DOI: https://doi.org/10.5770/cgj.27.735
Keri-Leigh Cassidy, David Conn, Kiran Rabheru, Cindy Grief, Amy Gough, Marie-France Rivard
Positive Psychiatry is a branch of our field dedicated to the science of wellbeing. Applied positive psychiatry to address the complexities of seniors’ mental healthcare is more relevant than ever. This symposium will review the Fountain of Health, a promising practice recommended by the Mental Health Commission of Canada to promote seniors’ mental health. A new model called the “THRIVE Approach to Wellbeing” will be introduced. An evidence-based 3-step approach successfully used in a national KT project to promote behaviour change and wellbeing will be reviewed. Positive psychiatry training, tools and resources available through the new Thrive Learning Centre will be shared.
Positive Psychiatry is a newer branch of our field dedicated to the science of wellbeing. In the context of complexities in seniors’ mental healthcare—from population aging to ageism, the pandemic, rising healthcare costs and burnout among providers—applied positive psychiatry is more relevant to seniors’ healthcare than ever.
The rationale for applied positive psychiatry to redress complexities in seniors’ mental healthcare will be presented. The “THRIVE Approach to Wellbeing,” a positive psychiatry approach to promote wellbeing in healthcare, will be reviewed. The model modifies the “PERMA” model of positive psychology to integrate with lifestyle medicine, health behaviour change, brain neuroplasticity and 4th wave CBT methods.
The acronym THRIVE includes 6 evidence-based areas to promote wellbeing: Thoughts, Health habits, Relationships, Interests, Valued Goals and Emotions. The evidence for each of these domains to promote brain health and wellbeing will be reviewed.
Positive psychiatry is an important branch of our field to address healthcare complexities and improve outcomes. The THRIVE Approach to Wellbeing is a new model that puts positive psychiatry science into practice.
Fountain of Health Association is a national non-profit project in applied positive psychiatry to promote brain health and wellbeing.
A national knowledge mobilization project to share Fountain of Health behaviour change using a 3-step approach in frontline care was led by the Canadian Coalition for Seniors Mental Health. Over 2000 clinicians were trained to use the approach, among whom over 800 clinicians used the tools in practice.
Paper-based and electronic health behaviour change tools were used in the Brain Health and Wellness project. Among patients who used these tools, 80% reported improved health behaviours and greater wellbeing in four weeks. Implications of these results for wider scale up are discussed.
National scaling of applied positive psychiatry tools to promote brain health and wellbeing led to uptake into clinician practice and translation into patient health behaviours and wellbeing.
The Thrive Learning Centre is a new positive psychiatry resource to promote wellbeing in individuals, organizations and clinicians.
Tools and resources of the Thrive Learning Centre include: Wellbeing training for individuals and free Wellness App for a self-guided method; Training for groups in a 4-week Optimal Aging Workshops for adults 50+ (virtual and community-based formats); Wellbeing training for clinicians such as the “Thrive MD Program” and a focus on older physicians; the “5 minute CBT” Course offers a 5 week online training course and is available to all clinicians to promote personal wellbeing and to use in practice.
Quality outcomes of these above methods, including similarities and differences, are described. Overall, 80% of those who use these materials have reported improvements in health behaviours and personal wellbeing. Published results are shared and opportunities to access resources and training in positive psychiatry through the Thrive Learning Centre are described.
A wide range of positive psychiatry resource to promote wellbeing in individuals, organizations and clinicians are available through the new Thrive Learning Centre. These wellbeing resources help to address complexities in seniors mental healthcare.
Kathleen Bingham, Cindy Kosynski, Jenna Davis, Annalee King, Geoff Daniel, Sandra Easson-Bruno
The North Simcoe Muskoka Specialized Geriatric Services (NSM SGS) Program was established in 2016 to improve the health and wellbeing of older adults and their caregivers. With a goal to create a single integrated system of care within the region, NSM SGS implemented an innovative hub-and-spoke model. This model has transformed clinical care in our region for older adults living with complex mental health needs by improving access, equity and quality of care.
This symposium consists of three talks. To help participants advance integrated care in their local regions, each talk will describe how our hub-and-spoke model transformed clinical care and include key learnings from our experience at the leading edge of health system integration. Our first talk, a clinical case presentation, will show how our hub-and-spoke model can transform care at the patient level. Our second talk will describe our Behaviour Success Agent project. Designed to support older adults with responsive behaviours in acute care, we leveraged our hub-and-spoke model to build partnerships with area hospitals to improve the quality of care and support patient flow. Our third talk will showcase the innovative programming introduced by Recreation Therapy to address loneliness and isolation among older adults by using our hub-and-spoke model to build bridges between healthcare and community partners.
NSM SGS has successfully advanced a single integrated system of care for older adults with complex mental health needs and provides evidence of how integration and creative solutions can optimize outcomes for patients, caregivers, providers, partner organizations and the system.
Stephanie Gordon, Taz Lakhani
The Comprehensive Care & Integration Specialist Team (CCIST) exists to fill gaps in care and to support service transitions for individuals living with complex health and psychosocial issues. Our priority population is frail seniors and individuals living with mental health and/or addiction issues. The CCIS Team of Social Workers consists of a diverse group of staff that are representative of the population we serve. The team works from an anti-racist and anti-oppressive framework while supporting clients in accomplishing their goals and establishing a care team in the community.
Using CCIST practices as a reference, presenters will share comprehensive tools to engage seniors with complex needs, in building rapport and initiating individual coordinated care plans. (15 minutes) After outlining engagement techniques, presenters will split participants into groups and provide case scenarios. Participants will apply the presented techniques in the role-play activity. (30 minutes) After the interactions, presenters will allow 15 minutes for questions and reflections.
At the end of the session, participants will be able to venture into challenging spaces, build trust with clients, and work collaboratively with various partners from different sectors, to support people from diverse backgrounds living with multiple health challenges.
There is a relationship between high (re)admission rates amongst isolated vulnerable clients living with complex health issues and their lack of access to community services available to support their recovery at home. Presenters will show the importance of developing a client-centred care plan, in collaboration with partner agencies, to ensure the successful reintegration of clients into the community.
Ka Sing Paris Lai, Elaine Stasiulis, Patti Kelm, Gary Naglie, Mark Rapoport
Remaining mobile after driving cessation is critical for sustaining the quality of life for persons with dementia (PWD). PWD residing in rural communities are particularly disadvantaged during the transition to non-driving due to longer distances to services and limited access to transportation alternatives. The objective of this study was to explore the experiences of PWD undergoing driving cessation in rural and urban settings.
In-depth semi-structured interviews were conducted with 7 current drivers and 3 former drivers with dementia residing in Saskatchewan. Five participants lived in rural communities. Participants described their experiences with driving cessation or the prospect of driving cessation. Data was examined using interpretive phenomenological analysis (IPA).
PWD living in both rural and urban settings relied mainly on family members to drive them. While PWD in rural settings identified difficulties with being far from medical centers and the lack of transportation alternatives, they also described benefits of living in a smaller community. These included being in walking proximity to stores, services and having access to a network of friends and neighbours to drive them. PWD in urban settings described difficulties navigating the public transportation system, the inefficiency of para-transit services and the financial burden of taxis.
Although those living in rural settings lack formal transportation alternatives, PWD in urban settings also experience challenges accessing services to remain mobile resulting in a heavy reliance on family members to drive them. This study highlights the importance of developing innovative solutions to support PWD post-driving cessation.
Adam Morrison, Sophiya Benjamin, Sarah Gimbel, Joanne Ho
The formation of Ontario Health Teams (OHTs) enabled partnership development between health and social care providers, leading to promising shared care models for the support of older adults living with complex health and mental health conditions.
We conducted a 6-week pilot to assess a new integrated care model in Kitchener, Ontario. The pilot reviewed 138 patients waitlisted for specialized geriatric services. A proportion of these individuals were deceased or institutionalized during the waiting period. Among the 97 patients assessed, 77% received a new referral for community support services, 95% received a medication review with recommendations to optimize prescribing and 27 (28%) received an expedited referral to a geriatrician. Of those seen by a geriatrician for a comprehensive assessment, 96% did not require a follow-up specialist appointment, thus opening 13 new full consult spots with geriatricians. However, a gap was identified for those with complex mental health conditions.
Based on pilot data, an Integrated Care Team for Older Adults (ICT), with the inclusion of geriatric psychiatry, was developed by providers from the KW4 Ontario Health Team. This model is led by nurse practitioners and brings a clinical pharmacology consultation service (i.e. GeriMedRisk), community paramedicine, community support services, geriatric medicine, geriatric psychiatry, home care, hospice palliative care, primary care, acute care and seniors mental health together as one team to comprehensively support older adults living with multiple complex conditions.
Participants will learn about the building blocks to bring partners together to deliver integrated care for older adults living with multiple complex conditions.
David Gardner, Andrea Murphy, Malgorzata Rajda, Justin Turner, Sandra Magalhaes
Chronic use of benzodiazepine receptor agonists (BZRAs) is highest in Atlantic Canada and increases with age, as does the risk for cognitive and physical adverse effects. Direct-to-patient education resources embedded with behaviour change techniques can be used to modify health behaviours including insomnia management. The Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study assessed the impact of mailed packages intended to reduce BZRA use and increase cognitive-behavioural therapy for insomnia (CBTi) application.
YAWNS NB was a three-arm, open-label, randomized trial for people 65 and older taking BZRAs long-term living in the community across NB. Participants were allocated to receive the Sleepwell package, the Eliminating Medications through Patient Ownership of End Results (EMPOWER) package, or no package. Packages encouraged collaboration with clinicians and included education on BZRA harms, stopping BZRAs safely, and behavioural treatments for insomnia. Assessments (primary: sedative discontinuation; others: CBT-I resource use, sleep, anxiety, sleepiness, etc.) were completed at baseline and 6-months.
Study completion rate was 92% (517/565). Sleepwell participants demonstrated the highest rate of BZRA discontinuation (34%) as well as more CBT-I use and better sleep outcomes. EMPOWER participants had a similar rate of BZRA discontinuation and a higher rate of switching to other sedatives than Sleepwell. Patient factors associated with better outcomes are discussed.
The simple, direct-to-patient intervention, Sleepwell, is effective for ending chronic use of sedatives, encouraging use of CBT-I methods, and improving sleep outcomes. Sleepwell has the potential to be an efficient, scalable, health promotion strategy for older adults.
Cheryl Sadowski, Sammy Lowe, Allyson Jones, Susan Zhang, Tarek Turk, Joanne Olson, Pauline Paul, Elaine Yacyshyn
The self-reported benefits of cannabis are important to study as they may predict use. The purpose of our study was to identify factors associated with positive impacts of current cannabis use on psychological health and wellbeing indicators among older adults receiving care for rheumatologic conditions in Alberta.
Adults in Alberta were invited to participate in a survey regarding cannabis use if they had a rheumatologic condition and had contact with the health system. Participants completed an online survey capturing demographics, medical history, cannabis use, and lifestyle factors. Respondents were asked to rate how cannabis use impacted their mood, anxiety, sleep, energy, pain, and overall quality of life. Logistic regression was used to identify associations of positive impacts.
384 older adults reported current cannabis use. This sample consisted largely of female (54.9%) and white (92.2%) respondents, with a mean age of 71.7ys (SD=5.7). Osteoarthritis (68.5%) and rheumatoid arthritis (20.6%) were the most common rheumatologic conditions. 168 (43.8%) respondents reported at least one form of mental illness. Many respondents indicated that using cannabis had positive impacts for pain (n=311, 81.0%), sleep (n=261, 68.0%), quality of life (n=240, 62.5%), anxiety (n=169, 44.0%), mood (n=154, 40.1%), and energy (n=108, 28.1%). Participants were more likely to report positive impacts if they used cannabis once or more daily, were using cannabis to address two or more health conditions, and if they experienced high levels of calming symptoms when using.
Cannabis use has positive impacts on mental health and well-being among older adults accessing care for rheumatologic conditions.
Melissa Laroche, Kelly MacGregor, Christine Cook
Older adults living with chronic mental health disorders are at risk of developing physiological diseases and neurocognitive disorders. Persons with mental health disorders are at a much higher risk of developing dementia, sometimes at an earlier age than their counterparts without a mental health disorder diagnosis. (JAMA Psychiatry, 2022)
Queensway Carleton Hospital recognizes this trend of complex mental and physical health needs as well as the significantly increasing need for social support in this population. QCH has incorporated 3 different innovative strategies to try to address this concerning issue. The first, implementing a Behaviour Emergency Response Team (BERT), this team provides direct clinical expertise during a behavioural crisis. The second strategy is the development of a multidisciplinary Behavioural Support Champion (BSC) program, the goal of this program is to provide peer–to-peer support and knowledge capacity building 24/7 throughout the hospital. Lastly, through a partnership with the Dementia Society, we have a dementia care coach on site to provide ongoing support and education to care partners during hospitalization and after transitioning back to the community.
Our multidisciplinary approach will demonstrate a high number of trained staffing resources in geriatric psychiatry.
Canadian Acute Care Hospitals would benefit from establishing a comprehensive plan for the staff education that will be required to support the complex mental and physiological health needs of this growing population. A focus on inclusivity and equity of this patient population combined with the strategies implemented at Queensway Carleton Hospital demonstrates a patient-centered model of care.
Andrea Iaboni, Sébastien Grenier, Sarah Neil-Sztramko, Sarah Burke Dimitrova, Alastair Flint, Zahra Goodarzi, Amy Gough, Heli Juola, Kristin Reynolds, Shanna Trenaman, Carly Whitmmore, Erica Weir, Anthony Yeung
Anxiety is not a normal part of aging, and misconceptions about anxiety in older adults lead to it being underrecognized and undertreated. Anxiety has a negative impact on quality of life, increases disability and caregiver burden, and is a risk factor for depression and dementia. Anxiety in older adults is a treatable mental health condition and there are many evidence-based interventions that are helpful.
In this workshop, we will provide information about the development of anxiety clinical guidelines informed by the Guidelines International Network (GIN)-McMaster Checklist. The guideline working group included representation from psychiatry, psychology, geriatrics, family medicine, nursing, social work, and pharmacology. Systematic reviews informed Evidence to Decision Frameworks which consolidated evidence on the benefits and harms of each intervention to inform the draft recommendations.
In this workshop we will present: 1) the draft recommendations for the prevention, diagnosis, and treatment of anxiety in older adults, and 2) proposed knowledge translation products to support the implementation of recommendations in practice. In an interactive format, workshop attendees will provide their input on the recommendations and on the opportunities for dissemination of the guidelines.
The Canadian Coalition for Seniors Mental Health (CCSMH) has led a guideline project which has engaged with older adults and caregivers, healthcare providers, and community organizations across Canada to produce guidelines and tools that establish best practices for the care of older Canadians with anxiety. This workshop is an important opportunity to contribute to these guidelines and to the plan for their dissemination.
