Evaluating the impact of a national geriatric mental health ECHO educational program on healthcare providers' practice.

Project Extension for Community Healthcare Outcomes (ECHO) enables healthcare providers to share knowledge and best practices via telementoring. The ECHO model builds provider capacity and improves care for patients with a variety of health conditions. This study describes a Canada-wide National ECHO pilot project in the area of geriatric mental health and reports on the program's impact on providers' care practices. A mixed-methods approach was used to analyze surveys completed by participating healthcare providers. Program evaluation measured satisfaction, achievement of learning objectives, awareness of issues related to geriatric mental health, and comfort and self-efficacy working with older adults. The program led to a statistically significant increase in participants' awareness of issues related to support for older adults with mental illness and comfort and self-efficacy in managing these patients in their own practice. The National ECHO pilot project was successful in building healthcare providers' capacity to care for older adults with mental health issues and positively impacting their practice. These findings support using the ECHO model to provide ongoing geriatric mental health education for clinicians from across Canada and beyond.

Primary Progressive Aphasia Presenting With Neuropsychiatric Symptoms.

We describe a case of primary progressive aphasia (PPA) with an underlying neurodegenerative motor disorder (possible ALS or PSP), presenting with symptoms of irritability and frustration, that were misdiagnosed and treated as a primary psychiatric disorder, i.e. depression. PPA is a rare neurodegenerative disorder characterized by insidious onset and gradual progression of speech and language impairment. We emphasize that PPA can initially masquerade as or be accompanied by neuropsychiatric symptoms potentially leading to misdiagnosis. Most prevalent neuropsychiatric symptoms reported in the PPA literature are agitation, depression, anxiety, apathy, irritability, abnormal appetite and disinhibition. To ensure early diagnosis of PPA, if a patient presents with new psychiatric symptoms accompanied by new onset speech and/or language impairment, referral to a specialist (i.e., neurologist and/or speech-language pathologist) is recommended.

Comparing a clinician-assisted and app-supported behavioral activation intervention to promote brain health and well-being in frontline care.

BACKGROUND: Positive psychiatry offers an unique approach to promote brain health and well-being in aging populations. Minimal interventions through behavioral activation to promote wellness are increasingly available using self-guided apps, yet little is known about the effectiveness of app technology or the difference between clinician-supported behavioral activation versus self-guided app methodologies. OBJECTIVES: Investigate the difference in users and outcomes between two methods of the Fountain of Health (FoH) positive psychiatry intervention for behavioral activation to promote brain health and well-being: (1) clinician-assisted and (2) independent app use for behavioral self-management. DESIGN AND SETTING: As part of a larger knowledge translation intervention in positive psychiatry, two specific methods of a behavioral activation intervention were retrospectively compared. PARTICIPANTS: Two subsets of patients were compared; 254 clinician-assisted patients; 333 independent app users. INTERVENTION: A minimal positive psychiatry intervention in frontline care using the FoH health and behavior change clinical tools. MEASUREMENTS: Main outcomes were changes in psychological (health and resilience, well-being scores) and behavioral indices (goal attainment, items of goal SMART-ness). User profiles (age, sex and completion rates) were also compared. RESULTS: Clinician-assisted patients were more likely to be male, older, and have lower health and resilience scores at baseline. Clinician-assisted patients had notably higher completion rates (99.2% vs. 10.8%). Psychological outcomes (improved health and resilience, and well-being) were similar regardless of intervention method for those who completed the intervention. Behavioral outcomes revealed clinician-assisted patients set goals that better adhered to key goal-setting items. CONCLUSIONS: Clinician-patient relationships appear to be an important factor for intervention completion and behavioral outcomes, while further exploration of best practices for intervention completion using health apps in clinical practice is needed. A preliminary goal-setting methodology for effective behavioral activation, to promote brain health and wellness, is given.

Toward a learning-to-performance program for interprofessional long-term care teams: Team Essentials to foster engagement, reciprocity, and meaningful, sustained practice change.

