DECIDE

Staff approaches to managing challenging behaviour associated with dementia in the Emergency Department

Summary

Dementia is a group of symptoms including memory loss, difficulties with thinking, problem-solving or language, mood and behavioural disturbances. Alzheimer's disease is a common cause of dementia where brain damage occurs, affecting mainly older adults with symptoms worsening over time. Patients with dementia who present with an acute health problem at the emergency department (ED) can become agitated, confused and disorientated. They can be difficult to assess and can demonstrate violence or aggression towards staff. Research has shown distractional activities such as crafts, music or a baby doll can de-escalate agitation in these patients and lessen the use of restraint or sedation. Such distractional activities can be part of a standardised approach to managing challenging behaviour of persons with dementia (PWD) incorporating staff training, a hospital ready document and use of family/carer/staff close supervision. The aim of this study was to explore different professions' experiences of managing challenging behaviour associated with dementia in the ED and what has helped prevent or de-escalate aggression shown from PWD. The study was carried out at three ED sites in Bristol and Bath (University Hospitals Bristol and Weston NHS Foundation Trust (UHBW), North Bristol Trust (NBT), and Royal United Hospitals Bath (RUH)). An electronic survey was advertised to all ED staff at the three Trusts, and a proportion of ED staff took part in one-to-one (remote - telephone) interviews. PPI involvement was through the Alzheimer's society.

Main findings

There were 52 survey responses and 13 semi-structured interviews with ED staff from across the three Trusts. The main findings were:

• The ED is a unique and triggering setting for PWD. It is also limited as to the environmental changes that could be made to calm challenging behaviour (i.e. bright lights and noise are seen as a mostly unavoidable challenge of the ED environment) .
• Staff typically have not had any training on dementia for this specific environment (the ED). 
• Despite staff utilising a number of different techniques to manage challenging behaviour in PWD, there is no standard approach, and many of the techniques have drawbacks or barriers to use (e.g. requiring resources that are not available).
• Despite the use of current management techniques, episodes of agitation can last for a patient's entire stay in the ED. 
• Unmanaged challenging behaviour leads to resistance to medical care, safety issues and disruption to staff and patients. 
• Staff from all professions supported the idea of developing an intervention to prevent and/or de-escalate challenging behaviour associated with dementia. Staff highlighted that any intervention would need to have minimal impact on space and staff time, and would need to be championed by stakeholders.
• Staff suggested the possible value in developing an intervention that includes prompts for staff on potential prevention/de-escalation techniques (i.e. a flow-chart or similar, describing evidence-based techniques that could be tried in a range of different situations).

Impact

The findings from this work were used to develop a funding application for further work, which was submitted to the NIHR Research for Patient Benefit (RfPB) November 2021 call (Title: Development of an intervention to prevent the onset of delirium in patients with dementia treated in urgent and emergency care). Although this application was unsuccessful, the team received positive feedback from stakeholders and are continuing to develop research ideas in this area. We plan to carry out further background work in this area, along with involvement from additional external partners, and submit a revised funding application to the RfPB programme in November 2022.

Project outputs

Published: Manning S.N. Managing behaviour that challenges in people with dementia in the emergency department. Emerg Nurse. 2021 May 4;29(3):34-40. doi: 10.7748/en.2020.e2019. Epub 2020 Dec 30. PMID: 33377357.
In press:
Liddiard et al., Staff approaches to managing challenging behaviour associated with dementia in the Emergency Department: a mixed methods study