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

http://www.ozshots.com/map/

http://www.gsahs.nsw.gov.au/page.asp?t=about&p=2

MURRUMBIDGEE & LOWER WESTERN

F

Tooleybuc

F

Moulamein

1

Barham

CLUSTER NAME

Urban Locality Name

Major towns/cities

0 50 Kilometres 100 Mental Health Clusters

GOLDEN & WAGGA WAGGA

1

Hillston

F

Ungarie

SOUTHERN SLOPES

F

Weethalle

1

West Wyalong

&

1

Hay

CONARGO DENILIQUIN

2

Deniliquin

F

Mathoura

F

Moama

Griffith

F

Coleambally

4

Jerilderie

1

Finley

1

Berrigan

1

Tocumwal

2 2 4

Urana

F

Barellan

F

Ardlethan

F 2

Leeton Barmedman

2

Temora

2 2 1

Boorowa

4

Murrumburrah (Harden) Cootamundra Narrandera

4

Coolamon

1

Wagga Wagga

Junee

1

Gundagai

1

Lockhart

F

The Rock

4 4

Henty Culcairn

4

Holbrook

F

Tarcutta

F 2

Adelong Tumut

1

Batlow

4

Tumbarumba Corowa

9

Albury

1

Yass ACT

2 2 1

Crookwell

F

Gunning

9 9 F

Karabar

Queanbeyan

4

Braidwood Cooma

Goulburn

2 F 2

SOUTHERN TABLELANDS

Batemans Bay Moruya Narooma

GREATER ALBURY

2 1 4 F 9 Base Hospital and Health Service District Hospital and Health Service Community Hospital and Health Service Multipurpose service Community Health Service Other F

Jindabyne

MONARO

1 4

Delegate Bombala

2 2 F

Bega Pambula Eden

EUROBODALLA & BEGA VALLEY

Pambula

http://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 Anxiety BPSD/’Agitation’ Aggression Anti-depressants Cognitive Behaviour Therapy Non-clinical score on GDS or significant relative mean decline Non-clinical score on GAI or significant mean decline Reduced score on NPI Anti-psychotics 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 Anxiety BPSD/’Agitation’ Aggression Anti-depressants Cognitive Behaviour Therapy Non-clinical score on GDS or significant relative mean decline Non-clinical score on GAI or significant mean decline Reduced score on NPI Anti-psychotics 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 Anxiety BPSD/’Agitation’ Aggression Anti-depressants Cognitive Behaviour Therapy Non-clinical score on GDS or significant relative mean decline Non-clinical score on GAI or significant mean decline Reduced score on NPI Anti-psychotics Person-centred care or aroma therapy Behaviour ceases

Mean change from baseline in MMSE (ITT analysis)

0 -1 -2 -3 3 2 1 0 Donepezil 10mg 6 13 Galantamine 24mg 52

Mean change from baseline in MMSE (ITT analysis)

30 25 20 15 10 5 0 0 Donepezil 10mg 6 13 Galantamine 24mg 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)

•

GDI 11/29 Imogen, 79 years, living alone

• • • • • •

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

Frequency (per hour) calling out Frequency (per day) undressing in public 800 20 600 15 400 10 200 5 0 Baseline 2 mths post 5 mths post 0 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.

12 10 2 0 8 6 4

Depression (person with dementia)

From Living with Memory Loss Evaluation

Depression

n=84

adjusted for insight, adls, cdr Clinical subsample

n=20/84 (24%)

adjusted for insight, adls, cdr, attended ongoing group Start End 3 mths post

Depression (person with dementia)

16 14 12 10 8 6 4 2 0 -50 0 50 100 days before or after group 150 200 250 300

Angela

Frequency (per hour) calling out Frequency (per day) undressing in public 800 20 600 15 400 10 200 5 0 Baseline 2 mths post 5 mths post 0 Baseline Staff Measures: Stress down, Coping improved, Problem severity down 2 mths post

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 Anxiety BPSD/’Agitation’ Aggression Anti-depressants Cognitive Behaviour Therapy Non-clinical score on GDS or significant relative mean decline Non-clinical score on GAI or significant mean decline Reduced score on NPI Anti-psychotics Person-centred care or aroma therapy Behaviour ceases

Take home message

No magic bullet: complex cases require multi facetted interventions