IPA Bulletin
Recent Advances

Nursing Research and Practice
Wendy Moyle

Psychosocial Interventions
A recent US study aimed to explore culture change specifically related to staff decision-making around interventions for BPSD. Focus groups with 35 staff from 6 long-term care facilities explored staff perceptions of resident behaviours, the approaches used to address these behaviours and the rationale for selecting specific interventions. Data were analysed using both content and thematic analysis. Findings revealed the many challenges faced by staff to implementing non-pharmacological strategies including staff feeling a lack of control over the environment, resident co-morbidities and high acuity levels. While staff may be aware of interventions that modify state of person and environment, their limited work time posed a significant barrier to using non-pharmacological interventions. This cumulated in staff’s perceptions of pharmacological intervention as an efficient and reliable intervention to control behaviours and promote a quiet environment. Staff attention was on ‘challenging residents’ whereas passivity was not seen as an indication for intervention. Furthermore, staff were concerned with managing behaviours for the good of the organisation rather than understanding of the behaviours for the good of the individual. Nurses and care staff developed their repertoire of strategies through trial and error, rather than learning from research-based evidence. Recommendations include: implementation of staffing patterns and roles that allow staff time and skills to make a difference; development of education programs that focus on understanding rather than the need to control; and further research framed around theoretical frameworks that consider time and its influence on intervention selection.

Kolanowsi et al. It’s about time: Use of nonpharmacological interventions in the nursing home. J Nrs Scholarship 2010, 42 (2), 214-222.

An Australian randomised controlled trial investigated the effect of live music on quality of life and depression in 47 people with dementia using the QOL-AD and GDS. A live active music group (30 minutes of musician-led familiar song singing and 10 minutes of pre-recorded instrumental music for active listening) and an interactive reading group run for 40 minutes, three mornings a week for 8 weeks. Participants then crossed over into the opposite arm and the protocol was repeated for another 8 weeks. There was a five-week washout period between crossover to reduce the likelihood of carry over effects. The main significant finding was a significant difference in the mid-point QOL belonging scores between music and reading groups (F(1,45)=6,672, p<.05). Those participants who experienced the reading control group first reported higher feelings of belonging (3.61) than those who experienced the music first (3.17). Means showed that when the first reading group crossed over into the music group their scores decreased (3.61 to 3.46), whereas when the first music group crossed over into the reading group their scores increased (3.17 to 3.57). The authors conclude it may be that music does not have a stronger therapeutic effect than other group activities. They recommend introducing a third group of usual care into the research design.

Cooke et al. A randomised controlled trial exploring the effect of music on quality of life and depression in older people with dementia. J Hlth Psych, 2010, 15 (5), 765-776.

Staff Attitudes and management
A UK study aimed to explore the views of nursing staff in relation to aggressive behaviours in people with dementia and strategies used in practice. A survey of 36 staff (out of a possible 52) in 6 dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted alongside a 3-month observation audit using the Staff Observation Aggression Scale. Staff viewed aggressive behaviour by people with dementia as deriving from an interaction with the environment or with others. Staff responded to aggressive behaviours by using interpersonal interventions and a moderate use of medications. Over the 3-month observational period a total of 79 incidences of aggression were recorded in relation to residents whose family members consented and involved 31 residents. The results from the audit substantiated the views reported by staff. The authors acknowledge the study limitations including the small number of care homes and staff, and all facilities owned by the one owner may not be representative of other settings. In future research the authors suggest an audit of medication use would also be informative.

Pulsford et al. A survey of staff attitudes and response to people with dementia who are aggressive in residential care settings. J Psych & Mental Hlth Nrs, 2011, 18, 97-104.

An Australian study aimed to explore management of people with dementia in the acute care setting. A descriptive qualitative approach was used with semi-structured interviews with a cross section of 13 multi-disciplinary staff. Five subthemes were revealed with the over arching theme being paradoxical care, in that an inconsistent approach to care emphasised safety at the expense of well-being and dignity. Subthemes included: defining confusion, whereby in spite of decisions of how patients should be managed staff displayed limited understanding of the difference between acute and chronic confusion. Everyday challenges referred to the blame being centred on the patient rather than the management strategies or environment. Cultural barriers referred to the competing activities within the acute environment reducing the opportunity for the person with dementia to be appropriately cared for. The most common form of care management was ‘specialling’ whereby the most junior staff member with limited education was assigned to observe the patient. The need to maintain patient safety and a limited understanding of appropriate interventions encouraged specialling. There was an underlying sense of dissatisfaction with the care management and staff raised the need for greater optimal care practices. However, this environment created a risk management approach rather than one that incorporated injury prevention as one facet of an overall strategy. Furthermore, limited understanding of the difference between chronic and acute confusion resulted in superficial and general care management whereby staff assumed the strategies that were in use were suitable for any older person with confusion, whether it was chronic or acute. The authors emphasise the need for staff education and in particular, integration of an academic environment into the clinical setting to encourage incorporation of evidence-based practice.

