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.

Outcomes of a Medication Optimization Virtual Interdisciplinary Geriatric Specialist (MOVING) Program: A Feasibility Study.

BACKGROUND: Adverse drug events among older adults result in significant mortality, morbidity and cost. This harm may be mitigated with appropriate prescribing and deprescribing. We sought to understand the prescribing outcomes of an interdisciplinary geriatric virtual consultation service. METHODS: We conducted a retrospective, before-and-after feasibility study to measure prescribing outcomes for a medication optimization virtual interdisciplinary geriatric specialist (MOVING) programme comprised of expertise from geriatric clinical pharmacology, pharmacy and psychiatry for older adults (aged ≥ 65 years) between June and December 2018, Ontario, Canada. The primary outcome was the number of distinct prescriptions and the presence of polypharmacy (defined as ≥ 4 medications) before and after the service. Secondary outcomes included the number of as needed and regularly administered prescriptions, number of potentially inappropriate prescriptions as defined by the Beers and STOPP criteria, and number of prescriptions for psychotropics, long-acting opioids and diabetic medications. RESULTS: We studied 40 patients with a mean age of 80.6 [standard deviation (SD) 8.8] years who received a MOVING consult. We found no significant change in the mean total number of prescriptions per patient before (12.02, SD 5.83) and after the intervention (11.58, SD 5.28), with a mean difference of -0.45 [95% confidence interval (CI) -0.94 to 0.04; p = 0.07]. We found statistically significant decreases in as needed prescriptions (mean difference - 0.30, 95% CI - 0.45 to - 0.15; p<0.001), and potentially harmful medications as identified by the Beers (mean difference -1.25, 95% CI -2.00 to -0.50; p = 0.002) and STOPP (mean difference -1.65, 95% CI -2.33 to -0.97; p < 0.001) scores. Without including the cost savings from hospital diversion by a MOVING consult, the costs of a MOVING consult were $545.80-$629.80 per person, compared with the costs associated with traditional in-person consults involving similar specialist clinical services ($904.89-$1270.69 per person). CONCLUSION: A MOVING model of care is associated with decreases in prescriptions for potentially inappropriate medications in older adults. These findings support further evaluation to ascertain health system impacts.

Position Statement for Mental Health Care in Long-Term Care During COVID-19.

COVID-19 has disproportionately impacted older adults in long-term care (LTC) facilities in Canada. There are opportunities to learn from this crisis and to improve systems of care in order to ensure that older adults in LTC enjoy their right to the highest attainable standard of health. Measures are needed to ensure the mental health of older adults in LTC during COVID-19. The Canadian Academy of Geriatric Psychiatry (CAGP) and Canadian Coalition for Seniors' Mental Health (CCSMH) have developed the following position statements to address the mental health needs of older adults in LTC facilities, their family members, and LTC staff. We outlined eight key considerations related to mental health care in LTC during COVID-19 to optimize the mental health of this vulnerable population during the pandemic.

Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long-Term Care.

Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside.

One Size Does Not Fit All: Choosing Practical Cognitive Screening Tools for Your Practice.

Every year, millions of patients worldwide undergo cognitive testing. Unfortunately, new barriers to the use of free open access cognitive screening tools have arisen over time, making accessibility of tools unstable. This article is in follow-up to an editorial discussing alternative cognitive screening tools for those who cannot afford the costs of the Mini-Mental State Examination and Montreal Cognitive Assessment (see www.dementiascreen.ca). The current article outlines an emerging disruptive "free-to-fee" cycle where free open access cognitive screening tools are integrated into clinical practice and guidelines, where fees are then levied for the use of the tools, resulting in clinicians moving on to other tools. This article provides recommendations on means to break this cycle, including the development of tool kits of valid cognitive screening tools that authors have contracted not to charge for (i.e., have agreed to keep free open access). The PRACTICAL.1 Criteria (PRACTIcing Clinician Accessibility and Logistical Criteria Version 1) are introduced to help clinicians select from validated cognitive screening tools, considering barriers and facilitators, such as whether the cognitive screening tools are easy to score and free of cost. It is suggested that future systematic reviews embed the PRACTICAL.1 criteria, or refined future versions, as part of the standard of review. Methodological issues, the need for open access training to insure proper use of cognitive screening tools, and the need to anticipate growing ethnolinguistic diversity by developing tools that are less sensitive to educational, cultural, and linguistic bias are discussed in this opinion piece. J Am Geriatr Soc 68:2207-2213, 2020.

