Real-Time Epidemiology and Acute Care Need Monitoring and Forecasting for COVID-19 via Bayesian Sequential Monte Carlo-Leveraged Transmission Models.

COVID-19 transmission models have conferred great value in informing public health understanding, planning, and response. However, the pandemic also demonstrated the infeasibility of basing public health decision-making on transmission models with pre-set assumptions. No matter how favourably evidenced when built, a model with fixed assumptions is challenged by numerous factors that are difficult to predict. Ongoing planning associated with rolling back and re-instituting measures, initiating surge planning, and issuing public health advisories can benefit from approaches that allow state estimates for transmission models to be continuously updated in light of unfolding time series. A model being continuously regrounded by empirical data in this way can provide a consistent, integrated depiction of the evolving underlying epidemiology and acute care demand, offer the ability to project forward such a depiction in a fashion suitable for triggering the deployment of acute care surge capacity or public health measures, and support quantitative evaluation of tradeoffs associated with prospective interventions in light of the latest estimates of the underlying epidemiology. We describe here the design, implementation, and multi-year daily use for public health and clinical support decision-making of a particle-filtered COVID-19 compartmental model, which served Canadian federal and provincial governments via regular reporting starting in June 2020. The use of the Bayesian sequential Monte Carlo algorithm of particle filtering allows the model to be regrounded daily and adapt to new trends within daily incoming data-including test volumes and positivity rates, endogenous and travel-related cases, hospital census and admissions flows, daily counts of dose-specific vaccinations administered, measured concentration of SARS-CoV-2 in wastewater, and mortality. Important model outputs include estimates (via sampling) of the count of undiagnosed infectives, the count of individuals at different stages of the natural history of frankly and pauci-symptomatic infection, the current force of infection, effective reproductive number, and current and cumulative infection prevalence. Following a brief description of the model design, we describe how the machine learning algorithm of particle filtering is used to continually reground estimates of the dynamic model state, support a probabilistic model projection of epidemiology and health system capacity utilization and service demand, and probabilistically evaluate tradeoffs between potential intervention scenarios. We further note aspects of model use in practice as an effective reporting tool in a manner that is parameterized by jurisdiction, including the support of a scripting pipeline that permits a fully automated reporting pipeline other than security-restricted new data retrieval, including automated model deployment, data validity checks, and automatic post-scenario scripting and reporting. As demonstrated by this multi-year deployment of the Bayesian machine learning algorithm of particle filtering to provide industrial-strength reporting to inform public health decision-making across Canada, such methods offer strong support for evidence-based public health decision-making informed by ever-current articulated transmission models whose probabilistic state and parameter estimates are continually regrounded by diverse data streams.

The impact of alternate level of care on access block and operational strategies to reduce emergency wait times: a multi-center simulation study.

OBJECTIVES: Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times. METHODS: Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017-March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED. RESULTS: Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16-0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34-6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates. CONCLUSIONS: A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.

ABSTRAIT: OBJECTIF: Les longs temps d'attente dans les services d'urgence (SU) à cause de blocage de l'accès à l'hôpital sont une préoccupation croissante pour le système de santé canadien. Notre objectif était de quantifier l'impact d'un autre niveau de soins sur le bloc d'accès à l'hôpital et d'évaluer les effets probables d'interventions multiples sur les temps d'attente aux départements d'urgences. MéTHODES: Des modèles de simulation aux événements discrets ont été développés pour simuler les flux de patients dans les urgences et les soins aigus de six hôpitaux canadiens. Le mod èle a été rempli de données administratives ayant plusieurs sources (avril 2017 à mars 2018). Nous avons simulé et évalué l'impact de six scénarios d'intervention différents sur trois mesures de résultats : 1) le temps d'attente pour l'évaluation initiale du médecin, 2) le temps d'attente pour un lit pour des patients hospitalisés et 3) les patients qui partent sans être vus. Nous avons comparé chaque mesure de résultats de ce scénario au scénario de référence pour chaque département d'urgences. RéSULTATS: L'élimination de 30 % des jours d'hospitalisation à un autre niveau de soins des patients médicaux a réduit le temps moyen d'attente pour un patient hospitalisé de 0,25 à 4,22 heures. L'augmentation du nombre des médecins des urgences a réduit le temps moyen d'attente pour l'évaluation initiale du médecin (∆ 0,16 à 0,46 heures). Les transitions de soins de haute qualité ciblant les patients médicaux ont réduit la période moyen d'attente des patients hospitalisés pour tous les services d'urgence (∆ 0,34 à 6,85 heures). La réduction des visites à l'urgence pour des conditions sensibles à la médecine familiale ou l'augmentation de la continuité des soins ont entraîné des réductions cliniquement insignifiantes des temps d'attente et des taux de patients qui quittent sans être vus. CONCLUSIONS: Une réduction modérée du nombre d'un autre niveau de soins pour les patients médicaux pourrait non seulement soulager le blocage de l'accès mais aussi réduire les temps d'attente aux urgences, afin de l'ampleur de la réduction varie selon le site. L'augmentation du nombre de médecins des urgences et l'harmonisation de la capacité des médecins avec la demande d'afflux pourraient également réduire le temps d'attente. Les stratégies opérationnelles destinées à réduire les temps d'attente aux urgences devraient accorder la priorité à la résolution des facteurs de sortie et de débit plutôt qu'aux facteurs d'entrée.

