December 13, 2023
In this episode of AMDA On-The-Go, host Diane Sanders-Cepeda, DO, CMD, and special guests Tana Whitt, MSN, PMHNP-MC; Charissa Duffy DNP, MSN, APRN, PMHNP-BC; and Anthony Nedelman, PhD; discuss behavioral and psychological symptoms of Dementia (BPSD) to provide listeners with clear guidance on non-pharmacological crisis interventions, de-escalations, and pharmacological interventions available to patients and residents with BPSD.
There are three general types of behavioral disturbances—activity, mood, and psychotic—and each can have different symptoms. For instance, symptoms of activity disturbances include agitation, wandering, resisting care, and verbal or physical aggressiveness. Mood disturbances are often marked by fluctuations in mood, and symptoms of psychotic disturbances include delusions, false beliefs, paranoia, and hallucinations.
“We need to identify behaviors a patient has demonstrated already and how their caregivers have dealt with these,” said Ms. Whitt. She noted, “A lot of families are trying to avoid long-term care settings, and we see some residents coming in later than they should.” This, she suggested, has resulted in a proliferation of behavioral concerns that have caused issues with their families. She stressed, “We need to educate families about what symptoms they may see and when it might be appropriate to transition their loved one into long-term care.”
The good news, Dr. Nedelman explained, is that there is much that can be done to prevent and manage BPSD. He said, “The first line of treatment is to determine if psychotherapy might be appropriate. This has been seen to be effective in people with early dementia.”
As the dementia advances, he noted, counseling isn’t as viable an option. At this point, he said, “We focus on sensory stimulation in the environment.” For instance, there may be many sounds—TVs, music, conversation, alarms, and more—that cause a reaction. At the same time, things like harsh lighting can be an issue. “When you put all this sensory stimulation together, it is easy for residents, particularly those with dementia, to get overwhelmed and overstimulated. So, we need to be aware of these things and do what we can to reduce the likelihood of behavioral issues,” Dr. Nedelman said.
Dr. Nedelman also noted that it is important to have some safe areas with reduced stimulation for residents to navigate on their own and wander around. Quiet or soundproof rooms can also help de-escalate someone who is agitated.
Some nonpharmacological interventions involve how you interact with residents. Dr. Nedelman said, “It’s easy to accidentally trigger someone and make situations worse.” He added, “I’ve heard staff say well-meaning things that actually have made these worse.” For instance, they go into someone’s room and tell the person it’s time to get up instead of asking them if that is okay or if they are ready to get out of bed. He suggested, “To increase the chance of success with someone who is agitated, have a plan going in. You can’t wing it.”
Dr. Duffy observed, “The way we communicate with our residents has a big impact.” She noted that residents often are hard of hearing and this can exacerbate situations. She explained, “If you have a resident who is confused and hard of hearing, what they heard you say might not be what you actually said; and this can cause additional confusion or concerns. Taking the time to ensure what you are communicating is clearly understood by the resident is an important factor to consider.”
Ms. Whitt mentioned the value of using the DICE (Describe, Investigate, Create, Evaluate) model. This, she suggested, can help the team identify and address the root cause of behaviors (including pain), devise a plan to address the situation, evaluate the plan over time, and tweak it as appropriate. If you want to employ this model, Dr. Duffy suggested educating all team members on its use and helping them understand that this is an easy tool to help reduce behaviors with non-pharmacological approaches.
All three guests stressed the importance of documenting the resident’s history, including behaviors and triggers. Additionally, there should be a record of what behavioral interventions are initiated, what works, what doesn’t, and how the plan was changed or tweaked over time.
Listen to the entire podcast to get more insights and tips on addressing BPSD.