Annaliese Blair

An Art Gallery Access Programme for people with dementia: 'You do it for the moment'

Objectives: People with dementia often have decreased opportunities to engage in higher level intellectual or sensory activities. This programme investigated the effect of taking people with dementia to discuss artworks at the National Gallery of Australia (NGA). Method: Fifteen people from the community and eight from residential care attended the gallery once a week for 6 weeks. They discussed artworks with NGA Educators trained in dementia skills. Sessions were filmed and the level of engagement analysed using time sampling methods. Focus groups with participants, carers, and educators provided qualitative data. Results: Participants were engaged from the outset and remained engaged. They became animated, gained confidence and were able to discuss and interact with the artworks and the social process. This included the more impaired RACF groups, who were more withdrawn or behaviourally disturbed in their usual environment, raising the concept of excess disability. In focus groups these participants had impoverished memory for the programme but community participants remembered it with pleasure and wanted it to continue. Carers confirmed these sentiments but reported no lasting change in participants. Educators spoke mostly about what they had learned, including new ways to present to other clients. Conclusion: The programme went beyond many dementia activities. Despite no evidence for lasting effects, all involved wanted the programme to continue. A carer quote: You do it for the moment encapsulates a sense that an activity is worthwhile even if it gives benefit only whilst running. The programme is continuing and expanding.

Clinical Psychology and anxiety and depression in dementia

Both depression and anxiety are common in dementia but there are many complicating bio-psychosocial factors which can make diagnosis and treatment difficult. There is a small but expanding literature on psychosocial treatment of depression in mild to moderate dementia but almost nothing on treatment of anxiety. Three cases, one involving an anxiety disorder, another involving someone with severe dementia, are presented to illustrate the nature of the work that clinical psychologists can undertake with this population and the skills and knowledge required. They are discussed with reference to standard therapeutic approaches versus a highly individualised case-specific approach, the need for collaboration with other disciplines, using carers or residential care staff as co-therapists and co-clients, working with nursing home staff to maximise compliance, and the need for clinical psychologists working with this population to be literate about medical and health issues.

How do staff influence the quality of long-term dementia care and the lives of residents? A systematic review of the evidence.

BACKGROUND Research suggests and common sense indicates that there are relationships between staff variables in residential dementia care and the quality of life (QOL) of residents, with poor care due to staff factors increasing resident suffering. Despite these indications, we do not have a coherent picture of these relationships, which variables are important, and where to intervene in order to minimize suffering for people with dementia. METHODS This systematic review examined associations between staff variables, quality of care (QOC), and QOL for residents, using published peer-reviewed literature from the last 20 years. A comprehensive search was conducted using an exhaustive list of search terms, leading to the identification of 33,204 unique papers, which was reduced to 35 on-topic papers. RESULTS In the main, we were able to provide collective evidence to suggest there are relationships between potentially adjustable staff variables and QOC on to QOL. When staff treat and interact empathetically and humanely in care, there is a relationship with better mood for residents, delayed functional dependence and better food intake. Where staff are more skilled and educated, there is less psychotropic medication use. Unlimited empathy about the risk of residents falling or being in pain is not enough; staff need to know about the dangers of restraint. CONCLUSIONS Confidence in these indicative links is weakened by a lack of high-quality prospective longitudinal studies focusing on potentially adjustable staff variables, with a bias towards cross-sectional studies including only variables that are fixed or unlikely to change. (Review registration no. PROSPERO 2014:CRD42014015224).

