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?
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Agitation
Aggression
Calling out/ screaming
Disinhibition (sexual)
Wandering
Night time disturbance
Shadowing
Swearing
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Depression
Anxiety
Apathy
Delusions
Hallucinations
Irritability
Elation/euphoria
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Why are BPSD important?
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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
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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; 22:1025–1039
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How are BPSD
managed?
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Biological
Psychological
Interpersonal
Environmental
Photo courtesy of Cathy Greenblatt
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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.
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© 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.
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© 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.
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© 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
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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
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Robotic pets
Moyle W et al, 2012, study underway
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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
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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
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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
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Effects of DCM and PCC on agitation
Chenoweth et al.
Lancet Neurology
2009
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Effects of DCM and PCC on agitation
PPC reduces
agitation @ $ 6.43
per CMAI point
Chenoweth et al.
Lancet Neurology
2009
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Novel strategies
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PCC + PCE
Humour therapy
Volunteers
Integrating kindergarten/ babies
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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
Reduced agitation/aggression
-1
-2
Placebo
Mean dose
1.06 mls
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CMAI, Cohen Mansfield*Agitation Inventory
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* pRisperidone
< 0.05
Mean dose
0.95mg
1 Brodaty
et al 2003
Mortality rate: higher with haloperidol
•Amisulpride
•Olanzapine
•Quetiapine
•Risperidone
•Haloperidol
HOLLIS J et al
2007
Am J Ger Psych
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Analgesics
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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
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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 5-10g/h (39, 22%)
• Neuropathic pain  pregabaline 25-300mg/day
(12, 7%)
Husebo BS et al, BMJ, 2011;343:d4065 doi: 10.1136bmj.d0465
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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 Alzheimer’s 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 government’s 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 AA’s priorities have been addressed
• Alzheimer’s Australia is concerned about
very low level of investment in dementia
research
• AA is pursuing vigorously through the
Minister’s Strategic Review of Health and
Medical Research in Australia
www.mckeonreview.org.au
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Courtesy Cathy Greenblat
Love Loss & Laughter
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Courtesy Cathy Greenblat
Love Loss & Laughter
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Prevention
Diagnosis
Treatment
Care
Policy
Dementia - Who gets it?
National Dementia Research Forum
Canberra, Australia 27-28 September,
2012
• www.dementiaresearch.org.au
• [email protected]
Drug trials AD & MCI – 9382 3733
• Inspired Study – Young onset dementia
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Dementia in Australia: Focus on behavioural disturbances