This paper presents the design, delivery, and preliminary evaluation of a gerontological learning-to-performance program. An interprofessional educational team sought to integrate leading clinical and educational practices into Team Essentials to engage long-term care teams in learning to improve performance. Although the association between skilled, trained staff and quality of care is well-established in research, how best to engage learners from an increasingly diverse workforce is less well understood. This paper outlines the context, framework, methods, and preliminary evaluation of the program. Data from participant surveys, interviews, and field notes suggest that program content and delivery positively impacted participants. Four major themes emerged: Enabling engagement through experiential learning; Valuing reciprocity in long-term care training; Creating meaningful change through significant learning; and, Fostering sustained practice change through leadership involvement. The paper concludes with implications for LTC workforce training.

Ultrastructure and cytochemistry of intrauterine embryonic and larval stages of Ityogonimus lorum (Digenea: Brachylaimidae) involving transitory development of ciliated miracidia.

Results of the present study provide ultrastructural evidence that miracidial morphogenesis is fully completed within the intrauterine eggs while in the most posterior uterine regions of Ityogonimus lorum, a digenean parasite of an Iberian mole, Talpa occidentalis (Eulipotyphla, Talpidae). Using transmission electron microscopy (TEM), the ultrastructural characteristics of diverse cell types and their organelles of these developing embryos and fully formed miracidia within the eggshell were examined. The eggshell and embryonic envelopes are similar to those described previously by many authors for other digeneans. However, the developing miracidia are unique among previously described digeneans in possessing transitory cilia during larvigenesis, but completely lacking cilia in fully formed miracidium larvae. The evidence for completion of miracidial maturation in intrauterine eggs is based on the presence of the following structures: (1) transitional stage of ciliated differentiating miracidial epithelium; (2) apical and lateral glands, characteristic for digenean miracidia; and (3) fully developed germinative cells grouped together in the germinative sac localized in the posterior region of the miracidium. The protonephridial system with its characteristic flame cells and the nervous system with diverse types of neurons and nerve centers, which are characteristic for other digenean species reported until now, are absent from all these developmental stages of I. lorum. Based on these observations, we hypothesize that the life cycle of I. lorum is entirely terrestrial, involving passive transmission by ingestion of eggs containing unciliated miracidia to the first intermediate host.

Meaning-Centered Men's Groups: Initial Findings of an Intervention to Enhance Resiliency and Reduce Suicide Risk in Men Facing Retirement.

Objectives: To assess the preliminary effectiveness of Meaning-Centered Men's Groups (MCMG), a 12-session existentially-oriented, community-based, psychological group intervention designed to enhance psychological resiliency and prevent the onset or exacerbation of suicide ideation among men who are concerned about or struggling with the transition to retirement.Methods: We recruited 30 men (n= 10 per group), 55 years and older (M= 63.7, SD= 4.1) from community settings to participate in a course of MCMG to be delivered in a community center. Participants completed eligibility, pre-, mid-, and post-group assessments of suicide ideation and psychological risk and resiliency factors.Results: Participants experienced significant increases in attitudinal sources of meaning in life, psychological well-being, life satisfaction, retirement satisfaction, and general health, and decreases in depression, hopelessness, loneliness, and suicide ideation.Conclusions: Preliminary findings suggest that MCMG is a novel men's mental health intervention that may help to enhance psychological well-being and potentially reduce the severity or prevent the onset of symptoms of depression, hopelessness, and suicide ideation.Clinical Implications: Upstream psychological interventions may serve an important role in mental health promotion and suicide prevention with potentially vulnerable individuals facing challenging life transitions.

The Fountain of Health: effective health promotion knowledge transfer in individual primary care and group community-based formats.

