Difficult Behaviors in Dementia

Course Leader

Elizabeth (Dr Liz) has over twenty years of experience in providing medical care to the elders. She is board-certified in Internal Medicine, Geriatric Medicine and Palliative Care Medicine. Dr Landsverk founded ElderConsult Geriatric Medicine, a house calls practice, to address the challenging medical and behavioral issues often facing older patients and their families.

Dr Landsverk was an assistant professor of Medicine at University of California, San Francisco, an adjunct professor of Medicine at Stanford University, as well as consultant to the San Francisco Elder Abuse Forensics Center and Hospice Medical Director. She is currently the Medical Director for Silverado and Kensington Dementia Care Communities, as well as on the Scientific Panel for the Alzheimer’s Association. Dr Landsverk graduated from Stanford University, and trained at Cambridge Hospital, Harvard University, and Mt Sinai Medical School.

As a House Calls Geriatrician, she collaborates with local physicians to address the needs of complicated vulnerable elders to alleviate pain, agitation and discomfort through the utilization of geriatric and palliative care techniques.

Learning Objectives 

Lesson 1: Introduction and Key Learning Objectives

This lesson introduces the learner to Dr Liz, alongside the main concepts and learning objectives for the course. An overview of the potential behaviours that may be encountered is given. Causes of agitation in dementia are examined, followed by a brief overview of Dr Liz’s favoured strategy of stopping inappropriate medications, treating pain, and engaging people in meaningful and enjoyable activity. The learning objectives for the course are then presented. 

On completion of this lesson the learner will:

• Understand the course content, themes and learning objectives

Lesson 2:  Identifying Difficult Behaviours 

This lesson explores the variety of difficult behaviours that may be expressed by people with a diagnosis of dementia, alongside discussion of where in the disease process these behaviours may occur. The physical manifestation of these behaviours is described, followed by examination of behaviours that may not resolve with medication. The root cause of behaviours is discussed, and the learner is presented with an examination of external stimuli that may prompt difficult behaviours. Under stimulation is also discussed. Suggestions are made for behavioural and environmental interventions to reduce incidence of difficult behaviours. The need to rule out medical causes such as infection is emphasised, alongside the need for caution with medications in this patient group. 

On completion of this lesson the learner will: 

• Understand the range of difficult behaviours that may occur from a person with a diagnosis of dementia, and how these behaviours can present. 
• Understand the root cause for these behaviours, and how to manage the patient’s care and environment to reduce incidence of difficult behaviours.
• Understand the need to rule out all other causes before using medications to manage behaviour. Understand the need for caution with medications in this patient group.

Lesson 3: Medical Causes of Difficult Behaviours in Dementia. 

This lesson examines a number of medical causes that can prompt difficult behaviours in people with a diagnosis of dementia. Communication barriers and challenges are discussed, and how the difficulties people with dementia face in communicating their needs or expressing their feelings can exacerbate difficult behaviours. Medical issues such as infection, constipation, different types of pain and dental problems are explored. The learner is then presented with a number of case studies to consolidate learning.

On completion of this lesson the learner will: 

• Be able to identify some key medical causes that may prompt difficult behaviours.
• Understand the challenges and barriers to communication that exist in dementia care, and how these can prompt difficult behaviours.

Lesson 4: Addressing Goals of Care

This lesson examines the benefits of addressing goals of care with patients and their families. The need for a holistic, patient centred approach is emphasised. Learners are educated on the importance of involving patients and their family as early on in the disease process as possible in order to provide care that is in line with their wishes. The need to avoid restraining patients is emphasised, followed by suggested alternative interventions. The consequences of not discussing care goals and subsequent distress that can be caused to the patients is also examined.

On completion of this lesson the learner will:

• Understand the necessity of clear care goals, discussed with patient and family, forming a thorough plan of care.
• Understand interventions that can be implemented in order to reduce patient distress and in turn difficult behaviour. 

Lesson 5:  Medications for Pain Management

This lesson explores the different types of pain often experienced by people with dementia. Different types of medications to treat pain are discussed, alongside their cautions, contraindications, side effects and interactions. The need for careful consideration before using any medication is suggested. The need for behavioural and environmental interventions before medications is reiterated.

On completion of this lesson the learner will: 

• Understand the different types of pain that can be experienced by people with dementia.
• Have basic knowledge of some of the common drugs that are used for different types of pain, their side effects and their cautions for use in this patient group. 
• Understand the importance of environmental and behavioural interventions. 

Lesson 6: The Rational Use of Psychiatric Medications

This lesson explores the use of psychiatric drugs in people with dementia. Different types of psychiatric drugs are examined including antidepressants, mood stabilisers, antipsychotics, benzodiazepines, and sleeping medications. Side effects, cautions and contraindications are discussed. 

On completion of this lesson the learner will: 

• Know the main classes of psychiatric medications 
• Understand the situations in which these drugs may be administered to people with dementia.
• Know key information relating to side effects and cautions in this patient group.

Lesson 7: Summary

This lesson consolidates the information from previous lessons and emphasises key points. Emphasis is placed on the importance of behavioural and environmental modifications in managing difficult behaviour, caution with medications and the significance a multi disciplinary and specialist team can make to care. 

Course Summary

This course provides an overview of difficult behaviours often displayed by people with a diagnosis of dementia. The root causes of this behaviour are explored, alongside discussions of relevant strategies to manage the behaviour. The role of medications in both the cause and management of behaviour is examined. Learners are encouraged to take a holistic view of behaviour management. On completion of the course learners will be able to:

• Name common causes of agitation in dementia
• Identify behavioural techniques to use to address the causes of agitation without sedation
• Address medication effects such as the removal of medications that make agitation worse. 
• The treatment of pain and considering medications for agitation.