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Despite the common belief, dementia is not a disease or disorder in itself. It is rather a general term for a severe decline in memory and other cognitive skills of a person, which obstruct his/her normal performance of daily activities. Among the most common types of dementia are Alzheimer’s disease, vascular dementia, frontotemporal dementia, and Lewy body dementia. It is not uncommon for people develop more than one type of dementia at the same time, usually a combination of Alzheimer’s disease and some other type of dementia. Depending on each particular case, patients may exhibit different symptoms and engage in various problematic behaviours. The behaviours that are more or less common to all types of dementia include restlessness and irritability, apathy and anxiety, depression and delusions, changes in sleep patterns, agitation and aggressiveness. Just as with other diseases, people suffering from dementia may become agitated or even aggressive abruptly and for no particular reason, even though there may be some indicators of a forthcoming aggressive episode. In any case, the instances of agitation and aggression are distressing for caregivers. Relying on credible academic literature, this paper will begin with a brief discussion of the pathophysiology of dementia before delving into the analysis of behavioural changes in people with dementia, focusing particularly on agitation and aggression. Finally, it will describe the effectiveness of the person-centred dementia care, again with a particular focus on its impact on agitation and anxiety.
The Pathophysiology of Dementia
The understanding of dementia’s pathophysiology has not changed dramatically in the past several decades. Back in 1986, Plum stated that Alzheimer’s disease, as the common cause of dementia, also led to a “cortical-subcortical degeneration of ascending cholinergic neurons and large pyramidal cells in the cerebral cortex” (67). Today, the researchers also agree that dementia is closely associated with system degenerations in the organism (Esiri & Trojanowski 2004; Kalaria 2010). There is another agreement in the academic quarters that dementia is associated with multiple neuropathologic processes, such as vascular and neurodegenerative diseases (Kalaria 2010; Haslam 2014). All types of dementia are caused by the damage of brain cells. With brain cells impairment, individuals cannot communicate normally and engage in other regular behaviours. The pathophysiology of different types of dementia has its own specific aspects, as its various forms are caused by brain cells damage in different parts of the brain. Yet, all types of dementia presume the shrinkage of brain tissue and the loss of nerve cells (Haslam 2014). More importantly, dementia is almost necessarily developing together with some other comorbidity.
Behavioural Changes in People with Dementia
One of the sure facts about all types of dementia is that people suffering from it will start to behave differently with time. As dementia progresses, its symptoms usually become more and more abnormal. Oftentimes, when a person with dementia exhibits some unusual behaviour, it is erroneously regarded as another symptom of dementia (Spencer & White 2015). In reality, however, the reasons underlying behavioural change may have a different character. The potential causes of alterations in patients’ conduct may be psychological, social or biological. When biological causes are at play, a change in conduct ensues from the patient’s painful experiences (Wiggins & Middleton 2013). In terms of psychology, a change in behaviour most often signifies the perception of some threat by the person (Wiggins & Middleton 2013). When social or environmental forces are apparent, a person with dementia may begin to behave differently or even oddly because of disorientation and a dawning realization that the society cannot support his/her needs (Wiggins & Middleton 2013). In any case, the patient is not sure how to proceed and how to cope with the new challenge, struggling to understand what is happening.
Whereas social and psychological causes of dementia are typical to all types of this condition, biological causes vary, thereby causing different changes in conduct. Indeed, Wiggins and Middleton (2013) explain that the impairment of different areas of the brain result in different behavioural outcomes. For example, if the epicentre of damage is located in the frontal lobe of the brain, the person is most likely to exhibit personality changes. By contrast, if the temporal lobe of the brain is affected, the person’s memory will suffer, precipitating negative changes in conduct.
A common fact from the consulted literature is that individuals suffering from this condition commonly lose their ability of expression before they lose their ability of understanding (Wiggins & Middleton 2013; Spencer & White 2015). As a result, some patients use their behaviour – either consciously or subliminally – as a means of communication. In other words, people with dementia engage in some undesired conduct to impart their feelings and frustrations. Trying to stop the occurrence of some behaviour in people with dementia by teaching them new skills is often futile and even counterproductive, as dementia cannot be cured (Wiggins & Middleton 2013). On the contrary, it is essential for the family members and other caregivers to learn to decipher the messages that people with dementia seek to convey through their acts. Another feasible strategy is decreasing the frequency and/or intensity of undesired behaviours. This task can, in part, be achieved by learning to understand the underlying causes of each particular type of conduct.
