Background: Palliative care (PC) aims to enhance the quality of life for patients when confronted with serious illness. As stroke inflicts high morbidity and mortality, the integration of PC within acute stroke care remains an important aspect of quality inpatient care. However, there is a tendency to offer PC to stroke patients only when death appears imminent. We aim to understand why this may be by examining stroke patients admitted to a regional stroke centre who subsequently died and their provision of PC. Methods: We conducted a retrospective single-centre cohort study of patients who died during admission to the regional stroke centre at Sunnybrook Health Sciences Centre (SHSC) in Toronto, Ontario, Canada. Baseline demographics were assessed using means, standard deviations (SD), medians, interquartile ranges (IQR), and proportions. Descriptive statistics, univariate, and multivariate analyses were performed to ascertain relationships between collected variables. Results: Univariate modeling demonstrated that older age, being female, no stroke diagnosis at admission to hospital, ischemic stroke, and comorbidities of cancer or dementia were associated with a higher incidence of palliative medicine consultation (PMC), while admission from an acute care hospital and a Glasgow Coma Scale (GCS) coma classification were associated with a lower incidence of PMC. The multivariate model identified the GCS coma-related category as the only significant factor associated with a higher incidence of death but was non-significantly related to a lower incidence of PMC. Conclusion: These results highlight continued missed opportunities for PC in stroke patients and underscore the need to better optimize PMC.

Background: Older adults cared for in a geriatric mental health program often have medical co-morbidities causing physical symptoms which may be under-recognized. We explore the utility of palliative care tools in this patient population to identify the burden of symptoms and impact on patient dignity. Methods: Participants were recruited from a geriatric mental health inpatient unit and outpatient day hospital. Mood and somatic symptoms were tracked with self-report rating scales, including the Geriatric Depression Scale (GDS) and the Geriatric Anxiety Inventory (GAI) used in psychiatry, as well as the Edmonton Symptom Assessment Scale (ESAS) and Patient Dignity Inventory (PDI) used in palliative care. Demographic characteristics were collected from a retrospective chart review. Exploratory longitudinal models were developed for the GDS and GAI outcomes to assess change over time after adjusting for ESAS and PDI item scores. Results: Data were obtained for 33 English speaking patients (inpatients N = 17, outpatients N = 16) with a mean age of 76.5 (SD = 6.1). At baseline, several ESAS symptom burdens were rated as moderate and the PDI often captured physically distressing symptoms. GDS scores declined over time but at a slower rate for those reporting higher levels of pain on the ESAS (P = .04). GAI scores declined over time but at a slower rate for those identifying physically distressing symptoms on the PDI (P = .04). Conclusions: This study demonstrates how using the ESAS and PDI in a mental health population can be helpful in tracking symptoms and how these symptoms are related to psychiatric outcomes.

Online delivery is new to the field of music therapy (MT). This research investigated older adults' perceived quality of MT online by certified music therapists. In this feasibility study, applying both process and outcome assessments, nine older adults volunteered to participate. Zoom was used, and a virtual music therapy (VMT) kit was developed as a resource. Surveys and observed technical difficulties revealed that perceived quality varied slightly by level of technical difficulty experienced; however, overall mean perceived quality was 7.2 out of 9. Post-study interviews revealed three main themes: (a) individual experiences with VMT, (b) individuals' suggestions for further development of VMT sessions, and (c) individuals' personal outcomes from VMT sessions. Participants reported overall positive experiences with VMT. Despite a slight decline in perceived quality when more technical difficulties were present, each participant reported a desire for more sessions, and they would recommend it to others.

Caregivers of persons with dementia (PWD) frequently face physical assault and emotional abuse when providing care. Providing experiential opportunities for caregivers to develop skills that maximize safe, compassionate care is a priority. Human simulation has demonstrated greater effectiveness than didactic activities in developing clinical skills. However, this requires consideration of physical safety for both learners and simulated participants (SPs), limiting the full expression of behaviours. To address this limitation, we conducted a proof-of-concept study engaging SPs on a synchronous, facilitated VR platform responding realistically, but safely, to learners’ communication approaches. Learners negotiated online with potential threats of violence from the SPs. This study used a pre/post mixed-method research design. Both qualitative and quantitative approaches were used to explore the impact of this training on participants’ knowledge, confidence and comfort when providing care to PWD. Overall, participant ratings of knowledge, confidence and comfort increased post-training, as compared to pre-training ( Our findings provide insights into the implications of VR-based training for managing responsive behaviours of PWD. VR training has the ability to increase caregiver knowledge, confidence and comfort working with PWD who are exhibiting responsive behaviours, as shown by participants.

