Reinhard Lindner

Adherence to Medication in Patients with Dementia : Predictors and Strategies for Improvement

Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of older patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise adherence behaviour. Therefore, a literature review was performed to identify factors associated with adherence to medication in patients with cognitive impairment or dementia, and to discuss strategies for improvement of non-adherence.Evidence-based information on how to deal with adherence to medication in patients with dementia is scarce because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behaviour in older age, and emerging insight into the relationships between adherence behaviour and cognitive capacity, memory and executive function, in particular. Nevertheless, understanding elderly persons’ strategies for maintaining regular use of even complex drug regimens is still limited. Progress of research in this field is needed. It is notable that measures to improve adherence consist of combinations of educational interventions and cognitive support but assessment of study participants’ cognitive function is rare.In clinical practice, awareness of non-adherence as a result of cognitive impairment is relatively low. The most important step is early detection of cognitive impairment when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment. Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs) and proxy information. However, no feasible screening methods have as yet found their way into clinical practice. Patients with impaired executive function, lack of awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence. The question is when to switch patient medication self-management to another person’s responsibility if cognitive decline progresses.Further research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use and medication management. Also, studies evaluating the influence of personal support, health status and depression on the memory strategies used are needed. It is important to assess patients’ attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible. When providing medication organizers, it is important to observe the patient’s ability to use devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects. This holds true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient’s cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy. No evidence-based recommendations can be given as yet. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.

A systematic review of physical illness, functional disability, and suicidal behaviour among older adults

Objectives: To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older. Method: Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review. Results: Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed. Conclusion: Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.

Key considerations for preventing suicide in older adults: consensus opinions of an expert panel.

BACKGROUND The number of older adults is growing rapidly. This fact, combined with the high rates of suicide in later life, indicates that many more older adults will die by their own hands before rigorous trials can be conducted to fully understand the best approaches to prevent late life suicide. AIMS To disseminate key considerations for interventions addressing senior suicidal behavior. METHODS An international expert panel has reviewed and discussed key considerations for interventions against suicide in older adults based on existing evidence, where available, and expert opinion. RESULTS A set of new key considerations is divided into: universal, selective, and indicated prevention as well as a section on general considerations. CONCLUSIONS The suggestions span a wide range and are offered for consideration by local groups preparing new interventions, as well as large scale public health care planning.

PSYCHODYNAMIC IDEAL TYPES OF ELDERLY SUICIDAL PERSONS BASED ON COUNTER TRANSFERENCE

Suicidality among the elderly is a serious health and social problem. In contrast to the quantitative significance of suicidality in old age, utilisation of psychiatric and psychotherapeutic treatment by the suicidal elderly is low. Single case based knowledge of the intra‐psychic dynamics of the suicidal elderly exists but this has mostly been gained from long‐running psychotherapies, and not from people who remain silent about their suicidality, even during treatment. In a systematic qualitative study, in‐depth interviews were conducted with 30 people (60+), who judged themselves as suicidal but had not talked about it in treatment. Using the method of ‘forming types by understanding’, ideal types were developed by means of the suicidal elderlys transference offers on the background of their main biographic accounts and their suicidal symptoms. This typology presents the suicidal elderlys varied and multi‐reasoned dynamics of psychosocial retreat, which both encourage and maintain suicidality, also leading to the fact that these people keep silent about their suicidality in professional health care relationships, or they contribute to negative counter‐transference reactions, which make the start of a therapeutic relationship difficult.

Suicide and trauma: A case discussion

In this paper we explore the relationship between trauma and suicidal thoughts and behaviour. This exploration has a double perspective: a deeper understanding of trauma can illuminate the dynamics of suicidality; and the psychotherapeutic study of suicidal people increases our understanding of the impact of trauma. This discussion addresses three particular configurations: (a) the impact on the individual of the suicide of a close person; (b) the traumatic dimension of suicidal behaviour on the self; and (c) the impact of childhood traumatic experiences on the subsequent development of suicide. We describe the psychotherapy of a suicidal man, who had suffered many losses including that of his mother to suicide, as the basis for commentary by three discussants. The paper concludes that the approach linking trauma with suicide is a fruitful one and further study is recommended.

