International Journal of Psychiatry in Clinical Practice
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Adapting to needs in old-age psychiatry Brian Draper To cite this article: Brian Draper (1998) Adapting to needs in old-age psychiatry, International Journal of Psychiatry in Clinical Practice, 2:4, 307-308 To link to this article: http://dx.doi.org/10.3109/13651509809115379
Published online: 12 Jul 2009.
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Article views: 5
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [Nanyang Technological University]
Date: 10 November 2015, At: 03:32
0 1998 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 307-308
307
Adapting to needs in old-age psychiatry BRIAN DRAPER
Downloaded by [Nanyang Technological University] at 03:32 10 November 2015
Prince Henry Hospital and University of New South Wales, Sydney, Australia
Correspondence Address Dr Brian Draper, FRANZCP, Academic Department of Psychogeriatrics, Prince Henry Hospital, Little Bay, Sydney NSW 2036, Australia Tel: +61 293 825 007 Fax: +61 293 825 016 E-mail b.drape&ns w .edu.au
The patient described is a 56-year-old man presenting with chronic depression and eventually found to have Alzheimer’s disease. Issues in the diagnosis and evolution of early dementia are discussed. The importance of long-term psychological support to the dementing patient, as well as their carers, is emphasized (Int J Psych Clin Pract 1998; 2: 307 - 308)
Received 9 June; accepted for publication 15 July 1998
INTRODUCTION t is essential for an old-age psychiatrist to be interested in, and enthusiastic about, the assessment and management of dementia. It was probably my awareness that I had such interest and enthusiasm that steered me into my career path. Yet I discovered this with a middle-aged patient.
I
CASE HISTORY Mr KP, a 56-year-old married skilled labourer, presented at a general hospital psychiatry unit in Sydney in the early 1980s with an 18-month history of chronic depression that had failed to respond to antidepressant medication and psychotherapy provided by a community psychiatrist. His depression appeared to relate to long-term feelings of inferiority with problems at work, where his brother-in-law was the manager. His work performance had declined and his relationship with his somewhat dominant wife had deteriorated, largely through his withdrawal from family activities, He felt burdened by his responsibilitieswith their teenage children and blamed his wife for having them. While there was undoubtedly a depressive syndrome present, there were features that raised the possibility of early dementia, including subjective memory impairment and subjective difficulties in finding words. The results of standard dementia investigations, including a CT scan, were normal. The neuropsychology assessment was equivocal, with performance inconsistencies and task refusal suggestive of depression, but also some evidence of cognitive impairment. In the circumstances, my consultant and I decided that his depression should be vigorously treated.
Over the next 3 months, after a course of ECT and two courses of antidepressants, little change was noted apart from a lessening of his depressed mood. During this time, while I was providing supportive psychotherapy, it became clearer that he had an early dementia, as his behaviour was rigid and stereotyped and the content of his speech was repetitive and impoverished. Despite his lack of improvement, he obviously enjoyed talking about his family and work concerns. Meanwhile, his wife was seen both alone and with him, to address some of the marital and family issues. It became apparent during these sessions that she was quite devoted to him and had largely adopted a dominant role as a reaction to his increasing withdrawal from responsibility over the latter years of their marriage. As he failed to improve, she talked about her fears that his mental deterioration would be permanent and the effects this would have on her family. Over the next 6 months, before the diagnosis of probable Alzheimer’s disease was confirmed by his cognitive decline and deterioration on neuropsychology evaluation, ongoing supportive therapy allowed KP to ventilate his frustrations about his increasing incapacity to work and difficulties he perceived at home. Subsequently, with the acquiescence of his brother-in-law, his work was modified to his capacities, and over the next year he gradually retired. His wife was seen throughout this period, initially with her husband, but as his dementia progressed, more time was spent with her alone as she grieved for him. Indeed, she had become the ‘second patient’ so often described in the dementia care literature. Issues covered included her financial security, the raising of the children and her own intimacy needs.
308
B Draper
DEPRESSION OR DEMENTIA?
Downloaded by [Nanyang Technological University] at 03:32 10 November 2015
The initial diagnosis was difficult. Although we were concerned from the outset that KP might have early Alzheimer’s disease, we couldn’t exclude depressive pseudodementia without an adequate treatment trial. I became aware of the literature that was developing at that time about the high rates of misdiagnosis of pre-senile dementia, particularly due to depression.’ Just as importanly, I also started to realise that even if we were certain about the diagnosis of Alzheimer’s disease, his depression required adequate treatment as well.
