PERT Program

Tip of the Month: June 2005


BEHAVIORAL SYMPTOMS IN COGNITIVE DISORDERS: PART II


Delirium and dementia are common among older nursing home residents. Studies have indicated that delirium occurs in 60% of elderly nursing home residents.1 Dementia also is very common in nursing homes and a frequent reason for nursing home admission. Approximately 60–80% of nursing home residents have dementia.2 Residents may suffer from more than one type of dementia (e.g., from Alzheimer's disease and from vascular dementia), and they may suffer from delirium and dementia concurrently.

Delirium and dementia can cause several mood, functional, and behavioral symptoms. This month's Tip focuses on these common behavioral symptoms and outlines evidence-based strategies for managing them.


Behavioral Symptoms Related to Delirium or Dementia

Changes in brain functioning, whether acute or chronic, impair thinking functions. For example, amnesia can impair memory, aphasia can adversely affect language abilities, apraxia can cause difficulties with movement or speech, and agnosia can impair perceptual abilities.

[These cognitive disorders were discussed in the April 2005 Tip of the Month. For further information, please see: Behavioral Symptoms in Cognitive Disorders: Part I.]


Changes in brain functioning also affect insight and judgment. Many behavioral symptoms exhibited by people with delirium or dementia are difficult for professional and lay caregivers to deal with. Caregivers may be the recipients of physical or verbal aggression from residents with delirium or dementia. To maintain perspective and remain nonjudgmental and non-defensive, caregivers need to keep in mind that behavioral symptoms are a result of a medical condition rather than a logical, coherent, or controllable response on the part of the resident.

Communication

Impaired thinking caused by difficulties in communicating or understanding oral and written language (aphasia) worsens as dementia progresses. Residents with delirium or dementia, most notably Alzheimer's disease, may have agnosia — difficulty interpreting sensory information. For example, people with agnosia may be unable to recognize familiar words or music. They also may be unable to recognize and use familiar objects, such as a hairbrush. Aphasia and agnosia, in combination with sensory losses (e.g. hearing, visual, tactile), make it increasingly difficult for caregivers and residents to communicate effectively.

Management strategies are similar when working with residents with delirium or dementia. The cornerstone is to remain nonjudgmental and to communicate in gentle and affirming ways. For example, avoid questions such as, "What did you have for lunch today?" and replace that query with, "How was lunch today?" Another example would be to avoid a statement such as, "We talked about this last time," and to replace it with, "That sounds interesting. I'd like to know more about it."3 These communication strategies affirm the resident's dignity and maximize his remaining strengths.

There is one key difference between the communication strategies used for delirious residents and those used for demented residents. For delirium and other temporary confusional states, correct misperceptions and provide reality-based answers and cues. (This is known as reality therapy.) If, however, the confusion is expected to be permanent (e.g., in the case of Alzheimer's disease), then use communication techniques such as validation therapy.4 Validation therapy is a nonconfrontational communication strategy that attempts to understand the underlying meaning in the confused person's communication. This approach emphasizes empathizing with and minimizing the frustration of the confused adult.

Mood Symptoms

Mood symptoms such as anger, anxiety, and depression are common in confused adults.5 Anger from a confused resident is often an exaggerated or misdirected response to an internal or external stimulus. Typically this anger is the result of a misunderstanding. Because of their memory deficits, calm reassurance and gentle redirection will often cause residents to forget what provoked their anger.

Anxiety is also a common mood symptom in residents with dementia. Residents who are anxious may fidget or pace. They may repeatedly ask questions such as, "Where is my daughter?" or ask to go home. Anxiety may be caused by changes in the chemicals of the brain. Anxiety may also be a result of feeling confused in a seemingly unfamiliar place. Engaging residents in structured, preferred activities decreases boredom and redirects their energies.

All residents with dementia should be evaluated for depression. Symptoms of depression include crying episodes, sad facial expressions, loss of interest, withdrawal, loss of appetite, and sleeping problems. Some residents may not be able to express their sadness. Depressed residents require treatment with antidepressant medications, as well as other nonpharmacologic interventions such as supportive therapy. The most serious consequence of depression is suicide, and any mention of suicide should be taken seriously and the resident should be evaluated immediately.

The extreme form of mood disorder in confused residents occurs when the person becomes very upset and experiences rapidly changing moods. This may be a result of environmental demands such as excessive noise, crowds, being asked several questions at once, or being asked to do a task that is too difficult or complex. The confused person might react by refusing to perform an everyday task such as getting dressed. Catastrophic reaction is the term used to describe this behavior. Caregivers may believe mistakenly that the confused adult's behavior is a result of the person "merely being obstinate, critical, or overemotional."5 Again, remember that these behaviors are a result of a medical condition. In these situations, adjust your expectations and tasks to avoid catastrophic reactions that are emotionally and physically taxing for the resident.

