Ageing Perspectives: Current Research Initiatives in the Acute and Residential Settings

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Ageing Perspectives Current Research Initiatives
in the Acute and Residential Settings

• Dr Hemalatha Sivakumaran
• (Clinical Academic Psychologist)

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Eastern Health - Aged Persons Mental Health
Services

• Acute Services Peter James Centre
• 30 bed Secure Unit with a Multi
  Disciplinary Team (Southward)
• Community/Access Services
• Triage
• ICT (Intensive Care Team)
• APAT (Aged Persons Assessment Team)
• RSP (Residential Support Team)

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Eastern Health - Aged Persons Mental Health
Services

• Clin. Academic Psychologist
• Joint Appointment with Eastern Health and Deakin
  University
• Consultative Cover Doc Student on Placement

• Clinical Psychologist
• Doc Student on Placement

• Acute Services

• Residential Support Program

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Research Initiatives Acute Settings

• 2 major projects currently underway
• 1st specific to the acute aged persons mental
  health wards
• 2nd specific to psycho-geriatric nursing
  facilities
• Both projects due for completion early next year.

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The Use of Video Monitoring For Inpatients in an
Aged Mental Health Hospital Ward Enhancing
Clinical Care

• Dr Hemalatha Sivakumaran
• Dr Thirunavukarasu Ganesvaran
• Eastern Health Aged Persons Mental Health

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Clinical Presentation of mental health in the
aged

• Complex medical and psychiatric co-morbidities
  often a result of several pathological and
  degenerative processes in the elderly (Hall et
  al., 2004)
• Acute aged mental health inpatient settings see
  patients with increased episodes of behavioural
  and psychological symptoms associated with
  chronic mental illness and /or dementia (Savage,
  2007)

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Common Cause of Inpatient referral

• Agitated, aggressive and disinhibited behaviours
  in mentally ill, particularly in dementia
  patients
• Prevalence of agitated behaviours in different
  populations of dementia lies between 24 -98
  (Sourial et al., 2001)
• Contributory factors of agitation include gender,
  cognitive status, sensory loss, close proximity
  and/or invasion of personal space
• (Vance et al., 2003)

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Acute Aged Mental Health setting the reality

• Low staff to patient ratio
• High Staff Burnout
• Safety Issues for staff and other inpatients due
  to Behavioural and Psychological Symptoms
• Longer length of inpatient stay (trialling
  various medication)
• Inefficient use of behaviour charts
• Lack of individualised management plans or
  collaborative multi disciplinary approach

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Medical Model

• Diagnostic overshadowing
• Difficult behaviours seen as a set of symptoms to
  be controlled or a series of challenges to be
  managed through the use of psychotropic
  medication.
• Emphasis on containment or symptom control
• Reliance mainly on the use of neuroleptic
  medication increasing the incidence of side
  effect complications and mortality

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Use of restraints and seclusion

• A review in 2002 reports that between 12 47 of
  residents in residential care settings were
  routinely restrained for aggressive behaviours.
• Physical restraints and seclusion known to cause
  psychological and emotional distress, nerve
  damage, ischemic injury to hands, limb
  dislocation as well as death in some instances
• Chemical restraints resulting in undesirable side
  effects directly increasing the level of care of
  these individuals.

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Use of restraints and seclusion

• Greater scrutiny into the use of restraints in
  aged care hospital settings and residential care
  facilities in managing difficult behaviours
• Driven by Department of Human and Ageing Services
  and recently a call by APS to also consider other
  recommendations by Allied Health

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Bio-psychosocial model

• Engel (1977) first proposed this framework in the
  field of health and disability.
• Medical Model of disease failing to consider the
  social, psychological and behavioural dimensions
  of ill health
• WHO arguing for a synthesis thereby allowing for
  both multi-directional and multi-dimensional
  influences to work as part of an interactive
  process in the provision of health care

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Unmet Needs and Challenging Behaviours

• Cohen Mansfield (2000) looked at the link between
  unmet needs and difficult behaviours
• People with dementia actively do seek to make
  sense of and adapt to their altered experience of
  themselves and their world
• While the hippocampus (memory centre) and cortex
  (executive cognitive functioning) of the brain
  seem to be the main areas of degeneration, the
  amygdala (emotion centre) seems to be left
  untouched

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Unmet Needs and Challenging Behaviours

• Ones sense of self and emotional well being is
  constructed in relationship with others and the
  fit between the individual and his/her
  environment
• Neglect of a persons psychological needs
  therefore leading to the use of behaviour to
  communicate unmet needs.
• Greater need to explore reasons underlying such
  behaviours then to only treat the symptoms.

