Perceptions and outcomes of an embedded Alzheimer Society First Link Coordinator in rural primary health care memory clinics.

BACKGROUND: Primary health care has a central role in dementia detection, diagnosis, and management, especially in low-resource rural areas. Care navigation is a strategy to improve integration and access to care, but little is known about how navigators can collaborate with rural primary care teams to support dementia care. In Saskatchewan, Canada, the RaDAR (Rural Dementia Action Research) team partnered with rural primary health care teams to implement interprofessional memory clinics that included an Alzheimer Society First Link Coordinator (FLC) in a navigator role. Study objectives were to examine FLC and clinic team member perspectives of the impact of FLC involvement, and analysis of Alzheimer Society data comparing outcomes associated with three types of navigator-client contacts. METHODS: This study used a mixed-method design. Individual semi-structured interviews were conducted with FLC (n = 3) and clinic team members (n = 6) involved in five clinics. Data were analyzed using thematic inductive analysis. A longitudinal retrospective analysis was conducted with previously collected Alzheimer Society First Link database records. Memory clinic clients were compared to self- and direct-referred clients in the geographic area of the clinics on time to first contact, duration, and number of contacts. RESULTS: Three key themes were identified in both FLC and team interviews: perceived benefits to patients and families of FLC involvement, benefits to memory clinic team members, and impact of rural location. Whereas other team members assessed the patient, only FLC focused on caregivers, providing emotional and psychological support, connection to services, and symptom management. Face-to-face contact helped FLC establish a relationship with caregivers that facilitated future contacts. Team members were relieved knowing caregiver needs were addressed and learned about dementia subtypes and available services they could recommend to non-clinic clients with dementia. Although challenges of rural location included fewer available services and travel challenges in winter, the FLC role was even more important because it may be the only support available. CONCLUSIONS: FLC and team members identified perceived benefits of an embedded FLC for patients, caregivers, and themselves, many of which were linked to the FLC being in person.

What Happens to the Worried Well? Follow-Up of Subjective Cognitive Impairment.

BACKGROUND: Increasing concern around perceived neurocognitive decline is increasing the number of referrals to specialists and anxiety for patients. We aimed to explore the likelihood of the "worried well" experiencing neurocognitive decline and developing a neurological diagnosis. METHODS: A total of 166 "worried well" patients who attended the Rural and Remote Memory Clinic (RRMC) between 2004 and 2019 were included in this study. Demographic, health, social, and behavioral factors were measured at the initial visit. Mini-Mental State Examination (MMSE), Center for Epidemiologic Studies Depression Scale (CESD), and Functional Activities Questionnaire (FAQ) scores were measured and compared at initial assessment and at 1-year follow-up. MMSE scores over time were assessed with a mean follow-up of 2.95 years (SD 2.87). RESULTS: No statistically significant difference was seen in MMSE, CESD, or FAQ scores when comparing clinic day to 1-year follow-up, and no consistent pattern of MMSE score over time was seen. Of the 166 patients with subjective cognitive impairment (SCI) on initial assessment, 5 were diagnosed with Alzheimer's disease (AD) at 8.5, 3.5, 5, 3, and 1.75 years; 2 were diagnosed with MCI at 1 and 2 years; 1 was diagnosed with vascular cognitive impairment at 5 years; and 1 was diagnosed with frontotemporal dementia (FTD) at 0.5 years. CONCLUSION: The likelihood of a patient with SCI developing a neurological diagnosis is reassuringly low (9/166), but not irrelevant. This, along with the benefits of early diagnosis and treatment for dementia, leads us to believe that patients with SCI should still be seen in follow-up at least at the 1-year mark.

The importance of organizational commitment in rural nurses' intent to leave.

