Dementia caregiving: the role of the primary care physician.

BACKGROUND: Family and friends play an important role in caring for individuals with dementia living in the community. In preparation for the Canadian Consensus Conference on Dementia held in Montreal, Canada in February 1998, the subject of dementia caregiving was reviewed in order to provide primary care physicians with some guidelines for their practice. The review was updated in June 2000 in preparation for this article. METHOD: Pertinent English-language publications and resources from the Alzheimer Society of Canada were reviewed from 1985 onwards. Findings related to the consequences of caregiving, services for caregivers and recommendations regarding the role of the primary care physician were reviewed. FINDINGS: Dementia caregivers experience many positive and negative consequences of caregiving. Some comprehensive services for caregivers have been shown to delay institutionalization and reduce negative consequences of caregiving. The primary care physician has a role to play in working with families and should address the following issues: 1) education about dementia; 2) psychological support for caregivers; 3) assistance mobilizing caregiver social support networks. CONCLUSION: Primary care physicians have an important role to play in acknowledging and supporting the caregiving provided by family and friends to individuals with dementia.

Caregivers for people with dementia. What is the family physician's role?

OBJECTIVE: To examine the role of family physicians in providing support and care to caregivers for people with dementia. QUALITY OF EVIDENCE: Data were obtained from Alzheimer Society guidelines, published consensus statements, and guidelines for family physicians caring for people with dementia and their caregivers. Most of the reported findings and recommendations are based on information from expert consensus statements and opinion. MAIN MESSAGE: Caring for people with dementia causes substantial psychological and physical morbidity. Services developed for caregivers (in-home respite and individual psychological interventions) and comprehensive support programs are helpful in relieving caregiver distress. There is a role for family physicians in following caregivers longitudinally to assess their physical and emotional health and coping skills, to provide information and assistance in dealing with problems as they arise, to assist caregivers in mobilizing family and friends, and to facilitate referrals to appropriate services and resources. CONCLUSIONS: Family physicians have an important role in identifying caregiver problems and providing direct and ongoing support to caregivers in their day-to-day role.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia.

OBJECTIVE: To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians toward the recognition, assessment and management of dementing disorders and to disseminate and evaluate the impact of these statements and guidelines built on these statements. OPTIONS: Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral, management of complications (especially behavioural problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations; neuroimaging and referrals; and appropriate use of cognitive enhancing agents. EVIDENCE: Authors of each background paper were entrusted to perform a literature search, discover additional relevant material, including references cited in retrieved articles, consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based on this evidence, consensus statements were developed by a group of experts, guided by a steering committee of 8 individuals, from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems. VALUES: Recommendations have been developed with particular attention to the context of primary care, and are intended to support family physicians in their ongoing assessment and care of patients with dementia. BENEFITS HARM AND COSTS: Potential for improved clinical care of people with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations. RECOMMENDATIONS: Forty-eight recommendations are offered that address the following aspects of dementia care: early recognition; importance of careful history and examination in making a positive diagnosis; essential laboratory tests; rules for neuroimaging and referral; disclosure of diagnosis; importance of monitoring and providing support to caregivers; cultural aspects; detection and treatment of depression; observation and management of behavioural disturbances; detection and reporting of unsafe motor vehicle driving; genetic factors and opportunities for preventing dementia; pharmacological treatment with particular emphasis on cognitive enhancing agents. VALIDATION: Four other sets of consensus statement or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

Ethical issues in Alzheimer disease: the experience of a national Alzheimer society task force.

There has been increasing recognition of the ethical dilemmas that arise in the delivery of health care services and in planning and executing scientific research. Alzheimer disease (AD) and related dementias pose a particular challenge for families, care providers, and researchers because of the nature of the illness. Naturally, those at potential risk of developing the disease are eager for scientists to develop valid predictive tests for the disease. Alzheimer organizations have developed worldwide in response to the growing awareness and knowledge of the effects of dementia on individuals and their families. These organizations have played a role in advocating for research, increasing general awareness of the nature of the disease, and lobbying for more services for persons with dementia and their families. These organizations have also realized the increasing concern about the many ethical issues that arise in caring for those with AD and researching causes and cures. This paper describes a unique process one national Alzheimer society used to develop an Ethics Task Force to provide guidelines on ethical issues.

