A retrospective study of the behavioural and psychological symptoms of dementia in patients admitted to a Specialist Dementia Care Unit
[Correction added on 16 May, after first online publication: CAUL funding statement has been added.]
Funding information
None
Abstract
Objectives
To explore the nature and severity of behavioural and psychological symptoms of dementia (BPSD) and outcomes for patients admitted to a specialist dementia care unit (SDCU) at a tertiary Australian hospital.
Methods
This single-centre retrospective study categorised patients into a recognised seven-tiered model of severity of BPSD using a novel tool developed for this study. Descriptive characteristics, pharmacological management, and range and severity of BPSD were examined.
Results
There were 125 patients admitted over a two-year period reviewed, with 62% being males and a mean age of 82.4 years. Those with high severity BPSD (n = 61, 49%) had a longer length of stay (p = 0.049), were on a greater number of psychotropic medications on admission (p < 0.001) and were more likely to be trialled on a new psychotropic medication (p = 0.001). At least five behaviours on admission were demonstrated in 84% of patients. Behaviours were ameliorated with reduction in tier severity at discharge (p < 0.005). The mean number of psychotropic medications on admission was not significantly different to discharge (p = 0.14). Sixty-seven per cent of patients living independently at admission were discharged to residential care, and 44% in residential care were discharged to a new facility.
Conclusions
Multi-disciplinary management led to optimisation of behaviours and overall reduction in BPSD severity. This was achieved without a significant increase in the use of psychotropic medications, highlighting the importance of an individualised approach by a team skilled in the behavioural management of BPSD. The study confirms the high risk of transition to residential care for patients with BPSD.
Policy Impact
High severity BPSD poses a significant challenge to both health care and residential aged care systems. Planning and development of specialist dementia care units focussing on dementia-friendly design principles and a skilled multidisciplinary approach is required in both settings.
Practice Impact
Patients with high severity BPSD demonstrate a range of challenging behaviours. Results confirmed the importance of a multi-disciplinary and individualised approach to care for patients with BPSD, and the significant and positive impact of care in a specialist dementia care unit. Management of behavioural and psychological symptoms in dementia should be considered and implemented within the context of recent legislative amendments.
1 INTRODUCTION
In 2020, there were an estimated 459,000 Australians living with dementia, and dementia is now the second leading cause of death in Australia.1 Dementia is associated with cognitive deficits and also with non-cognitive psychiatric and behavioural symptoms. Behavioural and psychological symptoms of dementia (BPSD) describe a group of symptoms involving disturbed thought content, mood or behaviour, which frequently occur in patients with dementia.2 Behavioural and psychological symptoms of dementia are independently associated with poor outcomes, including poor quality of life among patients and caregivers,3 faster progression to more severe stages of dementia,4 increased risk for secondary complications including falls and Emergency Department presentations,5 and increased health-care costs.6 They are associated with longer hospitalisations and often lead to a transition from independent living to residential care.7
A seven-tiered model for service delivery based on the severity and prevalence of BPSD was proposed by Brodaty et al. and is often used in policy and planning processes.8 It is argued that gaps remain in the provision of BPSD care for those unable to be managed in mainstream residential care.9 The SAX Institute published a review of international literature regarding care for people with severe BPSD.10 Seventeen SDCUs were examined with common elements of effective units including an individualised approach with caregiver involvement, a supportive secure environment, collaboration between geriatricians and psychiatrists, staff with skills in behavioural management and a multidisciplinary team approach.
The local Australian tertiary hospital is part of a network of services providing health care to the district, with local prevalence data, which estimated that in 2010, there were almost 5000 people in the region living with dementia.11 The hospital has an SDCU for patients with dementia requiring multidisciplinary management for BPSD, and acute medical or psychosocial issues. Most patients have a known diagnosis of dementia following review in the outpatient setting, while the remainder are assessed and diagnosed as inpatients. The ward is a secure unit staffed by geriatricians and consulting psychogeriatricians, nursing staff and allied health practitioners experienced in behavioural interventions for BPSD.
By reviewing patient admissions over a two-year period from July 2018 to June 2020, and categorising patients into tiers of severity of BPSD based on Brodaty's seven-tiered model,8 the aim was to explore the nature and severity of BPSD in patients admitted to this SDCU. The primary objective was to review descriptive characteristics and outcomes including mode of separation and pharmacological management. The secondary objectives included describing range and severity of behavioural symptoms and whether these improved by the time of discharge.
