Contents: Introduction

Transcription

1 Dementia toolkit Take a look inside to find out more on Dementia... What is dementia? Symptoms Person centred care Activities Reminders and sensory Delirium / Depression Behaviours that challenge Medication References A joint initiative between Northamptonshire Healthcare NHS Foundation Trust, NHS Northamptonshire and Northamptonshire County Council

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3 Introduction This toolkit has been created by the Northamptonshire Healthcare NHS Foundation Trust (NHFT) Liaison Team, in collaboration with Northamptonshire County Council and Northamptonshire Primary Care Trust. It has been designed to assist staff who work in care home environments, as part of the reduction in anti-psychotic medication project, commissioned by the East Midlands Strategic Health Authority. The toolkit provides information about managing the most common mental health problems in older people with an emphasis on recognising and managing behaviours that challenge and looking at alternative strategies to anti-psychotics. This guide can be copied and shared, in whole or in part, so long as it is used for education and training purposes and is provided free of charge. Authors: Tracey Dodds, Matron Liaison Team for Older People Mandy Welch, Enhanced dementia Liaison nurse Jane Winson, Nurse Consultant, Dementia Contents: What is Dementia? Symptoms/Diagnosis of Dementia Person Centred Care Activities Delirium / Depression Memory / Sensory / Early/late stages Understanding challenging behaviour Antipsychotics

4 What is Dementia? The term dementia is used to describe symptoms that occur when the brain is affected by specific diseases and conditions. There are about 750,000 people in the UK with dementia. Dementia usually affects older people and some rare dementias can be inherited. Dementia is progressive which means the symptoms gradually get worse. How fast dementia progresses depends on the individual as each person is unique and will experience dementia in their own way. What causes dementia? There are several diseases and conditions that cause dementia. These include: These symptoms can occur suddenly, following a stroke or over time through a series of small strokes. Lewy Body Dementia- This form of dementia gets its name from tiny spherical structures that develop inside the nerve cells. Their presence in the brain leads to degeneration of brain tissue. Memory, concentration and language skills are affected. Fronto-temporal dementia- (including Pick s disease). Here, damage is usually focused on the front part of the brain. At first personality and behaviour are more affected than memory. Rarer causes of dementia- There are many other causes of dementia including Korsakoff s syndrome, HIV and Creutzfeldt-Jakob Disease. Alzheimer s disease-this is the most common form of dementia. During the course of the disease the chemistry and structure of the brain changes, leading to death of the brain cells. Vascular disease- The brain relies on a network of blood vessels to bring oxygen-bearing blood. If the oxygen to the brain fails, brain cells are likely to die and this can cause the symptoms of a vascular dementia.

5 Symptoms of dementia include: Loss of memory the person with dementia may forget what they ate for breakfast in the morning or be unable to remember names and places Mood changes particularly as the parts of the brain that control emotion are affected by the disease Communication problems there may be a decline in the ability to talk, read or write In later stages of dementia, the person affected will have problems carrying out everyday tasks and will become increasingly dependent on other people. Can dementia be cured? Most forms of dementia cannot be cured although research is continuing into developing drugs, vaccines and treatments. Some drugs can temporarily alleviate and stabilize some of the symptoms of Alzheimer s Disease in the early to middle stages. These drugs are Aricept (Donepezil) Exelon (Rivastigmine) Reminyl (Galantamine) A later drug called Ebixa works in a different way and is suitable for people in mid to late stages of dementia. Diagnosing dementia It is important to get a proper diagnosis to rule out illnesses that may have similar symptoms to dementia including depression and in order to be prescribed drugs for Alzheimer s disease. The GP or a specialist will make a diagnosis by carrying out a number of tests designed to test memory and ability to perform daily tasks. A brain scan (CT scan) will also confirm diagnosis.

6 Person Centred Care Is about valuing people with dementia and those who care for them, treating people as individuals, looking at the world from their perspective and providing a positive social environment. The three key features of this are: Working to eliminate or minimise any preventable factors that could be making life harder for the individual. Compensating for the difficulties caused by the person s dementia (filling the pieces of the missing jigsaw puzzle) Identify the persons abilities and strengths and finding plenty of opportunities for the person to use them. Activities No one likes having nothing at all to do. We are all happier being occupied. Finding activities that the person with dementia enjoys will improve their quality of life. Be imaginative and flexible in adapting activities to the person s changing capabilities and to their different moods. How activities can help Activities can help a person maintain their skills and give them a sense of achievement Activities can be interesting and fun. They can help the person feel better about themselves and be more alert and interested in what is going on around them

