Transcript Michael Bird, PhD Centre for Mental Health Research The

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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Mental Health Clusters
GOLDEN
&
WAGGA WAGGA
Hillston
1
F
SOUTHERN SLOPES
MURRUMBIDGEE
&
LOWER WESTERN
F
F
1
Weethalle
Hay
2
Barellan
F
2
Ardlethan
Coleambally
2
Narrandera
4
Tooleybuc
4
DENILIQUIN
2
Deniliquin
F
F
Mathoura
4
Urana
1
Finley
1
1
Jerilderie
1
1
F
4
4
Berrigan
The Rock
1 Boorowa
4 Murrumburrah (Harden)
1
4
2 Batemans Bay
2 Moruya
2
Major towns/cities
1
4
100
F
9
F
Cooma
Narooma
Jindabyne
Base Hospital and Health Service
2
Braidwood
4
Tumbarumba
9 Albury
Urban Locality Name
Goulburn
2 Corowa
Moama
CLUSTER NAME
Kilometres
2
ACT
F
50
F
F Karabar
Queanbeyan
Batlow
GREATER ALBURY
0
Yass
Gunning
Gundagai
1
4
Crookwell
99
F Tarcutta 2 Tumut
F Adelong
Culcairn
Holbrook
1
Cootamundra
1
Henty
Tocumwal
Young
1 Junee
Lockhart
SOUTHERN
TABLELANDS
9
Coolamon
Wagga Wagga
CONARGO
Barham
Temora
2
Leeton
2
&
Barmedman
FDarlington Point
F
F Moulamein
West Wyalong
1
F
Griffith
F
Ungarie
2
Bega
District Hospital and Health Service
Community Hospital and Health Service
1
Multipurpose service
Community Health Service
Other
4
MONARO
Bombala
Delegate
2
F
Pambula
Eden
EUROBODALLA
&
BEGA VALLEY
Pambula
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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
BPSD/’Agitation’
Anti-psychotics
Non-clinical score on
GAI or significant
mean decline
Reduced score on NPI
Aggression
Person-centred care or Behaviour ceases
aroma therapy
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
BPSD/’Agitation’
Anti-psychotics
Non-clinical score on
GAI or significant
mean decline
Reduced score on NPI
Aggression
Person-centred care or Behaviour ceases
aroma therapy
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
BPSD/’Agitation’
Anti-psychotics
Non-clinical score on
GAI or significant
mean decline
Reduced score on NPI
Aggression
Person-centred care or Behaviour ceases
aroma therapy
Mean change in MMSE (+/- se) from baseline (ITT)
Mean change from baseline in MMSE (ITT analysis)
3
2
1
0
-1
-2
Donepezil 10mg
-3
0
6
Galantamine 24mg
13
52
Mean change in MMSE (+/- se) from baseline (ITT)
Mean change from baseline in MMSE (ITT analysis)
30
25
20
15
10
5
0
Donepezil 10mg
0
6
Galantamine 24mg
13
52
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)
Main behaviours addressed
Cases
behaviours in the sample
Physical resistance to personal care
Calling out/screaming
Aggression including violence
Aggression verbal only
Repetitive questions
Other repetitive behaviours
Sexually inappropriate behaviour
Intrusive or dangerous wandering
Problems with feeding
Unspecified agitation
8
6
6
4
5
5
4
3
2
1
Bird, Llewellyn-Jones & Korten (2009)
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
Staff training
Environmental modification
Sensory stimulation
Behaviour management
Structured activity
Special care units
Validation and social contact
Simulated presence therapy
O’Connor et al., (2009)
International Psychogeriatrics
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 dementia
Problems:
Yelling and stripping off in lounge
Causes:
Chronic back pain
Recent 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
Angela
800
Frequency (per hour)
calling out
20
600
15
400
10
200
5
0
0
Baseline
2 mths post
5 mths post
Frequency (per day)
undressing in public
Baseline
2 mths post
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.
Depression (person with dementia)
From Living with Memory Loss Evaluation
Depression
12
n=84
clinical
8
adjusted for insight,
adls, cdr
Clinical subsample
n=20/84 (24%)
6
subclinical
Mean depression score
10
4
2
0
Start
End
3 mths post
adjusted for insight,
adls, cdr, attended
ongoing group
Depression (person with dementia)
16
14
12
10
8
6
LEEDS
4
2
0
-50
0
50
100
days before or after group
150
200
250
300
Angela
800
Frequency (per hour)
calling out
20
600
15
400
10
200
5
0
0
Baseline
2 mths post
5 mths post
Frequency (per day)
undressing in public
Baseline
2 mths post
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 2005
Seven 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 trials
Hinchliffe 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’ world
2. Understanding and ameliorating staff distress
3. 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 process
5. ENs assume greater autonomy in developing and
responsibility for implementation of care plans, and
resident advocacy.
Hallberg and colleagues: Clinical
supervision study
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
Replication of Lund study
Bird, 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 support
Only 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
BPSD/’Agitation’
Anti-psychotics
Non-clinical score on
GAI or significant
mean decline
Reduced score on NPI
Aggression
Person-centred care or Behaviour ceases
aroma therapy
Take home message
No magic bullet: complex cases require multifacetted interventions