Agitation and Aggression in People with Dementia
The most common forms of behaviour exhibited by people with dementia include restlessness, meaningless walking, uncalled-for shouting and screaming, sleep disturbance, trailing and checking, hoarding and hiding things, losing inhibitions and behaving embarrassingly, sundowning, and engaging in repetitive actions (Dickerson & Atri 2014). As mentioned earlier, different behaviours can be associated with the damage in different areas of the brain. Yet, there is no golden rule that would limit some particular type of conduct to the distinct kind of brain damage. Moreover, people with dementia may develop and exhibit several disturbing behaviours at the same time.
For the purposes of this essay, the author will focus on agitated and aggressive behaviours in people with dementia. As a form of conduct in itself, agitation is also associated with a series of other acts, including restlessness, sleeplessness, irritability, and physical or verbal aggression. The problem is that the borderland between some of these behaviours is very thin and difficult to understand. The causes of agitation in people with dementia range from feelings of anxiety and boredom, basic needs like thirst and hunger, and environmental stimuli, to medical reasons like medication side effects, constipation, and painful experiences (Dickerson & Atri 2014). Most often, however, people with dementia act aggressively when they feel that the control is being taken away from them (Wiggins & Middleton 2013). It is also important to comprehend that the disturbing conduct has a tendency to deteriorate as dementia progresses.
Aggressive behaviours are equally distressing and problematic in people with all types of dementia. Although aggression is more common in the moderate and severe cases of this disease, the “prevalence rate of agitation or aggression in demented people” is estimated at 30% (Woo & Keatinge 2008, p. 343). Physical aggression ranges from hair-pulling and pinching to biting and pummeling. Less dangerous but equally distressing symptoms is verbal aggression: shouting, accusing, swearing and threatening. Even though many demented patients have developed a penchant for aggressive acts long before their diagnosis, some of them may develop aggressive types of behaviour only after the diagnosis (Dickerson & Atri 2014). The causes of aggressive conduct in people with dementia are multiple and can be largely divided into three categories: biological, psychological and social. Some of these origins overlap with those underlying agitated acts, but others are unique to the displayed aggression.
People with dementia usually display agitation and aggression in in the late afternoon or in the evening. In the medical circles this pattern is known as “sundowning” (Woo & Keatinge 2008). Whenever this phenomenon occurs, the causes underlying agitated behaviours may be different from those during regular aggressive acts. Thus, in the cases of sundowning, aggression or agitation may be caused by excessive noise, excessive or insufficient light, disturbed sleep, the wearing-off effects of the prescribed pharmaceuticals, etc. (Dickerson & Atri 2014). Sundowning aggression and agitation require separate attention and treatment approaches.
Models of Dementia Care
There are several models of dementia care available to healthcare professionals. One of the most widely used models in the late 20th and early 21st century has been a collaborative dementia care model. This model focuses on delivering biopsychosocial interventions to both demented patients and their family caregivers. The model has earned relatively good reputation for improving quality of life and care as well as psychological and behavioural symptoms of demented patients and their caregiver (Hughes 2011). Palliative models of dementia have also focused on delivering holistic care and on integrating family members and other potential stakeholders in the delivery of care to people with dementia. Importantly, one major principle of palliative care is that patients themselves should often remain unaware of the fact that they are receiving this type of care (Hughes 2011). Supportive care, another model of dementia care, involves a “full mixture of biomedical dementia care, with good quality, person-centred, psychosocial, and spiritual care under the umbrella of holistic palliative care throughout the course of the person’s experience of dementia” (Hughes 2011, p. 201). In contrast to the previous model, supportive model of dementia care does not extend across the person’s entire experience of dementia and lasts a shorter period of time. Overall, it appears that, while each approach has its distinctive features, they are all based on some similar principles.
Person-centred dementia care is a model of dementia care that merits special attention, not least because it has been the predominant philosophy of care for demented people. This model is analysed in the following two subsections.
Person-Centred Dementia Care
Medical treatment of dementia is frowned upon, since there is no unassailable evidence that would prove its efficacy. Indeed, trying to control the troubling behaviours in people with dementia with the help of antipsychotics or other pharmaceuticals produces disturbing side effects, including premature death (Loveday 2012). Hence, in order to handle troubling acts in demented patients, caregivers need to try and understand the message that patients seek to impart through their conduct. Later, they ought to respond to that behaviour in an appropriate manner. Unsurprisingly, person-centred care is a preferred intervention for the patients with dementia.
