Post on 26-Dec-2015
Treatment of complex cases in later life: Problems with the model
Mike Bird
DSDC Bangor University
and
Aged Care Evaluation Unit, Greater Southern Area Health, NSW, Australia
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http://www.gsahs.nsw.gov.au/page.asp?t=about&p=2
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Gundagai
The RockUrana
QueanbeyanBraidwood
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ArdlethanTemora
Barellan
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Ungarie
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Mental Health ClustersMental Health Clusters
Pambulahttp://www.stayz.com.au/accommodation/nsw/south-coast/pambula-beach
http://www.wises.com.au/snowy/snodwn.htm
http://news.nationalgeographic.com/news/2007/11/photogalleries/Australia-pictures/photo3.html
Medical model
The traditional approach to the diagnosis and treatment of illness as practiced by physicians in the Western World since the time of Koch and Pasteur. The physician focuses on the defect or dysfunction within the patient using a problem-solving approach. The medical history, physical examination and diagnostic tests provide the basis for the identification and treatment of a specific illness.
Anderson et al (1994) cited in Macquarie Dictionary
One syndrome – one treatment (magic bullet) model
Syndrome Treatment Cure
Depression Anti-depressants Non-clinical score on GDS or significant relative mean decline
Anxiety Cognitive Behaviour Therapy
Non-clinical score on GAI or significant mean decline
BPSD/’Agitation’ Anti-psychotics Reduced score on NPI
Aggression Person-centred care or aroma therapy
Behaviour ceases
What’s wrong with the one syndrome – one treatment model in ageing?
1. Elusiveness of the ‘syndrome’
2. Poor response rates for standard treatments
3. What is a cure?
4. Case studies
5. Failures with challenging behaviour
One syndrome – one treatment model
Syndrome Treatment Cure
Depression Anti-depressants Non-clinical score on GDS or significant relative mean decline
Anxiety Cognitive Behaviour Therapy
Non-clinical score on GAI or significant mean decline
BPSD/’Agitation’ Anti-psychotics Reduced score on NPI
Aggression Person-centred care or aroma therapy
Behaviour ceases
Elusiveness of the syndrome: Depression
‘There is no consensus regarding the prevalence of depression in later life’ (Beekman)
Beekman review finds range of 0.4% to 35%Beekman et al. (1999)British J. Psychiatry
Terisi review find range of 9 -75% in estimated prevalence in nursing homes.
Teresi et al. (2001)Social Psychiatry Epidemiology
Problems in defining depression
Exclusion or not of physical/medical illness.
- Prevalence of depression up to 50% if included
Different presentations in older people
Different diagnostic tools
One syndrome – one treatment model
Syndrome Treatment Cure
Depression Anti-depressants Non-clinical score on GDS or significant relative mean decline
Anxiety Cognitive Behaviour Therapy
Non-clinical score on GAI or significant mean decline
BPSD/’Agitation’ Anti-psychotics Reduced score on NPI
Aggression Person-centred care or aroma therapy
Behaviour ceases
Mean change from baseline in MMSE (ITT analysis)
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-1
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3M
ean
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ge in
MM
SE
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/- s
e) f
rom
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elin
e (I
TT
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Donepezil 10mg Galantamine 24mg
0 6 13 52
0
5
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15
20
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30
Mea
n ch
ange
in M
MS
E (
+/-
se)
fro
m b
asel
ine
(IT
T)
Donepezil 10mg Galantamine 24mg
0 6 13 52
Mean change from baseline in MMSE (ITT analysis)
Response rates with older populations
Anti-depressants in placebo controlled trials – 46%Sneed et al., 2007 American Jnl Geriatric Psychiatry (2007)
CBT for moderate to severe depression – 43%DeBrueis et al. Archives of General Psychiatry (2005)
CBT (for generalised anxiety) - 45% Stanley et al. Jnl Consulting and Clin Psychology (2003)
Available evidence offers weak support to the contention that anti-depressants are effective for people with depression and dementia
(Bains et al., 2009)
