Motivation and emotion/Book/2017/Dementia and vocally disruptive behaviour

Dementia and vocally disruptive behaviour:
What motivates vocally disruptive behaviour by people living with dementia and how can it be managed?

Multimedia presentation (3 min)

Overview

Verbally disruptive behaviour (VBD) in people living with dementia (PLWD) poses a challenge to medical professionals, carers and family members as VDB can be out of character, aggressive, annoying and demanding; putting strain on relationships. Dementia is a neurodegenerative disease that results in abnormal cognition and mental processing. The progression of dementia is distressing to witness, not only as an observer but as a sufferer. As cognitive decline worsens the individual may not be able to express in words how they feel or what they need. The individual results to VBD in an attempt to notify others of their discomfort. Throughout the chapter the themes of motives and treatment of VDB are discussed with reference to theory and research.

Putting dementia into perspective

• "In 2015 there were an estimated 342,800 people living with dementia in Australia, an increase of nearly 100,000 people since 2005." (ABS,2017, p.1)
• "When compared to other leading causes of death over this period, the mortality rate for dementia has increased by the largest margin. In fact, rates for the top three leading causes in 2006 (heart disease, lung cancer and strokes) had decreased by 2015. As a result dementia has moved from the fourth to the second leading cause of death in Australia(ABS,2017,pg.1)".
• "There were 159,052 deaths in Australia in 2015. Almost 1 in 12 had dementia as the underlying cause of death (12,625 deaths).This equates to around 35 deaths per day(ABS,2017,pg.1)".

How can specific theory and research in motivation help to explain: What is dementia? What is and what motivates vocally disruptive behaviour in individuals with dementia? In individuals with dementia how can vocally disruptive behaviour be managed?

What is dementia?

Dementia is a progressive degenerative disease of the brain (neurodegenerative) resulting in abnormal mental processing and cognition. Dementia is characterised by a vast assortment of symptoms. As degeneration begins to worsen, the impact of the disease becomes more pronounced and disabling, impairing functions such as memory retention and retrieval, thinking and everyday behaviours. Dementia as an umbrella term and includes Alzheimer's disease (the most prevalent form of dementia), Lewy-Body disease, vascular dementia, alcohol-related dementia (Korsakoff's syndrome), Frontotemporal dementia, Parkinson's disease, Huntington's disease and creutzfeldt-jakob disease. Dementia interferes with every aspect of a persons life. 'Dementia’ is classified by The Diagnostic and Statistically Manual of Mental Disorders (DSM-5) as a major neurocognitive disorder, which begins with delirium and highlights primarily cognitive deficits that are acquired rather than occurring throughout development. To be diagnosed with a major neurocognitive disorder, an individual must have a significant decline in performance when compared to an earlier time in their lives on one or more cognitive domains. The classification of neurocognitive disorders focuses on neurocognitive domains addressing issues related cognitive decline:

Figure 1. Video. The role of plaques, tangles and proteins in apoptosis.

• complex attention
• executive functioning
• learning and memory
• language
• perceptual motor skills
• social cognition.

Furthermore, the deficits must interfere with the independence of a person's everyday life; not be explained by another mental illness; and delirium not the only context in which deficits occur (American Psychiatric Association, 2013).There is currently no cure for any form of dementia. After diagnosis there is little effective treatment to stop the progression of the disease and death ultimately results. However it is more common for another medical issue to cause death before complications of dementia does; such as pneumonia or heart attack. The causation of dementia is still uncertain as different types of dementia may be caused by a variety of differing factors. The video in Figure 1 discusses the presence of plaques, tangles and proteins forming within and around cells that result in apoptosis as a possible way of explaining dementia related degeneration.

What are vocal disturbances and how do they present in dementia?

