Leander Mitchell

Memory and communication support in dementia: research-based strategies for caregivers

BACKGROUND Difficulties with memory and communication are prominent and distressing features of dementia which impact on the person with dementia and contribute to caregiver stress and burden. There is a need to provide caregivers with strategies to support and maximize memory and communication abilities in people with dementia. In this project, a team of clinicians, researchers and educators in neuropsychology, psychogeriatrics, nursing and speech pathology translated research-based knowledge from these fields into a program of practical strategies for everyday use by family and professional caregivers. METHODS From the available research evidence, the project team identified compensatory or facilitative strategies to assist with common areas of difficulty, and structured these under the mnemonics RECAPS (for memory) and MESSAGE (for communication). This information was adapted for presentation in a DVD-based education program in accordance with known characteristics of effective caregiver education. RESULTS The resultant DVD comprises (1) information on the nature and importance of memory and communication in everyday life; (2) explanations of common patterns of difficulty and preserved ability in memory and communication across the stages of dementia; (3) acted vignettes demonstrating the strategies, based on authentic samples of speech in dementia; and (4) scenarios to prompt the viewer to consider the benefits of using the strategies. CONCLUSION Using a knowledge-translation framework, information and strategies can be provided to family and professional caregivers to help them optimize residual memory and communication in people with dementia. Future development of the materials, incorporating consumer feedback, will focus on methods for enabling wider dissemination.

Decisional capacity: toward an inclusionary approach

Capacity, defined as the ability to make ones own decisions, has traditionally been seen as a dichotomous or categorical construct. People either have capacity, and are therefore afforded autonomy, or they lack capacity, and are therefore provided with a proxy decision-maker. In a way this concept – and the related practice of conceptualizing capacity as an all or nothing phenomenon – resembles the situation of Kafkas protagonist Gregor Samsa in Metamorphosis (1972 (in German 1915)). The opening lines of this breathtaking essay are world famous. In English they run as follows: “As Gregor Samsa awoke one morning from uneasy dreams he found himself transformed in his bed into a gigantic insect.” As a consequence of this categorical change, Gregor is excluded and despised of. He is no longer considered an agent and ends up squashed by apples by his own relatives. Although the parallel may seem far-fetched, the atmosphere of estrangement and alienation resembles what can happen to people who are diagnosed with dementia or other mental disorders, when suddenly their health professionals turn to their relatives to make healthcare and other decisions and they themselves are no longer afforded a role – read for example Maartens experience in Bernlefs novel Out of Mind (1989 (in Dutch 1984)). Fortunately, this situation is changing and we are moving toward a more sophisticated approach, away from a categorical and exclusionary practice toward a more dimensional and inclusionary concept of capacity. One of the fundamental ideas underlying this alternative approach is that capacity assessments should primarily be undertaken not to judge whether people are capable or not to decide “autonomously,” but rather to assess what kind of support people with decision-making disabilities (DMD) need in order to be involved in decision-making and thus to promote their autonomy. This paradigm shift has been heralded by a number of human rights frameworks such as the European Convention on Human Rights and the United Nations Convention on the Rights of People with Disabilities (UNCORPD, 2012). These conventions promote autonomy and the enjoyment of equal recognition before the law for people with disabilities, thus underscoring the right of people with disabilities to enjoy legal capacity on an equal basis with other members of society. Importantly, UNCORPD Article 12 (2012) specifically recommends that signatories “take appropriate measures to provide access by persons with disabilities to the support they may require in exercising their legal capacity.” This obligation translates into a major challenge for healthcare and legal professionals alike. How do we support maximum participation in decision-making for those who lack decisional capacity? Some years ago, Beltram (1996) summarized the challenge of accurately assessing decisional capacity, referring to the usefulness of “pragmatic models of shared decision-making.” However, there is no consensus yet as to how models of supported decision-making might be utilized by people with DMD. In this contribution we propose a practical model for supported decision-making, which is inclusionary and founded in ethical and human rights frameworks. To this end we will first discuss how the ethical concept of autonomy has evolved during the past decades and how changing views on autonomy relate to support in decision-making.

