Rationale and protocol of the ENGAGE study: a double-blind randomized controlled preference trial using a comprehensive cohort design to measure the effect of a cognitive and leisure-based intervention in older adults with a memory complaint.

BACKGROUND: Leisure activities can be both enjoyable and cognitively stimulating, and participation in such activities has been associated with reduced age-related cognitive decline. Thus, integrating stimulating leisure activities in cognitive training programs may represent a powerful and innovative approach to promote cognition in older adults at risk of dementia. The ENGAGE study is a randomized controlled, double-blind preference trial with a comprehensive cohort design that will test the efficacy and long-term impact of an intervention that combines cognitive training and cognitively stimulating leisure activities. METHODS: One hundred and forty-four older adults with a memory complaint will be recruited in Montreal and Toronto. A particular effort will be made to reach persons with low cognitive reserve. Participants will be randomly assigned to one of two conditions: cognitive + leisure training (ENGAGE-MUSIC/SPANISH) or active control (ENGAGE-DISCOVERY). The ENGAGE-MUSIC/SPANISH training will include teaching of mnemonic and attentional control strategies, casual videogames selected to train attention, and classes in music or Spanish as a second language. The ENGAGE-DISCOVERY condition will comprise psychoeducation on cognition and the brain, low-stimulating casual videogames and documentary viewing with discussions. To retain the leisure aspect of the activities, participants will be allowed to exclude either music or Spanish at study entry if they strongly dislike one of these activities. Participants randomized to ENGAGE-MUSIC/SPANISH who did not exclude any activity will be assigned to music or Spanish based on a second random assignment. Training will be provided in 24 2-h sessions over 4 months. Outcomes will be measured at baseline, at 4-month follow-up, and at 24-month follow-up. The primary outcome will be cognitive performance on a composite measure of episodic memory (delayed recall scores for words and face-name associations) measured at baseline and at the 4-month follow-up. Secondary outcomes will include a composite measure of attention (speed of processing, inhibition, dual tasking, and shifting), psychological health, activities of daily living, and brain structure and function and long-term maintenance measured at the 24-month follow-up. Information on cognitive reserve proxies (education and lifestyle questionnaires), sex and genotype (apolipoprotein (Apo)E4, brain-derived neurotrophic factor (BDNF), and catechol-O-methyltransferase (COMT)) will be collected and considered as moderators of training efficacy. DISCUSSION: This study will test whether a program combining cognitive training with stimulating leisure activities can increase cognition and reduce cognitive decline in persons at risk of dementia. TRIAL REGISTRATION: NCT03271190 . Registered on 5 September 2017.

[Categorical refusal of treatment by psychiatric patients: balance, survey and prospects]. / Refus catégorique de traitement des patients psychiatriques: bilan, enquête et perspective.

BACKGROUND: In his or her practice, a psychiatrist must often deal with patients who refuse treatment. In 1990, Quebec radically changed this situation by introducing a Civil Code provision imposing judicial intervention to treat an individual deemed unfit to consent, against his or her will. This paper presents an assessment and survey of patients and attending psychiatrists who have used this Code provision. METHOD: Thirty-nine subjects who explicitly refused treatment were brought to court. We asked a subgroup of these patients to be interviewed, using the Drug Attitude Inventory (DAI), the Clinical Global Impression (CGI), and 2 questionnaires specifically considering the court experience of patients and attending psychiatrists. RESULTS: The results of the survey show that patients remember their experience in court as rather uncomfortable. However, the therapeutic alliance remained unchanged, even after the legal procedure. Physicians agreed that patients would not have been clinically well enough to leave the hospital if they had not received the drug regimen resulting from the court decision. The dissociation between the perceptions of patients and physicians is compared with that found in previous studies in the United States. CONCLUSION: Even with a limited sample, this study addresses a delicate, difficult situation that professionals are increasingly likely to confront. It also proposes further research on alternatives to judicial intervention.