Moyle et al. Acute care management of older people with dementia: a qualitative perspective. J Clin Nrs 2010, 20, 420-428.

Wandering
A US study aimed to explore the extent of and factors associated with a change of wandering status of male residents in nursing home care. Residents admitted to 134 Veterans Administration (VA) Nursing Homes over a 4-year period were examined using repeated assessments with the Minimum Data Set (MDS). This resulted in 6673 residents being included in the data set. The majority (86%) were classified as non-wanderers at time of admission and 94% of these remained with this status until discharge, or at the end of the study. 51% of those classified as wanderers changed status to non-wanderers. A number of factors were identified as influencing change in status to wanderers. Residents with severe cognitive impairment and who exhibited socially inappropriate behavior, or who required assistance with personal hygiene at admission were less likely to change from wandering to non-wandering. However, residents who were dependent for mobilisation were more likely to change status to a non-wanderer. The authors argue for more studies that delineate safe from unsafe wandering.

King-Kallimanis et al. Longitudinal investigation of wandering behaviour in department of veteran affairs nursing home care units. Int J Geriatric Psych 2010, 25, 166- 174.

Research and Practice
Mark Rapoport
February 15, 2011

ECT

Two recent European studies examined different aspects of electroconvulsive therapy (ECT). The first used MRI measures as predictors of ECT response and the second was an open trial assessing the impact of ECT among patients with mild cognitive impairment (MCI) or dementia.

A naturalistic study of 81 older adults with major depression who were undergoing ECT was conducted in the Netherlands. Each subject underwent an MRI and the researchers found that the presence of moderate or severe medial temporal lobe atrophy was associated with a 3-fold decreased likelihood of remission of depression with the ECT course. Neither cortical atrophy nor white matter hyperintensity burden were associated with response.

Oudega et al. White matter hyperintensity burden, medial temporal lobe atrophy, cortical atrophy, and response to ECT in severely depressed patients. J Clin Psychiatry 2011, 72(1), 104-112.

A small case series of ECT was conducted in Germany, in which 13 patients with no cognitive impairment (NCI), 19 with MCI and 12 patients with dementia underwent ECT for the treatment of major depression. An MMSE was conducted prior to each treatment, after the 6th ECT, and again 6 weeks and 6 months after treatment. The MMSE of the NCI and MCI groups improved significantly over 6 months, and there was a numerical but not statistical improvement in the MMSE of the dementia group. The improvement in the dementia group was significantly greater for those on anti-dementia drugs such as cholinesterase inhibitors.

Hausner et al. Efficacy and cognitive side effects of ECT in depressed elderly inpatients with coexisting mild cognitive impairment or dementia. J Clin Psychiatry, 72(1), 91-7.

Benzodiazepines.
Despite guidelines suggesting reduction or elimination of benzodiazepine use among older adults, recent evidence suggests they are robustly more common among older than younger adults, and that their discontinuation may reduce the attendant risks of cognitive impairment and dementia.

A longitudinal Canadian study was conducted from 1994 to 2006 with interviews every two years, and benzodiazepine/sedative-hypnotic use was recorded from a list of all medications taken in the 2 days preceding each interview. There was a 48.5% attrition rate in the study, largely from non-response. The frequency of use of benzodiazepines/sedative-hypnotics increased with age, with 0.6% of those aged 12-45 years, 2.1% for those aged 46-65 years, and 3.4% for those aged 66 and older. Age 66 and over was associated with a 5-fold increase in initiation of benzodiazepine/sedative hypnotic over time. The authors report that major depression had less of a relationship to benzodiazepine/sedative hypnotic initiation in older adults than in the younger group.

Patten, S.B. et al Pharmacoepidemiology of benzodiazepine and sedative-hypnotic use in a Canadian general population cohort during 12 years of followup. Can J Psychiatry 2010; 55(12): 792-799.

Researchers from Taiwan conducted a nested case-control study of dementia to determine the risks associated with benzodiazepines. The authors found that dementia was associated with almost a 3-fold increased likelihood of current benzodiazepine exposure. Interestingly, the risk reduced according to the length of time in which benzodiazepines had been discontinued with the risk being no longer significant by 3 years after discontinuation, except for heavy users.

Wu CS et al, Effect of benzodiazepine discontinuation on dementia risk. Am J Ger Psychiatry 2011, 19(2):151-159.

An eight week open-label study of benzodiazepine discontinuation was conducted in 30 nursing home residents in Japan. The average age of the subjects was 79.1 (SD 8.9), and they had various diagnoses. The mean daily flurazepam equivalent dose was 19.5mg (SD 10.9), and the benzodiazepine was tapered over 3 weeks. The subjects underwent testing of postural stability, sleep ratings, and subtests of the Repeateable Battery for the Assessment of Neuropsychological Status (RBANS) at baseline 12 hours post-dose, and again after 8 weeks. There were 26 completers, and among this group, measures of trunk motion, immediate and delayed memory, language, attention, and constructional ability robustly improved, without a decrement in sleep ratings. The absence of a control group is an important limitation, yet this study suggests that a controlled study would be warranted.