Pharmacological therapies are not particularly effective for management of neuro-psychiatric symptoms of dementia (BPSD). Of the agents reviewed, the atypical antipsychotics have the best evidence for efficacy. However the effects are modest and further complicated by an increased risk of stroke (Sink et al., 2005)
All meta-analyses over two decades show the same thing: Modest effects at best and frequent side effects
(e.g. Schneider et al, 1990; Margallo-Lana et al., 2001; Debert et al, 2005; Schneider et al, 2006)
Physical resistance to personal care 8Calling out/screaming 6Aggression including violence 6Aggression verbal only 4Repetitive questions 5Other repetitive behaviours 5Sexually inappropriate behaviour 4Intrusive or dangerous wandering 3Problems with feeding 2Unspecified agitation 1
Bird, Llewellyn-Jones & Korten (2009)
behaviours in the sampleMain behaviours addressed Cases
Reviews of ‘discrete’ psychosocial approaches
Aromatherapy
Person centred bathing
Carer education
Music and sound therapy
Multi-sensory stimulation
Simulated family presence
Personalised recreation
Validation therapy
Relaxation training
O’Connor et al., (2009)
International Psychogeriatrics
Staff training
Environmental modification
Sensory stimulation
Behaviour management
Structured activity
Special care units
Validation and social contact
Simulated presence therapy
Landreville et al., (2006)
International Psychogeriatrics
Some psychosocial interventions appear to have specific therapeutic properties…but their effects were modest with an unknown duration of action O’Connor et al (2009)
Imogen, 79 years, living alone
• GDI 11/29
Six month history of:• Feeling sad• Sleep disturbance• Appetite and weight loss• Social withdrawal• Ceased gardening, ceased going out• Poor grooming (all day in nightgown)
“Antidepressants made me feel like a Zombie”
Imogen: Causal/associated factors
• Pain in neck and shoulder• Loss of role
– Chauffeur for granddaughter– Carer for her cousin Gladys
• Not knowing what depression is• “I shouldn’t be like this”
Imogen: Therapy
• Physiotherapy• Pain management• Psycho-education
– Reasons for depression– Depression as an illness– You can do something
• Activity Scheduling• Reflective grief counselling
GDI at discharge: 6/29
Dusty 62: PGU inpatient
Problems• Stuck in psychiatric ward, multiple diagnoses (‘mad’)• Screeching, temper outbursts. • Cocktail of psychotropic medications
Causes• Institutionalised (both Dusty and staff)• Pain, hypothyroidism, catheter - frequent infections• Massive frustration because of physical limitations• Traumatic life, abusive former husband• Death of unborn daughter following abuse
Interventions
Anger management (‘volcano’ triggers) and arousal reduction
Development of distracters
Learning social skills
Pain management – including appropriate wheelchair
Sorting out medications (geriatrician)
Monitoring for infections and treating them promptly
Psychotherapy with PGU staff – noticing when Dusty was trying to be, and being ‘good’
Education for staff at RACF, and on-going support and ‘booster sessions’.
Angela 74: Nursing Home Resident with dementiaProblems:Yelling and stripping off in lounge
Causes: Chronic back painRecent bereavement Total disorientation due to: • large doses of anti-psychotics and benzodiazepines• lack of structure and no-one speaking Italian• Permanently tired because woken several times a night for toileting• Recent bereavement?Staff know little about dementia, nor that behaviour usually has causes
Interventions
• Cessation of neuroleptic and reduce benzodiazepines• Pain management including analgesics, massage, heat treatment• Activity programme involving Italian radio, visits from Italian priest, and
walks with family• Allowing her to sleep through night even if wet• Using difficult to remove clothing plus re-dressing her or pre-empting
attempts and showing her Italian signs that this was a public place
Plus• Developing rapport with staff and engaging them as co-therapists• Helping staff understand the effects of dementia, and also see person
behind the behaviour rather than just the behaviour
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800
Baseline 2 mths post 5 mths post
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Baseline 2 mths post
Angela
Frequency (per hour) calling out
Frequency (per day) undressing in public
Stress down a lot, Coping much better, Problem severity down a lot
Complexity in old age
As people age, the boundaries between physical, medical, mental, and cognitive health become increasingly blurred.
