One Size Does Not Fit All: Choosing Practical Cognitive Screening Tools for Your Practice.

Every year, millions of patients worldwide undergo cognitive testing. Unfortunately, new barriers to the use of free open access cognitive screening tools have arisen over time, making accessibility of tools unstable. This article is in follow-up to an editorial discussing alternative cognitive screening tools for those who cannot afford the costs of the Mini-Mental State Examination and Montreal Cognitive Assessment (see www.dementiascreen.ca). The current article outlines an emerging disruptive "free-to-fee" cycle where free open access cognitive screening tools are integrated into clinical practice and guidelines, where fees are then levied for the use of the tools, resulting in clinicians moving on to other tools. This article provides recommendations on means to break this cycle, including the development of tool kits of valid cognitive screening tools that authors have contracted not to charge for (i.e., have agreed to keep free open access). The PRACTICAL.1 Criteria (PRACTIcing Clinician Accessibility and Logistical Criteria Version 1) are introduced to help clinicians select from validated cognitive screening tools, considering barriers and facilitators, such as whether the cognitive screening tools are easy to score and free of cost. It is suggested that future systematic reviews embed the PRACTICAL.1 criteria, or refined future versions, as part of the standard of review. Methodological issues, the need for open access training to insure proper use of cognitive screening tools, and the need to anticipate growing ethnolinguistic diversity by developing tools that are less sensitive to educational, cultural, and linguistic bias are discussed in this opinion piece. J Am Geriatr Soc 68:2207-2213, 2020.

Key Lessons Learned in the Strategic Implementation of the Primary Care Collaborative Memory Clinic Model: A Tale of Two Regions.

BACKGROUND: Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario. METHODS: Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation. RESULTS: The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period. CONCLUSIONS: Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.

Key Lessons Learned in the Strategic Implementation of the Primary Care Collaborative Memory Clinic Model: A Tale of Two Regions.

Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario. Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation. The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period. Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.

Frailty: Identifying elderly patients at high risk of poor outcomes.

OBJECTIVE: To help family physicians better recognize frailty and its implications for managing elderly patients. SOURCES OF INFORMATION: PubMed-MEDLINE was searched from 1990 to 2013. The search was restricted to English-language articles using the following groups of MeSH headings and key words: frail elderly, frail, frailty; aged, geriatrics, geriatric assessment, health services for the aged; and primary health care, community health services, and family practice. MAIN MESSAGE: Frailty is common, particularly in elderly persons with complex chronic conditions such as heart failure and chronic obstructive pulmonary disease. Emerging evidence demonstrates the value of frailty as a predictor of adverse outcomes in older persons. While there is currently a lack of consensus as to how best to assess and diagnose frailty in primary care practice, individual markers of frailty such as low gait speed offer a promising feasible means of screening for frailty. Identification of frailty in primary care might provide an opportunity to delay the progression of frailty through proactive interventions such as exercise, and awareness of frailty can guide appropriate counseling and anticipatory preventive measures for patients when considering medical interventions. Recognition of frailty might also help identify and optimize the management of coexisting conditions that might contribute to or be affected by frailty. Further research should be directed at identifying feasible and effective ways to appropriately assess and manage these vulnerable patients at the primary care level. CONCLUSION: Despite its importance, little attention has been given to the concept of frailty in family medicine. Frailty is easily overlooked because its manifestations can be subtle, slowly progressive, and thus dismissed as normal aging; and physician training has been focused on specific medical diseases rather than overall vulnerability. For primary care physicians, recognition of frailty might help them provide appropriate counseling to patients and family members about the risks of medical interventions.

Geriatric medicine leadership of health care transformation: to be or not to be?

Geriatric Medicine is well-suited to inform and lead health-care system redesign to address the needs of seniors with complex conditions. We posit that geriatricians must urgently consider how to "brand" Geriatric Medicine in a manner that garners active support from those outside the specialty, including how to adapt practice patterns to better meet the needs of patients and of the health-care system.

