Analysis of causes

Symptoms of challenging behavior are resource demanding for the individual person with dementia; being more or less alert and in conflict or in apathy and resignation does not lead to good quality of life. In addition, relatives of people with dementia with challenging behavior may be significantly burdened with loss of quality of life and increased risk of depression.

In addition, the symptoms are resource-intensive in care and treatment and are often a decisive reason why the person with dementia must move into a nursing home, if possible. Therefore, it is essential to be able to prevent, identify and treat the behavioral and psychological symptoms of people with dementia. For the same reason, it is important to find out and clarify in each case what the life situation is for each individual with dementia before figuring out how to deal with the situations that arise when the person responds to his or her surroundings.

It is strongly recommends to make a systematic causal analysis of newly formed BPSD to make an individualized action plan. Causal analysis is an analysis that systematically examines the background or purpose of the person’s behavior, including seeking to understand the psychosocial needs underlying the behavior. In other words, the “translation” of behavior to communicate needs. On that background, concrete action plan and a joint effort and approach that can take into account the individual’s disease profile and individual cognitive and practical functional abilities, as well as needs and preferences, can be implemented.

Mapping facts. What type of behavior is involved?

1. How often does the person have this behavior?

2. What times of day does it occur, use. 24-hour registration forms before the effort and after

3. Can the behavior be linked to specific situations (before, during or after?)

4. Who is the behavior aimed at (other residents, caregivers, relatives)

Agree on what behavior to chart and why. Everyone must have the same view of what unease is.

Mapping conditions that influence the person’s behavior:

1. Dementia type and location of brain damage

2. The persons reaction to his own failure and degree of understanding and insight

3. The persons past personality

4. A critical assessment of the environment around the person

5. Relationship with other persons

6. Delirium

7. Drugs

Always check if there is a somatic cause of the behavior.

Clarification of the underlying cause is the first step in the management of BPSD, and often a reversible cause can be identified. Common somatic diseases such as constipation (constipation), urinary tract infection or dehydration can cause BPSD in people with dementia. If you suspect that the persons behavior is due to somatic conditions, these conditions must be investigated. Somatic causes of challenging behavior may e.g. be:

• Inflammatory conditions, e.g. cystitis

• Pain that the resident cannot explain, e.g. muscle, back or joint pain

• Sensory loss: Unseen visual or hearing loss that makes it difficult for the resident to find a way or to understand the surroundings

• Medications that are under or overdosed, or which, along with other medications, may cause confusion

• Lack of or incorrect nutrition

• Over-consumption of alcohol or similar

The vast majority of people with dementia are old and, therefore we must remember to be aware of the pain of the musculoskeletal system. It can be further complicated to find the cause of the behavior if the citizen has communication difficulties, vision or/and hearing loss. If we can exclude somatic illness as a cause, the existential needs exploring, such as recognition, inclusion, social contact and a meaningful daily life. (The list is by no means exhaustive) Conversely, overstimulation or high expectations can also cause behavioral changes.

The treatment of behavioral and psychological symptoms is complicated and varies depending on the situation and the triggering cause. First treatment in the care of BPSD is to take psychosocial and environmental measures. Psychopharmaceutic treatment is often reserved for severe cases where investigation and non-pharmacological measures have been ineffective or where the behavior poses a risk to the person himself or his environment.

Since BPSD is often situation-dependent and therefore time-limited, follow-up of the intervention initiated both pharmacologically and non-pharmacologically, is important.

People with dementia, who develop a depression, form a special group. They may have difficulty expressing sadness, decreased energy and similar symptoms of the condition. Thus, it can be difficult to detect depression in a person with dementia. In addition, the diagnostic requirements for a depression will not always be met strictly in people with dementia. Their symptoms of depression in

may be different from others, and their depression can manifest as apathy,

restlessness, delusions, or agitated and aggressive behavior. In other words, people with dementia may develop BPSD secondary to an unrecognized depression.

Detecting triggers and early signs that precede behavioral and psychological symptoms is crucial. In most cases, simple measures aimed at the earliest signs can prevent the development of symptoms. Nevertheless, it requires that we as care givers adapt our work to the capabilities of the individual. If the citizen with dementia cannot live up to the demands, we must lower them. It is also important to acknowledge that behavioral and psychological symptoms are not expressions of “bad behavior”. The symptoms are often associated with biochemical changes in the brain or triggered by social and environmental factors. Simple adaptations of the environment and social interaction can make a difference.

A common response to challenging behavior has been to prescribe antipsychotic medication. This is often used as the primary treatment. Although atypical antipsychotics have a modest effect in the treatment of aggression and psychoses over a 6-12 week period and they are associated with a number of serious side effects and complications such as lethargy, Parkinsonism, walking disorders, dehydration, and falls, and pneumonia, aggravation of cognitive impairment, apoplexy, and death.

In summary, that causal analysis reveals the underlying causes of BPSD. The analysis includes an initial assessment for somatic disease to be treated first. In practice, causal analysis initially includes a medical examination for infection, pain, and other somatic disease, including side effects for medication. When somatic disease is excluded or treated, any unmet needs are assessed, initially in the form of physical needs such as nutrition and hygiene. Finally, unfulfilled existential needs are assessed, such as the need for meaningful life content or sufficient social contact.