Ari Cuperfain, Ken Schwartz
Group psychotherapy is an effective treatment for depression in both general and older adult populations. Group therapy may be used in addition to pharmacotherapy or individual psychotherapy, or as an independent treatment, and it may follow a particular psychotherapeutic modality. A psychotherapy emphasizing interpersonal, psychodynamic, cognitive behavioural therapy (CBT), existential and life stage approaches is particularly suited for older adults.
This workshop was inspired by a “challenging care rounds” (formerly morbidity and mortality; M&M) presentation which discussed a medically and psychiatrically complex patient with depression and severe social anxiety who was participating in group psychotherapy with the authors. We reflected on the role of the group in the care of this patient, and more generally in managing similar complex older adults. We summarized themes and endeavored to develop a workshop which could function as a means for teaching and further exploration.
This experiential workshop would provide an opportunity for participants to discuss specific topics related to older adults though an integrated group psychotherapy frame. Recurring themes in the group include coping with aging and illness, dependency, interpersonal difficulties, agency, hope, gratitude and resilience.
An integrative group therapy approach can help older adults cope with developmental stressors in a psychologically safe and supportive environment. Leading group therapy sessions can also aid in the development of competencies in addressing important topics related to aging. In this workshop, we would reflect on the role of group therapy in managing medical and psychiatric complexity, expanding these themes to individual psychotherapy.
Danusha Vinoraj, Saumil Dholakia
Substantial differences exist in policy implementation and standard of care around use of physical and chemical restraints in hospitalized older adults, despite limited evidence of their effectiveness and clear potential for harm. Hospitalized older adults with major neurocognitive disorder (MNCD) and/or delirium are particularly vulnerable to use of restraints as a coercive measure in view of their disease process, inability to interpret the environment and/or communicate their needs.
This continuing quality improvement (CQI) project adopts a mixed methods research methodology. The Quantitative research component utilizes 3-month retrospective chart review to identify prevalence, precipitant factors and documented outcomes of restraint use in hospitalized older adults with MNCD and/or delirium at the Ottawa Hospital. The qualitative research component explores perspectives of involved nursing staff through semi-structured interviews and subsequent reflexive qualitative meta-synthesis of emerging themes around restraint use in this population.
By illustrating the prevalence, precipitant factors, and documented outcomes of chemical and physical restraints, this CQI project informs participants about gaps in standard of care for hospitalized older adults with MNCD and/or delirium. Nursing staff perspectives will help understand and explore unique stakeholder challenges around use of physical and chemical restraints in this population.
This hospital-based CQI project identifies the prevalence, along with patient, environment, and nursing-stakeholder related factors, associated with use of chemical and physical restraints in older adults with MNCD and/or delirium. Awareness of these factors can facilitate plans to bridge policy gaps and improve standard of care for this population in similar hospital settings.
Sarah Main, Saskia Sivananthan, Josee Guimond, Joshua Armstrong, Jhnelle McLaren
Family physicians are the entryway to a diagnosis and management of dementia in Canada, yet we know these processes are fraught with difficulty for family doctors who lack time and expertise. The development of practical, evidence-based guidelines that are GIN aligned, are essential in supporting family physicians who are currently struggling to provide support across the dementia continuum of care.
ASC partnered with the Government of Canada and the College of Family Physicians of Canada (CFPC) to develop the National Dementia Guidelines (NDG) Program, which addresses key topics by and for family physicians. At the core of the program is the guideline development framework, which is comprised of six working groups inclusive of community family doctors, persons with lived experience, and ethnocultural groups, who will collaboratively develop culturally safe guidelines and practical tools.
The NDG Program develops guidelines and tools for physicians, by physicians, which is essential to the uptake of these supports into practice. The engagement of interdisciplinary teams in collaborative processes ensures that the materials produced are reflective of the needs of Canadians impacted by dementia. Collectively, these teams will continue to prioritize and address areas where it has been identified that physicians are in dire need of more support.
The NDG Program will provide the much-needed guidance for family physicians to best support persons living with dementia across the continuum of care. By creating an inclusive framework focused on implementation and sustainability, ASC will be able to replicate these processes to other topic areas and populations.
David Conn, Bette Watson Borg, John Saunders, Claire Checkland, Lisa Tinley
An Angus Reid survey found that 48% of Canadians reported themselves as being socially isolated, lonely or both (Reid, 2019). Social isolation among older adults is associated with increased chance of premature death, depression, dementia, disability from chronic disease, increased use of health and support services and increased number of falls. (National Academies of Sciences, Engineering and Medicine (2020).
The Canadian Coalition for Seniors’ Mental Health (CCSHM) is developing Canadian guidelines for health and social service providers to support them in their roles with respect to the prevention, assessment, and management of social isolation and loneliness. Two national surveys have been carried out, to learn more about the lived experience and perspectives of health and social service providers as well as adults over the age of 65 years and their carepartners.
In this oral presentation, we will present the methodologies and the findings from the two national surveys of 1) Health and social service providers, and 2) Adults over the age of 65 years and their care partners. Results will include the perspectives of professionals with respect to their potential roles in the areas of prevention, assessment and intervention as well as the perspectives of older adults regarding these topics.
This oral presentation will result in increased awareness and knowledge regarding perspectives, of clinicians and older adults regarding social isolation and loneliness, including their awareness, knowledge, barriers and ideas related to this health issue.
Julia Kirkham
Standards establish levels of expected performance that are consistent with best practices and can increase care consistency across settings. They allow for both assessment of the current state and for the establishment of actionable benchmarks to guide improvement towards the highest quality of care. The many systemic problems in long-term care (LTC) exposed by the Covid-19 pandemic prompted the development of a number of standards to guide residential care in Canada. Several recent national standards have been published, are underway, or planned, including the Health Standards Organization (HSO) Long-Term Care Services Standard, and the Canadian Standards Association (CSA Group) Z8004 Long-Term Care Home Operations and Infection Prevention and Control Standard. This workshop will provide an overview of recently published Canadian standards, highlighting important areas for geriatric mental healthcare providers. We will specifically focus on the forthcoming CSA Z2004 Mental Health and Well-Being in Long-Term Care and Assisted Living Settings Standard. Developed by a committee of engaged stakeholders, the CSA Z2004 Standard will be available for public review at the time of the meeting. CSA Z2004 will concentrate on promoting mental health and well-being across the mental health continuum and will extend to other supported living settings where older adults reside, in addition to LTC.
We will describe the standard development process in Canada. Using a small groups’ format and facilitated discussion, we will solicit feedback on the draft content for CSA Z2004 Mental Health and Well-Being in Long-Term Care and Assisted Living settings. We will collaboratively discuss how geriatric mental healthcare providers and other stakeholders can support the successful dissemination and implementation of all relevant Canadian standards.
Feedback on the draft CSA Z2004 Mental Health and Well-Being in Long-Term Care and Assisted Living Settings Standard will be collected from the Public Review process that will inform the final version of the standard, with anticipated publication in March 2024.
Standards are establishing best practices in LTC and other settings in Canada. Such standards in Canada are long overdue, but they must be incorporated into practice to result in meaningful and lasting improvement in care for older adults residing in LTC and assisted living settings. Geriatric mental healthcare providers have an important role in both shaping standards and advocating for their uptake.
Robert Madan
Burnout amongst health care providers is a significant concern. Studies have reported high rates of burnout amongst health care providers prior to COVD19, and the rate has increased during the pandemic. Individual, institutional, and systemic factors interact to result in burnout. Interventions to prevent burnout and to promote wellness have been studied.
In this interactive session, participants will learn about the risk factors and signs of burnout, and reflect on their own personal and work contexts. A validated burnout scale will be reviewed. Data from studies regarding the causes of burnout and interventions will be presented. The relationship between burnout and medical errors will be discussed.
Burnout is common in health care providers with rates ranging between 40–50%, and occurs on any practice setting. The development of burnout involves individual, work, organizational, and systemic factors, and has an impact on the individual, their family, colleagues, and patients/clients. There is a relationship between burnout and medical errors. Wellness programs developed by organizations and peer support appear to be beneficial. The role of a Chief Wellness Officer in organizations has been proposed.
Burnout in health care is common and has wide ranging impacts. The causes of burnout include individual, organization, and systemic factors. Studies show that wellness interventions are generally well received. The proposal of the role of a Chief Wellness Officer in organizations may be beneficial.
Sophiya Benjamin
People living with dementia and their care partners have to navigate an increasingly complex system of providers and programs through their journey in living with this illness. Often their experiences take them across sectors from their homes in their communities to hospitals and communal living environments including long-term care homes. To provide specialist expertise to seamlessly support patients and their care partners across care settings and phases of their dementia, collaboration, the first pillar identified in the national guidance document, “A Dementia Strategy for Canada: Together We Aspire,” is required. As Ontario provincial programs serving individuals with dementia, Behavioural Supports Ontario, GeriMedRisk and the Virtual Behavioural Medicine program possess unique and complementary strengths. This symposium will feature presentations from each of these programs with a focus on their individual program features, contributions, and recent efforts to meaningfully integrate these services with regional specialists, healthcare services and each other.
Sophiya Benjamin, Jennifer Tung, Shazia Khokhar, Danielle Yantha, Joanne Man-Wai Ho
GeriMedRisk (GMR) was established as an interprofessional model of care with consultation and education components to meet the emerging needs of older adults with complex mental and physical comorbidities and polypharmacy.
We reviewed service delivery data from 2018–2022 calendar years. We performed a volumetric analysis of the numbers of consultation completed. We examined the data by mode of referral such as secure eConsult, fax or others and referral settings such as primary care, long term care homes and others. We also examined the data to understand the regions within Ontario from which referrals originated and the impact of integration efforts such as referrals generated through central intake pathways.
During this time, we completed 6993 consultations for 3352 referrals. Of these, 64% of referrals originated from the community through primary care, 17% were from long term care homes, 11% were from acute care and hospitals, and 8% were from other specialist physicians. Mode of referrals included eConsults (43%), fax (30%), phone (13%) and other (15%). While referrals originated from all regions of the province, the four regions with the highest numbers of referrals were those with formal integration within existing specialized geriatrics service pathways. Between 2017–2018, GMR’s hospital diversion rate was 88.2%.
GMR was created as a model of care with input from patients and stakeholders in 2017. Over the past 5 years, GMR has worked with frontline clinicians and system stakeholders to thoughtfully integrate and adapt its model to best serve local needs.
Andrea Iaboni, Monica Bretzlaff, Sarah Denton, Katelynn Aelick, Joanne Man-Wai Ho, Shazia Khokhar, Jennifer Tung, Sophiya Benjamin
Behavioural Supports Ontario (BSO) provides behavioural healthcare services for older adults in Ontario with, or at risk of, responsive behaviours associated with dementia, complex mental health, substance use, and/or other neurological conditions. BSO teams conduct comprehensive behavioural assessments to identify contributing factors and unmet needs that lead to the presentation of responsive behaviours. BSO teams prioritize non-pharmacological approaches to care and rely on specialty physicians to guide pharmacological interventions when clinically relevant.
In this session, we will introduce a pilot project that integrates the services of GeriMedRisk with North East BSO to provide rapid pharmacological review and advice to complement BSO’s innovative behavioural health framework and assist with triage of urgent or complex cases for geriatric psychiatry consultation.
Preliminary results of this pilot have been promising. Between Nov. 1, 2022, to March 27, 2023, 21 referrals from primary care (42.9%), LTC (33.3%), acute care (9.5%) and acute care-alternate level of care (ALC) (9.5%), and outpatient specialists (4.8%) have been received. A total of 50 consultations were provided by GeriMedRisk, on average within 5.7 days of a completed referral being received. Of these, 8 referrals required additional synchronous geriatric psychiatry consultation. Formalized electronic surveys, capturing the experience of each participant (e.g. patient, care partner, clinician, and primary care), is underway.
Highly specialized behavioural and mental health services for older adults require an innovative transdisciplinary approach. Together, BSO and GeriMedRisk continue to leverage their complementary strengths to enhance timely access to the right supports and expertise to enhance patient, care partner and system outcomes.
Morris Freedman, Malcolm Binns, Fidelma Serediuk, M Uri Wolf, Einat Danieli, Bradley Pugh, Deb Galet, Eslam Abdellah, Ericka Teleg, Mindy Halper, Lauren Masci, Adrienne Lee, Anne Kirstein, Jordanne Holland, Jagger Smith
The Virtual Behavioural Medicine Program (VBM) is a novel model of care that was developed at Baycrest Health Sciences as an innovative virtual inpatient neurobehavioural unit. VBM was designed to support management of individuals with severe neuropsychiatric symptoms (NPS) due to dementia without being uprooted from their familiar environment long-term care, the community, or acute care. We report the efficacy of VBM in reducing transfers to a specialized inpatient neurobehavioural unit for management of NPS.
We reviewed outcomes in the first consecutive 95 patients referred to VBM. The primary outcome was reduction in proportion of patients requiring admission to the Baycrest inpatient Behavioural Neurology Unit (BNU). We divided the patients into those who were referred to VBM plus the BNU and those referred to VBM alone.
The overall proportion of patients requiring admission to the BNU was reduced by 62.5%. For patients referred to VBM plus the BNU, the reduction was 60.42% %. For patients referred to VBM alone, it was 68.75%.
VBM is a novel virtual neurobehavioural unit for treatment of NPS and is a game changer that can reduce preventable emergency department visits and acute care hospital admissions. It is also a scalable model of novel virtual care that can be adopted across the world.
This work was published in Journal of Alzheimer’s Disease 86:1169–1184, 2022 (Freedman et al.) and presented virtually at the International Psychogeriatric Association Congress 2021.
Atul Sunny Luthra, Raymond LinBin Gao, Peter Carducci, Shannon Remers, Joanna Sue
LuBAIR™ Paradigm, a novel approach to ascribing meaning for behavioral expression in advanced neurocognitive disorder, was used to identify behavioral categories that are likely to respond to the use of atypical antipsychotics in their management.
Intervention: LuBAIR™ Inventory populated on all recruited patients on two separate occasions. The data collected on the second occasion, in the successful and failed de-prescribed groups, were compared in this retrospective study. Measurements: Chi-Square paired t-test and Cohen d Statistical tests were used to detect the difference in the behavioral categories between the two cohorts.
