living with ftd - neura€¦ · living with ftd symptoms and behaviour melissa kettle aftda...
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Living with FTD Symptoms and
Behaviour
Melissa KettleAFTDA National
Coordinator
Objectives
• Understand the links between FTD related brain damage, disabilities and behaviour
• Highlight non-pharmacological behavior assessment & modification approaches using CAUSED model
• Overview of appropriate responses, resources and support options
• AFTDA and promotion of upcoming FTD events
Partner logo here
FTD Carer Support Groups
• Established 2010• Monthly meetings• Clinician facilitated but carer driven discussion
• Longitudinal support & knowledge transfer
www.theaftd.org.au or email: [email protected]
No magic pills, quick fix or one size fits all solutionsLimited studies, weak evidence
SSRI’s (e.g.. Citalopram or Paroxetine)• disinhibition • compulsions• carbohydrate cravings • hyper sexuality due to effect on libido
Tetracyclic Anti-depressant (Trozadone)• irritability/agitation• depressive symptoms in PPA• eating and sleep disorder (Flebert et al 2004)
Mood Stabilisers (Na Valproate/Tegretol) • aggression/hyper-agitation
TauRx: (BV) FTD treatment trial underway at 3 major FTD centers in Australia
What C.A.U.S.E.D the Behaviour?
CommunicationActivityUnwell/Unmet NeedStoryEnvironmentDementia
The person with FTD
StoryPersonal and Family history preferences
Inner world
Impact of the Dementia
UnwellHealth and Wellbeing
Tasksand
Activities
EnvironmentPhysical and Social
S.Aberdeen, S. Leggat and S. Barraclough et al 2010
Communication
Manifestations of Aggression
Insults
Verbal Threats
Threatening Gestures
Hitting Shouting
Kicking
Biting
Pinching
PushingThrowing
ThingsSexual
Aggression
Aggression Prevention
Understanding and adjusting to
disabilities
Aggression in FTD
There is no point in trying to rationalise with someone once they have lost capacity to do so due to:
• Reduced insight/judgment• Lowered stress threshold • Emotional regulation
problems
Likely to just result in escalating distress, resistance and tensions
• Loss of emotional range/regulation• Loss of emotional recognition• Loss of social norms• Loss of empathy
Impacts of FTD on social cognitionand relationship discourse
Most prominent in BV FTD and SV FTD
Communicate to de-escalate
• Don’t over-verbalise, especially where there are language symptoms
• Avoid rationalizing, correcting & arguing back• Don’t persist/nag…where possible try again later• Avoid challenging statements “you can’t” or “why did you do
that?”• Validate the feelings: “I can see why you’re frustrated” • Calm and moderate tone (mirroring)
Agrammatical / Apraxic speechPerhaps adjust the focus from grammatically correct speech to getting meaning across• Speech Pathology intervention
It’s a lovely d…du….
Day? You can say day. Just try it!
It is! Should we go for a walk outside?
• Before stepping in to take over or deter the person from ritualistic, perseverative behaviour or an activity they may not be managing well….ask yourself; “How important is it?” CHOOSE YOUR BATTLES
• Use delay “let’s take some time out to cool off”
• Remove yourself “I’m sorry…lets take a timeout”
The impact of carer approach in behaviour modification
Remember dignity of risk
Do you want to be right or do you want to be
happy?
Prevention of Assault Modifying ActivityApproach
Remember Personal Space
Gain attention
Engage, explain, demonstrate
Position during re-direction
Don’t persist when the person becomes agitated, stop and try again later
Position during care delivery
Modifying Personal CareActivity to Prevent Resistive Aggression
www.bathingwithoutabattle.org
www.confidentcare.com.au
Redirection through Activity:Learn :• when/how to apply the ‘brakes’ to behaviour• how to re-direct utilisation and perseverative behaviour in to
repetitive purposeful tasks
• how to interrupt and re-direct the misfiring circuitry with auditory cues (touch, voice, music with headphones, singing, alarms, interactive toys, recordings)
• not fight battles over harmless rituals
Causes Related to Physical Symptoms or being Unwell
For example:• Delirium. • Discomfort, including pain• Illness and infection • Drug interactions and
side effects• Sensory deficits/hypersensitivity• Paranoia, anxiety, depression or hallucinations.