Cognitive behavior therapy for anxiety in Parkinson’s disease: outcomes for patients and caregivers

ABSTRACT Objective: Anxiety negatively impacts the quality of life of Parkinson’s disease (PD) patients and caregivers. Despite high prevalence, there is a paucity of trials investigating effective treatments for anxiety in PD. This uncontrolled study investigated the use of a manualized and tailored Cognitive Behavior Therapy (CBT) for anxiety in PD. Methods: Participants completed 6 weekly CBT sessions. Pre-, post- and follow-up (3 and 6 months) assessments were made. Change in outcomes were analysed using t-tests and Reliability Change Index. Of 17 PD patients who agreed to CBT, 12 completed the intervention. Results: This study showed a significant reduction in Hamilton Anxiety Rating Scale scores in PD immediately post CBT (t(11) = 3.59, p < .01), maintained at 3-month (t(8) = 2.83, p = .02) and 6-month (t(7) = 2.07, p = .04) follow-up. A reduction in caregiver burden (t(11) = 2.68, p = .03) was observed post intervention. Improvements in motor disability (t(11) = 2.41, p = .04) and cognitive scores (t(11) = −2.92, p = .01) were also observed post intervention and at follow-up. Conclusions: Tailored CBT can be used to treat anxiety in PD. Clinical Implications: This study provides preliminary evidence suggesting that tailored CBT reduces anxiety in PD with persisting benefits, and lowers caregiver burden.

Predictors of financial capacity performance in older adults using the Financial Competence Assessment Inventory

BACKGROUND Declines in financial capacity in later life may arise from both neurocognitive and/or psychiatric disorders. The influence of socio-demographic, cognitive, health, and psychiatric variables on financial capacity performance was explored. METHODS Seventy-six healthy community-dwelling adults and 25 older patients referred for assessment of financial capacity were assessed on pertinent cognitive, psychiatric, and financial capacity measures, including Addenbrookes Cognitive Examination - Revised (ACE-R), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), selected Neuropsychiatric Inventory (NPI) items, Financial Competence Assessment Inventory (FCAI), and Social Vulnerability Scale (SVS). RESULTS The internal consistency of the debt management subscale of the FCAI was relatively poor in our sample. Financial capacity performance differed between controls and patients. In our sample, performance on the FCAI was predicted by Mini-Mental State Examination, IQCODE, and GAI, but not by ACE-R, GDS, NPI items, or SVS (adjusted R(2) = 0.7059). CONCLUSIONS Anxiety but not depression predicted financial capacity performance, possibly reflecting relatively low variance of depressive symptoms in this sample. Current cognitive decline as measured by the informant-rated IQCODE was more highly correlated to financial capacity than either educational attainment or ACE-R scores. Lack of significance of ACE-R data may reflect the instruments decreased sensitivity to domains relevant to financial capacity, compared with more detailed neuropsychological assessment tools. The FCAI displayed fairly robust psychometric properties apart from the debt management subscale.

Brief on the role of psychologists in residential and home care services for older adults

Objective This brief examines the evidence that is currently available to inform the provision of psychological services within aged care services, considering both residential care and home care settings. Method A narrative literature review of the literature evaluating psychological approaches for common conditions in aged care settings was conducted, focusing on the assessment and treatment of common mental health disorders and dementia. Information on the current employment and training of Australian psychologists in geropsychology was also summarised. Results While further research is required, existing literature provides a clear rationale for the benefit of psychological approaches to address a range of conditions, including the management of dementia. There is only limited research focusing specifically on the home care setting, despite the increasing number of older adults who receive aged care services in their own homes. The current provision of psychological services in Australia is critically low, driven in part by funding limitations. Meanwhile, substantial gaps remain in the training provided to provisional psychologists. Conclusion A number of key recommendations are made to address the growing need for age‐specific psychological assessments and interventions to be included as part of the delivery of aged care services in this country. Given the continued high prevalence of mental health disorders and dementia within aged care settings, as well as even higher rates of subthreshold conditions, improved access to psychological services for older Australians must become a priority.

