Understanding Behaviour in Dementia that Challenges. Ian Andrew James

carer reaction and beliefs (plus worked example)

Table 2.9 Frontal lobe functions
Difficulties	Practical description of difficulty
Perseveration	Repeating actions and statements over and over again.
Unable to inhibit responses	Unable to control aggressive or sexual actions/statements that would normally be out of character.
Saying things to hurt other’s feelings	Making unkind comments about others which can serve to provoke or upset them.
Impulsive actions and emotions	Suddenly doing something dangerous or risky – ‘out of the blue’. Sudden outbursts of emotion.
Poor short-term/working memory	Unable to correctly remember things done during the present day (e.g. breakfast, activities, etc.).
Recognition of objects, but unaware how to use them	Able to name an object, but unable to demonstrate its use (e.g. able to name a fork, but not aware how to use it).
Overly fixated on people or activities	Repeatedly paying attention, talking about or touching things (people, objects). Repetitive actions or activities.
Poor at making decisions	Unable to make choices, or decisions about what to do next (e.g. the person can’t decide what he wants to wear or is unable to choose his food at meal times).
Poor planning	Unable to work out how to tackle a problem. For example, when a difficulty arises the client doesn’t know where to begin, or can’t grasp the nature of the problems (e.g. failing to move items off a table, before putting new ones on; doesn’t recognise it would be helpful to write-out a shopping list prior to going shopping).
Poor sequencing	Unable to carry out actions in a logical sequence (e.g. unable to dress themselves in a logical order, or when toileting tends to open bowels prior to removing underwear).
Concrete thinking	Unable to think in an abstract way. Conversations tend to be interpreted in an overly direct manner (If told ‘it will all come out in the wash’, he/she thinks this refers to washing clothes).
Confabulation	Prone to giving stories and/or explanations in order to fill in gaps in his/her memory.
Lack of insight	Unaware of his current difficulties and limitations. Not being aware of the risks associated with these limitations (e.g. failing to appreciate he would not be able to live by himself at home).
Poor concentration	Unable to concentrate on anything for an extended period of time (e.g. watching TV, reading). Client’s focus tends to move quickly on to something else.
Distractibility	Easily distracted by things going on in the environment. When undertaking a task will lose interest in the task if interrupted by someone or something (e.g. a sound).
Apathy	Emotionally unresponsive, even when being provoked.
Euphoria	Overly enthusiastic, and/or inappropriately laughing out loud.

      Table Key: Item is rated on 1–5 scale (not like person–totally like person).

Table 2.10 Some of the potential causal factors that are screened at referral
Key area	Type of problem	Example of problem which may be causal factor in BC
Age related issues	Sensory difficulties	Sight, hearing difficulties
	Pain	Arthritis, dental pain
Physiological and physical problems	Delerium	Confusion
	Constipation	Discomfort, problematic gait, irritability
	Seizures	Confusion
	Vascular events	Sudden deterioration in skills
	Infections	UTI, cellulitis
	Diabetes	Variable levels of insight/performance
	Cancer	Brain metastases
	Thyroid	Hyper (agitated), hypo (confused)
Mental health problems	Psychosis	Hallucinations, delusions
	Depression	Irritability, labile, sleep problems
	Anxiety	Reassurance seeking
	Other	OCD, social phobia, trauma
Medication	Anti-psychotics	Confusion
	Benzodiazepines	Over-sedation
	Parkinson’s meds	Hypersexuality
	Pain relief	Constipation
	Statins	Agitation
Environment	Confusion, disorientation, boredom	Noise, bright light, smell, crowding
Premorbid personality	Temperament and development	Learning disability, autism, difficult personality trait

Table 2.11 Cognitive deficits that may be causal factors in BC
Key cognitive area	Type of skill difficulty
Memory	Inability to lay down new memories (STM deficits) leading to forgetting what just been told or done.
	Recognition difficulties, misidentifying objects or people.
Frontal difficulties	Impulsiveness, disinhibition, apathy.
	Sequencing, planning, impaired, judgement and decision making (see Table 2.9).
Poor orientation	Inability to indicate the date, their age and/or name where they are.
Poor level of insight	Unaware of the extent of their difficulties, or abilities to look after self, thus may engage in risky behaviours.
Poor attention and concentration	Unable to focus, easily distracted.
Deficits in emotional regulation	Excessive laughing or weepiness.
Difficulties in communicating needs	Receptive and expressive problems, leading to frustration and agitation.

      Note: A full assessment involves examining the person’s history and life-preferences, and undertaking a detailed analysis of the behavioural difficulties. More detailed assessments of some of the features outlined in the table may also need to be undertaken.