[Déterminants du succès d'une démarche provinciale d'usage optimal des antipsychotiques chez les résidents en soins de longue durée selon les acteurs clés impliqués dans l'implantation].

Le Québec présente le taux de prescriptions d'antipsychotiques le plus élevé chez les personnes âgées de 65 ans et plus au Canada. La démarche « Optimiser les pratiques, les usages, les soins et les services - antipsychotiques ¼ (OPUS-AP) vise à pallier cet enjeu. Étant donné ses premiers résultats prometteurs, notre étude visait à identifier les déterminants de son succès. Elle repose sur un devis d'étude de cas regroupant une analyse documentaire et 21 entrevues auprès d'acteurs clés impliqués dans l'implantation. Les résultats mettent en lumière cinq déterminants centraux : 1) une démarche intégrée, collaborative et probante; 2) des communications et des réseaux au service de la démarche; 3) un climat d'implantation favorable aux changements; 4) un engagement et une implication des parties prenantes; et 5) une stratégie d'application des connaissances intégrée et appuyée. Des défis et recommandations pour assurer la pérennisation et la mise à l'échelle d'OPUS-AP et inspirer des démarches similaires sont identifiés.

[Trouble neurocognitif majeur et méthodes optimisant l'apprentissage].

Les difficultés cognitives consécutives aux troubles neurocognitifs majeurs (TNCM) engendrent des enjeux dans la réalisation d'activités de la vie quotidienne. Ce projet visait à identifier auprès des proches aidants et des intervenants des situations nécessitant des méthodes optimisant l'apprentissage pour faciliter l'engagement de personnes vivant avec un TNCM dans leurs activités de la vie quotidienne. Des entrevues individuelles semi-dirigées, d'une durée de 60 à 90 minutes, ont été menées auprès de proches aidants et d'intervenants. Les résultats montrent que les activités quotidiennes et domestiques sont notamment affectées par les difficultés à repérer ou à utiliser les objets, à garder en tête la tâche en cours, à mettre en séquences des étapes, à ne pas se laisser distraire par autre chose et à constater ses difficultés pour s'y adapter. Les proches aidants souhaitent du soutien dans l'application des méthodes optimisant l'apprentissage pour contribuer au maintien de l'autonomie des personnes vivant avec un TNCM.

The Performance Assessment of Self-Care Skills to Predict Adverse Events Post-Discharge.

Background. The Performance Assessment of Self-Care Skills (PASS) is a standardized assessment of the ability to perform daily activities. Purposes. This preliminary exploratory study aimed to 1) explore the ability of four PASS tasks to predict adverse events (readmissions and injuries) in older adults following hospitalization; 2) compare PASS's predictive validity to that of a generic tool (SMAF) and OT clinical judgement. Method.Twenty-two older patients were assessed in hospital at discharge and at home one week later. Adverse events were documented for six months post-discharge. Sensitivity and specificity analyses (ROC curves, Fisher's exact tests) were performed. Findings. Two PASS tasks (telephone, medication), the SMAF-Social and OT clinical judgement could identify individuals at risk of readmission (AUC > 0.7; p < 0.05). Implications. Using the PASS to assess more cognitively demanding tasks could be a promising way to predict adverse events after discharge, as a complement to clinical judgment.

Association between intergenerational solidarity involving elders and mental health of Indigenous people living off reserve.

