behaviours. These drugs have significant side-effects, and are effective in only one in five presentations.
•The national cost of dementia per year is £23 billion (50% for the cost of unpaid care; 40% social care costs; 10% health care costs).
The English National Dementia Strategy was launched in 2009, and was promised £150 million to oversee its implementation. Within the 17 objectives of the strategy, we see a positive vision of what good care provision could look like. However, few of the objectives specifically address behaviours that challenge (BCs), which are major sources of carer and family distress, and the reason why many people require hospitalisation or 24-hour care. The Scottish strategy provides more guidance on BCs, overtly articulating issues to do with client distress and the need for staff training. The current book intends to expand on many of the points made in these strategies, focusing on the perspectives of clinicians working with clients who are deemed to be challenging.
BEHAVIOURS THAT CHALLENGE (BC)
Behaviours that challenge were previously referred to as challenging behaviours. The latter term originally came from the learning disability literature and was used to describe problematic behaviours that cause difficulties for the person performing them, or for the setting in which they are displayed. Blunden and Allen (1987) suggest the term was introduced in order to shift the focus of attention away from individual pathology towards an understanding that challenges carers and service providers to find solutions to the problem behaviours. Many old age psychiatrists prefer to use the term behavioural and psychological symptoms of dementia (BPSD) to denote the link to dementia in their work. However, the term BPSD has been criticised because it implies the problematic behaviours are linked directly to the dementing process. As we will see in Chapter 1, this is clearly not the case because many of the behaviours are normal coping strategies used by the general population to deal with difficult settings.
This book contains eight chapters, providing theory and practical advice on the treatment of BC, using a biopsychosocial perspective. Thus it suggests that the management of BC should take account of the combined influences of the chemical neurological, physical changes, as well as the psychological and social features. In each of the following chapters this perspective will be illustrated and expanded upon, using case examples and research data. For example, Chapter 1 will examine the concept of BC, providing an overview of types of behaviours and categorisation systems. Chapter 2 examines the common causes of BCs, and provides examples of assessment tools. Chapters 3 and 4 describe the current treatment strategies, discussing the pharmacological and non-pharmacological approaches. Both of these approaches have been criticised because of their poor evidence bases, with particular concerns about the problematic side-effects of medication. Chapter 5 outlines a number of different conceptual models that have been developed in the field to enhance people’s understanding of dementia and BCs. By gaining better awareness, it is suggested that clinicians’ assessments and treatment strategies may be improved.
In the later chapters of the book, there will be a greater focus on practice and service issues. Chapter 6 describes the clinical approach I have developed with colleagues in Newcastle for working into 24-hour care settings. In Chapter 7 a number of case examples are presented, with comprehensive descriptions of the treatment processes.
Chapter 8 addresses the issue of service development, drawing on the recent government commissioned report ‘Time for Action’ (Banerjee 2009). In this report, that was accepted by the Minister of State, its author calls for a radical overhaul of BC services and treatment approaches; with a move from an anti-psychotic dominated mode of treatment to one that makes better use of non-pharmacological approaches. Indeed, Banerjee calls for a reduction in anti-psychotic usage of two-thirds over a three-year period, and puts forward 11 recommendations to allow this to be achieved.
RELEVANCE OF THIS BOOK
This book is timely as we start to implement the recommendations of the various national strategies. It is also relevant because there remains a great deal of confusion regarding the treatment of BC. Many psychiatrists think that they have been put in a difficult situation regarding the proposed restrictions on the use of medications, particularly the use of anti-psychotics. It is relevant to note, however, that psychiatrists continue to have a lot of faith in these drugs and are still prescribing them on a regular basis (Wood-Mitchell et al. 2008; Bishara et al. 2009). Currently, non-medical professionals may also be at a loss, because they have received little ‘quality’ guidance on what to offer as a practical alternative to drugs. Indeed, many of the non-pharmacological strategies suggested in the literature are preventative methods rather than treatment approaches. This book explores the distinction between ‘prevention’ and ‘treatment’ strategies and provides advice for dealing with BCs in their acute phases. This text also has particular relevance for those working in the private sector, describing a treatment approach designed to specifically work with residents in 24-hour care.
The book is also relevant to commissioners and government employees, particularly in light of the recent HERC (2010) publication that revealed each dementia client costs the UK economy £27,647 per year (cancer: £5999; heart disease: £3455). This figure does not include extra costs that are incurred when a client displays problematic behaviours.
It is evident that there is a need, and a desire, to improve care practices. The move away from a medical approach to BC is not new, it has been slowly happening over the last 20 years. However, the call for change has increased of late, gaining momentum owing to concerns about the use of drugs and the need to develop effective alternatives to them. In addition, and perhaps most importantly, additional impetus for change has come from our politicians and economists who seem to recognise that it is essential to plan for the future from both a financial and well-being perspective.
Chapter 1
Introduction to Behaviours that Challenge
DEFINITION
For the purposes of this book, behaviours that challenge (BC) are defined as actions that detract from the well-being of individuals due to the physical or psychological distress they cause within the settings they are performed. The individuals affected may be either the instigators of the acts or those in the immediate surroundings. Common BCs include: hitting, screaming, excessive pacing, apathy, etc. The BCs often have multiple causes (e.g. physical, mental, environmental, neurological), which are moderated by people’s emotions and beliefs. BCs are common, and generally managed well by carers, and many resolve with time. However, some problems can become chronic or risky, and on these occasions specialist assistance is required in the form of biopsychosocial approaches (i.e. medical and non-pharmacological). Such approaches require a thorough assessment of the situation, and then effective targeting of the causal factors underlying the behaviours.
The definition will be unpacked in the remainder of this chapter, and the following aspects emphasised:
•BC are problematic behaviours that cause difficulties for the person performing them, or for the setting in which they are displayed.
•What is perceived to be ‘challenging’ will differ between settings, with some onlookers being more tolerant than others. For this reason, the term ‘BC’ is viewed as a ‘social construct’.