Vocally Disruptive Behaviour (VBD), or inappropriate verbalisation, is present in around 90% of individuals diagnosed with dementia (Nazarko,2011). Vocalisation by suffers can be without an observable cause or due to a variety of factors. This type of behaviour can become an annoyance to others, such as residents who are living in care facilities, family and carers. VDB does not have a concrete operational definition, but is a term that will be discussed in reference to its constructs. This type of behavioural disturbance is often described as disruptive verbalisation or verbal agitation (McMinn & Drapper,2004). These types of behaviours are often repeated and maintained, enduring over time. Some examples of VDB include:

• Screaming
• Humming
• Moaning
• Excessive talking/ making noises
• Inappropriate requests
• Yelling abuse
• Repetition of the same few words, which occurs predominately in individuals in the later stages of dementia 

The vocalisation is generally attributable to increasing cognitive impairment, resulting in a reduction in appropriate measures of communication and expression, and reflecting an underlying discomfort or need that a suffer may feel.

What motivates vocal disturbances in dementia?

Before a PWD can be appropriately and effectively treated for verbal disturbances it is crucial to understand what causes these behavioural outbursts to occur, as most suffers cannot articulate an interpretable verbal response to a care giver or medical practitioner. To help understand and thus treat behavioural disturbance in dementia, three categories have been identified to address the underlying needs of the suffer:

1. Primary, which includes disturbances caused by underlying neurochemical changes happening in the brain, which can be further broken down into symptoms which pharmacological intervention can aid in reducing, such as some mental illness associated with the disease and forms of psychosis.
2. Secondary behavioural disturbances can be caused by pain, environment, medications, illnesses and delirium.
3. Mixed behavioural disturbances (Desai & Grossberg, 2001).

Desai et al (2001) emphasised how critical it is to pay as close attention as possible to the underlying needs of a PWD, otherwise they may go unmet due to misinterpretation of cues. A caregiver should consider verbal cues, even if what is expressed is disjointed and illogical. Some sufferers who have an underlying need are in discomfort or may engage in vocal disturbances to attract the attention of a caregiver. Valuable information is gathered about the underlying needs of a suffer from observations of new behavioural disturbances. Intervention to reduce the instances of disruptive verbal disturbances can be devised. Explored below is the impact that physical needs, environmental needs, operant conditioning, psychological distress and cerebral atrophy has on motivating VDB.

Additionally, when exploring what motivates VDB in PWD two theories of motivation can be applied; drive reduction theory and Maslow's hierarchy of needs. Drive reduction theory suggests that individuals are motivated or driven to reduce basic needs such as feeling of hunger and thirst, responses are said to increase until the need is satisfied (Berridge, 2004). Building on drive reduction theory, Maslow's hierarchy of needs goes further into explaining what needs as humans should to be meet to feel satisfied with our lives. The levels of the hierarchy may begin to explain VDB in PWD in relation to basic needs, respect, privacy and issues around social isolation. In both theories PWD behavioural disturbances would increase until the need is satisfied or recognised.

Figure 2. Nurse providing medical care to an elderly woman.

Physical needs

PWD methods of communication begin to degenerate leaving suffers with little means of communicating basic needs. This degeneration causes individuals to express how they feel through other means such as VDB to attract attention from others to have their needs met. These are basic innate needs such as hunger, thirst, discomfort, pain and wanting to use the toilet. Research has suggested that room temperature, hunger, mild deprivation and thirst were sources of discomfort, resulting in increased presence of VDB (Nelson, 1995).

As many dementia sufferers are elderly, there is an increased chance of individuals having medical conditions or comorbidities that cause them pain and distress due to age-related degeneration; with research suggesting that 40-80% of nursing home residences with dementia may be in pain at any time (Pieper, Achterberg, Francke, Steen, Scherder, Kovach, 2011). In a longitudinal study suffers who experience pain and negative affect, specifically depression, predicted the occurrence of verbal non-aggressive behaviours among suffers (McMinn & Drapper, 2005). With verbal disturbances such as screaming, shouting, heavy breathing and crying being associated with the presence of pain:. Furthermore, due to the nature of dementia, individuals are unable to express how they are feeling. It is not easy to interpret the root cause of an individual's pain; with research suggesting that individuals are under treated or mistreated for pain (Pieper et al, 2011).

