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.

Association between citalopram, escitalopram and QTc prolongation in a real-world geriatric setting.

BACKGROUND: Although the US Food and Drug Administration (FDA) recommended upper limits for citalopram dosing in older adults due to risk of corrected-QT (QTc) prolongation, which was adopted, and extended to escitalopram by Health Canada, the scientific basis is unclear. The objective of this study was to assess the relationship between citalopram/escitalopram dosages and QTc interval in a real-world geriatric setting. METHODS: We reviewed electronic health records at a university-affiliated geriatric health care center, over a 7-year period, to identify patients prescribed citalopram and escitalopram, who had an ECG within 90 days of initiation or dosage change. Linear regression analyses were conducted to assess the relationship between antidepressant dosage and QTc interval. RESULTS: 137 patients were identified (citalopram=97, escitalopram=40). No association was found between citalopram, escitalopram and QTc, in unadjusted or adjusted analyses. Among covariates, older age was significantly associated with QTc prolongation in the escitalopram group. LIMITATIONS: Limitations to the current study include its retrospective design and the small sample size. CONCLUSIONS: These data do not support the FDA or Health Canada's recommended maximum dosages of citalopram or escitalopram in the elderly. Therefore, for patients already on higher doses of these medications, the risk of QTc prolongation may not always outweigh the risk of dose lowering, such as relapse. Until larger prospective studies become available, the decision to comply or not with these federal agencies' recommendations should be weighed on an individual basis, taking into consideration all potential risk factors.

Evaluation of a National Online Educational Program in Geriatric Psychiatry.

OBJECTIVE: This study provides evaluation results of an online study group (OSG) for geriatric psychiatry continuing professional development. METHODS: The OSG is an interactive, expert-facilitated, asynchronous educational experience for psychiatrists and residents in Canada. A retrospective web survey assessed self-efficacy, knowledge in geriatric psychiatry, comfort with online learning, and perceived effectiveness of the instructional methods. Wilcoxon signed-rank tests and descriptive statistics were calculated. RESULTS: Twenty-nine (of 50) participants (58 %) completed the questionnaire. Although only 48 % of respondents reported improved perceived knowledge, 79 % reported improved efficacy beliefs, and 76 % reported improved comfort with online learning. Most (79 %) would consider taking OSG again, and 93 % would recommend it to others. CONCLUSIONS: The OSG was well-received, with greater benefits for self-efficacy with the material and comfort with online learning than for perceived knowledge itself. Further research is needed to ascertain actual knowledge change in the context of online learning in medical education.

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.

The enablers and barriers to the use of direct observation of trainee clinical skills by supervising faculty in a psychiatry residency program.

OBJECTIVE: Studies have reported that medical trainees do not get sufficient direct observation. Our study aimed to determine the frequency of direct observation and the enablers and barriers to direct observation in the department of psychiatry at a large Canadian university. METHOD: Focus groups and interviews explored the role and use of direct observation, followed by a survey both of faculty and of residents. RESULTS: Direct observation was used in various contexts in the residents' last rotation. Missed opportunities are identified. Enablers include financial compensation, guidelines, and a discussion at the beginning of each clinical rotation. Barriers are identified at the resident, faculty, and administrative levels. CONCLUSIONS: Direct observation is used in many contexts in psychiatric training. While there are barriers which limit its use, our data indicate numerous potential enablers and missed opportunities for more observation.

Basic essential education program (BEEP): a brief introductory faculty development course for medical teachers.

BACKGROUND: Physicians have a unique role in teaching future physicians and allied health professionals. Yet, most medical doctors have limited instruction in this critical component of their daily activity. METHODS: This study was a prospective cohort study of the effectiveness of a local teaching program at two teaching hospitals for junior faculty. Based on a needs analysis and literature review, the teaching program was developed in an accessible and compact format of six consecutive, one-hour "lunch and learn" sessions, held locally over a six week period. Pre-post questionnaires and focus groups were used to evaluate the program. RESULTS: Participants reported being satisfied with the course as whole, particularly in respect to the format and location. There was an improvement in their knowledge in all content areas covered. The greatest benefits were derived from fostering a community of practice and having the opportunity to role play and simulate teaching skills. An attitudinal change towards teaching was noted. CONCLUSIONS: A brief, local faculty development program was effective in enhancing physicians' knowledge, skills, and attitudes in teaching.

Use of sleep-promoting medications in nursing home residents : risks versus benefits.

This paper reviews the use of sleep-promoting medications in nursing home residents with reference to risks versus benefits. Up to two-thirds of elderly people living in institutions experience sleep disturbance. The aetiology of sleep disturbance includes poor sleep hygiene, medical and psychiatric disorders, sleep apnoea, periodic limb movements and restless leg syndrome. One key factor in the development of sleep disturbance in the nursing home is the environment, particularly with respect to high levels of night-time noise and light, low levels of daytime light, and care routines that do not promote sleep. Clinical assessment should include a comprehensive medical, psychiatric and sleep history including a review of prescribed medications. Nonpharmacological interventions for insomnia are underutilised in many clinical settings despite evidence that they are often highly effective. International studies suggest that 50-80% of nursing home residents have at least one prescription for psychotropic medication. Utilisation rates vary dramatically from country to country and from institution to institution. The most commonly prescribed medications for sleep are benzodiazepines and nonbenzodiazepine hypnotics (Z-drugs). The vast majority of studies of these medications are short-term, i.e. < or =2 weeks, although some longer extension trials have recently been carried out. Clinicians are advised to avoid long-acting benzodiazepines and to use hypnotics for as brief a period as possible, in most cases not exceeding 2-3 weeks of treatment. Patients receiving benzodiazepines are at increased risk of daytime sedation, falls, and cognitive and psychomotor impairment. Zaleplon, zolpidem, zopiclone and eszopiclone may have some advantages over the benzodiazepines, particularly with respect to the development of tolerance and dependence. Ramelteon, a novel agent with high selectivity for melatonin receptors, has recently been approved in the US. Use of the antidepressant trazodone for sleep in nondepressed patients is somewhat controversial. Atypical antipsychotics should not be used to treat insomnia unless there is also evidence of severe behavioural symptoms or psychosis.