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Rationale for this study

• Shaw (2004) proposed that staff should become
  more proactive in adopting dynamic and
  interactive processes especially around
  difficult residents that includes greater
  vigilance, intuitive practices and the creation
  of individual strategies taking on board issues
  from the perspective of residents and self care
  considerations of staff.
• Shah et al (1993) briefly explored the use of
  video monitoring of patients on psychiatric wards
  as a means of facilitating all of the above in
  their paper.

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Video Monitoring on Inpatient mental health wards

• Early detection, prevention and management of
  violent, absconding and suicidal behaviours
• Observations useful in diagnostic purposes,
  better management of psychopathology and
  treatment of side effects

• Initial capital cost to install equipment
• Staff needing to be trained and stationed to
  monitor behaviours
• Issues over rights and privacy of patients and
  staff
• Possible reduction in staff on the floor
  interaction opportunities between staff and
  patients

• Advantages

• Disadvantages

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Findings of previous studies

• Extensive and useful information in verifying
  aggressive incidents
• The role of planning in some assault incidents
• Confirming identities involved in violence
• Capturing warning signs of increasing tension
  before violent episodes.
• Opportunities to enhance clinical care as helped
  identify inpatients who were responding to
  internal stimuli.
• Identifying preventable falls with medication
  induced side effects

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Current study- Motivation

• Given the lack of similar studies in the area of
  aged mental health wards, the higher prevalence
  of behavioural and psychological symptoms a
  higher incidence of aggression due to dementia
  and acute mental illness
• DHS drive in reducing restraints and seclusion
  and instead exploring early intervention
  approaches in de-escalating and reducing
  behaviours of potential aggression to self and
  others.
• Clinical interest and motivation to put in place
  accountability and supportive resources amongst
  clinical staff.

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Aim of current study

• To gather the views of multidisciplinary staff
  and next of kin (family member/carer) of
  inpatients during the study period on the
  usefulness of having video monitoring devices on
  an Aged Persons Mental Health ward.
• Participants comprising of about 60
  multidisciplinary staff of the inpatient ward and
  community teams (ICT, Triage, RSP APAT) and 60
  next of kin (adult family member/carer) of
  inpatients.

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Materials Involved

• Staff questionnaire comprising of 15 questions
  requiring a Likert scale response and 4 questions
  requiring qualitative responses.
• Next of Kin questionnaire comprising of 12
  questions requiring a Likert scale response and 4
  questions requiring qualitative responses.

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Evaluation of an instrument for the management of
behavioural and psychological symptoms of
dementia in aged care 

• Marita McCabe, Hema Sivakumaran, David Mellor,
  Gery Karantzas,
• Tanya Davison and Sian Cole
•  

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Bpsd Study

• The purpose of this study to trial a
  Behavioural and Psychological Symptoms of
  Dementia (BPSD) Screening Measure among staff and
  dementia patients at the geriatric facilities
  within Eastern Health.
• Developed by 3 clinicians with a no of years of
  experience in the area.

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Bpsd Study

• The studys main focus is on investigating and
  identifying the causes of BPSD.
• This study is also particularly concerned about
  reducing levels of challenging behaviours
  associated with dementia now commonly known as
  behavioural and psychological symptoms of
  dementia (BPSD), which is a major source of
  distress to the person with BPSD, carers, and
  family members of people with dementia.

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BPSD Study

• Participation involves a total of 50 staff
  members across the 2 PGHN facilities of Eastern
  Health who will be trained to use the BPSD
  screening tool and where 60 residential patients
  will be observed for their behaviours.
• 1 facility acting as the control and another as
  the intervention

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BPSD Screening Tool 8 Steps

• 1.Identify challenging behaviour
• 2. Eliminating delirium or medical causes
• 3. Eliminating pain and discomfort issues
• 4.Eliminating MH issues of depression, anxiety
  and psychosis
• 5. Is the behaviour causing distress
• 6. Environmental causes of the behaviour
• 7.Specialist consult
• 8. Evaluation of behaviour after a month