Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada.

BACKGROUND: This article describes the evidence review and guideline development method developed for the Clinical Preventive Guidelines for Immigrants and Refugees in Canada by the Canadian Collaboration for Immigrant and Refugee Health Guideline Committee. METHODS: The Appraisal of Guidelines for Research and Evaluation (AGREE) best-practice framework was combined with the recently developed Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to produce evidence-based clinical guidelines for immigrants and refugees in Canada. RESULTS: A systematic approach was designed to produce the evidence reviews and apply the GRADE approach, including building on evidence from previous systematic reviews, searching for and comparing evidence between general and specific immigrant populations, and applying the GRADE criteria for making recommendations. This method was used for priority health conditions that had been selected by practitioners caring for immigrants and refugees in Canada. INTERPRETATION: This article outlines the 14-step method that was defined to standardize the guideline development process for each priority health condition.

Is stroke history reliably reported by elderly with cognitive impairment? A community-based study.

BACKGROUND/AIMS: Self-reported history of stroke has been questioned in the elderly due to the high prevalence of cognitive impairment. We tested the validity of response to a stroke questionnaire versus clinical diagnosis of stroke among elderly people with and without cognitive impairment. METHODS: Community-dwelling participants to the phase 1 Canadian Study of Health and Aging were screened for self-reported stroke. Physician-diagnosed stroke was set as the gold standard. The positive predictive value (PPV), sensitivity and specificity were determined. RESULTS: 1,536/ 1,659 (93%) participants aged 65 years and over had stroke information from both sources. Among stroke positive responders, the PPV was 81% overall: 76% for cognitively normal, 84% for cognitively impairment with no dementia (CIND), and 82% for demented. Among stroke diagnosed by physicians, history of stroke was reported by 38% cognitively normal, 54% CIND, and 55% demented. The specificity was over 97% in all cognitive categories. CONCLUSION: Among community-dwelling elderly people, any cognitive impairment did not imply inaccurate self-reported history of stroke. High prevalence of stroke and frequent contacts with health services among cognitively-impaired elderly may increase the awareness of stroke symptoms and signs. Stroke increases the risk of developing dementia in both cognitively normal and CIND, and efforts to accomplish stroke prevention are justified, especially in these categories.

Diagnosis and treatment of dementia: 1. Risk assessment and primary prevention of Alzheimer disease.

BACKGROUND: In addition to nonmodifiable genetic risk factors, potentially modifiable factors such as hypertension, hyperlipidemia and environmental exposures have been identified as risk factors for Alzheimer disease. In this article, we provide physicians with practical guidance on risk assessment and primary prevention of Alzheimer disease based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, held in March 2006. METHODS: We developed evidence-based guidelines using systematic literature searches, with specific criteria for study selection and quality assessment, and a clear and transparent decision-making process. We selected studies published from January 1996 to December 2005 that met the following criteria: dementia (all-cause, Alzheimer disease or vascular dementia) as the outcome; longitudinal cohort study; study population broadly reflective of Canadian demographics; and genetic risk factors and general risk factors (e.g., hypertension, education, occupation and chemical exposure) identified. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care. RESULTS: Of 3424 articles on potentially modifiable risk factors for dementia, 1719 met our inclusion criteria; 60 were deemed to be of good or fair quality. Of 1721 articles on genetic risk factors, 62 that met our inclusion criteria were deemed to be of good or fair quality. On the basis of evidence from these articles, we made recommendations for the risk assessment and primary prevention of Alzheimer disease. For the primary prevention of Alzheimer's disease, there is good evidence for controlling vascular risk factors, especially hypertension (grade A), and weak or insufficient evidence for manipulation of lifestyle factors and prescribing of medications (grade C). There is good evidence to avoid estrogens and high-dose (> 400 IU/d) of vitamin E for this purpose (grade E). Genetic counselling and testing may be offered to at-risk individuals with an apparent autosomal dominant inheritance (grade B). Screening for the apolipoprotein E genotype in asymptomatic individuals in the general population is not recommended (grade E). INTERPRETATION: Despite the personal and societal burden of dementia, our understanding of genetic predisposition to dementias and the contribution of other risk factors remains limited. More importantly, there are few data to explain the overall risks and benefits of prevention strategies or their impact of risk modification.

Who delivers preventive care as recommended?: Analysis of physician and practice characteristics.

ABSTRACTOBJECTIVETo ascertain which physician and practice characteristics are associated with self-reported provision of preventive care as recommended by the Canadian Task Force on Preventive Health Care.DESIGNCross-sectional analysis of data from a decennial survey.SETTINGSouthwestern Ontario.PARTICIPANTSA total of 731 family physicians in various practice settings.MAIN OUTCOME MEASURESNumber of patients to whom these physicians provided the recommended preventive services based on physicians' responses to various scenarios presented in the survey. The responses were scored, and the median score was used to dichotomize physicians into high- and low-scoring groups.RESULTSClose to two-thirds of the physicians (61%) were in the high-scoring group. Female family physicians, graduates of Canadian medical schools, and physicians whose practices were organized into family health teams, family health groups, family health networks, community health centres, or health services organizations were more likely to be in the high-scoring group. Physicians practising solo and international medical graduates were more likely to be in the low-scoring group.CONCLUSIONReorganizing delivery of primary care into group practice models might improve provision of preventive services. Licensing requirements for international medical graduates should ensure that these physicians are adequately trained to provide preventive services as recommended in the Canadian context. More research is needed before our results can be generalized beyond southwestern Ontario.