Can facility-based transitional care improve patient flow? Lessons from four Canadian regions.

Units providing transitional, subacute, or restorative care represent a common intervention to facilitate patient flow and improve outcomes for lower acuity (often older) inpatients; however, little is known about Canadian health systems' experiences with such "transition units." This comparative case study of diverse units in four health regions (48 interviews) identified important success factors and pitfalls. A fundamental requirement for success is to clearly define the unit's intended population and design the model around its needs. Planners must also ensure that the unit be resourced and staffed to deliver truly restorative care. Finally, streamlined processes must be developed to help patients access and move through the unit. Units that were perceived as more effective appeared to have satisfactorily addressed these population, capacity, and process issues, whereas those perceived as less effective continued to struggle with them. Findings suggest principles to support optimal design and implementation of transition units.

Changes in fall risk and functional status in women aged 50 years and older after distal radius fracture: A prospective 1-year follow-up study.

STUDY DESIGN: Prospective cohort study. INTRODUCTION: Few studies have evaluated the course of recovery after distal radius fracture (DRF) when functional decline and fracture risk may be affected. PURPOSE OF THE STUDY: The purpose of this study was to determine changes in overall functional status over the first year after a DRF in women aged 50 years and older. METHODS: Seventy-eight women were assessed for balance, balance confidence, lower extremity strength, gait speed, fall history, physical activity levels, and self-reported wrist pain and function (Patient-Rated Wrist Evaluation) at weeks 1, 3, 9, 12, 26, and 52 after DRF. Descriptive data were generated for all variables; a 3-way mixed analysis of variance with repeated measures was used to compare differences between participants aged 50-65 years and 65 years and older. RESULTS: There was a significant improvement in functional status measures for both age categories except single-leg balance and fast gait speed, from 1 week after fracture extending up to 1 year after fracture (ranging from 6.1% improvement to 25% improvement, P < .05). There was no significant time × age interaction, as both age groups had the same pattern of recovery; however, there was significantly lower functional status in the older group across all time points. CONCLUSION: Regardless of age, monitoring and addressing functional status including upper limb function, overall strength, balance, confidence, usual gait speed, and physical activity right up to 1 year after fracture is an important consideration for clinicians treating women recovering from DRF. Given the high future fracture risk for these women, identifying functional recovery patterns can help to direct future research and determine preventative strategies.

A Scoping Review of Frailty and Acute Care in Middle-Aged and Older Individuals with Recommendations for Future Research.

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

An evaluation of the comparative effectiveness of geriatrician-led comprehensive geriatric assessment for improving patient and healthcare system outcomes for older adults: a protocol for a systematic review and network meta-analysis.

