It is worth noting that there are many difficulties associated with defining BC in terms of behaviours. This is in part because it encourages clinicians to think of people’s difficulties in terms of their outwards signs (i.e. the actions) rather than their underlying cause(s). For example, by labelling a BC as ‘aggression’, one might be distracted from identifying its true cause which might be either pain or paranoia. Figure 1.1 is a diagram that serves to remind us about the links between behaviours and their causes.
Figure 1.1 BC iceberg analogy
As can be seen from the diagram, the link between the behaviours and their causes is often via some form of belief. Such beliefs are often emotionally charged by fear, anger, pride or despair. The beliefs are also related to ‘needs’, whereby a person who believes he is still working, may have a perceived need to leave the building at 5 am to do his morning shift. The causes, and their interactions with each other, will be explored further in the next chapter.
CATEGORISATION OF BCS
Over the last ten years researchers have tried to identify different categories of BC. Cohen-Mansfield 2000b has produced one of the most valid and helpful ways of differentiating between them; she distinguishes between physically aggressive acts (hitting, hair pulling); physically non-aggressive (pacing, over-activity) and verbally disruptive behaviours (shouting, repetitive questioning).
Based on these categories, Cohen-Mansfield has provided a useful framework for helping to determine causes of BCs, termed TREA (Treatment Routes for Exploring Agitation, Coleen-Mansfield 2000b). TREA is a comprehensive approach designed to help staff to identify causes and corresponding treatment plans. It uses a decision tree questionnaire format in which one arrives at the most likely cause of a problematic behaviour by assessment of the category and type of behaviour, the setting, and information about the individual (see Table 1.2). Once a cause has been hypothesised, one of a selection of treatments is chosen and carried out. If that treatment is unsuccessful, another is chosen, or a new hypothesis generated based on a better understanding of the problem.
Cohen-Mansfield’s questions differ for each of her three categories of challenging behaviour (physical non-aggression, physical aggression, verbal disruption).
For many years the Newcastle Challenging Behaviour Team (NCBT) used the above categorisation system to good effect. However, recently we have become interested in the role of people’s belief systems as causal features of BC (see Figure 1.1). As such, and from audits of our clinical work, we developed an alternate categorisation system (see Table 1.3). This system distinguishes between non-active and active forms of BC. The non-active types are related to apathy and depression. These are the most common categories of BC (Renauld et al. 2010; Moniz-Cook et al. 2001b). Some clinicians may not regard these behaviours as challenging, but clearly the conditions are distressing for the individuals experiencing them, and certainly undermine their levels of well-being.
| Table 1.2 Some questions to be used in the case of physical non-aggressive behaviours | ||
| Question 1 | Question 2 | Potential treatment |
| Does the person seem upset? | Is the person asking for home? | Try to make the place look more like home |
| Is the person restless? | Try to find activities which are meaningful | |
| Is the person uncomfortable? | Change position or provide other sources of comfort | |
| Does the person have a need for self-stimulation or exercise? | Are you concerned about the safety of the person? | Try to use safety devices: safety alarms, large enclosed environments, change appearance of exit door |
| Is the person trespassing and bothering others? | Try to develop a more inviting environment where the person can wander, camouflage other entrances | |
In relation to the active forms of BC, we have distinguished four types. The first group can be conceptualised as reactions to stressful situations. In this group, people can feel vulnerable, think their rights are being infringed, or feel frustrated that they are not being listened to. The BCs may be caused by misinterpretations of situations due to perceptual problems, or memory deficits or psychotic features (hallucinations or delusions). Thus their reactions to these perceptions are to either seek reassurance or become aggressive.
The second group of active BC are typified by walking and interfering activities. These behaviours reflect attempts by the clients to orientate themselves to their surroundings, which may be difficult due to their cognitive and memory problems.
Third, there is a group of BC that result from failures by the person with dementia to inhibit actions, thoughts and emotions. This group of behaviours is closely related to frontal lobe deficits.
Finally, there are behaviours that reflect a mismatch between the person and the environment he is in. These disruptive behaviours stem from the person rejecting the setting. For example, the person may not like the restrictions or features of his current living conditions. These various categories of BC are summarised in Table 1.3. We have found the distinctions useful, for despite some overlaps within groups, they help distinguish behaviours on social, neurological and emotional grounds, thus helping clinicians to see the sorts of things that might be driving the behaviours. And consequently, the groups provide some theoretical guidance towards treatment strategies.
The NCBT categorisation system differs in a number of ways to Cohen-Mansfield’s, but one of the chief differences is that it does not categorise by an actions typology, rather it focuses more on the causal features (i.e. the features driving the behaviour). Hence, a behaviour such as ‘excessive walking’ could be placed within a number of categories – it could be due to a disinhibition, anxiety, or an attempt to find a way out of the building. Recognising which category it belongs within the NCBT framework helps one to direct one’s intervention.
MANAGING BCs: A TREATMENT PROTOCOL
BC are common in dementia, with 90 per cent of those with dementia displaying some form of BC during their illness (Lyketsos et al. 2002). They often occur in the later stages of the illness, and there is an association with severity of BC and severity of dementia (Thompson et al. 2010). In most circumstances they are dealt with well by carers, with few problematic consequences. However, occasionally the behaviours persist, and some may even be reinforced by carers’ actions. It is in these latter circumstances that specialist help may be required either in the form of medication or non-pharmacological approaches.
| Table 1.3 BC categories derived from an audit of NCBT clinical work | ||
| Type of BC | Emotions and beliefs | Comment |
| Lack of motivation and initiation (non-active form of BC) | Apathy or depression associated with beliefs of helplessness and worthlessness. | Behaviourally apathy and depression look similar, but apathy is related to brain changes in the frontal lobes. In contrast depression is often a consequence of the person’s poor sense of worth and sense of hopelessness. Referrals for amotivation are common from family carers, but uncommon for residents in care homes. This is because care staff find it easier to look after residents who are less active; thus the behaviour
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