Daniel Whiting

Background and Objectives Despite their limited benefits and serious adverse effects, psychotropics remain frequently prescribed for neuropsychiatric symptoms (NPS) of dementia. Psychotropic polypharmacy, the use of two or more concomitant psychotropic medications, is therefore not recommended for people with dementia. The objectives of this study were to investigate the prevalence of psychotropic polypharmacy in Australians living with dementia whose caregivers sought external NPS support from Dementia Support Australia (DSA; the national provider of NPS support) and the association of psychotropic polypharmacy with their demographics and NPS characteristics. Methods A retrospective cross-sectional study of a subset of DSA referrals at baseline (i.e., yet to receive psychosocial intervention(s)) between 2016 and 2020 was conducted. Referrals with and without psychotropic polypharmacy were compared on the basis of demographic characteristics (e.g., sex, dementia subtype), NPS type (e.g., agitation), NPS severity and associated caregiver distress as measured by the Neuropsychiatric Inventory (NPI), using Pearson’s chi-square test and Welch’s t-test for categorical and continuous data, respectively. Logistic regression models were used to examine the relationship between individual NPI domains and exposure to psychotropic polypharmacy. Results A total of 421 referrals (mean age 81.5 (standard deviation 8.5) years, 52.3% males, 46.8% Alzheimer’s disease) were analysed. Of those, over 90% (n = 383) were prescribed at least one psychotropic, with 214 referrals (50.8%) prescribed psychotropic polypharmacy. The medication types most associated with psychotropic polypharmacy were antipsychotics (n = 162, 75.7%), opioids (n = 104, 48.6%), anxiolytics (n = 93, 43.5%), sedative/hypnotics (n = 52, 24.3%) and antidepressants (n = 47, 22.0%). No relationship between psychotropic polypharmacy and any variable tested was identified, including age, sex, dementia subtype and NPI severity. Conclusions Psychotropic polypharmacy is highly prevalent in Australians living with dementia referred to external dementia-specific behaviour support programs, but no factors were associated with its presence in this cohort.

Pain recognition for culturally diverse people is complex as pain experience is subjective and influenced by cultural background. We compared the prevalence, intensity, and association of pain with neuropsychiatric symptoms (NPS) between immigrants and non-immigrants living with dementia in residential aged care homes (RACHs) who were referred to two Dementia Support Australia programs. Immigrant status was defined by the documented country of birth. Pain and NPS were assessed using PainChek (R) and the Neuropsychiatric Inventory, respectively. Subgroup analyses were also completed for English-speaking and non-English-speaking immigrants. A total of 17,637 referrals [immigrants, n = 6340; non-immigrants, n = 11,297] from 2792 RACHs were included. There were no significant differences for the prevalence of pain across all groups. Immigrants were slightly more likely to have moderate pain or severe pain than non-immigrants. Non-English-speaking immigrants had 0.5 points higher total pain scores on average (Cohen's d = 0.10 [0.05, 0.15], p < 0.001) than non-immigrants. Total pain score had a significant effect on total NPS severity scores in all groups. While pain prevalence is similar across groups, higher pain intensities are more common among immigrants living with dementia. Increased care staff awareness, education, and training about the potential effect of culture on pain expression is needed.

Background: Untreated pain in aged care residents living with dementia has been linked to delirium, hospitalizations, inappropriate pharmacotherapy, disrupted activities of daily living, and reduced quality of life. Pain experiences and expressions are subjective and to a large extent culturally driven. As dementia advances, older immigrants living with dementia may revert to their culture and language of origin and may experience pain differently. Further, there is limited studies on the pain experience of immigrant residents living with dementia. This study aims to describe the pain experience in immigrants living with dementia in Australian residential aged care homes (RACHs).Methods: A sample of residents who were referred to Dementia Support Australia (DSA, a national behavior support service) for the period 01/06/2018‐30/06/2022 was eligible to be included in the study. Pain was assessed using PainChek^®, a validated point‐of‐care medical device for non‐verbal adults living with dementia. PainChek^® consists of six domains: Face (9 items), Voice (9 items), Movement (7 items), Behavior (7 items), Activity (4 items) and Body (6 items). The sum of domain scores produces a final score that match the following pain levels: 0‐6 (no pain), 7‐11 (mild pain), 12‐15 (moderate pain) and 16‐42 (severe pain). Immigration status was defined as country or place of birth reported other than Australia.Results: The eligible sample [n = 8607, 84.5 (7.0) y, 55.4% female, Alzheimer’s disease = 37.8%, vascular dementia = 12.9%, mixed dementia = 9.5%] had 4411 pain assessments completed, with an average total pain score of 9.4 (5.1). The prevalence of pain was 68.4% in the sample, with over one‐third of episodes represent mild pain (36.0%), and almost one‐third in moderate‐severe pain (20.1% and 12.2%, respectively). Among other factors, pain was the primary contributing factor (60.1%) in causing neuropsychiatric symptoms of dementia, such as agitation/aggression and depression. Top five countries of birth for DSA referrals were England, Italy, Greece, Scotland, and Germany.Conclusion: Pain is a prevalent clinical problem in immigrants living with dementia in Australian RACHs, who were seeking external behavior support for their neuropsychiatric symptoms.