BetterConduct

An interesting article published by the Journal of Clinical Psychiatry in 2001 (Desai and Grossberg) outlined both an algorithm for managing behavioral disturbances and an intriguing distinction for classifying behavioral symptoms in dementia.  The authors, two psychiatrists, divided behavioral disturbances into three categories. 

 

The first category of behavioral symptoms is primary disturbances.  These behaviors are caused by the underlying neurochemical changes associated with dementia.  The primary disturbances, or disruptive behaviors, are further divided into two groups depending on whether pharmacology is found to helpful in addressing the behaviors or not.  The first group of behaviors can benefit from medication.  The second group within the primary category is not responsive to drug therapy (Desai A and Grossberg G, 2001). The first subgroup of primary behavioral disturbances can respond well to pharmacologic interventions.  These behaviors include:

                                Psychosis, and in some cases, physical aggression attributed to this;

                                Depression, and

                                Anxiety in the early stages of dementia.

As one can see, this is a noticeably short list. In the medical model, most problems can be addressed with prescription or OTC medication.  Not so with many of the behavioral issues in dementia.  Environmental factors play a significant role in contributing to – and the resolution of – problem behaviors. 

 

The second subgroup of primary behavioral disturbances does not respond well to pharmacologic interventions.  These behaviors include:

            Loneliness

            Boredom

            Sundowning

            Apathy

            Screaming

            Sleep disturbances not attributed solely to depression

            Wandering/pacing

            Physical aggression - can also be attributed to pain (which should be targeted for treatment first)

            Hoarding

            Resistance to care

            Sexual disinhibition.

 

Secondary behavioral disturbances are caused by a comorbid medical illness, disease, or disorder.  These behaviors can also be caused by medications including side effects or drug interactions, pain, environmental factors, personal need(s), and/or delirium.   The most common secondary behavioral disturbances in dementia include:

• Pain

• Underlying medical issues – dehydration, urinary tract infection, polypharmacy (multiple prescriptions prescribed at one time resulting in another medication prescribed to address a side effect of another drug), adverse drug reactions, constipation/fecal impaction, abscessed tooth, fracture, congestive heart failure                        

• Delirium - “an acutely disturbed state of mind or … severe confusion which may be associated with hallucinations, hyperactivity, restlessness, and/or incoherence of thought and speech” (delirium.  2019.  In Medicine-Net.com.  Retrieved August 10, 2019 from https://medicinenet.com)

• Drug-induced – including medications prescribed for behaviors secondary to medical issues (without addressing an underlying medical issue), side effects of medication, drug interactions

• Environmental factors – noise, crowds, change of routine, lack of activity, needs not being met (hunger, thirst, toileting)                    

   

The third category, which the author calls mixed behavioral disturbances, occurs when a primary behavioral disturbance is exacerbated by a secondary disturbance.  The underlying neurochemical changes in the brain (primary disturbance) cause behaviors that are in turn influenced by the environment, an illness, etc. (secondary disturbance).    These behaviors involve several variables and are typically more difficult to decipher and address.  One of the most common behavioral issues in this category is physical aggression.  Examples of mixed behavioral disturbances include:

               Resistance to care due to unaddressed pain and accompanying fear and anxiety, and/or pain with movement.

               Psychosis, specifically hallucinations, coupled with changes in vision and low lighting (environmental) that trigger more episodes due                   to misinterpretation of sensory input. 

For a more detailed example, John, an Alzheimer’s patient, had been rearranging furniture and pacing the house at night.  After he developed a fever, it was found he had a urinary tract infection.  He was put on an antibiotic medication that kept him from sleeping due to intestinal discomfort.  He was then given a probiotic to help his intestinal issues, which were a side effect of the antibiotic.  John’s primary behavioral disturbances were wandering, pacing, and sleep disturbance due to the medication side effect of the infection.  Secondary issues were both the UTI and adverse drug reaction (digestive issues). 

 

In their article, the authors Desai and Grossberg (2001) offer an algorithm for the management of behavioral disturbances in dementia patients.  This algorithm still holds water in deciphering the approach that should be used in addressing behavioral issues.  The algorithm begins with ensuring that the patient is not an immediate danger to self or others, then primary disturbances are examined and addressed if found to be present.  Next, the flow chart separates into mild to moderate behavioral disturbances, for which nondrug approaches are the intervention of choice.  The second branch of the flowchart is for severe behavioral disturbances for which psychotropic drugs may be needed.  It branches into three categories of psychiatric symptoms and their recommended medications to address:

• Psychotic symptoms and severe aggression may be addressed with atypical antipsychotics.

• Depressive symptoms and anxiety addressed with antidepressants and anxiolytics, and

• Mania-like symptoms and aggression addressed with mood stabilizers or atypical antipsychotics. 

These decisions are made with careful consideration of a physician; it is always advocated that nonpharmaceutical approaches be tried first.  Isn’t this what we try to do in our own medical decisions?  If we have a stomachache, we do not immediately go to a physician for a prescription.  We try avoiding associated foods, eat blander or different foods to see if the issues resolve, try to remember what we ate and where that might have caused the issue, etc.  We check and modify environmental issues first unless the pain is acute or the symptoms unbearable. 

 

Source:

Desai A and Grossberg G. Recognition and management of behavioral disturbances in dementia.  J Clin Psychiatry 2001;3(3):93-109.