Anticonvulsants for behavioral and psychological symptoms in dementia: protocol for a systematic review.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are present in a majority of patients with dementia contributing to increased morbidity, health care costs, and caregiver burden. While there are no United States Food and Drug Administration (FDA)-approved medications for these symptoms, off-label use of medications such as antipsychotics have been shown to have significant adverse effects including increased mortality. The goal of this review is to examine the efficacy and safety of anticonvulsants in the treatment of BPSD. METHODS: We will systematically search for randomized trials of anticonvulsants compared to placebo or other treatments such as antidepressants and antipsychotics from the following sources: The Cochrane Library, MEDLINE (OVID SP) in Process and Other Non-Indexed Citations (latest version), EMBASE, clinicalTrials.gov , and the WHO Clinical Trials Registry. The studies will be limited to those published in English but the study location can be worldwide. We will include studies pertaining to individuals with dementia and symptoms of BPSD. The primary outcomes will be behavioral change as measured by validated scales and secondary outcomes will include caregiver burden, quality of life, placement in long term care facility, serious adverse effects, and treatment discontinuation due to adverse effects. Two sets of reviewers will independently screen select and extract data. We will narratively describe the major findings and conclusions from individual studies. Patients who are prescribed antiepileptic drugs (AEDs) for other indications, including seizures, will be excluded. Outcomes of interest will include a change in a validated scale that measures BPSD, serious adverse events, and caregiver quality of life outcomes. If the data are found to be appropriate for a meta-analysis, we will use a random effects model to compute summary estimates of treatment effects. DISCUSSION: This is a protocol for a systematic review addressing the anticonvulsant group of medications as a whole, and as such, our results will inform current clinical practice in the use of anticonvulsants for BPSD. It will also help clinicians and policy makers compare the efficacy of anticonvulsants compared to antidepressants and antipsychotics as well as identify areas which will need further study. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017079826.

GeriMedRisk, a telemedicine geriatric pharmacology consultation service to address adverse drug events in long-term care: a stepped-wedge cluster randomized feasibility trial protocol (ISRCTN17219647).

BACKGROUND: Multimorbidity, polypharmacy, and older age predispose seniors to adverse drug events (ADE). Seniors with an ADE experience greater morbidity, mortality, and health care utilization compared to their younger counterparts. To mitigate and manage ADEs among this vulnerable population, we designed a geriatric pharmacology consultation service connecting clinicians with specialist physicians and pharmacists and will investigate the feasibility and acceptability of this complex intervention in the long-term care setting, prior to conducting a larger efficacy trial. METHODS/DESIGN: We will conduct a cluster randomized feasibility trial and qualitative analysis of GeriMedRisk among four long-term care homes in the Waterloo-Wellington region from May 1 to December 31, 2017. The primary outcome is the feasibility and acceptability of GeriMedRisk and the stepped-wedge cluster randomized controlled trial design. We hypothesize that GeriMedRisk is a feasible intervention and its potential to decrease falls and drug-related hospital visits can be evaluated with a stepped-wedge cluster randomized controlled trial design. DISCUSSION: This mixed methods study will inform a larger efficacy trial of GeriMedRisk's ability to decrease adverse drug events among seniors in the long-term care setting. ETHICS AND DISSEMINATION: The Hamilton Integrated Research Ethics Board granted the approval for this study protocol 2812. We plan to disseminate the results of this study in peer-reviewed journals and also to our partners and stakeholders. TRIAL REGISTRATION: ISRCTN clinical trials registry, ISRCTN17219647 (March 27, 2017).

