Primary Care-Based Memory Clinics: Expanding Capacity for Dementia Care.

The implementation in Ontario of 15 primary-care-based interprofessional memory clinics represented a unique model of team-based case management aimed at increasing capacity for dementia care at the primary-care level. Each clinic tracked referrals; in a subset of clinics, charts were audited by geriatricians, clinic members were interviewed, and patients, caregivers, and referring physicians completed satisfaction surveys. Across all clinics, 582 patients were assessed, and 8.9 per cent were referred to a specialist. Patients and caregivers were very satisfied with the care received, as were referring family physicians, who reported increased capacity to manage dementia. Geriatricians' chart audits revealed a high level of agreement with diagnosis and management. This study demonstrated acceptability, feasibility, and preliminary effectiveness of the primary-care memory clinic model. Led by specially trained family physicians, it provided timely access to high-quality collaborative dementia care, impacting health service utilization by more-efficient use of scarce geriatric specialist resources.

Structured approach to patients with memory difficulties in family practice.

OBJECTIVE: To provide family physicians with a structured approach to patients presenting with memory difficulties. SOURCES OF INFORMATION: The approach is based on an accredited memory clinic training program developed by the Centre for Family Medicine Memory Clinic in partnership with the Ontario College of Family Physicians. MAIN MESSAGE: Use of a structured clinical reasoning approach can assist physicians in achieving an accurate diagnosis in patients presenting with memory difficulties. Delirium, depression, and reversible causes need to be excluded, followed by differentiation among normal cognitive aging, mild cognitive impairment, and dementia. Obtaining collateral history and accurate functional assessment are critical. Common forms of dementia can be clinically differentiated by the order in which symptoms appear and by how cognitive deficits evolve over time. Typically, early signs of Alzheimer dementia involve impairment in episodic memory, whereas dementia involving predominantly vascular causes might present with early loss of executive function and relatively preserved episodic memory. Frontotemporal dementia and Lewy body spectrum disorders might have early loss of executive function and visuospatial function, as well as characteristic clinical features. CONCLUSION: A clinical reasoning approach can help physicians achieve early, accurate diagnoses that can guide appropriate management and improve care for patients with memory difficulties.

Enhancing dementia care: a primary care-based memory clinic.

Memory clinics have been promoted as opportunities for improving dementia diagnosis and care. This article describes the implementation of an interdisciplinary memory clinic within primary care in Ontario, Canada, that aims to provide timely access to comprehensive assessment and care and to improve referring physicians' knowledge of the management of dementia through collaborative care and practice-based mentorship. Between July 2006 and September 2009, 246 initial and follow-up assessments were conducted with 151 patients, a high proportion of whom received a new diagnosis of mild cognitive impairment (44.4%) or dementia (19.2%). A trial of cholinesterase inhibitors was recommended for almost all patients newly diagnosed with dementia. Management interventions and recommendations included social worker outreach, long-term care planning, home safety or driving assessments, referral to community resources, and periodic follow-up and monitoring. A small proportion of patients (7.8%) were referred to a specialist. Surveyed patients and caregivers were very satisfied with their visit to the clinic. A chart audit conducted by two independent geriatricians indicated agreement with diagnosis and intervention, particularly related to use of specialists. The results indicate that memory clinics within primary care settings can support capacity building to ensure quality assessment and management of dementia at a primary care level.

Cost-effectiveness of memantine compared with standard care in moderate-to-severe Alzheimer disease in Canada.

OBJECTIVE: To conduct a cost-effectiveness analysis comparing the addition of memantine to standard care (that is, without acetylcholinesterase inhibitors) with standard care alone in moderate-to-severe Alzheimer disease (AD) in Canada. METHODS: A 2-year Markov model estimated clinical effects in terms of quality-adjusted life years (QALYs) and time in complete dependence as well as societal costs in four 6-month cycles. Health states were defined by AD severity assessed with the Mini-Mental State Examination (moderate = 10 to 19; severe < 10), by level of dependence in activities of daily living, and by death. Transition probabilities were estimated by combining data of patients with moderate-to-severe AD from all relevant clinical trials. QALYs were estimated from a UK epidemiologic study. The initial distribution and use of medical and support services for each health state was obtained from the Canadian Study on Health and Aging with current estimates of frequency of use and unit prices applied. RESULTS: Compared with standard care, the memantine strategy saved more than 1 month of complete dependence and produced 0.03 additional QALYs, with no additional cost. Probabilistic sensitivity analyses give an 83.3% chance that memantine treatment is cost-neutral, an 89.5% chance of its being cost-effective if the decision maker is willing to pay $20 000 for a QALY, and a 96.2% chance with a willingness to pay $100 000 per QALY. Robustness of results was confirmed through 1-way and scenario-based sensitivity analyses. CONCLUSIONS: Our evaluation found that memantine monotherapy produced relevant health benefit, compared with standard care alone, with no additional costs. Results are consistent with other economic evaluations of memantine conducted in Europe and the United States.

