Dementia-Related Factors and Anxiety in Assisted Living Facilities - Case Study Example

Dementia-Related Factors and Anxiety in Assisted Living Facilities Introduction Assisted living facilities (ALFs) are rapidly assuming an important role in the provision of health care to older adults. Originally marketed as a new model of care that promotes autonomy, dignity, maximum independence and aging-in-place, many questions are now raised about match of services provided in AL to the needs of older adults living in this environment. In specific, research supports the fact that a large number of older adults living in AL have dementia and other psychiatric disorders (Lyketsos, 2002), and that psychological and behavioural symptoms associated with dementia are common among residents in this setting (Sloane et al., 2005). Of importance, psychotropic medications are frequently prescribed to residents in AL, but often without a psychiatric diagnosis to explain its use (Aud & Rantz, 2005; Boustani et al., 2005). Furthermore, AL residents who experience cognitive, behavioural impairments are at greater risk for placement in nursing facilities (Aud, 2004; Aud & Rantz, 2005; Phillips et al., 2003). In short, the level and type of dementia care provided in AL is an area of interest and concern for older adults and their family members, clinicians, researchers, and policy-makers alike. Anxiety Symptoms in Dementia Although anxiety and anxiety-related symptoms are often the focus of clinical care (Mahoney et al., 2000), a limited number of studies have focused explicitly on anxiety-related symptoms in dementia. More often, anxiety is considered one of several behavioural and psychological symptoms in dementia (BPSD). For example, a review of BPSD evaluated with the NPI in three European studies found that frequency of anxiety was between 34% and 39%, making it one of the four most common behaviours observed across studies along with apathy, depression, and irritability (Robert et al., 2005). Among the studies that focus specifically on anxiety, Mega and colleagues examined the relationship between cognitive impairment in older adults with Alzheimer's disease (AD) and behavioural abnormalities as measured by the NPI. A substantial number of subjects exhibited apathy (72%), agitation (60%), and anxiety (48%). Agitation, apathy, dysphoria, and aberrant motor behaviour were associated with cognitive impairment, but anxiety was not (Mega, Cummings, Fiorello, & Gornbein, 1996). In contrast, Teri and colleagues found that anxiety was significantly related to cognitive impairment, as subjects with more severe cognitive impairment were more likely to be anxious (Teri et al., 1999). Of note, anxiety was defined as a composite score created from four items drawn from an established dementia checklist, including: anxious/fearful/apprehensive; agitated/restless, irritable/easy to anger; and suspicious/paranoid. In a sample of community-dwelling older adults with AD (N = 523), 70% experienced anxiety symptoms (as defined above) that were significantly related to behaviour problems and the need for assistance with activities of daily living. Comorbid anxiety and depression were also common, affecting 54% of the sample (Teri et al., 1999). A second study by this research group reported similar findings using clinician and caregiver-rated anxiety scales (Ferretti, McCurry, Logsdon, Gibbons, & Teri, 2001). Clinician assessments were conducted using the Hamilton Anxiety Rating Scale, an observer rated scale that is commonly used with older adults. Caregiver ratings of anxiety in the person with dementia were taken from five items of the Revised Memory and Behaviour Checklist (Teri et al., 1992), and included: appears anxious/worried, expresses fearfulness/worry, nightmares/fears on waking, constantly restless, and fidgets/unable to sit still/paces. Rates of anxiety were high (68% to 71 %) regardless of the method used. In both samples, anxiety symptoms were associated with depression, increased cognitive impairment, and behavioural disturbances. Collectively these studies support the fact that anxiety symptoms in dementia are common, affecting as many as 70% of individuals with dementia. Anxiety is associated with depression, and behavioural disturbance including agitation, aggression, and activity disturbance. However, all studies used community-dwelling outpatient samples. Questions about anxiety and its effect on those with dementia living in ALFs remain unanswered. Dementia-Related Factors and Anxiety in ALFs Depression Estimates suggest that 40% to 50% of older adults with dementia have clinically significant symptoms of depression (IPA, 2003) and as many as 25% have major depression (Ballard, Bannister, Solis, Oyebode, & Wilcock, 1996). Depression is widely recognised as a non-cognitive symptom of dementia that is associated with impairment in activities of daily living, wandering and other behavioural disturbance, including both physical and verbal aggression (Heeren et al., 2003). Like anxiety, depression is considered one of several neuropsychiatric syndromes that may contribute to agitation and should be assessed and treated as part of the agitation protocol. Depressive symptoms are also elevated in the preclinical phase (e.g., 3 year prior to diagnosis) of Alzheimer's disease (AD), are highly associated with MCI (Rosenberg, 2005), and may cause impairment that is commonly labeled "pseudodementia" that later progresses to dementia (Alexopoulos et al., 2002). Longitudinal study of depression in AD indicates that the prevalence of depressive symptoms is stable at 40% over the first three