Understanding Behaviour in Dementia that Challenges. Ian Andrew James

2.10.Perceptual deficitsIn recent years researchers have found associations between deficits in smell, vision and auditory skills with cognitive decline (Gater et al. 2008). Problems of communication can sometimes lead clinicians to fail to identify visual and hearing problems. If suspected, help can be obtained from the relevant specialists.Mental healthThe Cornell Depression Scale and DMAS are good tools for assessing affective problems in people with dementia. The RAID is also a useful brief tool for assessing anxiety. The rAQ can be used to assess those people with long-standing social and communication difficulties, who’ve always required rigid routines in order to function.Care practicesThe DCM is helpful for examining staff interactions and features associated with clients’ well-being. The QUIS is another useful observation tool, which examines carer’s positive and negative interactions with clients.Beliefs/emotionsClients’ beliefs and emotions are assessed using behavioural charts (see Figure 2.1). A more formal scale is currently under development by the NCBT to assess clients’ beliefs and emotions (see Figure 2.2). From a carer’s perspective, there are a number of scales that examine their beliefs and attitudes towards people with dementia (Formal Caregiver Attribution Inventory (Fopma-Loy 1991; Shirley 2005) and Controllability beliefs scale (Dagnan et al. 2004).

      Table Key: ADAS-cog (Alzheimer’s Disease Assessment Scale-cognitive sub-scale); ACER (Addenbrooke’s Cognitive Examination Revised, Mioshi et al. 2006); ADD (Assessment of Discomfort in Dementia Scale, Kovach et al. 1999); rAQ (Relatives autism quotient, Baron-Cohen et al. 2001); BADS (Behavioural Assessment of the Dysexecutive Syndrome, Wilson et al. 1997); Barthel ADL (Mahoney and Barthel 1965); CDRS (Clinical Dementia Rating Scale, Hughes et al. 1982); Cornell depression scale (Alexopoulos et al. 1988); CT (Computerised tomography); DAT (Dopamine transporter scan); DCM (Dementia care mapping, Kitwood and Bredin 1992); DMAS (Dementia Mood Assessment Scale, Sunderland et al. 1998); DisDat (Discomfort in Dementia of Alzheimer’s Type, Hurley et al. 2001); MMSE (Folstein et al. 1975); MRI (Magnetic resonance imaging); QUIS (Quality of interactions schedule, Dean et al. 1993); PBM (Pain Behaviour Measure, Keefe and Block 1982); RAID (Rating Anxiety in Dementia, Shankar et al. 1999); SPECT (Single positron emission computerised tomography).

      In addition to these scales, there are a number of other useful assessment tools in relation to BC. One of the most relevant sets of scales identify the type and nature of the BC. Many assessment tools in this group are overly comprehensive and too lengthy to function well in a clinical setting. However, three that are suitable clinically are: Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation Scale (CMAI, Cohen-Mansfield et al. 1989) and the Challenging Behaviour Scale (CBS, Moniz-Cook et al. 2001b).

      The NPI has 12 sub-scales, 10 covering BC and two measuring neurovegatative conditions. Each sub-scale has an entry question about presence of symptoms. If this is answered positively, the full scale is completed; if the features are not present, the interviewer moves on to the next symptom cluster. The frequency and severity of symptoms over the month prior to interview are assessed and multiplied to produce a measure of severity. There are a number of versions, one of the most clinically useful contains a carer distress scale (Cummings et al. 1994; Kaufer et al. 1998). There are at least five versions of the CMAI (short form has 12 items, long 29 items). Four subtypes of agitation are identified: physical non-aggression; physical aggression; verbal non-aggression; verbal aggression. It is completed via face-face interviews with a carer.

      The CBS is a 25-item scale designed to measure client behaviours (incidence, frequency, difficulty, and challenge) that carers find difficult to manage. It has been shown to have good validity and reliability and is completed by carers with assistance from clinicians. A helpful and comprehensive description of seven scales used to assess aggression in BC is provided by Johnson et al. (2008). Their article describes the features associated with scale selection.

      For an overview of other relevant scales see Ballard et al. (2001); Burns et al. (1999) and Neville and Bryne (2001). It is important to note that many of the scales described in these reviews tend to be used in research rather than in day-to-day clinical work. With clinical relevance in mind, Figures 2.1 and 2.2 present two charts used by the NCBT to collect descriptive information from carers about the problematic behaviours. The first scale is a standard ABC behavioural chart, placing particular emphasis on recording clients’ emotions.

Figure 2.1 Example of a behavioural chart incorporating an ABC analysis together with elements of the Newcastle approach

      Figure 2.2 describes a recent development that attempts to get staff to empathise with the beliefs of the client. The front page of the latter document has the following instructions:

      Instructions for behavioural grid

      Step 1: Identify the type of challenging behaviour (CB).

      Step 2: Provide details about the CB incident; do this in two stages. First, give information about the CB, then include details about how other people reacted to it and any consequences.

      Client’s CB → Others’ reactions to CB and consequences

      Step 3: Use the ‘Tables of Causes’ [as in Tables 2.1–2.6] to identify reasons for the CBs.

      Step 4: This step involves you imagining yourself in the position of the client. So try to guess what the client might’ve been thinking, and how these thoughts and beliefs led to the CB.

      Step 5: Use your knowledge of both the client and the setting to problem solve the best way to deal with the CB.

Type of challenging behaviours	Description of challenging behaviours, including carers’ reactions		Causes of the CB	Person’s thoughts that triggered CB	Potential solutions
	CB	Reaction of others to the CB and the consequences

Type of challenging behaviours	Description of challenging behaviours, including carers’ reactions		Causes of the CB	Person’s thoughts that triggered CB	Potential solutions
	CB	Reaction of others to the CB and the consequences
Aggression	Peter put his hand on Mary’s shoulder and asked her to sit next to him.	Nurse told Peter to leave Mary and pulled his hand from her shoulder. After this Peter hit the nurse in the mouth.	Owing to Peter misidentifying Mary as his wife due to his dementia, he is annoyed that she does not want to spend time with him. When the nurse takes his hand off Mary, Peter gets angry that someone else is interfering.	This is my wife and she should be doing what I tell her to do. And when nurse takes Peter’s hand away… Get off me, and keep out of my business with my wife.	1. Currently Mary looks like his wife. So ask the hairdresser to colour her hair and change the style. 2. Bring in photographs of his wife,