chapter examines some of the causes of BC and the variables associated with them. Details about these features are important, because they help clinicians develop effective treatments.
The key points emphasised in this chapter are:
•BCs often have a number of interacting biopsychosocial causes.
•It is important to identify the potential causes of BC because this helps with the development of targetted interventions.
•Clients’ beliefs play an important role in the development and manifestation of their BC. Indeed, attempts by a person to act on his beliefs can result in problems (e.g. an 80-year-old man who believes he is 30, and still doing early shift-work, may have a strong motivation to leave the building early each morning).
•There are many measures that can be used in the assessment of the causes of BC. The majority are too lengthy to be used clinically, and tend to be employed in research settings.
BACKGROUND INFORMATION
As outlined in the previous chapter, the most comprehensive BC model to date has been developed by Cohen-Mansfield (2000a). Her TREA framework first identifies categories of behaviour, and asks relevant questions, leading to potential solutions. (e.g. Continually screaming → Does this happen when she is been transferred from wheel-chair to a bed/toilet? → If yes, attempt pain relief). This approach is also supported by her unmet needs model, which requires clinicians to undertake a detailed analysis of the behaviour as well as background details of the person and his environment. She suggests that obtaining this contextual information is often helpful in determining the causes of the BC (see Chapter 5). Consistent with this are the requirements of the NCBT framework, which asks clinicians to collect eight pieces of background information about the client. It is relevant to note that these are the aspects previously outlined in the Iceberg Model (see Figure 1.1). These features are discussed below in terms of three groupings: biological, psychological and social factors. In Chapter 7 a series of case studies illustrates how the information is used clinically.
Biological
Cognitive and neurological difficulties
The brain and its functions determine how a person sees and interprets his environment. In the case of dementia, the cognitive deficits will often mean the person has a different sense of reality to other people. For example, he may be disorientated in time and place, and may not remember what happened a few minutes earlier.
It is important to note that having a different view of the world to the people one is interacting with does not automatically make someone’s behaviour challenging. However, it can bring the person into conflict with others, particularly if there is a dispute about whose views are correct. Consider an 85-year-old woman in care who is angry at being prevented from leaving the setting when she is convinced her children need to be collected from school.
Drugs
Polypharmacy is a fact of life for many older people, with the average older person taking five or more different types of medication. While we are aware of the side-effects of much of the medication used, we are less certain of the effects of the interactions. This is somewhat of a concern when we already know some of the drugs commonly used are known to increase BC, such as: statins (agitation) and Parkinson’s medication (hypersexuality). Furthermore, there are also major concerns about the tranquillising and sedating effects of many of the drugs used to routinely treat BC (Banerjee 2009).
Physical difficulties and metabolic changes
Dementia is an age-related illness, and many older people experience declining physical health and age-related illnesses (arthritis, backache, cancer, toothache, constipation and chiropody ailments). It is important to note that many BCs are related to pain and physical discomfort, which is often worsened during carer interactions (such as toileting, transfers and washing procedures). The body’s organs also become less efficient with age, leading to a reduction in the body’s ability to metabolise chemicals, including food and drugs.
Perceptual deficits
Age-related changes with respect to the five senses can trigger difficulties, as sensory loss may disorientate people further. Reductions in sight and hearing may also cause people to seek reassurance, or motivate them to search their environment in order to gain their bearings. Hearing problems are often associated with shouting (Cohen-Mansfield 2000a).
Psychological
Premorbid personality
It is important to recognise that a person’s personality endures through the course of dementia; their individuality will be apparent in various ways and at different stages of the illness. People with severe dementia may still wish to express lifestyle preferences (relating, for example, to accommodation, religious practices, food and sexual orientation). While some personality changes are related to changes in brain pathology, others are associated with psychological factors – for example, someone with dementia may feel they are vulnerable, become more emotional and seek out more physical attention. Finding out how the person coped with difficulties in the past can be revealing. Current problems may be explained by someone being unable to use familiar methods of coping, such as managing stress by going out for a walk.
Mental health
Mental health problems are common and it is important to acknowledge their potential influence. Past difficulties may interact with current problems; for example, a person with long-standing social phobic tendencies who develops dementia and moves into residential care may feel very anxious in a busy communal room (James and Sabin 2002). Changes in brain pathology may result in psychotic symptoms such as visual hallucinations, paranoid ideations or delusions of theft. Resolved issues, such as affective problems, may re-emerge, and chronic problems become magnified (e.g. Asperger traits, James et al. 2006c).
Social
Environment and care practice
Environmental factors (light, noise levels, room-layout) are important influences on the well-being of older people owing to their levels of dependency. This is particularly the case for people with dementia who have difficulties with memory, problem-solving and orientation. We need to recognise the link between people’s level of well-being and the opportunities they have to engage in fulfilling personal relationships. It is also worth checking whether a person’s ‘challenging behaviour’ might be triggered by him being too hot, too cold, hungry or being exposed to excessive stimulation such as a loud television or radio (DSDC 2008).
Care practices
Owing to the need for people with dementia to receive various forms of physical and practical help with aspects of daily living, conflict may arise with those providing such assistance. Carers are required to be skilled, patient practitioners and to have excellent communication skills. Such an angelic demeanour is not always possible, especially when there are competing issues with respect to carers’ time. As such, in many BC situations the triggers for the problems can be traced to carers outpacing the person with dementia, being too rushed or abrupt, and unempathic. The relevance of good care practices cannot be over-emphasised because many challenging behaviours occur during practical face-to-face interactions between carers and clients.
The biopsychosocial factors presented above are believed to be common causes of problematic behaviours. Hence, when investigating the potential causes of a BC, one would routinely collect information