years then decreases to 28% in the fourth year and 24% in the fifth year of follow up (Holtzer et al., 2005). The importance of recognising and treating depression in dementia is underscored by the recent development of provisional diagnostic criteria that are similar to DSM-IV criteria for major depression. The criteria for depression in dementia require three or more symptoms of depression (vs. five), include irritability and social isolation or withdrawal as symptoms, use "decreased positive affect or pleasure" instead of loss of interest or ability to experience pleasure, and replace the requirement of symptoms being "present nearly every day" with symptoms representing a "significant change" from the persons' previous level of function (Alexopoulos et al., 2002). Depression is often associated with anxiety, both in older adults with dementia and in the general population (Lecrubier, 2001). Of importance, comorbid anxiety and depression are associated with greater severity of illness, poorer treatment outcomes, and greater disability than either disorder on its own (Lecrubier, 2001; Steffens & McQuoid, 2005). Additional research suggests that improvement in depression severity, perhaps more than improvements in medical burden, cognitive function or psychosocial well-being, may be the most important factor to improving anxiety symptoms (Flint & Rifat, 2002). Depression in ALFs Depression and dementia are considered the most common problems in assisted living by facility administration (Wagenaar, Mickus, Luz, Kreft, & Sawade, 2003). However, less is known about either depression or depression in dementia among older adults who reside in assisted living compared to other settings. Reports to date suggest that a substantial number of AL residents experience depression. Using the CSDD scale cut point for moderate depression (>7), Watson and colleagues (2003) found that 13% of 2078 residents in ALFs were depressed. However, a third of the sample exhibited anxious expression, rumination or worrying (which are also characteristic of anxiety) and 25% displayed sad voice, sad expressions or tearfulness. Depression was significantly associated with medical comorbidity, social withdrawal, psychosis, and agitation, earlier discharge to nursing home care, and higher mortality (Watson, Garrett, Sloane, Gruber­ Baldini, & Zimmerman, 2003). Depression among AL residents is also associated with low life satisfaction and risk of discharge to nursing home care (Aud & Rantz, 2005). Depression among AL residents with dementia is also common. The CS-L TC Dementia Care study found that 25% of347 participants (238 in RC/AL and 109 in NHs) were depressed (using the CSDD cut point of >7 for moderate depression), and that depression was associated with severe cognitive impairment, behavioural symptoms, pain, and for-profit status of the facility (Gruber-Baldini et al., 2005). Throughout the sample, the two most frequent items endorsed on the CSDD were being anxious (48%) and easily annoyed (48%). Although the prevalence of depression was not significantly different in ALFs (24%) compared to NHs (27%), those living in nursing homes were more likely to be treated by a mental health professional or live in a facility that included mental health professionals in care planning processes (Gruber-Baldini et al., 2005). Additional research suggests that depression is one of several factors that predicts quality of life for persons with dementia in assisted living, along with agitation, apathy and irritability in one study (Samus et al., 2005), greater confusion, physical dependence and anxiolytic treatment in another (Gonzalez-Salvador et al., 2000), and behavioural symptoms and severity of both cognitive and functional impairments in yet another (Winzelberg, Williams, Preisser, Zimmerman, & Sloane, 2005). In sum, depression is both common in dementia and commonly related to important quality of life outcomes. In the general population, comorbid anxiety and depression are regularly associated with poorer outcomes, making this relationship an important one to consider in dementia care. Behavioural and Psychological Symptoms A wide range of psychological (e.g., anxiety, depression, and psychosis) and behavioural (e.g., agitation, verbal and physical aggression, irritability, and aberrant motor behaviours such as wandering) symptoms regularly accompany dementia. These non-cognitive symptoms have both clinical and social implications. Behavioural and psychological symptoms in dementia (BPSD) are associated with greater use of psychotropic medication, which in turn, may have untoward side-effects such as sedation, falls, and akathisia; use of physical restraints; higher rates of unfavourable clinical outcomes; and substantial burden and stress for caregivers (Moretti et al., 2004). The important role of BPSD in care is underscored by its inclusion (i.e., with or without behavioural disturbance) in dementia diagnoses. Unlike the progressive cognitive impairment of dementia, behavioural symptoms are considered highly treatable with psychosocial interventions, environmental adaptations, and, if indicated, medications, making them the primary focus of most dementia care (IPA, 2003). Behavioural symptoms are identified by family caregivers as an antecedent to admission to assisted living, a common phenomenon among residents of AL (Boustani et al., 2005) and a reason for discharge to nursing home care (Aud, 2004). Compared to older adults with dementia living in the community, those residing in dementia-specific AL are older, more cognitively impaired, and more likely to exhibit wandering, delusions