Proton Therapy Mediates Dose Reductions to Brain Structures Associated With Cognition in Children With Medulloblastoma.

PURPOSE: Emerging evidence suggests proton radiation therapy may offer cognitive sparing advantages over photon radiation therapy, yet dosimetry has not been compared previously. The purpose of this study was to examine dosimetric correlates of cognitive outcomes in children with medulloblastoma treated with proton versus photon radiation therapy. METHODS AND MATERIALS: In this retrospective, bi-institutional study, dosimetric and cognitive data from 75 patients (39 photon and 36 proton) were analyzed. Doses to brain structures were compared between treatment modalities. Linear mixed-effects models were used to create models of global IQ and cognitive domain scores. RESULTS: The mean dose and dose to 40% of the brain (D40) were 2.7 and 4.1 Gy less among proton-treated patients compared with photon-treated patients (P = .03 and .007, respectively). Mean doses to the left and right hippocampi were 11.2 Gy lower among proton-treated patients (P < .001 for both). Mean doses to the left and right temporal lobes were 6.9 and 7.1 Gy lower with proton treatment, respectively (P < .001 for both). Models of cognition found statistically significant associations between higher mean brain dose and reduced verbal comprehension, increased right temporal lobe D40 with reduced perceptual reasoning, and greater left temporal mean dose with reduced working memory. Higher brain D40 was associated with reduced processing speed and global IQ scores. CONCLUSIONS: Proton therapy reduces doses to normal brain structures compared with photon treatment. This leads to reduced cognitive decline after radiation therapy across multiple intellectual endpoints. Proton therapy should be offered to children receiving radiation for medulloblastoma.

Attentional Engagement During Mobile Application Skill Learning Among Patients With Memory Impairment: A Case Series Exploration.

IMPORTANCE: Attentional engagement is essential for successful cognitive rehabilitation, but little is known about longitudinal interactions with skill learning. OBJECTIVE: To examine how attentional engagement is associated with mobile application skill learning for memory compensation. We hypothesized that patients with greater functional capacity would demonstrate faster learning and attentional engagement drop with skill acquisition, whereas patients with lesser functional capacity would have to maintain attentional engagement to progress throughout training. DESIGN: A case series approach was used with longitudinal skill learning and electroencephalographic (EEG) data recorded across multiple trials and sessions of mobile calendar application training. SETTING: The study was run in a hospital-based neuropsychology clinic. PARTICIPANTS: Seven participants (5 with acquired brain injury, 1 with mild cognitive impairment, and 1 healthy older adult) were recruited. INTERVENTION: Mobile application operation was trained for the purpose of memory compensation. Skill learning was facilitated through a structured rehabilitation protocol, including large amounts of guided practice with the integration of errorless learning. OUTCOMES AND MEASURES: We quantified learning using the proportion of application steps completed independently at each session. We measured attentional engagement using an EEG marker: the Brain Engagement Index. RESULTS: For fast learners, attentional engagement generally decreased as mobile application learning progressed. In contrast, slow learners exhibited stable engagement over time with consistent, yet much slower, progress in skill learning. CONCLUSIONS AND RELEVANCE: The present data indicate that when cognitive impairment is more substantial, skill learning may involve greater attentional engagement. What This Article Adds: Patients undergoing memory rehabilitation may benefit from methods to enhance attentional engagement during skill learning when executive dysfunction is a considerable element of their cognitive profile. Monitoring attentional engagement during cognitive rehabilitation may be useful in identifying and addressing barriers to learning in real time.

A Novel Instrument for Caregivers in Managing Neuropsychiatric Symptoms of Dementia: Baycrest Quick-Response Caregiver ToolTM.

Background: Family caregivers can experience significant stress related to behaviour changes in persons with dementia (PWD). Approaches to support caregivers with stress management when responding to changes in behaviours are needed. The Baycrest Quick-Response Caregiver ToolTM (BQRCT) was developed to provide caregivers with an online tool that can be used in real time to recognize and manage their emotions when managing neuropsychiatric symptoms of dementia. Methods: A mixed-methods approach was used to evaluate the feasibility of this new tool. Family caregivers of persons with dementia received education about managing neuropsychiatric symptoms of dementia through the online tool. Caregiver demographic information and feedback about the tool was obtained through telephone and online surveys. Health-care providers accessed the tool and also provided feedback. Results: The 21 caregivers who completed the study found the tool helpful and reported high feasibility that included being able to access, complete, and implement the strategies presented in the tool. The 18 health-care providers found the tool useful and most would recommend it to peers and clients. Participants also provided specific suggestions for improvement, such as including more examples of complex behaviours. Conclusions: This tool adds to and complements existing strategies for managing neuropsychiatric symptoms of dementia. Its accessibility through the online platform is especially useful for caregivers who are unable to seek help in person, and for health-care providers and caregivers seeking additional resources.