Lessons learned from a longitudinal study of dementia care.

In a longitudinal study, the authors document the moves of dementia patients between different care settings, following up 103 individuals who had participated in an earlier study of the transition from home to institutional care. It was possible to document numerous moves between home, respite care, acute care hospital, and long-term care settings for these patients. The authors discuss the clinical implications of the many changes of residence for those suffering from dementia.

Predictors of high yield and purify of CD34(+) cell-selected PBPC, collected from patients with multiple myeloma.

BACKGROUND: Wide ranges i n cell recovery and purity may be observed following CD34(+) cell selection of mobilized HPC componetns. Characteristics of the mobilized HPC, associated with isolation of a high CD34(+) cell yield and purity following cell selection, have yet to be defined. METHODS: Cell number and purities were determined before and after 56 CD34(+) cell-selection procedures, performed using the CellPro Ceprate SC system from April 1997 to February 1998. HPC were collected from 28 patients with multiple myeloma, following cyclophosphamide (60mg/kg) and G-CSF (10microg/kg) mobilization. RESULTS: A medium of 47.9% (range 1.5-109.6%) CD34(+) cells were recovered in the enriched (ENR) fraction. A linear correlation existed between total CD34(+) cells in the ENR fraction and total CD34(+) cells in the START fraction (R2=0.93); there was a logarithmic correlation between CD34 ENR fraction purity and START fraction purity (R2=0.73). A START CD34(+) cell purity > 0.42% improved purity in the ENR fraction. A median of one (range one to nine) procedure was required to isolate 2 x 10 6 CD34(+) cells/kg. Three patients pretreated with alkylating agents failed to mobilized adequate numbers of HPC. DISCUSSION: Isolation of highly purified CD34(+) cell-selected components using the Ceprate SC system in dependent on the CD34(+) purity of the lekapheresis component collected. Mobilization regimens should be used to maximize CD34(+) cell purity in stem cell authografts if CD34(+) cell selection is to be performed. Similar strategies should be used to evaluate other cell-selection devices as they become available.

Ethical guidelines of the Alzheimer Society of Canada.

Alzheimer's disease raises numerous ethical issues which vary and evolve over the course of the illness. In recognition of the need for ongoing discussion of these issues, the Alzheimer Society of Canada established a Task Force on Ethics in 1995. Through a process of "discourse ethics" and consultation on a national scale, the Task Force produced a series of guidelines dealing with the issues of: communicating the diagnosis, driving, respecting individual choice, quality of life, participation in research, genetic testing, the use of restraints, and end-of-life care. This manuscript presents a summary of these guidelines as well as a summary of the ideas on which they were based. It was the hope of the Society that the publication of these guidelines will serve to facilitate discussion of the ethics of care of those with Alzheimer's disease.

Diagnosing and managing dementia patients. Practice patterns of family physicians.

OBJECTIVE: To examine the practice patterns of family physicians in diagnosing and managing patients with dementia. DESIGN: In-depth structured interviews. SETTING: Metropolitan Toronto family practices. PARTICIPANTS: Twenty family physicians who referred patients to a specialized community psychiatry service for the elderly in the previous year. METHOD: Two vignettes focusing on diagnosis and management issues were developed for the study. Physicians were asked how they would handle the clinical problems presented in the vignettes. Their responses were compared to standardized diagnostic and management protocols. MAIN FINDINGS: Participants were more comfortable with diagnosing dementia than with ongoing management issues, and most physicians were not using standardized cognitive screening protocols. Physicians were more oriented to immediate medical and psychiatric problems than to long-term psychosocial issues. CONCLUSIONS: More attention should be paid to the ongoing educational needs of family physicians with respect to this patient population.

Creating community agency placements for undergraduate medical education: a program description.

