Treatment of complex cases in later life: Problems with the model Mike Bird Greater Southern Area Health Service and Australian National University
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 Non-clinical score on Therapy GAI or significant mean decline BPSD/’Agitation’ Anti-psychotics 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? Case studies
One syndrome – one treatment model Syndrome Treatment Cure Depression Anti-depressants Non-clinical score on GDS or significant relative mean decline Anxiety Cognitive Behaviour Non-clinical score on Therapy GAI or significant mean decline BPSD/’Agitation’ Anti-psychotics 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 40% if included Different presentations in older people Different diagnostic tools
Mean change from baseline in MMSE (ITT analysis) Mean change in MMSE (+/- se) from baseline (ITT) 3 2 1 0 -1 -2 Donepezil 10mg Galantamine 24mg -3 0 6 13 52
Mean change from baseline in MMSE (ITT analysis) Mean change in MMSE (+/- se) from baseline (ITT) 30 25 20 15 10 5 Donepezil 10mg Galantamine 24mg 0 0 6 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 (BPSD) 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)
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 Frequency (per day) Frequency (per hour) undressing in public calling out 20 800 15 600 10 400 5 200 0 0 Baseline 2 mths post 5 mths post 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 10 adjusted for insight, �������� Mean depression score adls, cdr 8 Clinical subsample n=20/84 (24%) 6 ����������� adjusted for insight, 4 adls, cdr, attended ongoing group 2 0 Start End 3 mths post
Depression (person with dementia) 16 14 12 10 8 6 4 LEEDS 2 0 -50 0 50 100 150 200 250 300 days before or after group
Angela Frequency (per day) Frequency (per hour) undressing in public calling out 20 800 15 600 10 400 5 200 0 0 Baseline 2 mths post 5 mths post Baseline 2 mths post Stress down a lot, Coping much better, Problem severity down a lot
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
One syndrome – one treatment model Syndrome Treatment Cure Depression Anti-depressants Non-clinical score on GDS or significant relative mean decline Anxiety Cognitive Behaviour Non-clinical score on Therapy GAI or significant mean decline BPSD/’Agitation’ Anti-psychotics Reduced score on NPI Aggression Person-centred care or Behaviour ceases aroma therapy
Take home message No magic bullet: complex cases require multi- facetted interventions
Recommend
More recommend
