Patient sheet: tips for avoiding problems with polypharmacy.
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Age Factors↗
Biomedical subjects
David B Hogan
Publications and source records attributed to David B Hogan.
Outcomes of cognitively impaired not demented at 2 years in the Canadian Cohort Study of Cognitive Impairment and Related Dementias.
BACKGROUND: People who are cognitively impaired not demented (CIND) can be at an increased risk for developing dementia, but little is known about the natural history of CIND in clinical settings. METHOD: We examined the 2-year outcome of CIND subjects in the Canadian Cohort Study of Cognitive Impairment and Related Dementias.CIND was diagnosed when at least one positive item was endorsed on the DSM-III-R dementia criteria, but not all criteria were met. CIND was further subclassified as: pre-Alzheimer's disease (pre-AD), vascular cognitive impairment (VCI-ND), non-AD degenerative, psychiatric, other neurologic, other medical conditions, mixed disorders and no etiology identified (not otherwise specified [NOS]). RESULT: Of 146 CIND patients with 2-year follow-up data available, 49 (34%) progressed to dementia, while 20 (14%) recovered to not cognitively impaired (NCI). Progressors were significantly older than stable CIND and reverters (p < 0.0001; mean age = 71.1, 64.3, and 59.1, respectively), and there were significantly (p = 0.001) more ApoE epsilon4 carriers among progressors (67%) than stable CIND (29%) and reverters (12%). Pre-AD CIND and VCI-ND had the highest rate of conversion to dementia (41.0 and 40.0%, respectively), while psychiatric CIND and CIND NOS had highest rate of recovery to NCI (20.0 and 30.0%, respectively). All conversions in pre-AD CIND were to 'probable AD'. CONCLUSION: CIND consists of a heterogeneous group of disorders that can be classified syndromically. Many subclassess - not just those with pre-AD CIND - are at high risk of progression to dementia, usually to Alzheimer's disease.
Aged↗
Measuring health status and decline in at-risk seniors residing in the community using the Health Utilities Index Mark 2.
PURPOSE: The purpose of this study was to assess the responsiveness of one measure of HRQL, the HUI Mark 2 (HUI2), to changes in health status over time in an older community-based population. METHODS: The sample consisted of 192 individuals age 65 and over residing in their homes and receiving health and support services in Calgary, Canada. Subjects received three assessments at 6-month intervals using the HUI2, to measure health-related quality of life (HRQL), and the Minimum Data Set for Home Care (MDS-HC) for demographic and health status information. Change scores were calculated as the difference between scores at the second and third assessments. The relationship between the HUI2 and other measures of health status were examined using t-tests and ANOVA. Associations between the magnitude of decline in HUI2 and declines on other measures were examined using multiple linear regression. RESULTS: Lower HUI2 scores were significantly associated with the presence of depressive symptoms, impairment in activities of daily living (ADL), and clinical instability at baseline. Over 6 months of follow-up, HUI2 decline was associated with worsening depressive symptoms, increase in the number of chronic conditions, and age 85 and over. CONCLUSION: The HUI2 measure of HRQL in older persons at risk for institutionalization appears to reflect health status at a point in time and to be responsive to changes in health status over time.
Activities of Daily Living↗
Donepezil for severe Alzheimer's disease.
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Activities of Daily Living↗
Improving recruitment into geriatric medicine in Canada: Findings and recommendations from the geriatric recruitment issues study.
