associated with BCsBy identifying these beliefs, and linking them with the background information, one is in a better position to understand the person’s needs. In some situations the client’s communication can be so poor that it is difficult to identify his thoughts. On such occasions, a clinician would work with the carer to hypothesise what the underlying beliefs might be. The method for generating hypotheses is discussed in Chapter 6.
To assist with collecting information about the causal factors a number of assessment tools can be used. Some of these scales and procedures are explained in the next section.
MEASURES
In the following discussion, I shall examine some of the tools that help identify the causal factors. Table 2.8 provides examples of the scales that can be used to assess the features discussed in the first section of this chapter. For an extensive review of scales used in the area, see Moniz-Cook et al. 2008a. All the tables referred to in Table 2.8 are presented at the end of this chapter.
| Table 2.8 BC measures and tools | |
| Feature | Types of measures and assessment tools |
| Cognition and neuropsychology | Common global assessments of functioning include the MMSE* and ADAS-cog. Global neuropsychological measures are also sometimes employed, such as the ACE-R, CDRS. Specific measures are common, particularly the executive assessments (e.g. BADS). Table 2.9 presents a scale developed in Newcastle to help staff assess clients’ frontal lobe functioning. Scans are often useful, particularly the CT, DAT, and SPECT to identify areas of reduced functioning. |
| Drugs | It is helpful to keep a detailed record of people’s present and past history of receiving medication. Older people tend to be prescribed a lot of medication in relation to mental and physical health issues. Consequently negative reactions to drugs might be missed, or blamed on other causes, because of failures to closely monitor people’s drug histories. |
| Physical difficulties | Monitoring of vital signs (bloods, blood pressure, electrolytes, temperature, signs of infection) is common. Assessment of pain is particularly important, although difficult to assess in dementia (ADD; Cohen-Mansfield and Lipson 2002). A review by Stolee et al. (2005) favoured the use of DisDat and Pain Behaviour Measure. Other tools include: The Barthel ADL scale is useful for assessing people’s functional and physical abilities. A screening tool currently under development by NCBT is presented in Table 2.10. |
| Perceptual deficits | In recent years researchers have found associations between deficits in smell, vision and auditory skills with cognitive decline (Gater et al. 2008). Problems of communication can sometimes lead clinicians to fail to identify visual and hearing problems. If suspected, help can be obtained from the relevant specialists. |
| Mental health | The Cornell Depression Scale and DMAS are good tools for assessing affective problems in people with dementia. The RAID is also a useful brief tool for assessing anxiety. The rAQ can be used to assess those people with long-standing social and communication difficulties, who’ve always required rigid routines in order to function. |
| Care practices | The DCM is helpful for examining staff interactions and features associated with clients’ well-being. The QUIS is another useful observation tool, which examines carer’s positive and negative interactions with clients. |
| Beliefs/emotions | Clients’ beliefs and emotions are assessed using behavioural charts (see Figure 2.1). A more formal scale is currently under development by the NCBT to assess clients’ beliefs and emotions (see Figure 2.2). From a carer’s perspective, there are a number of scales that examine their beliefs and attitudes towards people with dementia (Formal Caregiver Attribution Inventory (Fopma-Loy 1991; Shirley 2005) and Controllability beliefs scale (Dagnan et al. 2004). |
Table Key: ADAS-cog (Alzheimer’s Disease Assessment Scale-cognitive sub-scale); ACER (Addenbrooke’s Cognitive Examination Revised, Mioshi et al. 2006); ADD (Assessment of Discomfort in Dementia Scale, Kovach et al. 1999); rAQ (Relatives autism quotient, Baron-Cohen et al. 2001); BADS (Behavioural Assessment of the Dysexecutive Syndrome, Wilson et al. 1997); Barthel ADL (Mahoney and Barthel 1965); CDRS (Clinical Dementia Rating Scale, Hughes et al. 1982); Cornell depression scale (Alexopoulos et al. 1988); CT (Computerised tomography); DAT (Dopamine transporter scan); DCM (Dementia care mapping, Kitwood and Bredin 1992); DMAS (Dementia Mood Assessment Scale, Sunderland et al. 1998); DisDat (Discomfort in Dementia of Alzheimer’s Type, Hurley et al. 2001); MMSE (Folstein et al. 1975); MRI (Magnetic resonance imaging); QUIS (Quality of interactions schedule, Dean et al. 1993); PBM (Pain Behaviour Measure, Keefe and Block 1982); RAID (Rating Anxiety in Dementia, Shankar et al. 1999); SPECT (Single positron emission computerised tomography).
In addition to these scales, there are a number of other useful assessment tools in relation to BC. One of the most relevant sets of scales identify the type and nature of the BC. Many assessment tools in this group are overly comprehensive and too lengthy to function well in a clinical setting. However, three that are suitable clinically are: Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation Scale (CMAI, Cohen-Mansfield et al. 1989) and the Challenging Behaviour Scale (CBS, Moniz-Cook et al. 2001b).
The NPI has 12 sub-scales, 10 covering BC and two measuring neurovegatative conditions. Each sub-scale has an entry question about presence of symptoms. If this is answered positively, the full scale is completed; if the features are not present, the interviewer moves on to the next symptom cluster. The frequency and severity of symptoms over the month prior to interview are assessed and multiplied to produce a measure of severity. There are a number of versions, one of the most clinically useful contains a carer distress scale (Cummings et al. 1994; Kaufer et al. 1998). There are at least five versions of the CMAI (short form has 12 items, long 29 items). Four subtypes of agitation are identified: physical non-aggression; physical aggression; verbal non-aggression; verbal aggression. It is completed via face-face interviews with a carer.
The CBS is a 25-item scale designed to measure client behaviours (incidence, frequency, difficulty, and challenge) that carers find difficult to manage. It has been shown to have good validity and reliability and is completed by carers with assistance from clinicians. A helpful and comprehensive description of seven scales used to assess aggression in BC is provided by Johnson et al. (2008). Their article describes the features associated with scale selection.
For an overview of other relevant scales see Ballard et al. (2001); Burns et al. (1999) and Neville and Bryne (2001). It is important to note that many of the scales described in these reviews tend to be used in research rather than in day-to-day clinical work. With clinical relevance in mind, Figures 2.1 and 2.2