A model of a virtual psychotherapeutic support group was developed for young-onset dementia (YOD; people with dementia under the age of 65) caregivers; one group for adult children and one for spouses. This pilot study evaluated the impact of support groups on YOD caregivers’ psychosocial well-being, coping abilities, and knowledge. At post, psychosocial measures revealed an increase in the number of coping strategies rated as helpful among the 13 spousal and 14 adult children caregivers who completed the study. Adult children were observed to have a reduction in both the negative impact of caregiving and depression scores. Caregivers reported that being able to share experiences with other caregivers in similar circumstances helped them feel supported and less alone. The virtual support groups demonstrated the potential to reduce the negative impact of caregiving, especially among adult children, and showed that the groups could improve knowledge and capacity building for all caregivers.

BACKGROUND:Palliative care (PC) aims to enhance the quality of life for patients and their families when confronted with serious illness.  As stroke continues to inflict high morbidity and mortality, the integration of palliative care within acute stroke care remains an important aspect of quality inpatient care. AIM:This study aims to investigate the experiences and perceived barriers of PC integration for patients with acute severe stroke in Canadian stroke physicians. METHODS:We conducted an anonymous, descriptive, cross-sectional web-based self-administered survey of stroke physicians in Canada who engage in acute severe stroke care. The questionnaire contained three sections related to stroke physician characteristics, practice attributes, and opinions about palliative care.  Descriptive statistics, univariate, and regression analysis were performed to ascertain relations between collected variables. RESULTS:Of the 132 physician associate members, 120 were surveyed with a response rate of 69 (58%). Stroke physicians reported that PC services were consulted "sometimes" and that PC services were consulted rarely for prognostication and more often for end-of-life care which they agreed was better delivered off the stroke unit. Several barriers for early integration of palliative care services were identified including uncertainty in prognosis. Stroke physicians endorsed education of both families and physicians would be beneficial. CONCLUSIONS:There remain perceived barriers for integration of palliative care within the acute stroke population. Challenges include consultation of PC services, uncertainty around patient prognosis, engagement, and educational barriers. There are opportunities for further integration and collaboration between palliative care physicians and stroke physicians.

INTRODUCTION:This study aimed to investigate the use of therapeutic touch (TT) in the management of responsive behaviors in patients with dementia.METHODS:A randomized, double-blinded control trial was used to compare response to TT in a population with responsive behaviors in dementia, in 3 phases, pretreatment, treatment, and posttreatment each lasting 5 days. The participants were divided into three groups: experimental, placebo, and control. The experimental group received regular TT, the placebo group received mimic TT, and the control group received regular routine care. Behavior was observed and recorded by trained research assistants every 20 min during the study time throughout each of the phases. Modified Agitated Behavior Rating Scale (ABRS) and Revised Memory and Behavior Check (RMBC) scores were used to assess the behavioral symptoms of dementia throughout the study.RESULTS:All groups had decreasing RMBC scores during the pretreatment period, however; the experimental TT group was the only group whose RMBC scores continued to decrease during the treatment period. All groups had a similar pattern of rates of change in ABRS scores over the 15-day period, with no differential pattern of results related to experimental TT.CONCLUSION:Despite limited evidence, TT should be explored as an adjunctive therapy for reducing behavioral symptoms in individuals with dementia. Further research is needed to determine the effects of TT on responsive behaviors in dementia. There is a need for studies with larger sample sizes, equal distribution of participants between groups (in terms of dementia stages), and longer post study follow-ups.

