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Translating dementia research into practice

Caregiver Mediated Intervention Trumps Pharmacotherapy for BPSD

Professor Henry BrodatyDirector

Dementia Collaborative Research Centre – Assessment and Better Care

© DCRC/Brodaty 2011

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Dementia – not only a memory problem!Dementia – not only a memory problem!

• Depression• Delusions• Hallucinations• Aggression• Wandering• Apathy• Agitation BPSD ubiquitous >90%

Behavioural & Psychological Symptoms of Dementia (BPSD)

© DCRC/Brodaty 2011

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Prevalence of BPSDPrevalence of BPSD• PWD up to 40x > rates of BPSD than rest of

age matched population1

• 61% any NPI disturbance1; Mean NPI = 7

• 32% severe disturbance 1 (NPI 6)

– Delusions: AD > VaD;

– Depression: VaD > AD

• Rates just as high in developing countries2

• Rates >90% in nursing homes3

1Lyketsos et al 2000; 2Prince M et al 2004; 3Brodaty et al, 2001

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1O’Brien JA, Shomphe LA,Caro JJ 2000; 2Rodney, 2000; 3Draper et al, 20004Maslow K 1994

Effects of BPSDEffects of BPSD• BPSD increase the cost of caring for a person

with dementia in an institution1

• BPSD increase nurse stress, especially

aggression2 & calling out3

• Residents with BPSD are more likely to4:– be physically restrained, receive

antipsychotic medication, negatively influence care staff & other residents


Effects of BPSDEffects of BPSD

• Greatest burden on family CG is BPSD1,2

• Predicts CG decision to institutionalise PWD3,4

Translating dementia research into practice © DCRC/Brodaty 2011

1Pinquart & Sorensen (2003). Int Psychogeriatr 16(4), 1-19.2Machnick et al. (2009). Int J of Geriatric Psych, 24(4), 382-389.3de Vugt et al (2005). Int Psychogeriatr, 17, 577-589. 4Chan et al. (2003). J Gerontol A Biol Sci Med Sci, 58(6), 548-554.


Limited drug efficacyLimited drug efficacy

• Can have adverse effects• Antipsychotic drugs associated with

increased risk of stroke and death1-3

• Little effect of antidepressants4


1Schneider et al. (2005). JAMA, 294(15), 1934-1943.2Wang et al. (2005). New Engl J Med, 353(22), 2335-2341. 3Brodaty et al. (2003). J Clin Psychiatry. 64(2), 134-143.4Weintrub et al. (2010). Am J Geriatr Psychiatry, 18(4), 332-340.


Non-pharmacotherapy interventionNon-pharmacotherapy intervention

• Demonstrated effectiveness in residential care• CG intervention reduce stress1,2

• Modest efficacy comparable to psychotropics but w/o adverse effects3

• Most studies in residential care, not community


1Livingston et al. (2005). Am J Psychiatry, 162(11)2O’Connor et al. (2009). Int Psychogeriatr, 21(2), 241-251. 3Ayalon, et al. (2006). Arch Intern Med, 166(20), 2182-2188.

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What is efficacy of CG interventions in

community on BPSD?



Systematic reviewSystematic review• Criteria– Peer reviewed, English language– Non-pharmacological interventions– Outcomes relevant to BPSD– >5 participants with dementia diagnosis– Primary CG = family member living w/ PWD

• Excluded– Review papers, respite care interventions


Partner logo hereSystematic Review: ResultsSystematic Review: Results


ResultsResults• 22 studies met all criteria• Categorised into 5 groups

1. Skills training for CG

2. Education for CG

3. Occupational therapist led intervention for CG

4. Enhancing support for CG

5. Self-care techniques for CG



1. Skills training for CG1. Skills training for CG

• Better management of BPSD• Better communication with CR• Using role play, videos modelling

management, vignettes, live interviews• Enhancing CR quality of life – (eg increasing pleasant events)



1. Skills training for CG1. Skills training for CG

• Gormley et al. (2001): Education & aggressive behaviour management training– 4 in-home sessions over 8 wks

