Developing the Driving and Dementia Roadmap: a knowledge-to-action process.

OBJECTIVES: Despite three decades of research, gaps remain in meeting the needs of people with dementia and their family/friend carers as they navigate the often-tumultuous process of driving cessation. This paper describes the process of using a knowledge-to-action (KTA) approach to develop an educational web-based resource (i.e. toolkit), called the Driving and Dementia Roadmap (DDR), aimed at addressing some of these gaps. DESIGN: Aligned with the KTA framework, knowledge creation and action cycle activities informed the development of the DDR. These activities included systematic reviews; meta-synthesis of qualitative studies; interviews and focus groups with key stakeholders; development of a Driving and Dementia Intervention Framework (DD-IF); and a review and curation of publicly available resources and tools. An Advisory Group comprised of people with dementia and family carers provided ongoing feedback on the DDR's content and design. RESULTS: The DDR is a multi-component online toolkit that contains separate portals for current and former drivers with dementia and their family/friend carers. Based on the DD-IF, various topics of driving cessation are presented to accommodate users' diverse stages and needs in their experiences of decision-making and transitioning to non-driving. CONCLUSION: Guided by the KTA framework that involved a systematic and iterative process of knowledge creation and translation, the resulting person-centered, individualized and flexible DDR can bring much-needed support to help people with dementia and their families maintain their mobility, community access, and social and emotional wellbeing during and post-driving cessation.

Expert elicitation of risk factors for progression to dementia in individuals with mild cognitive impairment.

INTRODUCTION: This study assesses experts' beliefs about important predictors of developing dementia in persons with mild cognitive impairment (MCI). METHODS: Structured expert elicitation, a methodology to quantify expert knowledge, was used to elicit the most important risk factors for developing dementia. We recruited 11 experts (6 neurologists, 3 geriatricians, and 2 psychiatrists). Ten experts fully participated in introductory meetings, two rounds of surveys, and discussion meetings. The data from these ten experts were utilized for this study. RESULTS: The expert elicitation identified age, CSF analysis, fluorodeoxyglucose-positron emission tomography (FDG-PET) findings, hippocampal atrophy, MoCA (or MMSE) score, parkinsonism, apathy, psychosis, informant report of cognitive symptoms, and global atrophy as the ten most important predictors of progressing to dementia in persons with MCI. DISCUSSION: Several dementia predictors are not routinely collected in existing registries, observational studies, or usual care. This might partially explain the low uptake of existing published dementia risk scores in clinical practice.

Evaluation of an initiative to improve advance care planning for a home-based primary care service.

BACKGROUND: Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future. There is evidence that ACP reduces hospital-based interventions, especially at the end of life. ACP for frail older adults is especially important as this population is more likely to use hospital services but less likely to benefit from resource intensive care. Our study goal was to evaluate whether an approach to ACP developed for frail older adults, known as the Palliative and Therapeutic Harmonization or PATH, demonstrated an improvement in ACP. METHODS: The PATH approach was adapted to a primary care service for homebound older adults in Vancouver, Canada. This retrospective chart review collected surrogate measures related to ACP from 200 randomly selected patients enrolled in the service at baseline (prior to June 22, 2017), and 114 consecutive patients admitted to the program after implementation of the PATH ACP initiative (October 1, 2017 to May 1, 2018). We compared the following surrogate markers of ACP before and after implementation of the PATH model, chart documentation of: frailty stage, substitute decision-maker, resuscitation decision, and hospitalization decision. A composite ACP documentation score that ascribed one point for each of the above four measures (range 0 to 4) was also compared. For those with documented resuscitation and hospitalization decisions, the study examined patient/ substitute decision-maker expressed preferences for do-not-resuscitate and do-not-hospitalize, before and after implementation. RESULTS: We found the following changes in ACP-related documentation before and after implementation: frailty stage (27.0% versus 74.6%, p < .0001); substitute decision-maker (63.5% versus 71.9%, p = 0.128); resuscitation decision documented (79.5% versus 67.5%, p = 0.018); and hospitalization decision documented (61.5% versus 100.0%, p < .0001); mean (standard deviation) composite ACP documentation score (2.32 (1.16) versus 3.14 (1.11), p < .0001). The adjusted odds ratios (95% confidence intervals) for an expressed preference of do-not-resuscitate and do-not-hospitalize after implementation were 0.87 (0.35, 2.15) and 3.14 (1.78, 5.55), respectively. CONCLUSIONS: Results suggest partial success in implementing the PATH approach to ACP in home-based primary care. Key contextual enablers and barriers are important considerations for successful implementation.

