Working with Complex Behaviour in a residential settings. Celia Stamper, Clinical Project Lead Sue Excell, Service Manager

Transcription

1 Working with Complex Behaviour in a residential settings Celia Stamper, Clinical Project Lead Sue Excell, Service Manager

2 Introduction to the evidence base: Background Challenging behaviour is a major source of family and carer distress and common reason for hospitalisation and 24hr care 25% of people with dementia are prescribed anti-psychotics, mainly for the treatment of problematic behaviours However, there are significant side-effects, and only effective in 1 in 5 cases National Dementia Strategy 2009/NICE guidelines state: Non-Pharmacological interventions to be used prior to medication in cases involving challenging behaviour However, clinicians are often unsure of useful alternatives; much literature based on prevention not treatment

3 Background Banerjee (2009) s Time for Action report (11 recommendations) Recommendation 8: Each primary care trust should commission from local specialist older people s mental health services and in-reach service that supports primary care in its work in care homes Multi-disciplinary service linked to CMHTOPs

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5 Understanding Complex Behaviour Complex behaviours are problematic behaviours that cause difficulties for the person themselves or for those around them. Common examples include: physical aggression, verbal aggression, excessive pacing, apathy etc.. What is perceived to be challenging differs between settings (a social construct) Complex behaviours have multiple causes

6 Understanding Complex Behaviour All behaviour has meaning and purpose so people s behaviour, even when challenging, can be understood. People s challenging behaviour is best understood in the context of their current or previous experience, and as a communication of need driven by a belief or related to distress

7 Sometimes Things Need To Change Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. AA Milne ( ), Winnie The Pooh

8 Need for a bio-psycho-social approach Newcastle Model Established in 2000 to bridge gap in services for people living in care (poor access to psychological care) Has become leading centre for best clinical practice and research into challenging behaviour in dementia care Guiding ethos: staff to feel involved in all phases (carer-centred, person focussed)

9 Newcastle Model Weeks 1-5 (intensive treatment phase) Expectations clarified Information gathered via multiple sources Baseline measures Behavioural analysis Information sharing session (understanding behaviour and developing interventions)

10 Newcastle Model Weeks 6 onwards Dissemination of formulation and care plan Supporting staff to carry out interventions consistently Revise care plan if necessary Weeks Discharge Outcome measures completed

11 KMPT Complex Behaviour Service Multi-disciplinary team: Clinical Lead (RMN, admiral nurse) Clinical Psychologist Occupational Therapist RMN OT assistant Support workers x2 Benefits: enable bio-psycho-social approach; able to offer variety of interventions and specialist input; effective skill mix

12 Referral from CMHTOP Multi-disciplinary Assessment Formulation Meeting Intervention support Discharge

13 Multi-disciplinary Assessment Standard procedures NPI Direct observations ABC charts and analysis Challenging Behaviour Checklist Bradford Well-being Profile Interviews with staff, family and resident (CBS Assessment form)

14 Multi-disciplinary Assessment Optional tool box Abbey Pain Scale Cornell Depression RAID (anxiety) SMMSE Frontal difficulties SASBA (sexual behaviour) OT assessment

15 Formulation Based on Information Sharing Session Feedback information gathered to staff & family Develop shared understanding of reasons for behaviour and unmet needs Develop intervention plan and identify staff training needs

16 Example formulation plan

17 Intervention support Meet the need Simulate the need Distract Therapeutic Lie

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19 Intervention support Hands-on/mirroring support Staff training (eg. Understanding of dementia; communication; reflection) Encouraging improved staff support systems (eg. Debriefing) Life-story work Activity planning and support Dementia Care Mapping Simulated Presence Therapy/Doll Therapy/Pet Therapy Ongoing monitoring and review; revise if necessary Integration with other services (eg. Social care; facilitating transfers/discharges to more appropriate settings)

20 Discharge Once no further input required Review meeting, including family Complete NPI and feedback

21 Challenges we ve faced Staffing Part-time team Developing skills Funding Changing objectives Engagement from homes and CMHTOP Complexity of culture change Poor links with social services

22 Small group discussions How do you currently meet the needs of people with dementia and complexities? What would you like to change What challenges do you foresee?

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