Clinical Assessment of Judgment in Adults and the Elderly: Development and Validation of the Three Domains of Judgment Test-Clinical Version (3DJT-CV).

(1) Background: This article discusses the first two phases of development and validation of the Three Domains of Judgment Test (3DJT). This computer-based tool, co-constructed with users and capable of being administered remotely, aims to assess the three main domains of judgment (practical, moral, and social) and learn from the psychometric weaknesses of tests currently used in clinical practice. (2) Method: First, we presented the 3DJT to experts in cognition, who evaluated the tool as a whole as well as the content validity, relevance, and acceptability of 72 scenarios. Second, an improved version was administered to 70 subjects without cognitive impairment to select scenarios with the best psychometric properties in order to build a future clinically short version of the test. (3) Results: Fifty-six scenarios were retained following expert evaluation. Results support the idea that the improved version has good internal consistency, and the concurrent validity primer shows that 3DJT is a good measure of judgment. Furthermore, the improved version was found to have a significant number of scenarios with good psychometric properties to prepare a clinical version of the test. (4) Conclusion: The 3DJT is an interesting alternative tool for assessing judgment. However, more studies are needed for its implementation in a clinical context.

Application of the Person-Centered Care to Manage Responsive Behaviors in Clients with Major Neurocognitive Disorders: A Qualitative Single Case Study.

OBJECTIVES: Our study aimed to describe "how" and "why" the person-centered care (PCC) approach was applied within a long-term care (LTC) community to manage responsive behaviors (RBs) in individuals with major neurocognitive disorders. METHODS: A descriptive holistic single case study design was employed in the context of an LTC community in Quebec, using semi-structured interviews and non-participatory observations of experienced care providers working with clients with RBs, photographing the physical environment, and accessing documents available on the LTC community's public website. A thematic content analysis was used for data analysis. RESULTS: The findings generated insight into the importance of considering multiple components of the LTC community to apply the PCC approach for managing RBs, including a) creating a homelike environment, b) developing a therapeutic relationship with clients, c) engaging clients in meaningful activities, and d) empowering care providers by offering essential resources. CONCLUSIONS: Applying and implementing the PCC approach within an LTC community to manage clients' RBs is a long-term multi-dimensional process that requires a solid foundation. CLINICAL IMPLICATIONS: These findings highlight the importance of considering multiple factors relevant to persons, environments, and meaningful activities to apply the PCC approach within LTC communities to manage RBs.

The Association Between Somatic Symptom Disorders and Neurocognitive Disorders: A Systematic Review.

OBJECTIVE: Onset of neuropsychiatric symptoms in older adults may represent prodromal manifestations of neurodegenerative disorders. The association between the onset of somatic symptom and related disorders (SSRD) and the subsequent development of neurodegenerative disorders remains unclear. A critical review of studies describing the association between SSRD and neurodegenerative disorders, such as Alzheimer's disease, Parkinson's disease, Frontotemporal dementia, and Lewy body dementia was performed. OBJECTIVE: To critically review studies describing the association between SSRD and neurodegenerative disorders, such as Alzheimer's disease, Parkinson's disease, Frontotemporal dementia, and Lewy body dementia. METHODS: A systematic review of Web of Science Core databases was carried out from inception of databases up to May 2021 to identify observational studies pertaining to both SSRD and neurodegenerative disorders. Data was extracted and compiled regarding subjects enrolled, age at onset of the SSRD and at onset of the neurodegenerative disorders, and specific SSRD manifestations and underlying neuropathologies reported. RESULTS: Thirteen articles were included. Of the 123 identified subjects with SSRD at baseline, 34.1% developed a neurodegenerative disorder, with 80.9% of these being a Lewy body spectrum disorder. The interval between onset of SSRD manifestations and subsequent development of a neurodegenerative disorder was less than 3 years for half of the cases. Of the 1,494 subjects with a neurodegenerative disorder at baseline retrieved, SSRD manifestations were reported in 33.4% of Lewy body spectrum disorders cases. Onset of SSRD manifestations antedated or was concomitant to the diagnosis of the Lewy body spectrum disorder in 65.6% of cases. CONCLUSION: While limited, current evidence suggests a possible association between late-onset SSRD and the subsequent development of neurodegenerative disorders, notably Lewy body spectrum disorders.

