Quarterly Newsletter For Health Care Providers

Happy June! It has been a busy and exciting Spring for our team, and we are thrilled to share a few announcements.

NEW CLINIC LOCATION

Plum Tree Memory Care has officially opened a second location in Oakville, Ontario and we are accepting new patient referrals for memory assessments!

• Location:
  231 Oak Park Blvd Unit 110, Oakville, ON L6H 758

• Eligibility:
  Any individual with a physician or nurse practitioner referral. Must be able to attend in-person appointments.

• OCEAN e-Referrals:
  Now live! Contact us if you wish to receive the referral package via email.

MINT MODEL EXPANSION

22 new MINT clinics have been trained across the country! This spring new MINT Clinics went live in Saskatchewan (2), New Brunswick (3), and Nova Scotia (3).

We even provided in-person training sessions to several physicians and allied health professionals in the Yukon! Our team was disappointed we missed the Northern Lights, only to find out all we had to do was step out on our Kitchener-Waterloo patios in May! 

NEW TRIAL NEWSLETTER FORMAT

We’re trying something new! This newsletter will not require a download and is more succinct than our recent editions. We would love to hear from you about this change, so please let us know what you think and continue to provide us with feedback and suggestions on topics of interest for future newsletters.

To get in touch with us, please send an email to support@plumtreememory.ca.

WHAT IS NEW IN DEMENTIA CARE?

Meta-analysis Finds no Increased Risk of CV event, Seizure, or Syncope with Donepezil.1

We receive a lot of questions regarding the safety of using cholinesterase inhibitors in individuals with dementia. Refer to our March 2023 Newsletter for our practical checklist when considering a cholinesterase inhibitor. A new meta-analysis looking at donepezil should bring you further comfort. Here is a brief summary:  

• Consists of 60 RCTs (n = 12,463), 25 of which included Alzheimer’s Dementia. Generally reflective of Canadian population with 26/60 RCTs conducted in North America.  

• Donepezil did not increase risk of MACE (all-cause mortality, sudden cardiac death, non-fatal cardiac arrest, Torsades de Pointes, ventricular tachycardia or fibrillation) compared to placebo:

• Overall MACE: RR 1.08 (0.88-1.33) 

• Mortality: RR 1.03 (0.81-1.31) 

• Seizure: RR 0.98 (0.61-1.57) 

• Syncope: RR 1.21 (0.82-1.77) 

*Note: A few important points to consider: 

• Quality of data was considered low for mortality, syncope, or seizures with downgrades in quality due to risk of bias identified in RCTs. 

• No sudden cardiac death, non-fatal cardiac arrest, TdP, or ventricular tachyarrhythmias events were documented. 

• There were no significant differences in pre-specified subgroup analyses (age, follow-up time, QT assessment at baseline and presence of cardiac comorbidities).  

• 25 of the trials excluded participants with cardiovascular conditions (uncontrolled hypertension, uncontrolled atrial fibrillation, ongoing angina or heart failure, significant CV disease and/or QT interval >460ms), therefore continue to use caution and monitor these individuals closely.  

Bottom line: A baseline ECG should still be available prior to starting a cholinesterase inhibitor (especially in those with cardiovascular risks) to rule out any contraindications (2nd/3rd AV block, LBBB, etc.). Based on this study’s findings donepezil may be considered in individuals with cardiovascular risk factors, syncope, or history of seizures. Continue to monitor heart rate and PR interval. Donepezil is the only cholinesterase inhibitor classified as a “known risk” for QT prolongation, but it does not appear to increase risk of MACE or TdP. Other cholinesterase inhibitors are unlikely to cause significant QT prolongation.2 

Methylphenidate for Apathy? 

