TOP CITED PAPERS IN INTERNATIONAL PSYCHOGERIATRICS: 6a. QUALITY OF LIFE FOR PEOPLE WITH DEMENTIA LIVING IN RESIDENTIAL AND NURSING HOME CARE: THE IMPACT OF PERFORMANCE ON ACTIVITIES OF DAILY LIVING, BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS, LANGUAGE SKILLS, AND PSYCHOTROPIC DRUGS

Abstract

The majority of people with dementia develop behavioral and psychological symptoms of dementia (BPSD) at some point during their illness (Jeste et al., 2008). These symptoms, which are especially common among care home residents, are frequently distressing for the patients who experience them (Gilley et al., 2006; Jeste et al., 2008) and problematic for their professional and/or family caregivers. The starting point for our paper “Quality of life for people with dementia living in residential and nursing home care: the impact of performance on activities of daily living, behavioral and psychological symptoms, language skills, and psychotropic drugs” (Ballard et al., 2001) was to try and understand the impact of BPSD, function and language skills on quality of life in care home residents with dementia. Although there were frequent statements in previous work referring to the capacity of psychiatric and behavioral symptoms to reduce quality of life, we had been unable to identify any empirical evidence to support this clinical impression in a thorough literature review. The parallel validation of Dementia Care Mapping (DCM), predominantly a practice development tool, as an observational measure of well-being/quality of life (Kitwood and Bredin, 1997; Fossey et al., 2002) provided an excellent opportunity to examine this issue in a care home setting. The study focused on 209 people with dementia living in residential and nursing home care in north-east England in the U.K., who received a detailed assessment of BPSD, function and cognition. A DCM evaluation was completed for 112 of these individuals, providing a detailed observational measure of well-being, activities and social withdrawal as indices of quality of life over a six-hour daytime period. To our surprise, there was actually no association between well-being, social withdrawal or activities and BPSD. In contrast, there was a significant association between antipsychotic medication and reduced well-being, social withdrawal and activities respectively, even after controlling for the severity of behavioral disturbance. Using an arbitrary definition of “ill-being”, defined as a well-being score of less than zero, 5% of people not taking antipsychotics, 10% of people taking atypical antipsychotics and 22% of people taking typical antipsychotics were defined as having ill-being. Lower levels of functional ability were also associated with significantly lower well-being, less activities and more social withdrawal. At first this latter finding appears to be contrary to one of the central principles of DCM – namely, that the assessment should be independent of dementia severity. Although high levels of well-being and engagement are possible for people with severe dementia, this probably requires higher staff numbers and a workforce with more specialized skills in order to achieve this.

Economic evaluation alongside a single RCT of an integrative psychotherapeutic nursing home programme

“…This means that the EQ5D proved to be relatively unresponsive to change. This corresponds to the findings of Ballard et al [44], who showed that clinically relevant improvement on Behavourial and Psychological Symptoms of Dementia (BPSD) had only small effects on general quality of life measurements. Completion of the EQ5D by proxy (i.e.…”

“…They confirm that psychotherapeutic treatment, based on person-oriented and problem-solving principles, is effective in psychogeriatric patients [46,48]. Moreover, the relative unresponsiveness of the patient’s EQ5D compared to the positive changes on the severity of MPS is in line with the results reported in literature [44-48]. Furthermore, as far as we know, our RCT-study was one of the first comprehensive studies in a nursing home setting with a relative large sample size to address integrative psychotherapeutic treatment of psychogeriatric patients and their caregivers [7,9].…”

Reduction in Use of Risperidone for Dementia in Australia Following Changed Guidelines

“…The adverse events associated with risperidone use are serious and there is limited evidence for the efficacy of risperidone in managing BPSD symptoms, [30,31,32] so the decision to use risperidone for the management of BPSD should only be made after other management strategies have been trialled and have failed. However, managing challenging behaviours in people with dementia can be difficult and a recent systematic review highlighted the competing pressures that influence the decision to use antipsychotics for BPSD in nursing home residents [33].…”

FITS into practice: translating research into practice in reducing the use of anti-psychotic medication for people with dementia living in care homes

“…A cluster randomised-controlled trial demonstrated that, compared with usual care, the FITS programme reduced the prescribing of antipsychotics for people with dementia by over 40% (Fossey et al, 2006 ). Crucially, this was achieved without any increase in BPSD (Ballard et al, 2009 ). However, this original intervention was resource intensive and experimental.…”