Browsing by Author "Goodarzi, Zahra"
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Item Open Access Adult day programs and their effects on individuals with dementia and their caregivers (ADAPT-DemCare): a realist synthesis to develop program theories on the how and why(2024-10-23) Nguyen, Hung; Rahman, Atiqur; Ubell, Andrea; Goodarzi, Zahra; Maxwell, Colleen J.; Allana, Saleema; Tate, Kaitlyn; Symonds-Brown, Holly; Weeks, Lori; Caspar, Sienna; Mann, Jim; Hoben, MatthiasAbstract Background Adult day programs aim to facilitate aging in place by supporting the health and well-being of persons with dementia and providing respite to their caregivers. However, studies on the effects of day programs are inconclusive, and we especially lack insights into the context conditions and mechanisms of day programs that may produce different outcomes for different groups of persons with dementia and their caregivers. Our objective was to conduct a realist review, synthesizing research on day programs to develop program theories explaining how and why day programs do or do not produce positive or negative outcomes for different groups of persons with dementia, and caregivers. Methods We identified 14 literature reviews (including 329 references published between 1975 and 2021) on adult day programs. From this initial pool of studies, we will include those that focused on day program attendees with dementia or meaningful cognitive impairment, and/or their caregivers, and that report how day program contexts (C) and mechanisms (M) bring about outcomes (O) for attendees and caregivers. We will extract CMO statements (i.e., narratives that explain how and why day programs do or do not bring about certain outcomes for whom and under what circumstances). Using additional focused searches, citation mapping, citation tracking, and discussions with our researcher and expert team members, we will identify additional references. CMO statements will be synthesized, transformed into hypotheses, and linked and visualized to form program theories. Using focus groups and the James Lind Alliance Priority Setting Partnership method, we will discuss and prioritize our CMO statements and refine our program theories with 32 experts (older adults, caregivers, Alzheimer societies, caregiver organizations, day program staff and managers, and health system and policy decision makers). Discussion By identifying essential elements and processes of day programs and related knowledge gaps, this study will generate much-needed knowledge to leverage the full potential of day programs so they can provide appropriate care, preventing premature institutionalization, and unnecessary acute and primary care use. This will ultimately improve the quality of life of persons with dementia and their caregivers, alleviate caregiver burden, and reduce social costs. Systematic review registration PROSPERO CRD42024504030Item Open Access Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care(2024-04-11) Wong, Britney; Ismail, Zahinoor; Watt, Jennifer; Holroyd-Leduc, Jayna; Goodarzi, ZahraAbstract Background Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups. Methods This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis. Results Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions. Conclusions This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC.Item Open Access Barriers and facilitators to diagnosing and managing apathy in Parkinson’s disease: a qualitative study(2019-05-24) Mele, Bria; Goodarzi, Zahra; Hanson, Heather M; Holroyd-Leduc, JaynaAbstract Background Apathy is a prominent non-motor symptom in Parkinson’s disease (PD). People with apathy show a lack of emotion, passion, and motivation. Between 17 and 70% of persons with PD have apathy; the extreme heterogeneity in these estimates is due to limited heterogeneous knowledge concerning how to diagnose PD. The lack of a widely utilized diagnostic process limits understandings on how to treat and manage apathy in PD. A scoping review of apathy in PD identified only one qualitative study investigating this symptom. It was our objective to assess perceived barriers and facilitators to diagnosing, treating, and managing apathy in PD, as described by key stakeholders. Methods This research applied qualitative methodology, utilizing focus groups and interviews with health care practitioners (HCPs), persons with PD, and caregivers. Evidence gathered from a scoping review on apathy in PD informed discussions that took place with participants. Data collection and analysis was conducted using framework analysis, applying the Theoretical Domains Framework and Behaviour Change Wheel. Results Eleven HCPs and five persons with PD/caregivers participated. Themes included interdisciplinary teams and communication with family to facilitate diagnosis and treatment, and the use of education and increased awareness of apathy to facilitate management. Themes surrounding barriers included lack of initiative and motivation to maintain treatment plans, and a lack of evidence for apathy specific interventions. While a key barrier identified was the lack of information HCPs have access to, persons with PD and caregivers would prefer to receive a