Clinical characteristics associated with the onset of delirium among long-term nursing home residents.

BACKGROUND: Nursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Most of the existing evidence base on delirium is derived from studies in the acute in-patient population. We examine the association between clinical characteristics and medication use with the incidence of delirium during the nursing home stay. METHODS: This is a retrospective cohort study of 1571 residents from 12 nursing homes operated by a single care provider in Ontario, Canada. Residents were over the age of 55 and admitted between February 2010 and December 2015 with no baseline delirium and a minimum stay of 180 days. Residents with moderate or worse cognitive impairment at baseline were excluded. The baseline and follow-up characteristics of residents were collected from the Resident Assessment Instrument-Minimal Data Set 2.0 completed at admission and repeated quarterly until death or discharge. Multivariate logistic regression was used to identify characteristics and medication use associated with the onset of delirium. RESULTS: The incidence of delirium was 40.4% over the nursing home stay (mean LOS: 32 months). A diagnosis of dementia (OR: 2.54, p < .001), the presence of pain (OR: 1.64, p < .001), and the use of antipsychotics (OR: 1.87, p < .001) were significantly associated with the onset of delirium. Compared to residents who did not develop delirium, residents who developed a delirium had a greater increase in the use of antipsychotics and antidepressants over the nursing home stay. CONCLUSIONS: Dementia, the presence of pain, and the use of antipsychotics were associated with the onset of delirium. Pain monitoring and treatment may be important to decrease delirium in nursing homes. Future studies are necessary to examine the prescribing patterns in nursing homes and their association with delirium.

A Randomized Controlled Trial of Team-Based Learning Versus Lectures with Break-Out Groups on Knowledge Retention.

OBJECTIVE: This goal of this study was to evaluate the efficacy of team-based learning (TBL) on knowledge retention compared to traditional lectures with small break-out group discussion (teaching as usual (TAU)) using a randomized controlled trial. METHODS: This randomized controlled trial was conducted during a daylong conference for psychiatric educators on attention-deficit hyperactivity disorder and the research literacy topic of efficacy versus effectiveness trials. Learners (n = 115) were randomized with concealed allocation to either TBL or TAU. Knowledge was measured prior to the intervention, immediately afterward, and 2 months later via multiple-choice tests. Participants were necessarily unblinded. Data enterers, data analysts, and investigators were blinded to group assignment in data analysis. Per-protocol analyses of test scores were performed using change in knowledge from baseline. The primary endpoint was test scores at 2 months. RESULTS: At baseline, there were no statistically significant differences between groups in pre-test knowledge. At immediate post-test, both TBL and TAU groups showed improved knowledge scores compared with their baseline scores. The TBL group performed better statistically on the immediate post-test than the TAU group (Cohen's d = 0.73; p < 0.001), although the differences in knowledge scores were not educationally meaningful, averaging just one additional test question correct (out of 15). On the 2-month remote post-test, there were no group differences in knowledge retention among the 42 % of participants who returned the 2-month test. CONCLUSIONS: Both TBL and TAU learners acquired new knowledge at the end of the intervention and retained knowledge over 2 months. At the end of the intervention day and after 2 months, knowledge test scores were not meaningfully different between TBL and TAU completers. In conclusion, this study failed to demonstrate the superiority of TBL over TAU on the primary outcome of knowledge retention at 2 months post-intervention.

Does this patient have generalized anxiety or panic disorder?: The Rational Clinical Examination systematic review.

