Figure 1.2 BC management protocol
A diagrammatic representation of a BC management protocol is provided in Figure 1.2. It identifies the various incremental steps used to treat problematic behaviours. The first step is the labelling of a behaviour as a ‘challenge’, followed by the initial attempts to resolve the difficulty by the carers. If the problems persist, an acute physical cause may be suspected, requiring an assessment from the primary care practitioner (e.g. a GP). If the GP fails to identify any infection on screening, she may suggest the referral to a specialist mental health service. At this point there are three possible responses, one pharmacological and two non-pharmacological. In terms of the former, if a discrete clinical disorder is identified (psychosis, depression, pain, delirium), then it will be treated through the use of medication. Or, if the behaviour is so extreme or risky, the appropriate medication may be given to tranquillise or sedate the person with dementia on a short-term basis. In relation to psychological approaches, one may either offer advice after undertaking a cursory assessment, or undertake a full functional analytical (FA, Moniz-Cook et al. in press) treatment package. The latter approach is the most comprehensive, involving a thorough assessment and the use of behavioural charts. If the FA methodology is unsuccessful and the behaviour persists, one may treat the BC chiefly via medication, but at this stage the rationale for using the medication is as a tranquilliser or sedative in order to improve the client’s well-being. Despite presenting this protocol in terms of sequential steps, it is relevant to note that many specialist services employ combined modes of treatment, using both non-pharmacological and drugs concurrently (Holmes 2009). It is my view that, owing to both the lack of efficacy and side-effects of the psychotropics used in this area, it is unethical to prescribe a drug without simultaneously prescribing a non-pharmacological strategy. Alistair Burns, UK National Clinical Director of Dementia, is currently working to produce a national set of treatment guidelines for BC.
CONCLUSION
This chapter has provided a brief introduction to some key topics which will be discussed in-depth in the later sections of the book. Because BC are not diagnosable disorders, with regular and consistent underlying causes, they will always be somewhat problematic to treat. Indeed, the method of treating them appropriately will invariably require one becoming a detective and gaining detailed information about the nature of the BC and the client. The kind of detail required and how to put it together into a coherent formulation-led treatment package is the subject of this book.
Chapter 2
Causes and Assessments
INTRODUCTION
This chapter examines some of the causes of BC and the variables associated with them. Details about these features are important, because they help clinicians develop effective treatments.
The key points emphasised in this chapter are:
•BCs often have a number of interacting biopsychosocial causes.
•It is important to identify the potential causes of BC because this helps with the development of targetted interventions.
•Clients’ beliefs play an important role in the development and manifestation of their BC. Indeed, attempts by a person to act on his beliefs can result in problems (e.g. an 80-year-old man who believes he is 30, and still doing early shift-work, may have a strong motivation to leave the building early each morning).
•There are many measures that can be used in the assessment of the causes of BC. The majority are too lengthy to be used clinically, and tend to be employed in research settings.
BACKGROUND INFORMATION
As outlined in the previous chapter, the most comprehensive BC model to date has been developed by Cohen-Mansfield (2000a). Her TREA framework first identifies categories of behaviour, and asks relevant questions, leading to potential solutions. (e.g. Continually screaming → Does this happen when she is been transferred from wheel-chair to a bed/toilet? → If yes, attempt pain relief). This approach is also supported by her unmet needs model, which requires clinicians to undertake a detailed analysis of the behaviour as well as background details of the person and his environment. She suggests that obtaining this contextual information is often helpful in determining the causes of the BC (see Chapter 5). Consistent with this are the requirements of the NCBT framework, which asks clinicians to collect eight pieces of background information about the client. It is relevant to note that these are the aspects previously outlined in the Iceberg Model (see Figure 1.1). These features are discussed below in terms of three groupings: biological, psychological and social factors. In Chapter 7 a series of case studies illustrates how the information is used clinically.
Biological
Cognitive and neurological difficulties
The brain and its functions determine how a person sees and interprets his environment. In the case of dementia, the cognitive deficits will often mean the person has a different sense of reality to other people. For example, he may be disorientated in time and place, and may not remember what happened a few minutes earlier.
It is important to note that having a different view of the world to the people one is interacting with does not automatically make someone’s behaviour challenging. However, it can bring the person into conflict with others, particularly if there is a dispute about whose views are correct. Consider