and aggression (Kopetz et al., 2000). Reports using CS-L TC data suggest that behavioural symptoms, as measured by the Cohen-Mansfield Agitation Inventory, affected 34% of 2078 AL/RC residents (Gruber-Baldini et al., 2004). Behavioural symptoms are associated with depression, psychosis, dementia, cognitive impairment, and functional dependency. These relationships persist whether the behaviours are classified as aggressive, non-aggressive, verbal, or resistance to care (Gruber-Baldini et al., 2004). In addition, use of psychotropic medications among all subjects exceeded 50%, including antipsychotics (21 %), antidepressants (33%), and antianxiety or hypnotics (24%). Of note, two-thirds of the sample had a mental health indicator such as dementia, depression, psychosis or other psychiatric illness (Gruber-Baldini et al., 2004). When subjects with dementia were evaluated, an even higher proportion of behavioural symptoms was reported. The CS-LTC Dementia Care study 56% of those in AL/RC settings (N = 238) have behavioural symptoms (as measured by the CMAI) compared to 66% of nursing home residents (N = 109) (Boustani et al., 2005). Behavioural symptoms were more common among those with greater cognitive impairment and depression, and less common in those who were immobile. Although antianxiety medication use was not reported, other psychotropic medication use among RC/AL residents included antipsychotics (36%), antidepressants (36%), and hypnotics (22%). However, use of professional services, including physicians, nurses or mental health professionals, to help treat behavioural symptoms was significantly less common in assisted living (59%) compared to nursing homes (71 %) (Boustani et al., 2005). According to AL administrators, wandering and resistance to care are the most common behavioural problems encountered (Wagenaar et al., 2003). Of note, discharge from AL to nursing home care is often related to behavioural symptoms, including wandering and aggression, as well as behaviours that reflect progression of dementia, declining abilities, and the need for more assistance (Aud, 2004; Kopetz et al., 2000). As suggested in the PLST model, anxiety recognition may facilitate recognition of low-level symptoms and avert escalation to more intense and threatening BPSD that are associated with safety for residents and caregivers (e.g., elopement, injury associated with physical aggression), increased medication use, and discharge to higher levels of care. Facility-Related Variables Like resident-level factors, a variety of facility-level factors may influence the development and effectiveness of nursing interventions for individuals with dementia living in ALFs. In fact, an important focus of most reports in the 1990s was to characterise the "state" of assisted living facilities and the care provided, particularly as it related to safety and quality (Mollica, 1998; Mollica & Johnson­-Le-Marche, 2005). Collectively these reports describe and characterise assisted living facilities, often focusing on factors that relate to quality of life and care, including: facility size; range of services available; staff type, number, training and ratios; characteristics of residents; payment sources, costs, reimbursements policies of states (e.g., use of waiver programs); state regulation or licensure policies; admission and discharge policies; and other general features that attempt to characterise and describe care in ALFs. These descriptive reports contribute substantially to general knowledge about ALFs, document the tremendous variability in services all labelled as AL, and help clarify differences between various types of services and facilities. However, research investigating important relationships between variables, and the potential impact of facility-level variables on resident care outcomes, is considerably less plentiful. Summary Although no research about anxiety among older adults with dementia in ALFs is reported in the literature, several findings suggest that anxiety is a problem in this setting: regular use of anti anxiety drugs; frequency and type of behavioural problems; and rates of discharge to nursing home care. Use of anti psychotics, physical restraints and reports of physical aggression are indicators of untreated anxiety that has escalated into more dysfunctional behaviour. A small but growing body of research documents the fact that anxiety-related symptoms in dementia are an important clinical phenomenon. These symptoms create discomfort and contribute to additional disability and dysfunction. Affecting large majority of outpatients with dementia, anxiety symptoms are prevalent but poorly understood. Assisted living facilities, a largely unstudied but rapidly growing part of the dementia care continuum, are proposed as an important environment in which to examine anxiety symptoms among individuals with dementia. Description of anxiety symptoms, and potentially interrelated factors contributing to its occurrence in dementia, is essential to later development of nursing interventions that promote comfort, function, and quality of life, and may promote aging in place. Reflection Literature reviewed in this paper suggest that anxiety is a problem in Assisted living facilities (ALFs). I believe that there is a need of research to describe anxiety among those with dementia who are living in ALFs. It will determine if improved anxiety recognition might effectively be incorporated into an ALF-specific, multimodal dementia nursing intervention to prevent and reduce distressed and dysfunctional behaviours. 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