Behavioral and psychological symptoms of dementia (BPSD) affect most individuals with dementia at some point in the disease process.3 This may include, but not limited to, depression, sleep disturbances, or aggression. Many of these symptoms typically respond well to medications, however apathy is challenging. The prevalence of apathy varies significantly in the literature, but studies suggest it impacts up to 26-82% of those with Alzheimer’s Dementia (AD), 29-92% of vascular dementia (VaD), 29-98% for Parkinson’s Disease Dementia (PDD), and 55-88% for frontotemporal dementia (FTD).4 

A recent Tools for Practice Continuing Education Module published by CFPC Learn has garnered attention and renewed interest/questions related to methylphenidate use for the treatment of apathy.5  

• A systematic review (4 RCTs, 346 patients) found minimal, but statistically significant improvement in apathy (6-point improvement on 72-point apathy scale vs. 1 point (placebo) within 12 weeks.6 (Note a 3-point change is considered clinically significant) 

• One small RCT (n=100) found a small, but statistically significant improvement in apathy (-1.25; 95% CI, -2.03 to -0.47; P = .002) based on the 12-item Neuropsychiatric Inventory (NPI), but it had no impact on quality of life and cognitive measures.7  

• Other pharmacologic options: no significant improvement in apathy with antidepressants (including bupropion) and antipsychotics.8-9 Antipsychotics have no role in treating apathy as they provide no benefit and may worsen symptoms.9 

• Non-pharmacologic approach: sensory stimulation (eg. music therapy) and pet therapy may provide benefit based on low-quality evidence.10 Learn more about this from a certified music therapist below. 

Bottom line: Methylphenidate 10mg twice daily is unlikely to provide significant benefit (5-point improvement on a 72-point scale compared to placebo, no significant change on a 12-point apathy scale) after ~12 weeks.6-7 It does not improve cognition (based on MMSE scores) and is associated with increased risk of weight loss, behavioral changes (irritability, aggression), insomnia and cardiovascular harms.11 

Anticoagulation in Older Adults with Atrial Fibrillation (AF) and Frailty

The FRAIL-AF RCT evaluated the safety and efficacy of switching from warfarin to direct oral anticoagulant (DOAC) therapy in frail elderly patients with atrial fibrillation.12 

Key Points:

1. Population: frail older patients (≥75 years of age plus a Groningen Frailty Indicator score ≥3) with a diagnosis of AF on warfarin therapy
   -Excluded: eGFR <30 mL/min/1.73m2, valvular AF 

2. Intervention: switch to any DOAC 

3. Comparison: continue warfarin 

4. Outcomes: (Follow-up 12 months) 

• Primary: Significant increase in major or clinically relevant non-major (CRNM) bleeding hazard ratio (HR) 1.69 (95% CI, 1.23–2.32) 

  -Note: primary outcome driven by CRNM bleeding (HR 1.77, 95% CI 1.24-2.52) vs. major bleeding (HR 1.52, 95% CI 0.81-2.87). Numerically, more gastrointestinal, and urogenital bleeding events were observed in the DOAC arm.  

• Secondary: No significant difference in all-cause thromboembolic events (ischemic stroke, transient ischemic attack, peripheral arterial thromboembolism) HR 1.26 (95% CI, 0.60–2.61) 

  -Note: After 102 participants had already been included, the INR threshold was reduced to <1.3 before switching from warfarin to a DOAC due to early concerns of elevated bleed risk.  

Bottom line: Switching frail older adults with nonvalvular AF from warfarin to a DOAC was associated with more bleeding complications. Although the study was not powered to demonstrate differences in effectiveness, there was no clear signal towards improved thromboembolic benefit in switching to a DOAC in this population.  

Improving Medication Non-Adherence 

The initial plan was to review the Livi Smart Medication Dispenser®. Unfortunately, it has come to our attention that this device is not available in Canada. Instead, we wanted to share a recent experience where Plum Tree’s Medication Reminder Service made a significant impact for not only our patient, but their care partner as well.

Plum Tree’s Medication Reminder Service is a personalized, customizable, and automated phone call service that reminds individuals to take their medications as prescribed. Managed by a pharmacist, it ensures medications are taken at the appropriate time and has no limits on the number of calls per day according to the individual’s schedule. 

Nancy is an older person with early Alzheimer’s Dementia. She continues to live alone and manages well with appropriate supports in place, except for medications. The family is now considering transitioning Nancy to a nursing home as medication adherence is becoming a problem. Upon review, we noticed her medications are currently taken four times daily in a blister pack. The daughter, who lives one hour away, reports having to call four to five times every day to ensure her mom has taken her medications. When she visits, she notices many of the blister pack slots still have pills in them.   

