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Dementia in Australia Focus on behavioural disturbances

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.

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Dementia in Australia Focus on behavioural disturbances

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  1. Dementia in AustraliaFocus on behavioural disturbances Henry Brodaty Dementia Collaborative Research Centre, UNSW www.dementiaresearch.org.au Translating dementia research into practice

  2. 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

  3. 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

  4. Prevalence 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 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

  5. How are BPSD managed? • Biological • Psychological • Interpersonal • Environmental Photo courtesy of Cathy Greenblatt Translating dementia research into practice

  6. Sydney Morning Herald 14th May 2012

  7. Psychotropics in Australia Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271. 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

  8. Psychotropic medication use in Sydney RACFs % Year Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271. Translating dementia research into practice

  9. Psychotropic medication use in Sydney RACFs % Year Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271. Translating dementia research into practice

  10. Psycholeptic use in aged care homes in Tasmania, Australia (Snowdon) (Tucker) Westbury, et al. (2010), Journal of Clinical Pharmacy and Therapeutics, 35: 189–193. doi: 10.1111/j.1365-2710.2009.01079.x

  11. 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

  12. Wander garden Outside space only beneficial in combination with staff interaction Fleming R – www.dementiaresearch.org.au Translating dementia research into practice

  13. Moderate 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

  14. Review on animal-assisted therapy (AAT)1 • 11 papers examining the impact of AAT on BPSD regarding their ability to • Reduce agitation and/or aggression • Promote social behaviour • Improve nutrition • Role of pet substitutes 1Filan & Llewellyn-Jones (2006) Int. Psychogeriatr; 18:4, 597-611 Translating dementia research into practice

  15. Robotic pets Moyle W et al, 2012, study underway Translating dementia research into practice

  16. BPSD outcome from family CG interventions in community 3279 dyads 17 studies ES = 0.34 (95% CI 0.20 – 0.48, p<0.01) Brodaty and Arasaratnam 2012 in press Am J Psychiatry Translating dementia research into practice

  17. CG reactions to BPSD from CG interventions for BPSD 12 studies ES = 0.15(95%CI 0.04 – 0.26, p=0.006) Brodaty and Arasaratnam 2012 in press Am J Psychiatry Translating dementia research into practice

  18. Examples: CGs administer…. • Behaviour therapies Teri L • Pleasurable events schedule • Problem solving techniques • Equal efficacy to haloperidol & trazadone • Exercise programs Teri L • Tailored activitiesGitlin L Translating dementia research into practice

  19. Effects of DCM and PCC on agitation Chenoweth et al. Lancet Neurology 2009

  20. Effects of DCM and PCC on agitation PPC reduces agitation @ $ 6.43 per CMAI point Chenoweth et al. Lancet Neurology 2009

  21. Novel strategies • PCC + PCE • Humour therapy • Volunteers • Integrating kindergarten/ babies Translating dementia research into practice

  22. Humour SMILE Study Elder clowns & LaughterBosses reduce agitation

  23. Clinically significant? • 20% reduction in agitation symptoms in SMILE • The same effect size as is achieved by antipsychotic medications used to treat agitation OR

  24. 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

  25. Agitation/aggression in NH residents with dementia (CMAI aggression) Placebo Mean dose 1.06 mls Reduced agitation/aggression * p < 0.05 Risperidone Mean dose 0.95mg * * CMAI, Cohen Mansfield Agitation Inventory * 1 Brodaty et al 2003 Translating dementia research into practice

  26. Mortality rate: higher with haloperidol • Amisulpride • Olanzapine • Quetiapine • Risperidone • Haloperidol HOLLIS J et al 2007 Am J Ger Psych Translating dementia research into practice

  27. Analgesics • 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  Husebo BS et al, BMJ, 2011;343:d4065 doi: 10.1136bmj.d0465 Translating dementia research into practice

  28. Analgesics • 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 5-10g/h (39, 22%) • Neuropathic pain  pregabaline 25-300mg/day (12, 7%) Husebo BS et al, BMJ, 2011;343:d4065 doi: 10.1136bmj.d0465 Translating dementia research into practice

  29. Legal 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

  30. 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

  31. DEMENTIA OUTCOMES IN THE AGED CARE REFORM PACKAGE • 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)

  32. 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.

  33. What the reforms mean: PEOPLE WITH DEMENTIA CAN STAY AT HOME LONGER Strengthening the community care system is central to any strategy for consumer choice and avoids premature entry into residential care 

  34. What the reforms mean: ADOPTING CONSUMER-DIRECTED CARE IN ALL CARE PACKAGES This enables consumers to have more say about the services they need, when they need them an who delivers them

  35. What the reforms mean: EMBRACING THE PRINCIPLE OF SUPPLEMENTARY FUNDING This will assist in meeting the extra costs of dementia care in both residential and community settings

  36. What the reforms mean: GREATER TRANSPARENCY IN THE QUALITY OF AGED CARE Consumers 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

  37. What the reforms mean: PLAN TO TACKLE DEMENTIA The 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

  38. 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

  39. www.mckeonreview.org.au

  40. ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss Courtesy Cathy Greenblat Love Loss & Laughter

  41. ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss Courtesy Cathy Greenblat Love Loss & Laughter

  42. ? Partner logo here Prevention Diagnosis Treatment Care Policy Dementia - Who gets it? National Dementia Research Forum Canberra, Australia 27-28 September, 2012

  43. 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

  44. Translating dementia research into practice

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