Preliminary Validation Study of the French-Quebec Version of the Mild Behavioral Impairment Checklist.

BACKGROUND: Alzheimer disease dementia may be preceded by cognitive stages during which behavioral and psychological changes can occur. More precisely, behavioral symptoms may be observed during the subjective cognitive decline (SCD) or the mild cognitive impairment (MCI) stages; these symptoms can be measured using the Mild Behavioral Impairment Checklist (MBI-C). OBJECTIVE: To validate the French-Quebec version of the MBI-C in individuals ages 60-85 years. METHOD: The sample included 60 participants (20 MCI, 20 SCD, 20 cognitively healthy) and their informants. To assess the discriminant validity of the MBI-C, a Kruskal-Wallis analysis with a multiple comparisons test was performed on the MBI-C Total score. To determine convergent validity, Spearman correlations were calculated between the MBI-C subscales and a set of validation tools. Finally, test-retest reliability was assessed with Spearman correlations of MBI-C scores between two test sessions. RESULTS: All of the analyses indicated satisfactory psychometric properties for the French-Quebec version of the MBI-C. CONCLUSION: This validation study reveals that the MBI-C can be used successfully in dementia risk assessments. From now on, the use of a validated MBI-C will be possible in the French-Quebec population.

[Improving the quality of care for people with behavioral and psychological symptoms of dementia in Quebec]. / Améliorer la qualité de la prise en charge des sujets présentant des symptômes comportementaux et psychologiques de la démence au Québec.

Major neurocognitive disorders (MND) affect more than 100,000 Quebecers and this number is expected to increase by 66% by 2030. The World Health Organization (WHO) considers MND as a public health priority in its "Closing the Gaps in Mental Health" program (WHO, 2011). Behavioral and psychological symptoms related to dementia (BPSD) are highly prevalent and are associated with cognitive and functional deterioration, caregiver burnout, early admission to hospital and additional costs. As part of the ministerial initiative stemming from the Plan Alzheimer du Québec (PAQ) promoted by le ministère de la Santé et des Services sociaux (MSSS) du Québec, innovative clinical practices have been implemented for the optimal management of this clientele, particularly through the creation or enhancement of teams dedicated to BPSD. With a view to continuous quality improvement, the MSSS has mandated a team of clinicians, researchers and deciders to paint a picture of current practices in the context of BPSD and to issue recommendations. This study offers a unique and innovative look at the development of quality care for BPSD in Quebec. Objectives 1. Review organizational and clinical practices, as well as care pathways for BPSD; 2. Propose an interprofessional management process based on best practices; 3. Advise the MSSS on the implementation of measures necessary to ensure access to safe, quality clinical services. Method A review of recent international literature and practice guides was conducted. Semi-structured interviews with professionals from BPSD teams were also conducted in order to paint a picture of the situation in Quebec. An outline of a logic model was proposed based on this information. A group of experts was formed to review clinical and organizational BPSD practices in light of the results. Results The ministerial initiative resulting from the PAQ has had an important structuring effect on the development, consolidation and prioritization of services for people with BPSD. Facilitating elements as well as barriers to the implementation of these services were identified and recommendations were issued to advise the ministry on the actions to be taken. Conclusion The essential conditions and strategies to be adopted to consolidate the trajectory of care for BPSD were transmitted to the MSSS. The main impact is to improve the accessibility and quality of BPSD care for the benefit of users and their families.

Isolating together during COVID-19: Results from the Telehealth Intervention Program for older adults.