IMPORTANCE: In primary care settings, generalized anxiety disorder (GAD) and panic disorder are common but underrecognized illnesses. Identifying accurate and feasible screening instruments for GAD and panic disorder has the potential to improve detection and facilitate treatment. OBJECTIVE: To systematically review the accuracy of self-report screening instruments in diagnosing GAD and panic disorder in adults. DATA SOURCES: We searched MEDLINE, PsycINFO, and the Cochrane Library for relevant articles published from 1980 through April 2014. STUDY SELECTION: Prospective studies of diagnostic accuracy that compared a self-report screening instrument for GAD or panic disorder with the diagnosis made by a trained clinician using Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria. RESULTS: We screened 3605 titles, excluded 3529, and performed a more detailed review of 76 articles. We identified 9 screening instruments based on 13 articles from 10 unique studies for the detection of GAD and panic disorder in primary care patients Across all studies, diagnostic interviews determined that 257 of 2785 patients assessed had a diagnosis of GAD while 224 of 2637 patients assessed had a diagnosis of panic disorder. The best-performing test for GAD was the Generalized Anxiety Disorder Scale 7 Item (GAD-7), with a positive likelihood ratio of 5.1 (95% CI, 4.3-6.0) and a negative likelihood ratio of 0.13 (95% CI, 0.07-0.25). The best-performing test for panic disorder was the Patient Health Questionnaire, with a positive likelihood ratio of 78 (95% CI, 29-210) and a negative likelihood ratio of 0.20 (95% CI, 0.11-0.37). CONCLUSIONS AND RELEVANCE: Two screening instruments, the GAD-7 for GAD and the Patient Health Questionnaire for panic disorder, have good performance characteristics and are feasible for use in primary care. However, further validation of these instruments is needed because neither instrument was replicated in more than 1 primary care population.

AGTR1 gene variation: association with depression and frontotemporal morphology.

The renin-angiotensin system (RAS) is implicated in the response to physiological and psychosocial stressors, but its role in stress-related psychiatric disorders is poorly understood. We examined if variation in AGTR1, the gene coding for the type 1 angiotensin II receptor (AT(1)R), is associated with a diagnosis of depression and differences in white matter hyperintensities and frontotemporal brain volumes. Participants comprised 257 depressed and 116 nondepressed elderly Caucasian subjects who completed clinical assessments and provided blood samples for genotyping. We used a haplotype-tagging single nucleotide polymorphism (htSNP) analysis to test for variation in AGTR1. For measurement of hyperintense lesions, 1.5 Tesla magnetic resonance imaging (MRI) data were available on 33 subjects. For measurements of the hippocampus and dorsolateral prefrontal cortex (dlPFC), 3 Tesla MRI data were available on 70 subjects. Two htSNPs exhibited statistically significant frequency differences between diagnostic cohorts: rs10935724 and rs12721331. Although hyperintense lesion volume did not significantly differ by any htSNP, dlPFC and hippocampus volume differed significantly for several htSNPs. Intriguingly, for those htSNPs differing significantly for both dlPFC and hippocampus volume, the variant associated with smaller dlPFC volume was associated with larger hippocampal volume. This supports the idea that genetic variation in AGTR1 is associated with depression and differences in frontotemporal morphology.

Review of the use of mirtazapine in the treatment of depression.

INTRODUCTION: Depression is a heterogeneous illness affecting large numbers of patients with far reaching effects on both psychiatric and medical outcomes as well as quality of life. Knowledge about the different treatment modalities used to treat depression is important to all physicians. AREAS COVERED: This article expands on one such treatment option, mirtazapine. The paper examines this medication's medicinal chemistry, pharmacological properties as well as the efficacy of the medication compared to other commonly used antidepressants. EXPERT OPINION: Mirtazapine is a medication unlike other agents used for depression both in its mechanism of action as well as its side effects. Knowing these distinct characteristics will enable physicians to better utilize this agent for the benefit of their patients.

Structural neuroimaging of geriatric depression.