Tsunoda, K. Effects of discontinuing benzodiazepine-derivative hypnotics on postural sway and cognitive functions in the elderly. Int J. Ger Psychiatry, 2010; 25: 1259–1265.

Imaging

Two recent cross-sectional studies using different imaging techniques shed important insights into mechanisms in dementia. The first used the Brain Derived Neurotrophic Factor (BDNF) Val66Met polymorphism to predict cognition, cortical thickness, and white matter integrity in a group of healthy adults across the lifespan, and the second used FDG-PET imaging to look at regional brain metabolism associated with executive dysfunction in dementia.

A group of 69 healthy adults ranging in age from 19 to 82 were examined in a cross-sectional study assessing the relationship of the BDNF-Val66Met polymorphism to measures of memory and cognition in Toronto, Canada. The authors used a measure of episodic memory from the Repeatable Battery for the assessment of Neuropsychological Status (RBANS), an MRI measure of T1 cortical thickness, as well as fractional anisotropy of the white matter tracts using diffusion tensor imaging. An intriguing age x genotype interaction was found, such that lower measures of cognition, cortical thickness (especially in the medial temporal areas) and white matter integrity (especially in temporal-parietal and temporal-frontal areas) were found for the carriers of the Met allele in younger adulthood, and in Val/Val individuals in later life.

Voineskos, A.M. et al. The Brain-Derived Neurotrophic Factor Val66Met
Polymorphism and Prediction of Neural Risk for Alzheimer Disease. Arch Gen Psych 2011;68(2):198-206

A PET study was conducted in California of 41 patients with Alzheimer’s disease in order to examine the correlation between cerebral metabolism and executive functioning in this population. Each subject was administered 5 tests of executive functioning and underwent FDG PET scanning. The authors reported that reduced activity in the right middle and inferior frontal gyrus, as well as the left middle frontal gyrus and both angular gyri was associated with lower scores on several executive measures. Other areas of lower metabolism correlating with executive measures were reported in the left temporal lobe and both parietal lobes, although the parietal lobe correlations were not significant once controlling for MMSE score. The study confirmed the recognized relationship between frontal lobe dysfunction and executive dysfunction in AD, but also raises the notion that posterior cortical metabolism contributes to performance on executive functioning tasks.

Woo B.K.P. et al Executive deficits and regional brain metabolism in Alzheimer’s disease. Int J Ger Psychiatry 25: 1150-1158.

Psychiatric Disorders in Long-Term Care

Researchers from Toronto, Canada and Manchester, UK conducted a systematic review of the prevalence of psychiatric disorders in long-term care. They limited their search for those using validated measures for symptoms or establishing diagnoses. They also determined the prevalence of disorders in the US long-term care population in 2004’s National Nursing Home Survey (NNHS). They found a median prevalence of 58% for dementia in the reviewed studies, and 52% in the NNHS. Of those with dementia, the median prevalence of BPSD was 78% in the reviewed studies, and about 37% in the NNHS. Major depression had a prevalence of 10% in the reviewed studies and only 1.33% in the NNHS. Most other psychiatric disorders had insufficient data to estimate prevalence. The authors commented on the small sample sizes and the few LTCs incorporated in the study samples, as well as the differing populations and measures in the different studies, making comparison difficult. They argued for more studies in countries outside of Europe and North America, as well as collaboration with standard measures across centres.

Seitz, D. et al. Prevalence of psychiatric disorders among adults in long-term care homes: A systematic review. Int Psychogeriatrics 2010; 22(7), 1025-39.

Psychotherapy

Researchers in San Francisco conducted a randomized controlled trial in which 221 older adults with major depression who had low scores in two executive function tests were randomized to either problem-solving therapy (PST) or supportive therapy for 12 weeks. There was little attrition in this study, with only 9% dropping out of treatment. At 12 weeks, response, defined as a 50% or greater reduction of HAMD score, common in the PST group (56.7%) than the supportive therapy group (34%). Remission, defined as a HAMD of less than 10 for 2 consecutive weeks, was also more common in the PST group than the supportive therapy group (45.6% vs 27.8%). The results of this study are similar to the demonstrated effectiveness of PST for cognitively intact depressed older patients, and the fact that the group differences were only apparent at 12 weeks (not at 6 weeks) suggests that adequate time was required for the development of problem-solving skills in this group.

Arean, P.A., et al Problem solving therapy and supportive therapy in older adults with major depression and executive dysfunction. Am J Psychiatry 2010, 167: 1391-1398.


Reprinted from IPA Bulletin, Volume 28, Number 1