2 METHODS
2.1 Study design
This was a single centre study. All admissions to the SDCU from 1 July 2018 to 30 June 2020 were identified through the hospital electronic medical record (EMR), using search criteria including ‘Geriatric Medicine service admission’, and ‘discharged from location’. For patients who had multiple admissions during the timeframe, their most recent admission was analysed to include most recent behavioural data. Descriptive data was collected, including baseline demographics, comorbidities using the Charlson comorbidity index,12 dementia diagnosis, triage location, length of hospital stay, length of stay in the SDCU, non-psychotropic and psychotropic medications on admission and discharge, psychotropic medications trialled during admission, and discharge destination. Frequency of admissions and deaths during the study period were also reviewed.
To review the nature and severity of BPSD, eligible patients were categorised into tiers of severity of BPSD, based on Brodaty's seven-tiered model.8 No current tool exists for categorising patients into these tiers as no tool incorporates all symptoms in conjunction with a severity assessment. Therefore, a tool was developed as part of this study to consistently and reproducibly categorise patients. Brodaty's tiers range from no dementia through tiers of increasingly severe behavioural disturbance. Neuropsychiatric symptoms (NPS) covered in Brodaty's model include activity disturbance, depression, agitation and aggression. The tool was developed using items taken from a number of validated measures assessing BPSD, ensuring all symptoms in the seven tiers were included. The tool involved rating the severity of ten NPS. In a review of published measures for the assessment of BPSD, the Behavioural Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD)13 was rated as one of the best measures for the assessment of behavioural disturbance.14 The study tool primarily used the severity scale described in the BEHAVE-AD across multiple domains.
However, as the BEHAVE-AD does not include all symptoms in Brodaty's tiers, items from other tools assessing specific NPS were required. A systematic review identified a number of psychometrically sound measures that targeted specific NPS15, including the dementia mood assessment scale (DMAS),16 aggressive behaviour scale17 and Pittsburgh agitation scale.18 Severity of depression, agitation and aggression help to distinguish between Brodaty's tiers, and these tools provided detailed descriptions for these symptoms. The scoring sheet was created by reviewing examples of NPS described for each tier. This prompted prediction of points scored for each tier and aimed to correlate the severity of NPS in Brodaty's paper with tiers in the study tool.
The tool was piloted to determine internal consistency. The gold standard was a clinical assessment by an experienced geriatrician. Twenty participants admitted to the SDCU between 1 July 2020 to 30 September 2020 were categorised into tiers using the tool by the principal investigator, using information from the EMR over the first seven days of admission. These patients were not included in the retrospective study. A study co-investigator, a geriatrician with expertise in cognition who provides service to the SDCU, was blinded to the tool results and assigned participants into tiers based on knowledge from recent provision of care and review of the EMR. Tool and clinician categorisation were compared. The study tool was refined after the initial process. The second version was used to categorise a new group of 125 patients discharged between 1 July 2018 to 30 June 2020 using the EMR over the first and last seven days of admission.
2.2 Data collection and management
Participant information was obtained from the EMR following identification of eligible participants. Patient data were collected in a non-identified format using a unique patient identifier. Data were stored securely and managed using the local health district's software licence for REDCap (Research Electronic Data Capture).
2.3 Statistical analysis
Data was analysed using SPSS version 24.0 (IBM Corp) statistics. For the study tool, Cronbach's alpha was used to assess internal consistency. Mean and standard deviations were calculated for normally distributed data and were compared using the independent sample t-test. Median and interquartile ranges were calculated for non-parametric data. Mann–Whitney tests were used to compare non-parametric data. Frequencies and per centages were calculated for categorical variables. Fisher's exact test was used to assess the relationship between two categorical variables. The Kaplan-Meier curve was used to analyse the length of stay, and the differences between groups were compared using the Pearson's Chi-square test. p-values <0.05 were considered significant.
2.4 Ethics approval
Ethics approval was granted by the Sydney Local Health District Human Research Ethics Committee (reference CH62/6/2020-203). A waiver for individual consent was granted.
