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Managing Behaviors Associated with Alzheimer's Dementia

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Behavioral disturbances are seen in up to 50 percent of individuals diagnosed with Alzheimer’s dementia. This is especially the case in those over 85 years of age (Jeste, et al. 2008). The middle stages of the disease are frequently the time when these behaviors are highlighted. The behavioral symptoms associated with Alzheimer’s dementia are often the source of issues ranging from basic safety to caregiver burnout. Agitation is frequently the catalyst for seeking treatment or seeking placement options. There are currently no pharmacological interventions approved to treat the behavioral disturbances associated with dementia, however medications are frequently the go-to intervention to treat behavioral issues. Using non- pharmacologic interventions can be effective tools in managing the behaviors and ultimately optimizing quality of life for all involved.

The term "agitation" itself creates a wide variety of interpretation. What may be identified as problematic to one practitioner may be tolerated by another. It is widely known that any transition can be a trigger for behavioral disturbances in the client diagnosed with Alzheimer’s dementia. In addition, the disturbance of physical needs, environmental issues, unmet needs, and mood disturbances can initiate agitation. Developing an understanding of the etiology of the behaviors is the initial step in intervening. Additionally, developing a comfort level and subsequently a tool box in managing the behavioral disturbances frequently seen in dementia are imperative to favorable outcomes.

This teaching strategy looks at the evolving knowledge pertaining to the non-pharmacologic treatment of clients diagnosed with Alzheimer’s dementia. It helps students recognize behaviors and start to assess the etiology of the disturbances as the first step in management to provide optimum quality of life.

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Managing Behaviors Associated with Alzheimer's Dementia

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Learning Objectives
Students will:
- Develop an understanding of behaviors associated with Alzheimer’s dementia
- Develop an understanding of the etiology of the behaviors
- Articulate an assessment of behavioral disturbances vs. aggressive behaviors
- Recognize the risks associated with caregiver burnout and behavioral issues
- Create a toolbox of approaches to intervening with the client demonstrating behavioral issues related to Alzheimer’s dementia
- Better understand the use of standardized tools in evaluating both behaviors and the etiology of behaviors
- Articulate possible safety concerns as they pertain to the behaviors discussed
- Explore situations involving common behavioral issues with Alzheimer’s dementia
Getting Started
1. What Would You Say? What Would You Do? Activity

These mini case studies portray common issues of agitation with Alzheimer’s dementia. Download the PowerPoint of mini case studies. Each slide has a scenario with speaker’s notes and additional resources to help the instructor guide the student through the process of managing behavioral issues associated with Alzheimer’s dementia.

2. View the Ertha Williams unfolding case.

This simulation series helps students recognize, assess, and intervene in behaviors commonly seen with Alzheimer’s dementia. Ertha’s symptoms worsen as the dementia progresses and as she experiences multiple transitions. The vulnerability of these transitions affects the behavioral problems associated with her dementia. The simulation can be done in its entirety, or the monologue and situation can be introduced at the start of a lecture.
- Download the faculty guide to look at issues in each simulation scenario that pertains specifically to the behavioral complications involving Ertha. Included in this guide are suggestions to guide the conversation and both pharmacological and non-pharmacological interventions to address Ertha’s behavioral issues.
- Utilize the following resources within this simulation to better assess Ertha’s cognitive behavioral issues:
Mental Status Assessment of Older Adults: The Mini-CogTM
Tool
Video

Fulmer SPICES: An Overall Assessment Tool for Older Adults
Tool
Video

Assessing Pain in Persons with Dementia
Tool
Video
- Utilize the following questions to help further process the content in this simulation. These can be especially helpful if using the monologue alone:
1. What are your concerns about this patient?
2. What is the cause of the concern?
3. What information do you need?
4. What are you going to do about it?
5. What is the patient experiencing?
Benner, P., Sutphen, M., Leonard, V., Day, L., & Shulman, L. (2010). Paradigm case: Lisa Day, classroom and clinical instructor. In Educating nurses: A call for radical transformation (p. 133). San Francisco, CA: Jossey-Bass.

