Clinico-demographics of people with younger-onset dementia and neuropsychiatric symptoms referred to an Australian dementia support service: A comparison study with older-onset dementia.

OBJECTIVE: Younger-onset dementia accounts for about 5-10% of all dementias in Australia. Little data is available on neuropsychiatric symptoms in people with younger-onset dementia compared to those with older-onset dementia. This study aims to compare the types of neuropsychiatric symptoms and their clinico-demographic characteristics of people with younger-onset dementia and older-onset dementia who are referred to a specific dementia support service. METHODS: A 2-year retrospective observational cross-sectional analysis was undertaken on referrals with neuropsychiatric symptoms from Dementia Support Australia programmes. Neuropsychiatric symptoms were measured using the Neuropsychiatric Inventory total severity scores and distress scores. Contributing factors to neuropsychiatric symptoms for dementia groups were examined. Logistic regression was used to examine the relationship between individual neuropsychiatric symptoms and having older-onset dementia vs younger-onset dementia. RESULTS: Of the 15,952 referrals, about 5% (n = 729, mean age: 60.7 years, standard deviation = 5.4) were individuals with younger-onset dementia. Referrals with older-onset dementia were more likely to be female (56%), whereas referrals with younger-onset dementia were more likely to be male (54%). There was a four times greater rate of frontotemporal dementia for those with younger-onset dementia (16.0%, n = 117) compared to those with older-onset dementia (2.8%, n = 427), χ2 (1) = 366.2, p < 0.001. Referrals with younger-onset dementia were more likely to be referred from community settings and those with older-onset dementia were more likely to be from residential aged care. Overall, there was no difference in the severity and distress of neuropsychiatric symptoms between the two groups. Contributing factors to neuropsychiatric symptoms were different between the groups, with pain being more frequently endorsed for individuals with older-onset dementia whereas communication difficulties were more commonly identified for those with younger-onset dementia. CONCLUSION: Clinico-demographics of referrals with younger-onset dementia differ from those with older-onset dementia. There were some differences in the characteristics of neuropsychiatric symptoms between younger-onset dementia and older-onset dementia. Our findings have implications for service provision and support for people with dementia at different ages.

Comparison of inpatients who were readmitted within 28 days of discharge with those not readmitted: an audit at an Australian private psychiatric hospital.

OBJECTIVE: To compare inpatients who had been readmitted within 28 days of discharge with patients not readmitted within the same period in a private psychiatric hospital. METHOD: Of 118 readmissions within 28 days in 2017 (7% of admissions), 50 were randomly selected and matched by age and gender with control patients who had not been readmitted within 28 days. Differences in demographics, diagnosis, length of stay and number of admissions in the previous 12 months were examined. RESULTS: Readmitted cases were 64% female, were aged 49.8 ± 18.2 years (range 19-89), 40% were in relationships and 24% were receiving disability support. Most patients were suffering an episode of depression. Cases had higher rates of multiple psychiatric diagnoses (p < .001) and physical disorders (p < .05). There were no significant differences between cases and controls on psychiatric diagnoses. Cases had a longer length of stay in their previous admission (p < .01) and a higher number of admissions in the preceding 12 months (p < .05) compared to controls. CONCLUSION: This study indicates that inpatients readmitted within 28 days of discharge were more likely to have multiple diagnoses, physical co-morbidity and relapsing conditions than patients who were not readmitted.

Limiting antipsychotic drugs in dementia.

Most patients with dementia have behavioural and psychological symptoms. The first-line treatments for these symptoms are not drugs, but behavioural and psychological interventions Antipsychotic drugs are widely prescribed for people living with dementia. This is despite a high adverse effect burden and limited evidence of efficacy Most behavioural and psychological symptoms will subside spontaneously within six months. Trials of deprescribing are therefore recommended Behaviours should be seen as symptoms that have an underlying cause. Treatment should target these causes, rather than the resultant behaviours.