Systematic review and meta-analysis of second-generation antidepressants for the treatment of older adults with depression: questionable benefit and considerations for frailty.

BACKGROUND: Frail older adults are commonly prescribed antidepressants. Yet, there is little evidence to determine the efficacy and safety of antidepressants to treat depression with concomitant frailty. To better understand this issue, we examined the efficacy and safety of second-generation antidepressants for the treatment of older adults with depression and then considered implications for frailty. METHODS: Due to the absence of therapeutic studies of frail older adults with depression, we conducted a systematic review and meta-analysis of double-blind, randomized controlled trials that compared antidepressants versus placebo for adults with depression, age 65 years or older. We searched PubMed/MEDLINE, Cochrane Library, reference lists from meta-analyses/studies, hand searches of publication lists, and related articles on PubMed. Outcomes included rates of response, remission, and adverse events. After evaluating the data, we applied a frailty-informed framework to consider how the evidence could be applied to frailty. RESULTS: Nine trials were included in the meta-analysis (n = 2704). Subjects had moderate to severe depression. For older adults with depression, there was no statistically significant difference in response or remission to second-generation antidepressants compared to placebo. Response occurred in 45.3% of subjects receiving an antidepressant compared to 40.5% receiving placebo (RR 1.15, 95% CI: 0.96 - 1.37, p = 0.12, I2 = 71%). Remission occurred in 33.1% with antidepressant versus 31.3% with placebo (RR 1.10, 95% CI: 0.92 - 1.31, p = 0.30, I2 = 56%) (Figure 2 and 3). There were more withdrawals due to adverse events with antidepressants, 13% versus 5.8% (RR 2.30, 95% CI: 1.45-3.63; p < 0.001; I2 = 61%; NNH 14, 95% CI:10-28). IMPLICATIONS FOR FRAILTY: Subjects in the meta-analysis did not have obvious characteristics of frailty. Using framework questions to consider the implications of frailty, we hypothesize that, like older adults, frail individuals with depression may not respond to antidepressants. Further, observational studies suggest that those who are frail may be less responsive to antidepressants compared to the non-frail. Given the vulnerability of frailty, adverse events may be more burdensome. CONCLUSIONS: Second-generation antidepressants have uncertain benefit for older adults with depression and cause more adverse events compared to placebo. Until further research clarifies benefit, careful consideration of antidepressant prescribing with frailty is warranted.

Treatment in a Geriatric Day Hospital improve individualized outcome measures using Goal Attainment Scaling.

BACKGROUND: Evidence regarding outcomes in the Geriatric Day Hospital (GDH) model of care has been largely inconclusive, possibly due to measurement issues. This prospective cohort study aims to determine whether treatment in a GDH could improve individualized outcome measures using goal attainment scaling (GAS) and whether improvements are maintained 6-months post-discharge. METHODS: A total of 469 outpatients admitted to a Canadian Geriatric Day Hospital, between December 2008 and June 2011, were included in the analysis (81.1 ± 6.7 years, 66.3% females); a smaller cohort of 121 patients received a follow-up phone call 6 months following discharge. Baseline, discharge and 6 month post-discharge observer-rated measures of mobility, cognition, and function were completed using GAS. Traditional psychometric measures were also captured. RESULTS: The mean number of goals set was 1.6 (SD 0.8) and patients set goals in the following domains: 88% mobility or falls reduction; 18% optimization of home supports; 17% medication optimization;12% cognition; 8% increasing social engagement; and 5% optimization of function. Total GAS was the most responsive measure to change with 86% of patients improving at discharge; mobility goals were the most likely to be achieved. Six-month GAS scores remained significantly higher than GAS scores on admission. Those who had more goals were more likely to improve during GDH admission (OR 1.49, CI 1.02-2.19) but this association was not seen 6 months after discharge. CONCLUSIONS: This study demonstrated short- and long-term effectiveness of GDH in helping patients achieve individualized outcome measures using GAS.

