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DEMENTIA RESEARCH

Caregiver Mediated Intervention Trumps Pharmacotherapy for BPSD. DEMENTIA RESEARCH. Collaborative partnerships • Translating evidence • Research partnerships. Professor Henry Brodaty Director Dementia Collaborative Research Centre – Assessment and Better Care.

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DEMENTIA RESEARCH

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  1. Caregiver Mediated Intervention Trumps Pharmacotherapy for BPSD DEMENTIA RESEARCH Collaborative partnerships•Translating evidence • Research partnerships Professor Henry Brodaty Director Dementia Collaborative Research Centre – Assessment and Better Care Translating dementia research into practice

  2. Dementia – not only a memory problem! Behavioural & Psychological Symptoms of Dementia (BPSD) • Depression • Delusions • Hallucinations • Aggression • Wandering • Apathy • Agitation •  BPSD ubiquitous >90% Translating dementia research into practice

  3. Prevalence of BPSD PWD up to 40x > rates of BPSD than rest of age matched population1 61% any NPI disturbance1; Mean NPI = 7 32% severe disturbance 1 (NPI  6) Delusions: AD > VaD; Depression: VaD > AD Rates just as high in developing countries2 Rates >90% in nursing homes3 Translating dementia research into practice 1Lyketsos et al 2000; 2Prince M et al 2004; 3Brodaty et al, 2001

  4. Effects of BPSD 1O’Brien JA, Shomphe LA,Caro JJ 2000; 2Rodney, 2000; 3Draper et al, 2000 4Maslow K 1994 • BPSD increase the cost of caring for a person with dementia in an institution1 • BPSD increase nurse stress, especially aggression2 & calling out3 • Residents with BPSD are more likely to4: • be physically restrained, receive antipsychotic medication, negatively influence care staff & other residents

  5. Effects of BPSD 1Pinquart & Sorensen (2003). Int Psychogeriatr 16(4), 1-19. 2Machnick et al. (2009). Int J of Geriatric Psych, 24(4), 382-389. 3de Vugt et al (2005). Int Psychogeriatr, 17, 577-589. 4Chan et al. (2003). J Gerontol A Biol Sci Med Sci, 58(6), 548-554. Greatest burden on family CG is BPSD1,2 Predicts CG decision to institutionalise PWD3,4 Translating dementia research into practice

  6. Limited drug efficacy 1Schneider et al. (2005). JAMA, 294(15), 1934-1943. 2Wang et al. (2005). New Engl J Med, 353(22), 2335-2341. 3Brodaty et al. (2003). J Clin Psychiatry. 64(2), 134-143. 4Weintrub et al. (2010). Am J Geriatr Psychiatry, 18(4), 332-340. Can have adverse effects Antipsychotic drugs associated with increased risk of stroke and death1-3 Little effect of antidepressants4 Translating dementia research into practice

  7. Non-pharmacotherapy intervention 1Livingston et al. (2005). Am J Psychiatry, 162(11) 2O’Connor et al. (2009). Int Psychogeriatr, 21(2), 241-251. 3Ayalon, et al. (2006). Arch Intern Med, 166(20), 2182-2188. Demonstrated effectiveness in residential care CG intervention reduce stress1,2 Modest efficacy comparable to psychotropics but w/o adverse effects3 Most studies in residential care, not community Translating dementia research into practice

  8. What is efficacy of CG interventions in community on BPSD? Translating dementia research into practice

  9. Systematic review • Criteria • Peer reviewed, English language • Non-pharmacological interventions • Outcomes relevant to BPSD • >5 participants with dementia diagnosis • Primary CG = family member living w/ PWD • Excluded • Review papers, respite care interventions Translating dementia research into practice

  10. Systematic Review: Results

  11. Results • 22 studies met all criteria • Categorised into 5 groups • Skills training for CG • Education for CG • Occupational therapist led intervention for CG • Enhancing support for CG • Self-care techniques for CG Translating dementia research into practice

  12. 1. Skills training for CG • Better management of BPSD • Better communication with CR • Using role play, videos modelling management, vignettes, live interviews • Enhancing CR quality of life • (eg increasing pleasant events) Translating dementia research into practice

