Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community.

BACKGROUND: Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour. OBJECTIVES: To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies. SELECTION CRITERIA: This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition. DATA COLLECTION AND ANALYSIS: Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias. CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD -0.23, 95% CI -0.36 to -0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD -0.24, 95% CI -0.41 to -0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD -0.28, 95% CI -0.40 to -0.15; 5 studies, 1185 participants; moderate-certainty of evidence). CBT interventions for reducing FoF may reduce activity avoidance (MD -2.57, 95% CI -4.67 to -0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD -0.41, 95% CI -0.60 to -0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence). All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article. No studies reported adverse effects due to their interventions. AUTHORS' CONCLUSIONS: CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months. Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects. Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.

Evidence-oriented teaching of geriatric psychiatry: a narrative literature synthesis and pilot evaluation of a clerkship seminar.

Introduction: The field of geriatric psychiatry has in recent decades developed into an independent discipline, incorporating elements of psychiatry, neurology and internal medicine. In view of demographic changes, this field is becoming increasingly relevant for primary care and undergraduate medical training. So far, however, there is little educational guidance for instructional design of geriatric psychiatry in undergraduate medical education. Project description: A narrative literature review of medical education studies in the field of geriatric psychiatry was conducted. Student evaluations of a geriatric psychiatry clerkship seminar were analyzed, followed by a target group analysis. Results informed the iterative development of new clerkship seminar content and structure. This was implemented and evaluated over several academic cycles. Learning material was made available via the open-source learning management system "ILIAS". Results: A total of 29 medical education articles were identified and evaluated. The previous seminar in geriatric psychiatry at our university hospital was rated below average (Likert item overall rating of 4.3/6 compared to other seminars with an average overall rating of 5.2, p<0.001). An evidence-oriented revision of the content and instructional design was implemented. Activation of learners, self-reference effect, and audience questioning were used during the lecture. Additionally, two geriatric psychiatry case scenarios were adapted for discussion. We saw continuous improvement of student evaluations of the revised course, reaching a rating improvement of 5.3 out of 6 (p<0.01, U=135.5 Cohen's d=1.28). Conclusion: A systematic approach was used to develop a geriatric psychiatry clerkship seminar, based on medical education evidence, for undergraduate medical students, resulting in better student evaluations. The teaching materials can be adapted for local implementation at other teaching hospitals. Future studies should also explore effects regarding higher learning outcomes.

Instructional Design Strategies for Teaching the Mental Status Examination and Psychiatric Interview: a Scoping Review.

OBJECTIVE: The psychiatric mental status examination is a fundamental aspect of the psychiatric clinical interview. However, despite its importance, little emphasis has been given to evidence-based instructional design. Therefore, this review summarizes the literature from an instructional design perspective with the aim of uncovering design strategies that have been used for teaching the psychiatric interview and mental status examination to health professionals. METHODS: The authors conducted a scoping review. Multiple databases, reference lists, and the gray literature were searched for relevant publications across educational levels and professions. A cognitive task analysis and an instructional design framework was used to summarize and chart the findings. RESULTS: A total of 61 articles from 17 countries in six disciplines and three educational levels were identified for data extraction and analysis. Most studies were from the USA, presented as educational case reports, and carried out in undergraduate education in the field of psychiatry. Few articles described the instructional rationale for their curriculum. None of the studies compared the effectiveness of different instructional design components. Reported learning activities for each task domain (knowledge, skills, and attitudes) and for each step of an instructional design process were charted. Most articles reported the use of introductory seminars or lectures in combination with digital learning material (videos and virtual patients in more recent publications) and role-play exercises. CONCLUSIONS: Educators in psychiatry should consider all task domains of the psychiatric interview and mental status examination. Currently, there is a lack of empirical research on expertise acquisition and use of instructional design frameworks in this context.

Preventive treatment options for fear of falling within the Swiss healthcare system : A position paper.

Fear of falling (FoF) results in social, functional, physical, and psychological symptoms, including secondary disorders, such as depression and general anxiety disorder (GAD). A vicious cycle develops, where symptoms maintain and reinforce FoF and its consequences, including increasing the risk of falling. In this position paper, we suggest screening for FoF using the falls efficacy scale international (FES-I) questionnaire. The presence of a high score (> 23) warrants an investigation into frailty and exclusion of depression and GAD, during the clinical interview. Stratifying frailty, based on the Fried frailty criteria will guide treatment options based on the most significant health concerns. Frail older adults should first receive physiotherapy and exercise interventions, as physical disabilities are their most significant characteristic, while pre-frail and non-frail older adults should receive multicomponent interventions, consisting of cognitive behavioral therapy (CBT) with physical exercise. The non-frail with predominantly GAD and depression should receive specialized CBT interventions. Currently, only exercise interventions are available for FoF treatment in Switzerland. Although some exercise interventions use CBT elements, such as goal setting and reflections on behavior and feelings, they are not systematically used, are not part of a quality-assured procedure, and do not address the psychological-cognitive aspects of FoF. As the pre-frail and non-frail are the largest groups to use these services, adapting current exercise programs by incorporating a CBT component would be the most practical means to provide optimized care.

Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta-analysis.

OBJECTIVE: To determine the associations of delirium with urinary tract infection (UTI) and asymptomatic bacteriuria (AB) in individuals aged 65 and older. METHODS: The protocol for this systematic review and meta-analysis was published on PROSPERO (CRD42020164341). Electronic databases were searched for relevant studies, professional associations and experts in the field were additionally contacted. Studies with control groups reporting associations between delirium and UTI as well as delirium and AB in older adults were included. The random effects model meta-analysis was conducted using odds ratios (ORs) with 95% confidence intervals (CIs) as effect size measures. The Newcastle-Ottawa scale was used to rate the studies' quality. Heterogeneity was assessed using the Q and I2 tests. The effects of potential moderators were investigated by both subgroup and meta-regression analyses. The risk of publication bias was evaluated using the funnel plot and Egger's test. RESULTS: Twenty nine relevant studies (16,618 participants) examining the association between delirium and UTI in older adults were identified. The association between delirium and UTI was found to be significant (OR 2.67; 95% CI 2.12-3.36; p < 0.001) and persisted regardless of potential confounders. The association between delirium and AB in older adults in the only eligible study found (192 participants) was insignificant (OR 1.62; 95% CI 0.57-4.65; p = 0.37). All included studies were of moderate quality. CONCLUSION: The results of this study support the association between delirium and UTI in older adults. Insufficient evidence was found to conclude on an association between delirium and AB in this age group. These findings are limited due to the moderate quality of the included studies and a lack of available research on the association between delirium and AB. Future studies should use the highest quality approaches for defining both delirium and UTI and consider AB in their investigations.

Working with entrustable professional activities in clinical education in undergraduate medical education: a scoping review.

BACKGROUND: Entrustable professional activities (EPAs) are increasingly used in undergraduate medical education (UME). We conducted a scoping review to summarize the evidence for the use of EPAs in clinical rotations in UME. METHODS: We searched multiple databases for scoping reviews based on the PRISMA guidelines for articles reporting qualitative and quantitative research, as well as conceptual and curriculum development reports, on EPAs in UME clinical rotations. RESULTS: We identified 3309 records by searching through multiple databases. After the removal of duplicates, 1858 reports were screened. A total of 36 articles were used for data extraction. Of these, 47% reported on EPA and EPA-based curriculum development for clerkships, 50% reported on implementation strategies, and 53% reported on assessment methods and tools used in clerkships. Validity frameworks for developing EPAs in the context of clerkships were inconsistent. Several specialties reported feasible implementation strategies for EPA-based clerkship curricula, however, these required additional faculty time and resources. Limited exposure to clinical activities was identified as a barrier to relevant learning experiences. Educators used nationally defined, or specialty-specific EPAs, and a range of entrustability and supervision scales. We found only one study that used an empirical research approach for EPA assessment. One article reported on the earlier advancement of trainees from UME to graduate medical education based on summative entrustment decisions. CONCLUSIONS: There is emerging evidence concerning how EPAs can be effectively introduced to clinical training in UME. Specialty-specific, nested EPAs with context-adapted, entrustment-supervision scales might be helpful in better leveraging their formative assessment potential.

[Entrustable Professional Activities in Graduate Medical Education in Psychiatry: A Promising Concept]. / Entrustable Professional Activities in der psychiatrischen Weiterbildung: Ein vielversprechendes Konzept.

Entrustable Professional Activities in Graduate Medical Education in Psychiatry: A Promising Concept Abstract. Entrustable Professional Activities (EPAs) are competency-based learning goals derived from observable clinical activities. In undergraduate medical education, they have now been adopted throughout Switzerland as part of the so-called PROFILES catalog (Principal Relevant Objectives and Framework for Integrated Learning and Education in Switzerland). The nine core EPAs to be mastered in undergraduate medical education can serve as a basis for introducing EPAs in graduate medical education as well. We will discuss this approach in the context of graduate medical education in psychiatry and psychotherapy from the perspective of different training contexts and a pilot example. In this position paper, we describe a promising opportunity to improve graduate medical training through the implementation of EPAs, both in terms of the quality of training and thus of patient care, as well as in terms of the attractiveness of the specialty for future residents.

Informant Questionnaires in Dedicated Memory Clinics: How Much Do They Contribute?