The Canadian Safe Driving Study-Phase I pilot: Examining potential logistical barriers to the full cohort study.

Multiple organizations and task forces have called for a reliable and valid method to identify older drivers who are medically unfit to drive. The development of a clinical decision rule for this type of screening requires data from a longitudinal prospective cohort of older drivers. The aim of this article is to identify potential design, sampling and data collection barriers to such studies based on an analysis of the Canadian Safe Driving Study-phase I pilot (Candrive I). A convenience sample of 100 active older drivers aged 70 years or more was recruited through the aid of a seniors' organization, 94 of whom completed the full study (retention rate 94%). Data were collected over the course of 1 year on various driving behaviours, as well as on cognitive, physical and mental functioning. Driving patterns were recorded using driving diaries, logs and electronic devices. Driving records from the Ministry of Transportation of Ontario (MTO) were obtained for the 3-year period preceding the study initiation and up to 1 year following study completion. An increased burden of illness was observed as the number of medical diagnoses and medication use increased over the study period. Study participants were involved in a total of five motor vehicle collisions identified through MTO records, which was comparable to the Ontario annual collision rate of 4.1% for drivers aged 75 years or older. In sum, many of the relevant logistical and practical barriers to studying a large sample of older drivers longitudinally have been shown to be addressable, supporting the feasibility of completing a large prospective cohort study of older drivers.

A review of barriers and enablers to diagnosis and management of persons with dementia in primary care.

BACKGROUND: With the rise in the prevalence of dementia disorders and the growing critical impact of dementia on health-care resources, the provision of dementia care has increasingly come under scrutiny, with primary care physicians (PCP) being at the centre of such attention. PURPOSE: To critically examine barriers and enablers to timely diagnosis and optimal management of community living persons with dementia (PWD) in primary care. METHODS: An interpretive scoping review was used to synthesize and analyze an extensive body of heterogeneous Western literature published over the past decade. RESULTS: The current primary care systems in many Western countries, including Canada, face many challenges in providing responsive, comprehensive, safe, and cost-effective dementia care. This paper has identified a multitude of highly inter-related obstacles to optimal primary dementia care, including challenges related to: a) the complex biomedical, psychosocial, and ethical nature of the condition; b) the gaps in knowledge, skills, attitudes, and resources of PWD/caregivers and their primary care providers; and c) the broader systemic and structural barriers negatively affecting the context of dementia care. CONCLUSIONS: Further progress will require a coordinated campaign and significantly increased levels of commitment and effort, which should be ideally orchestrated by national dementia strategies focusing on the barriers and enablers identified in this paper.

Safety and predictors of adherence of a new rehabilitation program for older women with congestive heart failure.

OBJECTIVES: To assess the safety of a cardiac rehabilitation program for older women with Congestive Heart Failure (CHF) and determine if certain factors influence adherence. METHODS: Women over the age of 65 with CHF attended an exercise program supervised by a physiotherapist. Quality of life was measured by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and severity of disease by the New York Heart Association (NYHA) Class. Subjects were classified into those who attended 90% or more of the sessions and those who attended less than 90% of the sessions. RESULTS: Fifty-one subjects were studied. Eight subjects did not attend any sessions. Of the 43 attendees, the average percentage of sessions attended was 87%. There were no significant differences between the two groups in age, MLHFQ or NYHA Class. There was only one adverse event out of 280 participant attendances. CONCLUSIONS: The program had a high level of adherence in this population. Age, MLHFQ or NYHA Class did not impact on session attendance. Our data suggests this program is safe for this population. Further research is needed to determine other predictors of attendance and the examination of safety issues and long-term adherence to exercise in this population.

Approach to assessing fitness to drive in patients with cardiac and cognitive conditions.