LuBAIR™ Inventory filled on two occasions. The data collected on the second occasion, in the successful and failed de-prescribed groups, were compared in this retrospective study. Chi-Square paired t-test and Cohen d Statistical tests were used to detect the difference in the behavioral categories between the two cohorts. Patients who did not have Mis-Identification and Goal-Directed Expressions were more likely to successfully de-prescribe: X2 (1, N = 40) = 29.119 p<.0001 and X2 (1, N = 40) = 32.374, p<.0001, respectively. Alternatively, the same behavioral categories were more likely to be present in patients who failed de-prescribing: paired t-test and Cohen-d (P<0.0001). Atypical antipsychotics, in their role as an antipsychotic and mood stabilizer, may be used to manage Mis-Identification and Goal-Directed Expressions, respectively.
Use of LuBAIR™ Inventory and Paradigm may have the potential to predict which behavioral categories associated with advanced NCD may justify the use of AAP, in their management.
Dallas Seitz, Jennifer Watt, Stacey Hatch
Behavioural symptoms of dementia are among the most common and complex conditions mental health conditions encountered by clinicians with older adults. The CCSMH and its stakeholders identified the need for guidelines on behavioural symptoms of dementia and are creating new guidelines to theses gap in our current knowledge. This symposium will present the preliminary results of the Public Health Agency of Canada funded project developing a Guidelines and knowledge tools for Behavioural Symptoms of Dementia. In this interactive symposium, the guideline co-chairs and project team members will present preliminary results of the guidelines and obtain feedback from participants to incorporate into the final guidelines. This symposium will begin with an overview the CCSMH Behavioural Symptoms of Dementia Guideline project. Then participants will learn about existing guidelines for behavioural symptoms of dementia including results of a systematic review of published guidelines. An overview of preliminary topics and guideline recommendations for the CCSMH Behavioural Symptoms of Dementia Guideline will be presented and feedback obtained on the draft recommendations from participants. Finally, results of a scoping review on knowledge mobilization strategies for guideline implementation will be presented along with preliminary results of guideline knowledge mobilization including a project website. Together, participants will gain insight into the CCSMH Guidelines on Behavioral Symptoms of Dementia and provide valuable input into the development of the guideline and its related resources for people living with dementia, their families and health care providers.
Jennifer Watt
In 2014 the Canadian Coalition for Seniors’ Mental Health (CCSMH) published a guideline update to inform the assessment and management of mental health issues in nursing homes, which included neuropsychiatric symptoms in dementia. Our objective was to review guideline recommendations on the assessment and management of neuropsychiatric symptoms in dementia to inform the next CCSMH guideline update.
We searched Medline, Embase, JBI EBM, PsycINFO, AgeLine, and grey literature for guidelines on dementia making recommendations on the assessment or management of neuropsychiatric symptoms of dementia published between 2011 and October 13, 2022. Reviewer pairs, working independently, conducted all study screening and data abstraction. Four independent reviewers completed guideline quality appraisal using the AGREE II tool. Included guidelines had a mean overall AGREE II score of at least four; we abstracted recommendations from these guidelines.
We screened 2197 article titles and abstracts and 295 full-text articles. We appraised 52 guidelines, of which 23 were included. People with lived experience contributed to six (26.1%) guidelines. Ten (43.5%) guidelines described one or more health equity considerations for guideline development or implementation. Eight (34.8%) guidelines made recommendations about assessing or detecting neuropsychiatric symptoms. Pharmacologic and nonpharmacologic recommendations were made by 18 (78.3%) and 16 (69.6%) of guidelines, respectively.
We identified guideline recommendations, which can be adapted for the next CCSMH guideline update on the assessment and management of neuropsychiatric symptoms in dementia, and areas for improvement in dementia guideline development, which included poor representation of people with lived experience and consideration of health equity factors.
Dallas Seitz
There are increasing numbers of people impacted by dementia in Canada and behavioural changes in dementia are some of the most challenging aspects related to dementia. There is a need for updated knowledge and clinical guidance on best practices related to the assessment and management of behaviours in dementia. This project funded by the Public Health Agency of Canada is developing new clinical practice related to the assessment and management of behaviours in dementia.
Our project followed the Guidelines International Canada recommendations for the development of guidelines. A guideline working group was established including 14 individuals representing different geographies and backgrounds with additional input from people with lived experience and external reviewers. A review of existing guidelines and stakeholder surveys were used to identify priority areas for guideline recommendation development.
Priority areas identified by the guideline working group and surveys led to the development of guideline recommendations in several topics and draft recommendations will be presented. These included topics related to general assessment of behavioural symptoms and syndrome specific guideline recommendations for agitation, sleep, apathy, mood changes and psychosis. Each syndrome contains specific recommendations for assessment, non-pharmacological and pharmacological management. Specific recommendations related to management of vascular dementia, dementia with Lewy bodies and frontotemporal dementia will be presented. Recommendations related to deprescribing of psychotropics will also be discussed.
The current project will present new guideline recommendations from the CCSMH Behavioural Symptoms of Dementia guidelines. Feedback from participants will inform the final recommendations contained in this guideline.
Stacey Hatch
Organizations leading guideline development need to identify key messages and strategies for the dissemination and implementation of guideline recommendations in order for clinicians to provide evidence-based care care. Scoping reviews are a useful tool in identifying knowledge gaps, scoping a body of literature, and to clarify concepts. We will present the results of a scoping review to describe the evidence on knowledge translation, mobilization and implementation strategies of clinical guidelines for seniors’ mental health care in community and residential settings.
The scoping review followed the Arksey and O’Malley (2005) framework and the JBI Scoping Review methodology. Searches of electronic databases and grey literature will be undertaken to identify studies addressing dissemination and implementation of guideline recommendations related to seniors’ mental health. Selected articles will undergo data charting to identify information on dissemination and implementation strategies, type of mental health condition, study location, and information on facilitators and barriers to dissemination and implementation.
We will describe effective knowledge mobilization strategies and novel knowledge mobilization strategies tailored to local and national contexts. Through adhering to the knowledge-to-action cycle of iterative knowledge mobilization, this dynamic project will be developed within a continuous knowledge creation and mobilization framework with clinicians, researchers, caregivers and people with lived experience.
Findings from this scoping review will effective knowledge mobilization strategies for specific local and national contexts. The results will inform development of a knowledge translation implementation framework for the CCSMH activities and inform the implementation of current CCSMH guidelines.
Maggie Hulbert, Susan Wang, Daniel Elder, Katherine Edmond, Daniel Kapustin, Jillian Alston, Ari Cuperfain, Michael Tau
The homeless population in Toronto is aging, and there are few service options directed towards older homeless adults, particularly those with serious and persistent psychiatric illnesses. A novel psychogeriatric intensive case management team was formed in 2022 with the goal of addressing these service gaps, and we intend to share reflections on our first year in practice.
During this interactive workshop, participants will learn about the implementation and demographics of a novel psychogeriatric intensive case management team focused on homeless adults with psychiatric and medical complexity. Participants will engage in case discussions illustrating common themes in working with homeless older adults through this model, which include increased medical complexity and reliance on hospital services, lack of appropriate housing, and the double stigma related to dual diagnoses of neurocognitive disorders and mental illness. A brief review of relevant literature will be presented, and participants will hear from a variety of interdisciplinary clinical perspectives.
By the end of the workshop, participants will be familiar with the literature on this population, and will have developed a nuanced understanding of the common themes in working with homeless older adults with psychiatric and medical complexity, and learned multidisciplinary strategies for addressing bio-, psycho- and social problems.
There is a need for more services aimed at serving homeless older adults with psychiatric and medical complexity. By reviewing demographic data from our novel psychogeriatric outreach team and discussing common themes, participants can feel more confident in working with this complex yet rewarding population.
Amy Gough, Keri-Leigh Cassidy, Margaret Casey, Michael Vallis, Gail Eskes, Erica Frank, Jean Robinson-Dexter
The Fountain of Health (FoH)’s Thrive MD Physician Wellness Program is a health promotion knowledge translation (KT) initiative using evidence-based domains of brain health and resilience, with emphasis on S.M.A.R.T. goal-setting and CBT-based behavioural activation. In this pilot study, the THRIVE © Approach to Wellbeing was adapted for use with older adult physicians in Canada as a CPD-accredited two-part webinar series to enhance health attitudes, reduce negative aging stereotypes, and increase self-reported health behaviours.
Observational quality assurance study inviting older physicians (defined as mid-late career, targeting age 50+) in Canada to participate in two, one-hour webinars four weeks apart. Webinar content includes KT on self-care using behavioural activation tools and S.M.A.R.T. goal-setting. Outcome measures include pre- to post- self-report on physicians’: 1) health attitudes, outlook on aging, self-care behaviours, and practice intentions (per Healthy Doc=Health Patient), and 2) goal-attainment scaling to assess behaviour change.
Preliminary results from the first webinar series (Spring 2022) demonstrated positive trends for all outcome measures assessed, but sample size was insufficient to offer meaningful quantitative data. Results from a second series of webinars in Spring 2023 will be presented.
We hypothesize that 1) Thrive MD Physician Wellness Program adaptation for older physicians will positively impact physician self-care attitudes, aging stereotypes, and health behaviours, and 2) participants’ raised awareness of evidence-based health promotion tools will contribute to self-reported intention to apply these in their own practices. Results will be used to guide future adaptation and scale up of the Thrive MD Physician Wellness Program in Canada.
Rochelle McAlister, Jordanne Holland
TSH is a partnership between WoodGreen, HCCSS, and Les Centres d’Acceuil Heritage, comprised of a team of registered healthcare professionals that offer essential supports to isolated, vulnerable seniors and/or caregivers. Supports include: access to timely supportive counselling, telephone crisis intervention, navigation to community services (with 30+ partner agencies), and activation of mobile crisis teams. Open 365 days a year, TSH has live answer in French and interpretation in 100+ languages. COSS is a partnership between LOFT, Reconnect, South Riverdale Community Health Centre, BSO and Haven Toronto, providing on-call mobile crisis service for older adults (65+) living in Toronto with cognitive, addictions issues or mental health concerns. The COSS team will meet in-person with clients, either in their home or local community; available 365 days a year from 9am to 5pm.
Toronto Seniors Helpline in conjunction with Crisis Outreach Service for Seniors will “pull back the curtain” to provide insight into the inner workings of the crisis care they provide. Presenters will highlight the knowledge transfer model developed by TSH and COSS, methods used within partnership development, and how staff training incorporates the most up-to-date information from research to practice, embedding research in our work with implementation of best practices. Consisting of the interorganizational TSH & COSS leadership teams, with representation from key collaborators, presenters will provide first-hand accounts of the development of the model used.
During Q&A and group activity, presenters will encourage attendees to explore how to build a similar model and interorganizational collaborative initiatives in their region.
Nick Ubels, Lauren Albrecht
Older adults’ increased need for relevant health information is often undermined by diminished access to that information. Barriers like chronic illness, disability, social isolation, marginalization, and low digital access are not sufficiently supported to enable their use of critical information that can improve their day-to-day lives. Everyone’s information experiences are unique and influenced by a wide range of individual and social factors. But by understanding trends among older adults’ health information needs, behaviours, and contexts, we can more effectively support, intervene, and empower with the provision of relevant, accessible, and evidence-based knowledge translation products.
An environmental scan of the academic literature was conducted on the information needs, behaviours, and contexts of older adults. A narrative synthesis of the literature was conducted to understand how older adults—especially those from equity-deserving groups who are under-represented in academic literature—interpret and respond to these principles, intervention effectiveness, and gaps in the literature.
The delivery of evidence-based strategies for information interventions that promote mental health will be discussed in the context of information studies scholarship. These findings will be deployed in CCSMH’s national knowledge mobilization project focused on mental health promotion among older adults.
Synthesized findings on information needs, behaviours, and contexts of older adults are drawn into dialogue with practical examples from a mental health knowledge mobilization project. Conference participants will develop a better understanding of how older adults encounter, experience, and share information alongside practical implications relevant to their own knowledge translation work.
Lauren Albrecht, Carolyn Brandly, Kate Ducak, Peter Snow, Nick Ubels, Avneet Vats
Knowledge mobilization (KMb) is a critical component of our work with the Canadian Coalition for Seniors’ Mental Health (CCSMH). KMb is an active practice of ensuring research evidence is used by clinicians, patients, and caregivers by making it accessible, relevant, and meaningful in different contexts.
To support health professionals, CCSMH synthesizes the best research evidence on a variety of mental health topics to create clinical practice guidelines regarding older adults for the assessment, management, and treatments of health conditions and symptoms. In tandem, we develop tools to assist health professionals implement these guidelines so that patients receive the best care. In addition, we make best practice information readily accessible and easy to understand for older adults, caregivers, and the general public.
For optimal uptake of our knowledge synthesis and knowledge translation products, we need to consider the needs of our audiences. Actively engaging in trauma-informed practice, cultural adaption, and challenging common terminology to ensure we are communicating our messages clearly and meaningfully and without stigma and harm is essential to being effective at conveying our messages. The three sessions for this symposium will grapple with the complexities of this work and offer examples, processes, and solutions for effective knowledge translation in mental health for older adults.
Embedding principles of equity, diversity, and inclusivity in research, knowledge mobilization, clinical, and community practice can combat issues of ageism and stigma and improve the health outcomes of older adults. Increasing our awareness, understanding, and application of these foundational principles can lead to effective and empowering knowledge mobilization practices in clinical and community settings.
David Conn, Bette Watson-Borg, Claire Checkland, John Saunders, Lisa Tinley
An Angus Reid survey found that 48% of Canadians reported themselves as being socially isolated, lonely or both (Reid, 2019). Social isolation among older adults is associated with increased chance of premature death, depression, dementia, disability from chronic disease, increased use of health and support services and increased number of falls (National Academies of Sciences, Engineering and Medicine (2020).
The Canadian Coalition for Seniors’ Mental Health (CCSHM) is developing Canadian guidelines for health and social service providers to support them in their professional roles with respect to the prevention, assessment, and management of social isolation and loneliness.
In this workshop, we will present the processes and methodologies taken to draft clinical guidelines, including the recruitment and support of a national Working Group, the findings of the Literature Reviews and the results of two national surveys. We will be seeking feedback and perspective with respect to the draft recommendations and the dissemination and knowledge translation of the guidelines.
This workshop will result in increased awareness and knowledge regarding the mental and physical health risks associated with social isolation and loneliness among older adults. It will provide evidence-based information with respect to the current state of research in this growing field. Finally, it will provide CCSMH with feedback on draft recommendations and ideas for effective dissemination and knowledge translation of the guidelines.
Cindy Grief, Christopher Kitamura
During the pandemic, virtual education for continuing professional development was indispensable. Today, virtual rounds continue to offer unique advantages, including the ability to learn from and with colleagues from different regions. The International Geriatric Mental Health (I-GeMH) Education Network launched its rounds series in September 2022. In this workshop, we outline the evolution of this initiative from its inception, including its goals, challenges and the steps needed to develop a global community of practice (CoP) in geriatric mental health.
