The CCSMH is proud to have been able to facilitate the development of these clinical guidelines. These are the first interdisciplinary, national best practices guidelines to specifically address key areas in seniors' mental health. These guidelines were written by and for interdisciplinary teams of health care professionals from across Canada. The aim of these guidelines is to improve the assessment, treatment, management and prevention of key mental health issues for seniors, through the provision of evidence-based recommendations. The recommendations are based on the best available evidence at the time of publication and, when necessary, supplemented by the consensus opinion of the guideline development group. AIMS OF GUIDELINE UPDATE: Guideline Updates summarize significant developments in the practice since the publication of the original guidelines in 2006. Guideline Updates are authored and reviewed by experts associated with the original guideline development project. Please refer to the original guideline, found on our website at www.ccsmh.ca, for more detailed information regarding the specific practice recommendations. DISCLAIMER: This publication is intended for information purposes only, and is not intended to be interpreted or used as a standard of medical practice. Best efforts were used to ensure that the information in this publication is accurate; however the publisher and every person involved in the creation of this publication disclaim any warranty as to the accuracy, completeness or value of the contents of this publication. This publication is distributed with the understanding that neither the publisher nor any person involved in the creation of this publication is rendering professional advice. Physicians and other readers must determine the appropriate clinical care for each individual patient on the basis of all the clinical data available for the individual case. The publisher and every person involved in the creation of this publication disclaim any liability arising from contract, negligence, or any other cause of action, to any party, for the publication contents or any consequences arising from its use.#
Since the publication of the 2006 Canadian Coalition for Seniors' Mental Health (CCSMH) guidelines on the Assessment and Treatment of Mental Health Issues in Long Term Care: (A Focus on Mood and Behaviours) much of the more recent literature is consistent with or enhances the recommendations made in 2006. This update focuses on the discussions and recommendations from the 2006 Guidelines related to assessment, psychological and social interventions, pharmacological interventions and organizational issues in long term care (LTC). It also includes two modified and one new recommendation summarized below.

# Summary of Modified Recommendations
For easy reference, all modified or additional recommendations are presented together with the page numbers for the original guideline recommendations at the beginning of this update. Subsequently, in each section we present the recommendation with a discussion of the relevant literature since the original publication in 2006. We strongly encourage readers to refer to the original 2006 guidelines and the discussion below, rather than only using the summary of modified recommendations.
The search terms used were the same as for the 2006 Guidelines. The database search included Medline, Embase and PsychINFO and was restricted to English papers published between July 2005 and June 2014.
A total of 411 papers were identified. One of the authors reviewed the titles and abstracts of these papers in order to select which should undergo a full-text review. Controlled trials (especially randomized), meta-analyses, reviews (especially systematic), and practice guidelines potentially relevant to the subject area were selected. Eighty-nine of the 411 papers identified in the literature search were selected for full-text review. The authors identified additional relevant papers of which they were aware. Based on this full-text review of identified papers, two modified and one new recommendations were developed by the authors.

# Part 3: Assessment of Mental Health Problems and Mental Disorders: Discussion
Several reviews (Bruhl, Luijendijk & Muller 2007;Kallenbach & Rigler 2006;Onega 2006) published in the mid-2000s draw conclusions that are consistent with the assessment recommendations for screening, detailed investigation, and ongoing evaluation in the CCSMH Long Term Care guideline. Reviews:
- support regular mental health screening (including within the early admission phase)
- underscore the value of using screening scales to improve detection of depressive symptoms by nurses
- attest to the importance of considering all contributing factors (e.g., comorbid medical conditions) when identifying and interpreting mood and behavior
- advocate for use of a logical and consistent process for connecting assessment findings with intervention. - improving communication between staff and residents;
- identifying unmet needs;
- understanding, recognizing and responding to mood and behavioral concerns in the LTC setting;
- increasing familiarity with practical intervention strategies such as therapeutic communication and pleasant activity scheduling; and
- enhancing capacity to cope with the stresses of difficult behavior (in recognition of the interrelationship between quality of workplace environment and resident behaviors).
In order to more efficiently direct limited resources, it will be necessary to better  (Boyce et al. 2012). The authors concluded that the limited amount of evidence suggests that depressed nursing home residents have a modest response to antidepressant medication. It is worth noting that the only two placebo-controlled randomized trials were both negative. There have also been recent meta-analyses casting some doubt regarding the effectiveness of antidepressants in milder forms of depression (Fournier et al. 2010). Escitalopram and duloxetine will be added to the list of appropriate first-line antidepressants (page 30). Duloxetine may have an additional benefit for patients with chronic pain syndromes (Gaynor et al. 2011). Clinicians should be aware that concern has been raised about use of higher dosages of citalopram (above 20mg per day) and escitalopram (above 10mg per day) in older adults due to possible prolongation of the QTc interval.
Some new evidence provides additional support for the use of psychostimulants (e.g., methylphenidate) for the treatment of apathy associated with Alzheimer Disease (Herrmann et al. 2008;Rosenberg et al. 2013), supporting the original recommendation (Conn et al. 2006: 31).