OBJECTIVE: To help physicians become more comfortable assessing the fitness to drive of patients with complex cardiac and cognitive conditions. QUALITY OF EVIDENCE: The approach described is based on the authors' clinical practices, recommendations from the Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia, and guidelines from the 2003 Canadian Cardiovascular Society Consensus Conference. MAIN MESSAGE: When assessing fitness to drive in patients with multiple, complex health problems, physicians should divide conditions that might affect driving into acute intermittent (ie, not usually present on examination) and chronic persistent (ie, always present on examination) medical conditions. Physicians should address acute intermittent conditions first, to allow time for recovery from chronic persistent features that might be reversible. Decisions regarding fitness to drive in acute intermittent disorders are based on probability of recurrence; decisions in chronic persistent disorders are based on functional assessment. CONCLUSION: Assessing fitness to drive is challenging at the best of times. When patients have multiple comorbidities, assessment becomes even more difficult. This article provides clinicians with systematic approaches to work through such complex cases.

Meanings, functions, and experiences of living at home for individuals with dementia at the critical point of relocation.

The sociophysical home environment is an integral component of everyday coping, self-identity, and well-being for individuals with dementia; however, residential discontinuity is a common experience for many of these individuals. This article examined the meanings, functions, and experiences associated with living at home for individuals with dementia at the critical point of relocation to a residential care facility. Qualitative research methods were used to analyze in-depth interviews with 16 individuals with dementia at their homes within 2 months prior to relocation. At the time of relocation, living at home had become a paradoxical experience for most participants. The findings inform practice and policy interventions at both individual and societal levels to help individuals with dementia age in place for as long as possible and to maximize their efforts to "place" themselves in their new living environments after relocation.

Clinical pathways: adherence issues in complex older female patients with heart failure (HF).

HF is a leading health care concern, often under-recognized and under-treated in older women. Management of this complex condition frequently requires a multidisciplinary approach and a clinical pathway can be used to deliver coordinated care. This report is based on the intervention/treatment arm (n = 45) of a randomized controlled trial in older women who participated in a multidisciplinary clinic. We describe the development of a clinical pathway for HF and the variance reporting including factors affecting adherence with the pathway. Variances are patient or staff actions that did not meet the expected outcomes. Of the 45 intervention arm female patients, 5 were able to fully complete the program, meaning that all of the intended 12 visits were completed successfully. Thirteen women missed more than three clinic visits, and the rest attended most visits. Variance tracking identified that visits were interrupted most often by patient-related health issues, such as fatigue and pain, which may not be surprising given the expected multiple co-morbidities in this population. Transportation problems were identified as a barrier to attendance. Our study demonstrates that a clinical pathway can be implemented in an older, female population with HF. This report identifies some of the challenges and provides future recommendations for prospective pathway development.

Have last-observation-carried-forward analyses caused us to favour more toxic dementia therapies over less toxic alternatives? A systematic review.

BACKGROUND: Intention-to-treat analysis is used in the analysis of randomized controlled trials to preserve trial power in the presence of missing subject data as well as to control for both known and unknown confounding factors. One form of intention-to-treat analysis is last-observation-carried-forward (LOCF). Concerns exist regarding whether it is appropriate to use LOCF in analyses involving progressive conditions or in situations where missing data are non-random (e.g., subjects drop out because of treatment side effects or differing disease severity). OBJECTIVE: To examine the use of intention-to-treat imputation of missing data techniques, and specifically LOCF, in randomized controlled trials of the use of cholinesterase inhibitors and memantine to treat Alzheimer's disease, vascular dementia, mixed dementia and mild cognitive impairment. METHODS: We conducted a systematic electronic search of MEDLINE and the Cochrane Central Register of Controlled Trials from 1984 to 2008 for double-blinded, randomized controlled trials of cholinesterase inhibitors or memantine that examined progressive symptoms in Alzheimer's disease, vascular dementia, mixed dementia and mild cognitive impairment. We collected data on the use of intention-to-treat and non-intention-to-treat analyses and on contraindications to the use of LOCF analysis and we performed quality assessments of included trials. RESULTS: Of the 57 studies that met the inclusion criteria, 12 did not report intention-to-treat analyses. Of the 34 studies that employed LOCF as the only form of intention-to-treat analysis, 24 reported conditions that could produce biased LOCF analyses favouring the drug under study. The latter finding was more common in cholinesterase inhibitor trials than in memantine studies. CONCLUSIONS: The published results of some randomized controlled trials of dementia drugs may be inaccurate (i.e., drug effectiveness may be exaggerated) or invalid (i.e., there may be false-positive results) because of bias introduced through the inappropriate use of LOCF analyses. This bias favours cholinesterase inhibitors, potentially preventing funding of and patient access to less toxic treatment options such as memantine. Licensing agencies should consider whether to accept LOCF analyses in research on dementias and other chronic progressive conditions.

