Adapting to needs in old-age psychiatry

A Person-Centred Approach to Counselling, Psychotherapy and Rehabilitation of People Diagnosed with Dementia in the Early Stages

This article considers a person-orientated approach to counselling, psychotherapy and rehabilitation for people with a diagnosis of dementia. It draws on the concepts developed by Tom Kitwood (1995) for describing the factors –neuropathology, health, personality, biography, social psychology – that affect the manifestation of dementia, but places more emphasis on personality and biography for the person in the early stages. The social context – or psychology – is the home in these early stages, and the family system is critical. It provides a supportive or negative environment in which the person expresses an experience of cognitive decline. The behaviours seen in dementia are regarded as adaptive responses to the experience of cognitive decline, rather than directly the result of brain pathology. Given this view of the syndrome of dementia being a reactive response to cognitive decline, and to stresses such as giving up driving, the types of interventions that might be offered are discussed. These are grief counselling, non-directive counselling, long-term supportive psychodynamic psychotherapy, cognitive-behavioural therapy and rehabilitation. The human brain has developed over a lifetime of experience, in a variety of psychosocial environments, and so exhibits its own unique coping mechanisms in the face of internal devastation. It is this aspect of dementia – its individual uniqueness and its reflection of a person’s past and present psychosocial context – that this article uses as the basis for suggesting effective treatment strategies.

Prevalence of psychiatric function disorders in psychogeriatric patients at referral to nursing home care--the relation to cognition, activities of daily living and general details

OBJECTIVES

This prospective, observation study (from June 2001 to October 2002) estimated the prevalence and co-occurrence of psychiatric function disorders (PFDs) in psychogeriatric patients suffering from cognitive function disorders at referral to clinical as well as non-clinical (transmural) psychogeriatric programmes. It is expected that PFDs, both total and individual, are positively related to the cognitive function disorders as well as the activities of daily living (ADL) handicaps. This expectation will be adjusted for general details particularly gender, age, marital status, domicile and type of primary caregiver. Exploratively, the structure of the interrelationship of PFDs, cognitive function disorders and ADL handicaps will be analysed. In addition, the general details and the structure to be identified will be described.

METHODS

We studied patients aged > or = 65 years (n = 487), who were suspected to suffer from cognitive function disorders (MMSE < or = 29) and were referred to trans-/intramural nursing home care in the Nieuwe Waterweg Noord region. General details, i.e. gender, age, marital status, domicile, primary caregiver, as well as PFDs (the Neuropsychiatric Inventory, NPI), cognition (MMSE) and ADL (Barthel Index, BI) were assessed.

RESULTS

Mean score NPI was 3.6 (SD = 2.3). Of the patients, 91.7% scored one or more NPI symptom; 81.6% two or more. Depression (43.9%), apathy (43.1%), anxiety (41.6%) and agitation/aggression (31.2%) had a high prevalence. With respect to the NPI symptoms, i.e. delusion, hallucination, anxiety (more in women), agitation/aggression and irritability (more in men), there were significant gender differences on the same MMSE level. Compared with women, men were significantly younger, ADL independent, lived together with their spouse, who was often the primary caregiver. The performance of the logistic regression models for total NPI score with MMSE, BI separately as well as combined with general details was minor. The results of the regression analyses for the individual NPI symptoms showed comparable low R(2) values; they explained a small proportion of the variance. However, in the PRINCALS analysis the MMSE and BI highly correlated with the cognitive dimension, and the NPI with the psychiatric dimension. The model fit was good; 82.6% of the variance was explained.

CONCLUSION

At the moment of referral to nursing home care, the prevalence and co-occurrence of PFDs was high. The four main NPI symptoms were depression, apathy, anxiety and agitation/aggression. On the same level of MMSE score, gender difference was important for 3 NPI symptoms: delusion, hallucination and anxiety. NPI scores (total and per symptom) were relatively independent from MMSE, BI and general details. The PFDs--measured by the NPI--were a dimension on their own. Therefore, in psychogeriatrics it is of clinical relevance to think and act in terms of dimensions. Irrespective of a more rational psychopharmaceutical regime, this opens the door to the regular psychiatric domain for (psycho)therapeutic strategies, e.g. for depression and anxiety adapted to the kind and level of the cognitive function disorder of the psychogeriatric patient.

ECT for major depression and mania with advanced dementia

Two patients with advanced dementia and severe affective disorders were successfully treated with electroconvulsive therapy (ECT) without significant adverse effects. These reports illustrate that ECT can be effective for depression and mania even when complicated by moderate or severe dementia.