Optimizing Behavioral Techniques Can Ease the Burden of Care

When treating agitation in the elderly, the optimization of certain behavioral techniques may enhance medication therapies or sometimes eliminate the need for them, said Kevin Gray, M.D., during his presentation "Hugs Not Drugs: Behavioral Techniques for Agitation in the Elderly" at the recent U.S. Psychiatric & Mental Health Congress.

Gray, director of the Memory Disorders Clinic at the Veterans Affairs North Texas Health Care System, began by describing some general misconceptions both physicians and caregivers have about people suffering from dementia.

"[When discussing] dementia," Gray explained, "there's a great deal of focus on cognitive impairment and the fact that people's mental capacities are stolen from them by the dementing illness...Yet, fundamentally, the dementias are disorders not just of cognition, but of behavior and personality...If you look at demented individuals, regardless of the diagnosis, you will see that almost all of them have associated personality and behavior changes; and at least half of them will become agitated at some point during the course of their illness."We have all sorts of views of older people," Gray told his audience. "Some appear very kind and benign. Then we have the ones that make our beepers go off and our phones ring."

In the past, physicians didn't intervene much in the early stages of the disease process, Gray said. "We [physicians] sort of shrugged our shoulders until things went badly, and then we tranquilized [the patients] with powerful drugs."

Gray advised clinicians to look more closely at the behavioral causes behind a demented older person's problem behavior, and has summarized a method he devised to facilitate the evaluation process-the Keys to E-Z Evaluation (Table). The keys include, for example, identifying the problem behavior and the timing and frequency of such behavior. Only after weighing all the components of the E-Z Evaluation, said Gray, should the physician make a recommendation.

After the evaluation is complete, Gray continued, management of the agitated elder is required. Gray uses two behavioral management keys: general environmental assessment and targeting specific problem behaviors. By performing an environmental assessment, physicians can help patients' families understand the principles of environmental management: serenity, safety, structure and sanity.

Serenity

Serenity means managing affect, said Gray. In other words, it's not what the physician or caregiver says, but how it is said. He explained that in a demented individual, the ancient parts of the brain that have to do with friend or foe, fight or flight, still work quite well, even as language breaks down and logic becomes unavailable. Thus, it is crucial that caregivers display a pleasant countenance and speak in a pleasant tone to the patient. It also is important not to overstimulate the patient-regardless of the environment. Speaking in a calm, clear voice, perhaps with gentle touching, can achieve a calm atmosphere. As words start to lose their meaning, caregivers should use as many modalities as they can to communicate effectively. Arguing is useless, because logic cannot be understood.

Safety

Within the rubric of safety lies childproofing, said Gray. He suggested that physicians advise caregivers to make all medications inaccessible, put away power tools and automatic weapons, take small appliances off the kitchen counter, install smoke alarms, check stairs and handrails, put a fence around the swimming pool, and discourage the patient from driving a car-something that is especially hard if the patient has been driving for 50 or more years. It might be a good idea to disable home shopping services on television, too, he added. The phone can be programmed to ring only once, or even silently, and can be equipped with a hidden answering machine to pick up messages. Mail can be a problem, he noted, especially when it involves sweepstakes mailers, since demented patients are unable to recognize deception.

Structure

Through structure, said Gray, physicians and caregivers can entrain new habit and motor memories. These memories are dopami-nergically mediated and available even at a time when "our magnificent neocortex is failing dismally," he added.

"One of the things that I've structured is prompted voiding or so-called scheduled voiding," he said. "Encouraging [patients] to toilet when they first get up or every three hours is a way to get around...accidents."

Sanity in the environment is very important. "You have heard the old saying, 'Don't pay attention, it's the liquor talking,'" said Gray. "I try to take the same tack and tell my families, 'Don't pay attention, it's the Alzheimer's talking.' So a caregiver doesn't have to convince me that she's not really sleeping with the preacher, as her spouse may have just informed me.

"Also realize that the patient's language may get saltier and the personality a little more detached as the disease progresses. Sometimes, dementia patients say things that can be quite hurtful, such as 'You're so stupid,' or 'That's the ugliest hat I've ever seen.' I advise my families that it's the disease talking, and these things need to roll off them to the extent that they're able to allow it."

