Daniel W. O’Connor

A literature review of spaced-retrieval interventions: a direct memory intervention for people with dementia

BACKGROUND With the increasing prevalence of dementia, there is a pressing need to identify effective interventions that prolong independent functioning. As pharmacological interventions aimed at slowing cognitive decline have been found to have a number of limitations, research has now moved toward studying complementary non-pharmacological cognitive training interventions. This review describes the use of spaced-retrieval as a method to teach new information and reduce behavioral problems in people with dementia. METHODS We searched the databases PsychINFO, MEDLINE, and Scopus as well as reference lists of relevant papers to identify articles describing the use of spaced-retrieval with people with dementia. Only primary, peer-reviewed research published in English was included in this review. RESULTS In total, 34 studies were identified, three of which were randomized controlled trials. We found that across studies, there was wide variability with regard to design, methodology, and outcome measures used. Nonetheless, the existing research demonstrates that spaced-retrieval training can be successfully used to teach people with dementia new and previously known face- and object-name associations, as well as cue-behavior associations aimed at alleviating problem behaviors and improving functional skills. The method can also assist with the recollection of past events. CONCLUSIONS Current evidence indicates that spaced-retrieval training is effective in enabling people with dementia to learn new information and behavioral strategies. Future research should attempt to address the limitations outlined in this review and focus on utilizing this technique to achieve more functional and clinically relevant outcomes. Recommendations are also made with regard to investigating potential secondary benefits of spaced-retrieval and strengthening study design.

Has electroconvulsive therapy use remained stable over time? A decade of electroconvulsive therapy service provision in Victoria, Australia

Objective: Despite the long history of electroconvulsive therapy (ECT) as a psychiatric treatment modality in Australia, existing literature regarding ECT use and practices in Australia is limited. In this unique study, we report ECT provision in Victoria to adults aged 25 years and over from 1998 to 2007, based on complete data from all public and private treatment settings within the State; compare our results to previous literature in the field; and offer possible explanations for these findings as a basis for future research. Method: Analysis of statutory ECT service provision data collected by the Office of the Chief Psychiatrist of Victoria. Results: ECT use declined overall from 2001 onward, followed by a small increase in use in 2007. Eighty per cent of patients received ECT for depression and 14% for psychosis. Sixty-two per cent of ECT recipients were women. Although patients aged 65 years and over were small in number, age adjustment of data was indicative of a higher utilisation rate in this group. With increasing age, the percentage of ECT recipients treated for depression increased, whereas the percentage treated for psychosis decreased. Sixty per cent of patients were treated in the public sector. Public-private sector ECT use did not differ greatly for depression, but more patients were treated in the public sector for psychosis. The majority of patients with depression received treatment voluntarily, but the converse was true for patients with psychosis. Unilateral electrode placement predominated. Conclusions: While utilisation rates gradually declined over the decade studied, patients continued receiving ECT in significant numbers, suggesting its role in treating severe mental illness is far from superceded. The present, population-level research cannot explain the causative factors underlying the patterns observed, but raises interesting questions for further investigation. Ongoing collection of statutory ECT data in a manner making it amenable to research applications is recommended.

Validity of the geriatric depression scale and the collateral source version of the geriatric depression scale in nursing homes.