BACKGROUND: Indigenous elders play an important role in transmitting knowledge, values and practices, hence fostering identity-building through intergenerational solidarity. We aimed to verify the association between intergenerational solidarity involving Indigenous elders and mental health of Indigenous people living off reserve. METHODS: We carried secondary analyses of data for a subsample from the cross-sectional 2012 Aboriginal Peoples Survey (total sample: n = 28,410 Indigenous persons aged ≥6 years old living off reserve; subsample: n = 13,020 aged 18-44 years old). Controlling for age as well as material and social deprivation, we used logistic regressions to verify the association between intergenerational solidarity (proxied as time spent with an elder and potential of turning to an elder or grandparent for support in times of need) and mental health (perceived mental health, mood disorders, anxiety, suicidal thoughts and attempts). RESULTS: About 39 and 9% of the respondents respectively reported having spent time with an elder and would have turned to an elder or grandparent for support in times of need. Women who would not turn to an elder or grandparent for support in times of need were more likely to report fair or poor perceived mental health (OR = 1.69, p = 0.03). Men not spending time with an elder were more likely to experience mood disorders (OR = 1.66, p = 0.004). Women who would not turn to an elder or grandparent for support in times of need were more likely to experience anxiety disorders (OR = 1.57, p = 0.04). Women not spending time with an elder or who would not turn to an elder or grandparent for support in times of need were respectively more likely to have suicidal thoughts (OR = 1.62, p = 0.04) or to have attempted suicide (OR = 3.38, p = 0.04). CONCLUSION: Intergenerational solidarity is associated with better mental health outcomes of Indigenous people living off reserve. These results could guide policies and practices that aim to enhance mental health and wellness in Indigenous populations.

Importance of Indigenous elders' contributions to individual and community wellness: results from a scoping review on social participation and intergenerational solidarity.

OBJECTIVE: Wellness is a challenge for Indigenous peoples, partly because Western services do not adopt a holistic approach. By devaluing traditional knowledge, Indigenous values and beliefs, these services lower Indigenous power and affect cultural identities. Indigenous elders participate in intergenerational solidarity by transmitting knowledge, values, and culture in a holistic approach. Despite widespread acceptance of the importance of Indigenous elders' contributions to wellness, a rigorous synthesis of knowledge has never been done. This study aimed to provide a comprehensive understanding of how Indigenous elders' social participation contributes to individual and community wellness. METHOD: A scoping review was conducted with Indigenous elders and stakeholders in Québec (Canada). Sixteen databases were searched with 57 keywords. Data from the documents retrieved were analyzed, organized, and synthesized based on the International Classification of Functioning, Disability and Health. SYNTHESIS: A total of 144 documents were examined, comprising 74 scientific papers and 70 sources from the gray literature. Indigenous elders contributed to wellness mainly through relationships and interactions with other community members and non-Indigenous people (72.2%); intergenerational oral and written communications (70.1%); community, social and civic life (45.8%); volunteering and jobs (35.4%); and family life (29.9%). Elders transmit traditional knowledge, strengthen social cohesion, and help to develop positive attitudes such as reciprocity. Their actions favour disease prevention and health promotion, as including traditional approaches increases the acceptability of health and social services. CONCLUSION: This scoping review highlights the need for longitudinal studies with mixed-method designs involving Indigenous communities at all stages of the research to deepen understanding of the contributions of Indigenous elders to individual and community wellness.

Optimizing Participation of Older Adults with Cognitive Deficits Post-stroke: Types of Help and Caregiver Burden.

ABSTRACTThis longitudinal mixed-method study examined the types of help provided by caregivers to optimize participation of older adults with cognitive deficits post-stroke (care recipients), and how these types of help varied with caregiver's burden. Twelve family caregivers of care recipients post-stroke completed a burden questionnaire and semi-structured interviews one month, three months, and six months following care recipient's discharge home from acute care, rehabilitation, or day hospital. Care recipients completed cognitive tests and a social participation questionnaire. Types of help caregivers provided differed according to the amount of daily living support, degree of concern for care recipient's well-being, and impact on caregivers' social life. Interestingly, types of help fostering care recipient's social participation, self-esteem, and abilities were unrelated to a negative impact on caregivers' social life. Understanding how different types of help relate to caregiver burden could improve the types of help to optimize care recipients' social participation without overburdening caregivers.

Risks Perceived by Frail Male Patients, Family Caregivers and Clinicians in Hospital: Do they Change after Discharge? A Multiple Case Study.

