| The clinical manifestation of dementia can include a wide range of behavioral disturbances which are frequently the ultimate cause for institutionalization.
Difficult behaviors associated with dementia
Problematic behaviors are defined as those that interfere with the patient's ability to function and/or create harm or potential harm to the patient, caregivers or others.
- Differential Diagnosis - patient specific evaluation
- New medical diagnoses
- Complications of chronic illness
- Environmental problems
- Medication effect
- Factors that May Worsen Mental Status and Behavior in Individuals with Dementia
- Host-related
- Infections
- Fluid, electrolyte, and metabolic disturbances
- Stroke or seizure
- Abrupt arrhythmias
- Silent myocardial infarction
- Cancer
- Hypo- or hyperthyroidism
- Urinary retention
- Significant pain or trauma
- Fecal impaction/constipation
- Weight loss
- Chronic pain
- Iatrogenic-Nosocomial
- Medications
- New prescriptions
- Withdrawal from chronic medications
- Substance use, abuse, withdrawal
- Recent admission
- Transfer to a new environment
- Recent hospitalization
- Recent surgery under general anesthesia
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Examples of behavioral disorders
- Agitation: i.e. Sundowning
Definition : Anxiety accompanied by restlessness that results in increased psychomotor activity with disruptive physical and/or vocal behavior
Seven I's of acute agitation in dementia
- Iatrogenic (medications)
- Infection
- Illness
- Injury
- Impaction
- Inconsistency of environment
- Is the patient depressed?
(Source: coa.kumc - Lehninger, 1998)
- Aggression: i.e. Inappropriate or impulsive sexual behavior, resistance to personal care
Definition : Hostile action directed toward someone or something; disruptive physical and/or vocal actions
- Delusional thoughts and hallucinations: i.e. Suspicion, Paranoia
Definition : Delusions are false ideas that are firmly believed and strongly maintained despite evidence to the contrary while hallucinations are a sensory experience where a person sees, hears, or feels something/someone that is not audible or visible to anyone else.
- Depression
- Incontinence
- Sleep disturbance - disruption in the usual day/night sleep cycle resulting in daytime somnolence or other adverse symptomatology.
- Wandering
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Examples of impairments in domains other than cognition
- Physical
- Risk of skin breakdown because of immobility
- Risk of injury because of forgetfulness
- Altered nutritional status because of poor food intake
- Functional
- Impaired mobility
- Self-care deficits
- Emotional
- Outbursts of anger or crying
- Persistent anxiety
- Behavioral
- Urinating or defecating in public
- Wandering unsafely
- Recurrent or persistent yelling
- Social
- Inappropriate sexual activity
- Impaired family relationships
- Environmental
- Inability to find room
- Running into furniture due to perceptual deficits
- Other
- Inability to manage financial or legal affairs
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Scope and severity
- Scope
- Occurs rarely - no more than a few times a month on an irregular basis
- Occurs occasionally - as much as a few times a week on an irregular basis
- Occurs often - almost daily on a regular basis
- Occurs continuously - many times a day on a regular basis
- Severity
- Behaviors pose minimal risk to self or others
- Wanders safely
- Appears anxious
- Behaviors pose slight risk to self or others
- Throws food
- Mildly verbally abusive
- Behaviors pose moderate risk to self or others
- Intrusive behaviors
- Wanders unsafely
- Behaviors pose major risk to self and others
- Defecates in public
- Exhibits violent behavior
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Problematic behavioral assessment model
Unmet need +cognitive changes+diminished language abilities+loss of frontal lobe function/control = problematic behavior
- Event specific factors - environmental
- physical - light, sound, temperature
- social - staff mix and variation, roommate, other residents, overall facility ambience
- psychosocial - depression, other mood disorder/affect, match of assistance to ability
- Patient specific factors
- physiological need - pain, hunger, thirst, fatigue, elimination
- pre-morbid personality/psychiatric history - life-long habits
- diagnosis
- demographics
- health status
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