‘Behaviour that challenges’ in dementia care: an update of psychological approaches for home and care home settings

Over and above the personal and financial costs associated with dementia, those for ‘behaviour that challenges’ (BtC) are significant (Lowry & Warner, 2009; Hermann et al., 2006). This briefing paper outlines the importance of having a psychological understanding of both the causes and appropriate interventions required for BtC. It highlights the role of clinical psychologists, ideally working within multi-disciplinary teams, in producing biopsychosocial formulations to meet the health and psychosocial needs of a person living with dementia (PwD). The paper also draws on relevant evidence including findings from a recently completed NIHR programme of work on the Management of Challenging Behaviour at home and in care homes (Moniz-Cook et al., 2017) to provide recommendations for action

A manifesto for cyborg pedagogy?

This paper was published in International Research in Geographical and Environmental Education, 10 (2), pp. 195 - 201, 2001. © 2001 T. Angus et al.This paper seeks to give an impression of what can happen if teachers encourage their students to take personally the issues they study, and to think and to write about how their identities and everyday lives are inseparable from the kinds of issues studied in the geography classroom. It discusses three principles – situated knowledge, cyborg ontologies and border pedagogy – which have guided the organisation of an undergraduate course on the geographies of material culture. This attempts to get students to think through their connections with the lives of distant others through simple acts of consumption, and the responsibilities which they might therefore have. This paper illustrates the kinds of student writing that can come out of such a course and the ways in which this issue of responsibility should be, and is, talked about

Nature of behaviours that challenge in residents living in aged care homes: implications for psychosocial interventions and service development

Background/Aims: Competing theories exist regarding the causes and nature of behaviours that challenge (BC). The present study attempted to provide better insight into these behaviours and determine whether there were any underlying relationships for people living in care homes with and without dementia. Methods: Cross sectional data for 2185 residents living in 63 UK care homes using the Challenging Behaviour Scale were collected. The incidence (i.e. presence/absence) of 25 commonly reported behaviours that challenge staff were determined using dichotomous scoring. Cluster analysis and Mokken scaling were used to examine underlying relationships. Mokken is a method of analysing data to determine whether there is a ‘latent’ structure within a data set. Results: The prevalence of reported BC was 87.5%. Cluster analysis revealed three main clusters: apathy, agitation with internal focus, agitation with active external focus. For seven of the 25 items a hierarchical model emerged, where behaviours at the bottom of the hierarchy tended to occur in the presence of those higher up. Behaviours at the bottom of the hierarchy (dangerous behaviour) were less frequently observed than the items at the top (lack of self-care, verbal aggression). Conclusion: Some common BC may occur in groups and themed clusters. This study has shown that a hierarchical structure of BC in residents may be present. The findings testify to the complexity in the aetiology and treatment of BC and hence the need for focussed high intensity bio-psychosocial interventions to be targeted towards those with high levels of ‘unmet need’. Implications for future research and practice are discussed

Challenging behaviour in dementia care: A novel framework for translating knowledge to practice

This article provides guidance on the management of challenging behaviours (CBs) in dementia care, and introduces concepts from positive behavioural support not usually applied to dementia. While the use of formulations has received a lot of attention in recent years, the mechanisms of how to apply the formulation-led interventions requires more consideration. In order to assist caregivers to deliver effective interventions we need to have a better understanding of the CBs we are attempting to manage, and also produce management strategies with clearer goals. Ideally we would also want caregivers to be able to describe the skills they employ in a coherent manner in order to facilitate selfreflection and to be able to pass on their skills to junior colleagues. This paper attempts to fulfil these needs by integrating two new models with philosophies already used in dementia care. In terms of new concepts, the first is the Arousal Cycle, which gives caregivers an awareness of the five phases of a typical CB (wellbeing, trigger, escalation, CB, and recovery phase). In relation to the second, the Traffic Light analogy examines CBs in terms of four management stages: Primary prevention, secondary prevention, reactive strategies, and calming strategies. It is proposed that we distinguish between these stages when composing our formulations and care plans, and thereby produce better targeted interventions. By the end of the paper the reader will have been presented with material integrating concepts from the fields of dementia and intellectual impairment, and been introduced to new ways of managing CBs

