Treatment of complex cases in later life: Problems with the model

1
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

2
http//www.ozshots.com/map/
3
http//www.gsahs.nsw.gov.au/page.asp?taboutp2
4
Mental Health Clusters
GOLDEN WAGGA WAGGA
1
Hillston
F
Ungarie
SOUTHERN SLOPES
SOUTHERN TABLELANDS
MURRUMBIDGEE LOWER WESTERN
Weethalle
F
1
West Wyalong
F
Barmedman
Griffith
9
F
2
Barellan
Young
F
Ardlethan
1
2
Boorowa
1
Temora
Crookwell
4
Hay
2
1
Leeton
Murrumburrah (Harden)
F
2
Darlington Point
Cootamundra
9
9
2
Narrandera
Goulburn
Gunning
Coleambally
F
Coolamon
F
1
Yass
4
1
Junee
Tooleybuc
Wagga Wagga
F
1
Gundagai
CONARGO
Moulamein
F
Lockhart
2
Tarcutta
Tumut
1
F
F
The Rock
Urana
Karabar
F
F
Jerilderie
4
Adelong
Queanbeyan
4
2
Braidwood
1
4
DENILIQUIN
2
ACT
Batlow
Henty
Deniliquin
4
Finley
Barham
1
1
1
Culcairn
4
Berrigan
Holbrook
2
4
Batemans Bay
Tumbarumba
4
1
Tocumwal
F
Mathoura
2
Moruya
2
Corowa
F
9
2
Albury
Moama
F
Narooma
Cooma
GREATER ALBURY
EUROBODALLA BEGA VALLEY
Jindabyne
F
2
Bega
1
Bombala
2
Pambula
Delegate
4
Eden
F
MONARO
5
Pambulahttp//www.stayz.com.au/accommodation/nsw/
south-coast/pambula-beach
6
http//www.wises.com.au/snowy/snodwn.htm
7

• http//news.nationalgeographic.com/news/2007/11/ph
  otogalleries/Australia-pictures/photo3.html

8
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

9
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

10
Whats 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

11
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

12
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

13
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

14
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

15
Mean change from baseline in MMSE (ITT analysis)
16
Mean change from baseline in MMSE (ITT analysis)
17
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)

18

• Available evidence offers weak support to the
  contention that anti-depressants are effective
  for people with depression and dementia
• (Bains et al., 2009)

19

• 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)

20
Main behaviours addressed Cases
behaviours in the sample
Physical resistance to personal care 8 Calling
out/screaming 6 Aggression including
violence 6 Aggression verbal only 4 Repetitiv
e questions 5 Other repetitive
behaviours 5 Sexually inappropriate
behaviour 4 Intrusive or dangerous
wandering 3 Problems with feeding 2 Unspecifi
ed agitation 1
Bird, Llewellyn-Jones
Korten (2009)
21
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 OConnor 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
22

• Some psychosocial interventions appear to have
  specific therapeutic propertiesbut their effects
  were modest with an unknown duration of action
  OConnor et al (2009)

23
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

24
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 shouldnt be like this

25
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

26
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

27
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.

28
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

29
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

30
Angela
Frequency (per day) undressing in public
Frequency (per hour) calling out
Stress down a lot, Coping much better, Problem
severity down a lot
31
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.

32
Depression (person with dementia)From Living
with Memory Loss Evaluation
n84
n20/84 (24)
33
Depression (person with dementia)
34
Angela
Frequency (per day) undressing in public
Frequency (per hour) calling out
Staff Measures Stress down, Coping improved,
Problem severity down
35

• 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

36
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

37
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

38
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?

39
Hallberg et al Clinical supervision study

• Lund Intervention
• Staff support and supervision sessions aimed at
• Increasing understanding of each residents world
• Understanding and ameliorating staff distress
• Care plans based on residents physical and
  emotional needs rather than the problems they
  present.
• Two RNs assist on the floor with the process
• 5. ENs assume greater autonomy in developing and
  responsibility for implementation of care plans,
  and resident advocacy.

40
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

41
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

42
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)

43
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

44
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

45
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

46
Take home message

• No magic bullet complex cases require
  multi-facetted interventions