Dementia and changed behaviours: supporting the person at the centre

Person-centred care for people with changed behaviours relies on comprehensive assessment and a multidisciplinary approach that includes the person and their carers.

Dementia and changed behaviours: supporting the person at the centre

Almost 1 in 10 Australians aged over 65 years are living with dementia.1,2 Over the next two decades the total number of Australians living with a diagnosis of dementia is predicted to sharply increase.2

While cognitive decline is the key symptom of dementia, many people will also experience non-cognitive symptoms as the dementia progresses.3 Described broadly as changed behaviours, these varied psychological and behavioural symptoms can be very distressing for the person as well as those who care for them. Australian studies suggest up to 90% of people with dementia may experience at least one changed behaviour over the course of their illness.4-6

These behaviours can include agitation, aggression, psychosis, depression, anxiety, sleep disturbance, wandering, screaming, disinhibition, hoarding and general restlessness.4

 

Meeting the needs of the person

Changed behaviours may result from pathophysiological changes occurring in the brain, or be symptoms of unmet needs or reactions to stressors in the person’s environment.7,8 The symptoms may also stem from other underlying issues not related to the dementia – such as pain, infection or dehydration.9,10

Taking a person-centred approach when caring for a person with dementia involves looking beyond the disease to consider the context of the person; their uniqueness, personality, current health, cultural background and more.3 Such an approach focuses on helping the person and meeting their needs, rather than just managing their dementia.

To provide this level of care requires comprehensive assessment and, where possible, a multidisciplinary team that includes the person and their carers and family.4,7,9

The challenges of managing dementia and the importance of a person-centred approach are explored in the NPS MedicineWise News article A portrait of dementia and changed behaviours.

 

Optimising management, individualising care

Non-pharmacological strategies are recommended in multiple guidelines as first line management of changed behaviours.4,7,11,12 Key benefits of these strategies are that they carry very little risk of harm, can be tailored to each person’s needs, and incorporate simple measures such as regular routine and healthy eating, alongside more formalised measures such as psychological therapies.4,7,10

Evidence suggests that some non-pharmacological interventions may be as effective as medicines for reducing aggression and agitation in people with dementia.13 However, implementation of these strategies is perceived to be a challenge by healthcare staff because of barriers including their lack of time, resources, and knowledge about changed behaviours.14

 

Balancing the role of medicines

In situations where first-line interventions have not succeeded or where risk of harm to the individual or others is high, psychotropic medicines including antipsychotics and benzodiazepines may be considered.3,11,15,16

It is important to remember however, that antipsychotic medicines are not effective for a majority of changed behaviours and their use is limited to behaviours such as aggression and psychosis.11,15,17 It is also estimated that only 20% of people with dementia who receive an antipsychotic medicine are likely to respond.17

In addition to these limitations, antipsychotics carry increased risk of side effects including cognitive decline, cerebrovascular events and mortality.7,15,18

If a medicine such as antipsychotic or benzodiazepine is being considered, this needs to proceed with informed consent and in consultation with the person with dementia, their family, carers and healthcare team. Quality use of medicine principles, such as lowest dose for shortest time and regular systematic review, should also be followed.3,4,7 

NPS MedicineWise has a deprescribing tool available to help facilitate review of antipsychotic medicines, including advice on how and when to taper.

 

NPS MedicineWise’s dementia and changed behaviours program

Overreliance on medicines for the management of dementia has been one of the areas of focus of the 2019–21 Royal Commission into Aged Care Quality and Safety.19

The NPS MedicineWise program, Dementia and changed behaviours: A person-centred approach, aims to reduce unnecessary use of antipsychotics and benzodiazepines for dementia, and to improve use of non-pharmacological management techniques to ensure people with dementia, in the community and in aged care, are supported.

Audiences for the program include GPs, pharmacists and nurses who care for older people with dementia, in the community and in residential aged care facilities, as well as people with dementia and their carers.

