Managing Psych Comorbidities and Dementia Using Allen Cognitive Levels

This article is devoted to promote better understanding of working with persons with dementia and the comorbidities of psychiatric illnesses. Overall, I would say there is little difference working with this population than those without psychiatric illnesses. Your overall interventions addressing dementia will be the same. The one addition, however, is the importance of inclusion of education in the psychiatric symptoms. All staff need to be able to recognize symptoms and know how to try the least restrictive, most supportive ways to reduce symptoms before the person becomes agitated. I will address some of these common comorbidities below.


Hallucinations and Delusions
If a person is diagnosed with schizophrenia or schizoaffective disorders, even bipolar illness, they may experience hallucinations and delusions.


Remember, hallucinations can impact all the senses:

  • auditory
  • visual
  • tactile
  • olfactory
  • even taste

Comments and Recommendations

  1. It would be important to discover if these clients have demonstrated symptoms of hallucinations recently and obviously what type of hallucination.
  2. If the person is actively "psychotic," they may interpret normal sensations as offensive or threatening. They could become fearful if you touched them, or they may become agitated with the day-to-day noises on the unit/in their living environment.
  3. You, the staff, need to be able to recognize these symptoms so you can identify when a medication might be needed. To do this, simply remember what is normal functioning for a person at an Allen level and therefore, what is not. For example, you know what is normal for persons performing in the middle stages/Allen Level 3. You know how quickly you can change/impact a person's affect with providing 1-to-1 attention and appropriate activity. However, these persons may not respond to your intervention. When you see a person talking to his hand for example, or a person who is easily agitated, unable to be redirected, or you are unable to break his obsession with picking lint from the air, probably medication is the answer.
  4. You must also be educated (by your nursing team) on the side effects of these medications, and you must look for these side effects. For example, often psychotropic medications can be serious sedatives and many of the medications make the person sensitive to light.
  5. On the other hand, you, the staff, can assist with titrating the medication, because if the medication works, you may see an improvement in function/Allen level, with the decrease in the interfering behaviors. This improvement means the medications are working! You then have a key role in helping measure the effectiveness of medications by measuring Allen levels.
  6. If a person is delusional, such as believing the television is talking specifically to him/her, or is sure that bread is poisonous, the staff should know that they should “enter their reality.” The staff do not have to agree with the patient necessarily (i.e. "I understand that you believe the bread is poisonous"); but you will not be able to talk the person out of the delusion (which is “a fixed, false belief”). Obviously, trying to change those beliefs may only cause agitation.  

Depression presents with:

  • change in sleep pattern, usually sleeping all the time
  • change in appetite
  • anhedonia (lack of the ability to find pleasure in activities)
  • isolation
  • high anxiety
  • possibly suicidal ideation

Comments and Recommendations:

  1. It can be very difficult to get through to the person who has been chronically depressed. It is even more important with this population to discover at least one thing that is highly valued to this individual, then adapt per Allen level. 
  2. Don't attempt to force anything on this individual. Instead, try short interventions and support trials of medication.
  3. If there is a history of suicidal ideation, you want to make sure you select very safe tools during activities to reduce the risk for harm/injury!
  4. Try all your normal interventions based on their cognitive level.
  5. Watch for psychotic or depressive symptoms along with lack of response to your interventions.
  6. Make sure all the staff members really are involved in medication management/titration; the staff are the ones who will know if the medications are working by observing the change in performance (Allen level). The MD needs this input into the care plans.
  7. Know that some of these clients may be misdiagnosed. For example, currently, I have a client who is a holocaust survivor. She had been living in a psych facility and they regularly tied her down in a locked room because she was so easily agitated. We moved her to a different supportive facility. She has been there almost a year, and only becomes agitated when they turn the water on for a shower. I do not believe she has a psychiatric illness; her reactions are simply based on likely traumatic events in her history. She is not on any psych meds.

General Additional Recommendations:

  1. Provide a calm, quiet, or soothing environment. Also, there should be a place where a person can go when the first signs of anxiety or agitation appear.
  2. Of course, structure and consistency is an important intervention for persons with dementia and also for those with psych comorbidities.



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