Frailty in end-stage renal disease: comparing patient, caregiver, and clinician perspectives.

BACKGROUND: Frailty is associated with poor outcomes for patients on dialysis and is traditionally measured using tools that assess physical impairment. Alternate measurement tools highlight cognitive and functional domains, requiring clinician, patient, and/or caregiver input. In this study, we compared frailty measures for incident dialysis patients that incorporate patient, clinician, and caregiver perspectives with an aim to contrast the measured prevalence of frailty using tools derived from different conceptual frameworks. METHODS: A prospective cohort study of incident dialysis patients was conducted between February 2014 and June 2015. Frailty was assessed at dialysis onset using: 1) modified definition of Fried Phenotype (Dialysis Morbidity Mortality Study definition, DMMS); 2) Clinical Frailty Scale (CFS); 3) Frailty Assessment Care Planning Tool (provides CFS grading, FACT-CFS); and 4) Frailty Index (FI). Measures were compared via correlation and sensitivity/specificity analyses. RESULTS: A total of 98 patients participated (mean age of 61 ± 14 years). Participants were primarily Caucasian (91%), male (58%), and the majority started on hemodialysis (83%). The median score for both the CFS and FACT-CFS was 4 (interquartile range of 3-5). The mean FI score was 0.31 (standard deviation ± 0.16). The DMMS identified 78% of patients as frail. The FACT-CFS demonstrated highest correlation (r = 0.71) with the FI, while the DMMS was most sensitive (97%, 100%) and a CFS ≥ 5 most specific (100%, 77%) at corresponding FI cutoff values (>0.21, >0.45). CONCLUSIONS: Frailty assessments of incident dialysis patients that include clinician, caregiver and patient perspectives have moderate to strong correlation with the FI. At specified FI cutoff values, the FACT-CFS and DMMS are highly sensitive measures of frailty. The CFS and FACT-CFS may represent viable alternative screening tools in dialysis patients.

The validation of a care partner-derived frailty index based upon comprehensive geriatric assessment (CP-FI-CGA) in emergency medical services and geriatric ambulatory care.

BACKGROUND: The derivation of a frailty index (FI) based on deficit accumulation from a Comprehensive Geriatric Assessment (CGA) has been criticised as cumbersome. To improve feasibility, we developed a questionnaire based on a CGA that can be completed by care partners (CP-FI-CGA) and assessed its validity. METHODS: We enrolled a convenience sample of patients aged 70 or older (n=203) presenting to emergency medical services (EMS) or geriatric ambulatory care (GAC). To test construct validity, we evaluated the shape of the CP-FI-CGA distribution, including its maximum value, relationship with age and gender. Criterion validity was evaluated by survival analysis and by the correlation between the CP-FI-CGA and specialist-completed FI-CGA. RESULTS: The mean age was 82.2±5.9 years. Most patients were women (62.1%), unmarried (widowed, divorced and single) (59.6%) and lived in their own home or apartment (78.3%). The mean CP-FI-CGA was 0.41±0.15 and was higher in the EMS group (0.45±0.15) than in GAC (0.37±0.14) (P<0.001). The CP-FI-CGA correlated well with the specialist-completed FI-CGA (0.7; P<0.05). People who died had a higher CP-FI-CGA than did survivors (0.48±0.13 versus 0.38±0.15). Each 0.01 increase in the FI was associated with a higher risk of death (HR 1.04; 95% CI 1.02-1.06). CONCLUSION: The CP-FI-CGA has properties that resemble other published FIs and may be useful in busy clinical practice for grading degrees of frailty. It efficiently integrates information from care partners so that it can help guide decision-making.

Good days and bad days in dementia: a qualitative chart review of variable symptom expression.