Case study Jane has severe Alzheimer's disease limiting how effectively she can communicate with others. Recently she was walking along when she stumbled and bumped her hip into a table. Since then she has develop bruising and tenderness around the area. She has begun to engage in frequent heavy breathing and crying behaviours. Staff at first thought she was just having a bad day, but after acknowledging that these behaviours were out of character for Jane they searched for other causes to her discomfort. Upon medical examination they found the source of her pain and a treatment plan was put in place to minimise her discomfort.

Environmental factors

Changes in the environment surrounding individuals with the disease can cause behavioural disturbances (VDB). Often sufferers are quite aware of changes in their environment; such as loud noise, changing of carers, inadequate stimulation; and too many people around them (Desai & Grossberg,2001). In regard to level of stimulation in the environment of a PWD; too much or too little can cause behavioural disturbances. It is hard to find a balance, especially in a nursing home setting where there are a variety of patients with different needs.

Operant Conditioning

Operant conditioning has been suggested to contribute to the behavioural disturbances in PWD. Verbal disturbances in PWD are not always considered important as care givers may believe this is attention seeking behaviour;the disturbance is not always responded to in a consistent way or may be ignored entirely. The response to VDB is often followed by a intermittent reinforcement schedule which has been suggested to produce behaviours harder to extinguish. Attention or inattention given to individuals when they are vocally disruptive reinforces the disruptive behaviour (Turner,2004).

Psychological distress

The negative consequences of VDB include anxiety and distress for the PWD and for others around them; recurrent vocalisations can lead to social isolation (Beck, Richards, Lambert, Doan, Landes, Whall & Feldman, 2011), possibly resulting in feelings of helpless, fear or a sense of being lost (Nazarko,2011). PWD may be suffering from varying forms of psychological distress such as mental illnesses (most commonly), depression and anxiety, often caused by worsening cognitive decline. Under-diagnosis of these mental disorders can lead to negative affective states resulting in worsened symptoms associated with the mental illness(Nazarko,2011).

Cerebral atrophy

Figure 3. Representation of brain atrophy in Alzheimer's disease compared to healthy brain.

Cerebral atrophy in any form of dementia is widespread throughout the brain; as the disease progresses so does the severity of a PWD cognitive decline. It is hardly surprising that PWD develop behavioural and verbal disturbances as a result of brain degeneration. The composition of a brain that is affected by dementia has a variety of noticeable differences when compared to a person without the disease (see Figure 3). Research into brain atrophy is limited in dementia research; predominately to specific brain structures. Magnetic resonance imaging (MRI) has been used to investigate cognitive decline in people with dementia. MRI indicates that different regions of the brain decline at different stages. Alzheimer's disease suggests that global atrophy eventually occurs, with significant atrophy to the hippocampus, which is associated with memory retention and consolidation of memories; being present in presymptomatic to mildly affected individuals(Scahill, Schott, Stevens, Rossor & Fox, 2002). Patterns of cerebral atrophy in individuals with dementia with lewy-bodies (DLB) suggests that individuals with this form of dementia retain more of their temporal lobe, hippocampal and amygdala functioning. Grey matter loss was present in the insular cortex, frontal and temporal lobes in individuals with DLB (Burton, Karas, Paling, Barber, Williams, Ballard, O'Brien, 2002).

Test your knowledge choose the correct answer and click "Submit": What is the most common form of Dementia? Lewy-Body disease Alzheimer's disease Korsakoff's syndrome Frontotemporal dementia Vascular dementia Secondary behavioural disturbances are not caused by which of the following? Psychosis Pain Environment Medications Delirium

Ways to manage vocally disruptive behaviour in people with dementia

Investigating the aetiology of VDB enables carers/ family members and medical professionals to devise measures and effective strategies to reduce the occurrence of verbally disruptive behaviours among sufferers. Research suggests that before a treatment or management plan can be devised, a biopsychosocial assessment is required to discover how different causes for verbal disturbances interact with individual cases. A combination of biopsychosocial strategies coupled with realistic goals, including addressing the issue that dementia is a degenerative disease in which suffers do not recover, is essential so that affected parties become aware that treatment or strategies to reduce VDB will still result in a residual level of VDB as an outcome (Meares & Drapper, 1999).