True to its name, person-centred dementia care aims to devote separate attention to each individual patient. Instead of regarding each demented person as possessing all typical symptoms of dementia and, therefore, seeking to address these symptoms with a universal approach, person-centred dementia care considers each patient’s unique abilities, qualities, preferences and needs (Loveday 2012; Dickerson & Atri 2014). Based on the definition of Timothy Epp (2003), person-centred dementia care shifts away from “a task-oriented, professional-driven healthcare towards a more holistic model of care, which emphasizes patients’ perspectives and their subjectively defined experiences and needs” (1). Another salient feature of person-centred dementia care is putting people with dementia and their family members at the centre of decision making and encouraging them to work alongside professionals, so as to achieve the best outcomes.
The Impact of Person-Centered Dementia Care on Agitation and Aggression
Agitated and aggressive conduct can be difficult to tackle, because it can take various forms. It is important to realize that, just as any other behaviour exhibited by people with dementia, agitation and aggression may simply be the patient’s way of meeting his/her needs or communicating them. Of course, agitation and aggression may result from the unmet needs as well (Dickerson & Atri 2014). In any case, they have to be addressed with a degree of urgency and carefulness. Usually, a person-centred dementia care intervention would begin with a careful study of the patient’s behaviours, including the insights from family members. In such a way, practitioners would be able to understand the cause of these behaviours and select the most appropriate interventions.
Generally, a person-centred dementia care plan for handling, preventing or managing agitation and aggression would include:
In other words, it is clear that patient-centred model of dementia care puts a focus on the cognitive needs of patients rather than on their physical or medical needs. Very often, patient-centred dementia care programs concentrate on the remaining skills and abilities of individuals instead of trying to resuscitate the forgotten skills. These programs respect patients’ rights and wishes as well as maximize their independence.
This paper has shown that dementia is a complex health condition with a complicated etiological pathway. More importantly, dementia is a general term that includes a number of mental disorders, such as Alzheimer’s disease and vascular dementia, and not just a disease in itself. People suffering from dementia often suffer from more than its one type, co-occurring morbidity, and occasional abnormal behaviours. The associated acts include restlessness, sleep disturbance, hoarding and hiding things, losing inhibitions, agitation and aggressiveness, and sundowning. More specifically, people with dementia engage in agitated and aggressive acts because they want to communicate their needs to the caregivers or because of the protracted failure to have these needs met. This paper has shown that the use of medication to treat aggressive and agitated conduct in people with dementia is often counterproductive. Hence, person-centred dementia care is a preferable option of handling aggressive and agitated behaviours in demented persons. This practice requires active cooperation of family members and professionals and focuses on the special circumstances of each particular patient. Lastly, this paper has important implications for practice and education. The findings clearly suggest how agitated and aggressive acts in people with dementia should be managed. Likewise, it outlines the general information about the management of other problematic behaviours in the individuals with dementia.
Epp, T 2003, ‘Person-centered dementia care: a vision to be refined,’ The Canadian Alzheimer Disease Review, viewed 22 August 2016, <http://www.livingdementia.com/downloads/docs/person-centered_dementia_care.pdf>.
Dickerson, B & Atri, A 2014, Dementia: comprehensive principles and practice, Oxford UP, Oxford.
Esiri, M & Trojanowski, J 2004, The neuropathology of dementia, Cambridge UP, Cambridge.
Haslam, M 2014, Psychiatry: made simple, Elsevier, Amsterdam.
Hughes, JC 2011, Thinking through dementia, Oxford UP, Oxford.
Kalaria, R 2010, ‘Vascular basis for brain degeneration: faltering controls and risk factors for dementia,’ Nutrition Reviews, vol. 68, no. 2, pp. 74-87.
Loveday, B 2012, Leadership for person-centered dementia care, Jessica Kingsley Publishers, London.
Plum, F 1986, ‘The pathophysiology of dementia,’ Gerontology, vol. 32, no. 1, pp. 67-72.
Spencer, B & White, L 2015, Coping with behavior change in dementia: a family caregiver’s guide, Whisppub, Provo.
Wiggins, J & Middleton, A 2013, Getting the message across: communication with diverse populations in clinical genetics, Oxford UP, Oxford.
Woo, S & Keatinge, C 2008, Diagnosis and treatment of mental disorders across the lifespan, John Wiley & Sons, Hoboken.