 What did we do? 

1. Medications did not have to be taken four times daily. Our pharmacist reviewed her nine medications and noticed all but two were once daily medications that did not interact with each other.

2. Two medications were twice daily (a beta-blocker and metformin). We switched these to once daily alternatives.  

3. All medications were moved to once daily in the morning.  

4. The Plum Tree Medication Reminder Service was initiated every morning at 9am with the waterfall add-on option (daughter receives call if mom does not answer initial phone call or the second attempt 5 minutes later). 

What happened?

“Implementing Plum Tree’s Medication Reminder Service has taken such a load off me and significantly reduced my anxiety regarding my mom. She is now taking her medications every morning and I don’t have to worry about bugging her 4-5 times every day. This service allows us to keep mom at home safely for longer, which is what she wants. The most amazing part of this is I now get to call mom and simply chat with her to see how she is doing as opposed to nagging her about her medications. This service has made such a positive impact on our day-to-day life”. -Quote from care partner.

Interested in Plum Tree’s Medication Reminder Service?
Contact us to get started.
$20/month + tax. Free one month trial.

Music Therapy for Apathy

*Patient details have been altered for privacy reasons.

For many of us, music has a presence in a variety of forms over our lifetimes. Whether we are listening to music in times of joy, sadness, camaraderie, or tranquility, we build both positive and negative connections to music during our various lived experiences. The beauty of music is that it continues to move us irrespective of changes to our memory and cognition. Thus, when other forms of communication fail, music continues to find its way into our soul and speak to us, when spoken words may not. Here enters the profession of music therapy and the therapeutic use of music. Melissa Jessop, a local certified music therapist who has been practicing for close to 30 years, has seen the incredible impact music can have in clinical practice. 

There is a worldwide, time honored, universal appeal to music.  Musical tastes are unique to each person and vary by generation, genre, past exposure to music, and the undefinable personal preferences that speak to our inner selves. Music therapy is a relatively new health care profession, however the use of music to heal and inspire is not. Music therapy uses the magic of melody, harmony, rhythm, and instrumentation to provide cognitive, mental, and physical health stimulation and healing. Music bonds people to one another. Music therapy is used to facilitate relationships between people. For example, Melissa recounts multiple examples of nursing home residents, long reticent to engaging with staff or residents, who were pulled by the joy of music, into interaction and relationships. 

Therapeutic use of music is the essence of music itself, unknowingly used by persons around the world daily, to have an impact on a spectrum of emotions. It can be as simple as turning on your car radio after a day of work or playing a favorite opera, to a resident adjusting to transition to a nursing home. In an article for ‘Practical Neurology’, Dr. Ronald Devere notes that in those living with dementia, music can improve mood and behavior, the benefits of which can persist for hours and days after the music stops.13 Even when one’s ability to communicate has reduced, listening to familiar music can elicit pleasurable responses such as smiling or moving and dancing.14 Singing has also been shown to improve behavior, mood, and cognitive function in some dementia cases.15

This leads to the question, how can we use music to support those living with memory changes and BPSD? Music therapists should be working alongside other health professionals on care teams to ensure equitable access to meaningful, creative, musical experiences as part of an individual's overall health plan to address quality of life. There is so much potential in people if only given the opportunity.16 

An example shared by Melissa was of a person residing in a secure unit in long-term care. This individual, who went by Oz*, was quite apathetic and spent much of his time in bed. The family had shared that he had played guitar in a band for 50 years but unfortunately as his dementia progressed, he was no longer able to play, and they had sold his guitar. As Melissa recounts, “when there is a current or previous passion for music, a referral is often sent to me to connect with these new residents. When I entered his room, I noticed posters of his band proudly on display. Having a spare guitar on site, I invited Oz to play. He initially declined the offer but after a few visits agreed to participate. He not only could still play, but he could play well! We began playing weekly for others in the home and with each session he would come to life.”