AIMS: To examine determinants of intention to leave a nursing position in rural and remote areas within the next year, for Registered Nurses or Nurse Practitioners (RNs/NPs) and Licensed Practical Nurses (LPNs). DESIGN: A pan-Canadian cross-sectional survey. METHODS: The Nursing Practice in Rural and Remote Canada II survey (2014-2015) used stratified, systematic sampling and obtained two samples of questionnaire responses on intent to leave from 1,932 RNs/NPs and 1,133 LPNs. Separate logistic regression analyses were conducted for RNs/NPs and LPNs. RESULTS: For RNs/NPs, 19.8% of the variance on intent to leave was explained by 11 variables; and for LPNs, 16.9% of the variance was explained by seven variables. Organizational commitment was the only variable associated with intent to leave for both RNs/NPs and LPNs. CONCLUSIONS: Enhancement of organizational commitment is important in reducing intent to leave and turnover. Since most variables associated with intent to leave differ between RNs/NPs and LPNs, the distinction of nurse type is critical for the development of rural-specific turnover reduction strategies. Comparison of determinants of intent to leave in the current RNs/NPs analysis with the first pan-Canadian study of rural and remote nurses (2001-2002) showed similarity of issues for RNs/NPs over time, suggesting that some issues addressing turnover remain unresolved. IMPACT: The geographic maldistribution of nurses requires focused attention on nurses' intent to leave. This research shows that healthcare organizations would do well to develop policies targeting specific variables associated with intent to leave for each type of nurse in the rural and remote context. Practical strategies could include specific continuing education initiatives, tailored mentoring programs, and the creation of career pathways for nurses in rural and remote settings. They would also include place-based actions designed to enhance nurses' integration with their communities and which would be planned together with communities and nurses themselves.

Communication tools and sources of education and information: a national survey of rural and remote nurses.

OBJECTIVE: This study examined accessibility of communication tools in the workplace, use of education to update nursing knowledge, and use of information to make specific decisions in practice among registered nurses (RNs) and licensed practical nurses (LPNs) in rural and remote communities in Canada. METHODS: Data were analyzed from the cross-sectional survey, "Nursing Practice in Rural and Remote Canada II," of regulated nurses practicing in all provinces and territories of Canada. Data were collected from April 2014 to August 2015. RESULTS: The survey was completed by 3,822 of 9,622 nurses (40% response), and the present analysis was conducted with a subsample of 2,827 nurses. High-speed Internet was the most accessible communication tool, and nurses used "online/electronic education" more often than "in-person education" to update their nursing knowledge. Internet searches were used more often than several other online/electronic sources to inform decision making. Compared to LPNs, RNs reported greater workplace access to most communication tools and greater use of online/electronic education as well as information sources in online/electronic and print formats. Compared to nurses in community-based health care and hospital settings, nurses in long-term care settings reported lower access to most communication tools, lower use of online/electronic and in-person education, and lower use of online/electronic information. CONCLUSIONS: Access to continuing education and up-to-date information is important for effective patient care. This study points to a need for further research on the continuing education and information needs of rural and remote RNs and LPNs, and on their capacity to incorporate and apply new knowledge in practice.

Mistreated older adults with dementia in the home: practitioner experience and unattainable professional agency.

The experience of practitioners who encounter mistreatment of an older adult with dementia by a caregiver in the home has received little attention in the literature. A critical research methodology aimed to understand the experience of professional agency, the ability to control outcomes and act in a meaningful way, of health and social service practitioners when encountering these cases in the home. Fifty-one practitioners from urban, rural and Northeastern communities in Ontario participated in semi-structured interviews, reflective journals, as well as focus group discussions. Theoretical thematic analysis of data led to the discovery of five themes: weathering the storm to realization; cognitive uncertainty; emotional upheaval; one's inability to resolve the mistreatment; and the double-edge sword of self-reflection. Understanding this experience is an essential step toward improving practice and policy, and achieving positive outcomes for the mistreated older adult with dementia and their caregiver within the home.

The Worried Well? Characteristics of Cognitively Normal Patients Presenting to a Rural and Remote Memory Clinic.