Knee flexion and base of support in asymmetrical handling: effects on the worker's dynamic stability and the moments of the L(5)/S(1) and knee joints.

OBJECTIVE: To investigate the effects of knee flexion and of the variations of feet lateral spacing on dynamic stability and on the net joint moments distribution between the back and knees. BACKGROUND: The width of the base of support and knee flexion effects on joint moments in asymmetric handling and especially on the worker's stability have rarely been studied. METHODS: Fourteen healthy male subjects performed an asymmetrical lifting task, using four different techniques: two imposed lateral feet spacings (41 and 57 cm) and two knee flexion amplitudes (slightly and deeply flexed knees). A tridimensional dynamic rigid body model was used to estimate the triaxial net reaction moments at L(5)/S(1) and at the knees, using two force platforms. New developments have been undertaken to characterize workers' stability while handling: the horizontal force required to destabilize the worker was calculated as a measure of dynamic stability. RESULTS: The width of the base of support had little effect on L(5)/S(1) and knee moments; however, the subjects were less stable with the narrow base of support. Using the slightly flexed knees technique, trunk maximal resultant moments were slightly smaller (202 vs. 216 Nm), and maximal resultant knee moments were larger (96 vs. 62 Nm). Furthermore, asymmetric moments at the trunk and the asymmetric position of the knees were reduced with this technique, but subjects were less stable. CONCLUSIONS: The use of a slightly flexed knees technique in asymmetrical handling of low-lying loads appears advantageous because it reduces L(5)/S(1) moments while increasing the knees' flexing moments, although this may compromise workers' stability. RELEVANCE: Handling methods used by workers in asymmetrical handling have rarely been studied. Optimizing the safety of a handling method can involve many parameters, such as reducing joint moments and maximizing stability. The evaluation of the worker's stability while handling in conjunction with joint moments is an interesting alternative to study the safety of handling methods.

Load Acceleration and Footstep Strategies in Asymmetrical Lifting and Lowering.

Accelerated execution effects for lifting and lowering a 12-kg box using two footstep strategies associated with experienced workers were studied. Eight healthy male participants performed a normal and an accelerated execution of a lifting task and a lowering task, using a minimal feet displacement strategy (oblique-step) and a strategy with a step (crossed-step). It was hypothesized that the accelerated executions, as compared to the normal executions, would have a different effect on L5/S1 resultant moment, body posture, and other kinematic variables. A tridimensional dynamic rigid body model was used to compute L5/S1 resultant moments. Results showed that the accelerated condition did not reduce body asymmetry of posture, but it reduced the length of the path of the global center of gravity and the duration of the supporting phase of the box, and it did not significantly affect L5/S1 maximal resultant moments for lifting but increased them for lowering. These results indicate that the net work production for accelerated strategies might be smaller, which may represent an economy of energy. Furthermore, the results showed that the use of an accelerated strategy for lowering should be avoided.

Predictive Models of Lumbar Loadings When Handling Boxes.

Back problems resulting from the compression forces on the intervertebral disks during manual material-handling tasks are an important problem affecting workers in various industries. The quantification of these forces using intradiscal pressure or biomechanical modeling is complex, time consuming, and costly, and these methods cannot be readily used in the workplace to estimate loadings on the lower back. The objective of this study was to develop a predictive model that would allow the estimation of lumbar loadings for lifting and lowering boxes using easily measured anthropometric variables and variables related to the task. A dynamic and planar segmental model and a model of internal forces at L5/S1 were used to determine the compression forces on the lower back. Two predictive models, a field model and a laboratory model, were developed to estimate the compression forces when lifting or lowering 3.3 kg to 22.0 kg boxes between heights of 15 cm and 185 cm. Both models were validated by an examination of the residuals. Their predictive performance was also compared, with the laboratory model offering a slightly better prediction than the field model. Thus, these equations represent a practical tool for a better planning of handling tasks in the working environment with the purpose of reducing the back injuries of workers.

Handling Techniques: The Influence of Weight and Height for Experts and Novices.

The purpose of this study was to evaluate the influence of the weight of the load (12 kg, 22 kg) and of the height of the grasp (high: 126 cm; middle: 64 cm and 95 cm; low: 33 cm) on the handling techniques adopted by six experienced handlers and six novices having only limited handling experience during a free box-handling task. Each subject had to transfer two sets of 16 boxes from a platform to a four-wheel cart. The observations dealt with the position of the subject at the beginning of transfer and at deposit (position of the back, knees and feet, pelvic orientation, position of the hands), his way of moving during the transfer (position of the feet), and his way of positioning and moving the box during handling (tilt of the box, impulse given to the box, grip change). The results show that the weight and the height of grasp/deposit had an influence on the techniques adopted by expert handlers and novices. Some of these variations are common to both groups but many of them are not, such as the position of the knees, the grips and the position of the box. This study suggests that there is not one method that is suitable for all situations, and that expert handlers may have learned how to adjust their methods to the working environment. A better understanding of the experts' techniques could help in redesigning efficient training programs.