Background: A pressing challenge during the COVID-19 pandemic and beyond is to provide accessible and scalable mental health support to isolated older adults in the community. The Telehealth Intervention Program for Older Adults (TIP-OA) is a large-scale, volunteer-based, friendly telephone support program designed to address this unmet need. Methods: A prospective cohort study of 112 TIP-OA participants aged ≥60 years old was conducted in Quebec, Canada (October 2020-June 2021). The intervention consisted of weekly friendly phone calls from trained volunteers. The primary outcome measures included changes in scores of stress, depression, anxiety, and fear surrounding COVID-19, assessed at baseline, 4 and 8-weeks. Additional subgroup analyses were performed with participants with higher baseline scores. Results: The subgroup of participants with higher baseline depression scores (PHQ9 ≥10) had significant improvements in depression scores over the 8-week period measured [mean change score = -2.27 (±4.76), 95%CI (-3.719, -0.827), p = 0.003]. Similarly, participants with higher baseline anxiety scores (GAD7 ≥10) had an improvement over the same period, which, approached significance (p = 0.06). Moreover, despite peaks in the pandemic and related stressors, our study found no significant (p ≥ 0.09) increase in stress, depression, anxiety or fear of COVID-19 scores. Discussion: This scalable, volunteer-based, friendly telephone intervention program was associated with decreased scores of depression and anxiety in older adults who reported higher scores at baseline (PHQ 9 ≥10 and GAD7 ≥10).

Mindfulness-based cognitive therapy vs. a health enhancement program for the treatment of late-life depression: Study protocol for a multi-site randomized controlled trial.

Background: Late-life depression (LLD) affects up to 18% of older adults and has been linked to elevated dementia risk. Mindfulness-based cognitive therapy (MBCT) holds promise for treating symptoms of depression and ameliorating cognitive deficits in older adults. While preliminary findings are promising, a definitive RCT investigating its effects on late life depression and cognition have not yet been conducted. We present a protocol describing a multi-site blinded randomized controlled trial, comparing the effects of MBCT and of an active control, a Health Enhancement Program (HEP), on depressive symptoms, executive functioning, and brain biomarkers of LLD, among several other exploratory outcomes. Methods: Two-hundred and thirteen (n = 213) patients with LLD will be recruited at various centers in Montreal, QC, Canada. Participants will undergo stratified randomization to either MBCT or HEP intervention groups. We will assess changes in (1) depression severity using the Hamilton Depression Rating Scale (HAM-D17), (2) processing speed and executive functioning, (3) brain biomarkers of LLD (hippocampal volume, default network resting-state functional connectivity and executive network resting-state functional connectivity), and (4) other exploratory physiological and mood-based measures, at baseline (0 weeks), post intervention (8 weeks), and 26 weeks after baseline. Discussion: The proposed study will assess the clinical potential of MBCT to improve symptoms of depression, as well as examine its impact on cognitive impairments and neurobiological markers, and thus inform its use as a promising adjunct in the treatment of LLD. Clinical trial registration: www.ClinicalTrials.gov, identifier: NCT05366088.

Psychosis as a Treatment Target in Dementia: A Roadmap for Designing Interventions.

Psychotic phenomena are among the most severe and disruptive symptoms of dementias and appear in 30% to 50% of patients. They are associated with a worse evolution and great suffering to patients and caregivers. Their current treatments obtain limited results and are not free of adverse effects, which are sometimes serious. It is therefore crucial to develop new treatments that can improve this situation. We review available data that could enlighten the future design of clinical trials with psychosis in dementia as main target. Along with an explanation of its prevalence in the common diseases that cause dementia, we present proposals aimed at improving the definition of symptoms and what should be included and excluded in clinical trials. A review of the available information regarding the neurobiological basis of symptoms, in terms of pathology, neuroimaging, and genomics, is provided as a guide towards new therapeutic targets. The correct evaluation of symptoms is transcendental in any therapeutic trial and these aspects are extensively addressed. Finally, a critical overview of existing pharmacological and non-pharmacological treatments is made, revealing the unmet needs, in terms of efficacy and safety. Our work emphasizes the need for better definition and measurement of psychotic symptoms in dementias in order to highlight their differences with symptoms that appear in non-dementing diseases such as schizophrenia. Advances in neurobiology should illuminate the development of new, more effective and safer molecules for which this review can serve as a roadmap in the design of future clinical trials.