As the number of Canadians aged 65 and older continues to increase, declining recruitment into geriatric medicine (GM) raises concerns about the future viability of this medical subspecialty. To develop effective strategies to attract more GM trainees into the field, it is necessary to understand how medical students, residents, GM trainees, and specialists make career choices. The Geriatric Recruitment Issues Study (GRIST) was designed to assess specific methods that could be used to improve recruitment into geriatrics in Canada. Between November 2002 and January 2003, 530 participants were invited to complete the GRIST survey (117 Canadian geriatricians, 12 GM trainees, 96 internal medicine residents, and 305 senior medical students). Two hundred fifty-three surveys (47.7%) were completed and returned (from 54 participating geriatricians, 9 GM trainees, 50 internal medicine residents, and 140 senior medical students). The survey asked respondents to rate factors influencing their choice of medical career, the attractiveness of GM, and the anticipated effectiveness of potential recruitment strategies. Although feedback varied across the four groups on these issues, consistencies were observed between medical students and residents and between GM trainees and geriatricians. All groups agreed that role modeling was effective and that summer student research programs were an ineffective recruitment strategy. Based on the GRIST findings, this article proposes six recommendations for improving recruitment into Canadian geriatric medicine training programs.
Adult↗
Medication nonadherence and subsequent risk of hospitalisation and mortality among older adults.
BACKGROUND: Despite a higher risk for medication nonadherence among older adults residing in the community, few prospective studies have investigated the health outcomes associated with nonadherence in this population or the possible variations in risk in urban versus rural residents. OBJECTIVES: The primary objective of this study was to examine, in a prospective manner, the risk for hospitalisation (including an emergency department visit) and/or mortality associated with medication nonadherence in older, at-risk adults residing in the community. A secondary objective was to examine differences in the prevalence, determinants and consequences of medication nonadherence between rural and urban home care clients. METHODS: Data were derived from a 1-year prospective study of home care clients aged > or =65 years (n = 319) randomly selected from urban and rural settings in southern Alberta, Canada. Trained nurses conducted in-home assessments including a comprehensive medication review, self-report measures of adherence and the Minimum Data Set for Home Care (MDS-HC) tool. Hospitalisation and mortality data during 12-month follow-up were obtained via linkages with regional administrative and vital statistics databases. RESULTS: Nonadherent clients showed an increased but nonsignificant risk for an adverse health outcome (hospitalisation, emergency department visit or death) during follow-up (hazard ratio [adjusted for relevant covariates] = 1.24, 95% CI 0.93, 1.65). Subgroup analyses suggested this risk may be higher for unintentional nonadherence (unadjusted hazard ratio = 1.55, 95% CI 0.97, 2.48). The prevalence of nonadherence was similar among rural (38.2%) and urban (38.9%) clients and was associated with the presence of vision problems, a history of smoking, depressive symptoms, a high drug regimen complexity score, residence in a private home (vs assisted-living setting) and absence of assistance with medication administration. In both settings, approximately 20% of clients received one or more inappropriate medications. CONCLUSIONS: Although not associated with rural/urban residence, medication nonadherence was common in our study population, particularly among those with depressive symptoms and complex medication regimens. The absence of a significant association between overall medication nonadherence and health outcomes may reflect study limitations and/or the need to differentiate among types of nonadherent behaviours.
Aged↗
Nodding and napping in medical lectures: an instructive systematic review.
A comprehensive, international systematic review, spanning more than 100 years of data collection, suggests that soporific lectures at medical meetings are common, annoying and persistent. Low lights and boring material are prominent risk factors for nodding off during presentations. Extreme remedial measures are warranted.
Boredom↗
Functional status in rate- versus rhythm-control strategies for atrial fibrillation: results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Functional Status Substudy.