diagnosis of apathy even with limited management methods. Thus, education and awareness were noted as two of the most important facilitators, overall. Conclusion These findings suggest that diagnosing, treating, and managing apathy in PD requires interdisciplinary teams, that include family and caregivers. We identified that where HCPs perceive lack of knowledge as a barrier to diagnosis, persons with PD and caregivers find being given a diagnosis facilitates understanding. These findings highlight the importance of qualitative research involving persons with PD and apathy, caregivers, and HCPs who aid in management of this symptom. Barriers reported suggest future research must aim to identify apathy specific treatments, both pharmacologic and non-pharmacologic.Item Embargo Care for Older Adults Living with Dementia in the Emergency Department: Informing the Development of a Clinical Care Pathway(2024-06-11) Jelinski, Dana Christine; Goodarzi, Zahra; Holroyd-Leduc, Jayna; Reich, Krista; Lang, EddyBackground: People living with dementia (PLWD) are frequent users of the emergency department (ED). PLWD experience adverse outcomes in the ED at higher rates than older adults without dementia, and care partners play a vital role in supporting them. While there is some evidence that exists regarding best practices in caring for PLWD in the ED, there are gaps in evidence on the experiences of caring for PLWD in ED and implementing best practices from the view of healthcare providers (HCPs). Objectives: The objectives of this thesis were to (1) synthesize barriers and facilitators to care for PLWD in the ED through the perspective of care partners as well as HCP perceptions of care partner roles within the ED, and (2) explore barriers and facilitators to care through the perspective of HCPs. Methods: A systematic review and meta-synthesis were conducted following the Joanna Briggs Institute Manual for Evidence Synthesis to synthesize care partner perspectives and roles regarding care for PLWD in the ED. Semi-structured interviews with HCPs were used to directly understand experiences in caring for PLWD in the ED. Results: Care partners and HCPs reported similar barriers and facilitators to care for PLWD in the ED. Key barriers to care included gaps in primary care, the ED environment, and lack of dementia specific guidance and training. Key facilitators included the importance of care partner and patient involvement, and communication and collaboration among care teams. Conclusion: The findings of this study inform the development of interventions that target behavior change and promote dementia friendly EDs. Key implications highlighted in this study include education and training, staffing and environmental changes, and care guidance and policy implementation.Item Open Access Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews(2019-11-15) Rios, Patricia; Cardoso, Roberta; Morra, Deanna; Nincic, Vera; Goodarzi, Zahra; Farah, Bechara; Harricharan, Sharada; Morin, Charles M; Leech, Judith; Straus, Sharon E; Tricco, Andrea CAbstract Background This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed. Methods MEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal. Results A total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio. Conclusions Assuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews. Systematic review registration PROSPERO CRD42017072527.Item Open Access Comparative safety and efficacy of pharmacological and non-pharmacological interventions for the behavioral and psychological symptoms of dementia: protocol for a systematic review and network meta-analysis(2017-09-07) Watt, Jennifer; Goodarzi, Zahra; Tricco, Andrea C; Veroniki, Areti-Angeliki; Straus, Sharon EAbstract Background Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent in patients with dementia. Both pharmacological and non-pharmacological strategies are commonly used to treat these symptoms, but their comparative safety and efficacy is unknown. Methods We will conduct a systematic review of the published and unpublished literature to retrieve all articles pertaining to outcomes of safety and efficacy associated with pharmacological and non-pharmacological treatments of BPSD for patients living in the community and institutionalized care settings. Our primary outcome of efficacy is a change in aggression. Our primary outcome of safety will be risk of fracture. These primary outcomes were chosen by stakeholders involved in the care of patients experiencing BPSD. Possible secondary outcomes of efficacy will include a change in agitation, depressive symptoms, and night-time behaviors. Possible secondary outcomes of safety will include the risk of stroke, falls, and mortality. All article screening, data abstraction, and risk of bias appraisal will be completed independently by two reviewers. If the assumption of transitivity is valid and the evidence forms a connected network, Bayesian random-effects pairwise and network meta-analyses (NMAs) will be conducted. Relative treatment rankings will be reported with mean ranks and the surface under the cumulative ranking curve. Discussion We will identify the safest and most efficacious treatment strategies for patients with