Systemic approach to behavioural and psychological symptoms of dementia in residential aged care facilities

The perspective ‘Rethinking psychotropics in nursing homes’ (Hilmer and Gnjidic, 2013) raises justifiable concern regarding the potential overuse of psychotropic medication in Australian residential aged care facilities (RACFs), which we argue is actually a downstream effect of systemic problems in the provision of mental health care in the RACF environment (Snowdon, 2010) and thus requires broader scale interventions. The psychiatric morbidity of RACF residents is alarming: an international systematic review found that dementia had a prevalence of 58%, with 78% of those with dementia exhibiting behavioural and psychological symptoms (BPSD). In addition, major depression had a prevalence of 10% and depressive symptoms were evident in 28% (Seitz et al., 2010). There is no room for therapeutic nihilism (Macfarlane et al., 2012) in the presence of burgeoning evidence of the efficacy of non-pharmacological interventions (Cohen-Mansfield et al., 2012; Conn and Seitz, 2010; Kolanowski et al., 2011; Leone et al., 2013; O’Connor et al., 2009), as well as evidence for the judicious usage of antidepressants (Seitz et al., 2011), antipsychotics (Ballard et al., 2006) and cognition-enhancing agents in at least some residents with BPSD (Conn and Seitz, 2010). Routine discontinuation of antipsychotics (Devanand et al., 2012) and antidepressants (Bergh et al., 2012) in people with dementia may have adverse outcomes, with recurrence of the disorders and increased distress. As experienced geriatric psychiatrists, we argue that a comprehensive systemic approach is required to care for and support people with BPSD and other types of mental illness in RACFs. This approach should encompass structured assessment of problem behaviours and symptoms, targeted psychological and pharmacological interventions, appropriate levels of properly remunerated staff who have undergone dementia-specific education and training, and physical design components to produce a prosthetic environment.

Hilmer and Gnjidic (2013) asserted that ‘… we tend to use [psychotropic medications] too often, for too long, at doses that are too high, in dangerous combinations …’ (p.77). They cited findings from a series of studies in 44 nursing homes in Sydney (Snowdon et al., 2011). This series of studies found that between 1993 and 2009 the use of regularly administered antipsychotics rose from 27% to 28%; regular hypnotics dropped from 26% to 11%; regular anxiolytics dropped from 8.6% to 4.7%; regular antidepressants rose from 15.6% to 25.6%; and the overall psychotropic use (all classes combined) dropped from 58.9% to 47.5%. From these findings it is clear that lumping all psychotropic medications into a single category obscures the complexities of usage of these drugs (Snowdon et al., 2011). Despite this caveat, we agree that critical review of medications for the treatment of BPSD for persons residing in RACFs is important and that changes to treatment regimens, including starting and stopping medication, warrant careful consideration; especially since a recent Australian study showed that medications for RACF residents were infrequently reviewed (O’Connor et al., 2010).

We have argued elsewhere (Macfarlane et al., 2012) that the limited evidence of efficacy of antidepressants in people with dementia is likely to arise from the rather limited volume and sophistication of the available evidence, whilst acknowledging that depressive symptoms and disorders may be difficult to ascertain, monitor and treat in this population. A Cochrane Systematic Review noted there were few trials of treatment of BPSD with antidepressants, but concluded that two selective serotonin reuptake inhibitors (SSRIs) modestly reduced symptoms of agitation and psychosis (Seitz et al., 2011). Owing to the advanced nature of dementia of many persons in RACFs, there may be considerable overlap in depression, agitation and psychotic symptoms. Also, a recent study shows that double-blind discontinuation of antidepressants in 63 persons with neuropsychiatric symptoms associated with dementia, but not depression, compared to 68 continued on such treatment, resulted in the emergence of depressive symptoms – although this study had very high drop-out rates (Bergh et al., 2012). There is evidence that multidisciplinary specialist mental health consultation in RACF residents is more effective than usual care in treating clinical depression in persons with dementia, with significant reduction in scores on the Cornell depression scale (McSweeney et al., 2012). However, we agree that working out which patients may benefit from antidepressant treatment in RACFs is often difficult due to the multiplicity of factors impacting on depression.

Hilmer and Gnjidic (2013) correctly identify that many adverse effects arise from the usage of antipsychotics in persons in RACFs. However, psychotic symptoms, particularly when associated with agitation/aggression, can represent a serious risk to the person with dementia and to other residents, staff and family carers. A Cochrane Systematic Review concluded that there was modest evidence of efficacy of antipsychotics for BPSD; though significant risks of adverse effects were noted, and that ‘neither risperidone nor olanzapine should be used routinely to treat dementia patients with aggression or psychosis unless there is severe distress or risk of physical harm to those living and working with the patient’ (p.4) (Ballard et al., 2006). Thus, the prudent use of antipsychotics for BPSD should involve discussion of the modest benefits, potentially serious risks and common adverse effects with legal guardians, statutory health attorneys or other substitute decision-makers. In an open-label trial of 110 persons treated with risperidone for Alzheimer’s disease complicated by psychosis or agitation/aggression, 24 of 40 (60%) participants who were switched to placebo and 23 of 70 (33%) who continued on treatment had relapsed by 16 weeks; 13 of 27 of those switched to placebo relapsed, as opposed to two of 13 maintained on treatment, after 32 weeks (Devanand et al., 2012). Although this is an open-label trial, it demonstrates that psychotic symptoms and agitation/aggression may re-emerge after cessation of antipsychotics.

