Traumatic brain injuries among veterans and the risk of incident dementia: A systematic review & meta-analysis.

BACKGROUND: Traumatic brain injuries (TBI) among military veterans are increasingly recognized as important causes of both short and long-term neuropsychological dysfunction. However, the association between TBI and the development of dementia is controversial. This systematic review and meta-analysis sought to quantify the risks of all-cause dementia including Alzheimer's diseases and related dementias (ADRD), and to explore whether the relationships are influenced by the severity and recurrence of head injuries. METHODS: Database searches of Medline, Embase, Ovid Healthstar, PubMed and PROSPERO were undertaken from inception to December 2020 and supplemented with grey literature searches without language restrictions. Observational cohort studies examining TBI and incident dementia among veterans were analysed using Dersimonian-Laird random-effects models. RESULTS: Thirteen cohort studies totalling over 7.1 million observations with veterans were included. TBI was associated with an increased risk of all-cause dementia (hazard ratio [HR] = 1.95, 95% confidence interval [CI]: 1.55-2.45), vascular dementia (HR = 2.02, 95% CI: 1.46-2.80), but not Alzheimer's disease (HR = 1.30, 95% CI: 0.88-1.91). Severe and penetrating injuries were associated with a higher risk of all-cause dementia (HR = 3.35, 95% CI: 2.47-4.55) than moderate injuries (HR = 2.82, 95% CI: 1.44-5.52) and mild injuries (HR = 1.91, 95% CI: 1.30-2.80). However, the dose-response relationship was attenuated when additional studies with sufficient data to classify trauma severity were included. CONCLUSION: TBI is a significant risk factor for incident all-cause dementia and vascular dementia. These results need to be interpreted cautiously in the presence of significant heterogeneity.

The Care-of-the-Elderly Health Guide.

INTRODUCTION: The Evidence-Based Care of the Elderly Health Guide is a clinical guide with cross-references for care recommendations. This guide is an innovative adaptation of the Rourke Baby Record to support elderly care. In 2003, the guide was published with an endorsement from the Health Care-of-the-Elderly Committee of the College of Family Physicians of Canada. Since then, physicians have used the guide as a checklist and a monitoring tool for care to elderly patients. OBJECTIVE: We will update the 2003 Care-of-the-Elderly Health Guide with current published evidence-based recommendations. METHODS: This was a mixed methods study consisting of (1) the creation of a list of topics and corresponding guidelines or recommendations, (2) two focus group discussions among family physicians (n = 12) to validate the list for relevance to practice, and (3) a modified Delphi technique in a group of ten experts in Care of the Elderly and geriatrics to attain consensus on whether the guidelines/recommendations represent best practice and be included. RESULTS: The initial list contained 43 topics relevant to family practice, citing 49 published guidelines or recommendations. The focus group participants found the list of topics and guidelines potentially useful in clinical practice and emphasized the need for user-friendliness and clinical applicability. In the first online survey of the modified Delphi technique, 93% (63/66) of the references attained consensus that these represented standards of care. The other references (3/66) attained consensus in the second online survey. The final list contained 47 topics, citing 66 references. CONCLUSION: The Care-of-the-Elderly Health Guide is a quick reference to geriatric care, reviewed for relevance by family physicians and a panel of experts. The Guide is intended to be used in primary care practice.

Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: a pragmatic randomized controlled trial.

