with challenging behaviours difficult to manage, and disturbed behaviour is the most common reason for referring residents to psychiatric services. Given the growing number of people in aged care facilities with dementia, it is important to identify effective strategies to manage these behaviours.
Challenging behaviours are most commonly treated using psychotropic medications, particularly antipsychotics. This is despite meta-analyses over the last 15 years demonstrating only modest efficacy at best and frequent serious side effects, such as over-sedation, falls, cerebrovascular events and cognitive decline. This practice is also contrary to expert guidelines, which typically recommend that non-pharmacological interventions should be used as the first line of treatment before considering psychotropic medications. Unfortunately, the clinician seeking a non-medical alternative faces a problem - unlike other clinical presentations, such as mood or anxiety symptoms, there is a lack of clear information available on which interventions are most effective for treating challenging behaviours associated with dementia. This article outlines the use of non-pharmacological interventions in aged care settings, and also considers the potential role played by psychologists in responding effectively to dementia in aged care.
There are several studies that evaluate the effectiveness of standardised non-pharmacological treatments delivered to residents with challenging behaviours. Examples of these kinds of interventions include pet therapy, aromatherapy, music or white noise therapy, massage, bright light therapy, environmental changes (e.g., reducing noise, changes in the physical layout of the facility), structured activity programs, and the use of videotaped or audiotaped recordings of family members (simulated presence therapy). A recent meta-analysis suggested that only sensory interventions (such as aromatherapy, bathing, calming music and hand massage) reduced agitated behaviours among residents with dementia (Kong, Evans & Guevara, 2009). However, the documented benefits of these interventions tend to be rather short-lived, and so may be best seen as short-term solutions.
Several reviews of standardised non-pharmacological therapies have been published in the last five years. They tend to conclude that although some interventions show promise, evidence for effectiveness is weak. Reviewers consistently note methodological problems in research studies, such as small sample sizes, inconsistent definitions and measurements of behaviours, and variability in the nature and duration of intervention programs, which limit conclusions. Reviewers also note the wide variability in treatment response among residents, with some benefiting greatly while others show no response or become more agitated (O'Connor, Ames, Gardner & King, 2009).
It is widely recognised that environmental and social factors play a significant role in the aetiology of challenging behaviours among those with dementia. For example, over- or under-stimulation, poor staff communication skills, inappropriate routines and unskilled personal care, such as rough or hurried showering and toileting, are all common triggers for disturbed behaviours. Clinical services also receive many referrals for residents whose behaviours are found to be due to unrecognised pain, discomfort, depressive illness or delirium. These factors highlight the potential effectiveness of focusing resources on improving the knowledge and skills of the staff who care for residents with dementia.
Unfortunately, the literature on staff education is limited in terms of methodological rigour, and the results of studies have not been particularly encouraging. While some studies have reported improvements in staff knowledge and skills following training, these gains were often not sustained over time, and improvements reported by staff were not consistently translated into improved outcomes among residents (McCabe, Davison, & George, 2007). These studies indicated the existence of substantial barriers to changing the behaviour of staff in aged care settings, such as high staff turnover, lack of resources, poor management support for change, and an entrenched task-focused rather than person-focused approach to care.
In contrast to standardised interventions where a single approach is provided to all residents with dementia, individualised treatment packages are tailored to the aetiology of the presenting behaviour in each case. There is strong evidence that the causes of disturbed behaviour in dementia are diverse and case-specific. Two residents presenting with the same behaviour may have different triggering factors, which limits the effectiveness of a one-size-fits-all approach to interventions. This argument suggests that standardised pharmacological and non-pharmacological methods have only modest effects as a result of failing to account for the complexities of aetiology.
The individualised intervention approach is most commonly employed by mental health clinicians. The range of causes for problematic behaviour that are frequently considered include medical and physical problems (e.g., infections, drug interactions or pain), mental health (e.g., depression), multiple features of the environment (e.g. glare, or the way care is carried out), and the person's history (e.g., pre-morbid ways of dealing with problems). Extreme variability applies equally to the factors which make a behaviour ‘challenging'; there is not a one-to-one relationship between disturbed behaviour and carer distress. Faced with the same behaviour by the same person one staff member can see it as extreme, another as no problem. If a complex interaction of behaviour causes and nursing factors create a ‘case', then treatment must be tailored to the specific needs of each case, as determined by a detailed assessment or functional analysis.