MedSafer to Support Deprescribing for Residents of Long-Term Care: a Mixed-Methods Study.

Background: Polypharmacy is prevalent in long-term care homes (LTCH) and increases the risk of adverse drug events. Feasible and effective deprescribing interventions applicable in the LTCH environment are needed. Methods: We performed a mixed methods study to evaluate the feasibility, applicability, and effectiveness of an electronic deprescribing tool, MedSafer, to facilitate quarterly medication reviews (QMRs) on two pilot units in an academic long-term care home (LTCH). Chart reviews collected resident health data. The prevalence of deprescribing at a standard QMR was compared with a QMR conducted three months later with MedSafer. Feedback from physicians on their experience with MedSafer was obtained through semi-structured interviews. Results: Physicians found MedSafer helpful in guiding deprescribing decisions and suggested software improvements to increase the feasibility in LTCH. The average number of medications deprescribed per resident was significantly higher at the MedSafer QMR (mean reduction = 1.1 medications, SD = 1.3) compared to the standard QMR (mean reduction = 0.5, SD = 0.9) (absolute difference of 0.5; SD 1.1; p = .02). Conclusion: MedSafer has the potential to increase deprescribing in LTCHs by flagging potentially inappropriate medications. Integration in the electronic medical record might increase uptake in LTCHs. Further research should investigate the generalizability of MedSafer in a larger population and in non-academic LTCHs.

Enhancing Clinical Visibility of Hearing Loss in Cognitive Decline.

BACKGROUND: Hearing loss is the largest potentially modifiable risk factor for dementia and is highly prevalent among older adults, yet it goes largely unreported, unidentified, and untreated, at great cost to health and quality of life. Hearing screening is a proven cost-effective solution to overcome delays in its identification and management yet is not typically recommended by physicians for older adults. OBJECTIVE: To demonstrate the feasibility and value of hearing screening for older adults at risk for dementia in order to enhance physicians' awareness of hearing loss and improve access to timely hearing care. METHODS: Patients referred to two academic medical clinics for memory disorders were offered hearing screening as part of clinic protocol. Patients with hearing loss were recruited to the study if they consented to a post-appointment telephone interview and chart review. Memory Clinic physicians were surveyed about the usefulness of the screening information and referral of patients with hearing loss to audiology. RESULTS: Hearing loss was reliably detected in Memory Clinic patients with both in-office and online screening tools. Physicians reported that screening enhanced their awareness of hearing loss and increased the referral rate to audiology. CONCLUSION: Hearing screening in Memory Clinic patients is a useful component of clinic protocol that facilitates timely access to management and addresses an important risk factor for dementia.

Evaluation of a Workshop on Therapeutic Lying and Dementia Care for Long-Term Care Staff Supporting Persons With Dementia.

BACKGROUND: Therapeutic lying is an intervention used by health care professionals (HCPs) when a person with dementia is disoriented and distressed and when all other interventions have not succeeded in deescalating the symptoms of dementia. METHOD: The goal of this study was to evaluate a workshop on therapeutic lying and dementia care for HCPs specializing in the care of persons living with dementia with symptoms of dementia. Seventeen HPCs, including nurses and personal support workers (PSWs), participated in the workshop and evaluation survey. RESULTS: The workshop did not affect the attitudes of HCPs toward therapeutic lying and dementia, their sense of competence in providing care to patients with dementia, or their rate of admitting to using therapeutic lying in dementia care settings. All of the PSWs and 50.0% of the nurses admitted to using therapeutic lying as an intervention. Conclusion: Current nursing ethics standards and training practices may cause reluctance among nurses to include therapeutic lying in care plans as a last resort and as a person- and family-centered intervention to deescalate the symptoms of dementia. [J Contin Educ Nurs. 2021;52(9):438-444.].

ECHO Care of the Elderly: Innovative Learning to Build Capacity in Long-term Care.