7 Activities can help a person with dementia express their feelings. Talking about the past while looking at old photographs or listening to music may trigger strong emotions. It is the memory, reasoning and thinking parts of the brain that are damaged in dementia not the emotions If a person is occupied in a pleasant way they will not get bored or frustrated. Sharing an activity may enable you to relate to the person better. Exercise Walking is good exercise and uses up adrenaline which is produced by stress and frustration. Previous hobbies should be encouraged and maintained as far as possible. Reminders of the past People with dementia usually find it easier to remember events which happened when they were much younger rather than those in the recent past. If you can find a way to trigger these far off memories you may find that the person becomes more lively and interested. Look at and talk about old family photos or books with pictures from the past. A rummage box of old objects of interest including objects to touch can trigger memories more effectively than looking at pictures of them. Sensory stimulation As dementia progresses people find comfort in touching or stroking pieces of fabric or a cuddly toy. The person may find a hand massage, using scented oil such as lavender very soothing while a fish tank and a pleasant view can have a calming effect. Early stages In the early stages of dementia the person will want to do things they have always done. They will need encouragement and reminders They will need assistance to put any equipment in a place where they can easily see it. Use short sentences when advising

8 the person what to do Music is a great resource for people with dementia. People may still enjoy singing or dancing and listening to music. Later stages As the dementia advances the person will still be able to carry out very familiar tasks. They will probably be much more interested in the process of doing the activity than the end result. Directions for an activity need to be broken down into small, manageable chunks and should be very simple, At this stage the person will probably enjoy tasks with one step such as sweeping, dusting or winding wool. Although the reasoning part of the brain and language are breaking down in the later stages of dementia, the person s sense of taste, touch and smell are still functioning. Delirium (Acute confusional state) Dementia and delirium have very similar symptoms and it is important to be able to differentiate between them. Delirium is a sudden state of confusion which does not usually indicate dementia. There is often an underlying cause such as: Urinary tract infection Pneumomia Side effects of medication Trauma Poor diet Reduced fluid intake Diabetes Kidney failure Heart disease Constipation Hypothermia Bereavement Excess fatigue Environmental changes Any of these can also bring about a sudden increase in the confusion of a person who has dementia. If there is any possibility that the sudden confusion (or increased confusion) has a physical cause, the person must receive medical attention.

9 To think of a way to rule out delirium think- PINCH ME. Does the person have: Pain INfection Constipated Hydrated Medication Environment People with a history of depression are at increased risk of dementia and may be more prone to developing physical health complications and associated delirium. A large number of people with dementia become depressed, especially those in the earlier stages of the illness. Antidepressant medication works by correcting the chemical imbalance in the brain. There are several different types of medication and this normally takes at least two weeks to have an effect and must be taken regularly in order to work. Depression Dementia, depression and delirium have very similar symptoms and it is important to differentiate between them in order to help the person best. Don t forget that it is not unusual to have more than one problem at the same time. If symptoms of delirium are present as well as dementia or depression, always treat the delirium first. Is a mental illness characterised by low mood although the person can also present with similar symptoms as dementia such as confusion and disorientation. The brain is made up of billions of nerve cells called Neurons which talk to each other by sending chemical messages, using substances known as Neurotransmitters. If these Neurotransmitters become out of balance this can cause a variety of symptoms.

10 Understanding Challenging behaviour The terms difficult behaviour, problematic behaviour, behavioural disturbances and dysfunctional behaviour are commonly used by care staff caring for people with dementia. People with dementia often communicate much to us through their behaviour. At times, this behaviour might cause problems for us, but it is always important to try to understand the reasons for the behaviour rather than just trying to stop it to wonder why rather than assuming that it is because of the dementia. Many challenging behaviours are an expression of feeling or need so our response must be to attempt to address the underlying reason, not just the behaviour itself. This means that the response to each person and each instance of a particular behaviour should be different. The following are examples of challenging behaviours. Aggressive behaviour - possible reasons may include the person feeling threatened or frightened or asserting their own wishes when others are trying to make them do something they don t want to do. Our response to a person s aggressive behaviour must be understanding and sensitive to the strong emotions behind the behaviour. While we may need to make an immediate response to diffuse a situation, we should not lose sight of the needs which were being expressed. Walking (wandering) - possible reasons may include the person being lonely and bored, reliving an old routine or looking for someone/something which may or may not be there. It can be helpful to walk with the person and find ways of addressing their emotional needs. It is unhelpful to view walking as aimless wandering and trying to stop the person from walking fails to address the reason why they are walking. Difficulties related to using the toilet - possible reasons may include the person not being able to perceive or find the toilet, may not be able to get to the toilet or the person may have a urine infection. It is essential to respond with the utmost sensitivity to any difficulty related to use of