A needs assessment survey was disseminated to healthcare professionals through national and international organizations to solicit input for topics and format. The I-GeMH series was described as a forum for connection and a means for exchanging resources in geriatric mental health. Participants registered for monthly video conference sessions. Evidence-informed methods for enhancing engagement were utilized.
Connections were established with the Canadian International Scientific Exchange Program (CISEPO), the CAGP and other organizations. Each of the first six I-GeMH monthly sessions averaged over 150 registered participants from two dozen countries. Findings will be summarized in the workshop as we discuss strategies for engagement, reflect on establishing a CoP, and invite collaboration.
I-GeMH sessions are becoming a forum for connection and exchange of tools and resources between participants. We have introduced cross-promotion and are experimenting with ways to enhance engagement. Guided by CISEPOs principles, we are striving to incorporate an equity framework into I-GeMH programming as we work to build capacity in geriatric mental health.
Justine Giosa, Elizabeth Kalles, Paul Holyoke
As concern for older adults’ mental health continues to rise, it is essential for aging Canadians with diverse perspectives to have the opportunity to participate in planning, researching and mobilizing mental health-related knowledge for the purposes of improving support, care and treatment in Canada. For many reasons, including systemic ageism, mental health complexities, and logistical challenges, these individuals are often left out. We are committed to authentically engaging experts-by-experience in setting priorities, finding solutions and championing action-oriented change through participatory research.
Guided by the Participatory Research to Action (PR2A) Framework, we partnered with Canadian experts-by-experience in a series of projects. A modified priority setting partnership (PSP) in 2018–2021 generated a list of top unanswered research questions for future initiatives. A cross-Canada expert-by-experience steering group was formalized from the original PSP to mobilize knowledge about the priorities. Two priorities are incorporated in an CIHR-funded project Co-designing action-oriented mental health conversations between care providers and aging Canadians in the community.
The priority questions are publicly available for use planning research and action-oriented projects. The steering group has secured funding for 2023–2024 and is planning a portfolio of knowledge mobilization activities. A visual model of mental health for use starting mental health-related conversations was co-created and validated in 2022–2023. Guidelines for using the model will be developed from workshops (n=7) in 3 provinces.
Addressing and overcoming complexities to include experts-by-experience in mental health planning, research, and action increases the likelihood of relevant and acceptable solutions that result in positive health system change.
Although age-related changes can impact mental health, there are major gaps in aging-focused mental health research to better understand how to meet the mental health support, care and treatment needs of aging Canadians. There is a need to identify aging and mental health research priorities that are aligned with the most urgent questions and concerns of aging Canadians to ensure research funding and work is focused on areas that have the potential to make the biggest impact.
A modified priority setting partnership approach was used to identify and rank the top 10 unanswered research questions on aging and mental health according to older adults, caregivers, and health/social care providers in Canada. The project was guided by a steering group of experts-by-experience and involved 12 steering group meetings, two pan-Canadian surveys (n=305; n=703), a rapid evidence review, and a nominal group technique (n=52) to establish consensus.
The top 10 unanswered research questions centered on: 1) building skills for non-specialist providers; 2) addressing loneliness; 3) increasing care access; 4) achieving person-centred care; 5) technological challenges and opportunities; 6) supporting care transitions; 7) addressing provider burnout; 8) caregiver involvement in planning care; 9) financial help for care affordability; and 10) addressing mental health of caregivers. A list of important answered questions with prior evidence was also produced.
Understanding the top priority research questions according to aging Canadians is critical to informing research funding and scientific activity decisions within and across aging, mental health and other related academic fields of study.
The Canadian Aging Action, Research, and Education (CAARE) for Mental Health Group was formalized in 2021 to raise the profile of aging and mental health in Canada and to mobilize knowledge of the associated priority research questions. The group is composed of experts-by-experience from across Canada, including older adults, caregivers, health/social care providers, and representatives of mental health organizations.
The group’s formalization was supported by a CIHR-Institute of Aging grant with goals to: 1) build and sustain authentic partnerships advancing mental health in Canada; 2) support research and action-oriented projects addressing previously identified priority questions; and 3) advocate and/or apply for funding to support our priorities and activities. Work to-date has included establishing sustainable partnerships with existing organizations, recruiting new members, and mobilizing knowledge of the priority questions.
The CAARE Group is an example of how expert-by-experience groups (n=17) can be formalized on a complex topic. We have produced a group name, logo, quarterly meetings with honoraria, and opportunities to meet in person. Knowledge mobilization outputs include invitation materials, an informational video, and academic presentations. The group is vital in supporting and promoting initiatives addressing the priority research questions. Future activities include participating in an advisory capacity for mental health initiatives in other organizations, recruiting more diverse membership, and establishing a knowledge hub for aging and mental health resources in Canada.
Using a participatory approach, experts-by-experience can be engaged to mobilize knowledge and give prominence to the need for an aging and mental health research agenda in Canada.
Older adults may experience dual stigmas from systemic ageism and negative attitudes about mental health. These complexities can make it challenging to discuss their mental health needs during care interactions. With experts-by-experience, we are taking action on two previously identified research priorities to co-create and test an evidence-based approach to starting mental health conversations in home and community care. The long-term goal is to support improved access to mental health support, care, and treatment for aging Canadians.
The 3-phase project utilizes a participatory mixed methods approach to 1) adapt and validate a mental health continuum model with older adults; 2) co-design processes to guide mental health conversations across 3 provinces (n=7 sites); and 3) pilot and feasibility test the conversation processes at the same sites. We are guided by an expert-by-experience working group (n=31).
Workshop participants (n=59) affirmed using the model to visually representation mental health’s complex and multi-component nature. They felt it could be used to de-stigmatize conversations with some adaptations, including more neutral and action-oriented language; removing clinical jargon; more culturally inclusive use of colour; and integrating re-named domains with modified signs and signals. A survey of ~1000 Canadians confirmed overall acceptability of the model by aging Canadians with refinement opportunities. Implementation process maps, including tools and resources providers can use to guide conversations at the point-of-care are being produced.
Engaging experts-by-experience to co-design mental health conversations in home and community settings will help build skills for providers which guide meaningful and helpful conversations with aging Canadians.
Stacey Hatch, Marcia Finlayson, Soham Rej, Dorothy Kessler
The worldwide prevalence of anxiety is estimated to be between 6% and 10%. Anxiety has been linked to difficulties performing activities of daily living. Older adults have expressed interest in mindfulness-based treatments in for anxiety, delivered in community and primary care settings. Emotion Focused Mindfulness Therapy (EFMT) is a mindfulness-based group intervention. EFMT has been demonstrated to reduce symptoms of anxiety in community dwelling adults. The aim of this study was to determine the feasibility of EFMT for older adults living in community settings.
We used a randomized controlled trial design with a wait-list control group. The intervention was delivered virtually. Participants were 55 and older and were recruited through primary care and community organizations. Participants were allocated on a 1:1 allocation ratio. Data were collected at baseline, post-intervention and 17 weeks following baseline. Feasibility was evaluated based on recruitment, enrollment, and retention in the study. Acceptability was evaluated on adherence to all elements of the intervention. The secondary objective examined the extent to which participants who received the intervention had decreased levels of anxiety changes over time to anxiety. We used the Geriatric Anxiety Inventory to measure changes.
Recruitment of 48 participants was completed in eight weeks by telephone. Enrollment was 62.3%, based on 77 potential participants screened. Retention and adherence were excellent at 80% and 100% respectively. Anxiety scores on the GAI were significantly reduced at T2 and T3 measurements.
EFMT is feasible and acceptable to older adults with late-life anxiety, and reduced symptoms of anxiety.
Vanessa Thoo, Leslie Giddens-Zuker
Patients with SPMI can be challenging for their care providers to manage due to concerns about capacity and consent with respect to healthcare decisions. While CTOs can help to address concerns regarding adherence to medications and psychiatric follow-up in the community, the LTC setting can present as an opportunity to revisit the patient’s goals of care and understanding regarding their illness.
A case review was conducted with a focus on issues of patient autonomy and SPMI in the elderly population. We will discuss an interdisciplinary approach in developing a management plan for patients with psychiatric complexity in the LTC setting.
Patients with SPMI and limited insight present as uniquely challenging for management within the LTC setting; however, the challenges can differ significantly from that in the community. While these patients tend to be quite complex in regards to both their physical and mental health, consideration of the patient’s perspective and wishes can optimize the care of these complex individuals.
Recommendations for each patient should be assessed on a case-by-case basis; however, it is imperative to incorporate the patient’s established wishes with consideration of both physical and mental health sequelae in discussions of risks and benefits of medication interventions. The Geriatric Mental Health Outreach team (GMHOT) can best support these patients and their care providers in engaging in discussions regarding consent and capacity with a focus on the patient’s quality of life and goals of care.
Kathleen Bingham, Erin Dickie, Navona Calarco, George Alexopoulos, Meryl Butters, Barnett Meyers, Patricia Marino, Nicholas Neufeld, Anthony Rothschild, Ellen Whyte, Benoit Mulsant, Alastair Flint, Aristotle Voineskos
Psychotic depression is common in older adults, and associated with substantial morbidity. Patients with psychotic depression often demonstrate psychomotor disturbance that persists after remission, a feature which our group recently demonstrated is associated with relapse risk. As originally put forward in the vascular depression hypothesis, abnormalities in white matter microstructure are a potential mechanism underlying poorer outcome and psychomotor disturbance. In this analysis, we examined whether white matter microstructure is associated with relapse probability in psychotic depression and, if so, whether white matter microstructure accounts for the association between psychomotor disturbance and relapse.
We used tractography to characterize diffusion-weighted MRI data in 80 participants enrolled in a randomized clinical trial that compared efficacy and tolerability of sertraline plus olanzapine with sertraline plus placebo in the continuation treatment of remitted psychotic depression. Cox proportional hazard models tested the relationships between psychomotor disturbance (processing speed and CORE score) at baseline, white matter microstructure (fractional anisotropy [FA] and mean diffusivity [MD]) in 15 selected tracts at baseline, and relapse probability.
CORE was significantly associated with relapse. Higher mean MD was significantly associated with relapse in the each of the following tracts: corpus callosum, left striato-frontal, left thalamo-frontal, and right thalamo-frontal. CORE and MD were each associated with relapse in the final models.
While both psychomotor disturbance and MD were associated with psychotic depression relapse, MD did not account for the relationship between psychomotor disturbance and relapse. The mechanism by which psychomotor disturbance increases the risk of relapse requires further investigation.
Susmita Chandramouleeshwaran, Tarek Rajji, Fiona Inglis, Waqas Khan
Many older adults receive psychotropic medications, but the cognitive impact of these drugs (other than benzodiazepines and antidepressants) has not been studied in detail. The aim of this systematic review is to examine the association between psychotropic medications that include benzodiazepines, antidepressants, mood stabilizers, antipsychotics, or a combination of these drugs on cognition in older adults.
Five electronic databases were used in the search strategy: Medline, PsycINFO, and Embase through the Ovid platform, CINAHL through EBSCO, and Web of Science. Randomized control and cohort studies that used a validated scale to measure cognition with a follow-up period of at least six months were included. The primary outcome of interest was cognitive change associated with psychotropic medication use.
A total of 7551 articles were identified from the primary electronic literature search across the 5 databases after eliminating duplicates. Based on full-text analysis, 27 articles (2 RCTs, 25 cohort) met the inclusion criteria. A total of 27 articles (2 RCTs, 25 cohort) met the inclusion criteria. Of these, nine each examined the impact of benzodiazepines and antidepressants, five examined psychotropic combinations, three on antipsychotic drugs, and one on the effects of mood stabilizers.
To our knowledge, this is the first systematic review to examine the cognitive impact of multiple psychotropic drug classes in older adults over an extended follow-up period (6 months or more) and using robust sample sizes, control groups, and validated cognitive instruments. We found evidence indicating cognitive decline with the use of benzodiazepines, polypharmacy, and antipsychotics in older adults.
Saumil Dholakia
This presentation conceptualizes the implementation of Medical Assistance in Dying where Mental Disorder is the Sole Underlying Medical Condition (MAiD-MD-SUMC) as a ‘wicked problem’. A ‘wicked problem’ is one which, because of its complex interdependences, does not have a formulation. Hence, understanding the problem and providing solutions is similar to untying a Gordian Knot—addressing one aspect of the ‘wicked problem’ will lead to creating or revealing higher level problems. Defining ‘intolerable suffering’, assessing suicidality, ascertaining the futility/irremediability bar, and navigating structural vulnerability inherent with mental illnesses are some of the aspects that make MAiD-MD-SUMC a ‘wicked problem’.
This presentation engages in a robust ethical analysis of the ‘wicked problem of MAiD-MD-SUMC with paramount values of autonomy and self-determination as represented in the Canadian Charter of Rights and Freedoms, rightly conditioned and limited by considerations of constitutional values of dignity, equity and care that centers the margins for people with mental illness and their families.
While this presentation does not intend to propose solutions, this ethical analysis of issues around MAiD-MD-SUMC provides a platform for an argumentative process in the course of which an image of the problem and possible personalized moral compass emerge gradually among the participants, as a product of incessant judgment, subjected to the critical argument.
MAiD-MD-SUMC is polarizing ‘wicked problem’, whose implementation (or no implementation) raises more questions than answers. This presentation advocates for an ethical analysis of values, supported by critical argument as a way to balance seemingly intractable disagreements associated with MAiD-MD-SUMC.
Christopher Kitamura, Marilyn White-Campbell
Substance use disorders (SUDs) in people with dementia are common, arising from both prescription medications and recreational substances. SUDs may predate dementia or be a symptom of the illness itself. Most research and clinical tools targeting SUDs in older adults focus on cognitively healthy and community-bound people. SUDs in dementia present unique challenges in diagnosis and management; pose safety risks that lead to morbidity/morality, hospitalization, and initialization; and create significant pressures on human resources and healthcare costs.
The workshop will consist of an interactive review of 3 cases of older adults with comorbid dementia and SUDs. We will review the unique symptom presentations in this population, clinical approaches including screening (and use of available tools) and treatments (pharmacologic, non-pharmacologic, and collaborations), transitions to long term care, and share our real-world outcomes. We will also discuss the ethical and capacity/legal issues in these complex cases. Cases will be discussed with opportunities for participants to share their own ideas and experiences.
Workshop participants will gain skills in the assessment and treatment of SUDs in people with dementia and in multiple practice settings at all stages of change, including via the use of harm reduction approaches.
While SUDs in people with dementia are challenging to formulate and treat, clinicians can develop a systematic approach that harnesses available tools, that applies pharm- and non-pharmacologic treatments, and utilizes collaboration to reduce symptoms, improve safety and enhance functioning and independence, all while preserving dignity.