Abstract Objectives Our aim was to validate the online Brain Health Assessment (BHA) for detection of amnestic mild cognitive impairment (aMCI) compared to gold-standard neuropsychological assessment. We compared the diagnostic accuracy of the BHA to the Montreal Cognitive Assessment (MoCA). Methods Using a cross-sectional design, community-dwelling older adults completed a neuropsychological assessment, were diagnosed as normal cognition (NC) or aMCI, and completed the BHA and MoCA. Both logistic regression (LR) and penalized logistic regression (PLR) analyses determined BHA and demographic variables predicting aMCI; MoCA variables were similarly modeled. Diagnostic accuracy was compared using area under the receiver operating characteristic curve (ROC AUC) analyses. Results Ninety-one participants met inclusion criteria (51 aMCI, 40 NC). PLR modeling for the BHA indicated Face–Name Association, Spatial Working Memory, and age-predicted aMCI (ROC AUC = 0.76; 95% confidence interval [CI]: 0.66–0.86). Optimal cut-points resulted in 21% classified as aMCI (positive), 23% negative, and 56% inconclusive. For the MoCA, digits, abstraction, delayed recall, orientation, and age predicted aMCI (ROC AUC = 0.71; 95% CI: 0.61–0.82). Optimal cut-points resulted in 22% classified positive, 8% negative, and 70% inconclusive (LR results presented within). The BHA model classified fewer participants into the inconclusive category and more as negative for aMCI, compared to the MoCA model (Stuart–Maxwell p = .004). Discussion The self-administered BHA provides similar detection of aMCI as a clinician-administered screener (MoCA), with fewer participants classified inconclusively. The BHA has the potential to save practitioners time and decrease unnecessary referrals for a comprehensive assessment to determine the presence of aMCI.

Objective Young women with breast cancer and their partners are more distressed than couples who are affected later in life. While dyadic interventions in the context of cancer are promising, there are access barriers, particularly for younger couples. This study evaluated Couplelinks, a professionally facilitated, web-based program designed to help couples improve their conjoint coping. Method This randomised controlled trial employed a waitlist control evaluation of the program. Outcomes included dyadic coping, relationship adjustment, depression, and anxiety. Results Seventy-five couples consented to participate and were randomised. The final analysis included 31 couples in the treatment group and 36 couples in the waitlist group. Modest improvements were found in positive dyadic coping but effects were not maintained at 3-month follow-up. No effect was seen on overall relationship adjustment. Conclusions Our findings inform the rapidly expanding field of online programming for couples in general, and those affected by BC in particular. Intervention timing, 'dose', low overall relational distress, and the mainly enrichment rather than problem-focus of Couplelinks may help explain the lack of change on relationship adjustment.

BACKGROUND:Amnestic mild cognitive impairment (aMCI), a prodromal phase of Alzheimer's disease (AD), is characterized by episodic memory dysfunction, but inhibitory deficits have also been commonly reported. Time of day (TOD) effects have been confirmed in 1) healthy aging on cognitive processes such as inhibitory control, and 2) on behavior in AD (termed the sundowning effect), but no such research has addressed aMCI.OBJECTIVE:The present study examined the impact of TOD on the behavioral and electrophysiological correlates of inhibition in 54 individuals with aMCI and 52 healthy controls (HCs), all of morning chronotype.METHODS:Participants were randomly assigned to complete two inhibition tasks (Go-NoGo and Flanker) during their optimal (morning) or non-optimal (evening) TOD, while electroencephalography was recorded.RESULTS:Both tasks elicited changes in N2 and P3 event-related potential (ERP) components, which commonly index inhibitory functioning. Analyses showed that the Go-NoGo difference in P3 amplitude was reduced in individuals with aMCI relative to HCs. Compared to HCs, the Flanker difference in P3 amplitude was also reduced and coincided with more errors in the aMCI group. Notably, these behavioral and ERP differences were exaggerated in the non-optimal TOD relative to the optimal TOD.CONCLUSION:Findings confirm the presence of inhibition deficits in aMCI and provide novel evidence of sundowning effects on inhibitory control in aMCI. Results reinforce the need to consider the influences of TOD in clinical assessments involving individuals with aMCI.

