clients to orientate themselves to their surroundings, which may be difficult due to their cognitive and memory problems.
Third, there is a group of BC that result from failures by the person with dementia to inhibit actions, thoughts and emotions. This group of behaviours is closely related to frontal lobe deficits.
Finally, there are behaviours that reflect a mismatch between the person and the environment he is in. These disruptive behaviours stem from the person rejecting the setting. For example, the person may not like the restrictions or features of his current living conditions. These various categories of BC are summarised in Table 1.3. We have found the distinctions useful, for despite some overlaps within groups, they help distinguish behaviours on social, neurological and emotional grounds, thus helping clinicians to see the sorts of things that might be driving the behaviours. And consequently, the groups provide some theoretical guidance towards treatment strategies.
The NCBT categorisation system differs in a number of ways to Cohen-Mansfield’s, but one of the chief differences is that it does not categorise by an actions typology, rather it focuses more on the causal features (i.e. the features driving the behaviour). Hence, a behaviour such as ‘excessive walking’ could be placed within a number of categories – it could be due to a disinhibition, anxiety, or an attempt to find a way out of the building. Recognising which category it belongs within the NCBT framework helps one to direct one’s intervention.
MANAGING BCs: A TREATMENT PROTOCOL
BC are common in dementia, with 90 per cent of those with dementia displaying some form of BC during their illness (Lyketsos et al. 2002). They often occur in the later stages of the illness, and there is an association with severity of BC and severity of dementia (Thompson et al. 2010). In most circumstances they are dealt with well by carers, with few problematic consequences. However, occasionally the behaviours persist, and some may even be reinforced by carers’ actions. It is in these latter circumstances that specialist help may be required either in the form of medication or non-pharmacological approaches.
| Table 1.3 BC categories derived from an audit of NCBT clinical work | ||
| Type of BC | Emotions and beliefs | Comment |
| Lack of motivation and initiation (non-active form of BC) | Apathy or depression associated with beliefs of helplessness and worthlessness. | Behaviourally apathy and depression look similar, but apathy is related to brain changes in the frontal lobes. In contrast depression is often a consequence of the person’s poor sense of worth and sense of hopelessness. Referrals for amotivation are common from family carers, but uncommon for residents in care homes. This is because care staff find it easier to look after residents who are less active; thus the behaviour is often not seen as problematic in the context of the setting. |
| Threat related (active form of BC) | Anxiety and anger – on occasions anxiety precedes anger, with the anger being the active response when feeling threatened.Anxiety is associated with beliefs of being vulnerable.Anger is related to a sense that one’s rights are being infringed and one is being treated unjustly. | The actions are responses to emotional experiences, whether related to interactions with others or psychotic hallucinations or delusions. The person may feel fearful or threatened and thus avoid situations, or seek safety. On other occasions the person might react to a perceived threat with aggression either as a defence or as a pre-emptive action. Sometimes the threat is related to the person’s self-esteem, and the response is due to a self-perception that her rights are being infringed (James 2001). From a neurological perspective, damage to the amygdala or right somatosensory cortex (RSc) is associated with anger and anxiety. The amygdala processes emotions and is closely linked to the frontal lobes. The RSc is involved in the processing of people’s body language and emotional expressions. Thus problems here can lead to misinterpretation of other people’s intentions. |
| Information and solution seeking (active) | Curiosity and problem-solving behaviours – natural engagement with one’s surroundings, disrupted by memory problems, confusion, disorientation, and boredom.Associated with a belief that one must seek someone or something out to make sense of the situation. | Humans are natural explorers and problem solvers. When a person feels disorientated or confused she will attempt to reduce these uncomfortable states by either asking about, or exploring, her surroundings. Likewise if she comes across an object that is in some way familiar or interesting (perhaps relating to work or home-life) she may borrow it, use it or even try to dismantle it. |
| Failure to inhibit (active) | Sexual disinhibition, repetitive vocalisations and repetitive actions.Associated with egocentric beliefs and thoughts which are often impulsive. | Reduced frontal lobe functioning is one of the few universal features of an ageing brain (Schaie 2008). However, for some people this can result in them having difficulties in inhibiting inappropriate actions and speech (aka thought-action fusion – impulsively doing or saying what you think). |
| Poor environmental fit (active) | Rejection of one’s surrounding.Associated with beliefs about leaving the unpleasant setting. | The rejection may be due to a failure to recognise one’s surrounding or the people in it, or due to the perceived restraints imposed by the settings (i.e. the rules, regulations and attempts to control one’s life). |
Figure 1.2 BC management protocol
A diagrammatic representation of a BC management protocol is provided in Figure 1.2. It identifies the various incremental steps used to treat problematic behaviours. The first step is the labelling of a behaviour as a ‘challenge’, followed by the initial attempts to resolve the difficulty by the carers. If the problems persist, an acute physical cause may be suspected, requiring an assessment from the primary care practitioner (e.g. a GP). If the GP fails to identify any infection on screening, she may suggest the referral to a specialist mental health service. At this point there are three possible responses, one pharmacological and two non-pharmacological. In terms of the former, if a discrete clinical disorder is identified (psychosis, depression, pain, delirium), then it will be treated through the use of medication. Or, if the behaviour is so extreme or risky, the appropriate medication may be given to tranquillise or sedate the person with dementia on a short-term basis. In relation to psychological approaches, one may either offer advice after undertaking a cursory assessment, or undertake a full functional analytical (FA, Moniz-Cook et al. in press) treatment package. The latter approach is the most comprehensive, involving a thorough assessment and the use of behavioural charts. If the FA methodology is unsuccessful and the behaviour persists, one may treat the BC chiefly via medication, but at this stage the rationale for using the medication is as a tranquilliser or sedative in order to improve the client’s well-being. Despite presenting this protocol in terms of sequential steps, it is relevant to note that many specialist services employ combined modes of treatment, using both non-pharmacological and drugs concurrently (Holmes 2009). It is my view that, owing to both the lack of efficacy and side-effects of the psychotropics used in this area, it is unethical to prescribe a drug without simultaneously prescribing a non-pharmacological strategy. Alistair Burns, UK National Clinical Director of Dementia, is currently working to produce a national set of treatment guidelines for BC.
CONCLUSION
This chapter has provided a brief introduction to some key topics which will be discussed in-depth in the later sections of the book. Because BC are not diagnosable disorders, with regular and consistent underlying causes, they will always be somewhat problematic to treat. Indeed, the method of treating them appropriately will invariably require one becoming a detective and gaining detailed information about the nature of the BC and the client. The kind of detail required and how to put it together into a coherent formulation-led treatment package is the subject of this book.
Chapter 2
Causes and Assessments
INTRODUCTION