Symbolic meaning of relocation to a residential care facility for persons with dementia.

OBJECTIVES: This study explored the perspectives of persons with dementia (PWD) on the meanings and experiences associated with relocation to a residential care facility (RCF). METHODS: A qualitative design was employed, which involved in-depth interviews with 16 PWD at their homes within two months prior to relocation. The work of Strauss and Corbin guided the analysis process. RESULTS: Participants viewed relocation to an RCF as a major residential change and life transition requiring significant adaptive efforts. The experience clearly had a profound personal meaning for the participating PWD, shaped by their unique personal identities, psycho-environmental histories and current living circumstances. However, despite individual variations, four major themes captured the common perspectives and experiences in the sample. Relocation to an RCF: (a) symbolized the end of an era and a long-established way of life; (b) signaled the inevitable downward trajectory of old age; (c) meant living a more protected, dependent, structured and communal lifestyle in a place that is associated with 'hospitality' and 'rest'; and (d) presented a life course challenge that could be dealt with by drawing on one's sense of identity as a 'survivor'. CONCLUSION: The findings raise awareness of the subjective meanings of residential transitions in the experience of aging with dementia, and inform supportive interventions to optimize housing decisions for PWD in order to promote successful adaptation to their new living environments.

Systematic review of measures of clinical significance employed in randomized controlled trials of drugs for dementia.

The ability to define thresholds for the clinical significance (clinical importance) of outcome measures in dementia drug research is critical to determining the changes on outcome measures that patients and families would consider worth the cost and worth risking the side effects of medications (i.e., clinical importance is central to informed consent when starting such medications). Thresholds for clinical significance are also required for drug trial sample size calculation (if the studies are to be powered to detect clinically important difference) and for decisions regarding whether medications should be accepted on formularies and should be funded. To better understand what measures of clinical significance have been employed in dementia drug research, a systematic review was performed of double-blind randomized controlled trials (RCTs) of cholinesterase inhibitors and memantine in subjects with Alzheimer's disease, vascular dementia, mixed dementia, and mild cognitive impairment. Of the 57 dementia drug RCTs reviewed, only 46% discussed the clinical significance of their results. The most commonly cited measures of clinical significance were a 4-point change in the Alzheimer's Disease Assessment Scale--Cognitive Subscale and changes on global scales. The majority of measures of clinical significance were opinion based. Only one study empirically measured patient perspective regarding thresholds for clinical significance. Despite being central to the interpretation of trial results and to decisions regarding whether to employ trial findings in clinical practice, patient- and caregiver-centered measures of clinical significance have not been adequately studied and integrated into dementia drug RCTs. It is recommended that discussions of clinical importance receive greater emphasis in research standards published by organizations such as the CONSORT group (http://www.consort-statement.org). Drug formulary review committees and licensing agencies (e.g., U.S. Food and Drug Administration, European Agency for the Evaluation of Medicinal Products, Health Canada) should consider requiring an assessment of clinical significance of the drugs they review. To move this field forward, funding agencies should consider initiating requests for proposals focused on the determination of the minimally clinically important difference (MCID) of outcome measures employed in dementia research. Once empirical data on MCIDs are available, then these funding agencies should consider supporting a consensus conference to review and select the optimal measures of clinical importance in dementia research. A preliminary organizational framework of measures of clinical significance is presented in this article to facilitate the work of such a consensus forum.