BACKGROUND: Comprehensive geriatric assessment (CGA) is an integrated model of care involving a geriatrician and an interdisciplinary team and can prioritize and manage complex health needs of older adults with multimorbidity. CGAs differ across healthcare settings, ranging from shared care conducted in primary care settings to specialized inpatient units in acute care. Models of care involving geriatricians vary across healthcare settings, and it is unclear which CGA model is most effective. Our objective is to conduct a systematic review and network meta-analysis (NMA) to examine the comparative effectiveness of various geriatrician-led CGAs and to identify which models improve patient and healthcare system level outcomes. METHODS: An integrated knowledge translation approach will be used and knowledge users (KUs) including patients, caregivers, geriatricians, and healthcare policymakers will be involved throughout the review. Electronic databases including MEDLINE, EMBASE, Cochrane library, and Ageline will be searched from inception to November 2016 to identify relevant studies. Randomized controlled trials of older adults (≥65 years of age) that examine geriatrician-led CGAs compared to any intervention will be included. Primary and secondary outcomes will be selected by KUs to ensure the results are relevant to their decision-making. Two reviewers will independently screen the search results, extract data, and assess risk of bias. Data will be synthesized using an NMA to allow for multiple comparisons using direct (head-to-head) as well as indirect evidence. Interventions will be ranked according to their effectiveness using surface under the cumulative ranking curve (SUCRA). DISCUSSION: As the proportion of older adults grows worldwide, the demand for specialized geriatric services that help manage complex health needs of older adults with multimorbidity will increase in many countries. Results from this systematic review and NMA will enhance decision-making and the efficient allocation of scarce geriatric resources. Moreover, active involvement of KUs throughout the review process will ensure the results are relevant to different levels of decision-making. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014014008.

Falls and Wrist Fracture: Relationship to Women's Functional Status after Age 50.

Women experience a rapid rise in the incidence of wrist fracture after age 50. Accordingly, this study aimed to (1) determine the internal and environmental fall-related circumstances resulting in a wrist fracture, and (2) examine the relationship of functional status to these circumstances. Women aged 50 to 94 years reported on the nature of the injury (n = 99) and underwent testing for physical activity status, balance, strength, and mobility (n = 72). The majority of falls causing wrist fracture occurred outdoors, during winter months, as a result of a slip or trip while walking. Half of these falls resulted in other injuries including head, neck, and spine injuries. Faster walking speed, lower grip strength, and higher balance confidence were significantly associated with outdoor versus indoor falls and slips and trips versus other causes. This study provides insights into potential screening and preventive measures for fall-related wrist fractures in women.

Rationalizing prescribing for older patients with multimorbidity: considering time to benefit.

Given the growing number of older adults with multimorbidity who are prescribed multiple medications, clinicians need to prioritize which medications are most likely to benefit and least likely to harm an individual patient. The concept of time to benefit (TTB) is increasingly discussed in addition to other measures of drug effectiveness in order to understand and contextualize the benefits and harms of a therapy to an individual patient. However, how to glean this information from available evidence is not well established. The lack of such information for clinicians highlights a critical need in the design and reporting of clinical trials to provide information most relevant to decision making for older adults with multimorbidity. We define TTB as the time until a statistically significant benefit is observed in trials of people taking a therapy compared to a control group not taking the therapy. Similarly, time to harm (TTH) is the time until a statistically significant adverse effect is seen in a trial for the treatment group compared to the control group. To determine both TTB and TTH, it is critical that we also clearly define the benefit or harm under consideration. Well-defined benefits or harms are clinically meaningful, measurable outcomes that are desired (or shunned) by patients. In this conceptual review, we illustrate concepts of TTB in randomized controlled trials (RCTs) of statins for the primary prevention of cardiovascular disease. Using published results, we estimate probable TTB for statins with the future goal of using such information to improve prescribing decisions for individual patients. Knowing the relative TTBs and TTHs associated with a patient's medications could be immensely useful to a clinician in decision making for their older patients with multimorbidity. We describe the challenges in defining and determining TTB and TTH, and discuss possible ways of analyzing and reporting trial results that would add more information about this aspect of drug effectiveness to the clinician's evidence base.

Cross-education for improving strength and mobility after distal radius fractures: a randomized controlled trial.