The effectiveness of pharmacological intervention on VDB

Pharmacological interventions, predominately antipsychotic medications, have traditionally been the treatment of choice for behavioural disturbances for PWD, especially in a nursing home setting where the safety and comfort of residents is a priority. These types of behaviours can pose a threat to the individual and the people around them. Specifically, antipsychotics are used for the treatment of delusions and/or hallucinations that often present during the disease. Delusions of grandiosity, theft, infidelity, somatic delusions, persecutory delusions and hallucinations are reported in up to 80% of individuals who suffer from dementia with lewy-bodies (DLB;) and approximately 24% of individuals with alzheimer’s disease (AD) present with hallucination resulting in VDB (Desai, Schwartz, Grossberg,2012).

A meta-analysis of the effectiveness of traditional antipsychotics versus a placebo in severely affected PWD, suggested that antipsychotics only moderately outperformed the placebo (Schneider, Pollock, Lyness, Geriatr, 1990). In the older population, the usage of atypical and typical antipsychotic medication has been associated with an increased risk of detrimental cerebrovascular events and overall mortality, or increased risk of sudden death (Schneider, Dagerman & Insel, 2005). The detrimental effects of the prolonged use of antipsychotic medication include sedation, increased risk of falls, worsening cognitive decline, pneumonia, extrapyramidal symptoms and increased risk of urinary and respiratory infections (Leon ,Gerretsen, Uchida, Suzuki, Rajji & Mamo, 2010). Research into the usage of pharmacological interventions to treat behavioural disturbances in dementia, suggest that it is crucial for medication to only be provided after other avenues fail. Additionally, there should be careful consideration of the limitations, risks and benefits associated with each class of drug on a case by case basis to ensure minimal harm to the receiver (Gauthier, Cummings, Ballard, Brodaty, Grossberg, Robert & Lyketsos, 2010).

Psychosocial Structural Model

Figure 4. Turner (2005) psychosocial structural model for how to work with individuals displaying behavioural disturbances. See reference list for full citation.

Turner (2005) devised a psychosocial structural model for deciding on how best to work with PWD presenting with behavioural disturbances; as research has suggested that the usage of pharmacological interventions may alone not be be the most successful way of reducing VDB. Turner (2005) suggested one of the most critical factors in managing behavioural disturbances involves educating caregivers about the disease and employing a person-centred approach; improving the way a caregiver responds to the disturbance. Instead of tiring or becoming agitated by the recurrent disturbances, a caregiver should adopt a more understanding approach centred around the needs of the PWD. Additionally, it is recommended that modifications are made to a PWD environment to help prevent the occurrences of behavioural disturbances. Modifications to the environment and specific therapeutic interventions are often used to modify the frequency and severity of VDB (Turner, 2005). Creating a "dementia friendly" environment involves careful monitoring of noise levels; having a comfortable room temperature; increased amount of time spent in communal areas; delivering the correct amount of stimulation; appropriate levels of lighting; and stimulating activities (Barton, Findlay & Blake, 2005).

Reducing social isolation and respecting PWD

Research suggests that social isolation plays a role in VDB, with the manifestation of screaming occurring when individuals are unable to control their own social interactions, resulting in isolation. Research by Saulnier (1988) used physical contact (touch) to reassure suffers that the career would stay with them. Results suggested that a significant reduction in screaming duration and frequency occurred when the suffer felt reassured by the touch of their caregiver. However, in a case study of a woman with severe dementia exhibiting behavioural disturbances, such as aggressive verbalisation, violence and screaming towards carers, suggested that privacy, autonomy, identity and security were important factors to her (Graneheim, Norberg & Jansson,2011). When carers respected her wishes, or gave her the choice of when to engage in behaviours, her behavioural disturbances decreased. For example, in the mornings they would knock on her bedroom door before entering. If she yelled at them to go away the carer would come back later to check on her. Carers would phrase requests in way that put control back into the sufferers hand; for example, "would it be a good time to have a shower now?" instead of "let's go have a shower"; the difference being that the carer respected her privacy and autonomy. This sufferer, contrary to the previous study, did not like people touching her, especially people who it would be likely to assume she didn't remember. When people touched her she reacted verbally or physically; instead carers would ask if she would like to take their arm to go for a walk; in these instances less behavioural disturbances occurred (Graneheim, Norberg & Jansson,2011).