BPSD from among our most highly ranked treatments. The results of this study will be used to guide decision-making and improve patient care. Systematic review registration PROSPERO registry number CRD42017050130.Item Open Access Correction: Prevalence and factors associated with polypharmacy: a systematic review and meta-analysis(2022-09-12) Delara, Mahin; Murray, Lauren; Jafari, Behnaz; Bahji, Anees; Goodarzi, Zahra; Kirkham, Julia; Chowdhury, Mohammad; Seitz, Dallas P.Item Open Access Depressive symptoms in long term care facilities in Western Canada: a cross sectional study(2019-12-02) Hoben, Matthias; Heninger, Abigail; Holroyd-Leduc, Jayna; Knopp-Sihota, Jennifer; Estabrooks, Carole; Goodarzi, ZahraAbstract Background The main objective is to better understand the prevalence of depressive symptoms, in long-term care (LTC) residents with or without cognitive impairment across Western Canada. Secondary objectives are to examine comorbidities and other factors associated with of depressive symptoms, and treatments used in LTC. Methods 11,445 residents across a random sample of 91 LTC facilities, from 09/2014 to 05/2015, were stratified by owner-operator model (private for-profit, public or voluntary not-for-profit), size (small: < 80 beds, medium: 80–120 beds, large > 120 beds), location (Calgary and Edmonton Health Zones, Alberta; Fraser and Interior Health Regions, British Columbia; Winnipeg Health Region, Manitoba). Random intercept generalized linear mixed models with depressive symptoms as the dependent variable, cognitive impairment as primary independent variable, and resident, care unit and facility characteristics as covariates were used. Resident variables came from the Resident Assessment Instrument – Minimum Data Set (RAI-MDS) 2.0 records (the RAI-MDS version routinely collected in Western Canadian LTC). Care unit and facility variables came from surveys completed with care unit or facility managers. Results Depressive symptoms affects 27.1% of all LTC residents and 23.3% of LTC resident have both, depressive symptoms and cognitive impairment. Hypertension, urinary and fecal incontinence were the most common comorbidities. Cognitive impairment increases the risk for depressive symptoms (adjusted odds ratio 1.65 [95% confidence interval 1.43; 1.90]). Pain, anxiety and pulmonary disorders were also significantly associated with depressive symptoms. Pharmacologic therapies were commonly used in those with depressive symptoms, however there was minimal use of non-pharmacologic management. Conclusions Depressive symptoms are common in LTC residents –particularly in those with cognitive impairment. Depressive symptoms are an important target for clinical intervention and further research to reduce the burden of these illnesses.Item Open Access Detecting agitation and aggression in persons living with dementia: a systematic review of diagnostic accuracy(2024-06-26) Wong, Britney; Wu, Pauline; Ismail, Zahinoor; Watt, Jennifer; Goodarzi, ZahraAbstract Objective 40–60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD. Methods Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools. Results 6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI). Conclusions The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.Item Embargo Developing a Novel Care Pathway for Symptoms of Agitation or Aggression in Persons Living with Dementia in Long-Term Care: A Multi-Methods Implementation Research Study(2023-06) Wong, Britney; Goodarzi, Zahra; Holroyd-Leduc, Jayna; Ismail, Zahinoor; Watt, JenniferBackground: Agitation and/or aggression are common among persons living with dementia (PLWD) in LTC, and together pose a significant burden to residents and their caregivers. Current treatment practices for agitation and/or aggression are highly variable among PLWD in LTC. There is a need to develop a more effective approach to treatment and to explore the barriers and facilitators to providing care for agitation and/or aggression among PLWD in LTC. Objectives: The first objective was to develop an evidence-informed clinical care pathway co-designed with stakeholders, to improve care for agitation and/or aggression among PLWD in LTC. The second objective was to identify barriers and facilitators to agitation and/or aggression care across the spectrum of care. Methods: Objective 1 used a modified Delphi panel to develop the clinical care pathway. Objective 2 used semi-structured interviews with key stakeholders to identify the barriers and facilitators to care. Framework Analysis was used to map identified barriers and facilitators to key behavioral domains of the Theoretical Domains Framework. Results: Crucial pathway features included using an interdisciplinary care team approach across the spectrum of care and featuring a broad range of non-pharmacological interventions. Several statements in our pathway did not reach agreement and require a third round of the Delphi. Perceived barriers for agitation and/or aggression care included a lack of validated tools to detect agitation and/or aggression, inconsistent training practices, and a limited number of available non-pharmacological interventions. Key facilitators were using an interdisciplinary care team