INTRODUCTION: In an effort to better understand why cognitively normal patients were referred to a memory clinic, we sought to identify features of "worried well" patients to better identify those more likely to be cognitively normal. METHODS: In total, 375 consecutive patients referred by primary care practitioners to a Rural and Remote Memory Clinic were categorized into two groups based on their neurologic diagnosis, "worried well" (cognitively normal, N=81) or "other" (patients with any neurologic diagnosis, N=294). Data collected included: age, sex, years of formal education, Mini-Mental Status Examination score from initial visit, Center for Epidemiologic Studies Depression Scale score, Self-Rating of Memory Scale, alcohol consumption, marital status, hours per week of work, past medical history, sleep concerns, and family history of memory concerns. The two groups were compared using t-tests and χ2 tests. The same comparison was done between the same set of "worried well" patients (cognitively normal, N=81) and the subgroup of patients with a diagnosis of Alzheimer's disease (N=146) from the "other" group. RESULTS: Significant differences included younger age, more formal education, more frequently having previous psychiatric diagnosis and more self-reported alcohol consumption in the "worried well" group. The "worried well" and "Alzheimer's disease" comparison had the same significant differences as the "worried well" and "other" comparison. CONCLUSION: We observed a pattern of differences unfold between the "worried well" patients and those with cognitive disease. No one variable was pathognomonic of a "worried well" patient. However, taking all the above into account when evaluating a patient may help clinically.

Simultaneous temporal trends in dementia incidence and prevalence, 2005-2013: a population-based retrospective cohort study in Saskatchewan, Canada.

BACKGROUND: Original studies published over the last decade regarding time trends in dementia report mixed results. The aims of the present study were to use linked administrative health data for the province of Saskatchewan for the period 2005/2006 to 2012/2013 to: (1) examine simultaneous temporal trends in annual age- and sex-specific dementia incidence and prevalence among individuals aged 45 and older, and (2) stratify the changes in incidence over time by database of identification. METHODS: Using a population-based retrospective cohort study design, data were extracted from seven provincial administrative health databases linked by a unique anonymized identification number. Individuals 45 years and older at first identification of dementia between April 1, 2005 and March 31, 2013 were included, based on case definition criteria met within any one of four administrative health databases (hospital, physician, prescription drug, and long-term care). RESULTS: Between 2005/2006 and 2012/2013, the 12-month age-standardized incidence rate of dementia declined significantly by 11.07% and the 12-month age-standardized prevalence increased significantly by 30.54%. The number of incident cases decreased from 3,389 to 3,270 and the number of prevalent cases increased from 8,795 to 13,012. Incidence rate reductions were observed in every database of identification. CONCLUSIONS: We observed a simultaneous trend of decreasing incidence and increasing prevalence of dementia over a relatively short 8-year time period from 2005/2006 to 2012/2013. These trends indicate that the average survival time of dementia is lengthening. Continued observation of these time trends is warranted given the short study period.

Incidence and prevalence of dementia in linked administrative health data in Saskatchewan, Canada: a retrospective cohort study.

BACKGROUND: Determining the epidemiology of dementia among the population as a whole in specific jurisdictions - including the long-term care population-is essential to providing appropriate care. The objectives of this study were to use linked administrative databases in the province of Saskatchewan to determine the 12-month incidence and prevalence of dementia for the 2012/13 period (1) among individuals aged 45 and older in the province of Saskatchewan, (2) according to age group and sex, and (3) according to diagnosis code and other case definition criteria. METHODS: We used a population-based retrospective cohort study design and extracted data from 10 provincial health databases linked by a unique health services number. The cohort included individuals 45 years and older at first identification of dementia between April 1, 2001 and March 31, 2013 based on case definitions met within any one of four administrative health databases (Hospital Discharge Abstracts, Physician Service Claims, Prescription Drug, and RAI-MDS, i.e., Long-term Care). RESULTS: A total of 3,270 incident cases of dementia (7.28 per 1,000 PAR) and 13,012 prevalent cases (28.16 per 1,000 PAR) were identified during 2012/13. This study found the incidence rate increased by 2.8 to 5.1 times and the prevalence rate increased by 2.6 to 4.6 times every 10 years after 45 years of age. Overall, the age-standardised incidence rate was significantly lower among females than males (7.04 vs. 7.65 per 1,000 PAR) and the age-standardised prevalence rate was significantly higher among females than males (28.92 vs. 26.53 per 1,000 PAR). Over one-quarter (28 %) of all incident cases were admitted to long-term care before a diagnosis was formally recorded in physician or hospital data, and nearly two-thirds of these cases were identified at admission with impairment at the moderate to very severe level or a disease category of Alzheimer's disease/other dementia. CONCLUSIONS: Linking multiple sources of registry data contributes to our understanding of the epidemiology of dementia across multiple segments of the population, inclusive of individuals residing in long-term care. This information is foundational for public awareness and policy recommendations, health promotion and prevention strategies, appropriate health resource planning, and research priorities.

