Rural and remote dementia care challenges and needs: perspectives of formal and informal care providers residing in Saskatchewan, Canada.

INTRODUCTION: Rural and remote settings pose particular healthcare and service delivery challenges. Providing appropriate care and support for individuals with dementia and their families living in these communities is especially difficult, and can only be accomplished when the needs of care providers and the context and complexity of care provision are understood. This paper describes formal and informal caregivers' perceptions of the challenges and needs in providing care and support for individuals with dementia living in rural and remote areas of Saskatchewan, Canada. METHODS: A mixed-methods exploratory approach was used to examine caregivers' needs. This research was a component of a broader process evaluation designed to inform the initial and ongoing development of a community-based participatory research program in rural dementia care, which included the development of the Rural and Remote Memory Clinic (RRMC). Four approaches were used for data collection and analyses: (1) thematic analysis of consultation meetings with rural healthcare providers: documented discussions from consultation meetings that occurred in 2003-2004 with rural physicians and healthcare providers regarding plans for a new RRMC were analysed thematically; (2) telephone and mail questionnaires: consultation meeting participants completed a subsequent telephone or mail questionnaire (2003-2004) that was analysed descriptively; (3) thematic analysis of referral letters to the Rural and Remote Memory Clinic: physician referral letters over a five-year period (2003-2008) were analysed descriptively and thematically; and (4) examination of family caregiver satisfaction: four specific baseline questionnaire questions completed by family caregivers (2007-2010) were analysed descriptively and thematically. RESULTS: Both physician and non-physician healthcare providers identified increased facilities and care programs as needs. Physicians were much more likely than other providers to report available support services for patients and families as adequate. Non-physician providers identified improved services, better coordination of services, travel and travel burden related needs, and staff training and education needs as priorities. Physician needs, as determined via referral letters, included confirmation of diagnosis or treatment, request for further management suggestions, patient or family request, and consultation regarding difficult cases. One-third of informal caregivers expressed not being satisfied with the care received prior to the Rural and Remote Memory Clinic assessment visit, and identified lack of diagnosis and long wait times for services as key issues. CONCLUSIONS: Delivering services and providing care and support for individuals with dementia living in rural and remote communities are especially challenging. The need for increased extent of services was a commonality among formal and informal caregivers. Primary care physicians may seek confirmation of their diagnosis or may need assistance when dealing with difficult aspects of care, as identified by referral letters. Differences between the needs identified via referral letters and questionnaire responses of physicians may be a reflection of the rural or remote context of care provision. Informal caregiver needs were more aligned with non-physician healthcare providers with respect to the need for improved access to additional healthcare professionals and services. The findings have implications for regional policy development that addresses human and other resource shortages.

Lessons learned: feasibility and acceptability of a telehealth-delivered exercise intervention for rural-dwelling individuals with dementia and their caregivers.