While individualised interventions may appear to have clinical utility and tend to be more successful than standardised techniques, the multifaceted nature of both the clinical presentations (with residents typically presenting with more than one behaviour of concern) and the interventions used do not lend themselves well to controlled outcome research. The literature consists mostly of uncontrolled case studies. While many report impressive reductions in challenging behaviours, these reports must be interpreted with caution due to methodological limitations.
In recent years some larger studies of individualised interventions published by clinical psychologists appear promising. These studies have achieved reductions in the severity or frequency of challenging behaviours and improved affect among people with dementia, and lower levels of stress or burden among their carers (Bird, Llewellyn Jones, Korten, & Smithers, 2007; Cohen-Mansfield, Libin, & Marx, 2007; Davison et al., 2007). Some of these studies have also demonstrated that the implementation of non-pharmacological interventions in nursing homes can lead to reductions in antipsychotic use, and fewer visits by GPs or hospitalisations being required (Bird et al., 2007; Davison et al., 2007). However, while this growing body of evidence is encouraging, there remains the need for more research using randomised controlled designs.
Although there is a lack of evidence for many non-pharmacological interventions, this is different to evidence of lack of efficacy. Clearly, more rigorous studies are required to adequately assess the efficacy of these interventions to enable us to recommend evidence-based treatment. Research needs to examine a range of outcomes, such as treatment effectiveness, side effects, caregiver burden and impact on medical resources. Monitoring of adverse side effects is particularly important in aged care settings, given the context of high medical co-morbidities and polypharmacy. Reducing the severity of challenging behaviours through over-sedation is clearly a poor outcome.
Psychologists can add to the research literature, especially through the development of valid techniques to measure challenging behaviours. The limitations in demonstrating improved outcomes in intervention research are partly due to variability in the clinical presentation of people with dementia and difficulty in measuring changes in their behaviours. Existing tools tend to consist of generic lists of behaviours, and are not specific to the behaviours actually targeted in an individual case. These instruments also have very low inter-rater reliability. Psychologists have suitable expertise in measurement issues to effectively implement behavioural monitoring and to design and evaluate valid and reliable assessment instruments for research in this field.
The current available evidence to date supports the use of an individualised package of interventions to address the specific needs and circumstances of each case. Psychologists have the ideal clinical training and expertise, particularly in behaviour therapy, to develop interventions to address challenging behaviours, and can add a unique contribution to the traditional medical and nursing perspectives. There will continue to be a role for pharmacology. For example, behaviours identified to be due to untreated pain, delirium, depression or anxiety are likely to benefit from appropriate medication. However, the current over-reliance on medication to suppress behaviours, over extended periods of time and without attention paid to the complex factors involved in each case, is in need of change.
Unfortunately, nursing home residents in this country currently have only limited access to psychological expertise. While many aged psychiatric services employ psychologists, the demand for these services typically outstrips the available resources, and aged care facilities frequently report difficulty accessing these specialists. Unfortunately, residents in Commonwealth-funded aged care places are ineligible for Medicare rebates, and, as a result, many older people are unable to access private psychologists¹. In addition, rebates are not provided for the treatment of symptoms of dementia. Another barrier to access in psychological services is the lack of initiative taken by the psychology profession itself in training new practitioners in aged mental health, for example by providing clinical placements in residential care settings. Given the ageing of the population, with particularly rapid growth among those over 85 who are at greatest risk of developing dementia, the time is ripe for psychology to position itself as a key player in reducing the burden of challenging behaviours in age care settings.
¹ Note that some residents are eligible for treatment under the Aged Care Access Initiative, an Australian Government scheme designed to improve access to GP and allied health services. This scheme is not well known by practitioners or aged care facilities - details can be found at: www.health.gov.au/internet/main/publishing.nsf/content/aged_care_access.
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Bird, M., Llewellyn Jones, R. H., Korten, A., & Smithers, H. (2007). A controlled trial of a predominantly psychosocial approach to BPSD: Treating causality. International Psychogeriatrics, 19, 874-891.
Cohen-Mansfield, J., Libin, A., & Marx, M. S. (2007). Non-pharmacological treatment of agitation: A controlled trial of systematic individualized intervention. The Journal of Gerontology, 62, 908-916.
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O'Connor, D. W., Ames, D., Gardner, B., & King, M. (2009). Psychosocial treatments of behavior symptoms in dementia: A systematic review of reports meeting quality standards. International Psychogeriatrics, 21, 225-240.