Availability and Primary Health Care Orientation of Dementia-Related Services in Rural Saskatchewan, Canada.

Community-based services are important for improving outcomes for individuals with dementia and their caregivers. This study examined: (a) availability of rural dementia-related services in the Canadian province of Saskatchewan, and (b) orientation of services toward six key attributes of primary health care (i.e., information/education, accessibility, population orientation, coordinated care, comprehensiveness, quality of care). Data were collected from 71 rural Home Care Assessors via cross-sectional survey. Basic health services were available in most communities (e.g., pharmacists, family physicians, palliative care, adult day programs, home care, long-term care facilities). Dementia-specific services typically were unavailable (e.g., health promotion, counseling, caregiver support groups, transportation, week-end/night respite). Mean scores on the primary health care orientation scales were low (range 12.4 to 17.5/25). Specific services to address needs of rural individuals with dementia and their caregivers are limited in availability and fit with primary health care attributes.

Attitudes toward physical activity and exercise: comparison of memory clinic patients and their caregivers and prediction of activity levels.

Regular physical activity and exercise (PA&E) reduces cognitive aging, may delay dementia onset, and for persons with dementia, may slow progression and improve quality of life. Memory clinic patients and caregivers described their PA&E and completed the Older Persons' Attitudes Toward Physical Activity and Exercise Questionnaire (OPAPAEQ). Caregivers and patients differed in their PA&E attitudes: patients were less likely to believe in the importance of PA&E for health promotion. PA&E attitudes were explored as predictors of self-reported exercise habits. Belief in the importance of high intensity exercise for health maintenance was the only variable that significantly predicted engagement in regular PA&E. Moreover, caregivers' attitudes toward high intensity exercise predicted memory patients' participation in PA&E. These findings may aid in development of exercise interventions for people with memory problems, and suggest that modification of specific attitudes toward exercise is an important component to ensure maximum participation and engagement in PA&E.

The telehealth satisfaction scale: reliability, validity, and satisfaction with telehealth in a rural memory clinic population.

INTRODUCTION: Patient satisfaction is a key aspect of quality of care and can inform continuous quality improvement. Of the few studies that have reported on patient satisfaction with telehealth in programs aimed at individuals with memory problems, none has reported on the psychometric properties of the user satisfaction scales used. MATERIALS AND METHODS: We evaluated the construct validity and internal consistency reliability of the Telehealth Satisfaction Scale (TeSS), a 10-item scale adapted for use in a rural and remote memory clinic (RRMC). The RRMC is a one-stop interprofessional clinic for rural and remote seniors with suspected dementia, located in a tertiary-care hospital. Telehealth videoconferencing is used for preclinic assessment and for follow-up. Patients and caregivers completed the TeSS after each telehealth appointment. With data from 223 patients, exploratory factor analysis was conducted using the principal components analysis extraction method. RESULTS: The eigenvalue for the first factor (5.2) was greater than 1 and much larger than the second eigenvalue (0.92), supporting a one-factor solution that was confirmed by the scree plot. The total variance explained by factor 1 was 52.1%. Factor loadings (range, 0.54-0.84) were above recommended cutoffs. The TeSS items demonstrated high internal consistency reliability (Cronbach's alpha=0.90). Satisfaction scores on the TeSS items ranged from 3.43 to 3.72 on a 4-point Likert scale, indicating high satisfaction with telehealth. CONCLUSIONS: The study findings demonstrate high user satisfaction with telehealth in a rural memory clinic and the sound psychometric properties of the TeSS in this population.