ABSTRACTBackground:The Fountain of Health (FoH) initiative is a knowledge transfer (KT) project on the science of brain health and resilience promotion, in alignment with positive psychiatry. OBJECTIVES: Assess the effectiveness of FoH KT delivered in individual and group-based formats. DESIGN: Pre- and post-intervention quality assurance survey of FoH KT. SETTING: Interventions occurred in Nova Scotia, Canada. PARTICIPANTS: Adults over age 50 years without pre-existing dementia were targeted. A total of 92 participants received FoH KT in individualized (n = 41) and group-based (n = 51) formats. INTERVENTION: FoH KT (e.g. sharing evidence, lifestyle coaching, and goal setting) using a range of KT supports (e.g. FoH website, paper materials) was delivered to (1) individual patients by primary care clinicians and (2) community-based groups by lay leaders. MEASUREMENTS: The main outcome measure was participant pre- and post-quality assurance self-reports. RESULTS: Improvements were found in participant awareness of FoH, knowledge of evidence-based mental health promotion initiatives, and in application of this information in daily life in both individual and group-based settings. Improvements in participant knowledge about epigenetic factors that impact health and confidence with health behavior goal setting were reported in both contexts. Changes in self-perceptions of aging scores reached significance in the group intervention. CONCLUSIONS: FoH KT produced short-term positive self-reported changes in participants in both individual and group formats. Larger control studies with long-term follow up are needed to better assess effects of both individual and group formats of FoH KT and longer term impacts on health behaviors and outcomes.

The Effect of Intravenous Citalopram on the Neural Substrates of Obsessive-Compulsive Disorder.

This study investigated the effect of an intravenous serotonin reuptake inhibitor on the neural substrates of obsessive-compulsive disorder (OCD), as intravenous agents may be more effective in treating OCD than conventional oral pharmacotherapy. Eight OCD subjects and eight control subjects received alternate infusions of citalopram and placebo during functional magnetic resonance imaging, in a randomized, symptom-provocation, crossover design. Compared with baseline, OCD subjects displayed significant changes in prefrontal neural activity after the citalopram infusion relative to placebo, and these changes correlated with reductions in subjective anxiety.

Functional ultrastructure of eggs and cellular organization of hexacanths of the cyclophyllidean cestode Thysanotaenia congolensis: a phylogenetic implication of obtained results.

The functional ultrastructure of eggs and cellular organization of hexacanths from gravid proglottids of Thysanotaenia congolensis, from black rats from Cape Verde, were examined by transmission electron microscopy. Mature eggs with fully formed hexacanths are grouped within parenchymatous capsules of gravid proglottids. Oncospheral envelopes surrounding mature hexacanths are reduced to a very thin membranous embryophore as their protective function is taken over by the parenchymatous capsules originating from the medullary parenchyma of immature proglottids and composed of three layers. Six major cell types are present: a bi-nucleate medullary centre; a six-nucleate U-shaped penetration gland; a second type of penetration gland; two neurosecretory-type nerve cells; about 30 somatic cells; and about 12 germinative cells. Present results on the functional ultrastructure of eggs and cellular organization of hexacanths support the phylogenetic distinction between T. congolensis and cestodes of the subfamily Anoplocephalinae.

Ultrastructural study of the egg wall surrounding the developing miracidia of the digenean Prosotocus confusus (Looss, 1894) (Plagiorchiida: Pleurogenidae), with the description of a unique cocoon-like envelope.