There is also increasing variability between people as they age.
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Start End 3 mths post
Mea
n de
pres
sion
sco
reDepression
adjusted for insight,adls, cdr
Clinical subsample
adjusted for insight,adls, cdr, attendedongoing group
Depression (person with dementia)From Living with Memory Loss Evaluation
n=20/84 (24%)
n=84
subclinical
clinical
Depression (person with dementia)
days before or after group
300250200150100500-50
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ED
S
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Baseline 2 mths post 5 mths post
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Baseline 2 mths post
Angela
Frequency (per hour) calling out
Frequency (per day) undressing in public
Staff Measures: Stress down, Coping improved, Problem severity down
Progress?
Combined programme in controlled trial: Teri et al 2003• In home exercise programme for people with dementia• Teaching problem-solving to minimise behaviour problems
Produced reductions in depression scores relative to controls
Review of controlled psychosocial trials. Teri et al 2005Seven out of 11 trials show improvement relative to
control groups in depression scores. Common features of successful interventions were:
Multi-facetted, carer/family as co-therapists, case-specific
Slim grounds for hope
Australian Government DBMAS programme
NSW Health BASIS programme (including reform of CADE units)
Case-specific trialsHinchliffe et al. (1995): Int. Jnl. Geriatric Psychiatry
Fossey et al. (2006): British Med. Journal
Bird et al. (2007) Int. Psychogeriatrics; (2009) Ageing & Mental Health
Cohen-Mansfield et al. (2007): Jnls. Gerontology
Davison et al. (2007): Int. Jnl. Geriatric Psychiatry
Challenging Behaviour in Dementia: Models known to be effective
• Dementia-literate trouble shooting team
• Dementia-friendly physical and care environment
• BPSD-literate telephone help-line
Recent failures
Twice attempting replication of the ‘Lund’ model: Systematic emotional and practical support of staff
Instrument guiding staff through all the questions to ask?
Hallberg et al: Clinical supervision study
Lund Intervention Staff support and supervision sessions aimed at:
1. Increasing understanding of each residents’ world2. Understanding and ameliorating staff distress3. Care plans based on residents’ physical and
emotional needs rather than the problems they present.
4. Two RN’s assist on the floor with the process5. ENs assume greater autonomy in developing and
responsibility for implementation of care plans, and resident advocacy.
Outcome
Improvements in staff morale, job satisfaction, job creativity, quality of resident/staff interactions, nursing care, resident mood
Decreases in staff stress, task oriented nursing, difficult resident behaviour
Hallberg and colleagues: Clinical supervision study
Replication of Lund studyBird, Blair, Murdoch, McNess & Caldwell
Design• All staff from sample of dementia-specific units are provided
with a 12 hour accredited workshop in person-centred care (Control condition)
• Core staff in three dementia-specific units receive a watered down version of the Lund intervention once a fortnight
• Multiple staff, resident, and staff/resident interaction measures taken at baseline, after 5 months, and after 10 months
Outcome• Reductions in pejorative attitudes to patients,
medical visits to ‘treat’ behaviour, and psychotropic medication changes.
But no effect of condition
• Huge differences in qualitative measures (optional staff comments post programme, and focus groups 8-11 months later)
Instrument to help staff in residential care assess and deal with most cases themselves
Where used, the instrument clinically effective, well-received, and changes staff approach and attitude.
BUT
Requires high level of external supportOnly one facility has used it (inconsistently) since the project finished
Best way of delivering the case-specific information gathering approach to residential care facilities?
Trouble-shooting/behaviour support team using something like the Lund approach, integrated with a specialist medium stay in-patient unit for selected cases
One syndrome – one treatment model
Syndrome Treatment Cure
Depression Anti-depressants Non-clinical score on GDS or significant relative mean decline
Anxiety Cognitive Behaviour Therapy
Non-clinical score on GAI or significant mean decline
BPSD/’Agitation’ Anti-psychotics Reduced score on NPI
Aggression Person-centred care or aroma therapy
Behaviour ceases
Take home message
No magic bullet: complex cases require multi-facetted interventions