INTRODUCTION: Up to 40% of hospitalised seniors are frail and most want to return home after discharge. Inaccurate estimation of risks in the hospital may lead to inadequate support at home. This study aimed to document convergences and divergences between risks and support needs identified before hospital discharge and perceived at home post-discharge. METHODS: This research used a multiple case study design. Three cases were recruited, each involving a hospitalised frail patient aged 70+, the main family caregiver and most of the clinicians who assessed the patient before and after hospital discharge. Thirty-two semi-structured interviews were conducted and their transcripts analysed using a qualitative thematic analysis approach. RESULTS: Among risks raised by participants, falls were the only one with total inter-participant/inter-time/inter-case convergence. In all cases, all participants mentioned, before and after discharge, home adaptations and use of technical aids to mitigate this risk. However, clinicians recommended professional services while patients and family caregivers preferred to rely on family members and their own coping strategies. CONCLUSION: The divergences identified for most risks and support needs between users and clinicians, before and after discharge, provide new insights into a comprehensive and patient-centred risk assessment process to plan hospital discharge for frail elderly.

MEMO+: Efficacy, Durability and Effect of Cognitive Training and Psychosocial Intervention in Individuals with Mild Cognitive Impairment.

BACKGROUND/OBJECTIVES: There is no consensus on the efficacy of cognitive training in persons with mild cognitive impairment (MCI) because of the paucity of well-designed randomized controlled trials. The objective was to assess the effect of memory training on the cognitive functioning of persons with MCI and its durability and to evaluate whether this effect generalizes to daily life and whether positive effects could be obtained from psychosocial intervention. DESIGN: Single-blind randomized controlled trial. SETTING: Research centers of the Institut Universitaire de Gériatrie de Montréal and Institut Universitaire en Santé Mentale de Québec. PARTICIPANTS: Older adults meeting criteria for amnestic MCI (N = 145). INTERVENTION: Participants were randomized to cognitive training, a psychosocial intervention, or a no-contact control condition. Interventions were provided in small groups in eight 2-hour sessions. MEASUREMENT: Outcome measures were immediate and delayed composite performance memory scores, psychological health (depression, anxiety, well-being), and generalization effects of the intervention (strategy use in everyday life, difficulties in complex activities of daily living, memory complaints). Testing was administered before training and immediately, 3 months, and 6 months after training. RESULTS: Participants in the cognitive training condition improved on the delayed composite memory score and on strategy use in everyday life. Improvement was maintained at the 3- and 6-month follow-up assessments. Participants in the psychosocial and no-contact conditions did not show any significant improvement. CONCLUSION: Cognitive training improves the memory of persons with amnestic MCI. The effect persists over a 6-month period, and learned strategies are used in everyday life. Cognitive training is a valid way to promote cognition in MCI.

A scoping review protocol on social participation of indigenous elders, intergenerational solidarity and their influence on individual and community wellness.

INTRODUCTION: Indigenous elders have traditionally played an important role in maintaining social cohesion within their communities. Today, part of this role has been taken over by government social and healthcare services, but they are having limited success in addressing social challenges. Increasing elders' social participation and intergenerational solidarity might foster community development and benefit young people, families, communities and the elders themselves. However, knowledge of the contribution of elders' social participation and intergenerational solidarity to wellness is scattered and needs to be synthesised. This protocol presents a scoping review on the social participation of indigenous elders, intergenerational solidarity and their influence on individual and community wellness. METHODS AND ANALYSIS: This scoping review protocol is based on an innovative methodological framework designed to gather information from the scientific and grey literature and from indigenous sources. It was developed by an interdisciplinary team including indigenous scholars/researchers, knowledge users and key informants. In addition to searching information databases in fields such as public health and indigenous studies, an advisory committee will ensure that information is gathered from grey literature and indigenous sources. ETHICS: The protocol was approved by the Ethics Review Board of the Université du Québec en Abitibi-Témiscamingue and the First Nations of Quebec and Labrador Health and Social Services Commission. DISCUSSION: The comprehensive synthesis of the scientific and grey literature and indigenous sources proposed in this protocol will not only raise awareness within indigenous communities and among healthcare professionals and community organisations, but will also enable decision-makers to better meet the needs of indigenous people. CONCLUSION: The innovative methodological framework proposed in this scoping review protocol will yield richer information on the contribution of elders to community wellness. This work is an essential preliminary step towards developing research involving indigenous communities, drawing on the social participation of elders and intergenerational solidarity.