INTRODUCTION: Until dementias can be prevented or cured, interventions that maintain or maximize cognitive and functional abilities will remain critical healthcare and research priorities. Best practice guidelines suggest that individualized exercise programs may improve fitness, cognition, and function for people with mild to moderate dementia; however, few high quality exercise intervention trials exist for this population. Increasingly, telehealth is being used to improve the delivery and availability of healthcare services for individuals living in rural areas, including exercise. This article describes the feasibility of a telehealth-delivered exercise intervention for rural, community-dwelling individuals diagnosed with dementia and their caregivers. METHODS: A mixed-methods two-phase exploratory approach was used. In phase 1, Rural and Remote Memory Clinic (RRMC; Saskatoon, Saskatchewan, Canada) patients and caregivers were surveyed about current exercise levels, perceptions about exercise, exercise preferences, and perceived barriers to exercise; community resources, acceptability of telehealth exercise interventions, and physical activity and exercise attitudes (Older Persons Attitudes Toward Physical Activity and Exercise Questionnaire). Data were analyzed using descriptive statistics and factors associated with willingness to participate in a telehealth exercise intervention were explored using hierarchical linear regression. In phase 2, acceptability, practicality, and implementation were examined. Two RRMC patient-caregiver dyads completed a 4-week exercise program delivered via telehealth. Observed engagement in the telehealth-based exercise intervention, using a revised version of the Menorah Park Engagement Scale (by Hearthstone Alzheimer Care), and attendance were monitored. Patient-caregiver dyads were interviewed at the end of the intervention phase and completed a telehealth and intervention satisfaction questionnaire. Interviews were thematically analyzed and questionnaire data were analyzed descriptively. RESULTS: Phase 1: Survey response rate was 50% (n=77). Patients (n=42) and caregivers (n=35) were equally likely to express interest in participating in the telehealth-based intervention. Willingness to participate in group exercise was the only significant predictor of willingness to participate in a telehealth-based intervention, accounting for 24.4% of the variance (F-statistic=16.14, p<0.001). Phase 2: Attendance rates were high for the telehealth-delivered exercise sessions. Engagement scale data indicated that the caregivers helped the patient participants during the intervention and that, overall, all participants were engaged in the target activity during the sessions. Ease of getting to the telehealth department, how well privacy was respected, ability to focus without distraction due to telehealth, ability to engage with group, and ability to engage with facilitator over telehealth were rated highly, as was the overall intervention experience. Telehealth voice and visual quality, ease of room set-up and conduciveness of the room to exercise were rated as good. Thematic analysis found that both dyads liked participating in the intervention together as a couple, and that participating in an exercise intervention with persons who were in a similar situations was deemed beneficial. CONCLUSIONS: Study results identified that although there are barriers to overcome, the development and evaluation of telehealth-delivered exercise interventions is a timely and important research activity that has the potential to facilitate improved healthcare services for individuals with dementia and their caregivers.

Maintaining health and wellness in the face of dementia: an exploratory analysis of individuals attending a rural and remote memory clinic.

INTRODUCTION: Worldwide, countries are calling for a chronic disease management approach to people with dementia. In response, 'living well' with dementia and 'supported self-care' frameworks are being adopted by advocacy and volunteer organizations, and more attention is being directed towards health and wellness promotion as a critical component for 'living well'. This exploratory study examined the health and wellness self-management behaviors of patients attending a rural and remote memory clinic; and relationships between engaging in health and wellness behaviors and psychological and neuropsychological function, independence in daily activities, and balance. METHODS: The cross-sectional sample comprised 260 patients referred to the Rural and Remote Memory Clinic (RRMC), Saskatchewan, Canada. Patients were diagnosed with amnestic or non-amnestic mild cognitive impairment, Alzheimer's disease (AD), or non-AD dementia. Via questionnaire, patients were asked how many days a week they exercised for at least 20 minutes, if their diet met the Canada's Food Guide to Healthy Eating recommendations, and what they did to maintain their psychological health. Patients completed a depression scale, a neuropsychological battery, and a balance scale. Caregivers completed the Functional Assessment Questionnaire. Questionnaire data were analyzed using descriptive statistics and correlational analyses. Bivariate associations between variables were assessed using point-biserial and Spearman's correlations, where appropriate. Open-ended responses were analyzed thematically. RESULTS: Participants were aged between 44 and 97 years, and had between 0 and 20 years of formal education. About half of those with Alzhemier's disease and more than half of the other diagnostic groups reported having five or more chronic conditions. Over a third of the total sample reported not exercising at all on a weekly basis. Less than half (42.7%) of the Alzhemier's disease group reported exercising for 20 minutes less than three times per week, while more than half of the other groups reported exercising for 20 minutes less than three times per week. Associations between exercise and tests of neuropsychological function and balance were statistically non-significant for the non-AD dementia group. In contrast, for the group with AD, engagement in exercise for 20 minutes for three or more times a week was moderately associated with better Stroop interference test scores and better balance. Seventy-four percent reported they met most or all of the Canada's Food Guide to Healthy Eating dietary recommendations, and 71% indicated they were engaged in activities to maintain their psychological health. Although many who reported engaging in activities to maintain their psychological health reported more than one activity, only 2.1% reported engaging in a combination of physical activities, social activities, and mentally stimulating activities. CONCLUSIONS: Patients referred to the RRMC reported good nutrition habits and participating in a variety of activities to maintain psychological health. Engaging in exercise and good nutrition was found to have beneficial effects for the sub-sample of patients with AD. Patients and their caregivers may require additional education and information regarding beneficial health and wellness promoting behaviors related to their diagnosis and concurrent comorbid conditions.

