Table 2.5The common biopsychosocial causes of walking with/without purpose
Table 2.6The common biopsychosocial causes of absconding
Table 2.7Beliefs and thoughts associated with BCs
Table 2.8BC measures and tools
Table 2.9Frontal lobe functions
Table 2.10Some of the potential causal factors that are screened at referral
Table 2.11Cognitive deficits that may be causal factors in BC
Table 3.1List of medications used to treat challenging behaviours
Table 3.2The top five psychotropics chosen for Bishara’s three vignettes
Table 4.1Non-pharmacological approaches and their evidence-base
Table 4.2LCAPS guidelines for working with care staff
Table 5.1Cognitive themes and their relationships to emotional appearance
Table 6.1LCAPS guidelines for working with care staff
Table 6.2The stages of the ‘5 plus 9’ NCBT treatment model
Table 6.3Some of the skills required to work with staff in care facilities
Table 6.4Cognitive themes and their relationships to emotional appearance
Table 6.5Illustration of how the emotional presentation of the person can help identify need and develop the intervention
Table 7.1Queries and responses: demonstrating how therapists’ questions can help illuminate features underpinning the BC
Table 7.2John’s score on the FOT: an observation tool for assessing frontal functioning
Table 7.3Summary of NCBT Interventions (Makin 2009)
Table 8.1Demographics for areas in North East England that have BC teams
Table 8.2Summary of responses to the question ‘Do you engage in any of the following activities when using a toilet which is not in your home?’
Introduction
THE RISING PROFILE OF DEMENTIA
In recent years the topic of dementia has received a lot of attention internationally (Vernooij-Dassen et al. 2010). In 2010, the International Journal of Geriatric Psychiatry dedicated a special issue on the global response with respect to the management of dementia (Burns 2010). In the UK, all of the four home countries are publishing, or have already published, national dementia strategies and plans (England, Scotland, Wales and Northern Ireland). Throughout the world governments are preparing for the consequences of ageing populations and the tsunami of dementia related issues. This is in marked contrast to the whole of the previous century in which this condition received comparatively little attention at a governmental level in relation to conditions such as cancer and heart disease. The Health Economic Research Centre, UK (HERC 2010) calculated that Government and charitable spending on dementia research is 12 times lower than on cancer research (£50 million compared to £590 million), and less than a third of the spending on heart disease (£169 million). This is in contrast to the cost of the three diseases to the economy, with dementia costing £23 billion, cancer £12 billion and heart disease £8 billion.
The major spurs in the UK have been key publications such as the National Audit Office’s ‘Improving Services and Support for People with Dementia’ (NAO 2007); ‘Remember, I’m still me’ (CC/MWC 2009) and the National Dementia Strategies for England (DoH 2009) and Scotland (Scottish Government 2010). Many of the influential documents have been critical of existing service provision. For example, The Audit Commission’s publication of ‘Forget Me Not’ (CHAI 2002) was critical of the role of professionals, particularly primary care services, and ‘Living Well in Later Life’ (2006) described the problems in attempting to implement the National Service Framework for Older People (DoH 2001).
To illustrate some of the reasons for the UK government’s concerns consider the following data and demographics (information from NAO 2007; DoH, National Dementia Strategy for England 2009b; Time for Action report, Banerjee 2009; HERC 2010):
•820,000 people in the UK have dementia; this is 1.3 per cent of the population. The majority of these people live in England.
•Approximately 30 per cent of people (230,000) with dementia in the UK live in care homes.
•15,000 people with dementia are under 65 years of age, and services for this younger group are underdeveloped.
•15,000 dementia sufferers come from minority ethnic groups, and this figure is set to rise sharply owing to the ageing of people who settled in the UK from the 1950s onwards.
•69 per cent of General Practitioners (GPs) do not believe they have received sufficient training to diagnose dementia and manage difficult behaviours. This is a decrease in perceived abilities compared to 8 years ago (‘Forget Me Not’ report 2002), and may be accounted for by the increasing expectation from service-users and their families.
•25 per cent of people with dementia in the UK are prescribed anti-psychotics, mainly for the treatment of problematic behaviours. These drugs have significant side-effects, and are effective in only one in five presentations.
•The national cost of dementia per year is £23 billion (50% for the cost of unpaid care; 40% social care costs; 10% health care costs).
The English National Dementia Strategy was launched in 2009, and was promised £150 million to oversee its implementation. Within the 17 objectives of the strategy, we see a positive vision of what good care provision could look like. However, few of the objectives specifically address behaviours that challenge (BCs), which are major sources of carer and family distress, and the reason why many people require hospitalisation or 24-hour care. The Scottish strategy provides more guidance on BCs, overtly articulating issues to do with client distress and the need for staff training. The current book intends to expand on many of the points made in these strategies, focusing on the perspectives of clinicians working with clients who are deemed to be challenging.
BEHAVIOURS THAT CHALLENGE (BC)
Behaviours that challenge were previously referred to as challenging behaviours. The latter term originally came from the learning disability literature and was used to describe problematic behaviours that cause difficulties for the person performing them, or for the setting in which they are displayed. Blunden and Allen (1987) suggest the term was introduced in order to shift the focus of attention away from individual pathology towards an understanding that challenges carers and service providers to find solutions to the problem behaviours. Many old age psychiatrists prefer to use the term behavioural and psychological symptoms of dementia (BPSD) to denote the link to dementia in their work. However, the term BPSD has been criticised because it implies the problematic behaviours are linked directly to the dementing process. As we will see in Chapter 1, this is clearly not the case because many of the behaviours are normal coping strategies used by the general population to deal with difficult settings.
This book contains eight chapters, providing theory and practical advice on the