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Freedman M, Binns MA, Serediuk F, Wolf MU, Danieli E, Pugh B, Gale D, Abdellah E, Teleg E, Halper M, Masci L, Lee A, Kirstein A. Virtual Behavioral Medicine Program: A Novel Model of Care for Neuropsychiatric Symptoms in Dementia. J Alzheimers Dis 2022; 86:1169-1184. [PMID: 35180119 PMCID: PMC9108590 DOI: 10.3233/jad-215403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with severe neuropsychiatric symptoms (NPS) due to dementia are often uprooted from their familiar environments in long-term care or the community and transferred to emergency departments, acute care hospitals, or specialized behavioral units which can exacerbate NPS. To address this issue, we developed the Virtual Behavioral Medicine Program (VBM), an innovative model of virtual care designed to support management of patients with NPS in their own environment. OBJECTIVE To determine efficacy of VBM in reducing admission to a specialized inpatient neurobehavioral unit for management of NPS. METHODS We reviewed outcomes in the first consecutive 95 patients referred to VBM. Referrals were classified into two groups. In one group, patients were referred to VBM with a simultaneous application to an inpatient Behavioral Neurology Unit (BNU). The other group was referred only to VBM. The primary outcome was reduction in proportion of patients requiring admission to the BNU regardless of whether they were referred to the BNU or to VBM alone. RESULTS For patients referred to VBM plus the BNU, the proportion needing admission to the BNU was reduced by 60.42%. For patients referred to VBM alone, it was 68.75%. CONCLUSION VBM is a novel virtual neurobehavioral unit for treatment of NPS. Although the sample size was relatively small, especially for the VBM group, the data suggest that this program is a game changer that can reduce preventable emergency department visits and acute care hospital admissions. VBM is a scalable model of virtual care that can be adopted worldwide.
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Affiliation(s)
- Morris Freedman
- Department of Medicine (Neurology), Baycrest Health Sciences, Mt. Sinai Hospital, and University of Toronto, Ontario, Canada.,Rotman Research Institute of Baycrest Centre, Toronto, Ontario, Canada
| | - Malcolm A Binns
- Rotman Research Institute of Baycrest Centre, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | | | - M Uri Wolf
- Department of Psychiatry, Baycrest Health Sciences and University of Toronto, Ontario Canada
| | | | - Bradley Pugh
- Rotman Research Institute of Baycrest Centre, Toronto, Ontario, Canada.,Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Deb Gale
- Department of Psychiatry, Baycrest Health Sciences and University of Toronto, Ontario Canada
| | | | - Ericka Teleg
- Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Mindy Halper
- Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Lauren Masci
- Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Adrienne Lee
- Baycrest Health Sciences, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW This article reviews the treatment of aggression and agitation in dementia. Both nonpharmacologic and pharmacologic approaches to responsive behaviors are discussed. Practical treatment strategies are applied to common behavioral symptoms. RECENT FINDINGS Aggressive and agitated behavior is common in dementia. Behavioral symptoms lead to reduced quality of life and distress for both patients and caregivers. They can also lead to poor outcomes and are associated with significant financial implications for the individual and health care system. A wide range of difficult behaviors exists, with limited evidence for deciding on treatment. Clinicians should integrate the available evidence with practical and commonsense strategies to target these difficult-to-treat behaviors. SUMMARY Treating aggression and agitation in dementia is challenging. Viewing behaviors as a response to either internal or external stimuli can help guide treatment. Treatment should emphasize nonpharmacologic approaches as an initial step, using practical and commonsense strategies. Caregivers and family should be actively involved in the planning and implementation of behavioral plans. It is essential to minimize both medical and nonmedical factors that may be contributing to behaviors. When pharmacologic options are required, it is important to choose medications that will target specific behavioral goals, having both practical consideration and the best evidence in mind.
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Freedman M, Leach L, Carmela Tartaglia M, Stokes KA, Goldberg Y, Spring R, Nourhaghighi N, Gee T, Strother SC, Alhaj MO, Borrie M, Darvesh S, Fernandez A, Fischer CE, Fogarty J, Greenberg BD, Gyenes M, Herrmann N, Keren R, Kirstein J, Kumar S, Lam B, Lena S, McAndrews MP, Naglie G, Partridge R, Rajji TK, Reichmann W, Uri Wolf M, Verhoeff NPLG, Waserman JL, Black SE, Tang-Wai DF. Correction to: The Toronto cognitive assessment (TorCA): normative data and validation to detect amnestic mild cognitive impairment. Alzheimers Res Ther 2018; 10:120. [PMID: 30526675 PMCID: PMC6286597 DOI: 10.1186/s13195-018-0446-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Upon publication of this article [1], it was brought to our attention that one of the 303 participants in the normative study should have been deleted from the database.
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Affiliation(s)
- Morris Freedman
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada. .,Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada. .,Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada. .,Toronto Dementia Research Alliance, Toronto, ON, Canada. .,Mt. Sinai Hospital, Toronto, ON, Canada.