Measuring the impact of cognitive and psychosocial interventions in persons with mild cognitive impairment with a randomized single-blind controlled trial: rationale and design of the MEMO+ study.

BACKGROUND: Several studies have suggested that cognitive training is a potentially effective way to improve cognition and postpone cognitive decline in older adults with mild cognitive impairment (MCI). The MEMO+ study is a randomized, controlled, single-blind trial designed to test the efficacy, specificity, and long-term effect of a cognitive training intervention and a psychosocial intervention in persons with MCI. METHODS: One hundred and sixty-two participants with MCI will be recruited. They will be randomized into three groups: cognitive training, psychosocial intervention, and no-contact. Each intervention will last for eight weeks (one session per week) and a booster training session will be provided three months after the end of the intervention. Various proximal and distal outcomes will be measured at pre-intervention as well as at one week, three months, and six months post-training. Proximal outcomes include memory and psychological health measures. Distal outcomes focus on self-rated functioning in complex daily activities and strategies used in daily life to enhance function. Socio-demographic factors (age, gender, and education), general cognition, personality traits, engagement in activities, and self-efficacy will be used as moderators. Enrolment began in April 2012 and will be completed by December 2014. CONCLUSIONS: This study is likely to have a significant impact on the well-being of persons with MCI by contributing to the development of adapted and scientifically supported cognitive and psychosocial interventions.

Differences in participation according to specific cognitive deficits following a stroke.

This study compared participation following a stroke according to the presence of specific cognitive deficits. Participation is defined as the involvement of a person in daily activities and social roles. Three weeks after being discharged home, 197 older adults (aged 65 years and older) who had a stroke were evaluated using the Assessment of Life Habits, which includes 12 domains of daily activities and social roles. The presence of a cognitive deficit was determined by the scores obtained on tests assessing memory, visual perception, language, unilateral attention, and the inhibition component of executive functions. After adjusting for depressive symptoms, time since stroke, and comorbidities, five of the domains of participation are significantly more restricted by some cognitive deficits. Memory deficits affect the communication (p = .006) and leisure (p = .032) domains. In the presence of visual perception deficits, the nutrition (p = .019), communication (p = .004), and responsibilities (p < .0005) domains are more limited. Language deficits have an impact on several domains of participation, namely communication (p < .0005), responsibilities (p < .0005), community life (p = .001), and leisure (p = .021). Unilateral neglect and deficits in the inhibition component of executive functions are not found to restrict participation. Overall, participation after stroke is related to cognitive function. Looking carefully at individual domains of activities and roles provides essential information in guiding rehabilitation interventions aimed at enhancing participation after discharge.

Participation after a stroke: changes over time as a function of cognitive deficits.

Participation refers to the engagement of a person in daily activities and social roles. The goal of this study was to compare changes in older adults' participation over time following a stroke as a function of the presence of deficits in memory, visual perception, executive functions, visual attention or language. A total of 197 persons with stroke were assessed 3 weeks, 3 months and 6 months after discharge from an acute care hospital, rehabilitation unit or geriatric day hospital. The Assessment of Life Habits (ALH) was used to measure participation. Neuropsychological measures were used to assess the presence of a cognitive deficit in the domains of memory, visual perception, executive functions (inhibition), visual attention and language. Overall, results indicate that participation after a stroke improves over time after hospital discharge in spite of cognitive deficits. Changes in participation over time differed between unimpaired and impaired participants only for language and executive deficits in three domains: interpersonal relationships, community life and responsibilities. These results indicate that when returning to the community after a stroke, positive changes in participation over time are possible even with cognitive deficits.

