Early Clinical Exposure to Geriatric Psychiatry and Medical Students' Interest in Caring for Older Adults: A Randomized Controlled Trial.

OBJECTIVE: In the next 25 years, the population aged 65 and older will nearly double in many countries, with few new doctors wishing to care for older adults. The authors hypothesize that early clinical exposure to elderly patient care could increase student interest in caring for older adults during their future career. METHODS: The authors conducted a pragmatic medical education randomized controlled trial (RCT) at the Jewish General Hospital and the Douglas Mental Health Institute, McGill University, in Montreal, Canada. Third-year medical students undergoing their mandatory 16-week half-time clerkship rotation in psychiatry were randomly assigned to the equivalent of 2-4 weeks of full-time exposure to clinical geriatric psychiatry (n = 84). RESULTS: Being randomly assigned to geriatric psychiatry exposure (n = 44 of 84) was associated with increased "comfort in working with geriatric patients and their families" at 16-week follow-up (59.1% versus 37.5%, χ2 (1) = 3.9; p = 0.05). However, there was no significant association found between geriatric psychiatry exposure and change "in interest in caring for older adults," or change in "interest in becoming a geriatric psychiatrist." CONCLUSION: The results of this pragmatic education RCT suggest that exposing third-year medical students to 2-4 weeks of geriatric psychiatry did not increase their interest to care for older adults or become a geriatric psychiatrist. However, it did increase their comfort level in working with older adults and their families. However, more research is necessary to identify potential interventions that could inspire and increase medical student interest in caring for older adults as part of their future careers.

Feasibility and acceptability of an iPad intervention to support dementia care in the hospital setting.

BACKGROUND: Staying in the hospital can be a very stressful experience for older people with dementia. A familiar face and reassuring voice of a family member or friend can offer a sense of safety and comfort. AIMS: To explore the feasibility and acceptability of using an iPad Simulated Presence Therapy intervention with hospitalized older people with dementia. DESIGN: We used a mixed-method design, incorporated video-ethnographic methods, video-recorded observations, and staff interviews. METHODS: Four people with dementia from an older adult mental health hospital unit in British Columbia, Canada participated in two weeks of iPad Simulated Presence Therapy intervention. The intervention involved the older person watching a one-minute video prepared by their family prior to receiving care. The video included a reassuring, comforting and supportive message to be played to the older adult with dementia while staff perform a specific care task. The care interactions with the iPad intervention were video-recorded. Staff interviews were conducted to elicit perceived enabling factors and barriers to use the iPad intervention in their practice. Using an inductive and deductive approach, we applied a qualitative thematic analysis to identify themes in our data set. RESULTS: We identified four themes: (a) positive responses, (b) person-centred care, (c) video content, and (d) technical skills. CONCLUSION: The iPad delivered Simulated Presence Therapy is an acceptable and feasible means of supporting the care of older people with dementia in the hospital setting. Considerations for future research and clinical practice are presented.

Changes in mindfulness following repetitive transcranial magnetic stimulation for mood disorders.

OBJECTIVE: Mindfulness practices are associated with changes in different cortical regions, including the dorsolateral prefrontal cortices (DLPFCs). Our study sought to examine how an index course of repetitive transcranial magnetic stimulation (rTMS) over the DLPFC improved components of mindfulness as assessed by Baer's Five Facet Mindfulness Questionnaire (FFMQ) and the Experience Questionnaire (EQ). METHOD: Our preliminary study is a retrospective chart review of 32 patients who had undergone an index course of rTMS for major depressive episode between 2009 and 2012. The following information was collected prior to rTMS: patient demographics, diagnosis, and age of onset of primary diagnosis. The following information was collected prior to and after rTMS: 21-item Hamilton Rating Scale for Depression (HRSD) scores, Patient-Health Questionnaire (PHQ-9) scores, Generalized Anxiety Disorder 7-item (GAD-7) scale scores, FFMQ scores, and EQ scores. RESULTS: Following rTMS, results showed statistically significant decreases in HRSD, PHQ-9, and GAD-7 scores. There was significant improvement in the nonreactivity to inner experience subscale of the BFFMQ and in the decentring subscale of the EQ. Subgroup analysis between patients who did not improve on the HRSD by 50% or more following rTMS and those who did revealed no baseline difference in mindfulness. There was significant improvement in the decentring subscale of the EQ in both subgroups. CONCLUSIONS: Our study provides preliminary data that rTMS may be associated with improvement in some components of mindfulness, independently of changes in depression.