BACKGROUND Depression is a common psychiatric disorder in older people. The study aimed to examine the screening accuracy of the Geriatric Depression Scale (GDS) and the Collateral Source version of the Geriatric Depression Scale (CS-GDS) in the nursing home setting. METHODS Eighty-eight residents from 14 nursing homes were assessed for depression using the GDS and the CS-GDS, and validated against clinician diagnosed depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders (SCID) for residents without dementia and the Provisional Diagnostic Criteria for Depression in Alzheimer Disease (PDCdAD) for those with dementia. The screening performances of five versions of the GDS (30-, 15-, 10-, 8-, and 4-item) and two versions of the CS-GDS (30- and 15-item) were analyzed using receiver operating characteristic (ROC) curves. RESULTS Among residents without dementia, both the self-rated (AUC = 0.75-0.79) and proxy-rated (AUC = 0.67) GDS variations performed significantly better than chance in screening for depression. However, neither instrument adequately identified depression among residents with dementia (AUC between 0.57 and 0.70). Among the GDS variations, the 4- and 8-item scales had the highest AUC and the optimal cut-offs were >0 and >3, respectively. CONCLUSIONS The validity of the GDS in detecting depression requires a certain level of cognitive functioning. While the CS-GDS is designed to remedy this issue by using an informant, it did not have adequate validity in detecting depression among residents with dementia. Further research is needed on informant selection and other factors that can potentially influence the validity of proxy-based measures in the nursing home setting.

Systemic approach to behavioural and psychological symptoms of dementia in residential aged care facilities

Australian & New Zealand Journal of Psychiatry, 48(2) The perspective ‘Rethinking psychotropics in nursing homes’ (Hilmer and Gnjidic, 2013) raises justifiable concern regarding the potential overuse of psychotropic medication in Australian residential aged care facilities (RACFs), which we argue is actually a downstream effect of systemic problems in the provision of mental health care in the RACF environment (Snowdon, 2010) and thus requires broader scale interventions. The psychiatric morbidity of RACF residents is alarming: an international systematic review found that dementia had a prevalence of 58%, with 78% of those with dementia exhibiting behavioural and psychological symptoms (BPSD). In addition, major depression had a prevalence of 10% and depressive symptoms were evident in 28% (Seitz et al., 2010). There is no room for therapeutic nihilism (Macfarlane et al., 2012) in the presence of burgeoning evidence of the efficacy of non-pharmacological interventions (CohenMansfield et al., 2012; Conn and Seitz, 2010; Kolanowski et al., 2011; Leone et al., 2013; O’Connor et al., 2009), as well as evidence for the judicious usage of antidepressants (Seitz et al., 2011), antipsychotics (Ballard et al., 2006) and cognition-enhancing agents in at least some residents with BPSD (Conn and Seitz, 2010). Routine discontinuation of antipsychotics (Devanand et al., 2012) and antidepressants (Bergh et al., 2012) in people with dementia may have adverse outcomes, with recurrence of the disorders and increased distress. As experienced geriatric psychiatrists, we argue that a comprehensive systemic approach is required to care for and support people with BPSD and other types of mental illness in RACFs. This approach should encompass structured assessment of problem behaviours and symptoms, targeted psychological and pharmacological interventions, appropriate levels of properly remunerated staff who have undergone dementia-specific education and training, and physical design components to produce a prosthetic environment. Hilmer and Gnjidic (2013) asserted that ‘... we tend to use [psychotropic medications] too often, for too long, at doses that are too high, in dangerous combinations ...’ (p.77). They cited findings from a series of studies in 44 nursing homes in Sydney (Snowdon et al., 2011). This series of studies found that between 1993 and 2009 the use of regularly administered antipsychotics rose from 27% to 28%; regular hypnotics dropped from 26% to 11%; regular anxiolytics dropped from 8.6% to 4.7%; regular antidepressants rose from 15.6% to 25.6%; and the overall psychotropic use (all classes combined) dropped from 58.9% to 47.5%. From these findings it is clear that lumping all psychotropic medications into a single category obscures the complexities of usage of these drugs (Snowdon et al., 2011). Despite this caveat, we agree that critical review of medications for the treatment of BPSD for persons residing in RACFs is important and that changes to treatment regimens, including starting and stopping medication, warrant careful consideration; especially since a recent Australian study showed that medications for RACF residents were infrequently reviewed (O’Connor et al., 2010). We have argued elsewhere (Macfarlane et al., 2012) that the limited evidence of efficacy of antidepressants in people with dementia is likely to arise from the rather limited volume and sophistication of the available evidence, whilst acknowledging that depressive symptoms and disorders may be difficult to ascertain, monitor and treat in this population. A Cochrane Systematic Review noted there were few trials of treatment of BPSD with antidepressants, but concluded that two selective serotonin Systemic approach to behavioural and psychological symptoms of dementia in residential aged care facilities