Informant-based tools for assessment and monitoring of cognition, behavior, and function in neurocognitive disorders: Systematic review and report from a CCCDTD5 Working Group.

OBJECTIVE: As part of the fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, we assessed the literature on informant-based tools for assessment and monitoring of cognition, behavior, and function in neurocognitive disorders (NCDs) to provide evidence-based recommendations for clinicians and researchers. METHODS: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards guidelines. Publications that validated the informant-based tools or described their key properties were reviewed. Quality of the studies was assessed using the modified Quality Assessment tool for Diagnostic Accuracy Studies. RESULTS: Out of 386 publications identified through systematic search, 34 that described 19 informant-based tools were included in the final review. Most of these tools are backed by good-quality studies and are appropriate to use in clinical care or research. The tools vary in their psychometric properties, domains covered, comprehensiveness, completion time, and ability to detect longitudinal change. Based on these properties, we identify different tools that may be appropriate for primary care, specialized memory clinic, or research settings. We also identify barriers to use of these tools in routine clinical practice. CONCLUSION: There are several good-quality tools available to collect informant-report for assessment and monitoring of cognition, behavior, or function in patients with NCDs. Clinicians and researchers may choose a particular tool based on their specific needs such as domains of interest, desired psychometric properties, and feasibility. Further work is needed to make the tools more user-friendly and to adopt them into routine clinical care.

Optimizing Practices, Use, Care, and Services-Antipsychotics (OPUS-AP) in Long-Term Care Centers in Quebec, Canada: A Successful Scale-Up.

OBJECTIVES: To evaluate the scale-up of the OPUS-AP program to improve the care of residents at long-term care (LTC) centers through the systematic implementation of resident-centered approaches to care, the application of nonpharmacologic interventions for the management of behavioral and psychological symptoms of dementia (BPSD), and the deprescribing of antipsychotics where these are not clinically indicated. DESIGN: Prospective, closed cohort. SETTING AND PARTICIPANTS: Residents with major neurocognitive disorder (MNCD) from 24 (phase 1) and 129 (phase 2) publicly funded LTC centers in Quebec, Canada. METHODS: The primary outcome was antipsychotic deprescribing (cessation or dose reduction). Secondary outcomes included changes in benzodiazepine and antidepressant prescriptions, BPSD, and falls. Comparisons were made between assessments at baseline and after 9 months. RESULTS: OPUS-AP phase 2 was conducted from March to December 2019 in 329 clinical wards at 129 LTC centers. At baseline, the 10,601 included residents had a mean age of 82.9: 64.6% were of female sex, 73.7% had a diagnosis of MNCD, and 47.0% had an antipsychotic prescription. These characteristics were similar to those of the 1054 residents at the 24 LTC centers in phase 1. In phase 2, successful antipsychotic deprescribing was achieved for 77.1% of residents in whom this approach was attempted, compared to 85.5% in phase 1. Phase 1 and 2 showed statistically significant improvements in the Cohen-Mansfield Agitation Inventory score and reduced use of benzodiazepines in residents with successful antipsychotic deprescribing. These improvements were of a smaller magnitude in phase 2. Statistically significant reductions in falls were observed in phase 2. CONCLUSIONS AND IMPLICATIONS: The scale-up of the OPUS-AP program from 24 to 129 LTC centers was successful and resulted in a significant reduction in antipsychotic use, as well as improvement in BPSD, and reductions in benzodiazepine use and falls in residents with successful antipsychotic deprescribing.