BACKGROUND: Type II diabetes mellitus (T2DM) affects upwards of 25% of Canadian older adults and is associated with high comorbidity and burden. Studies show that lifestyle factors and self-management are associated with improved health outcomes, but many studies lack rigour or exclude older adults, particularly those with multimorbidity. More evidence is needed on the effectiveness of community-based self-management programs in older adults with T2DM and multimorbidity. The study purpose is to evaluate the effect of a community-based intervention versus usual care on physical functioning, mental health, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with T2DM and 2 or more comorbidities. METHODS: Community-living older adults with T2DM and two or more chronic conditions were recruited from three Primary Care Networks (PCNs) in Alberta, Canada. Participants were randomly allocated to the intervention or control group in this pragmatic randomized controlled trial comparing the intervention to usual care. The intervention involved up to three in-home visits, a monthly group wellness program, monthly case conferencing, and care coordination. The primary outcome was physical functioning. Secondary outcomes included mental functioning, anxiety, depressive symptoms, self-efficacy, self-management, and the cost of healthcare service use. Intention-to-treat analysis was performed using ANCOVA modeling. RESULTS: Of 132 enrolled participants (70-Intervention, 62-Control), 42% were 75 years or older, 55% were female, and over 75% had at least six chronic conditions (in addition to T2DM). No significant group differences were seen for the baseline to six-month change in physical functioning (mean difference: -0.74; 95% CI: - 3.22, 1.74; p-value: 0.56), mental functioning (mean difference: 1.24; 95% CI: - 1.12, 3.60; p-value: 0.30), or other secondary outcomes.. CONCLUSION: No significant group differences were seen for the primary outcome, physical functioning (PCS). Program implementation, baseline differences between study arms and chronic disease management services that are part of usual care may have contributed to the modest study results. Fruitful areas for future research include capturing clinical outcome measures and exploring the impact of varying the type and intensity of key intervention components such as exercise and diet. TRIAL REGISTRATION: NCT02158741 Date of registration: June 9, 2014.

Educational needs of healthcare professionals and members of the general public in Alberta Canada, 2 years after the implementation of medical assistance in dying.

Medical assistance in dying (MAID) was implemented across Canada in June of 2016, after each Canadian province and territory had developed their own MAID processes. Over the first 2 years, just under 300 Alberta citizens received MAID services, a very small proportion (<0.5%) of all 52,000 decedents. An online 2017-2018 survey of Alberta healthcare providers and members of the general public was conducted to assess and compare their knowledge of MAID. A devised brief survey tool was posted online, with broad-based advertising for voluntary participants. The survey was taken down after 282 Albertans had participated (100+ healthcare professionals and 100+ members of the general public), a non-representative sample. Through SPSS data analysis, educational needs were clearly evident as only 30.5% knew the correct approximate number of MAID deaths to date, 33.0% correctly identified the point in life when MAID can be done, 48.9% correctly identified the locations where MAID can be performed, 49.3% correctly identified who can stop MAID from being carried out, and 52.8% correctly identified how MAID is performed to end life. Healthcare professionals were significantly more often correct; as were participants born in Canada, university degree holders, working persons, those who identified a religion, had experience with death and dying care, had direct prior experience with death hastening, thought adults had a right to request and receive MAID, had past experience with animal euthanasia, and had hospice/palliative education or work experience. Age, gender, and having previously worked or lived in a country where assisted suicide or euthanasia was performed were not significant for educational needs. These findings indicate new approaches to meet sudden assisted suicide educational needs are needed.

The ACHRU-CPP versus usual care for older adults with type-2 diabetes and multiple chronic conditions and their family caregivers: study protocol for a randomized controlled trial.