and having trained healthcare providers to administer non-pharmacological interventions. Conclusions: Our study advances the state of evidence for agitation and/or aggression care among PLWD in LTC. Our efforts will inform future implementation research strategies working to improve the delivery and management of care. With more effective care approaches, the quality of life of PLWD in LTC will also improve.Item Open Access Diagnostic accuracy of eHealth literacy measurement tools in older adults: a systematic review(2023-03-29) Huang, Yu Q.; Liu, Laura; Goodarzi, Zahra; Watt, Jennifer A.Abstract Background In Canada, virtual health care rapidly expanded during the COVID-19 pandemic. There is substantial variability between older adults in terms of digital literacy skills, which precludes equitable participation of some older adults in virtual care. Little is known about how to measure older adults’ electronic health (eHealth) literacy, which could help healthcare providers to support older adults in accessing virtual care. Our study objective was to examine the diagnostic accuracy of eHealth literacy tools in older adults. Methods We completed a systematic review examining the validity of eHealth literacy tools compared to a reference standard or another tool. We searched MEDLINE, EMBASE, CENTRAL/CDSR, PsycINFO and grey literature for articles published from inception until January 13, 2021. We included studies where the mean population age was at least 60 years old. Two reviewers independently completed article screening, data abstraction, and risk of bias assessment using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We implemented the PROGRESS-Plus framework to describe the reporting of social determinants of health. Results We identified 14,940 citations and included two studies. Included studies described three methods for assessing eHealth literacy: computer simulation, eHealth Literacy Scale (eHEALS), and Transactional Model of eHealth Literacy (TMeHL). eHEALS correlated moderately with participants’ computer simulation performance (r = 0.34) and TMeHL correlated moderately to highly with eHEALS (r = 0.47–0.66). Using the PROGRESS-Plus framework, we identified shortcomings in the reporting of study participants’ social determinants of health, including social capital and time-dependent relationships. Conclusions We found two tools to support clinicians in identifying older adults’ eHealth literacy. However, given the shortcomings highlighted in the validation of eHealth literacy tools in older adults, future primary research describing the diagnostic accuracy of tools for measuring eHealth literacy in this population and how social determinants of health impact the assessment of eHealth literacy is needed to strengthen tool implementation in clinical practice. Protocol registration We registered our systematic review of the literature a priori with PROSPERO (CRD42021238365).Item Open Access Neuropsychiatric Symptoms and Incident Cognitive Decline and Dementia in Cognitively Normal Older Adults: A Systematic Review and Meta-Analysis(2022-06) Elbayoumi, Heba; Ismail, Zahinoor; Patten, Scott; Goodarzi, Zahra; Bulloch, Andrew; Pringsheim, Tamara MilkaObjective: To determine risks of cognitive decline or dementia in cognitively normal cohorts with neuropsychiatric symptoms (NPS), stratified by mild behavioral impairment (MBI) domains. Methods: A systematic search (MEDLINE, EMBASE, and PSYCINFO) was completed up to January 2022. Pooled hazard ratios (HR) with Standard Error (SE), I2, and tau2 were determined utilizing DerSimonian-Laird random-effects models. Heterogeneity and publication bias were investigated. PRISMA and MOOSE checklists were followed. Results: Of 12,674 screened abstracts, 36 prospective studies representing 326,739 participants were included. Risks (HR) for incident cognitive decline or dementia by MBI domain were: 1) apathy 2.00 (95%CI:1.57-2.57); 2) affect 1.61 (95%CI:1.45-1.80; adjusted 1.44, 95%CI:1.30-1.61); 3) agitation 3.07 (95%CI: 2.15-4.38); 4) social inappropriateness 3.84 (95%CI:1.54-9.55); and 5) psychosis 3.99 (95%CI:3.05-5.23). Heterogeneity was most evident in affect (I2=86.56%, tau2=0.04), with time and NPS ascertainment as the main contributors. Conclusion: Cognitively normal older adults with NPS are at greater risk for mild cognitive impairment and dementia than those without NPS. Risks differ between the 5 MBI domains.Item Open Access Optimizing the diagnosis and management of dementia within primary care: a systematic review of systematic reviews(2021-08-11) Fernandes, Brooklynn; Goodarzi, Zahra; Holroyd-Leduc, JaynaAbstract Background To understand how best to approach dementia care within primary care and its challenges, we examined the evidence related to diagnosing and managing dementia within primary care. Methods Databases searched include: MEDLINE, Embase, PsycINFO and The Cochrane Database of Systematic Reviews from inception to 11 May 2020. English-language systematic reviews, either quantitative or qualitative, were included if they described interventions involving the diagnosis, treatment and/or management of dementia within primary care/family medicine and outcome data was available. The