The management of challenging
behaviour in people with dementia
Dr G Theodoulou
Consultant Older Adult Psychiatrist
7.9.16
Who am I?
Dr George Theodoulou
MBChB
MRCPsych
Consultant Older Adult Psychiatrist,
Worcestershire Health and Care NHS Trust
DGM
I have worked as a substantive consultant psychiatrist since 2008; working in community, inpatient
and acute hospital liaison settings. I completed my psychiatric training in the West Midlands gaining
specialist registration in old age and general psychiatry. I am currently section 12(2) approved, a
MHA Approved Clinician, a Deprivation of Liberty Safeguards mental health assessor, an Honorary
Senior Lecturer at the University of Worcester and sit on the Midlands and East of England Section
12(2)/Approved Clinician approval panel. I have also been the clinical director for older adult mental
health services in Worcestershire Health and Care NHS Trust (2013-2016). I have considerable
clinical experience in applying the Mental Health Act and the Mental Capacity Act as well as dealing
with the interface of the two Acts. I regularly carry out Mental Health Act assessments, DoLS
assessments and mental capacity assessments for the Court of Protection. I lecture and teach widely
on all aspects of psychiatric practice.
Dementia
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Decline in two cognitive domains
Impairment of ADLS
Brain disease
Six months duration
Not easily reversible
Mind your language!
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Dementia sufferer
Demented
Senile or senile dementia
Burden e.g. people are a burden or cause burden
Victim
Plague
Epidemic
Enemy of humanity
Living death e.g. dementia is a living death
Person with dementia
• ‘Person centred care’- Kitwood 1997
• Uniqueness of every individual’s experience of
dementia
Behaviour that challenges
………..a manifestation of distress in the person
with dementia or of distress in the carer……
Bird and Moniz-Cook 2008
What are the behaviours that
challenge?
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Perceived aggression
Agitation or restlessness; screaming
Anxiety
Depression
Psychosis, delusions, hallucinations
Repetitive vocalisation, cursing and swearing
Sleep disturbance
Shadowing (following the carer closely)
Sundowning
Travelling alone causing concern
Non-specific behaviour disturbance e.g. hoarding, putting
food in wardrobe
Newcastle model framework
(James 2011)
Mental health, care home in-reach
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MH nurses
Intensive input
Smaller caseload (cf OACMHT)
Use Newcastle model
Use medication
Consultant OA psych support
Available in south Worcestershire
Access via OACMHT
Medication for challenging behaviour
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Acetylcholinesterase inhibitors
Memantine
Benzodiazepines
Antipsychotics
Antidepressants
Miscellaneous
• Consider capacity to consent, best interest
decision + LPA for H&W
Acetylcholinesterase inhibitors
Donepezil, Galantamine and Rivastigmine
AD and DLB/PDD only
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May alleviate agitation
May cause agitation
May reduce psychosis
Specialist initiation
Memantine
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Licensed for AD only
NMDA receptor antagonist
Reduces agitation
Reduces psychosis
Specialist initiation
Can take up to 3 months for +ve effects
Benzodiazepines
• For rapid tranquilisation
• Lorazepam best
• Avoid diazepam- active long half life
metabolite
• IMO- first line when there is severe distress or
behaviour that puts PWD in harms way
• 0.25mg -0.5mg prn, Max 1.5mg/24hrs
Antipsychotics in dementia(1)
• Best avoided unless distressing psychosis, general
severe distress or harmful behaviour
• Do more harm than good
• Only 10% gain benefit
• Increase risk of stroke, infection, DVT, MI,
arrhythmia, constipation, dehydration, early
death
• Before prescribing should try to evidence psychosocial intervention ineffective or not practicable
Antipsychotics (2)
• Risperidone 0.25mg to 1mg/24hrs
• Olanzapine 2.5mg to 5mg/24hrs
• Aripiprazole 2.5mg to 10mg/24hrs
Antidepressants in dementia
High rate of depression in all dementias
Best evidence for mirtazapine
• Mirtazapine 15-45mg/24hrs
• Sertraline 25-150mg/24hrs
• Venlafaxine 37.5-150mg/24hrs
Others
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Carbamazepine
Pregabalin
Melatonin
Zopiclone
Trazadone
….so in conclusion, the last
professional a PWD and
challenging behaviour needs to see
is a psychiatrist!