• Outcomes: CR aggressive behaviour & overall behavioural problems

• Results: Sig reduction in aggressive behaviour score for tmt group (controlling for baseline aggression)

Gormley et al. (2001). Age and Ageing, 30(2), 141-145


2. Education for CG2. Education for CG• Psychoeducation• Improved homecare• Tailored advice/recommendations• Problem solving methods• Improving support network• Computer mediated automated voice

response• Planning, legal, financial



2. Education for CG2. Education for CG• Teri et al. (2005): CG taught communication

strategies & BMT, enhanced CG support– 8 wks plus 4 months phone support

• Outcomes: frequency & severity of problem behaviours, CG reactions to behaviours

• Results: Sig reduced freq & severity of problem behaviours– Sig improved CG reactions to CR problem

behaviours

Teri et al. (2005). Gerontologist, 45(6), 802-11.


3. Occupational therapist led 3. Occupational therapist led interventionintervention

• Planning activities with CG for CR• Modifying CR physical and social

environment



3. Occupational therapist led 3. Occupational therapist led interventionintervention

• Graf et al. (2007): CR taught to use compensatory/environmental strategies to improve performance of daily activities– OT in 10 sessions over 5 wks

• Outcomes: CR mood (depression)• Results: CR mood (depression) was

significantly improved

Graff et al. (2007). J Gerontol A Biol Sci Med Sci, 62(9), 1002-9


4. Enhancing support for CG4. Enhancing support for CG

• Social support• Web/phone support• Strategies on how to access support• Family counselling



4. Enhancing support for CG4. Enhancing support for CG

• Belle et al. (2006): Education & support for CG– In-home & phone sessions: 12 sessions, 6

months• Outcomes: change in problem behaviours • Results: Significant improvement in problem

behaviours for Hispanic/Latino group (ns for white & African-American groups)


Belle, et al. (2006). Annals of Internal Medicine, 145(10), 727-738.


5. Self-care techniques for CG5. Self-care techniques for CG

• Health management• Stress management• Coping with change as a result of

caregiving• Music therapy• Counselling



5. Self-care techniques for CG5. Self-care techniques for CG• Gitlin et al. (2010): OT prescribed tmt plan for

managing problem behaviours & CG self-care, skill building– Up to 11 home/phone contacts over 16 wks

• Outcomes: change in freq of most distressing behaviour; CG upset & confidence in managing behaviour; overall CG upset

• Results: Sig improved target behaviour, reduced upset & enhanced confidence. Less overall upset with all behaviours

Gitlin et al. (2010). J Am Geriatr Soc, 58(8), 1465-1474.

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BPSD BPSD outcomesoutcomes



BPSD outcomes BPSD outcomes

• Skills training for CG, 0.15 (-0.03-0.33)• Education for CG, 0.51 (0.24-0.78)• OT led interventions, 0.23 (-0.03-0.48)• Enhancing support for CG, 0.18 (-0.08-0.45)

• Self-care techniques for CG, 0.21 (0.08-0.34)


Partner logo hereCaregiver OutcomesCaregiver Outcomes



CGs’ reactions to BPSD (all NS) CGs’ reactions to BPSD (all NS)

• skills training for CG, 0.03 (-0.16-0.23)• education for CG, 0.02 (-0.14-0.18)• OT led intervention, 0.08 (-0.08-0.24)• enhancing CG support, 0.31 (-0.08-0.71)• self-care techniques for CG, 0.14 (-0.05-0.34)

• Miscellaneous for CG……..



LimitationsLimitations

• Categorisation of interventions• Different BPSD may differ in response



InterpretationInterpretation• CG interventions can significantly reduce BPSD– ES = 0.46 (95% CI = 0.24-0.68), significant

• Interventions less effective for CG outcomes – ES = 0.05 (95% CI = -0.09-0.18), not significant

• Comparable to pharmacological treatments– Small overall effect of antipsychotics on

delusions, aggression and agitation– ES = 0.16 (0.11 to 0.22)1

© DCRC/Brodaty 20111Schneider et al. (2006). Am J Ger Psychiat, 14(3), 191-210

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