Implementation conditions leading to the scale-up of an innovation involving the optimal use of antipsychotics in long-term care centers: The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) program.

BACKGROUND: Antipsychotics are often used for the first-line management of behavioral and psychological symptoms of dementia despite their limited efficacy and the risk of serious adverse drug events, compounded with disregard for guidelines recommending prioritizing non-pharmacological interventions. Some innovative interventions promote the deprescription of antipsychotics in long term care (LTC) settings. OBJECTIVE: The objective of this article is to present the conditions leading to the scale-up of an innovative program on the appropriate use of antipsychotics in LTC centers. METHODS: The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) program is a mixed-method project that aims to improve LTC residents' care through increased knowledge and competency among staff, resident-centered approaches, nonpharmacologic interventions, and by deprescribing antipsychotics when appropriate. This article consists of a qualitative study focused on exploring the implementation conditions of the OPUS-AP program. This study was carried out in an integrated health area of Québec. It consisted of 46 semi-structured interviews with staff members and managers involved in the implementation of OPUS-AP. The qualitative data analysis was inspired by a realistic evaluation approach, which shed light on the causal chain between context, mechanisms, and perceived effects. RESULTS: This study identified certain conditions conducive to scaling up the OPUS-AP program: an integrated, collaborative and evidence-based approach; communications in support of the process; stakeholder engagement at the strategic, tactical and operational levels; an implementation climate conducive to change; and an integrated knowledge translation strategy. CONCLUSION: Despite evidence of clinical efficacy, deprescribing programs require great deal of scaling up efforts. Hence, this study underscores the need to further examine conditions for scaling up medication usage programs in real life contexts.

Position Statement for Mental Health Care in Long-Term Care During COVID-19.

COVID-19 has disproportionately impacted older adults in long-term care (LTC) facilities in Canada. There are opportunities to learn from this crisis and to improve systems of care in order to ensure that older adults in LTC enjoy their right to the highest attainable standard of health. Measures are needed to ensure the mental health of older adults in LTC during COVID-19. The Canadian Academy of Geriatric Psychiatry (CAGP) and Canadian Coalition for Seniors' Mental Health (CCSMH) have developed the following position statements to address the mental health needs of older adults in LTC facilities, their family members, and LTC staff. We outlined eight key considerations related to mental health care in LTC during COVID-19 to optimize the mental health of this vulnerable population during the pandemic.

Connecting During COVID-19: A Protocol of a Volunteer-Based Telehealth Program for Supporting Older Adults' Health.

Introduction: Social-distancing due to COVID-19 has led to social isolation, stress, and mental health issues in older adults, while overwhelming healthcare systems worldwide. Telehealth involving phone calls by trained volunteers is understudied and may be a low-cost, scalable, and valuable preventive tool for mental health. In this context, from patient participatory volunteer initiatives, we have adapted and developed an innovative volunteer-based telehealth intervention program for older adults (TIP-OA). Methods and analysis: To evaluate TIP-OA, we are conducting a mixed-methods longitudinal observational study. Participants: TIP-OA clients are older adults (age ≥ 60) recruited in Montreal, Quebec. Intervention: TIP-OA volunteers make weekly friendly phone calls to seniors to check in, form connections, provide information about COVID-19, and connect clients to community resources as needed. Measurements: Perceived stress, fear surrounding COVID-19, depression, and anxiety will be assessed at baseline, and at 4- and 8-weeks. Semi-structured interviews and focus groups will be conducted to assess the experiences of clients, volunteers, and stakeholders. Results: As of October 15th, 2020, 150 volunteers have been trained to provide TIP-OA to 305 older clients. We will consecutively select 200 clients receiving TIP-OA for quantitative data collection, plus 16 volunteers and 8 clinicians for focus groups, and 15 volunteers, 10 stakeholders, and 25 clients for semi-structured interviews. Discussion: During COVID-19, healthcare professionals' decreased availability and increased needs related to geriatric mental health are expected. If successful and scalable, volunteer-based TIP-OA may help prevent and improve mental health concerns, improve community participation, and decrease healthcare utilization. Clinical Trial Registration: ClinicalTrials.gov NCT04523610; https://clinicaltrials.gov/ct2/show/NCT04523610?term=NCT04523610&draw=2&rank=1.