risk of bias was assessed using AMSTAR 2. The review followed PRISMA guidelines and is registered with Open Science Framework. Results Twenty-one articles are included. The Mini-Cog and the MMSE were the most widely studied cognitive screening tools. The Abbreviated Mental Test Score (AMTS) achieved high sensitivity (100 %, 95 % CI: 70-100 %) and specificity (82 %, 95 % CI: 72-90 %) within the shortest amount of time (3.16 to 5 min) within primary care. Five of six studies found that family physicians had an increased likelihood of suspecting dementia after attending an educational seminar. Case management improved behavioural symptoms, while decreasing hospitalization and emergency visits. The primary care educational intervention, Enhancing Alzheimer’s Caregiver Health (Department of Veterans Affairs), was successful at increasing carer ability to manage problem behaviours and improving outcomes for caregivers. Conclusions There are clear tools to help identify cognitive impairment in primary care, but strategies for management require further research. The findings from this systematic review will inform family physicians on how to improve dementia diagnosis and management within their primary care practice.Item Open Access Prevalence and factors associated with polypharmacy: a systematic review and Meta-analysis(2022-07-19) Delara, Mahin; Murray, Lauren; Jafari, Behnaz; Bahji, Anees; Goodarzi, Zahra; Kirkham, Julia; Chowdhury, Zia; Seitz, Dallas P.Abstract Introduction Polypharmacy is commonly associated with adverse health outcomes. There are currently no meta-analyses of the prevalence of polypharmacy or factors associated with polypharmacy. We aimed to estimate the pooled prevalence of polypharmacy and factors associated with polypharmacy in a systematic review and meta-analysis. Methods MEDLINE, EMBASE, and Cochrane databases were searched for studies with no restrictions on date. We included observational studies that reported on the prevalence of polypharmacy among individuals over age 19. Two reviewers extracted study characteristics including polypharmacy definitions, study design, setting, geography, and participant demographics. The risk of bias was assessed using the Newcastle-Ottawa Scales. The main outcome was the prevalence of polypharmacy and factors associated with polypharmacy prevalence. The pooled prevalence estimates of polypharmacy with 95% confidence intervals were determined using random effects meta-analysis. Subgroup analyses were undertaken to evaluate factors associated with polypharmacy such as polypharmacy definitions, study setting, study design and geography. Meta-regression was conducted to assess the associations between polypharmacy prevalence and study year. Results 106 full-text articles were identified. The pooled estimated prevalence of polypharmacy in the 54 studies reporting on polypharmacy in all medication classes was 37% (95% CI: 31-43%). Differences in polypharmacy prevalence were reported for studies using different numerical thresholds, study setting, and publication year. Sex, study geography, study design and geographical location were not associated with differences in polypharmacy prevalence. Discussion Our review highlights that polypharmacy is common particularly among older adults and those in inpatient settings. Clinicians should be aware of populations who have an increased likelihood of experiencing polypharmacy and efforts should be made to review the appropriateness of prescribed medications and occurrence of adverse effects potentially associated with polypharmacy. Conclusions and implications Clinicians should be aware of the common occurrence of polypharmacy and undertake efforts to minimize inappropriate polypharmacy whenever possible.Item Open Access Safety of pharmacologic interventions for neuropsychiatric symptoms in dementia: a systematic review and network meta-analysis(2020-06-16) Watt, Jennifer A; Goodarzi, Zahra; Veroniki, Areti A; Nincic, Vera; Khan, Paul A; Ghassemi, Marco; Thompson, Yuan; Lai, Yonda; Treister, Victoria; Tricco, Andrea C; Straus, Sharon EAbstract Background Prescribing trends suggest that pharmacologic alternatives to antipsychotics are gaining in popularity, but randomized trial (RCT) data of their comparative safety is scarce. Our objective was to describe the comparative safety of pharmacologic interventions for treating neuropsychiatric symptoms in dementia. Methods We searched MEDLINE, EMBASE, CENTRAL, CINAHL, and PsycINFO, from inception to May 28, 2019, for studies of pharmacologic interventions used to treat neuropsychiatric symptoms in dementia. Dementia care partners selected fracture risk as our primary outcome. Pairs of reviewers, working independently, conducted all study screening, data abstraction, and risk of bias appraisal. We conducted Bayesian random-effects network meta-analyses (NMAs) using data from RCTs to derive odds ratios (ORs). In secondary analyses, we conducted frequentist random-effects NMAs using data from RCTs and Bayesian three-level hierarchical random-effects NMAs incorporating data from RCTs and non-randomized studies. Results Our systematic review included 209 randomized and non-randomized studies (889,378 persons