Barbara Eppingstall

Cognition in elderly patients receiving unilateral and bilateral electroconvulsive therapy: A prospective, naturalistic comparison

BACKGROUND The cognitive side-effects of ECT are minimized by individualized, supra-threshold dosing with brief pulse electrical stimuli. Unilateral ECT is associated with fewer cognitive sequelae but bilateral ECT is possibly more effective. Little is known of the relative effectiveness and tolerability of the two placements in the treatment of elderly, severely depressed inpatients. METHODS Patients of five public aged psychiatry services and a private psychiatric hospital who received right unilateral ECT (n=47) dosed on average at 3 times seizure threshold or bitemporal ECT (n=16) dosed at 1.5 times threshold completed an abbreviated Rey Auditory Verbal Learning Test, a visual memory test and a section of the Autobiographical Memory Inventory as close as possible to 24h after the first or second treatment and again after the fifth or sixth treatment. This design was intended to maximize recruitment of severely depressed patients with a limited ability to consent and cooperate with testing. RESULTS Only 35% of eligible patients completed both assessments, mostly due to refusal or lack of capacity to consent. Moderate dose unilateral and bilateral ECT produced equivalent improvements in mood. There was a tendency for scores on most cognitive tests to decline more with bilateral than unilateral ECT but these differences were statistically significant only for immediate verbal memory and autobiographical memory. CONCLUSIONS Our findings suggest that bilateral ECT is no more effective as an antidepressant than moderately dosed unilateral ECT, at least on a short-term basis, and confers a slightly greater risk of cognitive impairment. This supports the rationale of prescribing unilateral ECT in the first instance in this vulnerable clinical population. LIMITATIONS It proved impossible to recruit most ECT recipients, limiting the capacity to generalize findings to all aged patients. Reports concerning ECT should list recruitment rates to help set findings in context.

The study protocol of a blinded randomised-controlled cross-over trial of lavender oil as a treatment of behavioural symptoms in dementia

BackgroundThe agitated behaviours that accompany dementia (e.g. pacing, aggression, calling out) are stressful to both nursing home residents and their carers and are difficult to treat. Increasingly more attention is being paid to alternative interventions that are associated with fewer risks than pharmacology. Lavandula angustifolia (lavender) has been thought, for centuries, to have soothing properties, but the existing evidence is limited and shows mixed results. The aim of the current study is to test the effectiveness of topically applied pure lavender oil in reducing actual counts of challenging behaviours in nursing home residents.Methods/DesignWe will use a blinded repeated measures design with random cross-over between lavender oil and placebo oil. Persons with moderate to severe dementia and associated behavioural problems living in aged care facilities will be included in the study. Consented, willing participants will be assigned in random order to lavender or placebo blocks for one week then switched to the other condition for the following week. In each week the oils will be applied on three days with at least a two-day wash out period between conditions. Trained observers will note presence of target behaviours and predominant type of affect displayed during the 30 minutes before and the 60 minutes after application of the oil. Nursing staff will apply 1 ml of 30% high strength essential lavender oil to reduce the risk of missing a true effect through under-dosing. The placebo will comprise of jojoba oil only. The oils will be identical in appearance and texture, but can easily be identified by smell. For blinding purposes, all staff involved in applying the oil or observing the resident will apply a masking cream containing a mixture of lavender and other essential oils to their upper lip. In addition, nursing staff will wear a nose clip during the few minutes it takes to massage the oil to the residents forearms.DiscussionIf our results show that the use of lavender oil is effective in reducing challenging behaviours in individuals with dementia, it will potentially provide a safer intervention rather than reliance on pharmacology alone. The studys findings will translate easily to other countries and cultures.Trial RegistrationAustralian New Zealand Clinical Trials Registry - ACTRN 12609000569202

The study protocol of a cluster-randomised controlled trial of family-mediated personalised activities for nursing home residents with dementia

