Anticonvulsants in the Treatment of Behavioral and Psychological Symptoms in Dementia: A Systematic Review.

OBJECTIVES: Behavioral and psychological symptoms of dementia (BPSD) are common and impart a significant burden to patients, caregivers, and the health system. However, there are few pharmacological options for treating BPSD. We conducted a systematic review of clinical trials examining the efficacy of anticonvulsants in BPSD. METHODS: We searched five electronic databases through January 2023, for randomized controlled trials and systematic reviews evaluating the efficacy of non-benzodiazepine anticonvulsants for the treatment of BPSD. We used the Cochrane risk of bias tool to ascertain the risk of bias in included trials. Because statistical pooling of results using meta-analysis was not feasible, we synthesized findings using the Cochrane Synthesis Without Meta-analysis reporting guidelines. RESULTS: We identified 12 studies, including randomized controlled trials (RCTs) and 1 systematic review. Five RCTs evaluating valproic acid were synthesized by a recent Cochrane review which concluded that this drug is likely ineffective for BPSD. We extracted data from 6 trials involving 248 individuals comparing non-benzodiazepine anticonvulsants to either placebo or risperidone. Four trials (n = 97 participants) evaluated carbamazepine, only one of which demonstrated an improvement in the Brief Psychiatric Rating Scale measuring agitation, hostility, psychosis, and withdrawal/depression (effect size: 1.13; 95% confidence interval [CI]: 0.54-1.73) relative to placebo. Adverse effects were more common in patients receiving carbamazepine (20/27; 74%) relative to placebo (5/24; 21%). There is low quality evidence that oxcarbazepine is likely ineffective and that topiramate may be comparable to risperidone. CONCLUSION: Anticonvulsants are unlikely to be effective in BPSD, although the quality of existing evidence is low.

Chronic high-dose dimenhydrinate use contributing to early multifactorial cognitive impairment.

Dimenhydrinate is an over-the-counter antihistaminergic medication with anticholinergic properties used to treat nausea or motion sickness worldwide. There is a well-established correlation between the use of anticholinergic medications and dementia, however, it is unclear if a causal role exists. We report a case of minor neurocognitive disorder in a woman in her 40s with several years of high-dose daily dimenhydrinate abuse who subsequently developed significant delusional beliefs. Her clinical presentation was confounded by numerous other factors that could have impacted her cognition, such as a longstanding presumed learning disability, ankylosing spondylitis with adalimumab treatment, extensive cannabis use or potential development of a primary psychotic disorder. Her workup was within normal limits, and she has not responded to first-line antipsychotic medications to date. This case report adds to the growing evidence supporting concerns about potentially irreversible cognitive deficits in chronic misuse of anticholinergic agents, an association previously observed only in the elderly population.

Geriatric care physicians' perspectives on providing virtual care: a reflexive thematic synthesis of their online survey responses from Ontario, Canada.

BACKGROUND: During the COVID-19 pandemic, telemedicine was widely implemented to minimise viral spread. However, its use in the older adult patient population was not well understood. OBJECTIVE: To understand the perspectives of geriatric care providers on using telemedicine with older adults through telephone, videoconferencing and eConsults. DESIGN: Qualitative online survey study. SETTING AND PARTICIPANTS: We recruited geriatric care physicians, defined as those certified in Geriatric Medicine, Care of the Elderly (family physicians with enhanced skills training) or who were the most responsible physician in a long-term care home, in Ontario, Canada between 22 December 2020 and 30 April 2021. METHODS: We collected participants' perspectives on using telemedicine with older adults in their practice using an online survey. Two researchers jointly analysed free-text responses using the 6-phase reflexive thematic analysis. RESULTS: We recruited 29 participants. Participants identified difficulty using technology, patient sensory impairment, lack of hospital support and pre-existing high patient volumes as barriers against using telemedicine, whereas the presence of a caregiver and administrative support were facilitators. Perceived benefits of telemedicine included improved time efficiency, reduced travel, and provision of visual information through videoconferencing. Ultimately, participants felt telemedicine served various purposes in geriatric care, including improving accessibility of care, providing follow-up and obtaining collateral history. Main limitations are the absence of, or incomplete physical exams and cognitive testing. CONCLUSIONS: Geriatric care physicians identify a role for virtual care in their practice but acknowledge its limitations. Further work is required to ensure equitable access to virtual care for older adults.

Geriatric Specialists' Perspectives on Telemedicine during the COVID-19 Pandemic: a Concurrent Triangulation Mixed-Methods Study.