Characteristics, diagnoses and risk profiles of inpatients readmitted within 28 days of discharge to an Australian private psychiatric hospital.

OBJECTIVE: The objective of this study was to perform a clinical and risk audit of private hospital inpatients who had been readmitted within 28 days of a preceding admission. METHOD: Of 118 readmissions within 28 days in 2017 (7% of all admissions), 50 were randomly selected for audit. Characteristics, illness severity and clinical risk profiles were ascertained at discharge from the index admission and at readmission. RESULTS: Cases were 64% female, age 49.9 ± 18.2 years (range 19-89), 40% in relationships and 24% on disability support. At readmission, 88% posed danger to self due to effects of illness, 46% had high suicide risk and 40% had high physical risk. Illness was rated as severe in 58%, while 40% were rated markedly ill. Relapse or exacerbation of major depression was a cause of readmission in 78%, relapse of alcohol/substance use requiring readmission in 22% and relapse of psychosis in 20%. Index admission length of stay of cases did not differ from that of all hospital admissions. CONCLUSION: Most readmitted patients were suffering severe exacerbation of depression, were acutely suicidal and were otherwise at high risk of harm. If these patients had been denied readmission on the basis of insurer funding disincentives, catastrophic outcomes may well have occurred.

Quality indicators of psychotropic prescribing to people with dementia in aged psychiatry inpatient units.

OBJECTIVES: To develop indicators of safe psychotropic prescribing practices for people with dementia and to test them in a convenience sample of six aged mental health services in Victoria, Australia. METHOD: The clinical records of 115 acute inpatients were checked by four trained auditors against indicators derived from three Australian health care quality and safety standards or guidelines. Indicators addressed psychotropic medication history taking; the prescribing of regular and 'as needed' psychotropics; the documentation of psychotropic adverse reactions, and discharge medication plans. RESULTS: The most problematic areas concerned the gathering of information about patients' psychotropic prescribing histories at the point of entry to the ward and, later, the handing over on discharge of information concerning newly prescribed treatments and the reasons for ceasing medications, including adverse reactions. There were wide variations between services. CONCLUSION: The indicators, while drawn from current Australian guidelines, were entirely consistent with current prescribing frameworks and provide useful measures of prescribing practice for use in benchmarking and other quality improvement activities.

A comparison of the neuropsychological profiles of people living in squalor without hoarding to those living in squalor associated with hoarding.

OBJECTIVE: Squalor affects 1 in 1000 older people and is regarded as a secondary condition to other primary disorders such as dementia, intellectual impairment and alcohol abuse. Squalor frequently is associated with hoarding behaviour. We compared the neuropsychological profile of people living in squalor associated with hoarding to those presenting with squalor only. METHODS: This study is a retrospective case series of hospital inpatient and community healthcare services of 69 people living in squalor (49 from aged care, 16 from aged psychiatry, 3 from acute medical and 1 from a memory clinic). Forty per cent had co-morbid hoarding behaviours. The main outcomes were neuropsychologists' opinions of domain-specific cognitive impairment. RESULTS: The squalor-hoarding group (M age 75.8, SD = 6.9,) was significantly older (p < 0.05) than the squalor-only group (M age 69.9 years, SD = 13.1), significantly more likely to have vascular or Alzheimer's type neurodegeneration (p < 0.05) and significantly less likely to have alcohol-related impairment (p < 0.05). Chi-square analyses revealed significantly greater rates of impairment for the squalor-only group (p < 0.05) in visuospatial reasoning, abstraction, planning, organisation, problem solving and mental flexibility, compared with the squalor-hoarding group. Logistic regression analysis indicated that impaired mental flexibility was a significant predictor and strongly indicated squalor only (odds ratio = 0.07; 95% confidence interval: 0.01-0.82). CONCLUSIONS: Preliminary evidence suggests that squalor associated with hoarding may have distinct neuropsychological features compared against squalor only. Future work should be conducted using a larger sample and a common neuropsychological battery to better understand the deficits associated with hoarding-related squalor. Copyright © 2016 John Wiley & Sons, Ltd.