BACKGROUND: Older adults are entering long-term care (LTC) homes with more complex care needs than in previous decades, resulting in demands on point-of-care staff to provide additional and specialty services. This study evaluated whether Project ECHO® (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC)-a case-based online education program-is an effective capacity-building program among interprofessional health-care teams caring for LTC residents. METHODS: A mixed-method, pre-and-post study comprised of satisfaction, knowledge, and self-efficacy surveys and exploration of experience via semi-structured interviews. Participants were interprofessional health-care providers from LTC homes across Ontario. RESULTS: From January-March 2019, 69 providers, nurses/nurse practitioners (42.0%), administrators (26.1%), physicians (24.6%), and allied health professionals (7.3%) participated in 10 weekly, 60-minute online sessions. Overall, weekly session and post-ECHO satisfaction were high across all domains. Both knowledge scores and self-efficacy ratings increased post-ECHO, 3.9% (p = .02) and 9.7 points (p < .001), respectively. Interview findings highlighted participants' appreciation of access to specialists, recognition of educational needs specific to LTC, and reduction of professional isolation. CONCLUSION: We demonstrated that ECHO COE-LTC can be a successful capacity-building educational model for interprofessional health-care providers in LTC, and may alleviate pressures on the health system in delivering care for residents.

Using Standardized Tools to Characterize Adult Day Program Populations: Implications for Future Research and Clinical Practice.

OBJECTIVES: To demonstrate the usefulness of primary data collection using clinician-rated and self-rated standardized measures to describe adult day program (ADP) populations and address programming issues such as identifying members at risk of dropping out. SETTING AND PARTICIPANTS: One ADP in London, Ontario, and 2 ADPs in Toronto, Ontario, Canada. A total of 223 community-dwelling older adults were recruited across the 3 different programs. METHODS: The interRAI Community Health or Home Care Assessment and self-rated psychosocial assessments were collected on program enrollment. Data analyses included descriptive statistics, comparison of the populations between ADPs, and multinomial regression models to assess reasons for program withdrawal. RESULTS: Mean ages across the 3 programs ranged from 78.3 to 83.8 years and the proportion of women ranged from 49.3% to 56.6%. Compared with one of the ADPs, members from 2 other ADPs exhibited higher use of mobility aids (P < .001), higher levels of cognitive impairment (P < .05), increased risk for institutionalization (P < .001), lower levels of depression (P < .01), and greater need for supervision for basic and instrumental activities of daily living (P < .01). Members assessed to be at higher risk for institutionalization and have increased medical complexity showed possible association with program withdrawal at one ADP. CONCLUSIONS AND IMPLICATIONS: The tools were useful in identifying differences in physical and psychosocial characteristics of members across the 3 ADPs. Information collected from interRAI and self-rated psychosocial assessments may be helpful in the development of individualized care plans, program services, and recommendations that target transitional care. By understanding member profiles and reasons for withdrawal, ADPs may be able to develop strategies to help members stay in the program and live in the community longer.

Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model.

OBJECTIVES: The onset of the COVID-19 pandemic significantly challenged the capacity of long-term care (LTC) homes in Canada, resulting in new, pressing priorities for leaders and health care providers (HCPs) in the care and safety of LTC residents. This study aimed to determine whether Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education program, was effective at delivering just-in-time learning and best practices to support LTC teams and residents during the pandemic. DESIGN: Mixed methods evaluation. SETTING AND PARTICIPANTS: Interprofessional HCPs working in LTC homes or deployed to work in LTC homes primarily in Ontario, Canada, who participated in 12 weekly, 60-minute sessions. METHODS: Quantitative and qualitative surveys assessing reach, satisfaction, self-efficacy, practice change, impact on resident care, and knowledge sharing. RESULTS: Of the 252 registrants for ECHO COE-LTC: COVID-19, 160 (63.4%) attended at least 1 weekly session. Nurses and nurse practitioners represented the largest proportion of HCPs (43.8%). Overall, both confidence and comfort level working with residents who were at risk, confirmed, or suspected of having COVID-19 increased after participating in the ECHO sessions (effect sizes ≥ 0.7, Wilcoxon signed rank P < .001). Participants also reported impact on intent to change behavior, resident care, and knowledge sharing. CONCLUSIONS AND IMPLICATIONS: The results demonstrate that ECHO COE-LTC: COVID 19 effectively delivered time-sensitive information and best practices to support LTC teams and residents. It may be a critical platform during this pandemic and in future crises to deliver just-in-time learning during periods of constantly changing information.

Responding to responsive behaviours: A clinical placement workshop for nursing students.

As our population ages, it is important for the next generation of nurses to feel prepared to care for people with dementia. Communicating with a person with dementia who is experiencing responsive behaviours can be challenging. Furthermore, new graduate nurses may experience a phenomenon called reality shock when they do not feel prepared for the reality of nursing. Reality shock can lead to nurse turnover and poor retention rates. This study evaluated a workshop for first-year practical nursing students focusing on applying a person-centered communication framework when caring for people with dementia experiencing responsive behaviours. The results suggested that training students during their clinical placements on dementia communication may be effective in helping prepare nurses to care for this patient population.