OBJECTIVES: The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) functional status substudy aimed to test the hypothesis that functional status is similar in rate-control and rhythm-control strategies. BACKGROUND: Randomized studies, including the AFFIRM study, have failed to demonstrate survival benefits between rate-control and rhythm-control strategies for atrial fibrillation (AF). However, AF may cause functional capacity or cognitive impairment that might justify maintenance of sinus rhythm. METHODS: Investigators of the AFFIRM study enrolled 4,060 patients with AF who required long-term therapy and who were 65 years of age or older or who had another risk factor for stroke or death. New York Heart Association functional class (NYHA-FC) and Canadian Cardiovascular Society Angina Classification were assessed at initial and each follow-up visit. From 22 randomly chosen functional status substudy sites, 245 participants underwent 6-min walk tests and Mini-Mental State Examination (MMSE) at initial, two-month, and yearly visits. Patients were assigned randomly to rate-controlling drugs, allowing AF to persist, or rhythm-controlling antiarrhythmic drugs, to maintain sinus rhythm. RESULTS: The NYHA-FC worsened with time in both rate-control and rhythm-control groups, with no differences between groups. Presence of AF was associated with worse NYHA-FC (p < 0.0001). No differences were observed in Canadian Cardiovascular Society Angina Classification or MMSE scores. Six-minute walk distance improved over time in both study arms. On average, walk distance was 94 feet greater in the rhythm-control group (adjusted p = 0.049). CONCLUSIONS: Modest improvement in 6-min walk distance was noted in the rhythm-control arm. Presence of AF was associated with worse NYHA-FC. No difference in cognitive function was detected.
Aged↗
Clinical and radiographic subtypes of vascular cognitive impairment in a clinic-based cohort study.
BACKGROUND AND PURPOSE: There is a need for empirical studies to define criteria for vascular cognitive impairment (VCI) subtypes. In this paper, we report the predictive validity of a subtype classification scheme based on clinical and radiographic features. METHODS: Nine Canadian memory clinics participated in the Consortium to Investigate Vascular Impairment of Cognition. This cohort consisted of 1347 patients, of whom 324 had VCI, and was followed for up to 30 months. RESULTS: Clinical and neuroimaging features defined three subtypes: vascular cognitive impairment, no dementia, (n=97), vascular dementia (n=101) and mixed neurodegenerative/vascular dementia (n=126). Any ischemic lesion on neuroimaging increased the odds (odds ratio=9.31; 95% confidence interval 6.46, 13.39) of a VCI diagnosis. No VCI subtype, however, was associated with a specific neuroimaging abnormality. Compared to those with no cognitive impairment, patients with each VCI subtype had higher rates of death and institutionalization (hazard ratio for combined adverse events=6.08, p<0.001). CONCLUSIONS: Both clinical features and radiographic features help establish a diagnosis of VCI. The outcomes of VCI subtypes, however, are more strongly associated with clinical features than with radiographic ones.
Aged↗
A global clinical measure of fitness and frailty in elderly people.
BACKGROUND: There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. METHODS: We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. RESULTS: The CSHA Clinical Frailty Scale was highly correlated (r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%-30.6%) and entry into an institution (23.9%, 95% CI 8.8%-41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). INTERPRETATION: Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.
Aged↗
Supplemental use of antioxidant vitamins and subsequent risk of cognitive decline and dementia.
There are conflicting reports about the potential role of vitamin antioxidants in preventing and/or slowing the progression of various forms of cognitive impairment including Alzheimer's disease (AD). We examined longitudinal data from the Canadian Study of Health and Aging, a population-based, prospective 5-year investigation of the epidemiology of dementia among Canadians aged 65+ years. Our primary objective was to examine the association between supplemental use of antioxidant vitamins and subsequent risk of significant cognitive decline (decrease in 3MS score of 10 points or more) among subjects with no evidence of dementia at baseline (n=894). We also explored the relationship between vitamin supplement use and incident vascular cognitive impairment (VCI; including a diagnosis of vascular dementia, possible AD with vascular components and VCI but not dementia), dementia (all cases) and AD. After adjusting for potential confounding factors assessed at baseline, subjects reporting a combined use of vitamin E and C supplements and/or multivitamin consumption at baseline were significantly less likely (adjusted OR 0.51; 95% CI 0.29-0.90) to experience significant cognitive decline during a 5-year follow-up period. Subjects reporting any antioxidant vitamin use at baseline also showed a significantly lower risk for incident VCI (adjusted OR 0.34, 95% CI 0.13-0.89). A reduced risk for incident dementia or AD was not observed. Our findings suggest a possible protective effect for antioxidant vitamins in relation to cognitive decline but randomized controlled trials are required for confirmation.
Aged↗
Assessing outcomes through congruence of course objectives and reflective work.