The need for holistic management of behavioral disturbances in dementia.

Dementia is now the leading cause of admission to residential aged care facilities (RACF) in the developed world (Van Rensbergen and Nawrot, 2010), with prevalence rates among residents estimated to be approximately 70% (Zimmerman et al., 2014). In addition, dementia is now the 4th leading cause of death in high-income countries with this expected to rise to the 3rd leading cause of death by 2030 (World health Organization, 2015). Despite the prevalence of the condition, the amount of teaching time devoted to dementia in medical school curricula remains low and does not adequately prepare graduates for their work as doctors (Tullo and Allan, 2011; Tullo and Gordon, 2013). As a consequence, many general practitioners feel their level of confidence in managing behavioral and psychological symptoms of dementia (BPSD) is very low (Buhagiar et al., 2011).

The Clinical and Service Outcomes of Unilateral and Bilateral ECT Electrode Placements in Australian Aged Psychiatry Services.

OBJECTIVE: The aim of the study was to determine whether depressed aged inpatients treated with brief pulse unilateral electroconvulsive therapy (ECT) differed from those treated with bilateral (bitemporal or bifrontal) ECT with respect to numbers of treatments, length of hospital admission, changes in scores on depression and cognitive scales, and serious adverse effects. METHODS: An audit of routinely collected data regarding 221 acute ECT courses in 7 public aged psychiatry services in Victoria, Australia. RESULTS: Patients given unilateral, bifrontal, and bitemporal treatments were similar with respect to personal, clinical, and treatment characteristics. Most treatments were administered in line with local clinical guidelines and were rated as effective. Psychiatrists preferred unilateral ECT in the first instance with stimulus dosing based on patients' seizure thresholds. Approximately a quarter of unilateral courses were switched later to bitemporal placement, most probably because of insufficient progress. Bilateral treatments were associated with a larger number of treatments, less improvement in scores on mood and cognitive scales, and more refusals to continue treatment than unilateral-only ECT. DISCUSSION: Brief pulse unilateral ECT proved more effective than bitemporal and bifrontal ECT for most aged patients, especially when coupled with stimulus dosing based on seizure threshold.

Managing behavioural and psychological symptoms in dementia.

Most patients with dementia have some behavioural and psychological symptoms. While aggression and agitation are easily recognised, symptoms such as apathy may be overlooked. Behavioural and psychological symptoms should be managed without drugs whenever possible. Although there is little evidence to support their use, antipsychotic drugs are often prescribed to people with dementia. Before prescribing it is important to exclude other causes of altered behaviour, such as pain or infection. Some symptoms may be artefacts of memory loss rather than psychosis. Patients with dementia who are prescribed antipsychotic drugs have an increased risk of falls, hospitalisation and death. They should be regularly monitored for adverse effects. If the patient's symptoms resolve with drug treatment, reduce the dose after two or three months. Stop the drug if the symptoms do not return.

Uptake of a newly implemented advance care planning program in a dementia diagnostic service.

BACKGROUND: Advance care planning (ACP) provides a framework for discussion and documentation of future care preferences when a person loses cognitive capacity. It can assist people in the early stages of dementia to document their preferences for care at later stages of the illness. METHOD: A three-stage project introduced ACP to clients with mild cognitive impairment (MCI) or recently diagnosed dementia and their families through a specialist memory clinic. Over 8 months, all English-speaking clients (n = 97) and carers (n = 92) were mailed a survey assessing completed documentation for future care; understanding of the principles of ACP and willingness to get further information about ACP (Stage 1). Participants wanting more information were invited to a seminar introducing the ACP program and service (Stage 2). Participants wanting to complete ACP documentation could make an appointment with the ACP clinicians (Stage 3). RESULTS: Forty-eight (52.2%) carers and 34 clients (35.1%) responded to the survey. Most clients (62.1%) and carers (79.1%) expressed interest in ACP, and 78.6% of clients and 63.6% of carers believed that clients should be involved in their future medical decisions. Nine clients (26.5%; diagnoses: MCI = 5; AD = 3; mixed dementia = 1) and 9 carers (18.8%) attended the seminars, and 2/48 (4%) carers and 3/34 (8.8%) clients (diagnoses: MCI = 2; AD = 1) completed ACP. CONCLUSION: Despite initial interest, ACP completion was low. The reasons for this need to be determined. Approaches that may better meet the needs of people newly diagnosed with MCI and dementia are discussed.

