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Dementia in Australia Focus on behavioural disturbances. Henry Brodaty Dementia Collaborative Research Centre, UNSW www.dementiaresearch.org.au. What are BPSD?. Agitation Aggression Calling out/ screaming Disinhibition (sexual) Wandering Night time disturbance Shadowing Swearing. - PowerPoint PPT Presentation
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Translating dementia research into practice
Dementia in AustraliaDementia in AustraliaFocus on behavioural disturbances Focus on behavioural disturbances
Henry Brodaty
Dementia Collaborative Research Centre, UNSW
www.dementiaresearch.org.au
What are BPSD?What are BPSD?• Agitation• Aggression• Calling out/ screaming• Disinhibition (sexual)• Wandering• Night time disturbance• Shadowing• Swearing
• Depression• Anxiety• Apathy• Delusions• Hallucinations• Irritability• Elation/euphoria
Translating dementia research into practice
Why are BPSD important?Why are BPSD important?
• Ubiquitous, >90% of PWD during course• Distress to PWD and to caregivers• Increase rate of institutionalisation• Higher rate of complications in hospital• Faster rate of decline• Associated with increased mortality
Translating dementia research into practice
Prevalence of BPSDPrevalence of BPSD• In community
– 2/3 PWD have at least one behavioural Sx– 1/3 PWD have significant level of symptoms
• In developing countries similar rates• In residential care
– 40- 90% RWD have BPSD– Rates in similar NHs vary >3-fold
Translating dementia research into practice
1Lyketsos et al, Am.J. Psychiatry, 2000; 157:708-714; 2Prince M et al 2004; 3Brodaty H et al, 2001;4 Seitz et al, Int Psychogeriatrics, 2010; 22:1025–1039
Translating dementia research into practice
How are BPSD managed?
• Biological• Psychological• Interpersonal• Environmental Photo courtesy of Cathy Greenblatt
Sydney Morning Herald 14th May 2012
Partner logo herePartner logo here
Psychotropics in AustraliaPsychotropics in Australia
• 2009 medication use in RACFs in Sydney SW Area Health Service
• 44/48 Nursing Homes in the area• Use = 25 of previous 28 days• N = 2465; age M = 78.7 yrs• Mean number medications = 8.7
Translating dementia research into practice © DCRC/Brodaty 2012
Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271.
Partner logo herePartner logo here
Psychotropic medication use in Sydney RACFs Psychotropic medication use in Sydney RACFs
Translating dementia research into practice © DCRC/Brodaty 2012
Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271.
%
Year
Partner logo herePartner logo here
Translating dementia research into practice © DCRC/Brodaty 2012
Psychotropic medication use in Sydney RACFs Psychotropic medication use in Sydney RACFs
%
Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271.
Year
Partner logo here
Psycholeptic use in aged care homes in Psycholeptic use in aged care homes in Tasmania, AustraliaTasmania, Australia
Westbury, et al. (2010), Journal of Clinical Pharmacy and Therapeutics, 35: 189–193. doi: 10.1111/j.1365-2710.2009.01079.x
(Snowdon)
(Tucker)
Figure 1. Dispensed use (define daily dose/1000 population/day) of antipsychotics, antidepressants and anxiolytic, sedative-hypnotic (AHS)
drugs by gender and age.
Hollingworth et al. Aust N Z J Psychiatry 2011;45:705-708
Translating dementia research into practice
Wander garden
Outside space only beneficial in combination with staff interaction
Fleming R – www.dementiaresearch.org.au
Translating dementia research into practice
Moderate evidenceModerate evidence• Small unit size• Opportunity to engage in ordinary
daily activities such as cooking
Fleming R – www.dementiaresearch.org.au
Translating dementia research into practice
Review on animal-assisted therapy (AAT)1
• 11 papers examining the impact of AAT on BPSD regarding their ability to
11Filan & Llewellyn-Jones (2006) Int. Filan & Llewellyn-Jones (2006) Int. Psychogeriatr; 18:4, 597-611Psychogeriatr; 18:4, 597-611
– Reduce agitation and/or aggression
– Promote social behaviour
– Improve nutrition– Role of pet substitutes
Robotic pets
Translating dementia research into practice
Moyle W et al, 2012, study underway
BPSD outcome from family CG interventions in community
Translating dementia research into practice
Brodaty and Arasaratnam2012 in press Am J Psychiatry
3279 dyads17 studies ES = 0.34 (95% CI 0.20 – 0.48, p<0.01)
CG reactions to BPSD from CG interventions for BPSD
Translating dementia research into practice
12 studies ES = 0.15 (95%CI 0.04 – 0.26, p=0.006)
Brodaty and Arasaratnam2012 in press Am J Psychiatry
Translating dementia research into practice
• Behaviour therapies Teri L
– Pleasurable events schedule
– Problem solving techniques
– Equal efficacy to haloperidol & trazadone
• Exercise programs Teri L
• Tailored activities Gitlin L
Examples: CGs administer….Examples: CGs administer….
Partner logo here
Translating dementia research into practice
Effects of DCM and PCC on agitationEffects of DCM and PCC on agitation
Chenoweth et al. Lancet Neurology 2009
Partner logo here
Translating dementia research into practice
Effects of DCM and PCC on agitationEffects of DCM and PCC on agitation
Chenoweth et al. Lancet Neurology 2009
PPC reduces agitation @ $ 6.43 per CMAI point
Novel strategies• PCC + PCE• Humour therapy• Volunteers• Integrating kindergarten/ babies
Translating dementia research into practice
Humour
SMILE StudySMILE Study
Elder clowns & LaughterBosses reduce agitationElder clowns & LaughterBosses reduce agitation
Clinically significant?Clinically significant?
