David Lie

Self-Destructive Behaviors in Nursing Home Residents

OBJECTIVES: To validate the Harmful Behaviors Scale (HBS) as a measure of direct and indirect self‐destructive behaviors in nursing home residents and to determine the prevalence of self‐destructive behaviors and their relationship to other variables.

ECT efficacy and treatment course: a systematic review and meta-analysis of twice vs thrice weekly schedules.

BACKGROUND Electroconvulsive therapy (ECT) guidelines, across various regulatory bodies, lack consensus as to the optimal frequency of treatment for individual patients. Some authors postulate that twice weekly ECT may have a similar efficacy to thrice weekly, and may have a lower risk of adverse cognitive outcomes. We did a systematic review and a meta-analysis to assess the strength of associations between ECT frequency and depression scores, duration of treatment, number of ECTs, and remission rates. METHODS We searched on Medline, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (to December 2009), and searched reports to identify comparative studies of frequency of ECT. We did both random-effects (RE) and quality effect (QE) meta-analyses to determine the risk of various outcomes associated with lesser frequency as compared to the thrice weekly frequency. RESULTS We analysed 8 datasets (7 articles), including 214 subjects. Twice-weekly frequency of ECT was associated with a similar change in depression score (QE model SMD -0.11 [-0.55-0.33] and RE model SMD -0.17 [-0.77-0.43]) as compared to thrice weekly ECT. The number of real ECTs trended towards fewer in the twice weekly group. There was a statistically significant longer duration of treatment with a twice weekly protocol (QE model 6.48 days [4.99-7.97] and RE model 4.78 days [0.74-8.82]). There was a statistically significant greater efficacy for thrice weekly ECT compared to once weekly ECT (QE model SMD 1.25 [-0.62-1.9] and RE model SMD 1.31 [0.6-2.02]). CONCLUSIONS Twice weekly ECT is associated with similar efficacy to thrice weekly ECT, may require fewer treatments and may be associated with longer treatment duration when compared to thrice weekly. These epidemiological observations support the routine use of twice weekly ECT in acute courses, though choice of frequency should take into account individual patient factors. These observations have implications for resource utilisation e.g. costs of duration of admission vs cost of provision of ECT, as well as issues of access to inpatient beds and anaesthetist time.

The stages of driving cessation for people with dementia: needs and challenges

BACKGROUND The impact of dementia on safe driving is well recognized and is generally accepted that all people with dementia are likely to need to cease driving at some stage in the disease process. Both driving and driving cessation can have poor outcomes for people with dementia and their caregivers in terms of health, safety, community access, and well-being. Although approaches to facilitate better outcomes from driving cessation are being developed, the processes of driving cessation for people with dementia are still not fully understood. METHODS Within a descriptive phenomenological framework, semi-structured interviews were undertaken with key stakeholders, including retired drivers with dementia, family members, and health professionals. RESULTS Findings from four retired drivers with dementia, 11 caregivers, and 15 health professionals characterized driving cessation for people with dementia as a process with three stages and associated challenges and needs. The early stage involved worried waiting, balancing safety with impending losses, and the challenge of knowing when to stop. The crisis stage involved risky driving or difficult transportation, acute adjustment to cessation and life without driving, and relationship conflict. The post-cessation stage was described as a long journey with ongoing battles and adjustments as well as decreased life space, and was affected by the disease progression and the exhaustion of caregiver. CONCLUSIONS The concept of stages of driving cessation for people with dementia could be used to develop new approaches or adapt existing approaches to driving cessation. Interventions would need to be individualized, optimally timed, and address grief, explore realistic alternative community access, and simultaneously maintain key relationships and provide caregiver support.

Barriers and enablers of health promotion, prevention and early intervention in primary care: Evidence to inform the Australian national dementia strategy

A comprehensive literature review was undertaken to: (i) identify and summarise the research evidence regarding barriers and enablers of health promotion, prevention and early intervention (PPEI) in primary care to reduce the risk of chronic disease in the older population; and (ii) use this evidence to make recommendations to inform the Australian national dementia prevention strategy around the translation of evidence‐based care into practice. PPEI activities in primary care have the potential to not only reduce the prevalence and impact of a number of chronic diseases, but may also prevent or slow the onset of dementia given the apparent overlap in risk factors. While sizeable gaps exist regarding the most effective ways to promote the adoption of these activities, limited evidence suggests that, to be effective, PPEI activities should be quick and easy to administer, have a sound rationale and be readily incorporated into existing work processes.