The program has been developed in consultation with key stakeholders in aged care including the Aged Care Quality and Safety Commission and the Aged Care Division of the Australian Government Department of Health.

Key elements include:

  • educational visits to individual GPs and small groups in general practices, who work in the aged care sector
  • a multimodal educational program for aged care facilities aimed at supporting champion nurses and pharmacists working in the sector
  • webinars for GPs, pharmacists and nurses
  • online resources for consumers and GPs

For more information on the new program go to www.nps.org.au/professionals/antipsychotic-medicines

 

References

  1. Australian Institute of Health and Welfare. Dementia in Australia. Canberra: Australian Government, 2012 (accessed 25 October 2020).
  2. The Institute for Governance and Policy Analysis. Economic cost of dementia in Australia 2016-2056. Canberra: University of Canberra, 2017 (accessed 22 October 2020).
  3. Royal Australian & New Zealand College of Psychiatrists. Assessment and management of people with behavioural and psychological symptoms of dementia (BPSD): A handbook for NSW health clinicians. North Sydney: NSW Ministry of Health, 2013 (accessed 24 October 2020).
  4. Guideline Adaptation Committee. Clinical practice guidelines and principles of care for people with dementia. Sydney: NHMRC Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People, 2016 (accessed 26 October 2020).
  5. Brodaty H, Draper BM, Low LF. Behavioural and psychological symptoms of dementia: a seven-tiered model of service delivery. Med J Aust 2003;178:231-4.
  6. Brodaty H, Draper B, Saab D, et al. Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors. Int J Geriatr Psychiatry 2001;16:504-12.
  7. Royal Australian College of General Practitioners. RACGP aged care clinical guide (Silver Book) 5th edition Part A. East Melbourne: RACGP, 2019 (accessed 22 October 2020).
  8. Dementia Australia. Changed behaviours and dementia. Sydney: Dementia Australia, 2015 (accessed 22 October 2020).
  9. Pond D, Phillips J, Day J, et al. Caring for people with behavioural & psychological symptoms. Sydney: NHMRC partnership centre for dealing with cognitive and related functional decline in older people, 2019 (accessed 23 October 2020).
  10. Pond D, Phillips J, Day J, et al. People with Dementia: A Care Guide for General Practice. Australia: NHMRC Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People (CDPC), 2019 (accessed 24 October 2020).
  11. Psychotropic Expert Group. Dementia. West Melbourne: Therapeutic Guidelines Ltd, 2015 (accessed 24 October 2020).
  12. Dyer SM, Laver K, Pond CD, et al. Clinical practice guidelines and principles of care for people with dementia in Australia. Aust Fam Physician 2016;45:884-9.
  13. Watt JA, Goodarzi Z, Veroniki AA, et al. Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: A systematic review and network meta-analysis. Ann Intern Med 2019;171:633-42.

  14. Belcher J, Warwar S, Mak J. Formative Research: Psychotropic medicines in older people (community and aged care). Sydney: NPS MedicineWise, 2020 (accessed 24 October 2020).

  15. Royal Australian & New Zealand College of Psychiatrists. Professional practice guideline 10: Antipsychotic medications as a treatment of behavioural and psychological symptoms of dementia. Australia: RANZCP, 2016 (accessed 22 October 2020).
  16. Banerjee S. The use of antipsychotic medication for people with dementia: Time for action. London: Department of Health, 2009 (accessed 22 October 2020).
  17. Peisah C, Skladzien E. The use of restraints and psychotropic medications in people with dementia. Sydney: Alzheimer's Australia, 2014 (accessed 24 October 2020).
  18. Aged Care Quality and Safety Commission. Psychotropic medications used in Australia: information for aged care. Canberra: Australian Government, 2020 (accessed 24 October 2020).
  19. Royal Commission into Aged Care Quality and Safety. Interim report: neglect. Canberra: Australian Government, 2019 (accessed 22 October 2020).