Saumil Dholakia, Susmita Chandramouleeshwaran, Sarah Russell, Milena Ducic, Song Yang (Simon) Yu, Vera Hula, Margaret Neil, Susan Ball, Kristyn Hubert, Jennifer Koop, Laura Wilding
Behavioural and Psychological symptoms of Dementia or BPSD in hospitalized older adults with major neurocognitive disorder is associated with significant poor outcomes, including higher length of stay and readmission rates, declining nutritional status and increased risk of falls, delirium and mortality. A challenging hospital environment and care-design which is busy, constantly changing and unfamiliar, presentations with complex medical comorbidities, and divergent nature of goals of care are common contributory factors to these outcomes. While pharmacological and non-pharmacological interventions which are patient and caregiver centered can help reduce BPSD symptoms in any care setting, these are uniquely challenging to implement in a hospital setting.
This workshop will present management experiences of an interprofessional consultation-liaison Dementia Behavioural Supports Team (DBST) and highlight some of the facilitators and barriers to care of hospitalized older adults with BPSD in this milieu. Workshop participants, especially geriatric psychiatry residents and learners from interprofessional fields will engage in case-based learning exercises enriched over a 10-year experience of the DBST team (Behavioural Support Ontario nurses, geriatric psychiatrists, dementia-care coach) that focuses on clinical (pharmacological and non-pharmacological), and educational interventions for hospitalized older adults with BPSD and their families.
By the end of the workshop, participants will take home ideas to integrate care-interventions for hospitalized older adults with BPSD and their families.
Learning interprofessional health-care interventions for hospitalized older adults with BPSD can help center their margins of care. This will likely stimulate individual, organizational and system level discussions on future care-models for these patients in hospital-based settings.
Jessica Hung King Sang, Catherine Hickey
There is a critical need to recruit psychiatry residents into geriatric psychiatry. Canada’s population is aging at a rapid rate, and the supply of geriatric psychiatrists is inadequate to meet current and projected demands. Unfortunately, uptake of residents into existing accredited Canadian geriatric psychiatry subspecialty training programs has been suboptimal, with unfilled positions each year. Understanding what factors influence psychiatry residents to commit to geriatric psychiatry subspecialty training is critical to improving recruitment. However, to our knowledge, there are no recent Canadian studies that address this specific question. The primary objective of this observational study is to identify factors that influence a resident’s choice to enroll in geriatric psychiatry subspecialty residency training. A secondary objective is to determine when during medical training individuals reach this educational decision.
In spring 2023, psychiatry residents who are either currently enrolled in or have been accepted into a Canadian geriatric psychiatry residency program will have the opportunity to complete a one-time questionnaire that uses a rating scale to assess the degree of influence of various personal, educational, subspecialty training, and job factors on their decision to complete geriatric psychiatry training. Aggregate data will be graphed and analyzed qualitatively for patterns that indicate what factors or category of factors are most influential.
The study is in progress. Final results will be available in June 2023.
At the study conclusion, the hope is to identify modifiable factors that can inform future strategies to improve uptake into geriatric psychiatry residency programs.
Yasser Karam, Leia C. Shum, Twinkle Arora, Amy Cockburn, Shehroz S. Khan, Andrea Iaboni
The design of the physical environment has an important impact on people with dementia. Decline in working memory and spatial orientation can cause anxiety and motor behaviours such as entering other’s private spaces and trying to leave. Door decals are an environmental modification that support wayfinding by helping residents to recognize their door. In this quality improvement study, we asked: Do door decals 1) help residents find their own rooms? and 2) reduce interactions with concealed doors?
On a Specialized Dementia Unit, door decals were applied in two phases (case-control and pre-post designs) over 11 months on resident’s rooms, offices, and an exit. The number of approaches and entrances by residents to doors with and without decals were tracked using an indoor location system and percent differences calculated.
Residents entered rooms that were not their own 23% less if the other person’s room had a decal, and when a resident occupied a room with a decal, they entered rooms without decals 62% less. After a decal was added to a door, the number of entrances by people not resident in the room was reduced by 21%. A door concealed with a bookcase decal was approached 68% less compared to one without a decal, and when a bookcase decal was added to a door, the number of approaches were reduced by 44% and dwell time reduced by 54%.
The findings support that door decals can be an effective way to promote wayfinding in people living with dementia.
Cindy Grief, Shabbir Amanullah, Mark Rapoport, Leslie Giddens-Zuker, Laura Petta
The Geriatric Psychiatry Online Course (GPOC) is an award-winning national virtual course covering key topics in geriatric mental health run under the auspices of the Canadian Association of Geriatric Psychiatry. Consisting of 14 asynchronous modules, the course was initially developed to help trainees prepare for subspecialty exams. While unique when launched in 2012, there are now multiple options for online learning. As well, allied health registrants currently outnumber physicians. While evaluations are positive, preliminary feedback suggests gaps in the areas of equity, diversity and inclusion (EDI), including accessibility for French-speaking clinicians.
Stakeholder input was sought to identify motivations for taking the course as well as barriers. The GPOC committee reviewed evaluations and considered potential innovations. A plan to evolve the GPOC curriculum with expert input was refined. A needs assessment was disseminated nationally in the spring of 2023.
Issues posing a threat include the lack of a process to ensure content is up-to-date, challenges in maintaining learner and faculty engagement and meeting the needs of allied health and physician participants simultaneously. A process to embed EDI principles in the course is essential but lacking. The results of the national needs assessment are pending.
We will describe the results of a national needs assessment and discuss the challenges and opportunities in evolving an online asynchronous curriculum in geriatric mental health. Discussion will focus on motivations for learning about geriatric mental health, strategies to optimize knowledge translation and ways for incorporating an EDI framework into an existing course.
Katelynn Aelick, Teresa Judd, Jacquie Seguin, Jillian McConnell, Monica Bretzlaff
The process of moving from one place to another for people living with dementia and geriatric mental health conditions often poses considerable risk due to the complex nature of these illnesses and inadequate exchanges of information between healthcare providers. To better equip Behavioural Supports Ontario team members and partnering healthcare providers with tools to support moves during the pandemic, the Behavioural Support Integrated Teams (BSIT) Collaborative released ‘My Transitional Care Plan during the COVID-19 Pandemic’ (MTCP-C19) in October 2020.
Seeing continued value in the use of the tool to support transitions in the post-pandemic era, the BSIT Collaborative re-adapted MTCP-C19 into a version that is no longer specific to supporting moves during the pandemic. Now called ‘My Transitional Care Plan’ (MTCP), this updated version was trialed in the summer of 2022 in seven pilot sites spanning several sectors across Ontario. Feedback collected by the pilot sites informed additional edits to the tool.
MTCP was released in December 2022 in English, followed by a French version ‘Mon plan de soins de transition’ in January 2023. In this presentation, we will share data highlights of MTCP download data and how it has been used to inform a comprehensive dissemination strategy for the tool and its supporting resources.
MTCP is a free, publicly available, evidence-based tool that can be used to support people to transition across sectors.
Shabbir Amanullah, Kuppuswami Shivakumar
Sleep disorders are common in patients with Alzheimer’s dementia with a prevalence of 44%. Given the high prevalence and its impact on quality of life, management of sleep disorders takes on a new level of relevance. Rapid eye movement (REM) sleep duration decreases after the age of 80 years and with age chronic medical conditions, psychiatric and neurologic conditions along with chronic pain add to the complexities. Insomnia, excessive daytime sleepiness (EDS) along with REM sleep behavior disorder (RBD) and restless leg syndrome (RLS)-Willis Ekbom disease, are well known.
An extensive search of literature was conducted using Pubmed, Cinalh,, conference proceedings, seminars. From the key studies including a study of persons with mild cognitive impairment (MCI) or dementia, it showed that in excess of 60% had 1 or more sleep disorders. The commonest was SDB (60%) and then EDS (50.1%), insomnia (49.9%), RBD (22.6%).
Sleep disturbances are associated with a higher risk of all-cause dementia, AD, and vascular dementia. Sleep disorders are seen as prodromal biomarkers for dementia and potentially has a therapeutic role and likely even serves as a preventive target in dementias.
Poor management of sleep disorders is associated with worsening neuropsychiatric symptoms in dementia. As is well known, this increases care giver burnout and hence needs to be managed properly which in turn are associated with higher medical cost, increased risk of nursing home placement, and reduced quality of life for both caregiver and patient.
Kerstina Boctor, Wegdan Abdelmoemin, Shabbir Amanullah
Impulse Control Disorders (ICDs) in Parkinson’s disease (PD) are ill defined in existing taxonomies and can have negative consequences on patients and their families. The aim of this study is to identify current ICDs in PD, neurochemical pathways involved, current screening tools and management options.
Two screeners conducted a database search using PubMed, Medline, and Google Scholar to identify literature from 2013–2023. 20 papers were selected based on specific inclusion criteria (18+, English, Human studies, presence of PD+ICD). Studies were excluded if (animal models, non-English papers, presence of a major neurocognitive disorder or brain injury).
Our study identified ICD’s in PD to include: pathological gambling, shopping, eating, sexuality, Dopamine dysregulation syndrome, punding, body-focused compulsivity, and substance abuse. These ICDs were found to be disproportionately reported in patients on dopamine agonists; except for substance abuse, and were associated with mesolimbic rather than ventral-tegmental pathways. Measurement based tools include QUIPS-RS and BIS. First line treatments were: reducing or withdrawing dopamine agonists, increasing levodopa dosage, temporary replacement of pramipexole with bromocriptine. For refractory ICDs: amantadine, intrajejunal levodopa, clozapine, Gabapentin, NAC, and TMS have shown some evidence. CBT was also effective in reducing the severity of ICDs. Negative studies were found for Naltrexone/Naloxone and mirtazapine. Limited results were found for trazodone and topiramate.
There is a lack of overall clarity of ICDs and a gap in available research for measurement-based care as well as effective treatment strategies especially in PD to treat these conditions.
Carolyn Brandly, Meaghan Adams, David Conn
The National ECHO: Geriatric Mental Health program is an adaptive response to a growing demand for evidence-informed information among primary care providers treating older adults with mental health concerns. The aim of the National ECHO: Geriatric Mental Health program is to build capacity among primary care providers and improve care for older adults with mental health concerns by connecting experts and learning partners for collaboration, problem solving and professional growth.
Following a successful pilot collaboration in 2021, CCSMH, Baycrest Health Sciences, and the Canadian Academy of Geriatric Psychiatry are collaborating to lead 3 cycles (30 unique sessions) of a Geriatric Educational series. The program adapted the Project ECHO principles of amplification, best practices, case-based learning, and outcome measurement to develop a program that addressed the complexity inherent in geriatric mental health care and adapted content to a pan-Canadian context. This included recruiting interdisciplinary clinicians caring for older adults from across Canada, locating subject matter experts with deep expertise, and soliciting real-world case studies for just-in-time learning. Qualitative and quantitative data were collected and analyzed to measure the program’s impact.
Learning partners reported high satisfaction with the National ECHO: Geriatric Mental Health program, and indicated that the program improved their self-efficacy and confidence in caring for older adults with mental health concerns.
The National ECHO: Geriatric Mental Health program was well-received by learning partners and is effective in building capacity among clinicians to address the complexity inherent in providing care to older adults with mental health concerns.
Karen Cassells, Nicole Chwastyk
Resources allocated for individuals under 65 years of age requiring long term care placement is often limited, and necessitates judicious administration to ensure those within that age group receive timely access addressing individual care needs and a suitable environment to live.
For over ten years BSO teams have been supporting seniors and baby-boomers with transition based models of care when “highest need” for placement is present as defined within the Long Term Care Act.
Transition support with consistent approaches in advance of LTC admissions are proven effective for success, preserving autonomy and staff in long term care often provide beyond core tasks when supporting complex mental health transitions into LTC settings when personhood is known.
Caring for future cohorts of the elderly may potentially stabilize if the health care system is appropriately managed. Broader community education relating to impacts of mental health and dementia progression remains ever present; not just within healthcare but also legal and public sectors however, many older individuals experiencing mental health and dementia remain highest risk for early LTC admissions due to social-economic standings and overall cost.
Vincent Dagenais-Beaulé
Prescription of antipsychotics and sedatives in older people is a well-known problematic. There is help to choose which medications should be reassessed in older adults, namely Beers criteria and STOPP/START criteria there are also many more explicit criteria lists. While there is growing interest in appropriate use of the resources, there is much less guidance on the “how to” deprescribe. This current initiative wanted to provide algorithms to help the clinician reassess the antipsychotics and sedatives in older people while hospitalized.
Literature review was done to create the initial prototype, which was presented in a semi-structured interview to 11 experts who suggested modifications. Deprescribing guidelines were modulated with iterative versions using a modified Delphi approach, with a pre-specified agreement rate of 80%. Questionnaires aimed at assessing 1) quality of the tool, 2) the suggested clinical approaches, and 3) the feasibility of implementation.
A variety of experts participated in this project: inpatient and outpatient settings, pharmacists and physicians, with Geriatrics and Psychogeriatrics specialty, from 8 individual academic and non-academic centers, from 4 different administrative regions in the Province of Québec. Three rounds of Delphi approach were needed. One algorithm was created for the antipsychotics, another one for the BZRA, and a table with usual dosing regimens for psychotropics in elderly.
We created a tool that can help the inpatient clinical team to discuss and decide about a reasonable path for the initial reassessment of psychotropic drugs, with an approach to combining data from the literature, as well as clinical experience.
Marie d’Amours, Farah Ettis, Lauriane Ginefri, Johnny Lim, Angela-Sinlan Lin Poo Yuan, Jennifer Fontaine, Dana Wazzan, David Williamson, Vincent Dagenais-Beaulé
Psychotropic medications are frequently prescribed during acute care, even in the elderly. They represent a risk for inappropriate long-term use and increase the overall risk of morbidity and mortality in this population. Our project aimed to evaluate the feasibility of a psychotropic medication stewardship program led by pharmacists.
We conducted a prospective, observational pilot study in patients aged 75 years and older, admitted to a surgical unit with at least one active prescription of a psychotropic medication (antipsychotic, benzodiazepine or non-benzodiazepine receptor agonist). Each psychotropic medication was assessed for potential deprescription, and if eligible, a recommendation from the stewardship pharmacist was made to the medical team.
Among 183 patients, 93.4% were eligible for a potential deprescription. A total of 298 prescriptions were evaluated by the stewardship pharmacists of which 57.7% were antipsychotics, 23.2% were benzodiazepines and 19.1% were non-benzodiazepine receptor agonists. Most of the assessed prescriptions were started during current hospitalization (62.7%). The median time required for the intervention per patient was 17min30s. The stewardship pharmacists made 192 suggestions for 258 eligible prescriptions, with 69.8% being deprescription recommendations. Of all the deprescription suggestions, 75.4% were accepted by the medical team and 84.8% of those accepted persisted at discharge.