BACKGROUND: Despite its importance in the lived experience of dementia, symptom fluctuation has been little studied outside Lewy body dementia. We aimed to characterize symptom fluctuation in patients with Alzheimer's disease (AD) and mixed dementia. METHODS: A qualitative analysis of health records that included notations on good days and bad days yielded 52 community-dwelling patients (women, n = 30; aged 39-91 years; mild dementia, n = 26, chiefly AD, n = 36). RESULTS: Good days/bad days were most often described as changes in the same core set of symptoms (e.g. less/more verbal repetition). In other cases, only good or only bad days were described (e.g., no bad days, better sense of humor on good days). Good days were typically associated with improved global cognition, function, interest, and initiation. Bad days were associated with frequent verbal repetition, poor memory, increased agitation and other disruptive behaviors. CONCLUSIONS: Clinically important variability in symptoms appears common in AD and mixed dementia. Even so, what makes a day "good" is not simply more (or less) of what makes a day "bad". Further investigation of the factors that facilitate or encourage good days and mitigate bad days may help improve quality of life for patients and caregivers.

Transforming Communication on Serious Illness and Frailty: A Comprehensive Approach to Empowering Informed Decision-Making.

Health care professionals can enhance conversations about serious illness and medical decision-making by adopting a transparent, standardized approach. This article critiques established communication strategies, which often emphasize patient values and goals without providing the necessary medical information to align these goals with a shared understanding of prognosis. We propose an alternate strategy that (1) provides detailed explanations of medical conditions at the beginning of the conversation, (2) includes support persons in discussions, (3) considers capacity, and (4) offers tailored advice by clinicians. The proposed framework aims to provide patients (or their delegates) with the information they need to integrate their values in pursuit of well-informed medical decisions. This strategy builds trust by providing honest information about medical conditions and their trajectories. It empowers decision makers to consider realistic outcomes, allowing them to accept or reject treatments in accordance with their preferences. This article presents a thorough step-by-step guide on how to conduct a serious illness conversation and facilitate medical decision-making, including a supplement that provides example phrases for use in clinical practice.

Assessing frailty in elderly patients with hip fractures: A retrospective review comparing geriatrician and orthopedic trainee assessments.

To assess the correlation of orthopedic surgery residents compared with expert geriatricians in the assessment of frailty stage using the Clinical Frailty Scale (CFS) in patients with hip fractures. A retrospective chart review was performed from January 1, 2015 to December 31, 2019. Patients admitted with a diagnosis of hip fracture were identified. Those patients with a CFS score completed by orthopedic residents with subsequent CFS score completed by a geriatrician during their admission were extracted. Six hundred and forty-eight patients over age 60 (mean 80.5 years, 73.5% female) were admitted during the study period. Orthopaedic residents completed 286 assessments in 44% of admissions. Geriatric medicine consultation was available for 215 patients such that 93 patients were assessed by both teams. Paired CFS data were extracted from the charts and tested for agreement between the 2 groups of raters. CFS assessments by orthopedic residents and geriatrician experts were significantly different at P < .05; orthopedic residents typically assessed patients to be one CFS grade less frail than geriatricians. Despite this, the CFS assessments showed good agreement between residents and geriatricians. Orthopaedic surgery residents are reliable assessors of frailty but tend to underestimate frailty level compared with specialist geriatricians. Given the evidence to support models such as orthogeriatrics to improve outcomes for frail patients, our findings suggest that orthopedic residents may be well positioned to identify patients who could benefit from such early interventions. Our findings also support recent evidence that frailty assessments by orthopedic surgeons may have predictive validity. Low rates of initial frailty assessment by orthopedic residents suggests that further work is required to integrate more global comprehensive care.

Elicited clinician knowledge did not improve dementia risk prediction in individuals with mild cognitive impairment.