Altered Thought Processes

Altered thought processes, such as hallucinations or delusions, are common with delirium and dementia. A hallucination occurs when a person perceives an object or event when no such stimulus or situation is present. Hallucinations may be visual, auditory, olfactory, gustatory, or tactile. A delusion is a false belief or wrong judgment that a person maintains despite evidence that the belief or judgment is inaccurate.6 Hallucinations and delusions are often frightening both for the person experiencing them and for the caregiver. Moreover, these events may cause the person experiencing them to become suspicious of or hostile towards others. Sudden onset of delusions or hallucinations is typically associated with delirium,5 while ongoing delusions and hallucinations are common in dementing disorders.7

When treating any symptom related to delirium, the healthcare provider needs to treat the underlying cause of the delirium. In treating hallucinations and delusions caused by dementia, calm reassurance and avoidance of confrontation are critical. Psychoactive medications such as haloperidol or risperidone may be necessary to treat problematic hallucinations (e.g., ones that cause dangerous aggression or that severely impede function). Before initiating pharmacologic therapy, however, the risks and benefits need to be identified and balanced.8

Verbal and Physical Aggression

Delirious or demented residents can exhibit verbal and/or physical aggression. Aggression may be triggered when a confused resident feels overwhelmed by internal or external stresses. Pain is a common stressor that can result in verbal or physical aggression. Medications, including psychoactive drugs and antihistamine drugs (e.g., diphenhydramine - Benadryl®), rather than decrease adverse behaviors, may increase confusion and exacerbate behavioral symptoms. Hunger and thirst also may lead to aggressive behavior.9 Checking for constipation or foul-smelling urine may uncover the cause for discomfort. Again, when these behaviors have a sudden onset they are indicative of delirium, however mild, and should trigger an evaluation for a physiologic cause.

Successful strategies in caring for aggressive residents include eliminating pain and discomfort; distraction and redirection to a desired activity; and provision of food, drink, or rest as necessary.5 Intergenerational activities, music, dance, pet therapy, and exercise have also proven to be very successful.10

Socially Inappropriate Behaviors

Confused residents often are unable to maintain the social rules imposed by society. Memory impairments and apraxia (inability to complete tasks) negatively affect their ability to carry out day-to-day activities. These impairments may range from mild to severe. Additionally, impairments in insight and judgment further incapacitate the person's ability to maintain social rules. Therefore, a person walking around partially or fully unclothed may be unable to dress, may feel hot, or may need to toilet. Sexually inappropriate remarks or behavior may also occur in residents with dementia or delirium as a result of poor impulse control, lack of insight, or confusion about the identity of people in the environment. Again, gentle distraction and redirection typically are successful when dealing with these behaviors.

Resistance to Care (e.g., Bathing or Grooming)

Dementia and delirium can prevent a resident from understanding the purpose of day-to-day activities. They also cause anxiety regarding simple activities of daily living because the person cannot anticipate what is going to happen. For these reasons, confused residents often resist caregiving tasks such as bathing and grooming.

Segmenting tasks into simple, easily managed steps assists the confused adult in maximizing his independence and avoids overwhelming him and causing catastrophic reactions. For example, people too frightened to use a shower or bathtub may have a sponge bath. Today, multiple products, including rinseless soaps and shampoos, make it easier to maintain good hygiene while avoiding needless confrontations and possible injuries. Each individual with delirium and/or dementia is unique. Therefore, approaches to care need to be tailored to each individual, taking into consideration his or her remaining strengths and maximizing those to maintain independence and dignity.11

Many family caregivers want to assist in providing care for their loved one. Staff may want to encourage them to engage in various tasks including brushing teeth, combing hair, feeding, or taking the resident outside. These activities may decrease the adverse physical and psychosocial consequences that families suffer as a result of grieving their loved one's decline. Staff members are also a source of support for families and may refer them for professional help or support groups for additional support.12

Wandering

Wandering and elopement are very dangerous behavioral manifestations of dementia and delirium in that they place residents at high risk for injury. Secured units are often the best option for providing a safe environment. Other interventions include wander alarm bracelets, stop signs at exit doors, structured activities, exercise areas, and adequate supervision.13 Facilities may also consider enrolling residents in the Alzheimer's Association Safe Return program to provide another measure of safety.

Hoarding

Some confused residents will hoard or stash items, including clothing, jewelry, and even food. They often put things away and forget where they put them. Confronting the person or removing items in front of them may result in a catastrophic reaction. Remove the majority of items but not everything (the resident will realize that items have been removed). Of course, any food that has the potential to spoil needs to be removed. Residents or families who want to keep some minimal cash at the bedside should negotiate with facility staff as to the available means to do so.