Musical Interventions

Musical interventions have been implemented by occupational therapists in small sample sizes within a nursing home setting to reduce the occurrence of screaming behaviour among PWD. The intervention consisted of playing no music; classical; or the participant's favourite music for 10 minutes, 4 times a day. Results indicated a significant reduction in screaming behaviour and overall negative affect (Casby & Holm, 1994). Morning care routines in nursing homes can evoke resistance among PWD, often leading to behavioural disturbances. Caregiver and patient singing during these routines increased positive emotions and reduced the frequency and severity of behavioural disturbances (Hammar, Emami, Götell & Engström, 2011)

Test your knowledge choose the correct answer/s and click "Submit": How would you create a 'dementia friendly environment'? Comfortable room temperature,appropriate level of stimulation and increased amounts of time spent in communal area Loud noise and bright lights There is no such thing as a 'dementia friendly environment' Under stimulating group activities According to the psychostructural model proposed by Turner (2005), what is the best approach to reduce behavioural disturbance? Psychodynamic approach Behavioural approach Person-centred approach Leaving the PWD alone Using operant conditioning to reinforce behavioural disturbances

Conclusion

VDB presenting in PWD has been explored through a review of psychological theory and research, addressing the key concepts of what motivates these disturbances to occur and how to best to manage these behaviours in suffers. Physical needs, environmental factors, operant conditioning principles, psychological distress and cerebral atrophy are implicated as probable causes for VDB. What is important to remember is that once the aetiology of a behaviour is discovered it makes effective treatment possible. Treatment for dementia is predominately about enhancing quality of life and minimising the negative symptoms that arise with worsening cognitive decline.

Pharmacological interventions have been traditionally used for treatment, however the usage of medications such as antipsychotic have detrimental effects to the already suffering individual; putting them at risk of further medical issues. For this reason, it is advocated that other interventions be tested such as a person-centred approach, educating care givers, environmental modifications "creating a dementia friendly environment", reducing social isolation and increasing respect and autonomy as well as musical interventions have been suggested to reduce the occurrence and severity of VDB. Issues surrounding many research studies were in relation to their publication age, it appears that research may no longer be directed to improving quality of live for PWD but rather towards a cure. However, if research is currently being directed to finding a cure, the suffers who currently have dementia may not benefit from future research.

See also

• Dementia and Motivation (Book chapter, 2010)
• Dementia and Emotion (Book chapter, 2013)
• Dementia (Wikipedia)
• Motivation (Wikipedia)

References

Australian Bureau of Statistics (2017, July 26). Dementia and death in Australia. Retrived from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2015~Main%20Features~Dementia~10002.

American Psychiatric Association. DSM-5 Task Force, & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association.

Barton, S., Findlay, D., & Blake, R. A. (2005). The management of inappropriate vocalisation in dementia: A hierarchical approach.International Journal of Geriatric Psychiatry, 20(12), 1180-1186. doi:10.1002/gps.1416

Berridge, K. C. (2004). Motivation concepts in behavioral neuroscience. Physiology & Behavior, 81(2), 179-209. doi:10.1016/j.physbeh.2004.02.004

Bourbonnais, A., & Ducharme, F. (2008). Screaming in elderly persons with dementia: A critical review of the literature. Dementia, 7(2), 205-225. doi:10.1177/1471301208091156.

Burton, E. J., Karas, G., Paling, S. M., Barber, R., Williams, E. D., Ballard, C. G., O'Brien, J. T. (2002). Patterns of cerebral atrophy in dementia with lewy bodies using voxel-based morphometry. Neuroimage, 17(2), 618-630. doi:10.1006/nimg.2002.1197.

Beck, C., Richards, K., Lambert, C., Doan, R., Landes, R. D., Whall, A.,Feldman, Z. (2011). Factors associated with problematic vocalizations in nursing home residents with dementia. The Gerontologist, 51(3), 389-405. doi:10.1093/geront/gnq129.