General risk factors for dementia: a systematic evidence review.

This review identifies and quantifies general (ie, nongenetic) risk factors for all-cause dementia, Alzheimer's disease, and vascular dementia specifically.

Primary prevention of dementia.

The purpose of this article is to recommend strategies to practicing physicians for the prevention of dementia in people without preexisting cognitive deficits.

The reciprocal risks of stroke and cognitive impairment in an elderly population.

BACKGROUND: Stroke, dementia, and cognitive impairment no dementia (CIND) pose major threats to the elderly but have rarely been studied together in the same population. We aimed to compare the relative frequencies of stroke, CIND, and dementia in an elderly population and to examine whether cognitive impairment poses a risk for stroke. METHODS: Prevalences of stroke, CIND, and dementia were estimated among participants in the first clinical examination of the Canadian Study of Health and Aging (CSHA-1, n = 2,914). Incidence rates were determined at the 5-year follow-up (CSHA-2) among those cognitively normal and stroke free at CSHA-1 (n = 828). The associations between cognitive impairment and stroke were assessed by Cox regression analyses. RESULTS: Among elderly Canadians, the age-standardized prevalence of stroke, CIND, and dementia were 8%, 17%, and 8%, respectively. Alone or combined, they affected one fourth of the elderly. Among stroke survivors, 64% had cognitive impairment compared with 21% among stroke-free persons. Among the cognitively impaired, 25% had a stroke compared with 4% among the cognitively normal. The incidence rates of stroke, CIND, and dementia were 3, 6, and 3 per 100 person-years, respectively. Compared with cognitively normal subjects, the adjusted risk for incident stroke was 1.3 (95% confidence interval [CI], 0.9 to1.9) in patients with CIND and 2.3 (95% CI, 1.7 to 3.2) in patients with dementia regardless of whether "questionable stroke" was included. CONCLUSIONS: Stroke and cognitive impairment pose risk for each other. CIND is highly prevalent, and some of its subtypes may represent treatable preludes to stroke and/or dementia.

Factors associated with the effectiveness of continuing education in long-term care.

PURPOSE: This article examines factors within the long-term-care work environment that impact the effectiveness of continuing education. DESIGN AND METHODS: In Study 1, focus group interviews were conducted with staff and management from urban and rural long-term-care facilities in southwestern Ontario to identify their perceptions of the workplace factors that affect transfer of learning into practice. Thirty-five people were interviewed across six focus groups. In Study 2, a Delphi technique was used to refine our list of factors. Consensus was achieved in two survey rounds involving 30 and 27 participants, respectively. RESULTS: Management support was identified as the most important factor impacting the effectiveness of continuing education. Other factors included resources (staff, funding, space) and the need for ongoing expert support. IMPLICATIONS: Organizational support is necessary for continuing education programs to be effective and ongoing expert support is needed to enable and reinforce learning.

A 10-year follow-up of urinary and fecal incontinence among the oldest old in the community: the Canadian Study of Health and Aging.

Urinary incontinence is common in the elderly. The epidemiology of fecal and double (urinary and fecal) incontinence is less known. The Canadian Study of Health and Aging (CSHA) is a national study of elderly living in the community at baseline (n = 8,949) and interviewed in 1991-1992, 1996, and 2001. Using data from the CSHA, we report the prevalence of urinary, fecal, and double incontinence in each wave and the cumulative incidence between waves and investigate the predictors of urinary and fecal incontinence. Urinary incontinence increased rapidly in old age, being almost twice as high in women as in men. Fecal and double incontinence were less common, but also increased rapidly with age. In women, parity showed a positive relationship with (prevalent) urinary incontinence. In men, diabetes was a risk factor for urinary and fecal incontinence. We conclude that urinary, fecal, and double incontinence increase rapidly with age and that inquiry about incontinence should be part of routine medical and nursing assessment of all elderly.

Effectiveness of preventive primary care outreach interventions aimed at older people: meta-analysis of randomized controlled trials.

OBJECTIVE: To determine the effectiveness of preventive primary care outreach interventions aimed at older people. Knowing whether such interventions are effective could help busy family physicians make choices about which preventive care services to provide. DATA SOURCES: We searched MEDLINE, CINAHL, AgeLine, Cochrane Controlled Trials Register, and EMBASE databases and reviewed the reference lists of retrieved articles. STUDY SELECTION: We included studies of preventive primary care interventions aimed at patients 65 years and older if the studies were randomized controlled trials and if any of the following outcomes was reported: mortality, living in the community, admission to acute care hospitals, and admission to long-term care. We defined preventive primary care outreach as proactive, provider-initiated care, which can be provided by nurses, physicians, other professionals, or volunteers, that is in addition to usual care and is provided in primary care settings. Such care can be provided through home visits, office visits, telephone contacts, or a combination of these methods. SYNTHESIS: We assessed the quality of studies and extracted descriptive information on study populations, interventions, and outcomes for 19 trials involving 14,911 patients. Summary odds ratios were estimated for each outcome using a random effects model. CONCLUSION: This review showed that studies of preventive primary care outreach interventions aimed at older people were associated with a 17% reduction of mortality and a 23% increased likelihood of continuing to live in the community.