Lessons learned: feasibility and acceptability of a telehealth-delivered exercise intervention for rural-dwelling individuals with dementia and their caregivers.

INTRODUCTION: Until dementias can be prevented or cured, interventions that maintain or maximize cognitive and functional abilities will remain critical healthcare and research priorities. Best practice guidelines suggest that individualized exercise programs may improve fitness, cognition, and function for people with mild to moderate dementia; however, few high quality exercise intervention trials exist for this population. Increasingly, telehealth is being used to improve the delivery and availability of healthcare services for individuals living in rural areas, including exercise. This article describes the feasibility of a telehealth-delivered exercise intervention for rural, community-dwelling individuals diagnosed with dementia and their caregivers. METHODS: A mixed-methods two-phase exploratory approach was used. In phase 1, Rural and Remote Memory Clinic (RRMC; Saskatoon, Saskatchewan, Canada) patients and caregivers were surveyed about current exercise levels, perceptions about exercise, exercise preferences, and perceived barriers to exercise; community resources, acceptability of telehealth exercise interventions, and physical activity and exercise attitudes (Older Persons Attitudes Toward Physical Activity and Exercise Questionnaire). Data were analyzed using descriptive statistics and factors associated with willingness to participate in a telehealth exercise intervention were explored using hierarchical linear regression. In phase 2, acceptability, practicality, and implementation were examined. Two RRMC patient-caregiver dyads completed a 4-week exercise program delivered via telehealth. Observed engagement in the telehealth-based exercise intervention, using a revised version of the Menorah Park Engagement Scale (by Hearthstone Alzheimer Care), and attendance were monitored. Patient-caregiver dyads were interviewed at the end of the intervention phase and completed a telehealth and intervention satisfaction questionnaire. Interviews were thematically analyzed and questionnaire data were analyzed descriptively. RESULTS: Phase 1: Survey response rate was 50% (n=77). Patients (n=42) and caregivers (n=35) were equally likely to express interest in participating in the telehealth-based intervention. Willingness to participate in group exercise was the only significant predictor of willingness to participate in a telehealth-based intervention, accounting for 24.4% of the variance (F-statistic=16.14, p<0.001). Phase 2: Attendance rates were high for the telehealth-delivered exercise sessions. Engagement scale data indicated that the caregivers helped the patient participants during the intervention and that, overall, all participants were engaged in the target activity during the sessions. Ease of getting to the telehealth department, how well privacy was respected, ability to focus without distraction due to telehealth, ability to engage with group, and ability to engage with facilitator over telehealth were rated highly, as was the overall intervention experience. Telehealth voice and visual quality, ease of room set-up and conduciveness of the room to exercise were rated as good. Thematic analysis found that both dyads liked participating in the intervention together as a couple, and that participating in an exercise intervention with persons who were in a similar situations was deemed beneficial. CONCLUSIONS: Study results identified that although there are barriers to overcome, the development and evaluation of telehealth-delivered exercise interventions is a timely and important research activity that has the potential to facilitate improved healthcare services for individuals with dementia and their caregivers.

Maintaining health and wellness in the face of dementia: an exploratory analysis of individuals attending a rural and remote memory clinic.