OBJECTIVES: This study aims to develop and validate a Bayesian risk prediction model that combines research cohort data with elicited expert knowledge to predict dementia progression in people with mild cognitive impairment (MCI). STUDY DESIGN AND SETTING: This is a prognostic risk prediction modeling study based on cohort data (Alzheimer's disease neuroimaging initiative [ADNI]; n = 365) of research participants with MCI and elicited expert data. Bayesian Cox models were used to combine expert knowledge and ADNI data to predict dementia progression in people with MCI. Posterior distributions were obtained based on Gibbs sampler and the predictive performance was evaluated using ten-fold cross-validation via c-index, integrated calibration index (ICI), and integrated brier score (IBS). RESULTS: 365 people with MCI were included, mean age was 73 years (SD = 7.5), and 39% developed dementia within 3 years. When expert knowledge was incorporated, the c-index, ICI, and IBS values were 0.74 (95% CI 0.70-0.79), 0.06 (95% CI 0.05-0.08), and 0.17 (95% CI 0.14-0.19), respectively. These were similar to the model without expert knowledge data. CONCLUSION: The addition of expert knowledge did not improve model accuracy in this ADNI sample to predict dementia progression in individuals with MCI.

Goals of Care Conversations in Long-Term Care during the First Wave of the COVID-19 Pandemic.

Goals of care discussions typically focus on decision maker preference and underemphasize prognosis and outcomes related to frailty, resulting in poorly informed decisions. Our objective was to determine whether navigated care planning with nursing home residents or their decision makers changed care plans during the first wave of the COVID-19 pandemic. The MED-LTC virtual consultation service, led by internal medicine specialists, conducted care planning conversations that balanced information-giving/physician guidance with resident autonomy. Consultation included (1) the assessment of co-morbidities, frailty, health trajectory, and capacity; (2) in-depth discussion with decision makers about health status and expected outcomes; and (3) co-development of a care plan. Non-parametric tests and logistic regression determined the significance and factors associated with a change in care plan. Sixty-three residents received virtual consultations to review care goals. Consultation resulted in less aggressive care decisions for 52 residents (83%), while 10 (16%) remained the same. One resident escalated their care plan after a mistaken diagnosis of dementia was corrected. Pre-consultation, 50 residents would have accepted intubation compared to 9 post-consultation. The de-escalation of care plans was associated with dementia, COVID-19 positive status, and advanced frailty. We conclude that during the COVID-19 pandemic, a specialist-led consultation service for frail nursing home residents significantly influenced decisions towards less aggressive care.

Respecting frailty.

While the medical treatment of older individuals often results in desirable outcomes, indiscriminate use of aggressive treatment at the end-of-life can cause paradoxical harm and suffering. Comprehensive assessment and communication can help foster decisions that consider the effect of frailty on health outcomes.

Specialist physician approaches to discussing cardiopulmonary resuscitation for frail older adults: a qualitative study.

BACKGROUND: Despite the impact and importance of end-of-life discussions, little is known about how physicians discuss cardiopulmonary resuscitation (CPR) with patients and their families. The necessary components for successful communication about CPR are poorly understood and an established framework to structure these conversations is lacking. Here, we were motivated to understand how physicians approach resuscitation planning with families when older patients have limited life expectancy and a high burden of illness. METHOD: Qualitative analysis was conducted of semi-structured interviews of 28 physicians of varying medical sub-specialties in a tertiary care hospital. RESULTS: Most physicians explored the surrogates' goals and values, but few provided explicit information about the patients' overall health status or expected long-term health outcome related to CPR and underlying illnesses. CONCLUSION: There is considerable heterogeneity in physicians' approaches to CPR discussions. The principle of autonomy is dominant with less emphasis on providing adequate information for effective decision-making.

Comparison of EXIT-25 and the Frontal Assessment Battery for evaluation of executive dysfunction in patients attending a memory clinic.

BACKGROUND/AIMS: The Frontal Assessment Battery (FAB) and the EXIT-25 have emerged as 2 widely used screening instruments for executive dysfunction, but their screening properties have not been evaluated in a head-to-head comparison. METHODS: Prospective cohort study of 92 individuals presenting for cognitive assessment at a community hospital. RESULTS: The EXIT-25 took longer than the FAB to complete (mean difference = 9.27 min, 95% CI: 9.86-8.68). EXIT-25 and FAB scores showed significant correlation (Spearman's r = -0.79, p < 0.001) with one another, and each showed acceptable convergent validity and divergent validity. CONCLUSIONS: The 2 tests provide similar information about the presence of executive dysfunction. The FAB takes less time to complete, and appears to be less frustrating for patients, making it more feasible as a screening test for executive dysfunction in a memory clinic setting.