There is a large literature on the neuroanatomy of late-life depression that continues to grow with the discovery of novel structural imaging techniques along with innovative methods to analyze the images. Such advances have helped identify specific areas, characteristic lesions, and changes in the chemical composition in these regions that might be important in the pathophysiology of this complex disease. This article reviews relevant findings by each structural neuroimaging technique. When validated across many studies, such findings can serve as neuroanatomic markers that can help generate rational hypotheses for future studies to further understanding of geriatric depression.

Systematic review: factors associated with risk for and possible prevention of cognitive decline in later life.

BACKGROUND: Many biological, behavioral, social, and environmental factors may contribute to the delay or prevention of cognitive decline. PURPOSE: To summarize evidence about putative risk and protective factors for cognitive decline in older adults and the effects of interventions for preserving cognition. DATA SOURCES: English-language publications in MEDLINE, HuGEpedia, AlzGene, and the Cochrane Database of Systematic Reviews from 1984 through 27 October 2009. STUDY SELECTION: Observational studies with 300 or more participants and randomized, controlled trials (RCTs) with 50 or more adult participants who were 50 years or older, drawn from general populations, and followed for at least 1 year were included. Relevant, good-quality systematic reviews were also eligible. DATA EXTRACTION: Information on study design, outcomes, and quality were extracted by one researcher and verified by another. An overall rating of the quality of evidence was assigned by using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. DATA SYNTHESIS: 127 observational studies, 22 RCTs, and 16 systematic reviews were reviewed in the areas of nutritional factors; medical factors and medications; social, economic, or behavioral factors; toxic environmental exposures; and genetics. Few of the factors had sufficient evidence to support an association with cognitive decline. On the basis of observational studies, evidence that supported the benefits of selected nutritional factors or cognitive, physical, or other leisure activities was limited. Current tobacco use, the apolipoprotein E epsilon4 genotype, and certain medical conditions were associated with increased risk. One RCT found a small, sustained benefit from cognitive training (high quality of evidence) and a small RCT reported that physical exercise helps to maintain cognitive function. LIMITATIONS: The categorization and definition of exposures were heterogeneous. Few studies were designed a priori to assess associations between specific exposures and cognitive decline. The review included only English-language studies, prioritized categorical outcomes, and excluded small studies. CONCLUSION: Few potentially beneficial factors were identified from the evidence on risk or protective factors associated with cognitive decline, but the overall quality of the evidence was low. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality and the National Institute on Aging, through the Office of Medical Applications of Research, National Institutes of Health.

The brain-derived neurotrophic factor Val66Met polymorphism, hippocampal volume, and cognitive function in geriatric depression.

OBJECTIVE: The Val66Met polymorphism of the brain-derived neurotrophic factor (BDNF) gene is associated with geriatric depression. In studies of younger adults without depression, met allele carriers exhibit smaller hippocampal volumes and have poorer performance on neuropsychological tests. The authors examined the relationship between the BDNF gene and hippocampal volumes in depressed and nondepressed older individuals and its relationship with memory functions mediated by the hippocampus. DESIGN: One hundred seventy-six elderly depressed white participants and 88 nondepressed participants completed clinical assessments, neuropsychological testing, and provided blood samples for genotyping. One hundred seventy-three participants also underwent brain magnetic resonance imaging. Statistical modeling tested the relationship between genotype and hippocampal volume and function while controlling for diagnosis and other covariates. RESULTS: BDNF genotype was not associated with a difference in performance on tests mediated by the hippocampus, including word list learning, prose recall, nonverbal memory, or digit span. After controlling for covariates, BDNF genotype was not significantly associated with hippocampal volume (F[1, 171] = 1.10, p = 0.30). CONCLUSION: Despite different findings in younger populations, the BDNF Val66Met polymorphism is not significantly associated with hippocampal volume or function in a geriatric population. The authors hypothesize that other factors may have a stronger effect on hippocampal structure in older individuals and that the association between the Val66Met polymorphism and geriatric depression is mediated through other mechanisms.