Provision of rehabilitation services in Québec following stroke: a comparative survey conducted by postal questionnaire.

We conducted a survey to document the rehabilitation services available to clients aged 65 years and older who had suffered a stroke. In all, respondents - gleaned from 295 resources located in three health regions in the province of Québec - completed a postal questionnaire describing the services that they offer, in terms of type of intervention (related to nine capabilities and seven areas of social participation) and type of services (evaluation, rehabilitation, and support). The results show that most rehabilitation services offered to older people with stroke address motor skills and mobility. Somewhat unexpectedly, for four capability-related interventions and two social-participation-related interventions, there appear to be more active rehabilitation services offered in regions with rural areas than in metropolitan regions.

Effect of a home leisure education program after stroke: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of a leisure education program on participation in and satisfaction with leisure activities (leisure-related outcomes), and well-being, depressive symptoms, and quality of life (primary outcomes) after stroke. DESIGN: Randomized controlled trial. SETTING: Home and community. PARTICIPANTS: Sixty-two people with stroke. INTERVENTION: Experimental participants (n=33) received the leisure education program at home once a week for 8 to 12 weeks. Control participants (n=29) were visited at home at a similar frequency. Participants were evaluated before and after the program by a blinded assessor. MAIN OUTCOME MEASURES: Change from preintervention to postintervention in: minutes of leisure activity per day, number of leisure activities, the Leisure Satisfaction Scale, the Individualized Leisure Profile, the General Well-Being Schedule (GWBS), the Center for Epidemiological Studies Depression Scale, and the Stroke-Adapted Sickness Impact Profile (SA-SIP30). RESULTS: There was a statistically significant difference in change scores between the groups for satisfaction with leisure with a mean difference of 11.9 points (95% confidence interval [CI], 4.2-19.5) and participation in active leisure with a mean difference of 14.0 minutes (95% CI, 3.2-24.9). There was also a statistically significant difference between groups for improvement in depressive symptoms with a mean difference of -7.2 (95% CI, -12.5 to -1.9). Differences between groups were not statistically significant on the SA-SIP30 (0.2; 95% CI, -1.3 to 1.8) and GWBS (2.2; 95% CI, -5.6 to 10.0). CONCLUSIONS: The results indicate the effectiveness of the leisure education program for improving participation in leisure activities, improving satisfaction with leisure and reducing depression in people with stroke.

Rehabilitation needs for older adults with stroke living at home: perceptions of four populations.

BACKGROUND: Many people who have suffered a stroke require rehabilitation to help them resume their previous activities and roles in their own environment, but only some of them receive inpatient or even outpatient rehabilitation services. Partial and unmet rehabilitation needs may ultimately lead to a loss of functional autonomy, which increases utilization of health services, number of hospitalizations and early institutionalization, leading to a significant psychological and financial burden on the patients, their families and the health care system. The aim of this study was to explore partially met and unmet rehabilitation needs of older adults who had suffered a stroke and who live in the community. The emphasis was put on needs that act as obstacles to social participation in terms of personal factors, environmental factors and life habits, from the point of view of four target populations. METHODS: Using the focus group technique, we met four types of experts living in three geographic areas of the province of Québec (Canada): older people with stroke, caregivers, health professionals and health care managers, for a total of 12 groups and 72 participants. The audio recordings of the meetings were transcribed and NVivo software was used to manage the data. The process of reducing, categorizing and analyzing the data was conducted using themes from the Disability Creation Process model. RESULTS: Rehabilitation needs persist for nine capabilities (e.g. related to behaviour or motor activities), nine factors related to the environment (e.g. type of teaching, adaptation and rehabilitation) and 11 life habits (e.g. nutrition, interpersonal relationships). The caregivers and health professionals identified more unmet needs and insisted on an individualized rehabilitation. Older people with stroke and the health care managers had a more global view of rehabilitation needs and emphasized the availability of resources. CONCLUSION: Better knowledge of partially met or unmet rehabilitation needs expressed by the different types of people involved should lead to increased attention being paid to education for caregivers, orientation of caregivers towards resources in the community, and follow-up of patients' needs in terms of adjustment and rehabilitation, whether for improving their skills or for carrying out their activities of daily living.