BACKGROUND: Many community-based self-management programs have been developed for older adults with type-2 diabetes mellitus (T2DM), bolstered by evidence from randomized controlled trials (RCTs) that T2DM can be prevented and managed through lifestyle modifications. However, the evidence for their effectiveness is contradictory and weakened by reliance on single-group designs and/or small samples. Additionally, older adults with multiple chronic conditions (MCC) are often excluded because of recruiting and retention challenges. This paper presents a protocol for a two-armed, multisite, pragmatic, mixed-methods RCT examining the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP), a new 6-month interprofessional, nurse-led program to promote self-management in older adults (aged 65 years or older) with T2DM and MCC and support their caregivers (including family and friends). METHODS/DESIGN: The study will enroll 160 participants in two Canadian provinces, Ontario and Alberta. Participants will be randomly assigned to the control (usual care) or program study arm. The program will be delivered by registered nurses (RNs) and registered dietitians (RDs) from participating diabetes education centers (Ontario) or primary care networks (Alberta) and program coordinators from partnering community-based organizations. The 6-month program includes three in-home visits, monthly group sessions, monthly team meetings for providers, and nurse-led care coordination. The primary outcome is the change in physical functioning as measured by the Physical Component Summary (PCS-12) score from the short form-12v2 health survey (SF-12). Secondary client outcomes include changes in mental functioning, depressive symptoms, anxiety, and self-efficacy. Caregiver outcomes include health-related quality of life and depressive symptoms. The study includes a comparison of health care service costs for the intervention and control groups, and a subgroup analysis to determine which clients benefit the most from the program. Descriptive and qualitative data will be collected to examine implementation of the program and effects on interprofessional/team collaboration. DISCUSSION: This study will provide evidence of the effectiveness of a community-based self-management program for a complex target population. By studying both implementation and effectiveness, we hope to improve the uptake of the program within the existing community-based structures, and reduce the research-to-practice gap. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT02158741 . Registered on 3 June 2014.

Cultural transition of international medical graduate residents into family practice in Canada.

OBJECTIVE: To identify the perceived strengths that international medical graduate (IMG) family medicine residents possess and the challenges they are perceived to encounter in integrating into Canadian family practice. METHODS: This was a qualitative, exploratory study employing focus groups and interviews with 27 participants - 10 family physicians, 13 health care professionals, and 4 family medicine residents. Focus group/interview questions addressed the strengths that IMGs possess and the challenges they face in becoming culturally competent within the Canadian medico-cultural context. Qualitative data were audiotaped, transcribed, and analyzed thematically. RESULTS: Participants identified that IMG residents brought multiple strengths to Canadian practice including strong clinical knowledge and experience, high education level, the richness of varied cultural perspectives, and positive personal strengths. At the same time, IMG residents appeared to experience challenges in the areas of: (1) communication skills (language nuances, unfamiliar accents, speech volume/tone, eye contact, directness of communication); (2) clinical practice (uncommon diagnoses, lack of familiarity with care of the opposite sex and mental health conditions); (3) learning challenges (limited knowledge of Canada's health care system, patient-centered care and ethical principles, unfamiliarity with self-directed learning, unease with receiving feedback); (4) cultural differences (gender roles, gender equality, personal space, boundary issues; and (5) personal struggles. CONCLUSIONS: Residency programs must recognize the challenges that can occur during the cultural transition to Canadian family practice and incorporate medico-cultural education into the curriculum. IMG residents also need to be aware of cultural differences and be open to different perspectives and new learning.

Geriatric core competencies for family medicine curriculum and enhanced skills: care of elderly.

BACKGROUND: There is a growing mandate for Family Medicine residency programs to directly assess residents' clinical competence in Care of the Elderly (COE). The objectives of this paper are to describe the development and implementation of incremental core competencies for Postgraduate Year (PGY)-I Integrated Geriatrics Family Medicine, PGY-II Geriatrics Rotation Family Medicine, and PGY-III Enhanced Skills COE for COE Diploma residents at a Canadian University. METHODS: Iterative expert panel process for the development of the core competencies, with a pre-defined process for implementation of the core competencies. RESULTS: Eighty-five core competencies were selected overall by the Working Group, with 57 core competencies selected for the PGY-I/II Family Medicine residents and an additional 28 selected for the PGY-III COE residents. The core competencies follow the CanMEDS Family Medicine roles. Both sets of core competencies are based on consensus. CONCLUSIONS: Due to demographic changes, it is essential that Family Physicians have the required skills and knowledge to care for the frail elderly. The core competencies described were developed for PGY-I/II Family Medicine residents and PGY-III Enhanced Skills COE, with a focus on the development of geriatric expertise for those patients that would most benefit.