# Part 5: Treatment of Behavioural Symptoms
There have been no major advances in the pharmacological treatment of behavioural symptoms over the past seven years that would warrant significant changes to the 2006 recommendations. We continue to emphasize the need to rule out underlying medical problems (e.g. delirium, pain, drug toxicity) and the need to use psychosocial interventions prior to using medication. We also emphasize the need to carefully weigh the potential benefits of pharmacological intervention versus the potential for harm. There continues to be concern about over-prescribing of psychotropic medication (especially antipsychotics) for people with dementia.
In some countries, such as, the United Kingdom, national targets have been set for reduced usage (Banerjee 2009), with recent evidence that significant reductions have taken place (Martinez et al. 2013).
We continue to believe that for some individuals, atypical antipsychotic medication can be of benefit. The best evidence in terms of pharmacological intervention for aggression and psychosis remains for this group of medication (Seitz et al. 2013). Nevertheless, concerns about increased rates of death and cerebrovascular events, as well as other adverse effects, underline the need for fully informed consent prior to initiation of treatment. As stated in the 2006 Guidelines, antipsychotics should be used only if there is marked risk, disability or suffering associated with the symptoms. The CCSMH has recently produced a pocket tool to assist clinicians in the pharmacological treatment of behavioural symptoms of dementia (Seitz et al. 2012, available at www.ccsmh.ca).
There is some evidence that selective serotonin reuptake inhibitors (SSRIscitalopram and sertraline) can reduce agitation associated with dementia (Seitz et al 2011). Clinicians may therefore prefer to initially prescribe an SSRI, as serious adverse effects appear to be less likely than with antipsychotics. That being said, a recent study reported that even at low doses, SSRIs are associated with increased risk of an injurious fall in residents with dementia, and higher dosages are associated with greater risk (Sterke et al. 2012). The evidence with respect to trazodone for the treatment of agitation remains relatively weak.
The evidence regarding the possible benefits of cholinesterase inhibitors for behavioural symptoms is relatively weak, with only one existing randomized placebo-controlled trial for which the primary outcome measure was behavior (Howard et al. 2007). In this trial, donepezil was no more effective than placebo. In a recent systematic review of 14 studies that examined the effect of cholinesterase inhibitors in BPSD (13 as a secondary outcome), 11 found no significant reduction in behavioural symptoms compared to placebo (Rodda et al. 2009). The evidence with respect to possible benefits of memantine is also weak (Maidment et al. 2008), although there is some evidence that memantine might delay the emergence of behavioural symptoms (Wilcock et al. 2008).  (Alldred et al. 2013). Medication review, multidisciplinary caseconferencing, education of staff, and use of clinical decision support technology were variably utilized. The authors concluded that the interventions led to the identification and resolution of medication-related problems, however evidence of an effect on resident-related outcomes was not established. A third Cochrane review focused on evidence for withdrawal versus continuation of antipsychotic medication in this population (Declercq et al. 2013). Nine studies were included in the review. The authors concluded that many individuals can be withdrawn from chronic antipsychotic medication without detrimental effects on their behaviour. However, two studies of people whose agitation or psychosis had previously responded well to antipsychotic medication found an increased risk of relapse or shorter time to relapse after discontinuation. Two other studies reported that people with more severe symptoms at baseline could benefit from continuing antipsychotic medication. This suggests that clinicians should be especially cautious when withdrawing antipsychotic medication from this group of residents. These studies led to the addition of one additional recommendation related to optimal prescribing of psychotropic medications in LTC.
Added Recommendation: Organizational Issues (page 39-41)
Long Term Care Home staff should develop Quality Improvement initiatives focused on how to optimize prescribing of psychotropic medication.

# ABOUT CCSMH MISSION:
To promote the mental health of seniors by connecting people, ideas and resources.
VALUE STATEMENT: Mental illness is not a normal part of aging. All seniors have the right and deserve to receive services and care that promotes their mental health and responds to their mental illness needs.
PRINCIPLES: Our actions and decisions are guided by: