Management Of Behavioral

Behavioral and psychiatric symptoms of dementia are driven by biological, psychological, psychosocial and environmental factors, and there is no single treatment that works for all patients or in all situations. A broad clinical assessment is essential before specific therapies are considered. It is essential to first perform a thorough history and physical examination to identify any medical illnesses that may contribute to the disruptive behavior (Cohen-Mansfield, 2000). There are currently no means for reversing the pathological processes of dementia, therefore therapy focuses on preservation of cognitive and functional ability, minimization of behavioral disturbances and maintenance of the quality of life for both the patient and care-givers (Allen-Burge, Stevens & Burgio, 1999). Current management of behavioral disturbances involves a number of pharmacological and non-pharmacological interventions. The decision to initiate a particular combination of therapies should be based on evaluation of benefits and risks associated with an individual patient.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

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A number of psychotropic drugs demonstrated efficacy in treatment of BPSD, such as cholinesterase inhibitors, antidepressants, sedatives and antipsychotics. Cholinesterase inhibitors provide modest improvement of symptoms and temporary stabilization of cognition in patients (Sink, Holden & Yaffe, 2005) antidepressants are effective in treating depression associated with dementia, while sedatives provide relief from mild anxiety in people with dementia. Antipsychotics have the best current evidence base for the treatment of BPSD and often used as the first-line pharmacological approach. Unfortunately they show only modest beneficial effect in the short-term treatment of aggression and limited benefits in longer term therapy (Sink, Holden & Yaffe, 2005). In addition, they may lead to development of extrapyramidal symptoms, sedation, tardive dyskinesia, gait disturbances, and falls (Katzman, 2008). All of the psychotropic drugs have known adverse events in the elderly, and the decision to manage the symptoms with pharmacotherapy should balance harms against benefit, or minimized with nonpharmacological treatments.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

An increasing number of nonpharmacological interventions are now available as an adjunct or alternative to pharmacotherapy for people with dementia. Their aim is to influence positively the emotional and behavioral changes associated with dementia (Graesel et al., 2003). These interventions are based on different theoretic frameworks of BPSD origin. Unmet needs interventions conceptualize problematic behaviors as a form of communicating an underlying need, such as the need for stimulation, pain reduction, and socialization (Douglas, James, & Ballard, 2004). Learning and behavioral interventions assume that BPSD are behaviors that have been inadvertently reinforced in the face of an environmental trigger (Douglas, James, & Ballard, 2004). Environmental vulnerability and reduced stress-threshold interventions, which assume a mismatch between the person’s environment and their abilities to cope with the situation (Douglas, James, & Ballard, 2004). Even if the source of BPSD is biological, any of these nonpharmacological interventions may still be applied (Graesel et al., 2003). Numerous nonpharmacologic interventions can aid in alleviating behavioral symptoms and reduce caregiver burden and stress by providing dementia patients with meaningful activities. Combined with a thorough history, these interventions and methodologies provide significant benefits to both the patient and the caregiver by reducing the burden of behavioral disturbances.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

Increasingly more attention is being paid to alternative interventions that are associated with fewer risks than pharmacology. Aromatherapy appears to have several advantages over the pharmacological treatments. It has a positive image and its use aids interaction while providing a sensory experience Aromatherapy has been investigated to reduce disturbing behavior, promote sleep and stimulate motivational behavior (Ballard et al., 2002; Holmes et al., 2002). It also seems to be well tolerated in comparison with psychotropic medication. The two main essential oils used in aromatherapy for dementia are extracted from lavender and melissa balm (Holmes et al., 2002). They also have the advantage that there are several routes of administration such as inhalation, bathing, massage and topical application in a cream. This means that the therapy can be targeted at individuals with different behaviors. There have been some positive results from recent controlled trials which have shown significant reductions in agitation, with excellent compliance and tolerance.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

The largest placebo-controlled study (Ballard et al., 2002), in which 72 patients with severe dementia were treated with lemon balm essential oil, demonstrated improvements in behavioral symptoms comparable with those seen with psychotropic agents in patients with less severe dementia, but it also indicated secondary improvements in quality of life and activities. Half of the patients were randomly assigned to aromatherapy with lemon balm essential oil (n = 36) and half to placebo (sunflower oil). The active treatment oil or placebo oil was combined with a base lotion and applied to patients’ faces and arms twice a day by care staff. Changes in clinically significant agitation (Cohen-Mansfield Agitation Inventory (CMAI) and quality of life indices (percentage of time spent socially withdrawn and percentage of time engaged in constructive activities, measured with Dementia Care Mapping) were compared between the two groups over a 4-week period of treatment. Sixty per cent of the active treatment group and 14% of the placebo-treated group experienced a 30% reduction in CMAI score, with an overall improvement in agitation (mean reduction in CMAI score) of 35% in patients receiving lemon balm essential oil and 11% in those treated with placebo. Quality of life indices also improved significantly more in people receiving essential balm oil. Importantly, at the end of the study no significant side-effects were observed.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

The term behavioural and psychological symptoms of dementia (BPSD; also termed neuropsychiatric symptoms) describes the heterogeneous group of symptoms and signs of disturbed perception, thought content, mood or behaviour that frequently occur in patients with dementia.1,2 Throughout the course of their dementia, the vast majority of patients will develop one or more BPSD.1–6 BPSD can have serious consequences. They are associated with worsening cognition and progression to more severe stages of dementia.7 BPSD also lead to individual suffering and impact the caregiver burden.8 Furthermore, they increase the risk for secondary complications such as falls and fractures leading to emergency room admissions,9 and ultimately institutionalization.10,11 Finally, BPSD result in higher costs of therapy and caregiving.  Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

The treatment of patients with BPSD can be challenging for physicians and healthcare teams. The etiopathogenesis of BPSD is often complex, with multiple contributing direct factors and indirect mediators. Biological factors (e.g. brain changes, comorbidities, medication) may interact with psychological (e.g. personal life history, personality) or social (support network, living arrangements) aspects. Consequently, treatment should be guided by a comprehensive etiopathogenetic assessment. Currently, there is limited evidence for symptomatic treatments and the available evidence-based options are only moderately effective. Psychosocial, that is non-pharmacological, approaches should be considered the mainstay of therapy and are complemented by psychotropic medication only if unavoidable. Ideally, the available treatment algorithms are used to devise an individualized treatment plan informed by a multifaceted understanding of the patient’s situation, clinical experience and expert knowledge.

Clinical presentation of BPSD
The clinical presentations of BPSD include apathy, depression, anxiety, delusions, hallucinations, sexual or social disinhibition, sleep–wake cycle disturbances, aggression, agitation and other behaviours considered inappropriate.14 There are several instruments to systematically assess the presence and severity of BPSD,15 among which the Neuropsychiatric Inventory (NPI)16 and Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD)17 are recommended.18 Some BPSD tend to cluster together, usually into four clusters – that is, the affective, psychotic, hyperactive and apathetic clusters.1,19 In a population-based study, the cumulative incidence of having one or more NPI-measured BPSD from the onset of cognitive symptoms was 80%,20 indicating that occurrence of BPSD has to be expected throughout the course of dementia. Apathy, depression, anxiety and agitation were found to be the most frequent forms of BPSD.2,20,21 However, a recent systematic review revealed substantial variation in the reported prevalence, incidence and longitudinal course between different studies.22 In an individual patient, the type and severity of BPSD tend to change over time, but some forms such as wandering seem to be more persistent.22 Overall, the ‘natural course’ of BPSD over time is still largely unknown.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

Most patients with dementia have depressive symptoms and signs at some point in time over the course of dementia (nearly 80% over the past 5 years). Some patients may present with a major depressive disorder (10–20%).1 A history of depressive disorder is likely to increase the risk of major depressive disorder during dementia. Insomnia, changes in circadian rhythm and anxiety may accompany depressive symptoms. Abnormalities in the serotonin, dopamine or epinephrine systems, frontal atrophy, and amygdala reactivity may be some of the neurobiological underpinnings of depressive features.

Another condition that should be considered is the Charles Bonnet syndrome, which is due to an eye disease. Visual hallucinations in Charles Bonnet syndrome are usually of short duration and patients are aware that they are not real; these hallucinations are often well tolerated by the patient and therefore may not need treatment other than that prompted by the underlying eye disease. In some instances, carbamazepine may be useful.23 Auditory hallucinations must evoke an underlying psychotic state not primarily explained by dementia, and usually need treatment.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

In an inpatient clinical setting, agitation is often the most challenging BPSD since it may severely disrupt patient care. Hence, most treatment trials for BPSD have been performed for agitation. Agitation refers to an ill-defined spectrum of aberrant hyperactive motor behaviours (such as wandering, leaving home) and physically or verbally aggressive behaviours such as rejection of care. Only recently a provisional consensus definition has been suggested for agitation in cognitive disorders.24 Beyond the behavioural phenotype, this new definition emphasizes the emotional distress and excess disability that is associated with agitation. Agitation may worsen during the evening hours, a phenomenon referred to as ‘sundowning’.25

Since delusions in dementia are found to sometimes correspond to reality or to be neither incorrigible nor held with absolute certainty, they may not represent psychotic symptoms in a narrow sense and should certainly not preclude the attempt to understand their meaning.26 In terms of content, delusions in dementia are frequently persecutory in nature or revolve around theft – that is, lost objects,27 danger, abandonment and the idea that one’s house is not one’s home.26 Notably, only about half of the cases of delusions appear to lead to discomfort and are associated with behavioural disturbances.28 A frequent subtype of delusions in dementia is the misidentification syndromes in which a patient consistently misidentifies persons, places, objects or events (e.g. Capgras syndrome).29 Sensory impairment is widely considered a contributory factor in the development of certain delusions in dementia, most obviously in cases of Charles Bonnet syndrome in the context of visual impairment.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

Apathy is usually defined as loss of motivation and decreased interest in daily activities.30 In the most severe forms, the affected patients may be unable to initiate almost any kind of directed activity, thus spending most of the day in bed or sitting in a chair. Apathy is one of the most frequent forms of BPSD and is associated with poor prognosis and increased mortality.31,32 However, apathy rarely leads to hospital admissions since it is not usually as disruptive for caregivers as other BPSD.

Sleep problems and disturbances of circadian rhythms
Sleep problems are both risk factors and frequent symptoms of dementias and may also arise from comorbidities.33,34 Sleep problems are a major contributor to caregiver burden. Even though the clinical need for effective treatments is high, the evidence base for treatments is limited.35 In dementia with Lewy bodies (DLB), REM (rapid eye movement) sleep behaviour disorder (RBD) can be an early sign of the disease, with daytime fluctuations of attention, greater number of daytime naps and longer night sleeps.36,37 RBD can also be seen in other synucleopathies such as Parkinson’s disease and multiple system atrophy. In frontotemporal dementia (FTD), RBD is rare but may be confused with excessive nocturnal activity due to disturbed circadian rhythmicity.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

Knowledge gap

In this study, aromatherapy was used as an adjunct to existing psychotropic medication. Hence, although suggesting a place for aromatherapy as an adjunctive therapy, the study cannot be used as evidence that it is a viable alternative to sedative drugs in people with severe dementia.

In addition need to look at the pharmacologic effect as result of absorption versus the emotional effect that is dependent on perception of pleasant smell. It is known that severe dementia leads to asomnia, leadng to decreased ability to appreciate meaningful smells. With or without conscious awareness, aromas can evoke mood changes and reduce stress responses. Therefore, aromas may have positive influences on the behaviors of older persons who are in residential care, but the range of effects is largely unknown. There is a possible psychological link between the fragrant odors of aromatherapy oils and the individual’s perception of whether a particular odor is pleasant or unpleasant; past experience with an odor will introduce inter-individual variability and consequently influence treatment outcomes. The efficacy of conventional medicines is required to be demonstrated in double-blind placebo controlled studies. Only then can any benefits over placebo be quantified and common side-effects systematically evaluated. A recent review concluded that while aromatherapy, amongst other non-pharmacological treatments, was identified as a potential treatment of behavioral problems in dementia, studies were often weakened by small sample sizes, lack of controls and imprecise measures.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

The proposed study

The aim of the proposed study is to test the effectiveness of topically applied lavender oil of proven purity as a treatment of behavioral symptoms in dementia. The hypothesis is that lavender oil will lead to a greater reduction in the frequency of behavioral symptoms of dementia than a placebo oil. A randomized-controlled trial (RTC) will be conducted to test the hypothesis with an appropriate control condition and blinding. The study will be conducted in long term care facilities specially for persons with dementia. Selected participants must therefore display at least one high frequency, physically agitated behavior that occurs daily at times other than during nursing interventions, and to a degree that requires staff intervention. Up to two target behaviors will be selected per participant in discussion with nursing staff based on frequency and severity using the Cohen Mansfield Agitation Inventory. Consented, willing participants will be assigned in random order to one block of lavender oil and one block of neutral control oil.Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

A nurse will massage lavender or control oil into the resident’s forearms for one minute. Observations will commence 30 minutes pre-exposure and finish 60 minutes post treatment, giving a total observation period of 90 minutes per session. A discretely positioned, trained researcher will record if the selected physically agitated behavior is present or absent at one-minute intervals over the 90-minute observation period. The primary measure in this trial will be the change in mean counts of physically agitated behaviors before and after intervention phases. The 29-item Cohen-Mansfield Agitation Inventory completed by the researcher in discussion with nursing staff in closest contact with the resident at the end of each week, relating to behavior in the preceding week. The proposed study will help meet the need for better controlled trials of alternative treatments for agitated behaviors associated with dementia. The findings may guide family and professional carers in their selection of available evidence-based ways to reduce stressful behavioral symptoms that respond only partially to psychotropic medications. Management Of Behavioral And Psychiatric Symptom Of Dementia Nursing Essay

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