UK clinicians’ views on the use of formulations for the management of BPSD: a multidisciplinary survey

© 2020 Informa UK Limited, trading as Taylor & Francis Group. Background and objectives: The process of formulating in the area of dementia care is at an early stage of development. A review published in 2016, identified 14 different types of formulation-based approaches for the management of Behavioural and Psychological Symptoms of Dementia (BPSD). The present study examines professionals’ views about the use of systematic formulations for choosing first-line non-pharmacological interventions for BPSD. Methods: A 34-item online survey, with six items about formulation-based interventions for the management of BPSD, was circulated to multi-disciplinary UK dementia networks. Quantitative data were examined for the use of formulation-based frameworks in practice. Thematic analyses provided insight into the practicalities of using formulations. Results: The majority of the 355 participants responding to the questions stated they used formulation-led models to inform interventions, but 24% stated they did not. Thirty-two types of formulation frameworks were named, and there was a diverse spread across the UK. The Newcastle model was the most frequently used framework, with fifty percent of the participants who formulated reporting using this framework. Four themes regarding the use of formulation emerged, relating to function, process, reported outcomes and obstacles. Conclusion: Formulation-based approaches to targeting intervention are becoming popular in dementia care in the UK. More types of formulation frameworks are used in practice compared with the 2016 review. The use of formulations are seen as key to offering an alternative to pharmacological treatments. Understanding both the value of formulation-led approaches and the obstacles to their use are important to implementing NICE 2018 recommendations

Getting our terminology right: the power of language

For over 25 years, the term challenging behaviour (CB) has been used to describe agitation and other “distressed” behaviours associated with dementia (Stokes 2000). But such is the power of language and the importance of getting our terminology right, there has been much debate about whether we should continue to talk of “challenging behaviour”. We will discuss the results of a survey on what should replace the term, but first we will review the background to the debate

Behavioural and psychological symptoms of dementia : a new framework for holistic understanding and non-pharmacological management

The National Institute for Health and Care Excellence (NICE) informs us that the first-line treatments for behavioural and psychological symptoms of dementia (BPSD) are non-pharmacological. Although psychotropics used to be the main strategy in the management of behaviours that challenge, there has been an increase in the use of biopsychosocial formulations since 2010, and there are now over a dozen to choose from. However, many are overly focused on obtaining information about the agitation, and less specific about providing details of the actions required to manage the behaviours. The NICE guidelines too fail to provide specific guidance on which non-pharmacological approaches to use. This article argues for giving equal weight to both the collection of meaningful information and the development of 'informed actions', because it is the actions that lead to change. The article outlines a management programme providing a framework for the assessment, formulation and treatment of agitation in dementia. The work draws on theory, evidence-based practice and practice-based evidence to provide a model with sufficient structure and flexibility to be useful for clinicians across a range of settings and professional groups

Correlation of esophageal pressure-flow analysis findings with bolus transit patterns on videofluoroscopy