The implementation of a pharmacist-led psychotropic medication stewardship program on surgical units in our hospital is feasible and is a promising approach to improve geriatric care.
Saumil Dholakia, Alireza Bagheri, Alexander Simpson
Medical Assistance in Dying (MAiD) traverses challenging and emotionally overwhelming territories: Health Care Providers (HCP) across jurisdictions bridge the divide between normative yet opposing values of sanctity of life and dignity in death and dying resulting in a myriad of affective responses. These range from a rewarding experience on one end to an overwhelming sense of apprehension and unpreparedness on the other.
A systematic review research methodology was adopted to review qualitative research studies from 4 databases (OVID Medline, EMBASE, CINAHL, and Scopus) and grey literature. Key author, citation, and reference searches were also undertaken. Papers were included if they presented qualitative data regarding the emotional impact on HCPs involved in MAiD. Studies were restricted to English language. Analysis was conducted using thematic meta-synthesis. Once thematic synthesis was completed, the cumulative evidence was assessed using the Confidence in the Evidence from reviews of qualitative research (CERQual) approach.
The search identified 4523 papers. After applying inclusion/exclusion criteria and The Joanna Briggs Institute Critical Appraisal Tool for qualitative research, 35 papers were included in the meta-synthesis. Three distinct emotional themes were identified— (1) Strong, internalized basic emotions including moral distress, (2) Role-based emotions based on individual personal/moral/professional values, and (3) Reflective emotions that point towards MAiD being a ‘sense-making process’.
This systematic review and meta-synthesis maps the current emotional discourse amongst HCPs involved in MAiD and discusses the role of legal frameworks and the position of the health care provider in shaping this discourse.
Emily Goudie, Benjamin Campbell, Peter Hoang, Kyle Judd, Diane Lorenzetti, Rachelle Loo, Ashar Memon, Mark Shea, Jacqueline McMillan
Depression screening tools (DSTs) are frequently used to identify older adults at risk for depression. The aim of this study is to identify the scope of knowledge regarding the use of DTSs in culturally diverse older adult populations.
A scoping review of EMBASE, MEDLINE, and PsychINFO was performed in accordance with PRISMA guidelines. Covidence software was used to screen articles for inclusion/exclusion by two independent reviewers. Inclusion criteria: mean age ≥ 65 years (or ≥ 50 if at least 20% of the sample was ≥ 65 years), English language, validated DST, and clearly identified ethnicity of sample. Exclusion criteria: cognitive impairment, selective study populations (e.g. malignancy, stroke, COVID-19, etc), victims of trauma, and caregivers.
Initial search generated 7330 unique citations; 632 met inclusion criteria; 435 were included in full text review. A total of 61 countries were represented. The greatest number of studies was conducted in the USA (192), South Korea (56), China (59), Hong Kong (24), and Japan (17). There were 11 studies performed in Canada. A total of 140 self-identified cultural/ethnic categories were reported. The most commonly used DSTs were the CES-D (188, 27.1%), GDS (164, 23.7%) and PHQ (61, 8.8%). There were 33 DSTs identified.
Canadian studies favour the GDS (58%) and show a lack of diversity in DST use. Many used validated, translated tools for non-English speakers. While world-wide data has analyzed an array of self-identified ethnic and cultural groups, the Canadian data examines only a small, non-representative sample.
Sébastien Grenier, Philippe Landreville, Patrick Gosselin, Pierre-Hugues Carmichael
One way to improve access to psychological treatments is through self-help. This poster presents preliminary findings from a multisite RCT testing the efficacy of a self-help based on the principles of cognitive-behavior therapy and guided by undergraduate psychology students (GSH-CBT) for late-life generalized anxiety disorder (GAD).
150 participants (≥ 60 years old) with a diagnosis of GAD were randomly assigned to a 15-week GSH-CBT guided by students supervised by psychologists (n = 75) or to a waiting list (n = 75). Repeated measures regression models were used to compare changes in groups before and after 15 weeks on three primary outcomes [GAD symptom severity (Generalized Anxiety Disorder 7-item; GAD-7), tendency to worry (Penn State Worry Questionnaire; PSWQ), and anxiety levels (Geriatric Anxiety Inventory; GAI)] and three secondary outcomes [depressive symptoms intensity (Geriatric Depression Scale; GDS), insomnia severity (Insomnia Severity Index; ISI), and functional impairment level (Sheehan Disability Scale; SDS)].
At the first evaluation, the two groups were similar in terms of socio-demographics and outcomes. The GSH-CBT group decreased significantly on all three primary outcomes while the waiting list group remained stable over 15 weeks. The GSH-CBT group also decreased significantly on three secondary outcomes while the waiting list group remained stable over 15 weeks on the GDS or decreased to a lesser extent on the ISI / SDS. For ISI and SDS, the GSH-CBT group’s decrease was significantly different from that of the waiting list group.
GSH-CBT guided by students appears to be an effective intervention for treating late-life GAD.
Cindy Grief, Lisa Sokoloff, Daphna Grossman
We designed a virtual educational program for interprofessional team-based learning that addressed the challenging scenario of an older adult expressing a wish to die. This 2-part activity consisted of an asynchronous eLearning module outlining the clinical pathways for late-life depression, suicide and medical assistance in dying (MAiD) with a subsequent team-based synchronous expert-facilitated webinar.
Teams (N=14) were recruited from acute, long-term and community care settings. Individuals completed demographic questionnaires. Those randomly assigned to a bespoke group filled out an additional questionnaire to customize selection of cases and request topics and tools for inclusion. Responses informed refinement of the eLearning module, “A Wish to Die: Late-life Depression and MAiD”. The module was deployed for individual learners, followed 2 weeks later by a team-based webinar. Surveys post-webinar (immediate, 6-weeks) assessed learning outcomes. The project was REB-approved.
Eleven team-based webinars were completed, with key themes emerging. The majority of teams were interested in future educational resources around professional grief, guidance around debriefing, how to honour the person who has died, and the challenges of MAiD in long-term care (LTC). At 6-weeks post-completion, 100% of respondents stated they would recommend the activity to colleagues.
Teams identified a need for support around professional grief, especially among LTC staff who experienced MAiD deaths as sudden and unexpected. This has resulted in a new project to develop a debriefing tool for healthcare professionals in LTC who encounter loss in the professional context. Team-based learning helped contextualize module content for specific needs in this virtual-flipped classroom learning activity.
Nick Hayhow, Nardeen Yalda, Serena Wong, Martha Elliott, Talya Sametz-Madden, Sarah Arbing, Michele Doering
Loneliness is a key predictor of mortality in older adults. Previous research stresses the need for group-based loneliness interventions to undergo more randomized group comparisons. The Awareness, Courage, and Love (ACL) model of Functional Analytic Psychotherapy (FAP) offers a framework to address loneliness using positive reinforcement within relationships. The investigators will adapt, implement, and evaluate an ACL group for older adults in a psychiatric unit to target loneliness and answer 1) Are ACL groups for geriatric psychiatry inpatients feasible and acceptable? 2) Do such ACL groups demonstrate preliminary efficacy?
A randomized controlled trial design with a four-week duration. The waitlist control group will attend Mutual Help Meetings (standard of care). Participants are English-speaking geriatric psychiatry inpatientswith a Montreal Cognitive Assessment score greater than 10. Mixed ANOVAs will be conducted to determine if there is an interaction between time (3 levels: baseline, post-treatment, and follow-up) and group (2 levels: control, treatment) on each of the continuous outcome variables: loneliness, social connectedness, peer relational health, and life satisfaction. Feasibility and acceptability will be assessed via observations of affect, attrition, and program satisfaction surveys.
The study is still in its pilot phase awaiting Research Ethics Board (REB) approval. Preliminary sessions with staff have yielded positive feedback.
There is a pressing need for effective group-based interventions to meet the psychosocial demands of an increasingly growing older adult population. The investigators hypothesize that the ACL group will be well-received by geriatric psychiatry inpatients, alleviating loneliness and boosting social connectedness compared to treatment-as-usual.
Jessica Hung King Sang, Khalid Jat
Anticholinergic medications are widely prescribed in the elderly population but are known to produce adverse effects. Hospitalization is an important transition point that often results in new prescriptions of anticholinergic medications but can also provide a key opportunity for prescribers to reduce unnecessary anticholinergic burden. The Anticholinergic Cognitive Burden (ACB) Scale can be used to estimate anticholinergic burden. Geriatric psychiatry patients are particularly vulnerable to high anticholinergic burden, yet there is a paucity of studies pertaining to how psychiatric hospitalization of elderly patients impacts anticholinergic burden scores.
We conducted a retrospective chart review of 136 patients over 18 months to evaluate how local geriatric psychiatric hospitalization impacts anticholinergic burden. Using the ACB Scale, anticholinergic burden scores were calculated for each patient on admission and discharge and compared using nonparametric tests. Logistic regression was used to assess significance between sociodemographic factors and change in ACB Scale scores. P-values <0.05 were considered significant.
There was a statistically significant decrease in mean ACB Scale score from admission to discharge of 0.54 (p = 0.004). The most frequently discontinued medications were quetiapine and ranitidine. Increased ACB Scale scores were almost entirely due to psychiatric medications (54.1% antipsychotics and 40.5% antidepressants). Two factors were associated with an increased ACB Scale score: longer hospitalization and increased level of care on discharge.
This study suggests that hospitalization on a geriatric psychiatry unit provides clinicians an important opportunity to reduce anticholinergic burden. Clinicians should be particularly mindful of antipsychotic and antidepressant prescribing as contributing to increased anticholinergic burden.
Elizabeth Kalles, Justine Giosa, Carrie McAiney, Christopher Perlman
The mental health of older adults was affected by the COVID-19 pandemic in complex ways, but there is minimal research incorporating the perspectives of experts-by-experience. Investigating the mental health-related concerns of older adults, caregivers, and health/social care providers during the pandemic onset provides insight that can be used to guide mental health support, care, and treatment in meeting aging Canadians’ needs.
Secondary qualitative analysis was used to identify, categorize, and interpret key mental health considerations from: 1) a review of prior pandemic literature; and 2) responses to a survey (n=268) in 2020 originally focused on identifying aging and mental health priorities. The open-ended survey questions asked respondents to identify their mental health questions; the topics they wanted to know more about; and the types of [support/care/treatment] most important to them. This research formed part of a larger mixed methods master’s thesis.
Older adult mental health is a complex and multi-dimensional construct for experts-by-experience. Three considerations were identified, in addition to a range of mental health experiences and outcomes (e.g., suicidal ideation, social isolation). The considerations included 1) a set of core principles related to the need for older adults to have information, autonomy, and access for their mental health; 2) societal- and system-level factors that have the potential to affect older adults’ mental health; and 3) services, supports, and programs that might be beneficial.
Understanding the concerns of experts-by-experience during the pandemic can guide mental health service planning for high quality support, care, and treatment.
Daniel Kapustin, Shadi Zarei, Wei Wang, Malcolm A Binns, Paula M McLaughlin, Agessandro Abrahao, Sandra E Black, Michael Borrie, David Breen, Leanna Casaubon, Dar Dowlatshahi, Elizabeth Finger, Corinne E Fischer, Andrew Frank, Morris Freedman, David Grimes, Ayman Hassan, Mandar Jog, Donna Kwan, Anthony Lang, Brian Levine, Jennifer Mandzia, Connie Marras, Mario Masellis, Joseph B Orange, Stephen Pasternak, Alicia Peltsch, Bruce G Pollock, Tarek K Rajji, Angela Roberts, Demetrios Sahlas, Gustavo Saposnik, Dallas Seitz, Christen Shoesmith, Alisia Southwell, Thomas D L Steeves, Kelly Sunderland, Richard H Swartz, Brian Tan, David F Tang-Wai, Maria Carmela Tartaglia, Angela Troyer, John Turnbull, Lorne Zinman, ONDRI investigators, Sanjeev Kumar
Neuropsychiatric symptoms (NPS) are prevalent in neurodegenerative disorders, however their frequency and impact on function across different disorders is not well understood. We compared the frequency and severity of NPS across Alzheimer’s disease (AD), Cerebrovascular disease (CVD), Parkinson’s disease (PD), frontotemporal dementia (FTD), and amyotrophic lateral sclerosis (ALS), and explored the association between NPS burden and function.
We obtained data from Ontario Neurodegenerative Disease Research Initiative (ONDRI) that included following cohorts: AD (N = 111), CVD (N = 148), PD (N = 136), FTD (N = 50) & ALS (N = 36). We compared the frequency and severity of individual NPS (assessed by the neuropsychiatric inventory questionnaire) across cohorts using Generalized Estimating Equations and Analysis of Variance. Second, we assessed the relationship of NPS burden with instrumental and basic activities of living across cohorts using multivariate linear regression.
The FTD group demonstrated the greatest frequency and overall symptom burden of NPS as compared to all other cohorts. Further, there were differences among cohorts in terms of the association between NPS burden and ADLs. Post-hoc comparisons suggested that this finding was driven by the FTD group; however, the differences did not remain significant following Bonferroni correction. There were no differences among cohorts in terms of the association between NPS burden and IADLs.
NPS frequency and severity is markedly greater in FTD as compared to other neurodegenerative diseases. Further, NPS burden appears to be associated differently with function across neurodegenerative disorders, highlighting the need for individualized clinical interventions.
Daniel Kapustin, Aditya Nidumolu, Sameh Hassan, Shabbir Amanullah
Behavioral and Psychological Symptoms of Dementia (BPSD) are a heterogenous group of symptoms impacting up to 90% of patients with dementia. Multiple reviews have found ECT to be efficacious in treating refractory BPSD, however, no published guidelines exist to inform clinicians about how protocols for ECT should be implemented. This systematic review aims to identify parameters commonly utilized for BPSD in the literature.
MEDLINE and APA PsychInfo were searched from database inception until September 2022. Two reviewers independently screened and full text reviewed the retrieved articles.
A total of 800 unique citations were identified, and 160 were included in full text review. Ultimately, 32 studies were included. Most studies utilized thrice weekly ECT. The number of sessions needed for response ranged between 2–15, with improvement typically observed within 3–6 treatments. Multiple authors recommend starting with unilateral treatment and switching to bilateral if response is inadequate after 3–5 sessions. Typical pulse width was 0.30–0.37ms for ultrabrief and 1–2s for brief treatment. Minimum recommendations for adequate seizure duration ranged from 25 to 30 seconds on EEG and 15 to 20 seconds by observed motor movements. Stimulus dosage ranged between 1.5–2.5x seizure threshold for bilateral placement, and 4–6x seizure threshold for unilateral placement. Maintenance ECT was commonly used to reduce the risk of relapse.
