Understanding Behaviour in Dementia that Challenges. Ian Andrew James

2.4 The common biopsychosocial causes of strippingRemoving clothes (stripping) – environmental features (weather, room temperature), body temperature and cultural aspects play important roles with respect to this behaviour.BiologicalHypothalmus – temperature control impairedFrontal lobe deficits, resulting in disinhibitionSensitive skinDrug-induced rashDrug-induced restlessnessParkinson’s medication resulting in hypersexualityUnderlying physical condition – resulting in feel hotHigh temperature due to infectionProstate problemsExcess use of alcohol, feeling flushed and/or disinhibitedConfusing night with day, thus undressing to prepare for bedPsychologicalBoredRestlessDislikes the clothes given to wearProtesting that clothes given are not their own clothesDisinhibitionLifestyle preference (never worn many clothes)A method to be removed from a fearful situationSocial and environmentalCopying other peoplePreparing to engage in sexual actsCulture does not wear many clothes, or does not regard nudity as a problematic issueSetting is too hotWeather is very warm and closePerson’s room is very sunnyPreparation for going to the toiletClothes are irritable, itchyIll fitting clothes – too tight or looseUnderwear too tightChairs with surfaces that make people prone to sweating

Table 2.5 The common biopsychosocial causes of walking with/without purpose
Walking with/without purpose (wandering) – there are many positive aspects to this activity (exercise, stress reduction, etc.). Hence, it is often appropriate to provide safe walking areas, rather than deny people the opportunity to engage in the behaviour.
BiologicalDistraction from pain and discomfortRelief physical discomfort (back pain, constipation)Drug-induced restlessnessInfection induced confusionSearch for food or water due to hunger/thirstSundowningMemory difficulties, resulting in people forgetting their original intentionsCognitive disorientation	PsychologicalTo reduce anxiety or fearLonelinessBoredomOver/under stimulatedCoping with distressExerciseEnjoymentTo promote own sleepTo give a sense of controlContinuing a life-long habitLow moodTo explore surroundings due to memory and orientation difficultiesWalking after a meal
Social and environmentalSearching for carerSearching for objectsSearching for family membersSearching for toiletSearching for own roomEnables someone to meet othersPoor signageConfused layout in settingFinding way to access gardenFinding way out of buildingOrientate oneself to the surroundingsCurious about environmentCues from light cycle (day/night)

Table 2.6 The common biopsychosocial causes of absconding
Absconding
BiologicalDisorientationSuspicious and paranoid about surroundingsMisperception that environment is hostile	PsychologicalUpset at having liberty taken awayFear of staying in a strange placeFear of being around confused peopleLooking for comfort and securityTime displacement, thinking younger and person with care responsibilities
Social and environmentalEnvironment is confusingEnvironment is dirtyEnvironment is smelly, too hotEnvironment is under-stimulatingSearching for family membersSearching for objectSearching for own roomEnables someone to meet othersPoor signageConfused layout in settingUnable to make friends in settingFinding way to access gardenFinding way out of buildingOrientate oneself to the surroundingsCurious about environmentCues from light cycle (day/night)

      Biopsychosocial causes of a range of BC

      Tables such as Tables 2.1–2.6 above are helpful in providing ideas for treatment, and show the commonality of causes across the various types of BC. For example, pain may manifest itself behaviourally in numerous presentations from shouting to walking, and aggression. Thus to help clarify the specific causes of a BC, it is often beneficial to try to identify the idiosyncratic beliefs that may be driving the behaviour (e.g. I need to go home to collect the kids from school). This issue is discussed in more detail below.

      ROLE OF BELIEFS

      One of the chief ways NCBT’s treatment differs from other methods in the field is its emphasis on the role of cognitions (thoughts and beliefs). Indeed, it is my opinion that beliefs play a key role in determining how disruptive a BC can become. It is relevant to note that even when clients’ thinking becomes incoherent and muddled, one can often identify key beliefs that trigger and sustain their behaviours. Table 2.7 provides some examples of common motivating beliefs; note, they are described within the NCBT categorisation discussed in the first chapter in Table 1.2.

Table 2.7 Beliefs and thoughts associated with BCs
Type of BC	Beliefs and associated thoughts
Lack of motivation	Themes of hopelessness, negativity and learned helplessness: I am worthless; There’s no point in trying, nothing changes; They never listen to what I want anyway.
Threat related	i. Themes of feeling vulnerable: I’m scared, I don’t know where I am. This man thinks he’s my husband.ii. Themes of perceived injustice and need to respond aggressively:They don’t treat me with respect; You’ve got to stand-up for yourself. I’m not putting up with this!!
Information seeking	Themes of searching and making sense of things: Let me check this place out; If I go through there, maybe I’ll find out where I am; I’ll go and ask her where I am.
Failure to inhibit	Themes of impulsiveness and egocentric thinking: I want it straight away; She’s got nice breasts; I want to be fed now.
Poor environmental fit	Themes of discomfort with current environment: I don’t want to be here; This place stinks; The people here are old and weird.

      By identifying these beliefs, and linking them with the background information, one is in a better position to understand the person’s needs. In some situations the client’s communication can be so poor that it is difficult to identify his thoughts. On such occasions, a clinician would work with the carer to hypothesise what the underlying beliefs might be. The method for generating hypotheses is discussed in Chapter 6.

      To assist with collecting information about the causal factors a number of assessment tools can be used. Some of these scales and procedures are explained in the next section.

      MEASURES

      In the following discussion, I shall examine some of the tools that help identify the causal factors. Table 2.8 provides examples of the scales that can be used to assess the features discussed in the first section of this chapter. For an extensive review of scales used in the area, see Moniz-Cook et al. 2008a. All the tables referred to in Table 2.8 are presented at the end of this chapter.

Table 2.8 BC measures and tools
Feature	Types of measures and assessment tools
Cognition and neuropsychology	Common global assessments of functioning include the MMSE* and ADAS-cog. Global neuropsychological measures are also sometimes employed, such as the ACE-R, CDRS. Specific measures are common, particularly the executive assessments (e.g. BADS). Table 2.9 presents a scale developed in Newcastle to help staff assess clients’ frontal lobe functioning. Scans are often useful, particularly the CT, DAT, and SPECT to identify areas of reduced functioning.
Drugs	It is helpful to keep a detailed record of people’s present and past history of receiving medication. Older people tend to be prescribed a lot of medication in relation to mental and physical health issues. Consequently negative reactions to drugs might be missed, or blamed on other causes, because of failures to closely monitor people’s drug histories.
Physical difficulties	Monitoring of vital signs (bloods, blood pressure, electrolytes, temperature, signs of infection) is common. Assessment of pain is particularly important, although difficult to assess in dementia (ADD; Cohen-Mansfield and Lipson 2002). A review by Stolee et al. (2005) favoured the use of DisDat and Pain Behaviour Measure. Other tools include: The Barthel ADL scale is useful for assessing people’s functional and physical abilities. A screening tool currently under development by NCBT is presented in