Possible causes
of
challenging behaviour
Background factors
Factors, such
as
personality, leisure
and
occupational activities,and
a
person's habitual
way of
responding
to
stress,
are
important
to
consider;
for
example,
a
person might wanderbecause they were used
to
walking
in a
previous occupation(Monsour and Robb, 1982).
Current factors
These include medical
and
physiological factors, such as pain,hunger, need
for the
toilet, and need
for
exercise.
Emotional state
Consider whether behaviour
has
been triggered
by
emotion,such as boredom (people with dementia have a short attentionspan
but
still require stimulating activities), anger
or
anxiety.
Neuropsychological deficits
Changes within
the
brain
can
cause functional deficits, suchas
an
inability
to
carry
out
complex tasks, which
can
thenlead
to
frustration.
Inability to orientate spatially
Changes within
the
brain
can
affect perception
and
spatialawareness.This may result in
a
patient getting in the wrong bedor
not
being able
to put
their clothes
on in the
right order.
Environmental factors
Environmental factors
can
contribute towards challengingbehaviour especially
in the
hospital setting. These include:• Ward layout• Proximity
to
other people• Lacking control over routine (e.g. bed time and meal times)• Being
in a
strange environment• Unfamiliar tasks, such
as
catheterization
and
blood pressuremeasurement• Sensory stimulation overload:
the
general noise
and
atmosphere of
a
busy ward can be overwhelming to
a
personwith dementia who sometimes find
it
difficult to make senseof their usual home environment (Kerr, 1997).
Table
1.
Examples
of
challenging behaviour
in
dementia
Behaviour
Difficult behaviourAggressive/disruptiveDeficient behaviour
Example
Refusal to'cooperate with therapyVerbai
or
physicai aggression, destroying objects around othersor
self, e.g.
trying
to
pull
out
catheters, rummaging throughiockers, interfering with other people's belongings, wanderingBehaviour may
be
hypoactive, apathetic or withdrawn
Tabie
2.
Prevaience
of
neuropsychiatric symptomsin Aizheimer's disease
• Apathy (loss
of
drive
and
motivation
or
lack feeiing
or
emotion) (50-70%)• Agitation (excessive motor activity that may manifest
as
restlessness, wanderingand agitation) (20-60%)• Depression
and
anxiety (40%)• Psychotic symptoms such
as
hallucinations and delusions (25%)Source: Ballard
and
Howard (2006)
Communication difficulties
People with dementia might not be able to communicate their!needs verbally
due to
word-finding difficulty
or
dysphasia.
i
Behaviour, such
as
calling out, agitation
or
wandering, mightbe
a
way
of
communicating need.
Sundowning
|
In dementia
the
sleep-wake cycle
is
often disturbed with
'
individuals becoming more agitated
or
active
at
night
(in
[
some cases
the
cycle
is
reversed with individuals sleeping
j
during
the day and
awake
all
night). 'Sundowning' refers
to j
behavioural difficulties that worsen towards
the end of the
day, with symptoms including: restlesness, agitation, suspicious
j
behaviour, disorientation, visual
and
auditory hallucinations,
'
less cooperation
and
increased argumentative tendancies.
It
can often
be
worse after
a
move
or
change
in
routine.
j
Although
the
cause
of
sundowning
is
unknown
it
seems
to
result from changes within
the
brain
and may be
linked
to a
lack
of
sensory stimulation after dark (Alzheimer's Australia,2005); there
are
fewer cues towards late evening
and
lessroutine
at
night which may exacerbate confusion. People withdementia tire more easily
and can
become more difficult
to
manage.
This
can
often
be
very stressful
for
carers.
Coping with sundowning
• Keep person with dementia active during the morning andencourage
an
early afternoon
nap
• Avoid physical restraint, allow person with dementia
to
paceif
safe
to do
so; an evening walk
is
sometimes helpful• Avoid caffeine towards late evening,
and
promote sleep
by
providing
hot
milky drinks
and
gentle music• Some people find
it
reassuring
to
sleep with
the
radio
on
or night-lights• Preparing
the
environment, such
as
closing curtains
and
encouraging
the
person with dementia
to
assist
in
eveningmeal preparation, may promote routine
and
reduce anxiety• Consider whether loud noise from television mightexacerbate confusion• Encourage participation
in
activities familiar from earliertimes such
as
card games• Avoid invasive procedures towards evening
if
possible• Make sure physical needs
are met
such
as
nutrition,hydration, elimination, pain• Exclude physical illness
as a
possible cause
of
sundowning.Management
of
behavioural problems
in
dementia
is
oftenmultifactorial
and
needs
to be
tailored
for the
individualpatient. People with dementia should
be
managed
by
skilledmultidisciplinary teams,
and
psychiatric and/or psychologyexpertise
may be
needed. Delirium
and
depression mustalways
be
looked
for and
treated. Physical symptoms, such
as
pain
or
constipation, should
be
treated. Sensory deficits shouldbe corrected. Good dementia care practice means that
non-
pharmacological interventions should always
be
tried first.Pharmacological interventions should only
be
considered
if
there
is
serious distress
or
risk
to the
patient.
Case Studies
1
and
2
describe unusual behaviour
in
dementia
and
encouragepractitioners
to
consider various possible causes
of
challengingbehaviour
in
addition
to
providing advice
on how to
adoptnon-pharmacological ways
of
managing such behaviour.
244
British Journal
of
Nursing.2008,Vol 17,
No 4
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