3 RESULTS
3.1 Pilot study of tool to assess BPSD severity
The first version of the study tool was compared to the categorisation that would be made by a trained clinician, with assigned tiers in agreement for 11/20 patients (55%). The tool commonly underscored severity, and the scoring system was too complex. The tool was refined by simplifying the scoring system, which included the automatic categorisation to Tier 6 if a patient demonstrated physical aggression towards self or others without significant harm, and automatic categorisation to Tier 7 if they demonstrated physical violence towards self or others resulting in significant harm. Patients were categorised into tiers using the second version of the tool and compared to clinician tiers, with agreement for 18/20 patients (90%). Therefore, the second version of the tool was used. Once the tool was used in the main study to categorise 125 patients on admission and 125 patients on discharge, 250 scores were tested for internal consistency and this was found to be acceptable (Cronbach's alpha 0.66).
3.2 Patient demographics
There were 179 patients discharged from the SDCU between July 2018 and June 2020. Fifty-four of these patients were readmissions during the study timeframe, and each patient's most recent admission was included. This resulted in 125 unique patients discharged during the timeframe. The mean age was 82.4 years, and 62% of patients (n = 77) were male (Table 1). Fifty-two per cent of the patients (n = 65) were living independently at admission. Only 33% of patients (n = 22) living independently returned to independent living. Of those admitted from a residential aged care facility (RACF), 44% (n = 25) were discharged to a new RACF.
| Characteristic | |
|---|---|
| Age, years | |
| Mean (SD) | 82.4 (8) |
| Age group, n (%) | |
| 60–69 | 11 (8) |
| 70–79 | 31 (25) |
| 80–89 | 58 (46) |
| 90–100 | 25 (20) |
| Gender, n (%) | |
| Male | 77 (62) |
| Female | 48 (38) |
| Usual place of residence, n (%) | |
| Independent living | 65 (52) |
| Retirement village | 3 (2) |
| Residential aged care facility | 57 (46) |
| Triage location, n (%) | |
| Direct admission | 13 (11) |
| Emergency | 48 (38) |
| Acute ward | 55 (44) |
| Transfer from another hospital | 9 (7) |
| Length of stay, median (IQR) | 22 (36) |
| Length of stay in SDCU, median (IQR) | 21 (31) |
| Total number of days in SDCU | 4459 |
| Total Charlson Comorbidity Index, mean (SD) | 3.0 (1.7) |
| Median (IQR) | 3 (2) |
| Dementia diagnosis, n (%) | |
| Alzheimer's | 40 (32) |
| Vascular | 20 (16) |
| Dementia with Lewy Bodies | 3 (2) |
| Frontotemporal | 2 (2) |
| Traumatic brain injury | 1 (1) |
| Alcohol-related | 2 (2) |
| HIV-related | 1 (1) |
| Mixed | 45 (36) |
| Alzheimer's and vascular | 28 (62) |
| Other combination of above pathologies | 17 (38) |
| Unspecified | 11 (8) |
| Admission frequency during study perioda n (%) | |
| 1 | 93 (75) |
| 2 | 18 (14) |
| 3 | 9 (7) |
| ≥4 | 5 (4) |
| Mode of separation, n (%) | |
| Deaths | 7 (5) |
| Return to independent living | 22 (33) |
| Independent living to RACF | 45 (67) |
| RACF-returned to same | 26 (46) |
| RACF-discharged to new | 25 (44) |
- Abbreviations: IQR, interquartile range; RACF, Residential Aged Care Facility; SD, standard deviation; SDCU, Specialist Dementia Care Unit.
- a Study period: 1 July 2018 to 30 June 2020.
3.3 Severity of BPSD
Patients were categorised into Brodaty's tiers of severity on admission and discharge using the study tool (Table 2). Once tiers were assigned, they were merged to create two groups: low severity BPSD group (Tiers 3–4), and high severity BPSD group (Tiers 5–7). The characteristics of the groups were similar, with their mean age (t = 1.96, p = 0.07) and mean Charlson comorbidity index score not significantly different (t = 0.63, p = 0.53). On admission, 51% of patients (n = 64) were categorised as belonging to the low severity group, and 49% of patients (n = 61) were categorised into the high severity group. On discharge, 78% of patients (n = 98) were categorised into the low severity group, and 22% of patients (n = 27) were categorised as belonging to the high severity group. Of 61 patients classified as high severity on admission, 57% (n = 35) improved to low severity at discharge. On admission, there were a similar number of patients in both low and high severity groups, and at discharge, there were significantly more patients in the low severity compared to high severity group (Fisher's exact test, p < 0.001). The median length of stay for all patients was 22 days (range 2–248 days; IQR 36 days) (Table 1). The high severity group had a longer length of stay, with the median length of stay 20 days for low severity compared to 31 days for high severity BPSD (Table 2, χ2 = 3.81, p = 0.049). Four deaths occurred in the low severity group and three deaths occurred in the high severity group.