BACKGROUND/OBJECTIVES: The diagnostic process in a university memory clinic is based largely on cognitive testing. However, input from informants, acquired through interview or questionnaires, may significantly impact diagnosis. We sought to evaluate whether informant questionnaires for basic and instrumental activities of daily living, or for identifying progressive cognitive decline would improve diagnostic predictability of neurodegenerative disorders compared with either the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological test battery or the Mini-Mental State Examination score alone. DESIGN: Retrospective data analysis using logit models. SETTING: University hospital outpatient memory clinic. PARTICIPANTS: A total of 394 patients with dementia, mild cognitive impairment (MCI), depression, or subjective cognitive impairment were assessed. MEASUREMENTS: Bristol Activities of Daily Living Scale, Functional Activities Questionnaire, Informant Questionnaire on Cognitive Decline in the Elderly, and the Physical Self-Maintenance Scale questionnaires were obtained. Analyses through logit models were performed to predict outcome diagnoses, based on cognitive scores alone or in combination with one or more informant questionnaires. RESULTS: The four questionnaires were highly correlated (.31-.86). The addition of informant questionnaires improved diagnostic predictability between differential diagnoses of MCI and dementia, or dementia and depression. However, the misprediction rate was reduced by up to 6 percentage points only. Adding more than one questionnaire or all CERAD subtests instead of their sum score never improved prediction in regularized logit models to a clinically relevant extent. CONCLUSION: Although questionnaires contribute to a statistically better prediction of the outcome diagnosis, for some sets of differential diagnoses, the benefit may not be clinically pertinent when routine semistructured informant interviews are used by trained personnel. However, standardized assessment, particularly when patients are seen longitudinally, should not be underestimated.

Advances in Sensor Monitoring Effectiveness and Applicability: A Systematic Review and Update.

BACKGROUND AND OBJECTIVES: To provide an updated review article studying the applicability and effectiveness of sensor networks in measuring and supporting activities of daily living (ADLs) among non-demented older adults. RESEARCH DESIGN AND METHODS: Systematic review following PRISMA guidelines.Systematic search of PubMed, Embase, PsycINFO, INSPEC, and the Cochrane Library, from October 26, 2012 to January 3, 2018 for empirical studies, measuring and supporting ADLs among independently living, non-demented older adults, investigating wireless sensor monitoring networks. RESULTS: The search queries yielded 10,782 hits of which 162 articles were manually reviewed. Following exclusion criteria, 13 relevant articles were retained. Although various types of sensor networks with different analyzing algorithms were proposed, from simple video monitoring to complex sensor networks distributed throughout a house, all articles supported the use of wireless sensors for identifying changes in activity patterns. DISCUSSION AND IMPLICATIONS: Wireless sensor networks appear to be developing into an effective solution for measuring ADLs and for identifying changes in their patterns. They offer a promising solution to support older adults living independently at home. However, there is too much focus on technology, and practical usefulness still needs to be further elaborated. Sensors should focus on ADLs that are sensitive to the earliest signs of cognitive decline, as well as quantitative markers, such as errors in the execution of ADLs.

Entrustable Professional Activities in Psychiatry: A Systematic Review.

OBJECTIVE: Entrustable professional activities (EPAs) represent discrete clinical tasks that can be entrusted to trainees in psychiatry. They are increasingly being used as educational framework in several countries. However, the empirical evidence available has not been synthesized in the field of psychiatry. Therefore, the authors conducted a systematic review in order to summarize and evaluate the available evidence in the field of EPAs in undergraduate and graduate medical education in psychiatry. METHODS: The authors searched PubMed, Cochrane Library, ERIC, Embase, PsycINFO, all Ovid journals, Scopus, Web of Science, MedEdPORTAL, and the archives of Academic Psychiatry for articles reporting quantitative and qualitative research as well as educational case reports on EPAs in undergraduate and graduate psychiatry education published since 2005. All included articles were assessed for content (development, implementation, and assessment of EPAs) and quality using the Quality Assessment Tool for Studies with Diverse Designs. RESULTS: The authors screened 2807 records and included a total of 20 articles in the final data extraction. Most studies were expert consensus reports (n = 6, 30%) and predominantly conducted in English-speaking countries (n = 17, 85%). Papers reported mainly EPA development and/or EPA implementation studies (n = 14, 70%), whereas EPA assessment studies were less frequent (n = 6, 30%). Publications per year showed an increasing trend both in quantity (from 1 in 2011 to 7 in 2018) and quality (from a QATSDD score of 27 in 2011 to an average score of 39 in 2018). The main focus of the articles was the development of individual EPAs for different levels of training for psychiatry or on curricular frameworks based on EPAs in psychiatry (n = 10, 50%). The lack of empirical controlled studies does currently not allow for meta-analyses of educational outcomes. CONCLUSIONS: The concept of EPA-based curricula seems to become increasingly present, a focus in the specialty of psychiatry both in UME and GME. The lack of empirical research in this context is an important limitation for educational practice recommendations. Currently there is only preliminary but promising data available for using EPAs with regard to educational outcomes. EPAs seem to be effectively used from a curriculum design perspective for UME and GME in psychiatry.

Successful treatment of extensive vitiligo with monobenzone.

Vitiligo is one of the most common dermatological disorders, appearing as one or more white macules or patches and affecting up to two percent of the population worldwide. The undesirable aesthetic properties of vitiligo, especially facial, may result in significant negative psychosocial effects, particularly a rate of depression twice that of the general population. While there is no cure, there are several treatment options, notably depigmentation in severe cases. Monobenzone is the most potent depigmenting agent. However, its use is limited due to the permanent and potent nature of the drug. This case presents an example of when timely and aggressive treatment with monobenzone is warranted, demonstrating excellent clinical response, which resulted in a significant increase in the quality of life in a patient with severe vitiligo.