ECT is both safe and efficacious for patients with BPSD, and the present review focuses on commonly implemented ECT parameters in the literature.
Cindy Kosynski, Kathleen Bingham
We present the case of a 73F with complex medical and psychosocial challenges. Ms. A is a 73-year-old woman with a psychiatric history of MDD and cognitive dysfunction (including expressive aphasia) following a stroke. She was referred to the North Simcoe Muskoka Specialized Geriatric Services (SGS) team for physically expressive behaviours toward her husband. On assessment, the case was much more complex than the referral suggested, involving allegations of intimate partner violence, substance abuse, substantial trauma, and geographic isolation without access to technology. Navigating the hospital system was particularly challenging because of Ms. A’s aphasia. For example, Ms. A’s spouse was able to sign her out of hospital against medical advice despite abuse allegations. We ultimately followed Ms. A in hospital, in the community and in long-term care.
During this presentation, we will discuss how our team worked collaboratively to ensure that Ms. A received adequate patient-centred and safe assessment, both at home and in hospital, despite her aphasia. As part of this talk, we will review specific strategies to address aphasia in older adults accessing care.
Strategies to optimize Ms. A’s care involved advocacy with the hospital for care planning, recommendations by speech language pathology for effective communication, liaison with provincial police to address allegations of abuse, and safety planning around home visits without access to internet or cell phone reception.
This case illustrates how extensive collaboration among interdisciplinary clinical and social services resources can be leveraged to optimize patient care in a challenging medical and psychosocial situation.
Mark Lachmann, Dasha Choitova, Elizabeth Lee
Home unit takeover as a “situation in which a legitimate tenant or homeowner finds themselves unsafe, physically, financially, or psychologically, because of the presence of people in their hoe that they may or may not be able to remove” (1). Seniors may be particularly vulnerable to becoming unsafe in their own home because of social isolation, physical frailty, cognitive impairment, and poverty. Our workshop will explore 4 specific cases, and model an expanded interdisciplinary team approach for each case.
Four cases will be presented, drawn from author’s practice in the preceding 6 months. Each case explores a senior with either an early dementia or mild developmental delay living alone in the community, at risk of losing their housing due to their home being used by others leading to an unsafe living situation for the senior. The role of the geriatric psychiatrist, as well as the nature of an expanded interdisciplinary team created around each situation will be described.
Of the four cases presented two individuals were able to maintain their housing, one case is still in evolution complicated by a specific medical illness, and one case was unable to be resolved in a timely manner resulting in eviction.
Each case demonstrates the crucial nature of the interdisciplinary team approach, and the complexity and ambivalence in working with an older population struggling with poverty, isolation, and health challenges (2).
1. Crime Prevention Ottawa (2015) Home Takeovers Guidebook. Ottawa.
2. Weissman E et al. (2017) Safe at Home. City of Toronto.
Anthony J Levinson, Richard Sztramko, Stephanie Ayers, Sandra Clark, Lori Mosca, Rebekah Woodburn, Maureen Dobbins, Dante Duarte, Sid Feldman, Roland Grad, Nick Kates, Vladimir Khanassov, Sharon Marr, Doug Oliver, Alexandra Papaioannou, Pierre Pluye, Parminder Raina, Tarek Rajji, Karen Saperson, Henry Siu, Gillian Strudwick, Wei Wang, Sarah Neil-Sztramko
Recent research has shown that the risk of dementia can be reduced by as much as 40% through modifiable lifestyle factors. However, there is a lack of awareness among Canadians about dementia risk factors and prevention strategies. Our objective in this study is to evaluate and disseminate an e-learning intervention about dementia risk reduction.
In phase 1, we will randomize 485 Canadian adults to two groups: multimedia e-learning and emails for 4 weeks about dementia prevention strategies vs. control education about mild cognitive impairment. Validated tools will be used at baseline, 4 and 12 weeks to measure modifiable risk factor knowledge, health behaviours, and intention to engage in risk reduction activities. Feedback from phase 1 will inform improvements to the intervention. In phase 2, we will disseminate the e-learning through the McMaster Optimal Aging Portal and other channels, with measurement of uptake and impact through web and learning analytics.
Recruitment for this study will begin in March 2023, with expected completion of the randomized trial in August 2023. Phase 2 dissemination will begin in Fall 2023.
This study will contribute to our understanding of the effectiveness of web-based learning to help raise awareness of dementia risk reduction.
Frankie Lui, Orli Amar, Serena Wong, Michele Doering
Lonely older adults have diminished longevity and health, with psychosocial causes including sparse social support, perceived superficial relationships, lower relational self-efficacy, and limited social skills (Holt-Lunstad et al., 2015). In combatting loneliness, functional analytic psychotherapy (FAP) emerged as an empirically-based cognitive behavioral therapy focusing on social connection. It utilizes an Awareness, Courage, and Love (ACL) framework for groups, incorporating core components of social connectedness. FAP’s focus on social connection provided a logical foundation for therapeutic groups at Parkwood Institute Mental Health Care’s Geriatric Psychiatry program.
With leadership and internal grant support, the investigators completed an initial literature search to identify a therapeutic modality that would fit best for geriatric inpatients. FAP was chosen because outcomes of these groups include increased feelings of closeness with others (Tsai et al., 2020) and mindfulness (Kohlenberg et al., 2015). Existing traditional ACL sessions were adapted in consideration for accessibility and relevance. Session content was simplified and shortened, and roleplays among staff allowed for a refinement of the group protocol.
A four week-program was finalized with conceptual fidelity to the ACL model incorporating mindfulness practice and opportunities to develop deep, meaningful moments of connection to alleviate loneliness among geriatric inpatients.
Rooted in functional analytic psychotherapy, the ACL framework targets loneliness by addressing several related psychosocial factors. As a result, the Parkwood Institute Mental Health Team is now in the stages of implementing the group protocol and registration as a clinical trial.
Robert Madan
Weight loss is not an uncommon medical condition in late life. The differential diagnosis of weight loss includes a wide array of medical conditions such as malignancy, neurological disease, respiratory and gastroenterological conditions. Various psychiatric conditions can present with weight loss including depressive disorders, OCD, and neurocognitive disorders. Clinicians may not routinely consider the diagnosis of an eating disorder in older adults.
Two cases of weight loss will be presented, one occurring in long term care and another in the ambulatory context. In this interactive session, participants will work through the differential diagnosis and determine a process for assessment. These complex cases will highlight the need for an interprofessional and bio-psycho-social approach to assessment and treatment.
These cases highlight the complexity of assessing weight loss in older adults. A comprehensive interprofessional assessment is needed to determine the cause of weight loss. Physical and psychiatric conditions need to be considered. Co-morbidities must be considered in the formulation. Clinicians may consider pharmacotherapy, certain psychotherapies, and specialized eating disorder programs if an eating disorder is ultimately diagnosed.
Clinicians must consider a comprehensive, interprofessional, and collaborative approach when assessing and treating older adults with weight loss.
Mehtaab Mahal, Sandra Clark, Rebekah Woodburn, Dante Duarte, Nick Kates, Doug Oliver, Tarek Rajji, Karen Saperson, Gillian Strudwick, Wei Wang, Anthony J Levinson
Web-based education may be helpful to improve mental health literacy and complement patient and care partner psychoeducation. We created a new web-based platform with e-learning, curated resources, and detailed overviews of anxiety, depression, mild cognitive impairment, and brain health for older adults and their care partners. Our objective was to conduct usability testing prior to a field trial.
Participants were recruited through a panel of older Canadians and care partners representative of the target audience. They completed a survey that assessed the design, content, and overall usability of the website, including validated user experience scales such as the System Usability Scale (SUS). Descriptive statistics were used to summarize quantitative data and qualitative feedback was themed using a grounded theory approach.
Twenty participants (60% male, >75% between 65–74 years of age) completed the evaluation in February–March 2023. The mean SUS score was 83.75, indicating a very high degree of satisfaction with the usability of the website, and a strong positive correlation with other measures of site usability and satisfaction. Participants highly rated the components of usability, credibility, appearance, and loyalty. They reported strongly valuing the e-learning and detailed topic overviews. Qualitative feedback was generally positive and included a range of suggested enhancements.
Participants provided positive user experience evaluations of the usability and content of this new web-based resource. Minor updates to the site are planned prior to our field trial in retirement homes, primary care, geriatric medicine/psychiatry, and other settings.
Bernadette Mdawar, Tarek Rajji, Patricia Cavanagh, Sean Kidd, Petal Abdool
Integrated care pathways (ICPs) have been shown to improve quality of care across various mental health conditions. Previous studies assessing their efficacy in schizophrenia lacked rigorous methodology and resulted in mixed outcomes. We aim at evaluating the efficacy of ICP compared to treatment as usual (TAU) in late life schizophrenia (LLS)
We conducted an 18-month randomized controlled pilot study. Participants were 50 years or older, recruited from inpatient or outpatient services, had a diagnosis of schizophrenia or schizoaffective disorder, and were in acute relapse. Participants were randomized to either LLS-ICP in which physicians were prompted to follow a medication algorithm composed of 3 trials with titration schedule and use non-pharmacological interventions, or to TAU receiving current standard of care in addition to being offered the same non-pharmacological interventions. Primary outcome was response rate. Secondary outcomes were time to respond, rates of medication side effects and functional outcome.
A total of 24 participants (mean age [SD], 68.9 [6.2] years; 13 [54.2%] male; 20 [83.3%] schizophrenia) were randomized; LLS-ICP (mean age 70.1 [5.1]; 5 [41.7%] male; 9 [75%] schizophrenia) and LLS-TAU (mean age 67.7 [7.2]; 8 [66.7%] male; 11 [91.7%] schizophrenia). The LLS-ICP was feasible among those randomized to receive it. Primary and secondary outcome analysis results, including by gender, will be presented at the meeting.
The data of this study could be used to design a fully powered trial to test the efficacy of the LLS-ICP. Establishing efficacy of ICP will support its dissemination and implementation in several settings where patient with LLS are cared for.
Kirolos Milio, Elliot Lass, Virginia Wesson, Kristina Powles, Elena Irina Nica-Graham
Collaboration between geriatric psychiatrists and family physicians is key to the provision of psychiatric care to older adults. In order to develop targeted educational interventions for the family medicine residents at Mount Sinai Hospital at the University of Toronto, an interdisciplinary team identified gaps in knowledge and confidence within key domains of geriatric psychiatry amongst family medicine residents.
We are conducting a literature review in Medline (1946 to Oct 12, 2022), and a thematic analysis of data gathered in an environmental scan and focus group within the Family Medicine Residency Program at Mount Sinai Hospital, University of Toronto. The goal is identifying gaps in geriatric psychiatry teaching and knowledge for family medicine residents.
The environmental scan of current geriatric psychiatry training for family medicine residents reveals limited specific training. The literature review found that medical faculty are less confident in teaching more specialized geriatric topics, including cognitive impairment, and that geriatric specialist teaching can be limited. Overall, gaps in key areas of geriatric psychiatry—delirium, depression, dementia, issues of capacity, geriatric psychopharmacology, collaborative models of care—have been identified in primary care. There is a paucity of research on specific geriatric psychiatry educational tools for family medicine residents.
This project aims to identify key areas of geriatric psychiatry that can become the focus for targeted teaching for family medicine residency programs. Through a collaborative approach, the results of this project will inform a series of online educational modules touching on key domains of geriatric psychiatry for family medicine residents.
Kanza Naveed, Neda Rashidi-Ranjbar, Sanjeev Kumar, Reza Zomorrodi, Daniel Blumberger, Corinne Fischer, Benoit Mulsant, Bruce Pollock, Aristotle Voineskos, Tarek Rajji
Patients with Alzheimer’s dementia (AD) have impaired plasticity over the dorsolateral prefrontal cortex (DLPFC) as assessed using paired associative stimulation with electroencephalography (PAS-EEG). A 2-week course of repetitive PAS (rPAS) to the DLPFC was shown to be a promising intervention to reduce this impairment in plasticity when assessed the day after the rPAS course. This analysis explores whether the response to rPAS is moderated by structural measures of DLPFC and related pathways.
Twenty-nine participants with AD (females = 15, mean (SD) age = 75.66 (6.03) years) were randomized 1:1 to a 2-week (5 days/week) course of active or sham rPAS. DLPFC plasticity was assessed at baseline and one-day post-rPAS using PAS-EEG. DLPFC cortical thickness and surface area, and fractional anisotropy (FA) and mean diffusivity (MD) of the superior longitudinal fasciculus (SLF; a tract connecting the somatosensory region—which receives the peripheral PAS input—to the DLPFC) were generated using baseline brain T1-weighted MRI with Diffusion-Weighted Imaging.
Among the four brain structural measures, and after controlling for age and sex, only SLF MD was significantly associated with DLPFC plasticity and only after the active rPAS intervention (F3,7 = 4.823, p = 0.040; B = −1.002, p = 0.010).
This analysis suggests that the integrity of the tract connecting the somatosensory region to the DLPFC is critical for rPAS-induced plasticity enhancement in the DLPFC of patients with AD. If replicated, our finding could provide an approach to selecting patients with AD who are likely to respond best to rPAS.
Myanca Rodrigues, Anna Oprea, Keily Johnson, Alexander Dufort, Nitika Sanger, Pegah Ghiassi, Stephanie Sanger, Zuhayr Syed, Balpreet Panesar, Alesia D’Elia, Sameer Parpia, Zainab Samaan, Lehana Thabane
Findings from randomized controlled trials (RCTs) are synthesized in meta-analyses to inform evidence-based health care. However, unclear specification of outcomes in published RCTs impedes synthesis efforts and hinders knowledge translation and clinical decision-making. The comprehensiveness of outcome reporting across trials for older adults with major depressive disorder (MDD) remains unknown. The objective of our study was to assess the reporting of primary outcomes in trials evaluating treatments for geriatric MDD.
Eligible studies for outcome reporting assessment included RCTs which assessed interventions for older adults with MDD, and were published between 2011–2021, specifying a single, discernable primary outcome. Outcome reporting was assessed independently and in duplicate using a pre-defined checklist of 58 reporting items. Information for primary outcomes in each published trial were scored as “fully reported”, “partially reported”, or “not reported” for each item on the checklist.
Thirty-one of 49 identified publications had a single, discernable primary outcome, and were eligible for outcome reporting assessment. The majority of RCTs (60%) did not fully report over half the 58 checklist items. Less frequently reported items included: outcome measurement instrument properties (range: 5% to 50%) and justification of criteria used to define clinically meaningful change (9%).
There is variability in reporting of geriatric depression RCTs, with frequent omission of key details regarding primary outcomes. Omission of key details may impede interpretability of study findings, and hinder synthesis efforts which inform clinical guidelines and evidence-based decision-making. Consensus on the minimal criteria for outcome reporting in geriatric MDD trials is required.
