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 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.

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.

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."