During the COVID-19 pandemic, physicians provided virtual care to minimize viral transmission. This concurrent triangulation mixed-methods study assesses the use of synchronous telephone and video visits with patients and asynchronous eConsults by geriatric providers, and explores their perspectives on telemedicine use during the pandemic. Participants included physicians practicing in Ontario, Canada who were certified in Geriatric Medicine, or Care of the Elderly, or who were the most responsible physician in a long-term care for at least 10 patients. Participants' perspectives were solicited using an online survey and themes were generated through a reflexive thematic analysis of survey responses. We assessed the current use of each telemedicine tool and compared the proportion of participants using telemedicine before the pandemic with self-predicted use after the pandemic. We received 29 surveys from eligible respondents (87.9% completion rate), with 75.9% being geriatricians. The telephone was most used (96.6%), followed by video (86.2%) and eConsults (64%). Most participants using telephone and video visits had newly implemented them during the pandemic and intend to continue using these tools post-pandemic. Our thematic analysis revealed that telemedicine plays an important role in the continuity of care during the pandemic, with increased self-reported positive perspectives and openness towards use of virtual care tools, although limited by inadequate physical exams or cognitive testing. Its ongoing use depends on the availability of continued remuneration.

Emotional impact on healthcare providers involved in medical assistance in dying (MAiD): a systematic review and qualitative meta-synthesis.

BACKGROUND: Medical assistance in dying (MAiD) traverses challenging and emotionally overwhelming territories: healthcare providers (HCPs) across jurisdictions experience myriad of affective responses secondary to possible tensions between normative and interwoven values, such as sanctity of life, dignity in death and dying and duty to care. OBJECTIVE: To determine the emotional impact on HCPs involved in MAiD. METHODS: Inclusion restricted to English language qualitative research studies from four databases (OVID Medline, EMBASE, CINAHL and Scopus), from beginning until 30 April 2021, and grey literature up to August 2021 were searched. Key author, citation and reference searches were undertaken. We excluded studies without rigorous qualitative research methodology. Included studies were critically appraised using the Joanna Briggs Institute's critical appraisal tool. Analysis was conducted using thematic meta-synthesis. The cumulative evidence was assessed for confidence using the Confidence in the Evidence from Reviews of Qualitative Research approach. RESULTS: The search identified 4522 papers. Data from 35 studies (393 physicians, 169 nurses, 53 social workers, 22 allied healthcare professionals) employing diverse qualitative research methodologies from five countries were coded and analysed. The thematic meta-synthesis showed three descriptive emotional themes: (1) polarised emotions including moral distress (n=153), (2) reflective emotions with MAiD as a 'sense-making process' (n=251), and (3) professional value-driven emotions (n=352). DISCUSSION: This research attempts to answer the question, 'what it means at an emotional level', for a MAiD practitioner. Legislation allowing MAiD for terminal illness only influences the emotional impact: MAiD practitioners under this essential criterion experience more polarised emotions, whereas those practising in jurisdictions with greater emphasis on allaying intolerable suffering experience more reflective emotions. MAiD practitioner's professional values and their degree of engagement influence the emotional impact, which may help structure future support networks. English language literature restriction and absence of subgroup analyses limit the generalisability of results.

An Ethical Analysis of the 'Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna (PM-JAY)' Scheme using the Stakeholder Approach to Universal Health Care in India.

This paper analyses the ethical considerations using the stakeholder theory on two specific domains of the newly implemented 'Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna (PM-JAY)' scheme by the Government of India. The paper recommends a solidarity-based approach over an entitlement based one that focuses on out-of-pocket expenses for the most vulnerable and a stewardship role from the private sector to ensure equity, accountability, and sustainability of PM-JAY scheme.

Conducting controlled human infection model studies in India is an ethical obligation.

Weighing competing obligations and achieving the "greatest balance" of right over wrong guides an individual, an agency or a country in determining what ought to be done in an ethically challenging situation. Conducting controlled human infection model (CHIM) studies in India is one such situation. The ethical challenge in conducting a CHIM study lies in completing the difficult task of introducing standardised, attenuated strains of micro-organisms into normal healthy volunteers, at the same time ensuring the safety of these healthy individuals from potential and completely informed risks in a fashion that is transparent and accountable. The bar is further raised against the background of already fragile public confidence in biomedical research in India; especially when "deliberate" introduction of microbial agents into healthy individuals is involved, with the larger altruistic objective of gain to society as a whole. This paper discusses the uses of CHIM studies with respect to the larger scientific Indian research enterprise of the 21st century. It further explores etic and emic perspectives in conducting such trials in India and seeks to generate an ethical coherence to the justification for conducting CHIM studies in India. The paper deliberates on ethical issues arising out of conducting CHIM studies and reflects on how developing the capacity for CHIM studies in India is likely to strengthen the health research and development sector in the country.

Assessing decisional capacity for research participation in psychiatric patients and their relatives.