UNLABELLED: PROGRAM OBJECTIVE: To provide first- and second-year medical students with stimulating learning experiences in the community. SETTING: Three hundred placements representing a broad array of urban community agencies providing both general and specialized health care services. PARTICIPANTS: All first- and second-year medical students at the University of Toronto (n = 354). Other participants include staff of community agencies and tutors from the Faculty of Medicine and from the community. PROGRAM: The Health, illness and the Community course is mandatory and consists of 3 components. The first, in the first semester of first year, emphasizes the provision of health care in the community for individuals and populations. The second, in the second semester of first year, introduces a health promotion paradigm. The third component, throughout second year, allows students to engage in an in-depth study of the interconnection between a health problem and a social issue in a community agency setting. OUTCOMES: Students have expressed high levels of satisfaction with the community agency placements. The feedback from agencies has also been enthusiastic. Patients in the home care program have reported that visits by medical students are a positive experience. CONCLUSION: It is possible to recruit and maintain large numbers of urban community agencies as learning sites for medical students. It is hoped that this approach will help to produce socially responsive medical practitioners.

In vivo adsorption of isohemagglutinins with fresh frozen plasma in major ABO-incompatible bone marrow transplantation.

Despite techniques to deplete red cells from major ABO-incompatible allogeneic bone marrow (BM) or to remove recipient isohemagglutinins (IHGs) before transplantation, delayed erythropoiesis and hemolysis, red cell aplasia, and increased red cell transfusion requirements may occur. Twenty-nine recipients of major ABO-incompatible allografts received donor-type frozen fresh plasma (FFP) infusions twice daily to adsorb IHGs in vivo. Engraftment and transfusion requirements were compared between the 29 FFP-treated major ABO-incompatible allograft recipients, 5 recipients of major ABO-incompatible BM who did not receive FFP infusions, 35 recipients of minor ABO-incompatible BM, and 172 recipients of ABO-compatible BM. No significant differences in either transfusion requirements or engraftment were seen in the FFP-treated major ABO-incompatible vs. minor ABO-incompatible or ABO-compatible groups (p values > or = 0.10). The infusion of donor-type FFP represents a simple, effective treatment strategy to neutralize IHGs and to prevent adverse consequences of major ABO incompatibility in the setting of allogeneic BM transplantation. The role of this strategy in the care of patients receiving ABO-incompatible solid organs remains to be defined.

The SMARTT (Sunnybrook Memory Assessment Research Treatment and Training) Program: planning for dementia care.

Dementia is being recognized as a major public health challenge. Caring for those with dementia poses a unique problem for family and health care providers in community and institutional settings. This article describes the development of the Sunnybrook Memory Assessment Research Treatment and Training (SMARTT) Program at an academic health science centre. This program serves as a model for an integrated health system to meet the needs of dementia patients and their families.

Factors determining the decision to institutionalize dementing individuals: a prospective study.

This longitudinal study of 196 caregiver/care receiver dyads was undertaken to determine the variables predictive of caregiver decision to institutionalize a dependent with dementia. Seven variables (use of services, enjoyment of caregiving, caregiver burden and health, caregiver rating and reaction to care receiver behavior and memory problems, and presence of troublesome behaviors) predicted the decision to institutionalize. Six variables (caregiver health and burden, use of services, care receiver cognitive function and troublesome behaviors, and caregiver reaction to behaviors) predicted actual institutionalization at 18 months.

Acute opiate withdrawal in rats undernourished during infancy: impact of the undernutrition method.

Acute morphine withdrawal was assessed in adult rats following early postnatal undernutrition produced by two different methods (Large Litter procedure-20 pups/litter and Modified Slob procedure-rats cross-fostered on days 2, 4, and 6 to nonlactating dams for 24-hour periods). Response rates were first stabilized on a FR16 operant schedule. A single dose of morphine (20 mg/kg) was then administered, followed 4 h later by a single injection of naloxone (2.5 mg/kg). Males reared in large litters showed little behavioral disruption after morphine, suggesting either insensitivity to the opiate or the rapid development of tolerance. After naloxone. Modified Slob males displayed milder withdrawal than those in the well-nourished control or large litter groups. Thus the method of undernutrition influenced morphine's action and expression of withdrawal. A clear sex difference was also evident, females appearing to be generally less sensitive to the opiate- and naloxone-induced withdrawal than males. Body temperature underwent a characteristic elevation following morphine and a depression following naloxone across all groups, but undernutrition did not affect these responses. Hence, behavior proved to be the more sensitive measure for revealing differences in opiate dependence and withdrawal following early life undernutrition, under the test conditions employed.