Helminth eggs play a critical role in movement of the parasite from definitive to intermediate host. Eggs of the pleurogenid digenean trematode Prosotocus confusus (Looss, 1894), a parasite of naturally infected frogs Pelophylax lessonae (Amphibia: Ranidae) in Europe, are described here for the first time. Particular emphasis is placed on the ultrastructure on the egg wall and on the detailed description of a unique cocoon-like envelope. Each embryonating egg is composed of an early embryo surrounded by a four-layered egg wall: (1) an outer, anucleate layer external to the eggshell, which forms a thick cocoon; (2) the operculate eggshell; (3) not fully formed, a differentiating outer embryonic envelope containing large nuclei of macromeres; and (4) situated below, an undifferentiated layer of the future inner embryonic envelope containing mesomere nuclei. Layers enveloping the egg apparently play an important role in the protection, metabolism, and storage of nutritive reserves for the developing miracidium. The outer anucleate layer, or cocoon, is situated externally to the eggshell and composed of an electron-lucent substance with numerous electron-dense islands attached to its peripheral membrane. A cocoon envelope such as this has never been seen in previous TEM studies of the eggs of parasitic platyhelminths, with the exception of another pleurogenid Brandesia turgida. The origin, formation, functional ultrastructure, and chemical composition of this peculiar layer remain enigmatic, although its function appears to be protective. The thick, electron-dense eggshell resembles that of other trematodes, exhibiting a characteristic fissure zone around the operculum. Numerous lysosome-like structures observed in some eggs may be involved in the autolysis of both the embryonic envelopes (particularly the early degeneration of macromere nuclei of the outer envelope, characteristic for this species) and in the disintegration of several early micromeres. The inner envelope, which forms later from mesomeres, persists longer during embryogenesis.

Functional ultrastructure of the parenchymatic capsules of the cestode Thysanotaenia congolensis (Cyclophyllidea, Anoplocephalidae, Inermicapsiferinae).

Proglottids from adult Thysanotaenia congolensis from naturally infected black rats Rattus rattus from Santiago Island, Cape Verde, were examined by transmission electron microscopy (TEM). The uterus in mature proglottids is composed of an ephemeral transverse tube or sac that breaks down, releasing eggs into the parenchyma where they are sequestered in groups and encapsulated by parenchymatous layers. In gravid proglottids, eggs accumulate in groups of 6-12 at the distal end of sac-like uterine ducts. As eggs accumulate, the end of the uterine ducts expands until it pinches off, releasing groups of eggs into the parenchyma surrounded by remnants of uterine epithelium. These epithelium-bound groups of eggs remain in the parenchyma until they are encapsulated with several parenchymatous layers, forming parenchymatic egg capsules, typical for mature and gravid proglottids of Inermicapsiferinae. The parenchymatic capsules originate from the medullary parenchyma of immature proglottids, which undergoes differentiation into the three layers of gravid proglottids: (1) an outer connective tissue layer composed of long delicate filaments of unknown chemical nature embedded in a granular extracellular matrix; (2) a middle layer appearing as an accumulation of large closely packed PAS-positive mucous goblets that are intensely metachromatic after toluidine blue staining and (3) an inner compact layer composed of lipid-containing cells, muscle cells with elongated muscle fibres and cells of various sizes and shapes forming or containing calcareous corpuscles. The mature hexacanths of T. congolensis are surrounded by reduced oncospheral envelopes consisting of remnants of a very thin membranous layer of degenerating embryophore with long, irregularly shaped cytoplasmic processes and by remnants of uterine epithelium extending as numerous apical microlamellae into the parenchymatic capsule lumen.

Ultrastructural evidence for completion of the entire miracidial maturation in intrauterine eggs of the digenean Brandesia turgida (Brandes, 1888) (Plagiorchiida: Pleurogenidae).

Results of this TEM study provide ultrastructural evidence that miracidial morphogenesis is fully completed within the intrauterine eggs situated in the most posterior uterine regions of the pleurogenid trematode Brandesia turgida (Brandes, 1888). The ultrastructural characteristic of different larval organelles and cell types of these eggshell-enclosed, but fully formed, cilated miracidia is described. The body wall of the pyriform mature miracidium of B. turgida is composed of ciliated epidermis and underlying peripheral body musculature. Two miracidial flame cells of the protonephridial excretory system are localized in the central region of the ciliated larvae. Three types of miracidial glands were observed: a single apical gland, two lateral glands, and several small vesiculated glands; each gland type contains characteristic, but different types of secretory granules. The anterior end of each miracidium consists of an apical papilla on which are situated the exits of the three main larval glands: an exit of a single apical gland as well as the individual exits of two lateral glands. The exits of vesiculated glands, containing characteristic spherical membrane-bound and highly electron-dense granules, evidently different from the two other types of secretory granules of apical and lateral glands, were not identified. Germinative cells, grouped together in a sac-like germinative follicle, are situated in the medioposterior part of the larva, the germatophore. The germinative cells contain numerous electron-dense heterochromatin islands arranged in the form of a network or chain-like pattern and distributed mainly in the karyoplasm adjacent to the nuclear membrane. The thin layer of granular cytoplasm is rich in free ribosomes and contains a few small mitochondria. Both nuclear and cytoplasmic features if these cells indicate their great developmental potential for further growth and multiplication in postembryonic stages of the life cycle. In the mature eggs, the areas of focal cytoplasmic degradation were frequently observed and may be involved in the autolysis of some embryonic structures. Obtained results are compared with available literature data on the functional ultrastructure of the miracidia of other digeneans.