Background We implemented an opt-out clinic-based intervention pairing syphilis tests with routine human immunodeficiency virus (HIV) viral load testing. The primary objective was to determine the degree to which this intervention increased the detection of early syphilis. Methods The Enhanced Syphilis Screening Among HIV-Positive Men (ESSAHM) Trial was a stepped wedge cluster-randomized controlled trial involving 4 urban HIV clinics in Ontario, Canada, from 2015 to 2017. The population was HIV-positive adult males. The intervention was standing orders for syphilis serological testing with viral loads, and control was usual practice. We obtained test results via linkage with the centralized provincial laboratory and defined cases using a standardized clinical worksheet and medical record review. We employed a generalized linear mixed model with a logit link to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the intervention. Results A total of 3895 men were followed over 7471 person-years. The mean number of syphilis tests increased from 0.53 to 2.02 tests per person per year. There were 217 new diagnoses of syphilis (control, 81; intervention, 136), for which 147 (68%) were cases of early syphilis (control, 61 [75%]; intervention, 86 [63%]). The annualized proportion with newly detected early syphilis increased from 0.009 to 0.032 with implementation of the intervention; the corresponding time-adjusted OR was 1.25 (95% CI, .71-2.20). Conclusions The implementation of standing orders for syphilis testing with HIV viral loads was feasible and increased testing, yet produced less-than-expected increases in case detection compared to past uncontrolled pre-post trials. In a randomized, multisite trial that implemented standing orders for syphilis serological testing with HIV viral loads among men, we observed significant increases in syphilis testing and a 25% increase in detection of new cases of early infectious syphilis.

Background This study evaluated participant satisfaction with “Couplelinks,” an online psychological intervention designed for younger couples coping with breast cancer. The program included six experiential learning exercises (plus one optional module), psychoeducational information, and support from a personal mental health professional. Objective The primary objectives were to examine participants’ perceptions of: the online intervention’s structure and content; the value of including a professional facilitator; and benefits and drawbacks of the program. Methods A treatment satisfaction questionnaire comprised of Likert indices and open-ended questions pertaining to treatment satisfaction was completed by 26 patients and 27 male partners ( N = 53) approximately 1–2 weeks following the intervention which occurred in the context of a randomized controlled trial. Descriptive statistics were used to summarize satisfaction ratings and generalized linear models with fixed effect for gender were used to test for differences in male-female outcomes. A thematic analysis was undertaken in order to understand, organize and summarize the qualitative textual feedback. Results Participants reported an overall satisfaction rating of 4.3 out of 5 ( SD = 0.54) with patient satisfaction ratings being higher than that of male partners’ ( p = 0.01). The majority of participants considered the facilitator’s role to be necessary 4.6 ( SD = 0.60), and found the program to be convenient 4.1 ( SD = 0.81) despite some participants struggling to keep up with the modules. Subjective data revealed participants valued the convenience and flexibility of the online intervention and appreciated the program’s involvement of both partners. Participants also reported that including a professional facilitator humanized the intervention, served as motivation to progress through the program, facilitated insight into their relationship, and was reassuring. Experiential gains noted by participants included that the program: helped couples to open channels of communication; prompted them to designate quality time for one another; evoked feelings of unity and togetherness; and inspired new insight in the relationship. Conclusion Such feedback supports the feasibility and acceptability of the Couplelinks program while offering directions for improvement of online couple-based interventions in cancer.

Time of day (TOD) influences on executive functions have been widely reported, with greater efficiency demonstrated at optimal relative to non-optimal TOD according to one’s chronotype (i.e., synchrony effect). Older adults (OAs) show declines in inhibitory control and are more sensitive to the effects of circadian variation on executive functioning. To date, no studies have investigated the effects of TOD and aging on executive functioning using electrophysiological measures. The present study investigated the effects of aging and TOD on the neural correlates of inhibitory processing (N2 and P3) using event-related potentials (ERPs). Go-NoGo and Flanker tasks were administered to 52 OAs of morning chronotype and 51 younger adults (YAs) of afternoon-to-evening chronotype who were randomly assigned to morning or afternoon test sessions, with the optimal TOD for OAs in the morning and for YAs in the afternoon/evening. While behavioral results demonstrated no TOD effects, ERPs indicated synchrony effects. Both YAs and OAs showed greater modulation of Go-NoGo N2 and greater P3 amplitude during the non-optimal than optimal TOD, consistent with the synchrony effect. For the Flanker task, age differences in P3 amplitude were only apparent during the non-optimal TOD. These results suggest that processes associated with inhibitory control are differentially affected by TOD and aging, with age-related reductions in inhibitory efficiency during off-peak test times on measures of interference control. These findings highlight the sensitivity of ERPs to detect TOD effects in the absence of behavioral differences, confirm more pronounced TOD effects in OAs relative to YAs on ERP measures of interference control, and reinforce the need to assess and control for circadian typology in research studies.