A feasibility study of group-based cognitive behaviour therapy for older adults in residential care

Objective This study examined the feasibility of providing older adults living in residential aged care with group-based cognitive behavioural therapy (CBT) for depression and anxiety. Method Eighteen participants with subclinical to mild anxiety and/or depression were divided equally into a treatment group and a control group, with treatment consisting of a manualised CBT program for older adults with depression and anxiety. The residents who participated in the group program provided an accurate representation of “real-world” residential aged care facilities (RACF) populations; many with comorbid physical problems, mild cognitive impairment and functional decline, and a mean age of almost 80 years. Results The residents showed that not only could they successfully engage in psychotherapy, they were able to experience the benefits such as building their skills and resilience, receiving validation and emotional support from their fellow residents and fostering friendships and social networks. Encouragingly, the treatment group also showed fewer depressive symptoms post-treatment. Conclusions Group-based psychotherapy should continue to be explored as a strategy to promote good mental health in RACFs, with further studies focusing on the feasibility of recruiting and treating clinical populations in this setting.

Help-seeking intentions for anxiety among older adults

Mental health practices are not working for older people with anxiety in residential care, as there is a persistent lack of recognition and treatment. This suggests that alternative ways of reaching and meeting the needs of this population need to be explored. One possibility involves enabling older adults themselves to seek help. The current work explored various factors impacting on help-seeking behaviours. In total, 105 participants from independent living units in a residential care setting completed a questionnaire focusing on attitudes and stigma towards anxiety, likelihood to seek help, help-seeking barriers and literacy around the symptoms of anxiety. Participants in the main did not hold negative attitudes towards other people with anxiety, despite concerns that other people could view them negatively if they were experiencing anxiety. Barriers to help-seeking included: difficulties recognising physical anxiety symptoms as being indicative of anxiety; the effectiveness of treatments; costs; misdiagnosis; privacy; medication usage and the associated side-effects; and, uneasiness about the skills and knowledge of health professionals. Although concerns were not held by all participants, the fact remains that anxiety is largely undiagnosed and untreated for this population and these stoppages to appropriate care must be addressed.

Development and effectiveness of an integrated inpatient and community service for challenging behaviour in late life: From Confused and Disturbed Elderly to Transitional Behavioural Assessment and Intervention Service

A common method of managing challenging behaviour associated with dementia is long-stay special care units, though models are very diverse. In New South Wales, Australia, the five remaining state-run long-stay special care units for this population were funded to adopt a shorter-term model which had been trialled by one of the units. Transitional Behavioural Assessment and Intervention Service Units, incorporating an integrated outreach team, were to provide multi-disciplinary assessments, develop individualised bio-psychosocial management plans for, and appropriately discharge people with significant levels of Behavioural and Psychological Symptoms in Dementia. The current study assessed both the effects of the change and the clinical effectiveness of the model. Method A repeated measures design, supplemented by multiple one-time measures. A range of standard instruments were administered, patient data from other types of inpatient units were obtained, interviews conducted, and medical records examined. Results Transitional Behaviour Assessment and Intervention Service units were admitting patients with dementia and a variety of significant challenging behaviours. Length of stay was shortened in all units, patients turnover greatly increased, and there was a low re-admission rate. The model was substantially cheaper than psychiatric care in two units where it was fully implemented; one unit cost the same as psychiatric care, and two units were not cost-effective because of low occupancy – related to not fully implementing the model. Referring facilities reported that in the absence of the units, their main strategy would have been to increase sedation. In the Transitional Behavioural Assessment and Intervention Service units, behavioural incidents were primarily managed through psychosocial means. It is not known whether behaviour is reduced over time, staff become better at managing the behaviour when it occurs, or both. Conclusion The evaluation showed that the model can be transferred to other units and is a cost-effective way of assessing, managing, and successfully discharging people with complex challenging behaviours, though only when fully implemented.

Clinical psychology with complex presentations in old age

Five cases are presented in detail to illustrate the role of clinical psychology with patients who have complex presentations. They are discussed with reference to the need for psychotherapeutic interventions given the limitations of pharmacotherapy; the limitations of psycho-social techniques and the consequent need for multi-disciplinary collaboration; and, the richness and complexity of psychosocial interventions and the limitations of CBT alone. These cases also illustrate the fact that interventions – whether psychosocial or psychopharmacological or both – can significantly improve life for a population often regarded as beyond help or otherwise not worth treating.