11 the toilet, recognizing the feelings-such as shame or embarrassment-which the person might be experiencing. There are often ways of preventing such difficulties, such as making the toilet easier to find or perceive, or working out a routine based on the individuals habits and needs. It is important that we should not impose our priorities and standards on a person. The person with dementia should be encouraged to assert their own preferences and we should not expect them to cooperate with us; rather it is we who should cooperate with the person. Refusal - possible reasons may include, for example, not wanting to have a bath because it does not fit in with their past routines or they prefer to have a strip wash or feel embarrassed. A person may not be willing to eat because they are depressed or they don t like the food or they don t like to be rushed. A person may not wish to get dressed because they have nothing to get dressed for or don t feel safe with the person helping them, or simply frustrated by their difficulties. Accusations - possible reasons may include the person experiencing altered perception, a delusion or hallucination, which could have a physical cause. The person might be expressing a deep sense of insecurity, mistrust or unhappiness. It may sometimes help to give the person information to clear up any misunderstandings, but it is vital to respect the person s reality and try to empathise with their feelings. How should we respond? Ultimately when dealing with challenging behaviour you should stay calm, not argue but convey warmth and reassurance to the person. You will need to reduce the demands on the person when they are showing signs of stress and allow time for the person to succeed and slow down in communication to allow them time to think. Listen and engage with the person in whatever is the reality for them and always validate their feelings and try to find out the underlying cause.

12 Antipsychotics What are they designed for? To treat schizophrenia, other psychoses, and violent or dangerously impulsive behaviour. How do they work? By altering the levels of naturally occurring chemicals in the brain (called neurotransmitters) which control behaviour, mood, emotions, and sleep Some common antipsychotics Haloperidol Amisulpride The dangers Antipsychotics to people with dementia Death They cause 1800 deaths in the UK every year. Disability Around 1,620 additional cerebrovascular adverse events (such as stroke) will result from the treatment. About half of these will be severe. Unpleasant and painful side-effects Over sedation, drowsiness and sleeping during the day Quetiapine Risperidone Flupentixol Promazine Olanzapine Aripiprazole Zuclopenthixol Muscle stiffness Agitation and restlessness Odd or repetitive movements (e.g. poking tongue out, wringing hands, pacing) Dry mouth Excess saliva and dribbling Constipation Increased risk of falls & fall related injuries Older women, people with Parkinson s Disease and people with Lewy Body Dementia are at very high risk of developing side effects

13 Unlikely to work About 2/3 of people with dementia receive no benefit from them 145,000 people in the UK are prescribed them unnecessarily Not always needed long-term even if they work short-term Not recommended Against NICE guidance Oversedation may represent a deprivation of liberty None are licenced for use with people with dementia (with the exception of Risperidone, and only for 6 weeks) Dementia Trainers (2008) Dementia factsheets Department of Health (2009) Living well with dementia; a national dementia strategy. Available online at: NICE (2011) Dementia; supporting people with dementia and their carers in health and social care. Quick reference guide. Available online at: Social Care Institute for Excellence; SCIE (2011) Dementia Gateway. Range of videos and information available online at: mentia/index.asp References and further recommended reading Alzheimer s Society (2011) Factsheets about dementia. Available online at: uments.php?categoryid= Chapman,A., Jackson,G & McDonald, C. (1999) What Behaviour? Whose Problem? University of Stirling Walsh, D. (2006) Dementia Training Manual for staff working in Nursing and Residential Settings. London

14 This Dementia Toolkit is the property of Northamptonshire Healthcare NHS Foundation Trust, Northamptonshire County Council and Northamptonshire Primary Care Trust. We trust you find it helpful in your work. If you have any comments on the toolkit please contact... Tracey Dodds Matron Liaison Team for Older People Northamptonshire Healthcare NHS Foundation Trust St Mary s Hospital London Road Kettering NN15 7PW Tel: tracey.dodds@nhft.nhs.uk A joint initiative between Northamptonshire Healthcare NHS Foundation Trust, NHS Northamptonshire and Northamptonshire County Council