with dementia). In NMAs of data from randomized trials, there were no increased odds of fracture associated with any intervention in primary analyses; however, data were sparse. We found increased odds of cerebrovascular events associated with antipsychotics (odds ratio [OR] 2.12, 95% credible interval [CrI] 1.29 to 3.62; number needed to harm [NNH] = 99) and increased odds of falls associated with dextromethorphan-quinidine (OR 4.16, 95% CrI 1.47 to 14.22; NNH = 55) compared to placebo in persons with dementia. In a subgroup of persons with Alzheimer disease, antipsychotics were associated with increased odds of fracture compared to anticonvulsants (OR 54.1, 95% CrI 1.15 to 38,300; NNH = 18). In older persons (mean age ≥ 80 years) with dementia, anticonvulsants were associated with increased odds of death compared to placebo (OR 8.36, 95% CrI 1.17 to 203.4; NNH = 35) and antipsychotics were associated with increased odds of death compared to antidepressants (OR 5.28, 95% CrI 1.06 to 3.51; NNH = 47). Conclusion Although antipsychotics were associated with greater harm than antidepressants and anticonvulsants in subgroups of persons with dementia, medications used in lieu of antipsychotics for treating neuropsychiatric symptoms in dementia, such as anticonvulsants and dextromethorphan-quinidine, were also associated with harm. Decision-making concerning treatments prescribed in lieu of antipsychotics should include potential harms. PROSPERO registration CRD42017050130.Item Open Access Treating Anxiety in Older Adults Living in Long-Term Care(2021-08-10) Atchison, Kayla; Goodarzi, Zahra; Toohey, Ann; Ismail, ZahinoorBackground: We do not know which treatments for anxiety symptoms and disorders are most effective for residents of long-term care (LTC). There is a need to identify evidence-based treatment strategies for anxiety symptoms and disorders, specific to long-term care residents, to reduce additional suffering and improve care for this complex and vulnerable population. Objectives: The research objectives were first to identify which therapies for anxiety symptoms and disorders are efficacious in older adults living in LTC and second to understand what the common barriers and facilitators may be to the detection, diagnosis, and management of anxiety symptoms and disorders in LTC. Methods: First, a systematic review and meta-analysis was completed to identify and evaluate existing treatments for anxiety symptoms and disorders used in the LTC setting. Second, interviews with care providers were completed to explore the perceived barriers and facilitators to detecting, diagnosing, and treating anxiety symptoms and disorders in residents of LTC. Framework analysis methods were used to code the interview data, label each code as a barrier or facilitator, and classify each code within the Theoretical Domains Framework.Results: Various low-risk, readily implemented non-pharmacological treatments, such as therapeutic touch and music therapy, with evidence of benefit for anxiety symptoms in residents of LTC were identified. There was limited evidence supporting the use of pharmacological treatment options for anxiety symptoms and disorders in LTC. Perceived barriers to anxiety symptom and disorder detection, diagnosis, and/or treatment included a lack of available treatments, limited access to mental health professionals, and resident comorbidities. Facilitators such as teamwork, family involvement, and specialized training were also identified.Conclusions: The present research is critical to advancing knowledge on how to best treat anxiety symptoms and disorders in LTC. Treatment options for anxiety symptoms in residents of LTC exist but there is a need to better recognize anxiety symptoms and disorders in residents, provide tailored non-pharmacological treatments to residents, and create an environment within LTC that supports anxiety management.Item Open Access Understanding the Barriers to Guideline Use for Depression & Anxiety in Patients with Parkinson's Disease and Dementia.(2016) Goodarzi, Zahra; Holroyd-Leduc, Jayna M.; Hanson, Heather; Jette, Nathalie; Patten, Scott; Pringsheim, TamaraBackground: Depression or anxiety are under-diagnosed and under-treated in those with dementia or Parkinson’s disease (PD). Objectives: The objectives of this thesis were to first understand what high quality guideline recommendations exist for depression or anxiety in dementia or PD. Secondly to explore the barriers and facilitators to implementing these guidelines. Methods: A systematic review of guidelines was completed, following the PRISMA statement and using the AGREE II tool to assess quality. In focus groups with stakeholders, we assessed the barriers and facilitators to guideline use and implementation. Results: Guideline quality scores were lowest for stakeholder involvement, applicability, and editorial independence. Major barriers to use included a lack of evidence, lack of applicability to the practice population, impractical or out of date recommendations. Conclusions: There are guideline recommendations for depression or anxiety in dementia and PD. However, practitioners have difficulty with implementation due to a lack of evidence and applicability.