Acceptability and concurrent validity of measures to predict older driver involvement in motor vehicle crashes: an Emergency Department pilot case-control study.

INTRODUCTION: Older drivers have one of the highest motor vehicle crash (MVC) rates per kilometer driven, largely due to the functional effects of the accumulation, and progression of age-associated medical conditions that eventually impact on fitness-to-drive. Consequently, physicians in many jurisdictions are legally mandated to report to licensing authorities patients who are judged to be medically at risk for MVCs. Unfortunately, physicians lack evidence-based tools to assess the fitness-to-drive of their older patients. This paper reports on a pilot study that examines the acceptability and association with MVC of components of a comprehensive clinical assessment battery. OBJECTIVES: To evaluate the acceptability to participants of components of a comprehensive assessment battery, and to explore potential predictors of MVC that can be employed in front-line clinical settings. METHODS: Case-control study of 10 older drivers presenting to a tertiary care hospital emergency department after involvement in an MVC and 20 age-matched controls. RESULTS: The measures tested were generally found to be acceptable to participants. Positive associations (p

Measurement of driving patterns of older adults using data logging devices with and without global positioning system capability.

BACKGROUND: Methods to study driving patterns and exposure of older drivers have typically relied on surveys or driving diaries. Electronic data logging devices may offer a reliable, alternative method of measuring driving exposure, and global positioning system (GPS) technology may be able to provide further information about driving patterns. OBJECTIVES: The aim of this study was to compare a driving diary with two electronic data logging devices, one of which had GPS capability, in order to identify which method best assesses the driving exposure and habits of older drivers as well as the method most acceptable to study participants. METHOD: In this prospective cohort study we recruited 20 participants aged 70 years or more (mean 78; range 70-85) (15 men and 5 women). The participants' driving patterns were recorded for one week with an electronic data logging device with GPS (FleetPulse), followed by recording for a further week with an electronic data logging device without GPS (CarChip). During both time periods the subjects also completed a standard driving diary. RESULTS: More comprehensive information, including braking and acceleration patterns, duration of driving time, time of day, and maximum speeds, was collected with the electronic devices than with the driving diary. There was excellent correlation between the driving diary data and those obtained with the CarChip (r = 0.9; p < 0.01). The correlation between the driving diary data and the FleetPulse data was moderate (r = 0.56; p = 0.02). The subjects clearly preferred the electronic monitoring devices over the driving diary. GPS data were able to demonstrate driving routes. CONCLUSIONS: Electronic data logging devices are a valid method for recording the driving patterns of older adults. These devices also reduce burden and improve the completeness of data.

Dementia diagnosis disclosure: a study of patient and caregiver perspectives.

This paper reports the findings of a descriptive, exploratory, qualitative study of patient and caregiver perspectives of the disclosure of a dementia diagnosis. Data were collected at 3 points in time: (1) the disclosure meeting, (2) patient and caregiver interviews, and (3) focus group interviews. Thirty patient-caregiver dyads participated in the disclosure meetings at the Geriatric Day Hospital at the Ottawa Hospital, Ottawa, Canada. Within a week of the disclosure of diagnosis, 27 (90%) patients and 29 (97%) caregivers were interviewed in their homes, and 12 caregivers participated in 3 focus group interviews within 1 month after the disclosure meeting. Most patients and caregivers said they preferred full disclosure of the diagnosis. Patients expressed satisfaction with the physician providing the diagnosis and with their caregivers being present at the disclosure meeting, however, wanted more information about their condition. Caregivers provided further insight regarding the patient response, and suggested the need to emphasize hope in the face of a difficult diagnosis, the use of progressive disclosure to allow the person (and caregivers) to prepare, and the provision of detail about the disease and its progression.