INTRODUCTION: Course outcomes have been assessed by examining the congruence between statements of commitment to change (CTCs) and course objectives. Other forms of postcourse reflective exercises (for example, impact and unmet-needs statements) have not been examined for congruence with course objectives or their utility in assessing course outcomes. This study assessed the congruence of course objectives and statements of commitment to change, effects on practice, unmet-needs, and the utility of supplementing CTCs with other forms of reflective work in course evaluations. METHODS: A 3-module course on Alzheimer's disease and other dementias provided end-of-course CTC statements, follow-up data, and statements of effects on practice and unmet needs. Statements were aligned to module objectives and analyzed descriptively. RESULTS: Of the 932 physicians who registered for 1 of the 3 modules, 404 provided CTCs, 302 provided impact statements, and 265 provided unmet-needs statements. Sixty percent of the CTCs could be assigned to an objective for their module, and between 14% and 25% of CTCs were assigned to objectives for another module. Three-quarters of CTCs were fully or partially implemented. Physicians did not have an opportunity to implement the new content in 70% of nonimplemented CTCs. Fewer impact and unmet-needs statements were congruent with course objectives than CTCs. CONCLUSIONS: Commitment-to-change statements had more congruence with objectives than did impact or unmet-needs statements. These latter statements, particularly those that could not be assigned to an objective, may reinforce and supplement the information provided by CTC analyses.
Alzheimer Disease↗
Which older patients are competent to drive? Approaches to office-based assessment.
OBJECTIVE: To review three proposed approaches to office-based assessment of older drivers and to evaluate recommendations made about dementia and driving. QUALITY OF EVIDENCE: The American Medical Association's (AMA's) Physcian's Guide to Assessing and Counseling Older Drivers gives recommendations for office-based assessment of older patients' medical fitness to drive. Other approaches examined were those outlined in the sixth edition of Determining Medical Fitness to Drive produced by the Canadian Medical Association (CMA) and SAFE DRIVE. Recommendations for dementia and driving from these documents and other sources were reviewed. All evidence was level III. MAIN MESSAGE: The AMA document usefully identified ways to detect drivers at risk and key areas for assessment (vision, cognition, motor function). Recommendations on evaluating these areas require validation. .he CMA guide and SAFE DRIVE were overly broad in their recommendations. How best to detect cognitive impairment that tocld affect driving remains unclear. CONCLUSION: Office-based approaches to identifying older drivers who are either unsafe to drive or require more extensive evaluation need to be validated.
Aged↗
Incidence of and risk factors for nodding off at scientific sessions.
We conducted a surreptitious, prospective, cohort study to explore how often physicians nod off during scientific meetings and to examine risk factors for nodding off. After counting the number of heads falling forward during 2 days of lectures, we calculated the incidence density curves for nodding-off episodes per lecture (NOELs) and assessed risk factors using logistic regression analysis. In this article we report our eye-opening results and suggest ways speakers can try to avoid losing their audience.
Boredom↗
Cardiac report cards: the good, the bad and the unknown.
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Canada↗
Comparison studies of cholinesterase inhibitors for Alzheimer's disease.
There is uncertainty about which of the three available cholinesterase inhibitors should be prescribed as initial therapy for patients with Alzheimer's disease. We have assessed the reports of three trials that directly compared cholinesterase inhibitors. They were reviewed for sponsorship, authorship, main results, proportions of individuals who achieved maximum daily doses of the study cholinesterase inhibitors, and how the studies dealt with items on the CONSORT checklist for randomised controlled trials. All studies were funded by pharmaceutical companies, coauthored by their employees, and reported results that favoured the sponsor's product. In two studies, a significantly lower proportion of people achieved the target maximum daily dose for the comparator drug than for the sponsor's product. Between 27% and 55% of CONSORT items per study were rated as inadequately reported. The methodological limitations of these studies reduce our confidence in the validity of the conclusions drawn in the published reports.
Alzheimer Disease↗