A preliminary investigation of domestic squalor in people with a history of alcohol misuse: neuropsychological profile and hoarding behavior - an opportunistic observational study.

BACKGROUND: Domestic squalor has been associated with alcohol misuse but little work has explored this. Executive dysfunction is commonly observed in squalor and is also associated with alcohol misuse. Hoarding can accompany squalor, but it is unclear whether hoarding is also linked with alcohol misuse. This study compared neuropsychology and hoarding status of individuals living in squalor with and without a history of alcohol misuse. METHODS: A subgroup analysis was conducted on a series of 69 neuropsychological reports of people living in squalor. Data on cognitive profiles, basic demographics, alcohol use, and hoarding were extracted and analyzed. RESULTS: Alcohol misuse was reported in 25 of the 69 participants (36%). Alcohol misusers were significantly younger (mean age 66.2 years, SD = 10.7) than non-misusers (mean age 75.6 years, SD = 10.3) (p < 0.00) and significantly more likely to be male (p = 0.01). No significant differences between the two subgroups were found for estimated premorbid intellectual functioning, Mini Mental State Examination (MMSE) scores, or individual neuropsychological domains. Alcohol misusers were more likely to be living in squalor without hoarding than squalor with hoarding (p = 0.01). CONCLUSIONS: Alcohol misusers living in squalor were less likely to hoard than non-misusers. This finding suggests that alcohol misuse may be a risk factor for squalor via failure to maintain one's environment rather than through intentional accumulation of objects. The similar cognitive profile among those with and without a history of alcohol misuse could represent a common pattern of executive dysfunction that predisposes individuals to squalor regardless of underlying alcohol misuse diagnosis.

A guide to clinical research supervision for psychiatrists: a mentoring approach.

OBJECTIVES: To provide a guide for clinically-based psychiatrist supervisors of research projects for early career researchers. METHODS: This paper will describe a mentoring framework for supervision, for psychiatrist clinical research supervisors and early career researchers. RESULTS: The domains discussed include, across various aspects of a study: the role of the supervisor, project management, and where and when to seek advice. CONCLUSIONS: Supervision of clinical research can be a professionally rewarding experience for psychiatrists, as well as early career researcher supervisees.

Getting started in research: research questions, supervisors and literature reviews.

OBJECTIVES: Research can seem daunting, especially for trainees and early career researchers. This paper focuses on how to formulate and begin a research project such as the RANZCP Scholarly Project. METHODS: We outline an approach to framing a research question, developing theses and hypotheses, choosing a supervisor and conducting a literature review. CONCLUSIONS: Through systematic planning early career researchers and other clinicians can plan and conduct research suitable for the Scholarly Project or other research activity.

Getting started in research: designing and preparing to conduct a research study.

OBJECTIVE: To discuss common pitfalls and useful tips in designing a quantitative research study, the importance and process of ethical approval, and consideration of funding. CONCLUSIONS: Through careful planning, based on formulation of a research question, early career researchers can design and conduct quantitative research projects within the framework of the Scholarly Project or in their own independent projects.

Getting started in research: systematic reviews and meta-analyses.