Comparison across age groups of causes, circumstances, and consequences of falls among individuals living in Canada: A cross-sectional analysis of participants aged 45 to 85 years from the Canadian Longitudinal Study on Aging.

Falls are a leading cause of injury-related deaths and hospitalizations among Canadians. Falls risk has been reported to be increased in individuals who are older and with certain health conditions. It is unclear whether rurality is a risk factor for falls. This study aimed to investigate: 1) fall profiles by age group e.g., 45 to 54 years, 55 to 64 years, 65 to 74 years, 75 to 85 years; and 2) falls profiles of individuals, by age group, living in rural versus urban areas of Canada. Data (N = 51,338) from the Canadian Longitudinal Study on Aging was used to examine the relationship between falls and age, rurality, chronic conditions, need for medical attention, and fall characteristics (manner, location, injury). Self-reported falls within a twelve-month period occurred in only 4.8% (single fall) and 0.8% (multiple falls) of adults. Falls were not related to rural residence or age, but those with memory impairment, multiple sclerosis, as well as other chronic conditions such as mood disorder, anxiety disorder, and hyperthyroidism not often thought to be associated with falls, were also more likely to fall. Older individuals were more likely to fall indoors or fall while standing or walking. In contrast, middle-aged individuals were more likely to fall outdoors or while exercising. Type of injury was not associated with age, but older individuals were more likely to report hospitalization after a fall. This study shows that falls occur with a similar frequency in individuals regardless of age or urban/rural residence. Age was associated with fall location and activity. A more universally applicable multi-facted approach, rather than one solely based on older age considerations, to screening, primary prevention and management may reduce the personal, social, and economic burden of falls and fall-related injuries.

The effects of a long-term care walking program on balance, falls and well-being.

BACKGROUND: The effects of a regular and graduated walking program as a stand-alone intervention for individuals in long-term care are unclear. Exercise and fall prevention programs typically studied in long-term care settings tend to involve more than one exercise mode, such as a combination of balance, aerobic, strengthening, and flexibility exercises; and, measures do not always include mental health symptoms and behaviors, although these may be of even greater significance than physical outcomes. METHODS/DESIGN: We are randomly assigning residents of long-term care facilities into one of three intervention groups: (1) Usual Care Group--individuals receive care as usual within their long-term care unit; (2) Interpersonal Interaction Group--individuals receive a comparable amount of one-on-one stationary interpersonal interaction time with study personnel administering the walking program; and, (3) Walking Program Group--individuals participate in a supervised, progressive walking program five days per week, for up to half an hour per day. Assessments completed at baseline, 2 and 4 months during intervention, and 2 and 4 months post-intervention include: gait parameters using the GAITRite® computerized system, grip strength, the Berg Balance Scale, the Senior Fitness Test, the Older Adult Resource Services Physical Activities of Daily Living, the Geriatric Depression Scale Short Form, the Cornell Scale for Depression in Dementia, the Revised Memory and Behavior Problems Checklist, the Short Portable Mental Status Questionnaire, the Coloured Analogue Scale, pain assessment scales, and the number and nature of falls. Sophisticated data analytic procedures taking into account both the longitudinal nature of the data and the potential for missing data points due to attrition, will be employed. DISCUSSION: Residents in long-term care have a very high number of comorbidities including physical, mental health, and cognitive. The presence of dementia in particular makes standardized research protocols difficult to follow, and staff shortages, along with inconsistencies related to shift changes may impact on the accuracy of caregiver-rated assessment scales. Practical challenges to data collection validity and maintenance of inter-rater reliability due to the large number of research staff required to implement the interventions at multiple sites are also posed. TRIAL REGISTRATION: ClinicalTrials.gov NCT01277809.

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.