Psychodynamic Hypothesis About Suicidality in Elderly Men

Old men are overrepresented in the whole of all suicides. In contrast, only very few elderly men find their way to specialised treatment facilities. Elderly accept psychotherapy more rarely than younger persons. Therefore presentations on the psychodynamics of suicidality in old men are rare and mostly casuistical. By means of a stepwise reconstructable qualitative case comparison of five randomly chosen elderly suicidal men with ideal types of suicidal (younger) men concerning biography, suicidal symptoms and transference, psychodynamic hypothesis of suicidality in elderly men are developed. All patients came into psychotherapy in a specialised academic out-patient clinic for psychodynamic treatment of acute and chronic suicidality. The five elderly suicidal men predominantly were living in long-term, conflictuous sexual relationships and also had ambivalent relationships to their children. Suicidality in old age refers to lifelong existing intrapsychic conflicts, concerning (male) identity, self-esteem and a core conflict between fusion and separation wishes. The body gets a central role in suicidal experiences, being a defensive instance modified by age and/or physical illness, which brings up to consciousness aggressive and envious impulses, but also feelings of emptiness and insecurity, which have to be warded off again by projection into the body. In transference relationships there are on the one hand the regular transference, on the other hand an age specific turned around transference, with their counter transference reactions. The chosen methodological approach serves the systematic finding of hypotheses with a higher degree in evidence than hypotheses generated from single case studies.

SUICIDALITY IN MEN IN PSYCHODYNAMIC PSYCHOTHERAPY

Based on the evidence of empirical gender differences in attempted suicide and suicide, this paper develops psychodynamic hypotheses on gender‐specific biographic, intra‐psychic and treatment aspects of suicidality among men. ‘Forming Types by Understanding’ is a qualitative method, based on a systematic analysis of similarity and differential reference points to develop ideal types of suicidal men. A random sample of 20 suicidal men who were receiving out‐patient psychodynamic psychotherapy was studied. Four ideal types of suicidal men were identified: (1) ideal type ‘disconnected’: a predominance of disconnected feelings that is associated with rejection experiences; (2) ideal type ‘hurt’: aggressive conflicts and the realization of disillusioned life reality combined with experiences of real loss and real trauma; (3) ideal type ‘stormy’: an attached‐symbiotic transference offer mobilizes unrealistic wishes to help against a background of unresolved dependency conflicts; and (4) ideal type ‘object dependent’: concrete facts are important in relationships; in case of separation, real repossession of the woman must occur, a lack of emotional experience is compensated. The danger of suicidality, especially in the early stage of psychotherapy, is particularly acute for patients who cannot reach their therapists emotionally and vice versa. Disturbance of the early experience of inseparability from the mother, gender‐specific conflicts in the development of separation and individuation, and failed triangulation are of central psychodynamic importance.

Psychotherapie der Suizidalität

ZusammenfassungPsychotherapie ist eine wichtige therapeutische Möglichkeit der Behandlung der Suizidalität. Unabhängig von den verschiedenen Behandlungssettings werden psychotherapeutische Haltungen, Strategien und Techniken vorgestellt, wie sie auf dem Boden verhaltenstherapeutischer und psychoanalytischer Theorien entwickelt wurden. Ausgehend von der gemeinsamen Grundhaltung eines aktiven, zugewandten und für den Patienten auch erkennbaren Therapeuten ist die verhaltenstherapeutische Haltung von dem Gedanken eines „Teams“ geprägt, das gegen die Suizidalität antritt. Die zur Suizidalität führenden Probleme sollen genau definiert werden; spezifische verhaltenstherapeutische Strategien zielen auf eine Modifikation des Verhaltensrepertoires und kognitiver Strategien. Eine psychodynamische, an der inneren Reaktion des Therapeuten, der Gegenübertragung orientierte Strategie geht von einer primären Verstrickung von Patient und Therapeut in das, auch zur Suizidalität führende Beziehungsmuster aus, welches vom Therapeuten erkannt und dem Patienten auf „verdauliche“ Weise bewusst gemacht wird. Die Erfahrung eines zugewandten und doch unerwartet anders als gewohnt oder befürchtet handelnden Therapeuten ermöglicht die Ausbildung von Erkenntnissen und Beziehungsmustern, die keine suizidale Vernichtung mehr nötig erscheinen lassen. Abschließend werden empirische Belege für die Effektivität verhaltenstherapeutischer und psychodynamischer Behandlung der Suizidalität dargestellt.AbstractPsychotherapy is an important therapeutic option in the treatment of suicidality. Irrespective of the different treatment settings the psychotherapeutic attitudes, strategies and techniques are presented as they were developed on the basis of cognitive behavioral therapy and psychoanalysis. Starting from the common basic attitude of an active, approachable and for the patient recognizable therapist, the cognitive behavioral attitude is defined by the concept of a “team” involving patient and therapist, which fights against suicidality. The problems that led to suicidal ideation have to be exactly defined and specific behavioral strategies should aim at a modification of the behavioral repertoire and of cognitive strategies. A psychodynamic strategy starting from the analysis of the therapist’s inner reaction, the countertransference comes from a primary involvement of both patient and therapist, which the therapist has to recognize and interpret to the patient in a “digestible” way. The experience of an approachable therapist who unexpectedly behaves differently than usual or feared, enables the patient to come to insights and new relational patterns which make suicidal destruction unnecessary. Finally, empirical evidence for the effectiveness of cognitive behavioral and psychodynamic treatment of suicidality is presented.