BackgroundFollowing admission to a nursing home, the feelings of depression and burden that family carers may experience do not necessarily diminish. Additionally, they may experience feelings of guilt and grief for the loss of a previously close relationship. At the same time, individuals with dementia may develop symptoms of depression and agitation (BPSD) that may be related to changes in family relationships, social interaction and stimulation. Until now, interventions to alleviate carer stress and BPSD have treated carers and relatives separately rather than focusing on maintaining or enhancing their relationships. One-to-one structured activities have been shown to reduce BPSD and also improve the caring experience, but barriers such as a lack of resources impede the implementation of activities in aged care facilities. The current study will investigate the effect of individualised activities based on the Montessori methodology administered by family carers in residential care.Methods/DesignWe will conduct a cluster-randomised trial to train family carers in conducting personalised one-to-one activities based on the Montessori methodology with their relatives. Montessori activities derive from the principles espoused by Maria Montessori and subsequent educational theorists to promote engagement in learning, namely task breakdown, guided repetition, progression in difficulty from simple to complex, and the careful matching of demands to levels of competence. Persons with dementia living in aged care facilities and frequently visiting family carers will be included in the study. Consented, willing participants will be randomly assigned by facility to a treatment condition using the Montessori approach or a control waiting list condition. We hypothesise that family carers conducting Montessori-based activities will experience improvements in quality of visits and overall relationship with the resident as well as higher self-rated mastery, fewer depressive symptoms, and a better quality of life than carers in the waiting list condition.DiscussionWe hypothesise that training family carers to deliver personalised activities to their relatives in a residential setting will make visits more satisfying and may consequently improve the quality of life for carers and their relatives. These beneficial effects might also reduce nursing staff burden and thus impact positively on residential facilities.Trial RegistrationAustralian New Zealand Clinical Trials Registry - ACTRN12611000998943

A personalized multimedia device to treat agitated behavior and improve mood in people with dementia: A pilot study

Agitated behaviors and dysphoric moods in nursing home residents with dementia may be a response to a lack of personalized, meaningful activity and stimulation. To address this deficiency, a personal computer was adapted to play favorite music and display photographs, movies and messages that were selected or made by family members. The system (called Memory Box) is accompanied by a simplified interface to help people with dementia access material independently. The systems ability to reduce agitation, and improve symptoms of depression and anxiety, was tested by means of an eight-week randomized, single-blinded, cross-over trial comparing Memory Box with a control condition that offered equivalent contact with research staff. Eleven nursing home residents with mild to severe dementia and persistent, daily agitated behaviors completed the study. Outcome measures included ratings of anxiety, depression and agitated behavior made by knowledgeable staff members in collaboration with researchers. Memory Box was well utilized and highly rated by residents, families and staff members. There were significant reductions in depressive and anxiety symptoms during the course of the intervention. The system shows promise as a tool to assist families and nursing home staff to improve the wellbeing of cognitively impaired older people with agitated behaviors.

A pilot trial of acceptance and commitment therapy for symptoms of depression and anxiety in older adults residing in long-term care facilities

ABSTRACT Objectives: The aim of this study was to evaluate the efficacy and acceptability of a psychological intervention based on acceptance and commitment therapy (ACT) to improve symptoms of depression and anxiety among older adults living in long-term care. Method: Forty one residents aged between 63 and 97 years (M = 85.3 years) participated in this study. Residents were allocated to receive either a 12 session ACT intervention implemented by trainee psychology therapists or a wait-list control group. Measures of depression and anxiety were collected at baseline and 8 week post-intervention, and residents who received the intervention were tracked for three months. A treatment satisfaction questionnaire was administered to residents who received the intervention and a sample of 10 facility staff members. Results: Using an intention to treat approach and controlling for baseline scores, scores on depression measures were significantly lower after the ACT intervention than after the wait-list control. These outcomes were maintained at three-month follow-up. Treatment satisfaction was rated highly by both residents and their care staff. Conclusion: This preliminary trial suggests that ACT shows promise as a therapeutic approach to address symptoms of depression in long-term care.

