Dementia in Australia

Focus on behavioural disturbances

Henry Brodaty
Dementia Collaborative Research Centre, UNSW
www.dementiaresearch.org.au

Translating dementia research into practice

 What are BPSD?
Agitation Depression
Aggression Anxiety
Calling out/ screaming Apathy
Disinhibition (sexual) Delusions
Wandering Hallucinations
Night time disturbance Irritability
Shadowing Elation/euphoria
Swearing
Translating dementia research into practice
 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 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; 22:10251039
Translating dementia research into practice
How are BPSD
managed?
Biological
Psychological
Interpersonal
Environmental Photo courtesy of Cathy Greenblatt

Translating dementia research into practice

Sydney Morning Herald 14th May 2012
 Partner logo here

Psychotropics 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

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

Translating dementia research into practice DCRC/Brodaty 2012
 Partner logo here

Psychotropic medication use in Sydney RACFs

Year
Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271.
Translating dementia research into practice DCRC/Brodaty 2012
 Partner logo here

Psychotropic medication use in Sydney RACFs

Year
Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271.
Translating dementia research into practice DCRC/Brodaty 2012
 Partner logo here

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
 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

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

Moyle W et al, 2012, study underway

Translating dementia research into practice

 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

 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

 Examples: CGs administer.
Behaviour therapies Teri L
Pleasurable events schedule
Problem solving techniques
Equal efficacy to haloperidol & trazadone
Exercise programs Teri L
Tailored activities Gitlin L

Translating dementia research into practice

 Partner logo here

Effects of DCM and PCC on agitation

Chenoweth et al.
Lancet Neurology
2009

Translating dementia research into practice

 Partner logo here

Effects of DCM and PCC on agitation

PPC reduces
agitation @ $ 6.43
per CMAI point

Chenoweth et al.
Lancet Neurology
2009

Translating dementia research into practice

 Novel strategies
PCC + PCE
Humour therapy
Volunteers
Integrating kindergarten/ babies

Translating dementia research into practice

Humour

SMILE Study
Elder clowns & LaughterBosses reduce agitation
 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
Agitation/aggression in NH residents
with dementia (CMAI aggression)
baseline week 4 week 8 week 12 end point
0
-1
Reduced agitation/aggression

-2
Placebo
-3 Mean dose
-4 1.06 mls
-5
-6
-7
-8 * pRisperidone
< 0.05
*
-9 Mean dose
0.95mg
-10 *
CMAI, Cohen Mansfield*Agitation Inventory
1 Brodaty et al 2003
Translating dementia research into practice
Mortality rate: higher with haloperidol

Amisulpride
Olanzapine
Quetiapine
Risperidone
Haloperidol

HOLLIS J et al
2007
Am J Ger Psych

Translating dementia research into practice

 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

 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 5-10g/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
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

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
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 Alzheimers Australia)
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 LONGER
Strengthening 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 PACKAGES
This 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 FUNDING
This 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 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
WHAT THE REFORMS MEAN:

PLAN TO TACKLE DEMENTIA

The governments 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 AAs priorities have been addressed
Alzheimers Australia is concerned about
very low level of investment in dementia
research
AA is pursuing vigorously through the
Ministers Strategic Review of Health and
Medical Research in Australia
www.mckeonreview.org.au
 ssssssssssssssssssssssssssssss
ssssssssssssssssssssssssssssss
ssssssssssssssssssssssssssssss
ssssssssssssssssssssssssssssss
ssssssssssssssss

Courtesy Cathy Greenblat

Love Loss & Laughter
 ssssssssssssssssssssssssssssss
ssssssssssssssssssssssssssssss
ssssssssssssssssssssssssssssss
ssssssssssssssssssssssssssssss
ssssssssssssssss

Courtesy Cathy Greenblat

Love Loss & Laughter
 Partner logo here
Prevention

Diagnosis

Treatment

Care

Policy

Dementia - Who gets it?

National Dementia Research Forum
Canberra, Australia 27-28 September,
2012
 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

Translating dementia research into practice