| Brodaty's tier | Admission, n (%) | Discharge, n (%) | Length of staya, median (IQR) |
|---|---|---|---|
| 3 | 20 (16) | 45 (36) | 14.5 (21) |
| 4 | 44 (35) | 53 (42) | 23.5 (33) |
| 5 | 20 (16) | 15 (12) | 15.5 (26) |
| 6 | 34 (27) | 12 (10) | 26 (37) |
| 7 | 7 (6) | 0 (0) | 128 (103) |
| Mean (SD) | 4.7 (1.2) | 3.9 (0.9) | |
| Low severity (Tiers 3 and 4) | 64 (51) | 98 (78) | 20 (30) |
| High severity (Tiers 5–7) | 61 (49) | 27 (22) | 31 (40) |
- Abbreviations: IQR, interquartile range; SD, standard deviation.
- a Length of stay based on admission severity tier
3.4 Behaviours and psychological symptoms of those admitted to the SDCU
Table 3 describes the number and types of behaviours and the number of patients that demonstrated each behaviour on admission and discharge. The most common behaviours included wandering, sleep disturbance, resistance to care and agitation. At discharge, behaviours most responsive to management included paranoid delusions, hallucinations, agitation, and verbal and physical aggression. The high severity group demonstrated a significantly larger reduction in number of behaviours by the time of discharge than the low severity group (t = −6.94, p < 0.005).
| Admission, n (%) | Discharge, n (%) | |
|---|---|---|
| Number of behaviours | ||
| 1–2 | 3 (2) | 3 (2) |
| 3–4 | 17 (14) | 28 (22) |
| 5–6 | 47 (38) | 57 (46) |
| 7–8 | 50 (40) | 34 (28) |
| 9–10 | 8 (6) | 3 (2) |
| Type of behaviours | ||
| Wandering | 124 (99) | 124 (99) |
| Inappropriate activity | 42 (33) | 40 (32) |
| Disturbance in sleep-wake cycle | 98 (78) | 95 (76) |
| Depression/anxiety | 48 (38) | 48 (38) |
| Paranoid thoughts/delusions | 50 (40) | 4 (34) |
| Hallucinations (visual/auditory) | 23 (18) | 20 (16) |
| Resisting care | 91 (73) | 85 (68) |
| Agitation | 122 (98) | 116 (93) |
| Verbal agitation/aggression | 105 (84) | 85 (68) |
| Physical agitation/aggression | 78 (62) | 40 (32) |
| Mean (SD) number of behaviours in low severity group | 5.2 (1.4) | 5.7 (1.8) |
| Mean (SD) number of behaviours in high severity BPSD group | 7.4 (1.16) | 5.4 (1.6) |
- Abbreviations: SD, standard deviation; SDCU, Specialist Dementia Care Unit.
3.5 Medications
The mean number of psychotropic medications on admission was not significantly different to that on discharge (Table 4; t = 1.47, p = 0.14). The mean number of non-psychotropics on admission increased from 4.8 to 5.2 medications on discharge (t = −4.52, p < 0.001). Non-prescription medications including paracetamol and aperients were commenced in a number of cases; for example, 42% of patients (n = 53) were discharged on new aperients. Eighty-nine per cent of patients (n = 54) in the high severity group were on at least one psychotropic on admission, and these patients were on a greater number of psychotropics on admission than the low severity group (Table 5; z = −4.04, p < 0.001). Patients with high severity BPSD were more likely to be trialled on new psychotropic medication (59% [n = 36] vs. 35% [n = 22], z = −3.07, p = 0.002) and a larger number of new psychotropics (Table 5; z = −3.29, p = 0.001). Readmitted patients were discharged on more psychotropics than patients admitted for the first time to the unit (t = 2.38, p = 0.02).
| Number of medications | Psychotropic medications on admission, n (%) | Psychotropic medications on discharge, n (%) | Non-psychotropic medications on admission, n (%) | Non-psychotropic medications on discharge, n (%) |
|---|---|---|---|---|
| 0 | 35 (28) | 27 (21) | 10 (8) | 4 (3) |
| 1–2 | 72 (57) | 84 (67) | 25 (20) | 15 (12) |
| 3–4 | 16 (13) | 14 (12) | 31 (25) | 34 (27) |
| 5–6 | 1 (1) | 0 (0) | 23 (18) | 33 (26) |
| ≥7 | 1 (1) | 0 (0) | 36 (29) | 39 (32) |
| Mean (SD) | 1.3 (1.2) | 1.2 (0.9) | 4.8 (3.3) | 5.2 (2.6) |
- Abbreviation: SD, standard deviation.