INTRODUCTION: Worldwide, countries are calling for a chronic disease management approach to people with dementia. In response, 'living well' with dementia and 'supported self-care' frameworks are being adopted by advocacy and volunteer organizations, and more attention is being directed towards health and wellness promotion as a critical component for 'living well'. This exploratory study examined the health and wellness self-management behaviors of patients attending a rural and remote memory clinic; and relationships between engaging in health and wellness behaviors and psychological and neuropsychological function, independence in daily activities, and balance. METHODS: The cross-sectional sample comprised 260 patients referred to the Rural and Remote Memory Clinic (RRMC), Saskatchewan, Canada. Patients were diagnosed with amnestic or non-amnestic mild cognitive impairment, Alzheimer's disease (AD), or non-AD dementia. Via questionnaire, patients were asked how many days a week they exercised for at least 20 minutes, if their diet met the Canada's Food Guide to Healthy Eating recommendations, and what they did to maintain their psychological health. Patients completed a depression scale, a neuropsychological battery, and a balance scale. Caregivers completed the Functional Assessment Questionnaire. Questionnaire data were analyzed using descriptive statistics and correlational analyses. Bivariate associations between variables were assessed using point-biserial and Spearman's correlations, where appropriate. Open-ended responses were analyzed thematically. RESULTS: Participants were aged between 44 and 97 years, and had between 0 and 20 years of formal education. About half of those with Alzhemier's disease and more than half of the other diagnostic groups reported having five or more chronic conditions. Over a third of the total sample reported not exercising at all on a weekly basis. Less than half (42.7%) of the Alzhemier's disease group reported exercising for 20 minutes less than three times per week, while more than half of the other groups reported exercising for 20 minutes less than three times per week. Associations between exercise and tests of neuropsychological function and balance were statistically non-significant for the non-AD dementia group. In contrast, for the group with AD, engagement in exercise for 20 minutes for three or more times a week was moderately associated with better Stroop interference test scores and better balance. Seventy-four percent reported they met most or all of the Canada's Food Guide to Healthy Eating dietary recommendations, and 71% indicated they were engaged in activities to maintain their psychological health. Although many who reported engaging in activities to maintain their psychological health reported more than one activity, only 2.1% reported engaging in a combination of physical activities, social activities, and mentally stimulating activities. CONCLUSIONS: Patients referred to the RRMC reported good nutrition habits and participating in a variety of activities to maintain psychological health. Engaging in exercise and good nutrition was found to have beneficial effects for the sub-sample of patients with AD. Patients and their caregivers may require additional education and information regarding beneficial health and wellness promoting behaviors related to their diagnosis and concurrent comorbid conditions.

Less education predicts anticholinesterase discontinuation in dementia patients.

OBJECTIVE: We investigated patient socio-demographic, clinical and functional factors predicting cholinesterase inhibitor discontinuation by patients presenting to a memory clinic in Saskatoon, Saskatchewan. METHODS: Data collection began in March 2004 at the Rural and Remote Memory Clinic where family physicians referred their non-institutionalized patients. Neurological and neuropsychological assessment, patient and caregiver questionnaires provided the socio-demographic, clinical and functional variables. Univariate logistic regression analysis was used to examine possible associations between each independent variable and the binary outcome variable of treatment discontinuation. Multivariate logistic regression was used to determine predictors of cholinesterase inhibitor discontinuation within six months of drug initiation. RESULTS: Our sample consisted of the first 63 patients (60.3% female) for whom we prescribed a cholinesterase inhibitor. The mean age at clinic day was 74.56 years (SD=7.78). We found that years of formal education was the only variable significantly associated with cholinesterase inhibitor discontinuation by six months. The more years of formal education, the lower the rate of drug discontinuation by six months. CONCLUSIONS: Likelihood of cholinesterase inhibitor discontinuation by six months was predicted by fewer years of formal education.

Use and perceptions of information among family physicians: sources considered accessible, relevant, and reliable.

OBJECTIVES: The research determined (1) the information sources that family physicians (FPs) most commonly use to update their general medical knowledge and to make specific clinical decisions, and (2) the information sources FPs found to be most physically accessible, intellectually accessible (easy to understand), reliable (trustworthy), and relevant to their needs. METHODS: A cross-sectional postal survey of 792 FPs and locum tenens, in full-time or part-time medical practice, currently practicing or on leave of absence in the Canadian province of Saskatchewan was conducted during the period of January to April 2008. RESULTS: Of 666 eligible physicians, 331 completed and returned surveys, resulting in a response rate of 49.7% (331/666). Medical textbooks and colleagues in the main patient care setting were the top 2 sources for the purpose of making specific clinical decisions. Medical textbooks were most frequently considered by FPs to be reliable (trustworthy), and colleagues in the main patient care setting were most physically accessible (easy to access). CONCLUSIONS: When making specific clinical decisions, FPs were most likely to use information from sources that they considered to be reliable and generally physically accessible, suggesting that FPs can best be supported by facilitating easy and convenient access to high-quality information.

