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Antipsychotics, person-centred care and managing challenging behaviours in dementia.
- Albert ME Coleman (3 April 2006)
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Use of Physical and Chemical Restraints: A Traditional Approach
- Vibha Pandey (30 January 2008)
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Albert ME Coleman, Associate specialist psychiatrist WSHSC NHS trust, Greenarces CMHT, (OPMH), Homefield road. Worthing. W. Sussex BN11 2DH
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EDITOR- Andrew’s comment (1) on the study by Fossey et al (2), is interesting reading. For those of us involved in dementia care, person centred care may be the ideal care concept, more so considering the controversies surrounding the use of anti-psychotic medications in the control of behavioural symptoms of dementia (BSD), (3-4). However real- life day to day happenings in care homes, show that person-centred care practice is far from the ideal in practice. Desperation drives the staff of care homes to contact respective general practitioners, and or psycho- geriatricians, ending up in a fair number of patients with dementia ending up on medications (3). The efforts of Fossey et al need be commended; on the other hand whereas their study shows that progress could be achieved under experimental conditions. What was achieved in the 12 nursing homes drawn from three cities in the U.K. at the end of 12 months, in my opinion could serve as a template to be replicated in the naturalistic setting, taking into consideration the existing constraints (i.e. adequate trained staff, finances, stigma of dementia etc). A primary point of note is that the concept of person-centred care is a theoretical concept still in process of consolidation. With “few robust studies in gerontological nursing articulating the benefits (or otherwise) of person centred nursing to individual (patient and nurse) and organisational perspective, (5). A possible pathway to achieving person-centred care in patients with dementia in nursing homes (apart from NICE guidelines), is for adoption of the modified concept of “specialist palliative care in dementia” model (6), or using the arm of legislation to influence prescription and care practices (7). 1). Andrews GJ. Managing challenging behaviour in dementia. A person centred approach may reduce the use of physical and chemical restraint. BMJ 2006; 332:741 (1 April). 2). Fossey J, Ballard C, Juszczak E et al. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ 2006; 332:756-58 (1 April). 3). Ford GA, Ballard C, Thomas SHL. Antipsychotic drug use in older people. Age and Ageing 2002; 31:225-226. 4). U.S. Food and Drug Administration. F.D.A. Public Health Advisory. Deaths with antipsychotics in elderly with behavioural disturbances. http://www.fda.gov/cder/drug/advisory/antipsychotics.htm 2005 April 15. Accessed 02/04/2006. 5). McComack B. Person centredness in gerontological nursing: an overview of the literature. Int J of older people nursing. 2004; 13(3a): 31-38 6). Hughes J, Robinson, Volicer L. Specialist palliative care in dementia BMJ 2005; 330:57-8 (8 January). 7). Hughes CM, Lapane KL, Mor V et al. The impact of legislation on psychotropic drug use in nursing homes: a cross-national perspective. J Am Geriatr Soc. 2000 Aug; 48(8): 931-7. Competing interests: None declared |
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Vibha Pandey, Psychiatric Social Worker Central Institute of Psychiatry
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It has been rightly pointed out by the author that there is, however, little scientific evidence to suggest that mechanical restraints significantly reduce risk or harm; indeed, using fewer mechanical restraints may even reduce serious injuries in nursing home residents (1). Over the last three decades, interest has grown in the use of psychosocial intervention for people with dementia. Empirical studies and systematic reviews have been undertaken on a range of such interventions to examine their effectiveness. However, little account has been taken of the appropriateness of psychosocial interventions for people in different stages of the illness (2). In dementia there is disturbance of multiple higher cortical functions including memory, thinking, orientation, and comprehension, calculation, learning capacity, language and judgment. Impairment of cognitive function are commonly accompanied and occasionally preceded by deterioration in emotional control, deterioration in social behavior (3). Behavioral and psychological symptoms of dementia (BPSD) are common, occurring in 90% of those with dementia at some point in their course. These symptoms may lead to increased psychological morbidity in the carer and often to a need for residential care. The development of a dementing illness affects different families and family members in many different ways. It affects spouses, companions, children, grandchildren, and (as in case of AIDS) parents. Family members experience denial, bargaining, anger, depression and acceptance- the stages of adjustment to disability and grief- many times through the illness. Persons with dementia may experience decreased problem behaviors with interventions such as music, particularly during meals and bathing, walking, or other forms of light exercise. Although evidence is suggestive only, some patients may benefit from the following (4, 5, 6, and 7). • Simulated presence therapy, such as the use of videotaped or audiotape.
REFERENCES 1. Gavin J Andrews (2006) British Medical Journal; 332:741 (1 April), doi:10.1136/bmj.332.7544.741. 2. Jane Bates, Jonathan Boote, and Catherine Beverley (2003). Psychosocial interventions for people with a milder dementing illness: a systematic review. 3. WORLD HEALTH ORGANISATION (1991). The ICD-10, Classification of Mental and Behavioral Disorder, Clinical Presentation and Diagnostic Guideline, WHO. 4. Baldelli M.V., Pirani A., Motta M. et al., (1993). Effects of reality orientation therapy on elderly patients in the community. Archives of Gerontology and Geriatrics 17, 211–218. 5. Kasl-Godley J, Gatz M (2000). Psychosocial interventions for individuals with dementia: an integration of theory, therapy, and a clinical understanding of dementia. Clinical Psychological Review 6: 755- 782. 6. Logiudice D (2002). Dementia: an update to refresh your memory National Ageing Research Institute and Melbourne Extended Care and Rehabilitation Service, Melbourne, Victoria, Australian International Medicine Journal; 32: 535–540. 7. Woods RT: Cognitive approaches to the management of dementia. In RG Morris (ed.), The Cognitive Neuro psychology of Alzheimer-Type Dementia, 310-326. Oxford: Oxford University Press. Competing interests: None declared |
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