| | - Larry Leach
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychology, Glendon College, Toronto, ON, Canada
| | - M Carmela Tartaglia
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Tanz Centre for Research in Neurodegenerative Diseases, Toronto, ON, Canada
| | - Kathryn A Stokes
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Yael Goldberg
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Robyn Spring
- Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada
| | - Nima Nourhaghighi
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada
| | - Tom Gee
- Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada
| | - Stephen C Strother
- Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Mohammad O Alhaj
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Canada International Scientific Exchange Program, Toronto, ON, Canada
| | - Michael Borrie
- Lawson Health Research Institute, London, ON, Canada.,Parkwood Institute, London, ON, Canada
| | - Sultan Darvesh
- Department of Medicine (Neurology and Geriatric Medicine) and Department of Medical Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Alita Fernandez
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Corinne E Fischer
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jennifer Fogarty
- Lawson Health Research Institute, London, ON, Canada.,Parkwood Institute, London, ON, Canada
| | - Barry D Greenberg
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - Michelle Gyenes
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Nathan Herrmann
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Ron Keren
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Josh Kirstein
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Sanjeev Kumar
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Benjamin Lam
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Suvendrini Lena
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Mary Pat McAndrews
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Gary Naglie
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Medicine (Geriatric Medicine) and Institute of Health Policy, University of Toronto, Toronto, ON, Canada
| | - Robert Partridge
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Tarek K Rajji
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Toronto, ON, Canada
| | - William Reichmann
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - M Uri Wolf
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nicolaas P L G Verhoeff
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jordana L Waserman
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Sandra E Black
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,LC Campbell Cognitive Neurology Research Unit, Toronto, ON, Canada
| | - David F Tang-Wai
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada.,Krembil Research Institute, University Health Network, Toronto, ON, Canada
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Freedman M, Leach L, Carmela Tartaglia M, Stokes KA, Goldberg Y, Spring R, Nourhaghighi N, Gee T, Strother SC, Alhaj MO, Borrie M, Darvesh S, Fernandez A, Fischer CE, Fogarty J, Greenberg BD, Gyenes M, Herrmann N, Keren R, Kirstein J, Kumar S, Lam B, Lena S, McAndrews MP, Naglie G, Partridge R, Rajji TK, Reichmann W, Uri Wolf M, Verhoeff NPLG, Waserman JL, Black SE, Tang-Wai DF. The Toronto Cognitive Assessment (TorCA): normative data and validation to detect amnestic mild cognitive impairment. Alzheimers Res Ther 2018; 10:65. [PMID: 30021658 PMCID: PMC6052695 DOI: 10.1186/s13195-018-0382-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/08/2018] [Indexed: 11/10/2022]
Abstract
Background A need exists for easily administered assessment tools to detect mild cognitive changes that are more comprehensive than screening tests but shorter than a neuropsychological battery and that can be administered by physicians, as well as any health care professional or trained assistant in any medical setting. The Toronto Cognitive Assessment (TorCA) was developed to achieve these goals. Methods We obtained normative data on the TorCA (n = 303), determined test reliability, developed an iPad version, and validated the TorCA against neuropsychological assessment for detecting amnestic mild cognitive impairment (aMCI) (n = 50/57, aMCI/normal cognition). For the normative study, healthy volunteers were recruited from the Rotman Research Institute registry. For the validation study, the sample was comprised of participants with aMCI or normal cognition based on neuropsychological assessment. Cognitively normal participants were recruited from both healthy volunteers in the normative study sample and the community. Results The TorCA provides a stable assessment of multiple cognitive domains. The total score correctly classified 79% of participants (sensitivity 80%; specificity 79%). In an exploratory logistic regression analysis, indices of Immediate Verbal Recall, Delayed Verbal and Visual Recall, Visuospatial Function, and Working Memory/Attention/Executive Control, a subset of the domains assessed by the TorCA, correctly classified 92% of participants (sensitivity 92%; specificity 91%). Paper and iPad version scores were equivalent. Conclusions The TorCA can improve resource utilization by identifying patients with aMCI who may not require more resource-intensive neuropsychological assessment. Future studies will focus on cross-validating the TorCA for aMCI, and validation for disorders other than aMCI.
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Affiliation(s)
- Morris Freedman
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada. .,Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada. .,Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada. .,Toronto Dementia Research Alliance, Toronto, ON, Canada. .,Mt. Sinai Hospital, Toronto, ON, Canada.
| | - Larry Leach
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychology, Glendon College, Toronto, ON, Canada
| | - M Carmela Tartaglia
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Tanz Centre for Research in Neurodegenerative Diseases, Toronto, ON, Canada
| | - Kathryn A Stokes
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Yael Goldberg
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Robyn Spring
- Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada
| | - Nima Nourhaghighi
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada
| | - Tom Gee
- Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada
| | - Stephen C Strother
- Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Mohammad O Alhaj
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Canada International Scientific Exchange Program, Toronto, ON, Canada
| | - Michael Borrie
- Lawson Health Research Institute, London, ON, Canada.,Parkwood Institute, London, ON, Canada
| | - Sultan Darvesh
- Department of Medicine (Neurology and Geriatric Medicine) and Department of Medical Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Alita Fernandez
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Corinne E Fischer
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jennifer Fogarty
- Lawson Health Research Institute, London, ON, Canada.,Parkwood Institute, London, ON, Canada
| | - Barry D Greenberg
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - Michelle Gyenes
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Nathan Herrmann
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Ron Keren
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Josh Kirstein
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Sanjeev Kumar
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Benjamin Lam
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Suvendrini Lena
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Mary Pat McAndrews
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Gary Naglie
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Rotman Research Institute of Baycrest Centre, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Medicine (Geriatric Medicine) and Institute of Health Policy, University of Toronto, Toronto, ON, Canada
| | - Robert Partridge
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Tarek K Rajji
- Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Toronto, ON, Canada
| | - William Reichmann
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - M Uri Wolf
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nicolaas P L G Verhoeff
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jordana L Waserman
- Baycrest Health Sciences, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Sandra E Black
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,LC Campbell Cognitive Neurology Research Unit, Toronto, ON, Canada
| | - David F Tang-Wai
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.,Toronto Dementia Research Alliance, Toronto, ON, Canada.,Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada.,Krembil Research Institute, University Health Network, Toronto, ON, Canada
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