OBJECTIVE: To evaluate the effects of cross-education (contralateral effect of unilateral strength training) during recovery from unilateral distal radius fractures on muscle strength, range of motion (ROM), and function. DESIGN: Randomized controlled trial (26-wk follow-up). SETTING: Hospital, orthopedic fracture clinic. PARTICIPANTS: Women older than 50 years with a unilateral distal radius fracture. Fifty-one participants were randomized and 39 participants were included in the final data analysis. INTERVENTIONS: Participants were randomized to standard rehabilitation (Control) or standard rehabilitation plus strength training (Train). Standard rehabilitation included forearm casting for 40.4±6.2 days and hand exercises for the fractured extremity. Nonfractured hand strength training for the training group began immediately postfracture and was conducted at home 3 times/week for 26 weeks. MAIN OUTCOME MEASURES: The primary outcome measure was peak force (handgrip dynamometer). Secondary outcomes were ROM (flexion/extension; supination/pronation) via goniometer and the Patient Rated Wrist Evaluation questionnaire score for the fractured arm. RESULTS: For the fractured hand, the training group (17.3±7.4kg) was significantly stronger than the control group (11.8±5.8kg) at 12 weeks postfracture (P<.017). There were no significant strength differences between the training and control groups at 9 (12.5±8.2kg; 11.3±6.9kg) or 26 weeks (23.0±7.6kg; 19.6±5.5kg) postfracture, respectively. Fractured hand ROM showed that the training group had significantly improved wrist flexion/extension (100.5°±19.2°) than the control group (80.2°±18.7°) at 12 weeks postfracture (P<.017). There were no significant differences between the training and control groups for flexion/extension ROM at 9 (78.0°±20.7°; 81.7°±25.7°) or 26 weeks (104.4°±15.5°; 106.0°±26.5°) or supination/pronation ROM at 9 (153.9°±23.9°; 151.8°±33.0°), 12 (170.9°±9.3°; 156.7°±20.8°) or 26 weeks (169.4°±11.9°; 162.8°±18.1°), respectively. There were no significant differences in Patient Rated Wrist Evaluation questionnaire scores between the training and control groups at 9 (54.2±39.0; 65.2±28.9), 12 (36.4±37.2; 46.2±35.3), or 26 weeks (23.6±25.6; 19.4±16.5), respectively. CONCLUSIONS: Strength training for the nonfractured limb after a distal radius fracture was associated with improved strength and ROM in the fractured limb at 12 weeks postfracture. These results have important implications for rehabilitation strategies after unilateral injuries.

Validation of the Saskatoon Falls Prevention Consortium's Falls Screening and Referral Algorithm.

PURPOSE: To investigate the concurrent validity of the Saskatoon Falls Prevention Consortium's Falls Screening and Referral Algorithm (FSRA). METHOD: A total of 29 older adults (mean age 77.7 [SD 4.0] y) residing in an independent-living senior's complex who met inclusion criteria completed a demographic questionnaire and the components of the FSRA and Berg Balance Scale (BBS). The FSRA consists of the Elderly Fall Screening Test (EFST) and the Multi-factor Falls Questionnaire (MFQ); it is designed to categorize individuals into low, moderate, or high fall-risk categories to determine appropriate management pathways. A predictive model for probability of fall risk, based on previous research, was used to determine concurrent validity of the FSRI. RESULTS: The FSRA placed 79% of participants into the low-risk category, whereas the predictive model found the probability of fall risk to range from 0.04 to 0.74, with a mean of 0.35 (SD 0.25). No statistically significant correlation was found between the FSRA and the predictive model for probability of fall risk (Spearman's ρ=0.35, p=0.06). CONCLUSION: The FSRA lacks concurrent validity relative to to a previously established model of fall risk and appears to over-categorize individuals into the low-risk group. Further research on the FSRA as an adequate tool to screen community-dwelling older adults for fall risk is recommended.

Objectif : Étudier la validité concurrente de l'algorithme de dépistage des risques de chute et de renvoi en consultation (Falls Screening and Referral Algorithm, FSRA) du Saskatoon Falls Prevention Consortium. Méthode : Vingt-neuf personnes âgées (moyenne d'âge [ET] de 77,7 ans [4,0]) vivant dans une résidence pour personnes âgées autonomes satisfaisaient les critères d'inclusion; elles ont rempli un questionnaire démographique et ont été soumises à certaines composantes du FSRA et du test d'équilibre de l'échelle de Berg (EEB). Le FSRA comprend un test de dépistage des risques de chute (Elderly Fall Screening Test, EFST) et le questionnaire multifactoriel en matière de chutes (Multi-Factor Falls Questionnaire, MFQ). Il est conçu pour classer les individus dans trois catégories ­ risque de chute élevé, modéré ou faible ­ afin d'établir les approches de gestion appropriées. Un modèle prédictif de probabilité des risques de chute basé sur une étude antérieure a été utilisé pour établir la validité concurrente du FRSA. Résultats : Au total, 79 % des participants ont été classés dans la catégorie à faible risque du FSRA, puisque le modèle prédictif a permis d'établir la probabilité des risques de chute dans leur cas entre 0,04 et 0,74, avec une moyenne de 0,35 (ET=0,25). On n'a pu établir aucune corrélation significative sur le plan statistique entre le FSRA et le modèle prédictif de la probabilité des risques de chute (ρ de Spearman=0,35, p=0,06). Conclusion : Le FSRA manque de validité concurrente si on le compare à un modèle de risques de chute préalablement établi et semble « surclasser ¼ les individus dans le segment à faible risque. D'autres études sur le FSRA en tant qu'outil approprié de dépistage chez les aînés résidant dans la communauté sont recommandées.

