Psych Vivas · Old age psychiatry — residential care and systems of care
Residential aged care psychiatry — structured clinical viva
Fellowship viva covering RAC multifactorial assessment, Fossey/WHELD/Husebo non-drug evidence, Schneider mortality, cautious dosing, DART-AD deprescribing, restraint, and liaison.
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Target exams
FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the old-age psychiatry registrar visiting a residential aged care facility. A 79-year-old man with dementia has daily physical aggression during showering. Staff request standing olanzapine 10 mg. He is drowsy after PRN doses and had a fall this week. Discuss assessment, non-drug strategies with named trials, antipsychotic harm evidence, if and how you would prescribe, deprescribing, chemical restraint, and disposition.
Interpretation
Reveal interpretationShowHide
Working problem: aggression during personal care in RAC dementia — likely multifactorial (pain, approach, environment, possible delirium) with sedation and falls from current PRN antipsychotic use. Standing olanzapine 10 mg is excessive as an opening move in a frail older adult. Prioritise assessment, non-drug redesign of care, pain protocol, and only then consider lowest-dose short-term drug if residual severe risk, with deprescribing plan.[1][2][5]
References8ShowHide
- [1]Kales HC, Gitlin LN, Lyketsos CG Assessment and management of behavioral and psychological symptoms of dementia BMJ, 2015.PMID 25731881
- [2]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
- [3]Fossey J, Ballard C, Juszczak E, et al. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial BMJ, 2006.PMID 16543297
- [4]Ballard C, Corbett A, Orrell M, et al. Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial PLoS Med, 2018.PMID 29408901
- [5]Husebo BS, Ballard C, Sandvik R, et al. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial BMJ, 2011.PMID 21765198
- [6]Ballard C, Lana MM, Theodoulou M, et al. A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (the DART-AD trial) PLoS Med, 2008.PMID 18384230
- [7]Ballard C, Hanney ML, Theodoulou M, et al. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial Lancet Neurol, 2009.PMID 19138567
- [8]Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia Ann Intern Med, 2007.PMID 17548409