  13. 1. Skills training for CG • Gormley et al. (2001): Education & aggressive behaviour management training • 4 in-home sessions over 8 wks • Outcomes: CR aggressive behaviour & overall behavioural problems • Results: Sig reduction in aggressive behaviour score for tmt group (controlling for baseline aggression) Gormley et al. (2001). Age and Ageing, 30(2), 141-145

  14. 2. Education for CG Psychoeducation Improved homecare Tailored advice/recommendations Problem solving methods Improving support network Computer mediated automated voice response Planning, legal, financial Translating dementia research into practice

  15. 2. Education for CG • Teri et al. (2005): CG taught communication strategies & BMT, enhanced CG support • 8 wks plus 4 months phone support • Outcomes: frequency & severity of problem behaviours, CG reactions to behaviours • Results: Sig reduced freq & severity of problem behaviours • Sig improved CG reactions to CR problem behaviours Teri et al. (2005). Gerontologist, 45(6), 802-11.

  16. 3. Occupational therapist led intervention Planning activities with CG for CR Modifying CR physical and social environment Translating dementia research into practice

  17. 3. Occupational therapist led intervention • Graf et al. (2007): CR taught to use compensatory/environmental strategies to improve performance of daily activities • OT in 10 sessions over 5 wks • Outcomes: CR mood (depression) • Results: CR mood (depression) was significantly improved Graff et al. (2007). J Gerontol A Biol Sci Med Sci, 62(9), 1002-9

  18. 4. Enhancing support for CG Social support Web/phone support Strategies on how to access support Family counselling Translating dementia research into practice

  19. 4. Enhancing support for CG Belle, et al. (2006). Annals of Internal Medicine, 145(10), 727-738. • Belle et al. (2006): Education & support for CG • In-home & phone sessions: 12 sessions, 6 months • Outcomes: change in problem behaviours • Results: Significant improvement in problem behaviours for Hispanic/Latino group (ns for white & African-American groups) Translating dementia research into practice

  20. 5. Self-care techniques for CG Health management Stress management Coping with change as a result of caregiving Music therapy Counselling Translating dementia research into practice

  21. 5. Self-care techniques for CG • Gitlin et al. (2010): OT prescribed tmt plan for managing problem behaviours & CG self-care, skill building • Up to 11 home/phone contacts over 16 wks • Outcomes: change in freq of most distressing behaviour; CG upset & confidence in managing behaviour; overall CG upset • Results: Sig improved target behaviour, reduced upset & enhanced confidence. Less overall upset with all behaviours Gitlin et al. (2010). J Am Geriatr Soc, 58(8), 1465-1474.

  22. BPSD outcomes Translating dementia research into practice

  23. BPSD outcomes Skills training for CG, 0.15 (-0.03-0.33) Education for CG, 0.51 (0.24-0.78) OT led interventions, 0.23 (-0.03-0.48) Enhancing support for CG, 0.18 (-0.08-0.45) Self-care techniques for CG, 0.21 (0.08-0.34) Translating dementia research into practice

  24. Caregiver Outcomes Translating dementia research into practice

  25. CGs’ reactions to BPSD (all NS) • skills training for CG, 0.03 (-0.16-0.23) • education for CG, 0.02 (-0.14-0.18) • OT led intervention, 0.08 (-0.08-0.24) • enhancing CG support, 0.31 (-0.08-0.71) • self-care techniques for CG, 0.14 (-0.05-0.34) • Miscellaneous for CG…….. Translating dementia research into practice

  26. Limitations Categorisation of interventions Different BPSD may differ in response Translating dementia research into practice

  27. Interpretation • CG interventions can significantly reduce BPSD • ES = 0.46 (95% CI = 0.24-0.68), significant • Interventions less effective for CG outcomes • ES = 0.05 (95% CI = -0.09-0.18), not significant • Comparable to pharmacological treatments • Small overall effect of antipsychotics on delusions, aggression and agitation • ES = 0.16 (0.11 to 0.22)1 1Schneider et al. (2006). Am J Ger Psychiat, 14(3), 191-210

  28. Translating dementia research into practice

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