| Low severity BPSD, n (%) (n = 64) | High severity BPSD, n (%) (n = 61) | Total, n (%) (n = 125) | |
|---|---|---|---|
| Total number of psychotropic medications on admission | |||
| 0 | 28 (43) | 7 (12) | 35 (28) |
| 1 | 21 (33) | 26 (42) | 47 (38) |
| 2 | 11 (17) | 14 (23) | 25 (20) |
| 3 | 3 (5) | 8 (13) | 11 (8) |
| ≥4 | 1 (2) | 6 (10) | 7 (6) |
| Number of new psychotropics administered or trialled during admission | |||
| 0 | 42 (65) | 25 (41) | 67 (54) |
| 1 | 17 (27) | 17 (28) | 34 (27) |
| 2 | 4 (6) | 14 (23) | 18 (14) |
| ≥3 | 1 (2) | 5 (8) | 6 (5) |
- Abbreviation: BPSD, behavioural and psychological symptoms of dementia.
4 DISCUSSION
In this cohort of patients with dementia and BPSD, 49% of patients (n = 61) had high severity BPSD, indicating that there are a number of patients in the community requiring a multi-disciplinary management approach for severe BPSD. The remaining 51% of patients (n = 64) with lower severity BPSD likely related to balancing the case-mix of patients in the unit, with these patients still benefiting from care in the SDCU given their underlying dementia and BPSD. Patients with high severity BPSD had a significantly longer length of stay, and the majority of patients admitted from independent living were discharged to residential care. The results support literature that BPSD is associated with longer hospitalisation stay and frequently leads to transition from independent living to residential care.7 For those patients admitted from residential care, almost half required transition to a new RACF, with this high level of transition not previously reported in the literature.
The SDCU manages patients with a wide variety of simultaneous behaviours, with 84% of patients (n = 105) having at least five behaviours on admission. Behaviours were dampened for many patients, as evidenced by the reduction in tier severity by discharge. Given that there are no disease-modifying therapies in dementia, goals for pharmacotherapy are to optimise symptoms.19 Consistent with this, distressing symptoms such as paranoid delusions, hallucinations, and verbal agitation were ameliorated for many patients by the time they were discharged. Similarly, physical agitation or aggression was dampened for most patients and for 68% of patients (n = 85), this was no longer present at discharge. While the reduction in number of behaviours in the high severity BPSD group may represent regression to the mean, the reduction in BPSD severity supports a true reduction in BPSD. In light of dementia being an incurable and progressive disease,19 it was not unexpected that 26% (n = 32) of this complex cohort required readmission to the SDCU, and those who had multiple admissions were on significantly more psychotropic medications on discharge.
Patients were stabilised sufficiently to allow discharge, providing evidence for the vital role of the SDCU in optimising BPSD management. Behaviours may have improved due to treatment of a medical illness with associated delirium resolution, but for the majority of patients, improvement was likely due to a multidisciplinary approach to care in a supportive dementia-specific environment. Management of BPSD is highly individualised, and non-pharmacological management strategies are the mainstay of treatment.20 Pain may be a significant trigger, and routine monitoring and treatment of pain is pivotal.20 Optimisation of pain, comorbidities and constipation likely explains the small increase in number of non-psychotropic medications on discharge. There is increasing evidence for behavioural interventions focussed on the environment, including correcting overstimulation or under-stimulation, identifying triggers and establishing routine,21 with the SDCU focussing on these strategies. The unit was developed using evidence-based dementia-friendly design principles, including maximising visual access, provision of rooms for different functions including a lounge and dining room, indoor and outdoor spaces between which patients can move freely, a dementia-safe garden and a bird enclosure for pet therapy.22 A diversional therapist facilitates activities including group exercise, music therapy, art and craft therapy, targeted to patient interests. Furthermore, interventions that include problem-solving with a caregiver to identify modifiable causes of behaviour have been shown to reduce BPSD significantly.21 Carers complete ‘My Story’ which includes social history, identification of the patient's interests and triggers for behaviours, which together inform an individualised behavioural plan. On discharge, the SDCU refines and communicates this individualised plan to families, services, and facilities, and documents this in the discharge summary to facilitate community transition.23
Non-pharmacological management may need to be complemented by pharmacotherapy for severe BPSD. Use of psychotropic medications was tailored to the underlying dementia diagnosis and titrated to efficacy, with 89% (n = 54) on at least one psychotropic on admission, and 60% (n = 75) administered or trialled on at least one new psychotropic. Psychotropics were likely to have been beneficial in reducing depression, agitation, and aggression, consistent with a recent systematic review that found that risperidone and selective serotonin reuptake inhibitors were significantly more efficacious than placebo in reducing agitation in patients with dementia,24 and a meta-analysis that demonstrated risperidone and olanzapine provided significant improvement in aggression in Alzheimer's dementia.25 Pharmacological management, used in conjunction with first line non-pharmacological measures, remains an important therapeutic option to alleviate severe BPSD, with clinical practice guidelines recommending the lowest possible dose for the shortest possible time.26