Psychiatric drug prescribing in elderly Australians: Time for action

Recent epidemiological studies have revealed very high rates of antipsychotic, antidepressant and anxiolytic and sedative-hypnotic drug use among Australians [1 – 3]. These large-scale analyses supplement previous data across a number of settings demonstrating higher rates of use in those over 60 years, with highest rates in those 80 – 95 years of age (Figure 1). This issue is of growing concern, given the increasing size of the elderly population and the greater vulnerability of older people to adverse effects of drugs and to interactions among the multiple drugs often prescribed. On the basis of these new data and signifi cant previous fi ndings, we argue for the urgent need to review psychotropic prescribing among the elderly on the grounds of safety and cost [4]. We examined dispensed prescription data from Medicare Australia for three main drug classes. The amount of drug supplied was standardized using the defi ned daily dose (DDD) per 1000 population per day for all drugs with an anatomical therapeutic chemical code starting with N05A, N05B, N05C or N06A. The DDD is established by the World Health Organization Collaborating Centre for Drug Statistics Methodology [5]. It corresponds to an estimated mean daily dose of the drug when used for its main indication in adults. The number of Australians in each gender and fi ve year age group was used to standardize the DDD by population

Reclaiming the best of the biopsychosocial model of mental health care and ‘recovery’ for older people through a ‘person-centred’ approach

Aim: The ‘biopsychosocial’, ‘person-centred care’ (PCC) and ‘recovery’ models of care can be seen as distinct and competing paradigms. This paper proposes an integration of these valuable perspectives and suggestions for effective implementation in health services for the elderly. Method: An overview of PCC and recovery models, and their application for older people with mental health problems, is provided. Their overlap and contrast with the familiar ‘biopsychosocial’ model of mental health care is considered, together with obstacles to implementation. Results: Utilisation of PCC and recovery concepts allow clinicians to avoid narrow application of the biopsychosocial approach and encourages clinicians to focus on the person’s right to autonomy, their values and life goals. Conclusions: Service reform and development is required to embed these concepts into core clinical processes so as to improve outcomes and the quality of life for older people with mental health problems.

Dementia risk reduction in primary care: what Australian initiatives can teach us

Only limited research has been undertaken to identify factors that impede or facilitate the implementation of evidence-based health promotion, prevention and early intervention (PPEI) activities within primary practice. We examined recent Australian initiatives that encouraged primary care practitioners to implement PPEI activities to reduce the risk of chronic disease, particularly those that have focused on lifestyle risk factors. The aim was to identify barriers and facilitators to the uptake of these activities to inform the Australian National Dementia Prevention Strategy. Barriers that were consistently reported across evaluations and that appear to be of most concern to Australian general practitioners include the issues of financial remuneration and time constraints secondary to heavy work commitments. Factors that were effective in overcoming barriers included the integration of interventions within existing activities, the specification of a clear, funded role for practice nurses and the support of the Australian General Practice Network. It was concluded that these factors should be considered if PPEI activities for dementia are to be successfully incorporated within primary care.

Psychogeriatrics and general practice in Australia

We describe the interface between general practice and psychogeriatrics in Australia. While aged care services are complex and there are serious deficiencies in the management of the elderly, several initiatives appear set to improve the level of care. Economic considerations, mutual education of general practitioners and psychogeriatricians, and social factors are strong determinants of good primary care of the mental health needs of older people.

The care of older people during and after disasters: a review of the recent experiences in Queensland, Australia and Christchurch, New Zealand

Two major disasters hit Australasia in February this year. Physicians in Geriatric Medicine were involved, yet disaster management is not core knowledge for geriatricians. However, the experience and evidence described indicates we should increase our awareness of the issues for older people at times of disaster.

Insulin-like Growth Factor 1 (IGF-1) as a marker of cognitive decline in normal ageing: A review

Insulin-like Growth Factor 1 (IGF-1) and its signaling pathway play a primary role in normal growth and ageing, however serum IGF-1 is known to reduce with advancing age. Recent findings suggest IGF-1 is essential for neurogenesis in the adult brain, and this reduction of IGF-1 with ageing may contribute to age-related cognitive decline. Experimental studies have shown manipulation of the GH/GF-1 axis can slow rates of cognitive decline in animals, making IGF-1 a potential biomarker of cognition, and/or its signaling pathway a possible therapeutic target to prevent or slow age-related cognitive decline. A systematic literature review and qualitative narrative summary of current evidence for IGF-1 as a biomarker of cognitive decline in the ageing brain was undertaken. Results indicate IGF-1 concentrations do not confer additional diagnostic information for those with cognitive decline, and routine clinical measurement of IGF-1 is not currently justified. In cases of established cognitive impairment, it remains unclear whether increasing circulating or brain IGF-1 may reverse or slow down the rate of further decline. Advances in neuroimaging, genetics, neuroscience and the availability of large well characterized biobanks will facilitate research exploring the role of IGF-1 in both normal ageing and age-related cognitive decline.