Restraints

Physical restraints need to be used very carefully with confused adults. Although short-term use with the least restrictive device may be appropriate in acute situations, they typically are not to be used when caring for residents with dementia. Restraints have been shown to increase agitation and to reduce functional capacity. Other complications of physical restraints include skin problems, aspiration pneumonia, contractures, dehydration, and accidental death by asphyxiation.14

RESOURCES

For professional and family caregivers, it is important to get as much information as possible about delirium and dementia. The best interventions for behavioral symptoms are nonpharmacologic therapies,15 and there are many sources of information about these approaches. The Alzheimer's Association provides ongoing education and support to professional and family caregivers. Other resources include:
  • The Alzheimer's Association Web site (www.alz.org) is an invaluable source of information on behavioral strategies, information for caregivers, information on current research developments, and links to other Web sites.

  • The Alzheimer's Disease Education & Referral Center (ADEAR) Web site (www.alzheimers.org) also provides current, comprehensive information about Alzheimer's disease, including information and resources from the U.S. Government's National Institute on Aging (NIA).

  • The National Family Caregivers Association (www.nfca.cares.org) offers education, support, empowerment, and advocacy for family caregivers.


Conclusion

This month's Tip has covered little in the way of pharmacologic approaches to behavioral symptoms. As mentioned, nonpharmacologic strategies are safe, practical, and effective care strategies. In the rare case of behavioral symptoms that require an antipsychotic or anti-anxiety drugs, the risks and benefits to the resident must be carefully weighed. In most cases today, nonpharmacologic strategies are underutilized. Ongoing education and information from organizations such as the Alzheimer's Association are crucial. Our best teachers, however, are the confused adults themselves. Attending to their remaining strengths and adjusting our care strategies will continue to provide the answers needed to give compassionate and dignified care.



Dr. Mary Shelkey, PhD, ARNP, Geriatric Specialist, and Director, RN Clinical Research Unit of Benaroya Research Institute, Virginia Mason Medical Center, Seattle, WA, provided this month's Tip. Dr. Shelkey also is Assistant Professor at the Seattle University School of Nursing.



References

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  2. Beers, M. H. & Berkow, R. (Eds.) (2000). The Merck manual of geriatrics. (3rd ed.). Whitehouse Station, NJ: Merck Research Laboratories.
  3. Strauss, C. J. (2001). Talking to Alzheimer's: Simple ways to connect when you visit with a family member or friend. Oakland, CA: New Harbinger Publications, Inc.
  4. Feil, N. (2002). The validation breakthrough: Simple techniques for communicating with people with "Alzheimer's-type dementia" (2nd ed.). Baltimore: Health Professions Press.
  5. Mace, N. L., & Rabins, P. V. (1999). The 36-hour day: A family guide to caring for persons with Alzheimer's disease, related dementing illnesses, and memory loss in later life (3rd ed.). Baltimore: John Hopkins University Press.
  6. Stedman's Medical Dictionary [electronic version]. (2000). Lippincott, Williams, and Wilkens.
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  8. Lantz, M. (2005). Atypical antipsychotics and dementia: Dealing with an emerging risk profile. Clinical Geriatrics, 13(4), 26–30.
  9. Molloy, W., & Caldwell, P. (2003). Alzheimer's disease: Everything you need to know. Buffalo, NY: Firefly Books.
  10. Shelkey, M. (2001). Dementia: Nonpharmacologic therapy. In M. D. Mezey (Ed.), Encyclopedia of elder care (pp. 191–194). New York: Springer Publishing.
  11. Rader, J., & Tornquist, E. M. (1995). Individualized dementia care: Creative compassionate approaches. New York: Springer Publishing.
  12. Mittelman, M. S., Epstein, C., & Pierzchala, A. (2002). Counseling the Alzheimer's caregiver: A resource for health care professionals. Atlanta, GA: American Medical Association Press.
  13. Futrell, M. & Melillo, K. D. (2002). Wandering: Evidence-based protocol. The University of Iowa Gerontological Nursing Intervention Research Center Research Dissemination Core.
  14. Strumpf, N. E., Evans, L. K., & Bourbonniere, M. (2001). Restraints. In M. D. Mezey, (Ed.), The encyclopedia of elder care (pp. 567–569). New York: Springer Publishers.
  15. Cohen-Mansfield, J. (2003). Nonpharmacologic interventions for psychotic symptoms in dementia. Journal of Geriatric Psychiatry & Neurology, 16(4), 219–224.