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Bio-psychosocial model is required for patients with severe dementia
- Mokhtar G E K N Isaac (24 March 2006)
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Re: Bio-psychosocial model is required for patients with severe dementia
- susanne mccabe (27 March 2006)
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Behavioural and psychological symptoms of dementia and antipsychotic use
- Nilamadhab Kar (29 March 2006)
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Is the problem prescribing or the commissioning of care?
- Clive Bowman, Graham Stokes (30 March 2006)
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Care Staff Training
- Kuruvilla K Kuruvilla (31 March 2006)
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'The Ailment' revisited
- Gautam Gulati (3 April 2006)
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Old habits die hard
- Dr. Zaffar Ul Hassan (12 April 2006)
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Mokhtar G E K N Isaac, Specialist Registrar Old Age and General Adult Psychiatry Eastbourne DGH, Kings Drive< Eastbourne, East Sussex BN21 2UD
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Editor, I read with interest the article “Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial” by Fossey et al. I was surprised that despite some flaws in the design of the trail, the results were marginal with a very wide confidence Interval (0.5% to 37.7%). It is clear that the intervention group of residential homes were treated differently from the control group by having enhanced ongoing support from expert for 10 months. The contact was not comparable to any other contact with the control group, which should have had a contact for the same amount of time without using a specific model of training and support to exclude the placebo effect of having regular contact. I also notice that the control group had significantly higher incidence of aggressive episodes before the start of the study compared with the control group (15.5% and 6.5%) respectively. It is not clear if this was taken into account in the analysis of the results. I think people with severe dementia will definitely benefit from a Bio-Psychosocial model as long as we are clear about when and for what reason we prescribe antipsychotics and it is not used for longer than it is necessary. Competing interests: None declared |
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susanne mccabe, tai chi teacher cf5 6su
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When three independant inspections, Audit, Social care and Health Commission have again pin pointed serious concerns that the services provided to elderly people with mental health problems are too often lacking in dignity, lacking in basic care such as proper feeding, are provided without any real consultation or inclusion of people themselves in their design, many elderly people are actually fearful of becoming ill or dependant on others whether in residential homes or hospitals. Yet another policy is to be issued this week as a result of the reports.....will it make any difference? Reference: Health Service Commission; Social Care Inspectorate; Audit Report issued this week. Competing interests: None declared |
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Nilamadhab Kar, Consultant Psychiatrist, Wolverhampton City PCT Corner House Resource Centre, 300 Dunstall Road, Wolverhampton, WV6 0NZ
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It is an important observation that enhanced psychosocial care can decrease the use of antipsychotic medication in patients with severe dementia in nursing homes. [1] Although the statistical significance is debatable (with a wide 95% confidence interval) the results are in the direction of clinical experience. In this regard I wish to share observations from Indian perspective where most of the patients are taken care of by their own family members at home. Compared to Western reports behavioural and psychological symptoms of dementia (BPSD) are mostly similar in Indian patients, however screaming was more in nursing home residents in Western reports.[2] Management approaches to BPSD should involve psychosocial and pharmacological treatments, as well as structured activities and nursing care interventions. Treatment plan should be individualized considering the need of the person, problematic behaviour and previous response and pre-morbid experiences. [3] Combinations of interventions are usually tried. However, only in emergent situations or when the non- pharmacological methods have failed should medications be deployed. [4] The key general elements in management of BPSD are clarification of target symptoms, ruling out delirium, comorbid major psychiatric diagnoses, underlying medical problems and side effects, and creatively addressing possible social, environmental, or behavioural remedies. Cheong suggest considering these questions: ‘What if he or she were a 2 or 3 year -old-child; what would be causing this crying or agitation? How would I approach a small child in distress?’ which may help in orienting towards appropriate intervention. [5] Effective management of BPSD understandably decreases the degree of morbidity of the patient and improves their quality of life. Caregivers will be immensely benefited by the above as it will decrease their burden. In most cases psychosocial, nursing care and pharmacological treatment approaches should be combined for better result. [3] 1. Fossey J, Ballard C, Juszczak E, James I, Alder N, Jacoby R, Howard R. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ 2006, doi:10.1136/bmj.38782.575868.7C (published 16 March 2006) 2. Kar N, Sharma PSVN, Sengupta S. Behavioural and psychological symptoms in dementia – clinical features in an Indian population. Int J Geriatr Psychiatry 2001, 16, 540-541. 3 Kar N. Management of Behavioural and Psychological Symptoms of Dementia. In Handbook of Dementia, pp: 204-227, (eds. Kar N, Jolley D, Misra, N.), Paras Medical Publisher, Hyderabad, India, 2005. 4. Profenno LA and Tariot PN. Pharmacologic management of agitation in Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders 2004, 17, 65-77. 5. Cheong JA. An evidence-based approach to the management of agitation in the geriatric patient. Focus: The Lifelong Learning in Psychiatry 2004, 2, 197-205. Competing interests: Co-edited Handbook of Dementia with Prof. David Jolley and Prof. Baikunthanath Misra, for Geriatric Care and Research Organisation (GeriCaRe), a charity in Bhubaneswar, India. |
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Clive Bowman, Medical Director BUPA Care Services, Bridge House, Outwood Lane, Leeds, Graham Stokes