Identification of rehabilitation needs after a stroke: an exploratory study.

BACKGROUND: Services to meet adequate rehabilitation needs of elderly stroke survivors are not always provided. Indeed, since 1995, in the wake of the Quebec shift to ambulatory care, home care services, mainly those related to rehabilitation of the elderly, are either unavailable or incomplete. The aim of this study was to examine the rehabilitation needs of this clientele from their hospitalization to their reintegration into the community. METHODS: The "Handicap Production Process" conceptual approach was chosen to help identify the rehabilitation needs of persons affected by physical or cognitive disabilities due to the interactions between personal and environmental factors, and (activities of daily living, social roles). This qualitative exploratory study was performed in 2003. Data were collected among four groups of experts: patients, caregivers, health care providers and administrators. Data triangulation was used to ensure a rigorous analysis and validity of the results. RESULTS: Unfulfilled needs could be found in the categories of pertaining to residence, community living, psychological and emotional needs. Indeed, it appears that a psychological follow-up to discuss acceptance and consequences of non-acceptance would facilitate mid-to long-term rehabilitation. CONCLUSION: Improving accessibility to healthcare services, respecting priority parking spaces for the disabled as well as promoting public awareness would enable a better social reintegration and recovery of social roles, thus limiting the onset of handicap situations.

Validity of the Assessment of Life Habits in older adults.

OBJECTIVE: To study the construct validity of a participation scale, the Assessment of Life Habits, with older adults having functional limitations. More specifically, the study aimed to verify the ability of the Assessment of Life Habits to discriminate between clienteles in 3 living environments, and to compare participation scores to functional independence scores obtained with the Functional Autonomy Measurement System (Système de mesure de l'autonomie fonctionnelle). DESIGN: Participants were evaluated once with the Assessment of Life Habits and the Functional Autonomy Measurement System. SUBJECTS: Eighty-seven older adults (mean age 78.0 years (8.2)) living in 3 types of environment: own home, private nursing home or long-term care centre. RESULTS: Results suggest that the Assessment of Life Habits scores discriminate between different levels of participation according to the living environments of the participants. The Assessment of Life Habits measures some similar aspects to the Functional Autonomy Measurement System scale but also additional concepts not included in the Functional Autonomy Measurement System. CONCLUSION: This study supports the validity of the Assessment of Life Habits as a participation measure. It suggests the importance of going beyond disability measures to evaluate the overall functioning of older adults correctly.

Measuring social participation: reliability of the LIFE-H in older adults with disabilities.

PURPOSE: Much more attention should be paid to instruments documenting social participation as this area is increasingly considered a pivotal outcome of a successful rehabilitation. The purpose of this study was to document the reliability of a participation measure, the Assessment of Life Habits (LIFE-H), in older adults with functional limitations. METHODS: Eighty-four individuals with physical disabilities living in three different environments were assessed twice with the LIFE-H, an instrument that documents the quality of social participation by assessing a person's performance in daily activities and social roles (life habits). RESULTS: The intraclass correlation coefficients (ICC) computed for intrarater reliability exceeded 0.75 for seven out of the 10 life habits categories. For interrater reliability, the total score and daily activities subscore are highly reliable (ICC