Jane E. Fisher

Meta-Analysis of the Effectiveness of Atypical Antipsychotics for the Treatment of Behavioural Problems in Persons with Dementia

Background: To review published reports of the usage of atypical antipsychotics for behavioural problems of dementia patients. Methods: The electronic database Medline was searched from 1999 to 2006 with a combination of search terms including ‘behavioural problems’ and ‘atypical antipsychotics’. Results: Thirteen eligible studies were included in the overall analysis. The total number of participants was 1,683, of whom 1,015 received medication and 668 received placebo. Medications studied were risperidone, olanzapine, and quetiapine. Other studies examined other types of medications, such as typical versus atypical antipsychotics, but only data for atypical antipsychotics were included in the meta-analysis. The mean effect size for 7 placebo-controlled studies was 0.45 (95% CI = 0.16–0.74) for atypical antipsychotics, and 0.32 (95% CI = 0.10–0.53) for placebo. The mean effect size of all 13 studies included in the analysis was 0.31 (95% CI = 0.08–0.54). Conclusions: In general, effect sizes of atypical antipsychotics for behavioural problems are medium, and there are no statistically or clinically significant differences between atypical antipsychotics and placebo.

Behavior management of the dementias

Abstract Dementia affects over four million older adults in the United States and is the leading cause of institutionalization among the elderly. As the elderly population increases over the next decades the number of individuals with severe dementia is expected to rise dramatically. Although there is no known treatment for the cognitive impairment of dementia, behavioral approaches have been demonstrated to be moderately effective for reducing the behavior problems that accompany dementing disorders. In this article we critically review the behavioral assessment and treatment literature on dementia-related behavior problems. Future directions for research and clinical practice are also discussed.

Facilitating Conversation in Elderly Persons with Alzheimer's Disease

Abstract Deterioration of verbal abilities is among the most debilitating consequences of Alzheimers disease (AD). Recent research suggests that the common responses of conversational partners may contribute to excess verbal deficits in persons with AD in that they function to punish verbal behavior. The purpose of this study was to systematically evaluate two types of listener repair responses, indirect and direct repairs, on the conversational speech of older adults with AD. In an indirect repair, the listener paraphrases the speech of the person with AD. In a direct repair response, the listener interjects with corrective feedback. Three men diagnosed with AD participated in this study. A female confederate was trained in indirect and direct repair responses. An ABAC single subject design was used to evaluate the effects of listener repair responses on the amount, duration, and fluency of the speech of the participants during videotaped conversations with the confederate. The results indicate that the confederates responses significantly impacted the conversational speech of older adults with AD. Indirect repair responses by the confederate were associated with higher levels of coherent speech for all participants compared to the direct repair and baseline conditions. The results indicate that indirect repair responses may decrease the risk of excess verbal deficits in persons with AD by functioning to reinforce (i.e., increase) speech. The findings have implications for the training of care-givers of persons with AD. Training caregivers in responses that reinforce rather than punish verbal behavior may prevent or reduce excess disability thereby improving the quality of life for persons with AD and their care-givers.

A Contextual Model of Restraint-Free Care for Persons with Dementia

Publisher Summary This chapter focuses on dementia, its diagnosis and the related characteristics. There is currently no effective treatment for stopping or reversing the impairment caused by degenerative forms of dementia. Affected persons eventually become bedridden, unable to swallow, and completely dependent on others for their care. Persons close to someone with dementia typically perceive the declines in the repertoire as major changes in “personality”. However, the treatment of the behavior problems that develop in dementia has been dominated by the use of antipsychotic and atypical antipsychotic medications. The challenging behaviors that develop over the course of degenerative dementia continue to result in patients receiving restrictive pharmacological and mechanical restraint. Hence, within the field of the care of persons with dementia, there is increasing recognition of the need for the development of restraint-free interventions.

Psychopathology in the Aged

In this chapter, we reviewed the literature on psychopathology and aging. It is clear that early research and theory assumed that the incidence of psychological disorder increased with age. This was attributable, in part, to negative societal attitudes about the aging process and the methodological limitations of early research strategies.