A cross-sectional study among adult inpatients with non-organic psychiatric disorders, and among their key relatives, assessed their comprehension and recall of key information in consent forms. It also assessed their capacity to consent to participate in two hypothetical randomised controlled trials (RCTs) with different potential risks and burdens, using structured questionnaires and recorded interviews. Of the 24 participants (12 patient-key relative dyads), seven patients (58%) and three key relatives (25%) were clinically judged to lack the capacity to consent. Of the remaining 14 participants s, less than half the patients (2/5; 40%) or relatives (3/9; 33%) accurately recalled 50% of the key information on both trials. Among the eight participants (3 patients, 5 relatives) independently assessed on the MacArthur Competence Assessment Tool for Clinical Research, the proportions judged competent for each trial varied with the criteria for defining competence. No one fulfilled the stringent competence criteria for both trials. Routine assessments of the capacity of psychiatric research participants, and of relatives providing proxy consent, appear to be warranted. However, neither suboptimal understanding of consent forms, nor incompetence determined by the use of formal assessment tools, necessarily denote an incapacity to consent to research if detailed clinical assessments indicate otherwise. Research into incorporating participants' health literacy and clinical status in formal assessments may help determine the optimal standards for defining competence.

Participation in randomised controlled trials: perspectives of psychiatric patients and key relatives.

This study assessed the perspectives of adults who had acute nonorganic psychiatric disorders and were admitted in a private, not for- profit medical college hospital, and also of their key relatives, on randomised controlled trials (RCTs). Structured questionnaires and audio-recorded interviews were used for the purpose. We explored their willingness and motivation to participate in two hypothetical RCTs with different risks and burdens. The transcripts of the interviews were analysed using the principles of grounded theory and framework analysis. Of the 24 consenting participants (12 patient and key-relative dyads), the 20 who completed the interviews had largely positive attitudes towards research and RCTs. However, 50% of those interviewed declined to participate in either of the hypothetical RCTs. The refusal to participate seemed to be influenced by a lack of education; forgetfulness, which impeded the process of making informed decisions; unfavourable benefit-risk-burden ratios; practical difficulties; dependence on treating doctors and relatives for decision-making; and the wish to exercise one's choice regarding treatment options. The factors that motivated the patients and relatives were trust in doctors and organisations, altruism, expectation of personal benefits and favourable risk-benefit ratios. These observations indicate that while the respondents in this study valued research, they were discerning about whether or not to participate in the trials; their decision-making was influenced by individualised assessments of risks and burdens and pragmatic considerations, rather than only by the benefits they would obtain.

'Munchausen syndrome': a forgotten diagnosis in the spine.

PURPOSE: To present the case of a patient with Munchausen's syndrome who underwent multiple surgeries in the spine before the diagnosis was made and, therefore, to highlight the importance of this obscure condition that can result in unnecessary surgical treatment. METHODS: A 44-year-old businesswoman presented with multiple episodes of low back pain and weakness in both lower limbs over past 11 years. Past history consisted of multiple hospitalizations, and three surgeries on her lumbar spine at different hospitals, with dramatic improvement in symptoms being reported each time after surgery. Clinical examination showed inconsistent and nonspecific neurological findings. Imaging studies like X-rays, magnetic resonance imaging, and all neurophysiological studies were within normal limits. RESULTS: Multi-disciplinary evaluation by a team of orthopedicians, neurologist and psychiatrist and rehabilitation specialists diagnosed it as 'Munchausen syndrome'. Only one report of this fictitious disease in spine was found in review of literature (Association AP, Diagnostic and statistical manual of mental disorders: DSM-IV-TR(®), 2003). CONCLUSIONS: A history of multiple surgical interventions at multiple hospitals, often followed by dramatic improvement and then relapse, should trigger a suspicion of Munchausen syndrome, particularly in the scenario of normal imaging studies. Diagnosing this rare condition in spine is key to avoid unnecessary surgery.

Neurosis Meets Psychosis: Case Series from a Tertiary Care Center in South India.

The utility of the terms psychosis and neurosis in psychiatry have maintained their dichotomous stance since ages. Clinical observations and etiological hypothesis of psychiatric disorders have kept this polarity intact since the times of Freud and Jung. This case series attempts to revisit this perennial psychiatric controversy.

A case of mixed type of paroxysmal dyskinesia: is there an overlap between two clinical categories of paroxysmal dyskinesia?

We report a sporadic case of paroxysmal dyskinesia of predominantly choreic and ballistic movements of 10 years duration in a 22-year-old male. The movement starts after exercise for certain period. However, for the next 5-15 min, the movements are triggered by sudden voluntary activity. These dyskinesias persist for about 10-30 s after sudden voluntary activity. Patient has to be immobile once symptoms start after the exercise to prevent the kinesigenic involuntary movements. Involuntary movements could be induced in the lower limbs, upper limbs, facial and jaw muscle by local exercise. Overtime symptoms occurred with minimal exercise. Secondary dyskinesia was ruled out by investigations. Patient responded well to Carbamazepine, relapsed when stopped taking it.

Hemicrania continua-like headache with leprosy: casual or causal association?

Hemicrania continua is a strictly unilateral, moderate to severe, continuous, indomethacin-responsive primary headache disorder with ipsilateral autonomic cranial symptoms at the time of exacerbations. We describe a 30-year-old woman with a 4-month history of indomethacin-responsive hemicrania continua-like headache and one-month history of mononeuritis multiplex due to leprosy. Indomethacin was successfully weaned off after completion of antileprotic therapy.