OBJECTIVES: Systematic reviews are one of the major building blocks of evidence-based medicine. This overview is an introduction to conducting systematic reviews and meta-analyses. CONCLUSIONS: Systematic reviews and meta-analyses of randomised controlled trials (RCTs) represent the most robust form of design in the hierarchy of research evidence. In addition, primary data do not have to be collected by the researcher him/herself, and there is no need for approval from an ethics committee. Systematic reviews and meta-analyses are not as daunting as they may appear to be, provided the scope is sufficiently narrow and an appropriate supervisor available.

Neuropsychological characteristics of people living in squalor.

BACKGROUND: Squalor is an epiphenomenon associated with a range of medical and psychiatric conditions. People living in squalor are not well described in the literature, and prior work has indicated that up to 50% do not have a psychiatric diagnosis. Squalor appears to be linked with neuropsychological deficits suggestive of the presence of impaired executive function. We present a case series of people living in squalor that examines their neuropsychological assessment and diagnosis. METHODS: Clinicians from local health networks were invited to submit neuropsychological reports of patients living in squalor. These selected reports were screened to ensure the presence of squalor and a comprehensive examination of a set of core neuropsychological domains. Assessments were included if basic attention, visuospatial reasoning, information processing speed, memory function, and executive function were assessed. RESULTS: Sixty-nine neuropsychological reports were included. Sixty-eight per cent of the group underwent neuropsychological assessments during an inpatient admission. For participants where it was available (52/69), the mean Mini-Mental State Examination score was 25.29 (SD = 3.96). Neuropsychological assessment showed a range of cognitive impairment with nearly all the participants (92.75%) found to have frontal executive dysfunction. One person had an unimpaired neuropsychological assessment. Results indicated that dorsolateral prefrontal rather than orbitofrontal functions were more likely to be impaired. Vascular etiology was the most common cause implicated by neuropsychologists. CONCLUSIONS: Frontal executive dysfunction was a prominent finding in the neuropsychological profiles of our sample of squalor patients, regardless of their underlying medical or psychiatric diagnoses. Our study highlights the importance of considering executive dysfunction when assessing patients who live in squalor.

Top 10 Signs and Symptoms of Psychotropic Adverse Drug Events to Monitor in Residents of Long-Term Care Facilities.

OBJECTIVES: To produce a consensus list of the top 10 signs and symptoms suggestive of adverse drug events (ADEs) for monitoring in residents of long-term care facilities (LTCFs) who use antipsychotics, benzodiazepines, or antidepressants. DESIGN: A 3-round Delphi study. SETTING AND PARTICIPANTS: Geriatricians, psychiatrists, pharmacologists, general practitioners, pharmacists, nurses, and caregivers from 13 Asia Pacific, European, and North American countries. METHODS: Three survey rounds were completed between April and June 2023. In Round 1, participants indicated their level of agreement on a 9-point Likert scale on whether 41 signs or symptoms identified in a systematic review should be routinely monitored. Participants considered signs and symptoms that reduce quality of life or cause significant harm, are observable or measurable by nurses or care workers, and can be assessed at a single time point. Round 1 statements were included in a list for prioritization in Round 3 if ≥ 70% of participants responded ≥7 on the Likert scale. Statements were excluded if ≤ 30% of participants responded ≥7. In Round 2, participants indicated their level of agreement with statements that did not reach initial consensus, plus amended statements based on Round 1 participant feedback. Round 2 statements were included in Round 3 if ≥ 50% of the participants responded ≥7 on the Likert scale. In Round 3, participants prioritized the signs and symptoms. RESULTS: Forty-four participants (93.6%) completed all 3 rounds. Four of 41 signs and symptoms reached consensus for inclusion after Round 1, and 9 after Round 2. The top 10 signs and symptoms prioritized in Round 3 were recent falls, daytime drowsiness or sleepiness, abnormal movements (eg, shaking or stiffness), confusion or disorientation, balance problems, dizziness, postural hypotension, reduced self-care, restlessness, and dry mouth. CONCLUSIONS AND IMPLICATIONS: The top 10 signs and symptoms provide a basis for proactive monitoring for psychotropic ADEs.