The high rates of use of psychotropic medication in RACFs are a symptom of systemic problems: including inadequate levels of poorly remunerated staff with limited mental health and behavioural management training; facilities without ready access to multidisciplinary input from clinical geropsychologists and other specialist mental health workers; activity programs that are insufficiently tailored to the specific needs of people with dementia; and physical design limitations that do not provide a supportive prosthetic environment for people with dementia. A comprehensive systemic approach is required to address the management of BPSD in RACFs. BPSD is not a specific diagnosis; rather, it is an umbrella term that highlights an important clinical dimension of dementia that may occur for a range of reasons. In identifiable mental illness, such as psychosis (with or without dementia), anxiety and depression, there are appropriate treatment strategies comprising pharmacological and non-pharmacological interventions suitably modified for older persons (Looi et al., 2002). These treatment strategies can be implemented in a consultation-liaison model by district aged care mental health services (Snowdon, 2010). However, much of this care is provided by general practitioners (GPs), who are required to manage complex overlapping medical problems (O’Halloran et al., 2007) and are faced with many obstacles in rendering medical care in the RACF environment (Gadzhanova and Reed, 2007). The GP has a central role in assessing the patient, prescribing medications if required and coordinating care with RACF staff – in often very limited time and in a challenging environment. If better systems of care existed for people with dementia residing in RACFs, more GPs might be encouraged to work in this environment in collaboration with aged care mental health services (Snowdon, 2010).

There are a variety of effective non-pharmacological approaches to the neuropsychiatric symptoms of moderate to advanced dementia that rely upon professional (nursing, but primarily aged care nursing assistants) and non-professional carers (Conn and Seitz, 2010). As Hilmer and Gnjidic (2013) identify, there are problems hiring trained staff, and the majority of RACF care staff have had limited education and training in the recognition and management of mental illness and behavioural disorders when compared to nursing personnel working in acute aged care and mental health settings (Jones et al., 2007). Arguably, a business model which supported the employment of skilled mental health nursing personnel within RACFs would greatly improve the capacity for non-pharmacological psychosocial care (Jones et al., 2007). While district aged care psychiatry services can provide limited out-reach and advice, at least in urban areas (McSweeney et al., 2012; Snowdon, 2010), there is an ongoing need to educate and up-skill existing RACF care personnel. Provision of education for GPs, nursing (Beer et al., 2010) and allied health staff can be challenging, but this may be addressed by embedding education and training in the culture of RACFs (Snowdon, 2010). One such model is the teaching nursing home (Kirkevold, 2008), which may lead to markedly improved quality of care. Collaboration of physicians with psychologists, experienced aged care mental health nurses, nurse practitioners, pharmacists, diversional therapists, volunteers and family members may provide additional psychosocial skill and support, as may similar services accessed through non-governmental organisations (NGOs) such as the Dementia Behavioural Management and Assessment Service funded by the Australian Department of Health and Ageing.

The mode of delivery of general care can also impact on residents in RACFs, with personalised care and increased autonomy leading to improved quality of life (Brownie and Nancarrow, 2013), although implementation in the culture of RACFs has been challenging (Rosemond et al., 2012) due mainly to staffing limitations. There is evidence that a specific tailored and personalised approach to care coupled with meaningful activities has significant benefits for physical and mental wellbeing (Garland et al., 2006; O’Connor et al., 2009). The funding of the RACF can also significantly impact upon the total quality of care, with a systematic review showing non-profit RACFs generally provide better quality (Comondore et al., 2009). The physical design of RACFs may impact significantly on mental illness in residents, and there are studies underway to investigate quality of life in small home-like environments compared to traditional nursing homes (de Rooij et al., 2011).

Residents in aged care facilities are among our most frail and vulnerable citizens. In a humane society, they should be afforded comprehensive, high-quality care that explicitly addresses the known high prevalence of dementia with BPSD. This high-quality individualised care is likely to be predicated upon systematic changes in the RACF environment that go well beyond calls for a reduction in the use of psychotropic medication.

Potential proposals for systemic improvement may include:

• the provision of services for prompt assessment of residents with mental illness, such as consultation-liaison mental health services, GPs, nurses/appropriately supervised nurse-practitioners, psychologists, pharmacists and allied health professionals visiting RACFs;

• GP and specialist collaborative care with nurses/appropriately supervised nurse-practitioners, psychologists, pharmacists and allied health professionals visiting RACFs;

• the use of telemedicine and innovative technology approaches in support of the above;

• education and up-skilling of care staff to collaboratively implement personalised psychosocial/non-pharmacological interventions (including the health student teaching in RACFs and RACFs as teaching environments);

• training in the use of assessment instruments (observation scales/questionnaires) for common mental health problems by skilled care staff;

• changes in the design and organisational culture of RACFs towards improving the mental well-being of residents;

• the investigation and development of sustainable funding models for provision of care (Hilmer and Gnjidic, 2013) to allow improved remuneration for RACF personnel, including nursing staff and GPs;

• coordination of all of the above, preferably via strong links between primary care and specialist services.

Comprehensive systemic review and reform of the provision of mental health care for BPSD within RACFs is needed to address the problem of potential overuse of psychotropic medication.