Music therapy interaction patterns in relation to borderline personality disorder (BPD) patients

Music therapy for patients suffering from borderline personality disorder (BPD) has been a standard treatment option for many years in in-patient psychiatric work. The BPD symptoms, such as identity disturbance, emotional regulation and unstable relationships, lead to challenging and stormy therapy sessions for all therapists of all disciplines. In music therapy, difficulties in treatment include, for example, the patient’s refusal to play, extreme loud music or withdrawal from the process. This article presents the method and results of a systematic qualitative research of 20 BPD female patients undergoing individual psychoanalytical music therapy in an acute psychiatric context. The aim of the research was to identify typical interaction patterns, arising from the relationship between patient and therapist and also from the significance of music. The method “forming types by understanding” is based on the well-known sociological research method of “ideal types”. Abstracted results are generated by contrasting cases, and the research process is validated through communicative validation. In total, it was possible to identify 10 typical interaction patterns within music therapy, reflecting typical BPD themes such as regulation of proximity and distance, splitting phenomena, trauma genesis, aggression and mentalization. The 10 typical interaction patterns of BPD patients have provided a way of accessing individual music therapy cases and making them much easier to understand. The interaction patterns help to maintain and reconstruct the therapist’s capacity to play, improvise and to mentalize.

Sexualität suizidaler Älterer

ZusammenfassungSowohl Sexualität als auch Suizidalität scheinen bei Älteren in Wissenschaft und therapeutischer Praxis einem Tabu zu unterliegen. Umso dringlicher ist es, explorativ Erkenntnisse über beide Aspekte menschlichen Erlebens und Verhaltens zu gewinnen. Deshalb wurden aus einer Gesamtstichprobe (N=67) suizidaler und Nicht-Suizidaler Probanden über 60 Jahren die Antworten von 56 Probanden (Suizidale N=43, Nicht-Suizidale N=23) zu Fragen über ihre Sexualität transkribiert und mittels der systematisch qualitativen Methode der Typenbildung aus diesem Material Typen gebildet. Vier dieser Typen setzen sich aus deutlich mehr suizidalen Probanden zusammen, bei zweien überwiegen die Nicht-Suizidalen Probanden, der Rest ist eher heterogen strukturiert. Einige dieser Typenbildungen lassen sich sehr gut und eindeutig interpretieren und verstehen. Einer der Typen überraschte mit einer unvermutet vornehmlich suizidalen Struktur, des Weiteren ließen sich ein „weiblich narzisstischer“ und ein „männlich narzisstischer“ Typus finden. Diese explorative Typologie soll dem interessierten Behandler als Orientierung dienen, die Sexualität als ein wichtiges Lebensthema, auch im Alter, mit einzubeziehen und dieses auch zu nutzen um den Patienten besser verstehen zu können, gerade auch in suizidalen Krisen.AbstractSexuality and suicidality in the elderly seem to underlie a taboo in science and in therapeutic practice. It is urgent to find an understanding about both aspects of human experience and behaviour by explorative studies. In a sample (N=67), the narratives of 56 persons (suicidal=43 and non-suicidal=23) on questions concerning their sexuality were transcribed and ideal types were developed with the systematic qualitative method of forming types by understanding. Four of these types consist of clearly more suicidal persons, in two the non-suicidals predominate, the rest is more heterogeneous in this aspect. Some of these types can be interpreted unequivocally. One type was surprisingly clearly suicidal dynamic, while others were a “female narcissistic” or a “male narcissistic” type. This explorative typology may help the interested therapist/counsellor as a landmark to relate to sexuality as an important aspect of life, even in old age, and to use the discussion of sexuality to improve the understanding of patients, especially in suicidal crisis.