Cheryl Sadowski, Sammy Lowe, Allyson Jones, Susan Zhang, Tarek Turk, Joanne Olson, Pauline Paul, Elaine Yacyshyn
Cannabis use is increasing yet little is known about use in older adults. The objective of this study was to quantify the prevalence and associated factors related to cannabis use among older adults (65+) seeking care for rheumatologic conditions in Alberta.
Adults in Alberta were contacted through Alberta Health Services if they had a diagnostic code for a rheumatologic condition and had a billing code related to health system use in the past year. Participants completed an online survey capturing sociodemographics, medical history, cannabis use patterns, and lifestyle factors. Prevalence of rheumatologic conditions, mental health outcomes, and cannabis use was assessed with descriptive statistics. Logistic regression was used to identify the factors associated with cannabis use among those who had ever used cannabis.
Our sample included 2,208 older adults (female=49.8%), mean age 73.6y (SD=6.4), and 384 (17.4%) current users, 508 (23.0%) past users, 1,326 (60.1%) non-users. The most common rheumatic conditions were osteoarthritis (57.4%), rheumatoid arthritis (15.4%), and osteoporosis (12.5%). 878 of all respondents (39.8%) experienced at least one form of mental illness, with sleep disturbances (14.1%), mood disorders (10.9%), and anxiety disorders (8.2%) being the most common. Results from the logistic models indicate that respondents who were younger, male, using multiple non-medication therapies, did not have health insurance, smoke, and consume seven or more alcoholic drinks per week were more likely to use cannabis.
This study highlights that older adults are commonly using cannabis and a number of characteristics can help us predict use.
Nancy Searles, Carey Ferris, Dr. Shabbir Amanullah
The thalamus is a structure in the mid-brain that plays a role in cognition, among other functions. Thalamic stroke may mimic other neurological conditions and therefore it is important to obtain a precise and accurate timeline of the presenting symptoms, to be able to distinguish thalamic stroke from other neurological conditions, in order to provide the patient with effective treatment in a timely manner.
Review of the relevant literature from 2013 to 2023, pertaining to thalamic stroke.
We found that thalamic stroke is not a rare occurrence and may be under-diagnosed. More research is needed on this topic to provide increased clinician knowledge and awareness, leading to improved patient outcomes.
If not accurately investigated, thalamic stroke can be mistaken for other neurological conditions which have similar presenting features. Collaborating with the patient, caregivers and family members and taking time to obtain an accurate and through patient history, while detailing the timeline of presenting symptoms, will ensure the right investigations are completed and the correct diagnosis is made.
Kuppuswami Shivakumar, Shabbir Amanullah
Psychotropic medications as a montotherapy or combination therapy are widely used for the treatment of range of psychiatric conditions in psychogeriatric patients. There is a significant amount of evidence suggesting the risks of QTc prolongation with the use of psychotropic medications. Since the introduction of various newer psychotropic agents, it has become very common to use a combination of psychotropic medication in our clinical practice.
A PubMed and Medline search will be conducted to identify studies for period of 5 years evaluating the QTc prolonging effects of psychopharmacological agents used as a monotherapy or combination therapy in psycho-geriatric patients. Appropriate MESH times will be used to identify the studies. Literature search will be done to identify the studies and bibliography this will be reviewed for inclusion of additional studies. Case-control, prospective, retrospective, cohort and randomized controlled studies will be included. Studies involving the combination of various psychopharmacological agents will be included as reflecting the common clinical practice. English language studies and human subjects only considered for the review.
The results will be categorized into various groups including antidepressants, antipsychotic agents and other psychotropic agents including the combination of medications.
We hope that this study will summarize the current data regards to the QTc interval prolongation effects of various psychotropic medications in the elderly. It is also important to identify the other risk factors in the geriatric population because of the multiple comorbid medical, psychiatric, and cognitive conditions associated in treating elderly patients.
Peter Snow, Lauren Albrecht
Hope is an essential component in mental health recovery, and higher levels of optimism have been shown to increase long term survival. Receiving a diagnosis or experiencing a setback in treatment can be devastating for people and their health professionals. In one study, over 50% of health care workers surveyed indicated they had inadequate skills to foster hope in their patients. The presenter has significant clinical experience fostering hope in individuals dealing with mental health issues.
The presenter is completing an environmental scan on the psychology of hope, and current practices in delivering diagnosis, conveying bad news, and operating through a hope lens across health care disciplines. The multi-disciplinary knowledge mobilization team at Canadian Coalition for Seniors’ Mental Health is actively integrating hope into mobilization assets and clinical materials.
This presentation will review our current understanding of the nature of hope, and outline approaches to integrating hope in clinical practice. Participants will be given an overview of existing best practices with relevant practice examples related to conveying diagnosis, fostering hope in clinical interactions and creating practice materials.
Centering hope in clinical practice with older adults can improve quality of life, encourage active recovery, and increase provider confidence. Understanding the complexity of hope and the available tools for fostering hope in practice can facilitate these outcomes.
Claire Stanley, Vicky Stergiopoulos, Sarah Colman
Although assertive community treatment (ACT) has been shown to be a reproducible and adaptable model, to date, there has only been one randomized controlled trial studying a psychogeriatric ACT team. The promising results of this study, in conjunction with the growing body of literature reinforcing the importance of geriatric outreach, supports the development of a psychogeriatric ACT team. The aim of this project is to describe unique components of a novel psychogeriatric ACT team developed in Toronto, Ontario and highlight key aspects to implementation using a quality improvement approach.
Using the Dartmouth Assertive Community Treatment Scale as a comparator, we distinguished core components of this psychogeriatric ACT model compared to traditional ACT. Using a quality improvement lens, we have been executing a series of plan-do-study-act cycles with the aim of improving team satisfaction and model fidelity.
Key distinguishing features from traditional ACT include: variation in team structure and composition, emphasis on medical-psychiatric overlay as well as the identification and management of geriatric-specific issues. Specifically, the team has integrated a geriatric psychiatrist, geriatrician, occupational and behavioral therapy. The novel structure and composition of the team will be reviewed. We will further outline the results of our quality improvement project, which we aim to complete by June 2023.
Studying the implementation of a novel approach to care is essential to facilitate future research and reproducibility of this model. By sharing our findings, we hope to inspire development and study of intensive outreach services for geriatric patients with severe mental illness.
Shikha Walia, Lillian Hung, Michael Wilkins-Ho, Breanne Cantlon, Chloe Marie Brown, Paul Blackburn
Mental health professionals report poorer wellbeing than staff in other healthcare sectors, which along with higher burnout is associated with poorer quality and safety of patient care, higher absenteeism, and higher turnover. A study showed a smartphone application (app) supported older adults to promote health, with good acceptability and improved knowledge. We anticipate the same app may also offer support for wellness of staff in general and geriatric mental health programs and will examine its usability, acceptability, and feasibility in this group.
We recruited staff at a tertiary mental health program in Vancouver, BC. Using a mixed methods research design, pre and post numerical rating scales aimed at assessing any change in self-rated health and resiliency were administered via email and completed using UBC Qualtrics to 13 participants. There was also a structured focus group focusing on identifying acceptability, usability, enablers and barriers to the use of the app. Inductive and deductive coding techniques were used to illuminate data segments indicative of thematic patterns.
Data shows on average, the mean post rating score after using the app increased on all levels, with the biggest change having a difference between means p-value of 0.0699, which although not statistically significant, is a modest increase. Through the focus groups, the staff found the app acceptable, reporting it easy to use, and perceive it as helpful.
Data shows modest increases in staff’s subjective assessment of their level of wellness after using the app, although not statistically significant.
Debra Walko, Carolyn Donaldson, Jason Fuoco
Back to Home model is an award winning model designed to support seniors facing complex mental health challenges, addiction, dementia and responsive behaviours along with physical health and care needs, who do not have access to appropriate housing and social determinants of health. Often these individuals no longer require acute care but remain in hospital, as they require ongoing care; and are usually experiencing poverty and homelessness. This model builds on years of learning to design the next evolution of specialized supportive housing. It is a comprehensive model integrating; enhanced specialized transitional care, specialized supportive housing with wraparound supports through strong integrated partnerships.
The model adopts a flexible person-centred approach offering 24/7 specialized personal care, medical support, psychogeriatric case management, individual and group life enrichment activities, medication support, behavioral support, and meals. It integrates partnerships with hospital and community to ensure residents are attached to primary care, geriatric-psychiatry, pharmacy, etc.
This model improves patient flow from hospital and reduces ALC rates. One of LOFT’s newest sites, launched in 2021, hospitalizations and ED visits were reduced by over 85% during the first year, and total cost savings were estimated at $2,225,453 from housing 26 hospitalized individuals. LOFT replicated the model across Ontario.
Model can be scaled and spread. LOFT is in the process of developing a playbook to document the model, the learning, and support capacity building with other seniors or mental health organizations wanting to do this kind of work to support people in returning to the community with dignity.
Alex Whynot, Beverley Cassidy
Community-dwelling persons with dementia and their care partners face social isolation, stigmatization and reduced social supports, associated with negative health outcomes. Memory Cafés are non-profit volunteer-run community-based interventions promoting social connection and de-stigmatization. While some research explores participant experiences, volunteers are often overlooked. This study aims to explore the experience of volunteers and its possible impact on knowledge, attitudes, and beliefs toward community-dwelling persons with dementia and care partners.
An explorative mixed-methods study was conducted with a 2020–2022 cohort of volunteers. The data was analysed using constant comparative analysis and data triangulation focused on volunteers’ knowledge, attitudes, and beliefs. A social disability model lens was applied.
Seventy-five percent (n=9) and 33% (n=4) of total volunteers, completed the online questionnaire and a 1-hour semi-structured interview, respectively. Most volunteers reported enhanced comfort working with community-dwelling persons with dementia (n=8), understanding of care partner’s needs (n=7) and age-friendly communities (n=8). Main themes explored included volunteers’ knowledge (e.g., increased awareness, recognition of care partner’s needs), attitudes (e.g., the importance of inclusion, considering the whole person), and beliefs (e.g., isolation as an issue, maintained capacity for enjoyment).
Memory Cafés may provide an important community-level intervention for not only participants, but also volunteers as we strive to combat stigma, promote inclusion, and shape knowledge, attitudes and beliefs that contribute to age-friendly communities.
Khin Khin Win, Pauline Seah, Noorhazlina Ali, Justin Chew, Jun Pei Lim, Mark Chan, Wee Shiong Lim
The 6-item Chinese Frontal Assessment Battery (CFAB6) is a locally validated bedside tool to assess executive function in early cognitive impairment (ECI). Among the 6-items, environmental autonomy has demonstrated low discriminatory ability and internal consistency. We aimed to compare the diagnostic performance of CFAB5 vs. CFAB6, removing the item of environmental autonomy. We also determined the updated age and education adjusted cut-off scores for CFAB6 across ECI
All participants completed the CFAB5 and CFAB6. Clinical Dementia Rating scale was used to determine the severity of cognitive impairment. Receiver-Operating Characteristic curve analysis was performed to determine optimal cut-off scores adjusted for age and education. Areas under the curves (AUC) for CFAB6 and CFAB5 were compared.
We enrolled 204 cognitively intact community dwelling older adults and 281 with ECI (130 mild cognitive impairment (MCI) and 151 mild dementia (MD)) attending a memory clinic. The mean age and education were 71.1 years (±7.81) and 7.77 years (±4.65) respectively. The optimal cut-offs for CFAB6 and CFAB5 were ≤15 and ≤12 respectively. We observed higher cut-off scores for CFAB6 in overall ECI groups with or without adjustment by age/education compared to earlier validation studies. Diagnostic performance (AUC) of CFAB5 was comparable to CFAB6, (ECI:0.888 vs. 0.884, MCI:0.829 vs. 0.825, MD:940 vs. 0.935, p<0.05).
The comparable diagnostic performance of CFAB5 supports its use as a bedside tool for ECI in clinical practice [SB1]. The higher CFAB6 cut-off scores in this study allude to the influence of higher educational attainment and other population specific characteristic over time.
Mehar Kang, Jessica Chin, Tristan Willis, Dayle Ostapiuk, Teresa Tai, Meghan Ho, Paul Blackburn, Jennifer Laidlaw, Anyssa Shakeri
There can be many layers of complexity in caring for older adult patients including addressing safety, function, capacity, and medical/psychiatric comorbidities. Some gaps in care involve varied understanding and use of involuntary admission/treatment legislation and challenges navigating delirium or neurocognitive impairment. This project aims to improve clinical understanding and confidence regarding use of legislative acts among BC healthcare providers via educational interventions in at least 75% of participants.
Development and delivery of educational seminars on clinical decision-making and the intersection of BC’s Mental Health Act, Health Care Consent Act and Adult Guardianship Act for medical learners and allied healthcare providers (approx. 50 participants) in BC who work with older adult patients. We will evaluate this intervention after each educational session and in 6 months follow-up with a survey on self-assessed knowledge, confidence, and interest in further education.
Initial survey respondents have included 9 psychiatry residents and 1 nurse. 100% report improved knowledge of when to use legislative acts and interest in further clinical resources. 90% report improved understanding of the limitations of legislative acts. 80% report improved confidence in utilizing each act in a clinical setting.
There is a role for improving point-of-care access to concise clinical decision-making tools and standardizing clinical documentation. Further assessment on the impact of interventions on mental health certifications, capacity assessments, or patient-initiated discharges against medical advice may also be considered.
Samantha Reimer
We described a case of a 65-year-old woman who received electroconvulsive therapy (ECT) for severe depression with psychotic features in the setting of a newly discovered intracranial aneurysm (ICA). ECT was ultimately pursued, and this resulted in rapid resolution of her symptoms after four treatments. ECT is becoming increasingly popular in the elderly as it is a highly effective treatment in this population and is generally considered safe. However, there are certain conditions, including ICAs that are associated with an increased risk of adverse events.
To better understand and appreciate the risks of administering ECT in the setting of ICAs, we conducted a literature review on this topic.
A total of 25 cases were reviewed and summarized, in which there was one reported case of a fatal aneurysms rupture following ECT.
Further cases should be described to better appreciate the risk of delivering ECT to patients with cerebral aneurysms. Based on the one reported fatality in a geriatric patient, age may be an important risk factor for serious complications in the setting of ECT. Specifically calculating the 5 year cumulative aneurysm rupture rate may be particularly useful in the risk/benefit analysis. Involving the expertise of specialists, like neurosurgery and anesthesia, is also prudent and consideration should be given to administering ECT in a tertiary hospital in case of post treatment complications.
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This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 27, No. 1, MARCH 2024