Today’s re-blog as part of World Alzheimer’s Month focuses on an article by Susan Macaulay which comments on Dementia not the cause in majority of harmful resident-on-resident interactions.
“It is important to emphasize that the vast majority of harmful resident-to-resident interactions that involve people who live with dementia in long-term care homes are the result of negative and distressing factors in the social (i.e. other people) and physical environment. In most situations, unmet human needs, situational frustrations, and perceived and real threats contribute or directly cause these behavioral expressions.
These social and physical environmental factors and unmet needs intersect with the person’s cognitive disability to generate the episodes. Most elders with dementia are not inherently aggressive. Like us, they react, respond, defend, and protect themselves when they experience distress, and when they sense that their dignity, privacy, identity, and personhood are threatened.”
The Campaign to ban the medical model of BPSD, the Behavioural and Psychological Symptoms of Dementia, raises awareness of the need to move from the medical model of Dementia care to the social model, moving from treating the symptoms to treating the cause.
It looks for new and innovative approaches to Dementia and aged care philosophies and practices.
Removing the medical model, removes the pathway to chemical and physical restraint, sectioning, involuntary care and segregation, which leads to disengagement.
Embracing the social model leads to a pathway that looks at the individual and treats the causes and symptoms, through things like assessments and interventions, treating the symptoms and unmet needs by providing support, services and coping strategies, enabling the person to be engaged with life and their carer/family live within their community, reduce stigma and reduce Hospital admissions for as long as possible.
In saying all of this, I do understand that prescribing Risperidone, which is the only anti-psychotic medication licensed in the UK for Dementia, may benefit some with any chronic terminal disease, however, imagine the outcry if all the support and services were removed and a similar pathway to BPSD was applied to people living with cancer.
It should not be seen as the treatment of choice for professionals, rather coming at the end of a list of assessments to see if other interventions and coping strategies may benefit the person and their carer/family.
For too long, healthcare systems worldwide have used the medical model of healthcare to treat the symptoms for the benefit of big pharma and to the detriment of the person, rather than assess the causes and deal with them.
The number of people involved in this campaign is growing worldwide and as the number grows, so does it’s voice and I am proud to be involved myself.
Let me state from the outset reader, that the campaign to Ban BPSD in no way advocates the complete removal of antipsychotics.
As with any other chronic terminal disease they do have a place but the campaign wants to see healthcare systems move from the medical model which on further reading you will see that it abuses the person with Dementia and ignores their human rights, to the social model that treats the causes.
Currently, healthcare systems follow the medical model of BPSD which leads to the pathway of Chemical Restraint, Deprivation of Liberty and Involuntary Care.
The medical model treats the symptoms of BPSD usually by Chemical Restraint which leads to increase clusters of behaviours associated Dementia.
During nearly 20 years working in healthcare I saw many people living with Dementia given 0.5mg of Haloperidol/Haldol only for the person to disappear within 48 hours, unable to do the basic activities of daily living (ADLs), the person and quality of life gone.
The NICE/SCIE guideline “Antipsychotics in people with Dementia” Last updated :
“Advises against the use of any antipsychotics for non-cognitive symptoms or challenging behaviour of dementia unless the person is severely distressed or there is an immediate risk of harm to them or others. Any use of antipsychotics should include a full discussion with the person and carers about the possible benefits and risks of treatment.
In the May 2012 edition of Drug Safety Update, the MHRA advised that no antipsychotic (with the exception of risperidone in some circumstances) is licensed in the UK for treating behavioural and psychological symptoms of dementia. However, antipsychotics are often prescribed off-label for this purpose.”
Many pathways advocate reducing Polypharmacy that may contribute to BPSD but they do not advocate replacing them with alternatives. Polypharmacy refers to a person taking 5 or more different types of medication, surely ready they wouldn’t have been prescribed if they weren’t needed.
Removing medications without replacement may cause clusters of BPSD because symptoms of a pre-existing condition return causing distress to the person.
A social model is concerned with treating the causes of behaviours, reducing the need for Chemical Restraint, Deprivation of Liberty and Involuntary Care. It enables people to continue to live with their Dementia’s for longer, reducing the need for safeguarding, involuntary care, being moved to a Care Home and respects the persons rights to live their life without restraint.
A lot of pathways include the different types of Mental State Examinations and Cognitive Assessments which are subjective tests that only provide a snapshot of a moment in time and are subject to variations based on the time of day, and many of the causes of BPSD.
Some of the potential causes of behaviours in Dementia are:
Urinary Tract Infection (UTI)
Not Recognising People/Places
Regressing to a Different Time
Lack of Meaningful Activities
which require proper assessment and treatment/strategies rather than antipsychotic medication.
Alzheimer’s Association : Challenging Behaviours
“Following representations by Dementia Alliance International and Alzheimer’s Disease International, the CRPD Committee has responded to our joint request to make it clear to Member States that persons with dementia and their care partners are fully included in the implementation of the CRPD on the same basis as those with other disabilities.
In 2017, dementia has been specifically mentioned in the review process on Canada and in a Parallel Report submitted by Disability Rights UK in the ongoing review of the UK government. Dementia is now described in UN documents as a cognitive disability.“
The use of the model of BPSD, can be a treatment of convenience that makes it easier to care for a person with Dementia but it’s effect is the removal of the person, their quality of life and their rights.