Current concepts in vascular cognitive impairment and pharmacotherapeutic implications.

OBJECTIVE: To review evolution of the vascular cognitive impairment (VCI) construct, including diagnosis, pharmacotherapeutic implications, and address challenges that will shape future developments. DATA SOURCES: Literature retrieval was accessed through PubMed, from 1966 to December 2008, using the terms vascular cognitive impairment, vascular dementia, post-stroke dementia, vascular cognitive disorder, mild cognitive impairment, criteria, disease progression, outcomes, treatment, prevention, biomarkers, and neuroimaging. STUDY SELECTION AND DATA EXTRACTION: All articles in published English identified from the data sources were evaluated for inclusion. Regarding pharmacotherapy, prospective double-blind, placebo-controlled studies were included as well as extensions or relevant post hoc analyses. DATA SYNTHESIS: In the 1970s, "senile dementia due to hardening of the arteries" was used to describe dementia due to vascular causes. This was a narrow view of what is now known to be a common form of cognitive impairment in older people. Multiple infarct dementia (MID) was first proposed to describe dementia attributable to multiple cerebral infarcts, followed by the vascular dementia (VaD) construct, itself meant to be an improvement over MID. The VaD construct had limitations, not the least of which was that, by the time a patient was diagnosed with VaD, the opportunity for prevention was lost. Thus arose the concept of VCI, representing a group of heterogeneous disorders that share presumed vascular causes. The importance of VCI is centered on the fact that vascular risk factors are treatable, and thus should lead to a reduction in the incidence of cognitive impairment due to vascular causes. There is evidence that treatment of hypertension can lead to a reduction in the incidence of cognitive impairment and dementia, and that treatment of VaD with acetylcholinesterase inhibitors may be beneficial. CONCLUSIONS: Careful attention needs to be given to controlling vascular risk factors in at-risk patients. Pharmacists should play an active role in this important area of geriatric pharmacotherapy.

Advance Care Planning and Decision-Making in a Home-Based Primary Care Service in a Canadian Urban Centre.

BACKGROUND: Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future, and has been shown to reduce hospital-based interventions at the end of life. Our goal was to describe the current state of ACP in a home-based primary care program for frail homebound older people in Vancouver, Canada. We did this by identifying four key elements that should be essential to ACP in this program: frailty stage, documentation of substitute decision-makers, and decision-making with regard to both resuscitation (i.e., do not resuscitate (DNR)) and hospitalization (i.e., do not hospitalize (DNH)). While these elements are an important part of the ACP process, they are often excluded from common practice. METHODS: This was a cross-sectional, observational study of data abstracted from 200 randomly selected patient electronic medical records between July 1 and September 30, 2017. We describe the association between demographic characteristics, comorbidities, and four key elements of ACP documentation and decision-making as documented in the clinical record using bivariate comparison, a logistic regression model and multiple logistic regression analysis. RESULTS: In 73% (n=146) of the patient records, there was no explicit documentation of frailty stage. Sixty-four per cent had documentation of a substitute decision-maker. Of those who had their preferences documented, 90.6% (n=144/159) indicated a preference for DNR, and 23.6% (n=29/123) indicated a preference for DNH. In multiple regression modeling, a diagnosis of dementia and older age were associated with documentation of a DNR preference, adjusted odds ratio (AOR) = 4.79 (95% CI 1.37, 16.71) and AOR = 1.14 (95% CI 1.05, 1.24), respectively. Older age, male sex, and English identified as the main language spoken were associated with a DNH preference. AOR = 1.17 (95% CI 1.06, 1.28), AOR = 4.19 (95% CI 1.41, 12.42), and AOR = 3.42 (95% CI 1.14, 10.20), respectively. CONCLUSIONS: Clinician documentation of some elements of ACP, such as identification of a substitute decision-maker and resuscitation status, have been widely adopted, while other elements that should be considered essential components of ACP, such as frailty staging and preferences around hospitalization, are infrequent and provide an opportunity for practice improvement initiatives. The significant association between language and ACP decisions suggests an important role for supporting cross-cultural fluency in the ACP process.