FTD Symptom ExpressionInfluence of
Life Story and the Internal World
Manifestationsof Apathy in FTDAffectiveIndifferenceMay report lethargyDon’t identify as ‘depressed’
Behavioural Reduced InitiationReduced planning
CognitiveInactivation of goal directed thought processingPoverty of SpeechLoss of feedback about performance (no cue for action)
ApathyReduced initiation Reduced planningReduced attentionReduced insight
Strategies:Taking over “starter motor” functions• Structured daily routine /timetable• Visual cueing • Starting the task/activity yourself (physical demonstration)• Reducing length of interventions/activities• Task grading/breakdown• Reward systems for task completion• Adjust our own expectations
Poverty of speechInitiate conversation
Promote engagement with pictures, music or topics that are meaningful to the person
Accept limitations, adjust expectations and interact non verbally through activity, touch, gesture
Poor insight, problem solving and planning• Prompt the person with FTD to initiate & sequence tasks
• Assess decision making capacity and considerneed for substitute deciders(Advanced Care Planning, Financial/Medical POA, Guardianship)
• Driving Assessment
• Financial and support service
• Occupational Assessment(ADL’s, work capacity and community safety)
• Problems with set shifting • Perseveration• Utilisation Behaviour• Compulsive/ritualistic behaviours
Disinhibition and Impulsivity
Hyper-sexuality in FTD
• This is brain damage related behaviour not predatory
• Manage environmental cues/signals
• Firm but polite limits for unwanted sexual advances/comments
• Proactive hand occupation during personal care
• Use diversion or offer privacy and options for sexual release
• Offer sensory alternatives to divert from more sociallyinappropriate sexual behaviour (later stages)
• Pharmacological intervention last resort only where serious unmanageable risk identified
Sexual Changes in FTD
Report distress & risk in this domain
Are both partners willing to continue a sexual relationship?Exploring boundaries
Can the need for intimacy/sex be met in other ways?
Counselling for grief/loss in this area
Seek advice to help re-navigate this part of their relationship and manage any risks/distress associated with hyper sexuality and/or disinhibited sexual behaviour
Call Dementia Behaviour Management Advisory Service1800 699 799
Managing Environmental CuesGluttony and Hyper-orality
• Control portions sizes• One item at a time• Ready access to sweet healthy snacks
• Reduce visibility/ access toother food/alcohol
• Alcohol/cigarette substitution• Alternate safe oral stimuluse.g.: lollipops, chew toys Chew pendants can be
purchased on autism websites
Impulsive/compulsive spending and vulnerability• Assess decision making and money
handling capacity (OT)
• Reduce access to large
amounts of funds if vulnerable
• Reduce cues for impulse spending
• Consider OT ax of work place financial roles
• www.donotcall.gov.au• mail re-direction and no junk mail
Pacing and Intrusion
Visual cues
Enabling wandering through Environmental modification:
• Community safety assessment
• Security• Bed and wandering alarms &
GPS tracking• Respite workers,
volunteer visitors and family support Google:
Broda Glider Chair
Partner logo hereSupporting families affected by Behavioural Symptoms of FTD
• Disinhibition• Obsessions/Rituals• Impulsiveness• Perseveration• Aggression
FTD companion cards avail from Alzheimer’s Australia 1800 100 500 or DBMAS
Dementia Behavior Management Advisory Servicewww.dbmas.org.au or 1800 699 799
Extreme risk behavior: 000 or Local mental health service
What can’t be changed?
What can be changed?
FTD brain changes and related disabilities
No cure (yet)
Limited pharmacological options for symptom management
Underlying personality traits
The life story of the person with FTD and how this has shaped the person with FTD’s internal world
Our knowledge and skills
Our attitudes and thinking
Our communication
The way in which tasks are approached
The environment (Physical/Social)
Our understanding of life story to inform motivations for
engagement and behaviour
Partner logo here
Online FTD Support Forum for people with FTD and Caregivershttp://www.ftdsupportforum.com/
Online FTD Support Forum for Spouse Caregivershttps://groups.yahoo.com/neo/groups/FTD_Spouse_Caregiver_Support/info
http://www.theaftd.org/
Partner logo here
Supporting people with Language and Oro-motor changes in FTDEarly Speech Pathology Referral
• Diagnostic characterisation of language changes• Communication techniques (client/carer)• Communication Aides and Devices• Word re-training – Semantic Dementia• Swallowing assessment and MND screen
www.aphasia.org.au
PPA Groups
• Educational – learning about aphasia/dementia• Conversation group• Computer and iPad practice• Themed (game show, cooking)
• Websites:– http://www.adleraphasiacenter.org/– http://www.aphasiacenter.org/– http://www.ukconnect.org/about-aphasia.aspx– http://www.ppaconnection.org– http://groups.yahoo/group/PPA-support
Younger Onset FTD
Alzheimer’s AustraliaYoung Onset Dementia Key Worker Programhttps://fightdementia.org.au/support-and-services/services-and-programs-we-provide/national-younger-onset-dementia-key-worker-program
• Family Education, Counseling and Support• Assistance with financial and occupational stressors• Point of contact (help to navigate support systems,
National Disability Insurance Scheme eligibility, ACAS & age appropriate support and activities groups)
Helping Australians with dementia, and their carers
Partner logo here
Save the Date:
• World FTD Awareness Week25th Sep – 2nd Oct 2016
• How to participate in awareness and fund raising?
• Details will be posted from July 2016www.theaftd.org.au
Thanks for listening
www.theaftd.org.au