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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. - PowerPoint PPT Presentation
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DEMENTIA RESEARCHDEMENTIA RESEARCH
Collaborative partnerships • Translating evidence • Research partnerships
Translating dementia research into practice
Caregiver Mediated Intervention Trumps Pharmacotherapy for BPSD
Professor Henry BrodatyDirector
Dementia Collaborative Research Centre – Assessment and Better Care
© DCRC/Brodaty 2011
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Translating dementia research into practice
Dementia – not only a memory problem!Dementia – not only a memory problem!
• Depression• Delusions• Hallucinations• Aggression• Wandering• Apathy• Agitation BPSD ubiquitous >90%
Behavioural & Psychological Symptoms of Dementia (BPSD)
© DCRC/Brodaty 2011
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Translating dementia research into practice
Prevalence of BPSDPrevalence 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
1Lyketsos et al 2000; 2Prince M et al 2004; 3Brodaty et al, 2001
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1O’Brien JA, Shomphe LA,Caro JJ 2000; 2Rodney, 2000; 3Draper et al, 20004Maslow K 1994
Effects of BPSDEffects of BPSD• 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
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Effects of BPSDEffects of BPSD
• Greatest burden on family CG is BPSD1,2
• Predicts CG decision to institutionalise PWD3,4
Translating dementia research into practice © DCRC/Brodaty 2011
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.
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Limited drug efficacyLimited drug efficacy
• Can have adverse effects• Antipsychotic drugs associated with
increased risk of stroke and death1-3
• Little effect of antidepressants4
Translating dementia research into practice © DCRC/Brodaty 2011
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.
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Non-pharmacotherapy interventionNon-pharmacotherapy intervention
• 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 © DCRC/Brodaty 2011
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.
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What is efficacy of CG interventions in
community on BPSD?
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Systematic reviewSystematic 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
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ResultsResults• 22 studies met all criteria• Categorised into 5 groups
1. Skills training for CG
2. Education for CG
3. Occupational therapist led intervention for CG
4. Enhancing support for CG
5. Self-care techniques for CG
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1. Skills training for CG1. 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)
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1. Skills training for CG1. 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
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2. Education for CG2. Education for CG• Psychoeducation• Improved homecare• Tailored advice/recommendations• Problem solving methods• Improving support network• Computer mediated automated voice
response• Planning, legal, financial
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2. Education for CG2. 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.
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3. Occupational therapist led 3. Occupational therapist led interventionintervention
• Planning activities with CG for CR• Modifying CR physical and social
environment
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3. Occupational therapist led 3. Occupational therapist led interventionintervention
• 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
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4. Enhancing support for CG4. Enhancing support for CG
• Social support• Web/phone support• Strategies on how to access support• Family counselling
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4. Enhancing support for CG4. Enhancing support for CG
• 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 © DCRC/Brodaty 2011
Belle, et al. (2006). Annals of Internal Medicine, 145(10), 727-738.
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5. Self-care techniques for CG5. Self-care techniques for CG
• Health management• Stress management• Coping with change as a result of
caregiving• Music therapy• Counselling
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5. Self-care techniques for CG5. 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.
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BPSD BPSD outcomesoutcomes
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BPSD outcomes 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)
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Partner logo hereCaregiver OutcomesCaregiver Outcomes
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CGs’ reactions to BPSD (all NS) 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……..
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LimitationsLimitations
• Categorisation of interventions• Different BPSD may differ in response
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InterpretationInterpretation• 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
© DCRC/Brodaty 20111Schneider et al. (2006). Am J Ger Psychiat, 14(3), 191-210