Specialist physicians in geriatrics-report of the canadian geriatrics society physician resource work group.

BACKGROUND: At the 2011 Annual Business Meeting of the Canadian Geriatrics Society (CGS), an ad hoc Work Group was struck to submit a report providing an estimate of the number of physicians and full-time equivalents (FTEs) currently working in the field of geriatrics, an estimate of the number required (if possible), and a clearer understanding of what has to be done to move physician resource planning in geriatrics forward in Canada. METHODS: It was decided to focus on specialist physicians in geriatrics (defined as those who have completed advanced clinical training or have equivalent work experience in geriatrics and who limit a significant portion of their work-related activities to the duties of a consultant). RESULTS: In 2012, there are 230-242 certified specialists in geriatric medicine and approximately 326.15 FTE functional specialists in geriatrics. While this is less than the number required, no precise estimate of present and future need could be provided, as no attempts at a national physician resource plan in geriatrics based on utilization and demand forecasting, needs-based planning, and/or benchmarking have taken place. CONCLUSIONS: This would be an opportune time for the CGS to become more involved in physician resource planning. In addition to this being critical for the future health of our field of practice, there is increasing interest in aligning specialty training with societal needs (n = 216).

The longitudinal elderly person shadowing program: outcomes from an interprofessional senior partner mentoring program.

The University of Saskatchewan's Longitudinal Elderly Person Shadowing (LEPS) is an interprofessional senior mentors program (SMP) where teams of undergraduate students in their first year of medicine, pharmacy, and physiotherapy; 2nd year of nutrition; 3rd year nursing; and 4th year social work partner with community-dwelling older adults. Existing literature on SMPs provides little information on the sustainability of attitudinal changes toward older adults or changes in interprofessional attitudes. LEPS students completed Polizzi's Aging Semantic Differential and the Interdisciplinary Education Perception Scale. Perceptions of older men and women improved significantly and changes were sustained after one year. However, few changes were seen in interprofessional attitudes.

A review of monitoring technology for use with older adults.

BACKGROUND: Many Americans are living longer and recent studies report that the majority of older adults wish to live as independently as possible in their own homes, for as long as possible. This creates a need for effective monitoring, and technology has much to offer. PURPOSE: The purpose of this article is to provide a narrative review of current monitoring technology appropriate for older adults' home use. METHODS: A review of current literature provides a comprehensive discussion of the development of this technology. DISCUSSION: In the past several years, advancements have been made in the area of monitoring the movement and activity of older adults in their home environment. This technology may benefit older individuals by assisting them to remain living in their own homes for as long as possible. Unobtrusive monitoring and wearable technology, which is clothing or accessories that incorporate computer or electronic technology, are rapidly expanding areas of development. Various applications of this technology may assist in falls detection and overall safety. In addition, continuous monitoring of an older adult's specific movements or activity can identify changes in day-to-day activity levels, which may indicate a change in medical status. CONCLUSION: Although many devices are still at the developmental stage, the future of this technology may offer older adults a level of increased safety and security in their homes.

Evaluation of Telehealth for Preclinic Assessment and Follow-Up in an Interprofessional Rural and Remote Memory Clinic.