Objectif : Les pratiques de pleine conscience sont associées à des changements dans différentes régions corticales, notamment les cortex préfrontaux dorsolatéraux (CPFDL). Notre étude cherchait à examiner comment un traitement indiciel de stimulation magnétique transcrânienne répétitive (SMTr) sur le CPFDL améliorait les composantes de la pleine conscience telles qu'évaluées par le questionnaire de pleine conscience en 5 facettes (FFMQ) de Baer et le questionnaire sur l'expérience (EQ). Méthode : Notre étude préliminaire est une revue rétrospective des dossiers de 32 patients qui ont subi un traitement indiciel de SMTr pour un épisode de dépression majeure entre 2009 et 2012. Les renseignements suivants ont été recueillis avant la SMTr : données démographiques des patients, diagnostic et âge à l'apparition du diagnostic primaire. Les renseignements suivants ont été recueillis avant et après la SMTr : les scores à l'échelle de dépression en 21 items d'Hamilton (HRSD), les scores au questionnaire patient-santé (PHQ-9), les scores à l'échelle en 7 items du trouble d'anxiété généralisée (GAD-7), les scores au FFMQ, et les scores au EQ. Résultats : Après la SMTr, les résultats ont montré des diminutions statistiquement significatives des scores à la HRSD, au PHQ-9, et à la GAD-7. Il y a eu une amélioration significative de la non-réactivité à la sous-échelle de l'expérience intérieure du FFMQ et à la sous-échelle de décentration de l'EQ. L'analyse de sous-groupe entre les patients qui ne se sont pas améliorés de 50 % ou plus à la HRSD après la SMTr et ceux qui se sont améliorés n'a révélé aucune différence de pleine conscience au départ. Il y avait une amélioration significative à la sous-échelle de décentration de l'EQ dans les deux sous-groupes. Conclusions : Notre étude propose des données préliminaires selon lesquelles la SMTr peut être associée à une amélioration de certaines composantes de la pleine conscience, indépendamment des changements dans la dépression.

Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and metaanalysis.

OBJECTIVE: Systematic reviews show that repetitive transcranial magnetic stimulation (rTMS) is superior to sham control conditions in patients with major depressive disorder, but the clinical relevance is not clear. None have specifically examined outcomes in patients with treatment-resistant depression (TRD). METHOD: A systematic review was conducted by identifying published randomized controlled trials of active rTMS, compared with a sham control condition in patients with defined TRD (that is, at least one failed trial). The primary outcome was clinical response as determined from global ratings, or 50% or greater improvement on a rating scale. Other outcomes included remission and standardized mean differences in end point scores. Metaanalysis was conducted for absolute risk differences using random effects models. Sensitivity and subgroup analyses were also conducted to explore heterogeneity and robustness of results. RESULTS: A total of 24 studies (n = 1092 patients) met criteria for quantitative synthesis. Active rTMS was significantly superior to sham conditions in producing clinical response, with a risk difference of 17% and a number-needed-to-treat of 6. The pooled response and remission rates were 25% and 17%, and 9% and 6% for active rTMS and sham conditions, respectively. Sensitivity and subgroup analyses did not significantly affect these results. Dropouts and withdrawals owing to adverse events were very low. CONCLUSIONS: For patients with TRD, rTMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before rTMS can be considered as a first-line monotherapy treatment for TRD.