Improving Care for the Frail in Nova Scotia: An Implementation Evaluation of a Frailty Portal in Primary Care Practice.

BACKGROUND: Understanding and addressing the needs of frail patients has been identified as an important strategy by the Nova Scotia Health Authority (NSHA). Primary care (PC) providers are in a key position to aid in the identification of, and response to frailty as part of routine care. Unlike singular chronic conditions such as diabetes and hypertension which garner a disease-based approach and identification as part of standard practice, frailty is only just emerging as a concept for PC. The web-based Frailty Portal was developed to aid in the identification of, assessment and care planning for frail patients in PC practice. In this study we assess the implementation feasibility and impact of the Frailty Portal by: (1) identifying factors influencing the Frailty Portal's use in community PC practice, and (2) examination of the immediate impact of the 'Frailty Portal' on frail patients, their caregivers and PC providers. METHODS: A convergent mixed method approach was implemented among PC providers in community-based practice in the NSHA, Central Zone. Quantitative and qualitative data were collected concurrently over a 9-month period. A sample of patients who underwent assessment and/or their caregiver were approached for survey participation. RESULTS: Fourteen community PC providers (10 family physicians, 4 nurse practitioners) completed 48 patient assessments and completed or begun 41 care plans; semi-structured interviews were conducted among 9 providers. Nine patients and 5 caregivers participated in the survey. PC providers viewed frailty as an important concept but implementation challenges were met, primarily with respect to the time required for use and lack of fit with traditional practice routines. Additional barriers included tool usability and accessibility, training and care planning steps, and privacy. Impacts of the tools use with respect to confidence and knowledge showed early promise. CONCLUSION: This feasibility study highlights the need for added health system supports, resources and financial incentives for successful implementation of the Frailty Portal in community PC practice. We suggest future implementation integrate the Frailty Portal to practice electronic medical records (EMRs) and target providers with largely geriatric practice populations and those practicing within interdisciplinary, collaborative primary healthcare (PHC) teams.

The Pictorial Fit-Frail Scale: Developing a Visual Scale to Assess Frailty.

BACKGROUND: Standardized frailty assessments are needed for early identification and treatment. We aimed to develop a frailty scale using visual images, the Pictorial Fit-Frail Scale (PFFS), and to examine its feasibility and content validity. METHODS: In Phase 1, a multidisciplinary team identified domains for measurement, operationalized impairment levels, and reviewed visual languages for the scale. In Phase 2, feedback was sought from health professionals and the general public. In Phase 3, 366 participants completed preliminary testing on the revised draft, including 162 UK paramedics, and rated the scale on feasibility and usability. In Phase 4, following translation into Malay, the final prototype was tested in 95 participants in Peninsular Malaysia and Borneo. RESULTS: The final scale incorporated 14 domains, each conceptualized with 3-6 response levels. All domains were rated as "understood well" by most participants (range 64-94%). Percentage agreement with positive statements regarding appearance, feasibility, and usefulness ranged from 66% to 95%. Overall feedback from health-care professionals supported its content validity. CONCLUSIONS: The PFFS is comprehensive, feasible, and appears generalizable across countries, and has face and content validity. Investigation into the reliability and predictive validity of the scale is currently underway.

Vascular cognitive impairment: current concepts and clinical developments.

Vascular cognitive impairment (VCI) comprises a range of cognitive disorders related to cerebral vessel disease and has generally replaced the term multi-infarct dementia. Despite the heterogeneity of the VCI construct, some clinical patterns can be discerned, which enable subtypes, such as mixed dementia and VCI-no dementia, to be recognised. Diagnostic criteria for vascular dementia do not encompass the full range of the VCI construct, and clinical investigators now recognise the need for harmonised standards to study the many manifestations of VCI seen in daily practice and to inform the development of diagnostic criteria. Although executive dysfunction is a recognised feature of VCI, some data suggest a less exclusive role than was previously proposed. VCI might be preventable, although the evidence for this is not as complete as it is for the prevention of stroke. Future studies into specific therapies for VCI will need to consider the clinical features and outcomes carefully.