This is a pre-copyedited, author-produced version of an article accepted for publication in Diseases of the Esophagus following peer review. The version of record Omari TI, Szczesniak MM, Maclean J, Myers JC, Rommel N, Cock C and Cook IJ. Correlation of esophageal pressure-flow analysis findings with bolus transit patterns on videofluoroscopy. Dis Esophagus. 2016 Feb-Mar;29(2):166-73. and is available online at: http://dx.doi.org/10.1111/dote.12300 Copyright © 2017 The International Society for Diseases of the EsophagusPressure-flow analysis quantifies the interactions between bolus transport and pressure generation. We undertook a pilot study to assess the interrelationships between pressure-flow metrics and fluoroscopically determined bolus clearance and bolus transport across the esophagogastric junction (EGJ). We hypothesized that findings of abnormal pressure-flow metrics would correlate with impaired bolus clearance and reduced flow across the EGJ. Videofluoroscopic images, impedance, and pressure were recorded simultaneously in nine patients with dysphagia (62–82 years, seven male) tested with liquid barium boluses. A 3.6 mm diameter solid-state catheter with 25 × 1 cm pressure/12 × 2 cm impedance was utilized. Swallowed bolus clearance was assessed using a validated 7-point radiological bolus transport scale. The cumulative period of bolus flow across the EGJ was also fluoroscopically measured (EGJ flow time). Pressure only parameters included the length of breaks in the 20 mmHg iso-contour and the 4 second integrated EGJ relaxation pressure (IRP4s). Pressure-flow metrics were calculated for the distal esophagus, these were: time from nadir impedance to peak pressure (TNadImp to PeakP) to quantify bolus flow timing; pressure flow index (PFI) to integrate bolus pressurization and flow timing; and impedance ratio (IR) to assess bolus clearance. When compared with controls, patients had longer peristaltic breaks, higher IRs, and higher residual EGJ relaxation pressures (break length of 8 [2, 13] vs. 2 [0, 2] cm, P = 0.027; IR 0.5 ± 0.1 vs. 0.3 ± 0.0, P = 0.019; IRP4s 11 ± 2 vs. 6 ± 1 mmHg, P = 0.070). There was a significant positive correlation between higher bolus transport scores and longer peristaltic breaks (Spearman correlation r = 0.895, P < 0.001) and with higher IRs (r = 0.661, P < 0.05). Diminished EGJ flow times correlated with a shorter TNadImp to PeakP (r = −0.733, P < 0.05) and a higher IR (r = −0.750, P < 0.05). Longer peristaltic breaks and higher IR correlate with failed bolus clearance on videofluoroscopy. The metric TNadImp to PeakP appears to be a marker of the period of time over which the bolus flows across the EGJ

Inter-rater reliability and validity of automated impedance manometry analysis and fluoroscopy in dysphagic patients after head and neck cancer radiotherapy

This article may be used for non-commercial purposes in accordance With Wiley Terms and Conditions for self-archiving'.Copyright © 2015 John Wiley & Sons, Inc. All rights reserved.Introduction: Automated Impedance manometry (AIM) pressure-flow analysis is novel non-radiological method to analyse swallowing function based on impedance-pressure recordings of pharyngeal swallows. In a population of dysphagic head and neck cancer patients, we evaluated the reliability and validity of the AIM-derived swallow risk index (SRI) and a novel measure of post-swallow residue (iZn/Z) by comparing it against videofluoroscopy as the gold standard for assessing aspiration and post-swallow residue risk. Materials and Methods: Three blinded experts classified 88 videofluoroscopic swallows from 16 patients for aspiration and the degree of post-swallow residue using validated videofluroscopy scales. Pressure-impedance recordings of the swallows were also analysed using automated analysis software by one expert and two novice observers who derived the SRI and iZn/Z. Inter-observer concordance for videofluoroscopic and AIM measures was assessed using intraclass correlation coefficients (ICC). Patient SRI and iZn/Z measurements were compared with videofluoroscopy scores and control subjects to determine validity for detecting clinically relevant swallowing dysfunction. . Results: Among individual swallows, agreement among observers assessing presence of penetration and aspiration on videofluoroscopy was modest (ICC 0.57). Agreement among observers for AIM-derived swallow risk index (SRI) and the iZn/Z was good (ICC of 0.71 and ICC of 0.82 respectively). When compared with age-matched controls the SRI was higher in patients with aspiration (mean diff. 28.6, 95% CI [55.85 1.355], p<0.05). The iZn/Z was increased, suggesting greater post-swallow residues, in both patients with aspiration (Δ244 [419.7, 69.52, p<0.05]) and penetration (Δ240 [394.3, 85.77, p<0.05]) compared to controls. Discussion: AIM based measures of swallowing function have better inter-rater reliability than comparable fluoroscopically-derived measures. These measures can be easily determined and are objective markers of clinically relevant features of disordered swallowing following head and neck cancer therapy