Base rates of low neuropsychological test scores in older adults with subjective cognitive impairment: Findings from a tertiary memory clinic.

Base rates of low scores are typically determined from normative samples, which differ from clinical samples. We examined base rates of spuriously low scores for 93 older adults with subjective cognitive impairment presenting to a memory clinic. Crawford's Monte Carlo simulation algorithm was used to estimate multivariate base rates by calculating the percentage of cognitively intact memory clinic patients who produced normed scores at or below the 5th percentile. Neuropsychological tests included: Weschler Adult Intelligence Scale block design, digit span backwards, coding, Weschler Memory Scale logical memory immediate/delayed; California Verbal Learning Test immediate/delayed memory; Brief Visuospatial Memory Test immediate/delayed; and Delis-Kaplan Executive Functioning category switching, letter number sequencing, and inhibition/switching. An estimated 33.58% of the cognitively intact memory clinic population would have one or more low scores, 14.7% two or more, 6.55% three or more, 2.94% four or more, and 1.31% 5 or more due to chance. Base rates were then applied to a subset of clinical data: all with dementia and most with MCI had low scores that exceeded the base rates. Determining base rates of spuriously low scores on a neuropsychological battery in clinical samples could reduce false positives by using empirical adjustments for expected low scores.

Utilization of Health Services Before and After Diagnosis in a Specialist Rural and Remote Memory Clinic.

Background: Limited research exists on the use of specific health services over an extended time among rural persons with dementia. The study objective was to examine health service use over a 10-year period, five years before until five years after diagnosis in the specialist Rural and Remote Memory Clinic (RRMC). Methods: Clinical and administrative health data of RRMC patients were linked. Annual health service utilization of the cohort (N = 436) was analyzed for 416 patients pre-index (57.5% female, mean age 71.2 years) and 419 post-index (56.3% female, mean age 70.8 years). Approximately 40% of memory clinic diagnoses were Alzheimer's disease (AD), 20% non-AD dementia, and 40% mild or subjective cognitive impairment or other condition. Post-index, 188 patients (44.9%) moved to permanent long-term care and were retained in the sample; 121 patients died (28.9%) and were removed yearly. Results: Over the ten-year study period, a significant increase occurred in the average number of FP visits, all-type drug prescriptions, and dementia-specific drug prescriptions (all p <.001). The highest proportion of patients hospitalized was observed one year pre-index, the highest average number of specialist visits was observed one year post-index, and both demonstrated a significant decreasing trend in the five-year post-index period (p = .037). Conclusions: A pattern of increasing FP visits and drug prescriptions over an extended period before and after diagnosis in a specialist rural and remote memory clinic highlights a need to support FPs in post-diagnostic management. Further research of longitudinal patterns in health service utilization is merited.

Predictors of cognitive impairment severity in rural patients at a memory clinic.

OBJECTIVE: Patients with dementia benefit from early assessment and diagnosis. In an attempt to identify factors leading to delay in referral, we investigated socio-demographic, clinical, and functional predictors of greater severity of cognitive impairment in dementia patients presenting to a memory clinic in Saskatoon, Saskatchewan. METHODS: Data collection began in 2004 at the Rural and Remote Memory Clinic in Saskatoon, where non-institutionalized patients were referred by their family physicians. The patient and caregiver questionnaires and assessments administered at the clinic day appointment provided the socio-demographic, clinical, and functional patient variables, as well as the caregiver stress and burden variables. The dependent variable was patient cognitive impairment, as measured by Modified Mini-Mental State Examination (3MS) scores. Variables underwent univariate linear regression with 3MS scores in order to determine possible associations. A multiple regression analysis was conducted to determine predictors of cognitive impairment severity at clinic presentation. RESULTS: Our sample included 198 patients (62% female). The mean age was 73.9 years (SD=9.2). We found that an age and gender interaction, years of formal education, Functional Activities Questionnaire score, and Brief Symptom Inventory score were significantly associated with 3MS scores (p<0.05). CONCLUSIONS: Increased cognitive impairment at presentation was predicted by fewer years of formal education, poorer functional ability, and less caregiver psychological distress. There was a significant interaction between age and gender: younger females were more cognitively impaired than younger males at clinic day, while in older patients, males were more cognitively impaired than females.