 Melissa further shared that music therapists are often underutilized due to a lack of understanding of what they do, but there are many unexpected ways in which music therapy can have an impact. In fact, her greatest successes often come from those individuals with the greatest challenges. She shared the story of a person who consistently refused a bath. “Medications and traditional approaches were ineffective, but by introducing music therapy during this care routine, I was able to build a relationship with the patient and engage in music therapy while the care team successfully assisted with his bath. Thus, the bath routine became a pleasure experience.”

Music is such an integral part of our life and music therapy recognizes the immeasurable benefits to our life irrespective of our cognitive or physical abilities. Music therapy or the use of music therapeutically is not just isolated to those with a musical past but can be beneficial to all. Sometimes the best prescription is ‘The Sound Of Music’. 

If you reside in Canada and want to learn more or connect with a certified music therapist, please visit: http://www.musictherapy.ca/ 

References 

Meta-analysis Finds no Increased Risk of CV event, Seizure, or Syncope with Donepezil 
1. Nham T, Garcia MC, Tsang KJ, et al. Proarrhythmic major adverse cardiac events with donepezil: A systematic review with meta-analysis. J Am Geriatr Soc. 2024 Apr 5. 
2. Isik AT, Soysal P, Stubbs B, et al. Cardiovascular outcomes of cholinesterase inhibitors in individuals with dementia: a meta-analysis and systematic review. J Am Geriatr Soc. 2018;66(9):1805-1811.  

Methylphenidate for Apathy? 
3. Cloak N, Schoo C, Al Khalili Y. Behavioral and Psychological Symptoms in Dementia. 2024 Feb 27.
4. Parrotta I, Cacciatore S, D'Andrea F, et al. Prevalence, treatment, and neural correlates of apathy in different forms of dementia: a narrative review. Neurol Sci. 2024 Apr;45(4):1343-1376 
5. Baloun W, LeDrew B, Potter J, Falk J. #63 Making a difference for indifference? Medications for apathy in dementia. CFPC Learn. April 12, 2024. 
6. Lee C, Chen J, Ko C, et al. Psychopharmacology (Berl). 2022 Dec; 239(12):3743-3753. Epub 2022 Oct 15.  
7. Mintzer J, Lanctôt KL, Scherer RW, et al. Effect of Methylphenidate on Apathy in Patients With Alzheimer Disease: The ADMET 2 Randomized Clinical Trial. JAMA Neurol. 2021 Nov 1;78(11):1324-1332.  
8. Dean RL, Ruthirakuhan M, Herrmann N, et al. Cochrane Database Syst Rev. 2018 May; 5(5):CD012197. |
9. Ruthirakuhan MT, Herrmann N, Abraham EH, Chan S, Lanctôt KL. Pharmacological interventions for apathy in Alzheimer's disease. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD012197.  
10. Cai Y, Li L, Xu C, et al. Worldviews Evid Based Nurs. 2020 Aug; 17(4):311-318. 
11. Sassi KLM, Rocha NP, Colpo GD, et al. Curr Neuropharmacol. 2020; 18(2):126-135.

Anticoagulation in Older Adults with Atrial Fibrillation (AF) and Frailty 
12. Joosten LPT, van Doorn S, van de Ven PM, et al. Safety of Switching From a Vitamin K Antagonist to a Non-Vitamin K Antagonist Oral Anticoagulant in Frail Older Patients With Atrial Fibrillation: Results of the FRAIL-AF Randomized Controlled Trial. Circulation. 2024 Jan 23;149(4):279-289.  

Music Therapy for Apathy 
13. Devere, R. Music and Dementia: An Overview. Practical Neurology. June 2017.  

14. Cuddy LL., Duffin J, et al. Music Memory and Alzheimer’s Disease: Is music recognition spared in Dementia and How can it be assessed. Med. Hypothesis 2005, 64, 229-235 

15. Narme P, Clement S, et al. Efficacy of Music Intervention in Dementia, evidence from a randomized control study. Journal Alzheimer’s Disease 2014, 38, 359-3694. 

16. Jessop, Melissa. MMT, RP, MTA. Personal communication – May 2024.  

Thank you for reading!