Casby, J. A., & Holm, M. B. (1994). The effect of music on repetitive disruptive vocalizations of persons with dementia. The American Journal of Occupational Therapy.: Official Publication of the American Occupational Therapy Association, 48(10), 883-889. doi:10.5014/ajot.48.10.883.

Desai, A. K., & Grossberg, G. T. (2001). Recognition and management of behavioral disturbances in dementia. Primary Care Companion to the Journal of Clinical Psychiatry, 3(3), 93-109.

Desai, A. K., Schwartz, L., & Grossberg, G. T. (2012). Behavioral disturbance in dementia.Current Psychiatry Reports, 14(4), 298-309. doi:10.1007/s11920-012-0288-5.

Gauthier, S., Cummings, J., Ballard, C., Brodaty, H., Grossberg, G., Robert, P., & Lyketsos, C. (2010). Management of behavioral problems in alzheimer's disease. International Psychogeriatrics / IPA, 22(3), 346.

Graneheim, U. H., Norberg, A., Jansson, L. (2001). Interaction relating to privacy, identity, autonomy and security. an observational study focusing on a woman with dementia and ‘behavioural disturbances’, and on her care providers. Journal of Advanced  Nursing, 36(2), 256-265. doi:10.1046/j.1365-2648.2001.01966.x.

Hammar, L. M., Emami, A., Götell, E., & Engström, G. (2011). The impact of caregivers’ singing on expressions of emotion and resistance during morning care situations in persons with dementia: An intervention in dementia care. Journal of Clinical Nursing, 20(7‐8), 969-978. doi:10.1111/j.1365-2702.2010.03386.x.

Leon, C., Gerretsen, P., Uchida, H., Suzuki, T., Rajji, T., & Mamo, D. C. (2010). Sensitivity to antipsychotic drugs in older adults. Current Psychiatry Reports, 12(1), 28-33. doi:10.1007/s11920-009-0080-3.

McMinn, B., & Draper, B. (2005). Vocally disruptive behaviour in dementia: Development of an evidence based practice guideline. Aging & Mental Health, 9(1), 16-24.doi:10.1080/13607860512331334068.

Meares, S., & Draper, B. (1999). Treatment of vocally disruptive behaviour of multifactorial aetiology. International Journal of Geriatric Psychiatry, 14(4), 285-290. doi:10.1002/(SICI)1099-1166(199904)14:4<285::AID-GPS900>3.0.CO;2-2.

Nazarko, L. (2011). Coping with vocally disruptive behaviour in advanced dementia. British  Journal of Healthcare Assistants, 5(9), 430-432. doi:10.12968/bjha.2011.5.9.430.

Pieper, M. J. C., Achterberg, W. P., Francke, A. L., Steen, v. d., J.T, Scherder, E. J. A., & Kovach, C. R. (2011). The implementation of the serial trial intervention for pain and challenging behaviour in advanced dementia patients: A clustered randomized controlled trial.BMC Geriatrics, 11(1), 12-12. doi:10.1186/1471-2318- 11-12.

Schneider, L. S., Dagerman, K. S., & Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. Jama, 294(15), 1934-1943. doi:10.1001/jama.294.15.1934.

Schneider, L. S., Pollock, V. E., & Lyness, S. A. (1990). A metaanalysis of controlled trials of neuroleptic treatment in dementia. Journal of the American Geriatrics Society, 38(5), 553-563.

Saulnier, D. (1988). Reaction of elderly screaming repetitively to the affective touch of a nurse. Unpublished Master thesis, Université de Montréal.

Turner, S. (2005). Behavioural symptoms of dementia in residential settings: A selective review of non-pharmacological interventions.Aging & Mental Health, 9(2), 93-104. doi:10.1080/13607860512331339090.

External links

• Dementia Australia -additional information and statistic about dementia in Australia: [1]
• Dementia in Australia: Australian Institute of Health ad Welfare : [2]
• Vocally disruptive behaviour in dementia: Development of an evidence based practical guideline : [3]