CCCDTD5 recommendations on early and timely assessment of neurocognitive disorders using cognitive, behavioral, and functional scales.

INTRODUCTION: Earlier diagnosis of neurocognitive disorders and neurodegenerative disease is needed to implement preventative interventions, minimize harm, and reduce risk of exploitation in the context of undetected disease. Along the spectrum from subjective cognitive decline (SCD) to dementia, evidence continues to emerge with respect to detection, staging, and monitoring. Updates to previous guidelines are required for clinical practice. METHODS: A subcommittee of the 5th Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD) reviewed emerging evidence to address the following: (1) Is there a role for screening at-risk patients without clinical concerns? In what context is assessment for dementia appropriate? (2) What tools can be used to evaluate patients in whom cognitive decline is suspected? (3) What important information can be gained from an informant, using which measures? (4) What instruments can be used to get more in-depth information to diagnose mild cognitive impairment (MCI) or dementia? (5) What is the approach to those with cognitive concerns but without objective changes (ie, SCD)? (6) How do we track response to treatment and change over time? The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate quality of the evidence and strength of the recommendations. RESULTS: We recommend instruments to assess and monitor cognition, behavior, and function across the cognitive spectrum, including reports from patient and informant. We recommend against screening asymptomatic older adults but recommend investigation for self- or informant reports of changes in cognition, emergence of behavioral or psychiatric symptoms, or decline in function or self-care. Standardized assessments should be used for cognitive and behavioral change that have sufficient validity for use in clinical practice. DISCUSSION: The CCCDTD5 provides evidence-based recommendations for detection, assessment, and monitoring of neurocognitive disorders. Although these guidelines were developed for use in Canada, they may also be useful in other jurisdictions.

Behavioral and Psychological Symptoms that Predict Cognitive Decline or Impairment in Cognitively Normal Middle-Aged or Older Adults: a Meta-Analysis.

Epidemiological studies have revealed that behavioral and psychological (or non-cognitive) symptoms are risk factors for cognitive decline in older adults. This study aimed to systematically review the literature and determine which behavioral and psychological symptoms are most predictive of future cognitive decline among individuals with no pre-existing cognitive impairments. The selected studies included middle-aged or older adults without cognitive impairments. The predictors were assessed using behavioral and psychological questionnaires, or diagnostic interviews, to identify non-cognitive symptoms or psychiatric clinical conditions. The follow-up period was at least one year, and the design of the selected studies was either retrospective or prospective. This study compared individuals with and without non-cognitive manifestations and resulted in one of three outcomes: (a) a score change on a cognitive measure, (b) a diagnosis of mild cognitive impairment, or (c) a diagnosis of Alzheimer's disease or dementia. Four online databases were searched for eligible studies from the database inception to January 17, 2017: MEDLINE (PubMed), Embase (OVID), PsycINFO, and Web of Science. Pooled effect sizes were estimated using a random-effect model. Higgins I2, the Q statistic, and tau-squared were used to quantify the observed heterogeneity between the studies. Results indicate that depression and sleep duration (long and short) were the most consistent associations between behavioral or psychological symptoms and cognitive decline. This meta-analysis supports the need to assess behavioral and psychological symptoms in cognitively intact older adults to identify those who are at risk for cognitive decline.

Post-traumatic stress disorder mistaken for behavioural and psychological symptoms of dementia: case series and recommendations of care.