PSYCHOLOGICAL IMPACT ON THE PATIENT AND CARERS While these early diagnostic issues were considerable, it was the effects of the gradually evolving dementia on KP and his wife over the next 2 years that had the greatest influence upon me. 1 learnt that both the dementing person and their carer require individual attention in addition to their needs as a dyad. The importance of families in the management of psychiatric disorders has long been recognized, and my initial sessions with KPs wife were a standard part of our unit’s care. As the diagnosis of dementia became clearer, these sessions changed focus, to concentrate on her emotional needs. Carer support groups are now an integral part of dementia care and there is a growing recognition of the value of carer training programmes.’ But it is also important for the key medical professional, whether old-age psychiatrist, general practitioner or geriatrician, to have ongoing contact to monitor the progress of both patient and carer. It was possibly the circumstances of the case that enabled me to develop a therapeutic alliance with KP. I was
initially providing weekly psychotherapy as part of depression management, that later developed into a less frequent and more supportive role as the dementia progressed. Whether I would have commenced such supportive therapy with KP if the initial diagnosis of dementia had been certain is debatable. Although KP was aware of his declining capabilities, he had little insight and was easily frustrated by the consequences of his disabilities. Through appropriate reassurance, empathy and manipulation of his work and home environment, some of these symptoms were ameliorated.
CONCLUSION One of my current concerns about dementia care is that the psychological needs of the dementing patient have been relatively neglected by health professionals, as the carer’s emotional needs have become the focus of attention. Not every dementing patient requires the same level of psychological support as Mr KP, but many do. In my practice now I try to ensure that both patient and carers have the opportunity to ventilate their feelings.
REFERENCES 1. Ron MA, Toone BK, Garralda ME et a1 (1979) Diagnostic accuracy in presenile dementia. Br J Psychiatry 134: 161-8.
2. Brodaty H, Gresham M, Luscombe G (1997) The Prince Henry Hospital dementia caregivers’ training programme. Int J Geriatr Psychiatry 12: 183-92.
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Adapting to needs in old-age psychiatry Brian Draper To cite this article: Brian Draper (1998) Adapting to needs in old-age psychiatry, International Journal of Psychiatry in Clinical Practice, 2:4, 307-308 To link to this article: http://dx.doi.org/10.3109/13651509809115379
Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 5
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [Nanyang Technological University]
Date: 10 November 2015, At: 03:32
0 1998 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 307-308
307
Adapting to needs in old-age psychiatry BRIAN DRAPER
Downloaded by [Nanyang Technological University] at 03:32 10 November 2015
Prince Henry Hospital and University of New South Wales, Sydney, Australia
Correspondence Address Dr Brian Draper, FRANZCP, Academic Department of Psychogeriatrics, Prince Henry Hospital, Little Bay, Sydney NSW 2036, Australia Tel: +61 293 825 007 Fax: +61 293 825 016 E-mail b.drape&ns w .edu.au
The patient described is a 56-year-old man presenting with chronic depression and eventually found to have Alzheimer’s disease. Issues in the diagnosis and evolution of early dementia are discussed. The importance of long-term psychological support to the dementing patient, as well as their carers, is emphasized (Int J Psych Clin Pract 1998; 2: 307 - 308)
Received 9 June; accepted for publication 15 July 1998
INTRODUCTION t is essential for an old-age psychiatrist to be interested in, and enthusiastic about, the assessment and management of dementia. It was probably my awareness that I had such interest and enthusiasm that steered me into my career path. Yet I discovered this with a middle-aged patient.
I
CASE HISTORY Mr KP, a 56-year-old married skilled labourer, presented at a general hospital psychiatry unit in Sydney in the early 1980s with an 18-month history of chronic depression that had failed to respond to antidepressant medication and psychotherapy provided by a community psychiatrist. His depression appeared to relate to long-term feelings of inferiority with problems at work, where his brother-in-law was the manager. His work performance had declined and his relationship with his somewhat dominant wife had deteriorated, largely through his withdrawal from family activities, He felt burdened by his responsibilitieswith their teenage children and blamed his wife for having them. While there was undoubtedly a depressive syndrome present, there were features that raised the possibility of early dementia, including subjective memory impairment and subjective difficulties in finding words. The results of standard dementia investigations, including a CT scan, were normal. The neuropsychology assessment was equivocal, with performance inconsistencies and task refusal suggestive of depression, but also some evidence of cognitive impairment. In the circumstances, my consultant and I decided that his depression should be vigorously treated.