• 20% reduction in agitation symptoms in SMILE
• The same effect size as is achieved by antipsychotic medications used to treat agitation
OR
SMILE study findings
• Humour therapy sustained +ve effect in reducing agitation (2.64 pnts over 26 wks)
• Management and Laughterboss (staff) engagement important components
• After adjustment, +ve effects on depression and QoL
• No adverse effects• Cannot determine what elements work• Humour Therapy is popular
Translating dementia research into practice
Agitation/aggression in NH residents Agitation/aggression in NH residents with dementia (CMAI aggression)with dementia (CMAI aggression)
* p < 0.05
Red
uce
d a
git
atio
n/a
gg
ress
ion
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
baseline week 4 week 8 week 12 end point
PlaceboMean dose1.06 mls
Risperidone
Mean dose 0.95mg
*
**CMAI, Cohen Mansfield Agitation Inventory
1 Brodaty et al 2003
Translating dementia research into practice
HOLLIS J et al 2007
Am J Ger Psych
Mortality rate: higher with haloperidolMortality rate: higher with haloperidol
•Amisulpride
•Olanzapine
•Quetiapine
•Risperidone
•Haloperidol
AnalgesicsAnalgesics
• Cluster RCT, 60 NHs, 352 residents, 8 + 4wks• Mod-severe dementia, CMAI > 39• Stepped analgesia vs usual care• CMAI 17% (9.6 vs 3.4, p<.001)• CMAI score in four weeks after stop analgesia• NPI, Pain scores significantly
Translating dementia research into practice
Husebo BS et al, BMJ, 2011;343:d4065 doi: 10.1136bmj.d0465
AnalgesicsAnalgesics• No analgesic or low dose paracetamol 3g/day
paracetamol (n = 120, 69%)• Full dose paracetamol or low dose morphine 5mg bd
morphine (4, 2%)• Low dose buprenorphine or unable to swallow
buprenorphine patch 5-10g/h (39, 22%)• Neuropathic pain pregabaline 25-300mg/day (12, 7%)
Translating dementia research into practice
Husebo BS et al, BMJ, 2011;343:d4065 doi: 10.1136bmj.d0465
Legal consent for psychotropicsLegal consent for psychotropics• Depending on jurisdiction a Person
Responsible must give consent (?in writing)• Survey of 3 NHs; 77 residents without capacity
to give informed consent; on psychotropics1
• Only 6.5% written consent• + 6.5% partial or attempted consent
1 Rendina N et al, 2009
DEMENTIA OUTCOMES IN THE AGED CARE REFORM PACKAGE
$268.4 million over 5 years to tackle dementia
•$13m to expanding DBMAS services into primary care and hospitals
•$28.8m to improve timely diagnosis of dementia in primary care
•$41m to support people with severe BPSD in residential care through ACFI
•10% subsidy for people with dementia receiving community care packages (~26% of packaged care recipients)•$39.2m for improved identification of and services for people with dementia in hospitals•$23.6m for Younger Onset Dementia link workers (through the NDSP program delivered by Alzheimer’s Australia)
DEMENTIA OUTCOMES IN THE AGED CARE REFORM PACKAGE
DEMENTIA OUTCOMES IN THE AGED CARE REFORM PACKAGE
Non dementia-specific measures:•$48m Expansion of National Respite for Carers Program & Respite Brokerage•Shift to Consumer Directed Care packages (community, and possibly residential)•More funding for palliative care•Aged care gateway to link consumers to local services and support.
WHAT THE REFORMS MEAN:
PEOPLE WITH DEMENTIA CAN STAY AT HOME LONGERStrengthening the community care system is central to any strategy for consumer choice and avoids premature entry into residential care
WHAT THE REFORMS MEAN:
ADOPTING CONSUMER-DIRECTED CARE IN ALL CARE PACKAGESThis enables consumers to have more say about the services they need, when they need them an who delivers them
WHAT THE REFORMS MEAN:
EMBRACING THE PRINCIPLE OF SUPPLEMENTARY FUNDINGThis will assist in meeting the extra costs of dementia care in both residential and community settings
WHAT THE REFORMS MEAN:
GREATER TRANSPARENCY IN THE QUALITY OF AGED CAREConsumers are reassured through the independent Aged Care Financing Authority, the new Australian aged Care Quality Agency, My Aged Care website and greater independence of the Aged Care Complaints Scheme
WHAT THE REFORMS MEAN:
PLAN TO TACKLE DEMENTIAThe government’s proposals for tackling dementia address the key priorities in the Alzheimer's Australia Fight Dementia campaign, particularly in respect of timely diagnosis, improved acute care services, improved support for younger people with dementia and an expansion of DBMAS
WHAT THE PLAN LACKS:
• Not all AA’s priorities have been addressed
• Alzheimer’s Australia is concerned about very low level of investment in dementia research
• AA is pursuing vigorously through the Minister’s Strategic Review of Health and Medical Research in Australia
www.mckeonreview.org.au
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Courtesy Cathy GreenblatLove Loss & Laughter
ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss
Courtesy Cathy GreenblatLove Loss & Laughter
Partner logo here
National Dementia Research Forum
Canberra, Australia 27-28 September, 2012
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Translating dementia research into practice
• www.dementiaresearch.org.au
Drug trials AD & MCI – 9382 3733
• Inspired Study – Young onset dementia
Translating dementia research into practice