Responding to the Behavioural Symptoms of Dementia: We Must do Better

“For many people with dementia, their behavior is more challenging to grapple with than the diagnosis itself.” Dr. Nathan Herrmann

Nathan Herrmann

Nathan Herrmann, MD, FRCP(C); Head, Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre

Krista Lanctôt

Krista Lanctôt, PhD; Head, Neuropsychopharmacology and Senior Scientist (Sunnybrook Research Institute), Professor of Psychiatry and Pharmacology/Toxicology (University of Toronto).

Dallas Seitz

Dallas Seitz, MD, FRCP(C); Division Head, Geriatric Psychiatry; Assistant Professor Queen’s University

Dementia can colour one’s thoughts, emotions, attitudes, movements, and perceptions of reality…

Affecting nearly 90% of all long-term care residents living with dementia, behavioural symptoms (BSD) can take the form of wandering, repetitive questioning, bouts of anger, and depression. These symptoms not only lower quality of life, they also increase medication and healthcare use.

 

When experienced daily, BSD impacts relationships with care partners, healthcare providers, and other residents. For example, it can be challenging to assist someone with daily activities like bathing, dressing, eating, and grooming when they react negatively.

 

Traditional responses in long-term care residences have been guided by the belief that it is necessary to manage behaviours in order to minimize the threat of self-harm and harm to others. Using environmental restraints and medical interventions, residents have been restrained both physically and with medications that attempt to curb harmful behaviours.

 

Increasingly, these practices are being challenged on the grounds that they do not respect the autonomy, well-being, and personhood of the individual living with dementia. Not to mention, the overall effectiveness of these interventions is being widely questioned.

 

While the gold standard in long-term care residences is now to minimize the use of environmental restraints and medical interventions, as Dr. Nathan Herrmann points out, this is only possible if there are viable psychosocial interventions to replace them. After all, there have been tragic accidents where other residents have been seriously harmed by residents who have BSD.

 

Accordingly, and through the support of the CCNA, Drs. Nathan Herrmann, Dallas Seitz, and Krista Lanctôt are leading Team 11, whose project is to evaluate the effectiveness of 3 types of interventions within a network of 30 long-term care residences across Canada.

These interventions include determining:

(1) How well drugs actually address BSD, and investigating newer, safer alternative medications;

(2) Whether the use of personalized behavioral interventions, through touch-screen technology, can help to reduce symptoms like anxiety and agitation; and

(3) Whether prescribing habits of long-term care staff can be optimized through educational interventions, so that residents are only getting the medication they require.

Senile elderly man taking daily medicine at the nursing home.

(1) How well drugs actually address BSD, and investigating newer, safer alternative medications;

Smiling older gentleman working on a tablet in his living-room

(2) Whether the use of personalized behavioral interventions, through touch-screen technology, can help to reduce symptoms like anxiety and agitation; and

Elder care nurse playing jigsaw puzzle with senior woman in nursing home

(3) Whether prescribing habits of long-term care staff can be optimized through educational interventions, so that residents are only getting the medication they require.

Currently, the team is assessing the resources and best practices used by each residence within their network to support residents’ needs. This information will help to identify whether existing resources can be adapted to support the interventions, and it will also provide a baseline to compare how effective the interventions are once they are rolled out.   Herrmann is quick to emphasize that, prior to administering any type of intervention, there should be a thorough assessment conducted as to why a person may be displaying BSD.

“It is only by first understanding the source of the behaviour that a healthcare provider can attempt to determine whether it is the result of another medical condition, medications, a response to the environment, or a manifestation of the disease itself,” he explains.

 

In focusing on the individual’s activities, environment, and relationships with others, Herrmann suggests that the behavioural symptoms of dementia are not unpredictable, meaningless, and only manageable with medications. Consistent with this, he acknowledges the critical role that staff in long-term care residences can play in recognizing and avoiding situations that may trigger BSD.

 

Although overturning deep-seated cultures of practice will not happen overnight, Team 11’s research will go a long way in supporting guidelines, policies, and standards for practice that focus less on short-term attempts to curb behaviour and more on the psychological and psychosocial well-being of residents.