The findings from this study warrant careful consideration in light of recent recommendations from the Royal Commission into Aged Care Quality and Safety27 and the recently passed Aged Care and other Legislation Amendment28 where use of psychotropics to manage behaviour is considered a restrictive practice requiring consent from a restrictive practices substitute decision maker. This study identified that even in the setting of well-implemented multi-disciplinary behavioural support plans, the lowest possible dose medications for BPSD were still required to mitigate distress and risk of harm to self and others. This has important implications for future clinical practice with the SDCU experiencing an increasing need to apply to the local Guardianship authority for formal appointment of restrictive practices substitute decision makers to fulfil legislative requirements and facilitate discharge planning. While the legislation provides essential protection to people living with dementia, there is the potential for legislative requirements to disincentivise acceptance of those with the most challenging BPSD into long-term residential care facilities.29
4.1 Strengths and limitations
Strengths of the study included the opportunity to review and describe characteristics, range and severity of behaviours, and pharmacological management for this unique and complex cohort of patients. There are several limitations to the study. It is acknowledged that the developed study tool was novel and therefore not validated, however, the tool allowed a reproducible means of categorising the severity of BPSD into Brodaty's tiers. Further studies of the reliability of the tool would be useful. The tool has not yet been trialled in other behavioural units to determine utility in other populations. It is acknowledged that for those patients readmitted during the study period, including data from their most recent admission could introduce bias; however, the decision was made to review most recent behavioural data for unique patients in order to characterise the scope of behaviours present in the SDCU. While it is recognised that some patients may have had delirium contributing to behavioural disturbance and therefore improved with delirium management, data was not collected on this. It was considered that delirium likely played a lesser role on impacting behaviours in the SDCU compared with patients admitted to an acute hospital ward. The median length of stay suggests that delirium was not the sole contributor to admission. Doses of antipsychotic medications were not included in analyses and this information may have provided greater depth of information for those with severe BPSD. Finally, behavioural management strategies were not reviewed in this study, but this would have proved to be challenging given their highly individualised nature.
4.2 Future directions
A number of patients with BPSD are not admitted to the SDCU and are managed on an acute ward utilising alternative strategies such as provision of additional nursing staff to provide close supervision. It is possible that these patients have lower severity BPSD, and the decision to manage them on an acute ward is based on SDCU bed availability, presence of extreme behaviours in the SDCU creating patient safety and access issues, or failure of family consent for SDCU admission. Future research could examine behaviours of acute Geriatric Medicine inpatients to obtain a more complete view of the scope of patients with BPSD cared-for in hospital. Future review of data could also examine how often the unit is at maximum bed capacity, which may help to calculate the number of SDCU beds required for the district.
5 CONCLUSIONS
Patients admitted to the SDCU demonstrated numerous simultaneous and challenging behaviours, with most admitted from independent living unable to return to this. Multidisciplinary management led to optimisation of a wide range of behaviours and an overall reduction in BPSD severity, which helped facilitate community transition. Due to the multidisciplinary approach and comprehensive behavioural management plans, benefits were achieved without a significant increase in use of psychotropic medications. This emphasises the significant role the SDCU plays in management of patients with severe BPSD and highlights the importance of a multidisciplinary and individualised approach, with a team of health-care professionals with education and skills in non-pharmacological management of BPSD.
ACKNOWLEDGEMENTS
The authors acknowledge Leanne Kearney who was responsible for the development of the REDCap database. Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australian University Librarians.
CONFLICTS OF INTEREST
No conflicts of interest declared.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