BACKGROUND:Therapeutic lying is an intervention used by health care professionals (HCPs) when a person with dementia is disoriented and distressed and when all other interventions have not succeeded in deescalating the symptoms of dementia.METHOD:The goal of this study was to evaluate a workshop on therapeutic lying and dementia care for HCPs specializing in the care of persons living with dementia with symptoms of dementia. Seventeen HPCs, including nurses and personal support workers (PSWs), participated in the workshop and evaluation survey.RESULTS:The workshop did not affect the attitudes of HCPs toward therapeutic lying and dementia, their sense of competence in providing care to patients with dementia, or their rate of admitting to using therapeutic lying in dementia care settings. All of the PSWs and 50.0% of the nurses admitted to using therapeutic lying as an intervention. Conclusion: Current nursing ethics standards and training practices may cause reluctance among nurses to include therapeutic lying in care plans as a last resort and as a person- and family-centered intervention to deescalate the symptoms of dementia. [J Contin Educ Nurs. 2021;52(9):438-444.].

Introduction Mean cognitive performance is worse in amnestic mild cognitive impairment (aMCI) compared to control groups. However, studies on variability of cognitive performance in aMCI have yielded inconclusive results, with many differences in variability measures and samples from one study to another.Methods We examined variability in aMCI using an existing older adult sample (n = 91; 51 with aMCI, 40 with normal cognition for age), measured with an online self-administered computerized cognitive assessment (Cogniciti’s Brain Health Assessment). Our methodology extended past findings by using pure measures of variability (controlling for confounding effects of group performance or practice), and a clinically representative aMCI sample (reflecting the continuum of cognitive performance between normal cognition and aMCI).Results Between-group t-tests showed significantly greater between-person variability (interindividual variability or diversity) in overall cognitive performance in aMCI than controls, although the effect size was with a small to moderate effect size, d = 0.44. No significant group differences were found in within-person variability (intraindividual variability) across cognitive tasks (dispersion) or across trials of a response time task (inconsistency), which may be because we used a sample measuring the continuum of cognitive performance. Exploratory correlation analyses showed that a worse overall score was associated with greater inter- and intraindividual variability, and that variability measures were correlated with each other, indicating people with worse cognitive performance were more variable.Discussion The current study demonstrates that self-administered online tests can be used to remotely assess different types of variability in people at risk of Alzheimer`s. Our findings show small but significantly more interindividual differences in people with aMCI. This diversity is considered as “noise” in standard assessments of mean performance, but offers an interesting and cognitively informative “signal” in itself.

Objectives: Current guidelines suggest that patients with severe dementia on cholinesterase inhibitors (CHEIs) should discontinue their CHEIs by taper. This study aims to define the prevalence of patients admitted to a palliative care unit (PCU) with dementia on a CHEI and to determine whether these patients were tapered off their CHEIs according to current deprescribing guidelines. Design: This is a descriptive retrospective chart review that examined patients admitted to a PCU with dementia on a CHEI from January 2015 to June 2019. Methods: Individuals admitted to the PCU with a primary or comorbid diagnosis of dementia were identified. Their corresponding CHEI dose, frequency and discontinuation pattern were identified. Data were analyzed using descriptive statistics. Results: A total of 36 patients were admitted to the PCU with dementia on a CHEI (prevalence of 2.3%). The median length of stay was 21 days. For 31 of these patients, their CHEI was discontinued, only 9 of which had a taper. Of the 24 patients who discontinued their CHEI suddenly, 10 patients had an order to discontinue their CHEI in the last 2 days before their date of death. Conclusion: This study suggests that although patients admitted to a PCU with dementia have their CHEI discontinued, the discontinuation was done without a taper. In many cases the CHEIs were continued through the active stage of dying. Future work should explore reasons why PCU physicians are mostly late to taper CHEIs for patients admitted with dementia.