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The objective of The prospective study by Fossey et examining the effects of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia is admirable and welcome but their study raises a number of concerns,. The sample size of homes and individuals in each arm is small with respect to the variability of needs and care approaches of people with dementia and the care they receive that introduces a serious risk of bias in the results. It is not possible to determine from the paper whether the homes were reasonably matched. We personally observ from various audits of prescribed medication in care homes nationally, significant regional variations in prescribing behaviours and overview by pharmacists. The term severe dementia is undefined; we observe significant locality variation in assessment thresholds that have implications for the level of care provided and potentially the amenability of that care to respond to training as well as to seek support through the use of sedation. Neuroleptic prescribing may actually be a surrogate marker for inadequately commissioned care as well as an under developed provision of care The study, perhaps fortunately, occurred across the period when the Committee for Safety of Medicines advised against the prescription of Olanzepine and Risperidone for care home residents. What Fossey et al demonstrate is that the withdrawal of Olanzepine and Risperidone had little impact on prescribing behaviours in both intervention and control arms. This suggests that many more care home residents may be at risk from extrapyramidial side effects such as falls as a consequence of the CSM advice. The intervention homes are described as having a clinician attached but it is unclear what this critical variable had on holding down re-prescribing levels. Did the responsible GPs in the intervention homes not defer to the projects clinician given the project’s psychiatrists had advised the GPs to discontinue psychotropics. Fossey et al state "The psychiatrists were robust in their efforts to reduce psychotropic prescribing” The nature of the Psychosocial training is vague and it is not possible to discern what benefits can be attributed to specific psychosocial interventions, was it just staff tolerance that was affected? As the training had an insignificant impact on life quality and well-being as measured across the two conditions, there is little to suggest that the antecedent behaviour consequence models of challenging behaviour would have been affected by the training as the care environment did not reveal experimental effects. This provides credibility to the argument that carer tolerance and the presence of the clinician throughout the project were the key determinants. Perhaps greater focus could be brought to older peoples needs in dementia if prescribers simply had to register their use of neuroleptics. This should prompt a reassessment of needs, some older people with complex needs arising from dementia would, we suggest, have found themselves in increasingly supported and staffed care, and challenging behaviours may be much more manageable as well as being seen as amenable to change and not solely control Competing interests: The authors have responsibilities for standards and governance across the 299 care homes owned by BUPA in the UK |
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Kuruvilla K Kuruvilla, Specialist Registrar Devon Partnership NHS Trust
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This study by Fossey et al (1) highlights once again the importance of training and support of the care home staff, an area commonly ignored in current practice. There is growing evidence that training improves skills e.g. detection of depression (2) and now better psychosocial management and consequent reduction in neuroleptic use(1). Care home staff can make a difference in quality of life of its residents(3). A systemic view into exploring this opportunity and extending the role of the mental health services for older people to improve the quality of care for this already vulnerable and stigmatised group suffering from dementia is called for. 1. Fossey J, Ballard C, Juszczak E, James I, Alder N, Jacoby R, Howard R. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ 2006; 332: 756-761 2. Eisses AMH, Kluiter H, Jongenelis K, et al. Care staff training in detection of depression in residential homes for the elderly: randomised trial. British Journal of Psychiatry 2005;186:404–9. 3. Hyer-Lee-A, Ragan-Amie-M. Training in long-term care facilities: Critical issues. Clinical Gerontologist, 2002, vol. 25, no. 3-4, p. 197- 237. Competing interests: None declared |
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Gautam Gulati, Trainee Psychiatrist The Highfield Unit, Warneford Hospital, Oxford OX3 7JX.
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EDITOR- Fossey et al (1) make some interesting observations about reduction in the use of neuroleptics in severe dementia by enhancing ‘psychosocial care’. Their paper is reminiscent of an old classic paper by T. F. Main called ‘The Ailment’ (2). Main studied the feelings aroused in a team of nurses caring for a group of psychiatric patients who had little potential for recovery. He found that a sedative would be used in the management of a patient “only at the moment when the nurse had reached the limit of her human resources and was no longer able to stand the patient’s problems without anxiety, impatience, guilt, anger or despair”. The medicine would then cease the worry in the nurse even though it was not the nurse who had taken the sedative. Dementia is a chronic progressive illness. Caring for someone with dementia especially with ‘challenging behaviour’ is likely to evoke difficult feelings in the most experienced of care staff. Any form of support and encouragement offered to the care staff would do well to further the “limit of human resources” and thus potentially reduce the use of medication. It would be interesting to know whether the specific training as provided in the study by Fossey et al has any incremental benefit over simple encouragement and support, if offered regularly, to care staff working in these challenging conditions. References: 1. Fossey J, Ballard C, Juszczak E, James I, Alder N, Jacoby R, Howard R. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomized trial. BMJ 2006; 332: 756-761. 2. Main TF. The Ailment. Br J Med Psychol. 1957; 30:129-45. Competing interests: None declared |
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Dr. Zaffar Ul Hassan, Staff Grade Psychiatrist in Old age Psychiatry Fieldhead Hospital, Wakefield,West Yorkshire, WF1 3SP
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Dear Editor Fossey et al (1) have assumed that training and support of care home staff would reduce the use of neuroleptics in nursing homes. But what about the under funded and under staffed NHS services where the staff tries to solve the manpower crisis by chemical means? I remember very well that a couple of years ago when I was a junior doctor one of the senior nurses called me and gave an option to either hold the hands of a Day Hospital patient who may get agitated or prescribe an anti psychotic as they were short of staff. I believe that such studies may have academic values but in real life good old thinking by powerful staff to solve the crisis by magic pills will continue to prevail. 1. Fossey J, Ballard C, Juszczak E, James I, Alder N, Jacoby R, Howard R. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ 2006; 332: 756-761 Competing interests: None declared |
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