3. View the Judy Jones unfolding case

This case focuses on a client who has delirium superimposed on a dementia. She demonstrates an acute change in mental status, which is the hallmark of delirium. The case can be simulated in its entirety, or the monologue and situation scenarios can be introduced at the start of a lecture.
- Download the faculty guide to look at issues in each simulation scenario that pertains specifically to the behavioral complications involving Judy Jones. Within this guide are suggestions to guide the conversation and include both pharmacological and non- pharmacological interventions to address Judy’s behavioral issues.
- Utilize the following resources within this simulation to better understand behavioral issues with Judy Jones.
Confusion Assessment Method:
Tool
Video

Mental Status Assessment of Older Adults: The Mini-Cog TM
Tool
Video

Assessing and Managing Delirium in Older Adults with Dementia
Tool
Video

Recognition of Dementia in Hospitalized Older Adults
Tool
Video
- Utilize the following questions to help further process the content in this simulation. These can be especially helpful if using the monologue alone.
1. What are your concerns about this patient?
2. What is the cause of the concern?
3. What information do you need?
4. What are you doing to do about it?
5. What is the patient experiencing?
Benner, P., Sutphen, M., Leonard, V., Day, L., & Shulman, L. (2010). Paradigm case: Lisa Day, classroom and clinical instructor. In Educating nurses: A call for radical transformation (p. 133). San Francisco, CA: Jossey-Bass.
Materials

Therapeutic Activity Kit

Alzheimer’s Association: Managing Behavioral Symptoms

ConsultGeri resource for addressing agitation with dementia

American Geriatric Society Beers Criteria for Screening Inappropriate Use of Medications in Older Adults

Fick, D. M., & Semla, T. P. (2012). 2012 American Geriatrics Society Beers Criteria: New year, new criteria, new perspective. Journal of the American Geriatric Society, 60(4):614-615. doi:10.1111/j.1532-5415.2012.03922.x

Fitzsimmons, S., Barba, B., & Stump, M. (2015). Diversional and physical nonpharmacological interventions for behavioral and psychological symptoms of dementia. Journal of Gerontological Nursing, 41(2), 8-17. doi:10.3928/00989134-20141215-01

Joosse, L. L., (2012). Do sound levels and space contribute to agitation in nursing home residents with dementia? Research in Gerontological Nursing, 5(3), 174-184. doi:10.3928/19404921-20120605-02

Mace, N. L., & Rabins, P. R. (2017). The 36-hour day: A family guide to caring for people who have alzheimer’s disease, related dementias, and memory loss (6^th ed.). Baltimore, MD: Johns Hopkins Press Health Book.

Padilla, D. V., González, M.,TeresaDaza, Agis, I. F., Strizzi, J., & Rodríguez, R. A. (2013). The effectiveness of control strategies for dementia-driven wandering, preventing escape attempts: A case report. International Psychogeriatrics, 25(3), 500 4 doi:10.1017/S1041610212001810

Whall, A. L., Kim, H., Colling, K. B., Hong, G., DeCicco, B., & Antonakos, C. (2013). Measurement of aggressive behaviors in dementia: Comparison of the physical aggression subscales of the Cohen-Mansfield agitation inventory and the Ryden aggression scale. Research in Gerontological Nursing, 6(3), 171-7. doi:10.3928/19404921-20130321-01
Suggested Reading

Campbell-Reed, E. R. (2011). Educating Nurses: A Call for Radical Transformation – By Patricia Benner, Molly Sutphen, Victoria Leonard, Lisa Day; Educating Physicians: A Call for Reform of Medical School and Residency – By Molly Cooke, David M. Irby, Bridget C. O'Brien. Teaching Theology & Religion, 14(4):402-404. doi:10.1111/j.1467-9647.2011.00752.x

Jeste, D. V., Blazer, D., Casey, D., Meeks, T., Salzman, C., Schneider, L., et al. (2008). ACNP white paper: Update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology, 33, 957-970.
Author Information

Laureen Tavolaro-Ryley, MSN, RN
Community College of Philadelphia
Philadelphia, PA