Over the next 3 months, after a course of ECT and two courses of antidepressants, little change was noted apart from a lessening of his depressed mood. During this time, while I was providing supportive psychotherapy, it became clearer that he had an early dementia, as his behaviour was rigid and stereotyped and the content of his speech was repetitive and impoverished. Despite his lack of improvement, he obviously enjoyed talking about his family and work concerns. Meanwhile, his wife was seen both alone and with him, to address some of the marital and family issues. It became apparent during these sessions that she was quite devoted to him and had largely adopted a dominant role as a reaction to his increasing withdrawal from responsibility over the latter years of their marriage. As he failed to improve, she talked about her fears that his mental deterioration would be permanent and the effects this would have on her family. Over the next 6 months, before the diagnosis of probable Alzheimer’s disease was confirmed by his cognitive decline and deterioration on neuropsychology evaluation, ongoing supportive therapy allowed KP to ventilate his frustrations about his increasing incapacity to work and difficulties he perceived at home. Subsequently, with the acquiescence of his brother-in-law, his work was modified to his capacities, and over the next year he gradually retired. His wife was seen throughout this period, initially with her husband, but as his dementia progressed, more time was spent with her alone as she grieved for him. Indeed, she had become the ‘second patient’ so often described in the dementia care literature. Issues covered included her financial security, the raising of the children and her own intimacy needs.
308
B Draper
DEPRESSION OR DEMENTIA?
Downloaded by [Nanyang Technological University] at 03:32 10 November 2015
The initial diagnosis was difficult. Although we were concerned from the outset that KP might have early Alzheimer’s disease, we couldn’t exclude depressive pseudodementia without an adequate treatment trial. I became aware of the literature that was developing at that time about the high rates of misdiagnosis of pre-senile dementia, particularly due to depression.’ Just as importanly, I also started to realise that even if we were certain about the diagnosis of Alzheimer’s disease, his depression required adequate treatment as well.
PSYCHOLOGICAL IMPACT ON THE PATIENT AND CARERS While these early diagnostic issues were considerable, it was the effects of the gradually evolving dementia on KP and his wife over the next 2 years that had the greatest influence upon me. 1 learnt that both the dementing person and their carer require individual attention in addition to their needs as a dyad. The importance of families in the management of psychiatric disorders has long been recognized, and my initial sessions with KPs wife were a standard part of our unit’s care. As the diagnosis of dementia became clearer, these sessions changed focus, to concentrate on her emotional needs. Carer support groups are now an integral part of dementia care and there is a growing recognition of the value of carer training programmes.’ But it is also important for the key medical professional, whether old-age psychiatrist, general practitioner or geriatrician, to have ongoing contact to monitor the progress of both patient and carer. It was possibly the circumstances of the case that enabled me to develop a therapeutic alliance with KP. I was
initially providing weekly psychotherapy as part of depression management, that later developed into a less frequent and more supportive role as the dementia progressed. Whether I would have commenced such supportive therapy with KP if the initial diagnosis of dementia had been certain is debatable. Although KP was aware of his declining capabilities, he had little insight and was easily frustrated by the consequences of his disabilities. Through appropriate reassurance, empathy and manipulation of his work and home environment, some of these symptoms were ameliorated.
CONCLUSION One of my current concerns about dementia care is that the psychological needs of the dementing patient have been relatively neglected by health professionals, as the carer’s emotional needs have become the focus of attention. Not every dementing patient requires the same level of psychological support as Mr KP, but many do. In my practice now I try to ensure that both patient and carers have the opportunity to ventilate their feelings.
REFERENCES 1. Ron MA, Toone BK, Garralda ME et a1 (1979) Diagnostic accuracy in presenile dementia. Br J Psychiatry 134: 161-8.
2. Brodaty H, Gresham M, Luscombe G (1997) The Prince Henry Hospital dementia caregivers’ training programme. Int J Geriatr Psychiatry 12: 183-92.