A study protocol to investigate the management of depression and challenging behaviors associated with dementia in aged care settings

BackgroundThe high occurrence and under-treatment of clinical depression and behavioral and psychological symptoms of dementia (BPSD) within aged care settings is concerning, yet training programs aimed at improving the detection and management of these problems have generally been ineffective. This article presents a study protocol to evaluate a training intervention for facility managers/registered nurses working in aged care facilities that focuses on organisational processes and culture as well as knowledge, skills and self-efficacy.MethodsA Randomised Control Trial (RCT) will be implemented across 18 aged care facilities (divided into three conditions). Participants will be senior registered nurses and personal care attendants employed in the aged care facility. The first condition will receive the training program (Staff as Change Agents – Enhancing and Sustaining Mental Health in Aged Care), the second condition will receive the training program and clinical support, and the third condition will receive no intervention.ResultsPre-, post-, 6-month and 12-month follow-up measures of staff and residents will be used to demonstrate how upskilling clinical leaders using our transformational training approach, as well as the use of a structured screening, referral and monitoring protocol, can address the mental health needs of older people in residential care.ConclusionsThe expected outcome of this study is the validation of an evidence-based training program to improve the management of depression and BPSD among older people in residential care settings by establishing routine practices related to mental health. This relatively brief but highly focussed training package will be readily rolled out to a larger number of residential care facilities at a relatively low cost.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): The Universal Trial Number (UTN) is U1111-1141-0109.

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 ).

Organizational factors associated with readiness for change in residential aged care settings

BackgroundOrganizational change is inevitable in any workplace. Previous research has shown that leadership and a number of organizational climate and contextual variables can affect the adoption of change initiatives. The effect of these workplace variables is particularly important in stressful work sectors such as aged care where employees work with challenging older clients who frequently exhibit dementia and depression.MethodsThis study sought to examine the effect of organizational climate and leadership variables on organizational readiness for change across 21 residential aged care facilities. Staff from each facility (N = 255) completed a self-report measure assessing organizational factors including organizational climate, leadership and readiness for change.ResultsA hierarchical regression model revealed that the organizational climate variables of work pressure, innovation, and transformational leadership were predictive of employee perceptions of organizational readiness for change.ConclusionThese findings suggest that within aged care facilities an organization’s capacity to change their organizational climate and leadership practices may enhance an organization’s readiness for change.

An integrated exploration of factors associated with psychological distress among older prisoners

Abstract This paper compares the contributions of socio-demographic, health, mental health, social and environmental factors in explaining variations in psychological distress among older prisoners in two Australian states. One hundred and seventy-three prisoners (aged 50+ ) from 8 Australian prisons were interviewed using the Kessler Psychological Distress (K10) Scale. Three regression analyses were conducted to compare different models of 14 variables significantly associated with psychological distress. Independent variables most prominently associated with variations in psychological distress among older inmates were self-reported levels of social support, self-reported safety and ease of health care access. Difficulties in the built environment and mental health history were significantly explanatory of variations in older prisoner distress in two of the three models. The findings suggest that modifiable situational factors evident in current prison contexts are reasonably explanatory of variations in prisoner distress among older inmates.

Using spaced retrieval training to teach people with dementia to independently use their walking aids: Two case studies

This article describes two case studies that used spaced retrieval training to teach two aged care facility residents diagnosed with dementia to independently use their walking aids. Each resident received five consecutive 1-hour sessions of spaced retrieval and was observed before and after intervention and at a 1-week follow-up. The results indicate the potential for this memory intervention to improve walker use and highlight several clinical aspects to consider when using this technique with demented people.