Comparison of family satisfaction in Australian ethno-specific and mainstream aged care facilities

The aim in this study was to identify specific aspects of care that increased satisfaction of family members of Greek and Italian residents with dementia in mainstream or ethno-specific aged care facilities in Australia. Relatives of 83 aged care residents with Greek or Italian backgrounds who were also cognitively impaired were interviewed. They rated their satisfaction with the facility and suggested improvements regarding the care provided. Family members with relatives in ethno-specific care were more satisfied, in terms of the facilitys ability to meet the residents language and cultural needs, social/leisure activities, and the food provided. The presence of a bilingual staff member and greater perceived reduction in family caregiver stress upon admission were associated with higher satisfaction. Results implicate the role of activities programs, catering, resident interaction, supporting caregivers upon admission, and bilingual staff members to increase family satisfaction, with the potential to improve the care provided to residents in mainstream care.

Internet video chat (Skype) family conversations as a treatment of agitation in nursing home residents with dementia

The behavioral symptoms that often accompany dementia (for example, pacing, calling out, and resistiveness) are stressful to carers and greatly increase the risk of institutionalization. While psychotropic medications are commonly prescribed, their efficacy is limited. There is great interest, therefore, in developing non-pharmacological strategies to alleviate the distress that underpins many behavioral symptoms (O’Connor et al. , 2009 ).

Personalized one-to-one intervention in agitated individuals with dementia : Responders versus non-responders

The aim of the current study was to explore why some individuals with dementia and agitated behavior showed limited response to a personalized intervention. Ten consistently agitated individuals (i.e., non-responders) were compared with 34 individuals who were more settled during the intervention (i.e., responders). Most participants had severe cognitive deficits; however, non-responders were more impaired. Where responders showed large improvements across conditions, agitated behavior remained equally high in non-responders. Responders and non-responders showed increased interest and engagement during the intervention. Increased agitated behavior was associated with severe cognitive impairment. Although studies have shown that psychosocial interventions can reduce agitated behavior, there does seem to be a point where it becomes more difficult to reduce this behavior. However, non-responders still displayed interest, and the authors believe further personalization of the intervention is possible. Therefore, severe dementia and agitated behavior should not exclude individuals from psychosocial interventions; however, a more detailed and timely implementation plan of such treatments may be warranted.

The language needs of residents from linguistically diverse backgrounds in Victorian aged care facilities

To investigate the language needs of residents of aged care facilities within the State of Victoria, Australia, and determine what language resources were accessible to them.

Design of two studies on non-pharmacological interventions to reduce agitated behaviours in persons with dementia

pital setting to meet the unique needs of inpatients with memory loss and thinking difficulties. The process is simple and engages carers as active contributors to person-centered care for individuals with disabling conditions such as dementia, sensory impairment, and communication difficulties. Methods: Data sourced from carer stories showed carers were frustrated with healthcare experiences because their knowledge of the unique needs of the person they care for was often overlooked or discounted by staff. Many carers advised that when their expertise was sought, it was not effectively communicated to others. Staff reported difficulties in managing unsettled behaviors of confused patients and were keen to avoid the risk of adverse outcomes. Carer understanding of the person, their behaviors, and patterns of communication was seen as pivotal information for health professionals. Results: A pilot project demonstrated significant improvement in the experiences of patients, carers, and staff. Patients were noted to have a ‘‘quicker recovery,’’ had ‘‘less agitation, frustration and distress’’ and ‘‘more effective communication’’ and ‘‘increased ability to relate.’’ Staff reported a positive increase in their comfort and confidence in working and communication with inpatients with confusion. Carers reported that staff appeared to have an increased awareness of their role as carer and sought and acknowledged their advice. Conclusions: Rolling out Top 5 as a practice improvement initiative in the acute care setting has required the development of resources, an algorithm, staff training, consultations with carers and carer groups, and ongoing evaluation.