Treatment of complex cases in later life: Problems with the model Mike Bird DSDC Bangor University...

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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Mental Health ClustersMental Health Clusters

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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







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








Behaviour ceases

Mean change from baseline in MMSE (ITT analysis)

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Donepezil 10mg Galantamine 24mg

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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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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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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

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Baseline 2 mths post 5 mths post

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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








Behaviour ceases

Take home message

No magic bullet: complex cases require multi-facetted interventions

Treatment of complex cases in later life: Problems with the model Mike Bird DSDC Bangor University...

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