Association Between Exposure to General Versus Regional Anesthesia and Risk of Dementia in Older Adults.

BACKGROUND/OBJECTIVES: Cognitive changes are commonly observed in older adults following surgical procedures. There are concerns that exposure to general anesthesia (GA) may contribute to an increased risk of Alzheimer's disease. Our study examined the associations between exposure to GA compared with regional anesthesia (RA) administered for elective surgical procedures and the development of dementia. DESIGN: Population-based propensity matched retrospective cohort study. SETTING: Linked administrative databases were accessed from ICES (formerly called the Institute for Clinical Evaluative Services) in Ontario, Canada. PARTICIPANTS: We included all community-dwelling individuals aged 66 and older who underwent one of five elective surgical procedures in Ontario, Canada, between April 1, 2007, and March 31, 2011. Individuals with evidence of dementia preceding cohort entry were excluded. Individuals who received GA were matched within surgical procedures to those who received RA on age, sex, cohort entry year, and a propensity score to control for potential confounders. MEASUREMENTS: The baseline characteristics of the study sample were compared before and after matching. Individuals were followed for up to 5 years following cohort entry for the occurrence of dementia using a validated algorithm. Cox proportional hazards analysis was used to determine the hazard ratio (HR) and 95% confidence interval (CI) for the association between anesthetic type and dementia. Subgroup and sensitivity analyses were undertaken. RESULTS: A total of 7,499 matched pairs were included in the final analysis. Overall, no difference was observed in the risk of being diagnosed with dementia for individuals who received GA when compared with RA (HR = 1.0; 95% CI = .8-1.2). There was also no association between anesthesia and dementia in most subgroup and sensitivity analyses. CONCLUSION: Elective surgery using GA was not associated with an overall elevated risk of dementia when compared with RA. Future studies are required to determine whether surgery is a risk factor for dementia irrespective of anesthetic technique.

Optimizing Prescribing of Antipsychotics in Long-Term Care (OPAL): A Stepped-Wedge Trial.

BACKGROUND: Inappropriate antipsychotic prescribing is a key quality indicator by which clinical outcomes might be monitored and improved in long-term care (LTC), but limited evidence exists on the most effective strategies for reducing inappropriate antipsychotic use. OBJECTIVES: The objective of the study was to evaluate a multicomponent approach to reduce inappropriate prescribing of antipsychotics in LTC. DESIGN: A prospective, stepped-wedge study design was used to evaluate the effect of the intervention. SETTINGS AND PARTICIPANTS: Interdisciplinary staff at 10 Canadian LTC facilities. METHODS: The intervention consisted of an educational in-service, provision of evidence-based tools to assess and monitor neuropsychiatric symptoms (NPS) in dementia, and monthly interprofessional team meetings. The primary outcome was the proportion of residents receiving an antipsychotic without a diagnosis of psychosis using a standardized antipsychotic quality indicator. RESULTS: The weighted mean change in inappropriate antipsychotic prescribing rate from baseline to 12-month follow-up was -4.6% [standard deviation (SD) = 2.8%, P < .0001], representing a 16.1% (SD = 17.0) relative reduction. After adjusting for site, the odds ratio for the inappropriate antipsychotic prescribing quality indicator at 12 months compared to baseline was 0.73 (95% confidence interval = 0.48-0.94; chi-square = 6.59; P = .01). There were no significant changes in related quality indicators, including falls, restraint use, or behavioral symptoms. CONCLUSIONS AND IMPLICATIONS: This multicomponent intervention was effective in reducing inappropriate antipsychotic prescribing in LTC without adversely affecting other domains related to quality of care, and offers a practical means by which to improve the care of older adults with dementia in LTC.

Access to Psychiatrist Services for Older Adults in Long-Term Care: A Population-Based Study.

OBJECTIVES: Although mental health disorders are common among older adults in long-term care (LTC), little is known about access to psychiatric services in LTC. We described the need for psychiatric services in LTC settings and identified variables associated with receipt of psychiatric services. DESIGN: Population-based retrospective cohort study. SETTING AND PARTICIPANTS: All adults aged 66 years and older who resided in LTC homes in Ontario, Canada, between 2015 and 2016. Individuals were included in the study at the time of LTC admission or first annual reassessment. MEASURES: We determined the percentage of LTC residents who received any psychiatric service within 90 days. We then compared the characteristics of individuals who did and did not receive any psychiatric service to determine variables associated with receipt of psychiatric services. Multivariate logistic regression was used to determine independent variables associated with receipt of psychiatric services. RESULTS: A total of 67,165 unique participants were included in the study sample, 27,650 (41.2%) of whom had identified psychiatric need. Overall, 3175 (4.7%) individuals received any psychiatric service within 90 days following cohort entry. After adjustment for potential confounders, receipt of psychiatric services was positively associated with younger age, male gender, history of major mental disorders, previous receipt of psychiatric services, indicators of psychiatric need, residence in larger LTC homes, and health region of residence. CONCLUSIONS/IMPLICATIONS: Receiving psychiatric services in Ontario LTC homes is limited when compared to the high need for services. Several factors other than patient need symptoms are associated with receipt of services, which suggests inequities in access to care. Improving the distribution of psychiatric services may help address these inequities, and additional psychiatric resources are also likely required to meet these needs. Our results directly apply to a Canadian context and have implications for other comparable countries, including the United States.

Not Just Fun and Games: Toy Advertising on Television Targeting Children Promotes Sedentary Play.

OBJECTIVE: To examine the volume of television toy advertising targeting Canadian children and to determine if it promotes active or sedentary play, targets males or females more frequently, and has changed over time. METHODS: Data for toy/game advertising from 27 television stations in Toronto for the month of May in 2006 and 2013 were licensed from Neilsen Media Research (Montreal, Quebec, Canada). A content analysis was performed on all ads to determine what age group and gender were targeted and whether physical or sedentary activity was being promoted. Comparisons were made between 2006 and 2013. RESULTS: There were 3.35 toy ads/h/children's specialty station in 2013 (a 15% increase from 2006). About 88% of toy ads promoted sedentary play in 2013, a 27% increase from 2006 levels, while toy ads promoting active play decreased by 33%. In both 2006 and 2013, a greater number of sedentary toy ads targeted males (n = 1519, May 2006; n = 2030, May 2013) compared with females (n = 914, May 2006; n = 1619, May 2013), and between 2006 and 2013, these ads increased significantly for both males and females. CONCLUSION: Future research should explore whether such advertising influences children's preferences for activities and levels of physical activity.

Antipsychotic Use in Dementia.

Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exists over the role of antipsychotics in the management of neuropsychiatric symptoms (NPS) in persons with dementia. Although some NPS may be appropriately and safely treated with antipsychotics, a fine balance must be achieved between the benefits of these medications, which are often modest, and adverse events, which may have significant consequences. Approximately one-third of all persons with dementia are currently prescribed antipsychotic medications, and there is significant variation in the use of antipsychotics across care settings and providers. Reducing the inappropriate or unnecessary use of antipsychotics among persons with dementia has been the focus of increasing attention owing to better awareness of the potential problems associated with these medications. Several approaches can be used to curb the use of antipsychotics among persons with dementia, including policy or regulatory changes, public reporting, and educational outreach. Recently, there has been encouraging evidence of a downward trend in the use of antipsychotics in many long-term care settings, although prescribing rates are still higher than what is likely optimal. Although reducing the inappropriate use of antipsychotics is a complex task, psychiatrists can play an important role via the provision of clinical care and research evidence, contributing to improved care of persons with dementia in Canada and elsewhere.