Behavioural problems, in reality, are often why dementia sufferers come to reside in Residential Aged Care (RAC). It just gets too hard at home. The aim is that the facility provides a better environment for the resident, allowing family to spend quality time with their loved one.
An early family meeting is vital to develop good relationships and an opportunity for advanced care planning for the management of whatever lies ahead. Without this, the road can be filled with conflict and the resident’s journey sub-optimal. So first build the relationships with family and facility staff.
There is always a period of adjustment after admission to RAC. Depression tools such as the Cornell score will often be high, but we need not rush into prescribing antidepressants. It is better to involve family in socialisation and if necessary psychological counselling for those whose dementia is not too advanced. A well-managed adjustment period creates a good foundation for the rest of the resident’s life.
The next vital tool in managing behavioural problems in dementia is the skill of facility staff. Clinicians will often feel pressured to prescribe tranquillisers, antidepressants, and antipsychotics. Upskilling the staff is a more important intervention. Dementia Services Australia provides on-site staff training. It is not good practice to medicate when other answers can be found. Supporting and educating RAC staff is also a role to which GPs and Nurse Practitioners can contribute while managing difficult residents.
When challenging behaviours develop, look for and correct treatable physical causes such as UTIs, chest infections, pain, and constipation. If treating secondary causes does not resolve the behaviours, then pharmacological intervention can be considered.
So, where does medication fit into the management of the difficult behaviours of dementia? Firstly, there is no medication specific to this role. Pain and other secondary causes should be treated on their merits. If there are psychotic symptoms it is reasonable to try antipsychotics. Equally try anxiolytics for anxiety symptoms.
With insomnia, explore other symptoms that co-exist as treating these may resolve the issue (e.g. hallucinations, pain). The next step may be low-dose mirtazapine, then other sleep agents.
Sodium valproate has no evidence base in trials we are told, but our experience is that it is of value in some cases. In my experience it helps in the highly agitated who look at you with eyes like flame throwers, the ones who often leave you feeling unsafe. Maybe the trials don’t relate to a specific enough cohort, maybe my experience is coincidental, this is the nature of the space we work in. If it is of no benefit in modest doses, then withdraw.
The most significant error we make in medication management is that once behaviours are controlled, we don’t follow-up and minimise the doses.
We are implored to follow evidence-based guidelines (often from clinicals trial not done in an RAC) in managing challenging behaviour in residents. The problem is that experts who produce guidelines base them on evidence not including all the evidence we face as clinicians. We can be faced with agitated, sometimes paranoid and aggressive residents who are a physical risk to themselves, staff and other residents.
The intuitive decision-making skills of the clinicians are under siege as all involved deserve to be considered. Furthermore, there is little or no support from specialist services when crisis peaks. If ED is resorted to, I feel sorry for the clinicians there as they cannot resolve the real issue which revolves around society having marginalised this cohort of people to a place not equipped or staffed to cope with extreme behaviour.
The complication of these difficult moments is the fracturing of relationships we have worked hard to develop, as well as traumatised family members, other residents and staff. For the resident it can herald a significant deterioration and sometimes death.
Many sad stories have been told to the Royal Commission. Some are bad practice. In others I feel the urge to be protective of the staff, thrown in, out of their depth, to manage behaviours from people no longer responsible for their actions.
Sadly, I expect that the Royal Commission will deliver more oversight, and regulation but little to improve the current staffing and training deficits. Instead of random visits by a compliance officer that creates chaos, money is better spent on rapid response teams to help in crisis situations.
Ultimately, each case is different and the intuitive decision-making skills of the clinicians must take in the evidence from the history and examination and investigations, then apply the evidence from trials and seek the best solution for the person in question.
- Involve family from day one
- Treat secondary causes of behavioural problems
- Use symptom specific medication and minimise dose
References available on request.
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Author competing interests: nil relevant disclosures.
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