A RECENT US survey of physicians, psychologists and nurse practitioners involved in the management of nursing home residents compared the attitudes of these different groups to non-pharmacological interventions for behaviour problems associated with dementia.
The physicians who completed the web-based questionnaire were recruited from the American Medical Directors Association; the psychologists from the Psychologists in Long Term Care Network; and the nurse practitioners from the Gerontological Advanced Practice Nurses Association. Wow!
Where would we even find equivalent respondents in Australia? I don’t believe that we could because here residential aged care occurs effectively outside the health care system, which is another symptom — or is it a sign? — of the great federal–state divide.
The survey showed that all three groups agreed that there should be an increase in non-pharmacological interventions (NPHIs) as first-line treatment. Nurse practitioners were most favourably disposed to NPHIs, although this did not necessarily translate into actual interventions.
Physicians were most predisposed to pharmacological interventions but had a significantly lower knowledge of NPHIs than the other two groups.
Participants of the study were asked to indicate their familiarity with 30 NPHIs and there were significant differences between the modalities favoured by the three groups.
The items listed represented eight categories of interventions: environmental modification, behaviour change/modification, behaviour accommodation, self-affirming interventions, pleasant events/structured activities, social contact (real or simulated), sensory interventions, and cognitive interventions
Physicians were least familiar with “sensory interventions”, which in this study included music therapy and aromatherapy. In my experience, these are presumed to be somewhat alternative therapies.
When the researchers discussed their findings they noted that behavioural symptoms are close to universal among dementia sufferers in residential care, and that treatment is predominantly pharmacological, despite evidence of questionable efficacy. Current US guidelines recommend that NPHIs should be used as the first line of treatment.
From my observations, clinical guidelines always recommend that non-pharmacological interventions should be the first line of treatment.
However, having studied available guidelines, I am of the view that they are an exercise in political correctness rather than conviction. Where behavioural interventions are subjected to analysis like medications, the results offer only lukewarm endorsement.
The authors of the study rightly observe that there are major differences in education and training between the three disciplines that can explain the differences in knowledge and expectation.
Residential care should be equated to dementia care and such gulfs in knowledge are not acceptable.
Talking about behavioural symptoms so generically is also simplistic.
Behavioural symptoms are complex, as the lead author in this US study, Professor Jiska Cohen-Mansfield has pointed out in her many publications, and must be assessed and diagnosed before any intervention is chosen and can be rationally analysed.
This paper observes that all providers agree that staff behaviour, training and the availability of resources all affect the implementation of NPHIs. I would go much further, and suggest that they play a significant role in the aetiology of these problems.
Assessment and diagnosis takes time. This is not a plentiful commodity in general practice, where most Australian patients with dementia are managed, nor is it recognised through appropriate compensation.
Skilled management of dementia, not just behavioural problems, in residential care by GPs, other aged care workers and appropriate specialists could have a very significant impact on the utilisation of and length of stay in hospitals.
In fact, residential and other forms of long-term care should be a part of the continuum of heath care, not just an unwelcome appendage.
Dr Ludomyr Mykyta is a consultant geriatrician based on South Australia.
Posted 12 March 2011