Prospective Validation of the Ottawa 3DY Scale by Geriatric Emergency Management Nurses to Identify Impaired Cognition in Older Emergency Department Patients.

STUDY OBJECTIVE: Assessment of older emergency department (ED) patients with cognitive impairment is challenging because few tools exist that can be quickly administered by front-line practitioners. Our objective is to validate the Ottawa 3DY Scale, a 4-question screening tool for cognitive impairment, in older ED patients and compare its performance with that of the Animal Fluency Test. METHODS: We conducted a prospective cohort study in 2 EDs and enrolled a convenience sample of patients aged 75 years or older with no history of cognitive impairment. Eligible patients were assessed by geriatric emergency management nurses who administered the Mini-Mental State Examination, ordered with the Ottawa 3DY Scale questions first, followed by the Animal Fluency Test. Mini-Mental State Examination score less than 25 was our criterion standard for cognitive impairment. RESULTS: Study patients (N=238) had a mean age of 81.9 years and were 60.1% women, and 26.5% were admitted to the hospital. The Ottawa 3DY Scale and Mini-Mental State Examination were in agreement for 75.6% of cases, with a sensitivity of 93.8% (95% confidence interval [CI] 77.8% to 98.9%) and specificity of 72.8% (95% CI 66.1% to 78.7%). The Animal Fluency Test score less than 15 and Mini-Mental State Examination score were in agreement for 46.2% of cases, with sensitivity 90.6% (95% CI 73.8% to 97.5%) and specificity 39.3% (95% CI 32.7% to 46.4%). CONCLUSION: Both the Ottawa 3DY Scale and the Animal Fluency Test demonstrated excellent sensitivity versus the Mini-Mental State Examination; however, the Animal Fluency Test exhibited poor specificity. The Ottawa 3DY Scale is an effective tool to screen for cognitive impairment in older ED patients, and its use may facilitate improved care in this vulnerable population.

Pathways to dementia diagnosis among South Asian Canadians.

Urban centers are increasingly ethnically diverse. However, some visible minorities are less likely than their majority counterparts to seek and receive services and treatment for dementia. This study explored experiences of South Asian Canadians, Canada's largest visible minority group, prior to dementia diagnosis. Six persons with dementia and eight of their family carers described their early perceptions of dementia-related changes, actions taken, including help seeking and diagnosis, and affective responses. Early signs were attributed to aging or personality. Even after cognitive enhancers were prescribed, some respondents continued to believe that the dementia symptoms were 'normal'. Family carers' affective responses may be related to their attributions. Before seeking medical attention, family carers modified physical or social environments because of symptoms. Help seeking was delayed up to four years, even with significant dementia symptoms. Recognition of a health problem was influenced by safety concerns, emergence of new symptoms following trauma, and treatment for other health problems. For some, relatives living outside the home or outside Canada were instrumental in recognizing a problem and convincing family carers and persons with dementia to seek medical attention. The pathway to diagnosis might be easier with outreach to help South Asian immigrants differentiate between normal aging and dementia. Symptom recognition by physicians treating other acute conditions was a portal to dementia services for others. Screening and referral in acute care could result in earlier diagnosis and treatment.

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.

eLearning, knowledge brokering, and nursing: strengthening collaborative practice in long-term care.

Interprofessional collaboration is vital to the delivery of quality care in long-term care settings; however, caregivers in long-term care face barriers to participating in training programs to improve collaborative practices. Consequently, eLearning can be used to create an environment that combines convenient, individual learning with collaborative experiential learning. Findings of this study revealed that learners enjoyed the flexibility of the Working Together learning resource. They acquired new knowledge and skills that they were able to use in their practice setting to achieve higher levels of collaborative practice. Nurses were identified as team leaders because of their pivotal role in the long-term care home and collaboration with all patient care providers. Nurses are ideal as knowledge brokers for the collaborative practice team. Quantitative findings showed no change in learner's attitudes regarding collaborative practice; however, interviews provided examples of positive changes experienced. Face-to-face collaboration was found to be a challenge, and changes to organizations, systems, and technology need to be made to facilitate this process. The Working Together learning resource is an important first step toward strengthening collaboration in long-term care, and the pilot implementation provides insights that further our understanding of both interprofessional collaboration and effective eLearning.