Critical Problems

In the early stages of dementia, cues such as reminding patients what day and year it is can help with memory, Gray said. However, as the disease progresses, he cautioned, cueing doesn't last. Reminiscing with the patient is helpful, because ancient memories are burned in deeply and remain available, said Gray. Caregivers should talk about the old days, but also realize that as time goes on, these memories will become less available.

Regarding language, Gray recommended that clinicians and caregivers speak slowly and simply, and ask questions that require only a yes or no answer. He recommended further that they present only one idea at a time, since presenting demented patients with too many choices can be overwhelming. Nonverbal cues, such as body language, also work well. A powerful nonverbal cue is the handshake, according to Gray. Many times just extending a hand is enough to encourage a recalcitrant patient to accompany their caregiver.

During a visit to the physician's office, clichs can serve as social lubrication, and keep things upbeat. "Hey, I like that tie." "Where'd you get those shoes?" This sort of general social conversation can keep the tone of the interview at a very pleasant level, said Gray.

Loss of executive cognitive functions becomes obvious as the patient becomes increasingly unable to engage in activities that require planning, anticipation, sequencing, orchestration, goal-directed activity, response inhibition and abstraction. For example, Gray said, patients may be able to make toast for breakfast, but unable to manage the planning required to prepare a meal.

Signs of the dysexecutive state include disinhibition and poor judgment. This includes disrobing, sexual displays and hoarding. With a disrobing problem, it is helpful to alter the way clothing is worn, Gray advised. For example, he suggested that if there is a drawstring, it should be turned to the back, or double-knotted. For inappropriate sexual displays, he advised redirection, limitation, looking for antecedents, privacy and distraction with manual activities.

The notion of hoarding is important, Gray said. "Folks [go] on patrol, touring, picking up sugar packs, picking up dentures [and] putting them in, putting on glasses, but they may be [someone else's] glasses.

"Apathy also falls under the dysexecutive state. If a patient is apathetic, the best thing to do is try to engage them. If they're playing cards, play cards with them, or if they're raking the yard, rake with them," he said.

Psychiatric Syndromes

Gray touched briefly on effective ways clinicians can address psychiatric syndromes. With someone suffering from delusions and hallucinations, he advised, "Don't argue, don't confront, don't deny; give honest, noncommittal answers. Try to understand patient explanations."

He recommended optimizing sensory output with things such as improved lighting, glasses and hearing aids. Caregivers should remain visible and available, and help the patient focus on familiar aspects of the situation by using voice endearments and favorite belongings. Minimizing opportunities for failure and self-harm, and maximizing physical comfort can help in cases of depression. Engaging the patient in, and encouraging them to perform, simple, familiar, successful tasks may also ease their distress.

For someone suffering from anxiety, Gray recommended reassurance, affection and distraction, and keeping patients' hands busy in a serene milieu. He warned that asking for explanations may worsen the situation.

Agitation

With agitated patients, said Gray, clinicians should advise caregivers to sit with the individual, assess their needs and pains, and look for possible environmental triggers. Irritable patients can often be distracted and redirected if caregivers plan demanding activities for patients' best time of day. To curb yelling and screaming, caregivers should manage affects and not overreact. They might try using music, perhaps asking the patient to sing along; or encourage tactile activity.

Resistant patients, said Gray, respond best if the caregiver focuses on positive aspects and rewards, and is willing to compromise. It is important to remind and assist, not take over, and always be ready to gently try again.

For catastrophic reaction, Gray said, "It is important to keep calm, manage affects, reduce choices and stimuli; look for environmental triggers; and distract with tasks."

For aggression, Gray suggested looking for cues that the patient is decompensating and letting the patient relax. Clinicians need to be receptive and patient, and lead the patient to a quiet area.

In conclusion, Gray asked physicians to remember the person with the hardest job of all-the caregiver."Studies estimate that between 50% to 75% of the caregivers of demented individuals have significant episodes of clinical depressive symptoms that may require antidepressant medication," said Gray. "Be sure they know about adult day care, respite care and any other options that may help them."