Management of Challenging Behaviour in Primary Care

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Management of Challenging Behaviour in Primary
Care

• Daniel Collerton
• and
• Karen Franks
• Gateshead Older Peoples Mental Health Service

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Levels of Challenging Behaviour
Mental Health Services
Workbook
Non Specialist Services
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Character of challenging behaviours

• Reflects the capability of the setting to manage
  behaviour poorer settings generate more
  challenge
• Not related to severity of dementia
• Stressful and burdensome to carers
• Purposeful
• Limited potential to respond to interventions
• Usually transitory

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Principles

• Who, what, why, when?
• Why is this a problem?
• Always consider non-pharmacological management
  first
• Always consider physical illness, esp. delirium
  and pain

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Management guidelines

• Talk to the person whose behaviour is causing
  concern
• Identify purpose of behaviour
• Identify and intervene in contributory factors
• Support carers
• Balance risks
• Be mindful of legal frameworks
• Aim for tolerable behaviour
• Review and refer

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What is the behaviour that challenges you? Mild-
moderate behaviour e.g. wandering, night-time
disturbance, depression, apathy, repetitive
questioning, shadowing, verbal aggression, mild
sexual disinhibition. Severe- extreme behaviour
e.g. severe depression, psychosis, severe
agitation, screaming, physical violence, suicidal
behaviour, severe sexual disinhibition.
Is the person with dementia, or another person at
immediate and serious risk because of the
behaviour?
NO Is detail known about the behaviour?
YES Seek specialist advice consider transfer of
the person to a safer setting depending on need,
psychiatric or general hospital admission,
respite care. Contact Mental Health Service for
advice
YES
NO Describe exactly what the behaviour is, when,
where and with whom the behaviour occurs.
Detailed documentation is very useful.
Have you used an assessment tool? Examples
include ABC records, behavioural charts
Was onset quite sudden? If so this could be due
to physical illness, take a urine specimen if
possible and arrange medical review
Use the information To work through the
challenging behaviour workbook. Gather more
information At each stage you may need to gather
further information about the person, then go
back and use it. Identify reasons for the
behaviour make a plan and put the plan into
action Review the situation Has your plan worked?
Whose problem is it anyway? Could the persons
behaviour be due to the environment? Could
procedures or routines be made more flexible to
suit the persons needs?
YES Well done! Continue to review the situation
to ensure continuation of helpful strategies.
NO Has the behaviour improved but not
disappeared? If so is it now manageable? If not,
do you need help from someone else? People who
may be able to help include
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Specialist advice

• Mental health services
• Challenging Behaviour Teams

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Principles with Medication

• Keep it simple
• Start low, go slow
• Think about what you are trying to achieve
• Monitor effects
• Encourage effective recording
• Consider change in timings before increase in
  dose
• Can this setting cope with prn meds?

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Suggested Starting Dosages

• Lorazepam 0.5mg
• Clomethiazole 192mg
• Trazodone 25 50mg
• Sodium Valproate 100mg bd
• SSRIs
• Mirtazapine 15mg nocte
• Cholinesterase inhibitors incl patch
• (Memantine)

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Antipsychotics

• Should not be first line
• Probably should be started only with secondary
  care opinion/advice
• Keep under review
• Many do not benefit, some do
• Always a risk benefit decision
• Keep for some psychotic symptoms and severe
  aggression
• Some people may need to stay on

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Antipsychotics - Dosage

• Risperidone 0.5mg
• Quetiapine 25mg
• Amisulpiride 25 50 mg
• Olanzapine 2.5mg

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Questions?Scenarios?
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Further reading

• The use of antipsychotic medication for people
  with dementia. Sube Banerjee, Department of
  Health (2009)
• Dementia Supporting people with dementia and
  their carers in health and social care National
  Institute for Health and Clinical Excellence
  (2006)