dementia in australia focus on behavioural disturbances

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

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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.

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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

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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

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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….

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Effects of DCM and PCC on agitationEffects of DCM and PCC on agitation

Chenoweth et al. Lancet Neurology 2009

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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

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Courtesy Cathy GreenblatLove Loss & Laughter

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National Dementia Research Forum

Canberra, Australia 27-28 September, 2012

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Translating dementia research into practice

• www.dementiaresearch.org.au

• h.brodaty@unsw.edu.au

Drug trials AD & MCI – 9382 3733

• Inspired Study – Young onset dementia

Translating dementia research into practice