Can 'What Is Known' about Social Isolation and Loneliness Interventions Sufficiently Inform the Clinical Practice of Health Care and Social Service Professionals Who Work with Older Adults? Exploring Knowledge-to-Practice Gaps.

Establishing intervention effectiveness is an important component of a broader knowledge translation (KT) process. However, mobilizing the implementation of these interventions into practice is perhaps the most important aspect of the KT cycle. The purpose of the current study was to conduct an umbrella review to (a) identify promising interventions for SI&L in older adults, (b) interpret (translate) the findings to inform clinical knowledge and practice interventions in different settings and contexts, and (c) highlight research gaps that may hinder the uptake of these interventions in practice. The broader purpose of this study was to inform evidence-based clinical practice guidelines on SI&L for HCSSPs. In line with other reviews, our study noted variations in methods and intervention designs that prohibit definitive statements about intervention effectiveness. Perhaps, the most significant contribution of the current review was in identifying knowledge-to-practice gaps that inhibit the implementation of interventions into practice-based realities.

Timely Yet Long Overdue: Canadian Standards for Long-Term Care Homes.

The impact of the COVID-19 pandemic highlighted systemic problems in Canadian long-term care (LTC). While high mortality rates in LTC received significant attention, the pandemic also took an enormous toll on mental health of LTC residents, where mental health conditions, including cognitive disorders, are already much higher than in other community settings. The pandemic resulted in a renewed interest in improving quality of care in LTC and led to the recent development of several National Standards of Canada. The newly available Standards set ambitious targets, but many of the standards are practical and essential to moving beyond a focus on safety and physical needs in LTC and towards one that supports residents as whole persons. While the standards support good mental health indirectly, there is a need to recognize mental health in these settings as a fundamental human right and essential to quality of life, and for this to be reflected in ongoing and future standards development. Ensuring existing and forthcoming National Standards are meaningfully implemented, in whole or in part, will require extensive efforts at multiple levels. The guidance provided by Canadian Standards will shape this transformative process, necessitating aligned federal and provincial investments and policies, and stakeholder engagement to bring about the envisioned high-quality care.

Program evaluation of a telepsychiatry service for older adults connecting a university-affiliated geriatric center to a rural psychogeriatric outreach service in Northwest Ontario, Canada.

BACKGROUND: Weekly telepsychiatry consultations have been provided since 2002 to six communities in Northwest Ontario. Staff from a single community psychogeriatric outreach service who work within these communities facilitate the referrals. METHODS: The program evaluation included (a) a chart review of the last 100 referrals, (b) analysis of patient and staff evaluations, (c) a survey mailed to all physicians in referring communities, and (d) three focus groups of staff working in local community agencies. RESULTS: The mean age at the time of consultation was 76.7 years. Sixty-eight percent of patients were females. The most frequent diagnoses were dementia (54%), depression (28%), and mild cognitive impairment (19%). The most frequent medication recommendations were antidepressants or cholinesterase inhibitors. Two hundred ninety-four patient assessments and case consultations were carried out between 2002 and 2009. Post-session evaluation surveys rated the provision of information, whether objectives were met, and overall usefulness of recommendations. The mean scores for these questions on a 5-point scale were between 4.6 and 4.85. Referring physicians were confident and satisfied with the recommendations made for their patients. All planned to continue to use telepsychiatry as a care option for the future. The focus groups added useful information about challenges and potential barriers to utilizing the program. CONCLUSIONS: The program was rated as being highly valued across all modalities of evaluation. Members of the referring team believe that access to a geriatric psychiatrist has broadened the team's knowledge base, its use of assessment tools, and increased their ability to better construct their patients' treatment plans.

Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review.

BACKGROUND: Medications are frequently prescribed for neuropsychiatric symptoms (NPS) associated with dementia, although information on the efficacy and safety of medications for NPS specifically in long-term care (LTC) settings is limited. The objective of this study was to provide a current review of the efficacy and safety of pharmacological treatments for NPS in LTC. METHODS: We searched MEDLINE, EMBASE, PsychINFO, and the Cochrane Library for randomized controlled trials comparing medications with either placebo or other interventions in LTC. Study quality was described using the Cochrane collaboration risk of bias tool. The efficacy of medications was evaluated using NPS symptom rating scales. Safety was evaluated through rates of trial withdrawals, trial withdrawals due to adverse events, and mortality. RESULTS: A total of 29 studies met inclusion criteria. The most common medications evaluated in studies were atypical antipsychotics (N = 15), typical antipsychotics (N = 7), anticonvulsants (N = 4), and cholinesterase inhibitors (N = 3). Statistically significant improvements in NPS were noted in some studies evaluating risperidone, olanzapine, and single studies of aripiprazole, carbamazepine, estrogen, cyproterone, propranolol, and prazosin. Study quality was difficult to rate in many cases due to incomplete reporting of details. Some studies reported higher rates of trial withdrawals, adverse events, and mortality associated with medications. CONCLUSIONS: We conclude that there is limited evidence to support the use of some atypical antipsychotics and other medications for NPS in LTC populations. However, the generally modest efficacy and risks of adverse events highlight the need for the development of safe and effective pharmacological and non-pharmacological interventions for this population.

Impacts of medical and non-medical cannabis on the health of older adults: Findings from a scoping review of the literature.

BACKGROUND: Cannabis legalization has enabled increased consumption in older adults. Age-related mental, physical, and physiological changes may lead to differences in effects of cannabis in older adults compared to younger individuals. OBJECTIVE: To perform a scoping review to map the evidence regarding the health effects of cannabis use for medical and non-medical purposes in older adults. METHODS: Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched for systematic reviews (SRs), randomized controlled trials (RCTs) and non-randomized/observational studies (NRSs) assessing the health effects and associations of cannabis use (medical or non-medical) in adults ≥ 50 years of age. Included studies met age-related inclusion criteria or involved a priori identified health conditions common among older adults. Records were screened using a liberal accelerated approach and data charting was performed independently by two reviewers. Descriptive summaries, structured tables, effect direction plots and bubble plots were used to synthesize study findings. FINDINGS: From 31,393 citations, 133 publications describing 134 unique studies (26 SRs, 36 RCTs, 72 NRSs) were included. Medical cannabis had inconsistent therapeutic effects in specific patient conditions (e.g., end-stage cancer, dementia), with a number of studies suggesting possible benefits while others found no benefit. For medical cannabis, harmful associations outnumbered beneficial, and RCTs reported more negative effects than NRSs. Cannabis use was associated with greater frequencies of depression, anxiety, cognitive impairment, substance use and problematic substance use, accidents/injuries, and acute healthcare use. Studies often were small, did not consistently assess harms, and did not adjust for confounding. DISCUSSION: The effects of medical cannabis are inconsistent within specific patient conditions. For older adults, generally, the available evidence suggests cannabis use may be associated with greater frequencies of mental health issues, substance use, and acute healthcare use, and the benefit-to-risk ratio is unclear. Studies with a balanced assessment of benefits and harms may guide appropriate public health messaging to balance the marketing pressures of cannabis to older adults.