In late life, traumas may act cumulatively to exacerbate vulnerability to post-traumatic stress disorder (PTSD). PTSD is also a risk factor for cognitive decline. Major neurocognitive disorder (MND) can be associated with worsening of already controlled PTSD symptoms, late-life resurgence or de novo emergence. Misidentifying PTSD symptoms in MND can have negative consequences for the patient and families. We review the literature pertaining to PTSD and dementia and describe five cases referred for consultation in geriatric psychiatry initially for behavioural and psychological symptoms of dementia (BPSD), which were eventually diagnosed and treated as PTSD in MND subjects. We propose that certain PTSD symptoms in patients with MND are misinterpreted as BPSD and therefore, not properly addressed. For example, flashbacks could be interpreted as hallucinations, hypervigilance as paranoia, nightmares as sleep disturbances, and hyperreactivity as agitation/aggression. We suggest that better identification of PTSD symptoms in MND is needed. We propose specific recommendations for care, namely: clarifying diagnosis by distinguishing PTSD symptoms coexisting with different types of dementia from a specific dementia symptom (BPSD), gathering a detailed history of the trauma in order to personalise non-pharmacological interventions, adapting psychotherapeutic strategies to patients with dementia, using selective serotonin reuptake inhibitors as first-line treatment and avoiding antipsychotics and benzodiazepines. Proper identification of PTSD symptoms in patients with MND is essential and allows a more tailored and efficient treatment, with decrease in inappropriate use of physical and chemical restraints.

Revisiting Criteria for Psychosis in Alzheimer's Disease and Related Dementias: Toward Better Phenotypic Classification and Biomarker Research.

BACKGROUND: Psychotic symptoms are common in Alzheimer's disease (AD) and related neurodegenerative disorders and are associated with more rapid disease progression and increased mortality. It is unclear to what degree existing criteria are utilized in clinical research and practice. OBJECTIVE: To establish research criteria for the diagnosis of psychosis in AD. METHODS: The International Society to Advance Alzheimer's Research and Treatment (ISTAART) Neuropsychiatric Symptoms (NPS) Professional Interest Area (PIA) psychosis subgroup reviewed existing criteria for psychosis in AD and related dementias. Through a series of in person and on-line meetings, a priority checklist was devised to capture features necessary for current research and clinical needs. PubMed, Medline and other relevant databases were searched for relevant criteria. RESULTS: Consensus identified three sets of criteria suitable for review including those of Jeste and Finkel, Lyketsos, and the Diagnostic and Statistical Manual for Mental Disorders, 5th edition. It was concluded that existing criteria could be augmented by including a more specific differentiation between delusions and hallucinations, address overlap with related conditions (agitation in particular), adding the possibility of symptoms emerging in the preclinical and prodromal phases, and building on developing research in disease biomarkers. CONCLUSION: We propose criteria, developed to improve phenotypic classification of psychosis in AD, and advance the research agenda in the field to improve epidemiological, biomarker, and genetics research in the field. These criteria serve as a complement to the International Psychogeriatric Association criteria for psychosis in neurocognitive disorders.

The Interplay Between Post-traumatic Stress Disorder and Dementia: A Systematic Review.

BACKGROUND: Post-traumatic stress disorder (PTSD) has been reported to increase the risk for dementia in veterans and civilians. Conversely, case reports have described the delayed onset of PTSD in individuals developing dementia, suggesting a complex relationship between these two conditions. OBJECTIVES: To critically review studies investigating the association between PTSD and dementia and to assess the evidence for a bidirectional relationship between the two conditions. METHODS: A systematic review of Web of Science Core databases was carried out from inception of databases up to November 2018 to identify observational studies pertaining to both PTSD and dementia. Populations enrolled, stressors and neuropathologies, and main outcomes of studies were extracted, in addition to age at trauma and at onset of PTSD and dementia. The different temporal relationships between trauma and onset of the conditions were characterized. RESULTS: Twenty-five articles were included in the review; 14 articles assessed the association of PTSD with subsequent dementia and 11 articles reported the delayed onset of PTSD with the onset of dementia. Most reported traumas occurred in early-life (<40 years) and were related to war combat experiences. PTSD in mid-life (between 40 and 60 years of age) was associated with an increased risk of late-onset dementia. Numerous case series reported the delayed onset of PTSD in Alzheimer's disease and vascular dementia. CONCLUSION: Current evidence suggests that PTSD and dementia have a bidirectional relationship: PTSD increases the risk for late-onset dementia and dementia increases the risk for delayed-onset PTSD in those who experienced a significant trauma earlier in life.

Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) in Long-term Care Centers in Québec, Canada: A Strategy for Best Practices.

OBJECTIVES: Antipsychotic medications are often used for the first-line management of behavioral and psychological symptoms of dementia (BPSD) contrary to guideline recommendations. The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) strategy aims to improve the well-being of long-term care (LTC) residents with major neurocognitive disorder (MNCD) by implementing a resident-centered approach, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. DESIGN: Prospective, closed cohort supplemented by a developmental evaluation. SETTING AND PARTICIPANTS: Residents of designated wards in 24 LTC centers in Québec, Canada. METHODS: Provincial guidelines were disseminated, followed by the implementation of an integrated knowledge translation and mobilization strategy, including training, coaching, clinical tools, evaluation of clinical practices, and a change management strategy. Antipsychotic, benzodiazepine, and antidepressant prescriptions; BPSD; and falls were evaluated every 3 months, for 9 months, from January to October 2018. Semistructured interviews (n = 20) were conducted with LTC teams to evaluate the implementation of OPUS-AP. RESULTS: Of 1054 residents, 78.3% had an MNCD diagnosis and 51.7% an antipsychotic prescription. The cohort included 464 residents with both MNCD and antipsychotic prescription. Antipsychotic deprescribing (cessation or dose decrease) was attempted in 220 of the 344 residents still admitted at 9 months. Complete cessation was observed in 116 of these residents (52.7%) and dose reduction in 72 (32.7%), for a total of 188 residents (85.5%; 95% confidence interval: 80.1%, 89.8%). A decrease in benzodiazepine prescriptions and improvements in Cohen-Mansfield Agitation Inventory scores were observed among residents who had their antipsychotics deprescribed. Caregivers and clinicians expressed satisfaction as a result of observing an improved quality of life among residents. CONCLUSIONS AND IMPLICATIONS: Antipsychotic deprescribing was successful in a vast majority of LTC residents with MNCD without worsening of BPSD. Based on this success, phase 2 of OPUS-AP is now under way in 129 LTC centers in Québec.

Transcranial magnetic stimulation improves cognition over time in Parkinson's disease.

INTRODUCTION: Cognitive impairment can occur in the early phase of Parkinson's disease and increases the risk of developing dementia. Cognitive deficits were shown to be associated with functional alterations in the dorsolateral prefrontal cortex (DLPFC) and caudate nucleus. Two previous transcranial magnetic stimulation studies over the left DLPFC showed short-term improvement in cognitive performance and focused on specific task. METHODS: 28 patients with idiopathic Parkinson's disease and mild cognitive impairment received intermittent "theta burst" stimulation (iTBS) (active, N = 14; or sham, N = 14) over the left DLPFC, twice a day for three days with 1-2 days in between. Detailed neuropsychological assessment of five cognitive domains was performed before iTBS and on days 1, 10, and 30 after the last iTBS session. Composite Z-scores were calculated for each domain and for overall cognition. RESULTS: Our results showed an increase in overall cognition up to one month in both groups but this effect was only significant in the active group. Improvements were seen in the attention domain for both groups and in the visuospatial domain in the active group only. No significant differences were found between the groups. CONCLUSION: These preliminary findings suggest that active iTBS might improve overall cognitive performance in patients with Parkinson's disease with mild cognitive impairment and that this effect can last up to one month. This cognitive improvement, is likely mediated by improvement on visuospatial abilities. Further studies are needed to explore the potential of iTBS as a therapeutical tool to slow cognitive decline in patients with Parkinson's disease.