Promoting the use of enduring powers of attorney in older adults: A literature review

This review aims to identify factors that facilitate the establishment of enduring powers of attorney (EPOAs), and those that create a barrier to their establishment. The primary aim was to provide guidance about how to encourage future planning while people are cognitively able to make such important decisions. A detailed search of the literature was conducted to identify research looking at the motivating factors behind putting future‐planning strategies in place. The literature highlighted a number of broad areas motivating the establishment of EPOAs, including: demographic factors; intrapersonal and personality factors; health and psychological factors; cognitive factors; and socio‐emotional factors. While a number of factors play a role in determining whether or not a person establishes an EPOA, the factor most malleable to change is the awareness and knowledge of older adults and their families regarding the utility of EPOAs.

The availability of psychological services for aged care residents in Australia: a survey of facility staff

Objective Rates of depression and anxiety are high among older adults in residential aged care facilities (RACFs). This study examined the extent to which psychological services are made available to facility residents in Australia, and investigated barriers to accessing such services. Method The sample consisted of 90 senior staff from a random sample of RACFs. Participants completed self‐report questionnaires regarding their perspectives on the availability of psychological services and potential barriers to access psychological services. Results Access to psychological services was poor. Psychologists were employed at a rate only one third that of other providers of mental health services. Residents were rarely referred to psychologists or to psychological treatments. The most important barriers to access, as perceived by participants, were the low availability of psychologists specialising in treating older adults, lack of government funding for such access, and limited staff training in detecting depression and anxiety. Conclusion Access to psychologists and psychological services remains poor in Australian residential aged care settings. Such access may be improved by developing a workforce of clinical geropsychologists, improving funding mechanisms for residents to access psychological services, and addressing staff knowledge about depression and anxiety.

Contextual Adult Life Span Theory for Adapting Psychotherapy (CALTAP) and Clinical Geropsychology

The Contextual Adult Lifespan Theory for Adapting Psychotherapy (CALTAP) model is a transtheoretical model developed to assist in increasing the understanding of both who the older adult client is and the broad context within which he or she presents for therapy.

Working with people with dementia: The perspectives of an Australian psychology student

This series of papers presents reflections on the diagnostic complexities of late-life anxiety. Nancy Pachana and Richard Oude Voshaar are discussants.[Extract] Discussions of clinical psychology training can be placed more broadly within wider discussions of the best ways to train health professionals[1]. At issue is how to improve the ability of newly trained mental health professionals to respond to the changes in a dynamic health care environment [2]. This paper uses quantitative and qualitative data gathered in Australia to highlight difficulties in delivering a coherent curriculum in old age psychology. Australia as a country has some distinct advantages with respect to geropsychology training (e.g., much national awareness of clinical ageing issues) as well as important disadvantages (most prominently, a dearth of trained clinical psychology specialists in ageing) [3]. Data from a recent survey of Australian clinical directors highlights the increased need and demand for clinical psychology training to embrace specific training to meet the needs of older adults. Open-ended queries about the growth of ageing as an area of clinical psychology provoked a range of telling responses. This data, analysed via Leximancer version 3.5, led to 10 primary themes being identified. These included the fact that geropsychology was a subspecialty of increasing interest and importance; that current accreditation requirements posed a barrier to extending coursework and placement opportunities focussing on older adult, and that student interest in this area was growing (although the latter point was controversial). In another survey of student views of strengths and weaknesses in clinical psychology training in Australia, assessment of clinical competencies was highly desired yet often not adequate.