Using a social model to treat the causes/symptoms of Dementia can empower the person living with Dementia, retain the person and uphold their rights..
Dementia isn’t a mental health condition, it is a cognitive disability. Dementia is an umbrella term for over 100 chronic terminal neurological diseases which have a physical cause.
Obviously, as with any chronic terminal disease, there will be a minority that may require the intervention of a mental health professional and possibly pharmacological interventions during their journey with their disease but only after treating the causes of behaviours to improve their quality of life, using the social model, has failed.
The social model should recognise Dementia as a cognitive disability and begin at the point of diagnosis with state funded, inclusive rights based post-diagnosis support and services which continue along their journey with Dementia, regardless of age at diagnosis and in line with the UN Declaration of Human Rights and the Convention on the Rights of Persons with Disabilities (CRPD).
Leah Bisiani, MHlthSc, Dip Bus, dementia and aged care consultant, RN.1
Kate Swaffer, human rights activist, author, MSc dementia care, PhD candidate
Daniella Greenwood, consultant, author, speaker, activist
Dr Chris Alderman, B Pharm, PhD, FSHP, BCPP, CGP
Dr Al Power, Geriatrician, author, educator
Susan Macaulay, care partner, author, dementia advocate
BPSD stands for Behavioural and Psychological Symptoms of Dementia.
BPSD refers to the non_cognitive symptoms of Dementia, particularly in the middle and later stages.
It is estimated that up to 90% of people with dementia will experience Behavioural and Psychological Symptoms of Dementia (BPSD) at some time during their journey with Dementia.
Behaviours may result from any combination of neurodegenerative damage associated with the disease itself, unmet physical needs such as pain or discomfort, the environment they are currently in and unmet psychosocial needs, such as the need for meaningful human contact or fear.
Some examples of the BPSD are:
mood disturbance (e.g. depression);
psychosis, which may include delusions (false beliefs) and hallucinations (seeing or hearing things that are not actually there);
physical aggression; and
Commonly, BPSD is treated using the medical model that leads to a pathway of Chemical Restraint, Sectioning and Involuntary Care.
As an example, the model will suggest treating pain but does not mention that something as simple CoCodamol which may exacerbate BPSD by causing constipation thereby causing a cluster of symptoms which will eventually lead down the BPSD pathway.
It may also suggest reducing existing medications, well surely reader you wouldn’t be on any medication that was not needed. If any of my medications were stopped and not replaced by something that wouldn’t have a negative impact on BPSD, in time they could lead to the appearance of a cluster of BPSD symptoms and other medical problems moving on to sectioning and involuntary care.
There doesn’t seem to be any general recognition of environment in any of this either. If assessments for BPSD are done outside the home environment, any number of factors could lead to the appearance of BPSD.
Below is a summary of seven of the most common deficits seen in dementia that are most clearly linked to specific regions of the brain.
These are known as the 7 A’s:
1. Anosognosia – lack of insight into one’s deficits or illness attributable to temporo-parietal pathology.
2. Amnesia – loss of short-term and long-term memory due to pathology in the hippocampus and/or the temporal lobe. Short-term memory loss causes difficulty learning new information; long-term memory loss causes difficulty recalling
previously learned information and occurs in reverse order to the memory storage process (i.e. loss progresses from most recent to most remote).
3. Aphasia – loss of language expression or comprehension. In expressive aphasia (due to damage of Broca’s area of the frontal lobe), the individual may be able to comprehend speech, but is unable to express him or herself. In contrast, a person with receptive aphasia (due to damage of Wernicke’s area of the temporal/parietal lobe) may be able to express him or herself, but has impaired comprehension.
4. Agnosia – loss of ability to recognize people (including self), objects, or sounds despite intact sensory modalities of vision, touch, and hearing. The damaged area is the parietal lobe.
5. Apraxia – an inability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform them, due to impaired motor planning and sequencing processes controlled by the parietal lobe.
6. Altered perceptions – altered depth perception, visual distortions, and altered tactile perception are commonly seen in dementia due to damage to the parietal lobe.
7. Apathy – an inability to initiate activities or conversation due to damage in the
Polypharmacy which refers to the use of a large number of medications, commonly considered to be the use of five or more. Since polypharmacy is a consequence of having several underlying medical conditions, it is much more common in elderly patients and may be another cause of BPSD.
However, as an example, Primary Care in Ireland Definition , Assessment of a person with BPSD may be one of the better medical models however in their Medication Review they talk about stopping some treatments not replacing with other more suitable treatments, for example, Digoxin but not what to replace it with, which again could cause the appearance of a cluster of BPSD symptoms and other medical problems.
Kate Swaffer CEO of Dementia Alliance International recently wrote an article
Tomorrow reader, I will go on to give my opinion about why we should ban the medical model of BPSD in favour of a social model that retains empowers person and uphold the rights of a person living with Dementia.
However reader, the campaign to Ban BPSD does not advocate the complete removal of the use of antipsychotics in the treatment of Dementia, rather the ban on their inappropriate use which abuses the person and their rights.