Introduction: Patients often experience delirium at the end of life. Benzodiazepine use may be associated with an increased risk of developing delirium. Alternate medications used in conjunction with benzodiazepines may serve as an independent precipitant of delirium. The aim is to understand the role of benzodiazepines in precipitating delirium and advanced mortality in palliative care population at the end of life. Methods: A retrospective medical chart review was conducted at a hospice and palliative care inpatient unit between the periods of June 2017–December 2017 and October 2017–November 2018. It included patients in hospice and palliative care inpatient units who received a benzodiazepine and those who did not. Patient characteristics, as well as Palliative Performance Scale score, diagnosis, and occurrence of admission, terminal, and/or recurrent delirium, were collected and analyzed. Results: Use of a benzodiazepine was not significantly associated with overall mortality nor cause-specific death without terminal delirium rate. However, it was significantly associated with higher cause-specific death with terminal delirium rate and a higher recurrent delirium rate. Discussion: This retrospective chart review suggests an association between benzodiazepine use and specific states of delirium and cause-specific death. However, it does not provide strong evidence on the use of this drug, especially at the end of life, as it pertains to the overall mortality rate. Suggested is a contextual approach to the use of benzodiazepines and the need to consider Palliative Performance Scale score and goals of care in the administration of this drug at varying periods during patient length of stay.

Abstract Background HIV‐positive individuals may acquire HCV via injection drug use (IDU) and condomless anal sex. HIV care provides opportunities for HCV testing and cure with direct‐acting antiviral agents (DAAs). Methods We analyzed data from the Ontario HIV Treatment Network Cohort Study. Among those not HCV‐positive or diagnosed previously (n = 4586), we used Cox regression to test the rates of ever HCV testing (serological or RNA) in HIV care by DAA era (pre‐DAA: 2000‐2010; after DAA: 2011‐2015) and compared the proportion diagnosed with HCV. We identified correlates of annual proportions of serological testing using Poisson generalized estimating equations. Results After DAA vs pre‐DAA, the hazard rate ratio (95% CI) of ever HCV testing was 1.70 (1.59, 1.81). The proportion (95% CI) tested annually increased from 9.2% (8.0%, 10.7%) in 2000 to 39.1% (37.1%, 41.1%) in 2015 (P < 0.0001). The proportion diagnosed with HCV declined by 74% pre‐DAA to 11% after DAAs. Annual testing increased per calendar year (16% steeper slope after DAA vs pre‐DAA) and was more common among men who have sex with men; those more educated (post‐secondary vs ≤ high school); and those positive for syphilis or reporting any IDU. Annual testing decreased per decade of age and time since HIV diagnosis. Discussion Annual HCV testing increased over time with higher testing among those reporting sexual or IDU risk factors, but fell short of clinical guidelines. Targeted interventions to boost testing may be needed to close these gaps and reach WHO 2030 HCV elimination targets.

Background: Visiting restrictions placed on palliative care units due to the COVID-19 pandemic have resulted in emotional and psychological distress to patients, their caregivers and families. However, the informational needs of caregivers during pandemic visiting restrictions have never been studied. Aim: To identify the informational needs of caregivers of patients admitted to an end-of-life palliative care unit under COVID-19 visiting restrictions. Methods: Nineteen caregivers of patients admitted to a single palliative care unit while under pandemic visiting restrictions were recruited. A cross-sectional telephone survey was performed, which examined the importance of different informational needs of caregivers and how well these needs were being met. Results: Receiving information about hospital regulations/procedures, health updates about the patient, social support for the patient and how to communicate with the patient in light of visitor restrictions were 'very important' to caregivers. In contrast, caregivers were 'neutral' towards receiving information about accessing psychosocial/emotional support for the caregiver and religious/spiritual support for the patient. Qualitative data summaries provided a richer understanding of these quantitative rankings. Conclusion: These findings will assist healthcare professionals in providing optimal informational support to caregivers during visitor restrictions in order to improve the growing psychological impact on this population.

Our need for easily administered online assessments sensitive to mild cognitive difficulties is increasing as our population ages. Our team has recently presented data indicating the accuracy of an online, publicly available, self‐administered screening measure, Cogniciti’s Brain Health Assessment (BHA), in the detection of amnestic mild cognitive impairment (aMCI) in a sample of community dwelling older adults. This current work extends those findings by further examining diagnostic accuracy of this measure.