Using data from a sample of 169 patients, this study evaluates the acceptability and feasibility of telehealth videoconferencing for preclinic assessment and follow-up in an interprofessional memory clinic for rural and remote seniors. Patients and caregivers are seen via telehealth prior to the in-person clinic, and followed at 6 weeks, 12 weeks, 6 months, one year, and yearly. Patients are randomly assigned to in-person (standard care) or telehealth for the first follow-up, then alternating between the two modes of treatment, prior to 1-year follow-up. On average, telehealth appointments reduce participants' travel by 426 km per round trip. Findings show that telehealth coordinators rated 85% of patients and 92% of caregiversas comfortable or very comfortable during telehealth. Satisfaction scales completed by patient-caregiver dyads show high satisfaction with telehealth. Follow-up questionnaires reveal similar satisfaction with telehealth and in-person appointments, but telehealth is rated as significantly more convenient. Predictors of discontinuing follow-up are greater distance to telehealth, old-age patient, lower telehealth satisfaction, and lower caregiver burden.

Pulse transit time-based blood pressure estimation using hilbert-huang transform.

The pulse transit time (PTT) based method has been suggested as a continuous, cuffless and non-invasive approach to estimate blood pressure. It is of paramount importance to accurately determine the pulse transit time from the measured electrocardiogram (ECG) and photoplethysmo-gram (PPG) signals. We apply the celebrated Hilbert-Huang Transform (HHT) to process both the ECG and PPG signals, and improve the accuracy of the PTT estimation. Further, the blood pressure variation is obtained by using a well-established formula reflecting the relationship between the blood pressure and the estimated PTT. Simulation results are provided to illustrate the effectiveness of the proposed method.

A fall and near-fall assessment and evaluation system.

The FANFARE (Falls And Near Falls Assessment Research and Evaluation) project has developed a system to fulfill the need for a wearable device to collect data for fall and near-falls analysis. The system consists of a computer and a wireless sensor network to measure, display, and store fall related parameters such as postural activities and heart rate variability. Ease of use and low power are considered in the design. The system was built and tested successfully. Different machine learning algorithms were applied to the stored data for fall and near-fall evaluation. Results indicate that the Naïve Bayes algorithm is the best choice, due to its fast model building and high accuracy in fall detection.

Improving access to dementia care: development and evaluation of a rural and remote memory clinic.

The availability, accessibility and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.

The potential of gait analysis to contribute to differential diagnosis of early stage dementia: current research and future directions.

Early differential diagnosis of dementia is becoming increasingly important as new pharmacologic therapies are developed, as these treatments are not equally effective for all types of dementia. Early detection and differential diagnosis also facilitates informed family decision making and timely access to appropriate services. Information about gait characteristics is informative in the diagnostic process and may have important implications for discriminating among dementia subtypes. The aim of this review paper is to summarize existing research examining the relationships between gait and dementia, including gait classification systems and assessment tools, gait patterns characteristic of different dementias (Alzheimer's disease, vascular dementia, dementia with Lewy Bodies, and fronto-temporal dementia), and the utility of gait analysis in early-stage diagnosis. The paper concludes with implications for future research.

Supplemental use of antioxidant vitamins and subsequent risk of cognitive decline and dementia.

There are conflicting reports about the potential role of vitamin antioxidants in preventing and/or slowing the progression of various forms of cognitive impairment including Alzheimer's disease (AD). We examined longitudinal data from the Canadian Study of Health and Aging, a population-based, prospective 5-year investigation of the epidemiology of dementia among Canadians aged 65+ years. Our primary objective was to examine the association between supplemental use of antioxidant vitamins and subsequent risk of significant cognitive decline (decrease in 3MS score of 10 points or more) among subjects with no evidence of dementia at baseline (n=894). We also explored the relationship between vitamin supplement use and incident vascular cognitive impairment (VCI; including a diagnosis of vascular dementia, possible AD with vascular components and VCI but not dementia), dementia (all cases) and AD. After adjusting for potential confounding factors assessed at baseline, subjects reporting a combined use of vitamin E and C supplements and/or multivitamin consumption at baseline were significantly less likely (adjusted OR 0.51; 95% CI 0.29-0.90) to experience significant cognitive decline during a 5-year follow-up period. Subjects reporting any antioxidant vitamin use at baseline also showed a significantly lower risk for incident VCI (adjusted OR 0.34, 95% CI 0.13-0.89). A reduced risk for incident dementia or AD was not observed. Our findings suggest a possible protective effect for antioxidant vitamins in relation to cognitive decline but randomized controlled trials are required for confirmation.