Behavioral interventions for sexual dysfunction in the elderly

In this paper we review and evaluate the status of information regarding sexual dysfunction in advanced age. We argue that the behavioral approach has considerable promise for the conceptualization of the sexual problems of older adults, because in rejecting the medical model of nomothetically defining psychological disorders, it allows for considerable variability for individuals to define their problems in living. The great heterogeneity in health and psychological functioning that is found among the elderly can be mirrored in the heterogeneity of problem definitions. Further, the behavioral approach views problem definition as a behavior that may be a product of problematic societal contingencies that may need to be addressed themselves. The utility of this feature for guiding behavior therapists in helping their elderly clients understand their sexual functioning is discussed. Finally, we propose a research agenda that addresses the limitations in the extant literature regarding the assessment and treatment of sexual dysfunction in old age.

Preventing Excess Disability in an Elderly Person With Alzheimer's Disease:

Staff of an adult day treatment facility reported that a client diagnosed with Alzheimers disease was exhibiting physical and verbal aggression toward other clients. Direct observation of the clients interactions at the adult day treatment facility revealed that she was neither physically nor verbally abusive but was assertive and used a cane to access social attention. Treatment consisted of three in-service trainings during which staff received information about the symptomatology of dementia, environmental factors contributing to excess disability, and the importance of environmental support for maintaining adaptive behavior in persons with dementia. Results indicate that staff perceived verbal behavior less negatively, and allowed the client to interact with others at a significantly increased frequency.

Contextual factors in the assessment and management of aggression in dementia patients

Aggressive behaviors associated with dementia present serious problems for patients and caregivers. Aggression, which has often been assumed to be an inherent feature of dementia, may actually be adaptive for dementia patients who have limited skills available to manage an environment that becomes increasingly complex as cognitive deterioration progresses. When aggression in dementia patients is examined within a functional analytic framework, it emerges as an adaptive, albeit undesirable, means of communicating distress or discomfort. Idiographic assessment of the influence of setting events, environmental antecedents, and consequences associated with aggression may assist in the development of proactive interventions that modify environmental influences associated with aggressive behavior. Modifying environmental precipitants rather than relying on interventions that attempt to directly eliminate aggression from the patients already impoverished behavioral repertoire is presumed to be more humane.

Treatment Applications for Psychological and Behavioral Problems of the Elderly in Nursing Homes

About 1.3 million elderly people currently live in some 18, 000 nursing homes in this country (Eustis, Greenberg, & Patten, 1984). Although this number represents only 5% of the population of elderly persons, it is misleading to think that nursing home placement is a concern for an insignificant portion of the aged population. Only 5% reside in nursing homes at any point in time, but the lifetime probability of placement in a nursing home is 25–30% (Lesnoff-Caravaglia, 1978–1979). That is, for those elderly who live into advanced old age, the odds of placement increase from 1 in 20 to 1 in 4. As the aging population steadily grows in size, with the “old-old” segment growing fastest, the absolute number of old people living in nursing homes will continue to increase well past the turn of the century. By 2050, if present trends continue, the number of institutionalized elderly people is expected to reach 5.2 million (Brody & Foley, 1985). There is no doubt that this group of physically frail elderly, has psychological problems that demand our attention, problems that present significant economic, social, and ethical dilemmas for families, caregivers, and professionals involved in their care.

Meta-Analysis of Antidepressant Augmentation: Piling on in the Absence of Evidence

Background: Treatment of depression with a single pharmaceutical agent often does not work, and several agents may be tried or combined to increase efficacy. Augmentation involves the addition of one or more medications to an existing antidepressant monotherapy to enhance mood and overall antidepressant response. Approximately 22% of individuals with unipolar depression are prescribed augmentation strategies. This study examined the effectiveness of augmentation strategies. Methods: A Medline search of studies published before January 1, 2007 was conducted to assess the extent of published data on the most frequently prescribed augmentation strategies. Studies with completed original data, sufficient efficacy data, and participants diagnosed with unipolar depression were included. Letters to the editor, preliminary data, data only presented at conferences, and small uncontrolled case reports were excluded. Results: 13 studies contained sufficient data to calculate an effect size. Mean estimated effect size of all 13 studies calculated with random effects was 0.1782 with a 95% confidence interval of −0.2513−0.6076. Conclusions: There are minimal published data examining antidepressant augmentation, and augmentation is a minimally effective treatment option.