Henry Brodaty
Dementia Collaborative Research Centre, UNSW www.dementiaresearch.org.au
Translating dementia research into practice

• Agitation
• Aggression
• Calling out/ screaming
• Disinhibition (sexual)
• Wandering
• Night time disturbance
• Shadowing
• Swearing
•
•
•
•
•
•
•
Depression
Anxiety
Apathy
Delusions
Hallucinations
Irritability
Elation/euphoria
Translating dementia research into practice

• 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
Translating dementia research into practice

• 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
1 Lyketsos et al, Am.J. Psychiatry, 2000; 157:708-714;
2 Prince M et al 2004; 3 Brodaty H et al, 2001;
4 Seitz et al, Int Psychogeriatrics, 2010; 22:1025 –1039

• Biological
• Psychological
• Interpersonal
• Environmental
Photo courtesy of Cathy Greenblatt
Translating dementia research into practice

Sydney Morning Herald 14 th May 2012

• 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.
Translating dementia research into practice © DCRC/Brodaty 2012

Psychotropic medication use in Sydney RACFs
%
Year
Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271.
Translating dementia research into practice © DCRC/Brodaty 2012

Psychotropic medication use in Sydney RACFs
%
Year
Snowdon, et al. (2011), Medical Journal of Australia, 194(5): 270-271.
Translating dementia research into practice © DCRC/Brodaty 2012

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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

Outside space only beneficial in combination with staff interaction
Fleming R – www.dementiaresearch.org.au
Translating dementia research into practice

• Small unit size
• Opportunity to engage in ordinary daily activities such as cooking
Fleming R – www.dementiaresearch.org.au
Translating dementia research into practice

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
1 Filan & Llewellyn-Jones (2006) Int.
Psychogeriatr; 18:4, 597-611
Translating dementia research into practice

Moyle W et al, 2012, study underway
Translating dementia research into practice

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
Translating dementia research into practice

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
Translating dementia research into practice

• Behaviour therapies Teri L
– Pleasurable events schedule
– Problem solving techniques
– Equal efficacy to haloperidol & trazadone
• Exercise programs Teri L
• Tailored activities Gitlin L
Translating dementia research into practice

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Translating dementia research into practice
Chenoweth et al.
Lancet Neurology
2009

Partner logo here
PPC reduces agitation @ $ 6.43 per CMAI point
Translating dementia research into practice
Chenoweth et al.
Lancet Neurology
2009

• PCC + PCE
• Humour therapy
• Volunteers
• Integrating kindergarten/ babies
Translating dementia research into practice

SMILE Study
Elder clowns & LaughterBosses reduce agitation

• 20% reduction in agitation symptoms in SMILE
• The same effect size as is achieved by antipsychotic medications used to treat agitation
OR

• 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

-8
-9
-10
0
-1
-2
-3
-4
-5
-6
-7 baseline week 4 week 8 week 12 end point
*
*
Placebo
Mean dose
1.06 mls
Mean dose
0.95mg
Translating dementia research into practice 1 Brodaty et al 2003

• Amisulpride
• Olanzapine
• Quetiapine
• Risperidone
• Haloperidol
HOLLIS J et al
2007
Am J Ger Psych
Translating dementia research into practice

• 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
Translating dementia research into practice

• 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
Translating dementia research into practice

• Depending on jurisdiction a Person
Responsible must give consent (?in writing)
• Survey of 3 NHs; 77 residents without capacity to give informed consent; on psychotropics 1
• 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
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
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

• 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

Courtesy Cathy Greenblat
Love Loss & Laughter ssssssssssssssssssssssssssssss ssssssssssssssssssssssssssssss ssssssssssssssssssssssssssssss ssssssssssssssssssssssssssssss ssssssssssssssss

Courtesy Cathy Greenblat
Love Loss & Laughter ssssssssssssssssssssssssssssss ssssssssssssssssssssssssssssss ssssssssssssssssssssssssssssss ssssssssssssssssssssssssssssss ssssssssssssssss

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Prevention
Diagnosis
Treatment
Care
Policy
National Dementia Research Forum
Canberra, Australia 27-28 September,
2012

• Inspired Study – Young onset dementia
Translating dementia research into practice

Translating dementia research into practice