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.

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.

Family physicians and dementia in Canada: Part 1. Clinical practice guidelines: awareness, attitudes, and opinions.

OBJECTIVE: To assess Canadian family physicians' awareness of, attitudes toward, and use of the 1999 Canadian Consensus Conference on Dementia (CCCD) clinical practice guidelines (CPGs); to explore the barriers and enablers to implementing dementia CPGs in clinical practice; and to identify more effective strategies for future dementia guideline development and dissemination. DESIGN: Qualitative study using focus groups. SETTING: Academic family practice clinics in Calgary, Alta, Ottawa, Ont, and Toronto, Ont. PARTICIPANTS: Eighteen family physicians. METHODS: Using a semistructured interview guide, we conducted 4 qualitative focus groups of 4 to 6 family physicians whose practices we had audited in a previous study. Transcripts were coded using an inductive data analytic strategy, and categories and themes were identified and described using the principles of thematic analysis. MAIN FINDINGS: Four major themes emerged from the focus group discussions. Family physicians 1) were minimally aware of the existence and the detailed contents of the CCCD guidelines; 2) had strong views about the purposes of guidelines in general; 3) expressed strong concerns about the role of the pharmaceutical industry in the development of such guidelines; and 4) had many ideas to improve future dementia guidelines and CPGs in general. CONCLUSION: Family physicians were minimally aware of the 1999 CCCD CPGs. They acknowledged, however, the potential of future CPGs to assist them in patient care and offered many strategies to improve the development and dissemination of future dementia guidelines. Future guidelines should more accurately reflect the day-to-day practice experiences and challenges of family physicians, and guideline developers should also be cognizant of family physicians' perceptions that pharmaceutical companies' funding of CPGs undermines the objectivity and credibility of those guidelines.

Family physicians and dementia in Canada: Part 2. Understanding the challenges of dementia care.

OBJECTIVE: To explore the challenges Canadian family physicians face in providing dementia care. DESIGN: Qualitative study using focus groups. SETTING: Academic family practice clinics in Calgary, Alta, Ottawa, Ont, and Toronto, Ont. PARTICIPANTS: Eighteen family physicians. METHODS: We conducted 4 qualitative focus groups of 4 to 6 family physicians whose practices we had audited in a previous study. Focus group transcripts were analyzed using the principles of thematic analysis. MAIN FINDINGS: Five major themes related to the provision of dementia care by family physicians emerged: 1) diagnostic uncertainty; 2) the complexity of dementia; 3) time as a paradox in the provision of dementia care; 4) the importance of patients' families; 5) and familiarity with patients. Participants expressed uncertainty about diagnosing dementia and a strong need for expert verification of diagnoses owing to the complexity of dementia. Time, patients' family members, and familiarity with patients were seen as both barriers and enablers in the provision of dementia care. CONCLUSION: Family physicians face many challenges in providing dementia care. The results of this study and the views of family physicians should be considered in the development and dissemination of future dementia guidelines, as well as by specialist colleagues, policy makers, and those involved in developing continuing physician education about dementia.

A continuing medical education initiative for canadian primary care physicians: the driving and dementia toolkit: a pre- and postevaluation of knowledge, confidence gained, and satisfaction.

This study examined the effect of the Driving and Dementia Toolkit on physician knowledge and confidence gained and the anticipated change in patient assessment and evaluated the extent to which physicians found the material to be useful. Before receiving the driving toolkit, 301 randomly selected primary care physicians received a copy of the pretest questionnaire; 145 responded and met the eligibility criteria. This group was then sent the toolkit, a satisfaction a survey, and a posttest questionnaire. Physicians were faxed the questionnaires (with up to three reminders) and telephoned if necessary. Changes in pre- and posttest results were analyzed using the McNemar test and Wilcoxon signed rank test nonparametric procedures included in SPSS, Version 10.0, and paired-samples t test. Pre- and posttest data were available and could be matched for 86 physicians (59.3%) response. Knowledge and confidence increased significantly (P