More alike than different: a comparison of male and female RNs in rural and remote Canada.

AIM: To explore gender differences and similarities on personal, employment and work-life factors and predictors of job satisfaction among registered nurses in rural and remote Canada. BACKGROUND: Research suggests that men and women are attracted to nursing for different reasons, with job security, range of employment opportunities and wages being important for male nurses. METHODS: Using data from a large national survey of registered nurses in rural and remote Canada, descriptive and multiple linear regression analyses were used to identify gender differences and similarities. RESULTS: A larger proportion of male nurses reported experiencing aggression in the workplace. Age, annual gross income and colleague support in medicine were not found to be predictors of work satisfaction for the male nurses, although they were for women. CONCLUSION: There are more similarities than differences between male and female registered nurses in factors that affect job satisfaction. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing management needs to increase their awareness of the potential for workplace aggression towards male registered nurses and to explore the perceptions of interpersonal interactions that affect satisfaction in the workplace.

Knowledge exchange throughout the dementia care journey by Canadian rural community-based health care practitioners, persons with dementia, and their care partners: an interpretive descriptive study.

INTRODUCTION: Accessing, assessing, exchanging, and applying dementia care information can be challenging in rural communities for healthcare practitioners (HCPs), persons with dementia (PWD), and their care partners. The overall purpose of this research was to enable HCPs, care partners, and PWD to use dementia care information more effectively by examining their information needs, how these change over time, and how they access, assess, and apply the knowledge. METHODS: A qualitative interpretive descriptive approach was used. A convenience sample was initially recruited through study collaborators in Southwestern Ontario, followed by purposive sampling. Nine rural dementia care networks consisting of PWD (n = 5), care partners (n = 14), and HCPs (n = 14) were recruited and 80 interviews were conducted at three time points. Transcripts were coded using Lubrosky's thematic analysis. RESULTS: Six stages of the dementia care journey were identified: (1) recognizing the symptoms; (2) receiving a diagnosis; (3) loss of independence; (4) initiating and using home care and respite services; (5) long-term care (LTC) placement; and (6) decisions related to end-of-life care. Rural care partners identified the need for different types of knowledge during each of these critical decision points of the dementia care journey. They accessed information from family members, friends, local organizations, and dementia internet sites. Persons with dementia tended not to identify the need for dementia care information. The HCPs accessed dementia care information from their own organization, other organizations, and internet sites. Care partners and HCPs assessed the trustworthiness of the information based on whether the source was a well-known agency or their own organization. Barriers to knowledge exchange included: lack of rural community-based services for dementia care; care partners reluctant to seek help and had limited energy; and lack of integration of dementia-related services and supports. Facilitators of knowledge exchange included: rural care partners with healthcare experience who were actively seeking information; development of trusting relationships between HCPs, care partners, and PWD; and formal mechanisms for exchanging information within and across rural community-based organizations. METHODS: This research illustrates the stages of the dementia care journey, and the types of information typically needed, accessed, assessed, and applied at each stage. Healthcare practitioners can use these findings to support rural care partners in navigating their dementia care journey. Support is needed as care partners often do not have the time, energy, skills, or knowledge to seek out dementia care information independently. In addition, PWD typically do not recognize the need for this knowledge, leaving care partners potentially isolated in this journey. Developing formal linkages within and across rural organizations will facilitate knowledge exchange and the delivery of cost-effective, quality dementia care. However, additional rural community-based resources are urgently needed to implement these recommendations. This may require a redistribution of resources from acute care to rural community care.