An Environmental Scan of Tools That Help Individuals Living With Mild Cognitive Impairment or Neurocognitive Disorders Achieve Their Preferred Health or Well-Being

BACKGROUND AND OBJECTIVES

Older adults experiencing neurocognitive disease (NCD) contend with complex care often characterized by high emotional strain. Mitigating complex care with decision support tools can clarify options. When used in conjunction with the practice of shared decision making (SDM), these tools can improve satisfaction and confidence in treatment. The use of these tools for cognitive health has increased, but more is needed to understand how these tools incorporate social needs into treatment plans.

RESEARCH DESIGN AND METHODS

We conducted an environmental scan using a MEDLINE-informed search strategy and feedback from an expert steering committee to characterize current tools and approaches for engaging older adults experiencing NCD. We assessed their application and development, incorporation of social determinants, goals or preferences, and inclusion of caregivers in their design.

RESULTS

We identified 11 articles, 7 of which show that SDM helps guide tool development and that most center on clinical decision making. Types of tools varied by clinical site and those differences reflected patient need. A collective value across tools was their use to forge meaningful conversations. Most tools appeared designed without the explicit goal to elicit patient social needs or incorporate nonclinical strategies into treatment plans.

DISCUSSION AND IMPLICATIONS

Several challenges and opportunities exist that center on strategies to engage patients in the design and testing of tools that support conversations with clinicians about cognitive health. Future work should focus on building and testing adaptable tools that support patient and family social care needs beyond clinical care settings.

Identifying longitudinal healthcare pathways and subsequent mortality for people living with dementia in England: an observational group-based trajectory analysis

BACKGROUND

The number of people living with dementia (PLWD) continues to increase, particularly those with severe symptomatology. Severe symptoms and greater ill-health result in more acute care need. Early healthcare interventions can prove beneficial. Healthcare use has not been analysed as a holistic set of interlinked events. This study explores different healthcare pathways among PLWD, social or spatial inequalities in healthcare pathways and subsequent mortality risk.

METHODS

Group-based trajectory models (GBTM) were applied to electronic healthcare records. We generated clusters of PLWD with similar five-year, post-diagnosis trajectories in rates of primary and secondary healthcare use. Potential social and spatial variations in healthcare use clusters were examined. Cox Proportional Hazards used to explore variation in subsequent mortality risk between healthcare use clusters.

RESULTS

Four healthcare use clusters were identified in both early- (n = 3732) and late-onset (n = 6224) dementia populations. Healthcare use variations were noted; consistent or diminishing healthcare use was associated with lower subsequent mortality risk. Increasing healthcare use was associated with increased mortality risk. Descriptive analyses indicated social and spatial variation in healthcare use cluster membership.

CONCLUSION

Healthcare pathways can help indicate changing need and variation in need, with differential patterns in initial healthcare use post-diagnosis, producing similar subsequent mortality risk. Care in dementia needs to be more accessible and appropriate, with care catered to specific and changing needs. Better continuity of care and greater awareness of dementia in primary can enhance prospects for PLWD. Research needs to further illuminate holistic care need for PLWD, including health and social care use, inequalities in care, health and outcomes.

Exploring Information and Referral Needs of Individuals with Dementias and Informal Caregivers in Rural and Remote Areas

Objectives: The provision of information and referral (I&R) and connection to support services is crucial for individuals with Alzheimer's disease and related dementias (ADRD) and their informal caregivers, especially in rural and remote regions where care and support resources may be limited. The purpose of this study was to develop a deeper understanding of needs for I&R from community stakeholders across a rural and remote state.Methods: A series of town hall meetings were conducted across ten communities in a frontier state.Results: Participants were 175 adults with a mean age of approximately 60 years (SD = 15 years); a majority were non-Hispanic white, female, and self-identified as informal caregivers. Three themes emerged as primary areas of need: (1) to address stigma related to ADRD; (2) to improve the availability of dementia-related I&R; and (3) to efficiently disseminate dementia-related I&R.Conclusions: Findings suggest the importance of a single point of access for I&R with presence in local communities as well as initial and ongoing assessment and provision of appropriate I&R throughout the course of ADRDs.Clinical Implications: Existing community resources and funding support should be leveraged for multiple points and means of access to reliable I&R.

Correlates of Formal Support Service Use among Dementia Caregivers

Informal caregivers for persons with dementia frequently report needing assistance, yet formal support service use has been low. To better understand factors associated with service use, correlates of self-reported service use (e.g., support groups, family mediation, family leave, classes/trainings, and respite care) among dementia caregivers were assessed. The National Poll on Healthy Aging conducted a nationally representative web-based survey of adults aged 50-80 (N = 2,131) using Ispos' KnowledgePanel®; 148 reported caregiving for an adult with memory loss [61.5% female; 25% nonwhite, 54.1% aged 50-64]. Multivariable logistic regression analyzes assessed caregiver and care recipient characteristics associated with service use within the prior year. Nearly 25% of caregivers used at least one service. Caregiver characteristics associated with greater likelihood of service use included not working [7.5 OR; 2.73, 20.62 CI]; income <$30,000/year [5.9 OR; 1.27, 27.17 CI]; and residing in Western US [7.5 OR; 2.73, 20.62 CI]. Ability of care recipient to be left alone safely for only three hours or less [5.1 OR; 1.66, 15.46 CI] was associated with greater likelihood of use. Support service use remains low. Findings suggest need to consider caregivers' employment status, income, and geographical location in service design and implementation.

Family health strategy and older adults with dementia: care provided by health professionals

This is a qualitative, descriptive-analytical study developed in a primary health care facility organized by the ESF. Semi-structured interviews were conducted with five health professionals: two doctors, a nurse, and two community health workers (ACS). The interview's guiding topics were respondent data (name, gender, age, professional category, and seniority in the service); elderly care; care to relatives; perception of the experience of extreme situations in the elderly monitoring; and challenges in the ESF in assisting older adults. Representations related to ESF professionals are directly related to the position held. The ACS are appointed as the facility's thermometer and eyes. Doctors perceive a great demand and see themselves as biomedical knowledge holders and medication prescribers. Nursing is perceived as a professional mediator between ACS and doctors. The walk-in demands of older adults and their families continue to be sustained by the tripod doctor, equipment (tests and procedures), and medication. As family hardships comprise dementia, the perception of care as a burden, and the socioeconomic constraints are intensifying aspects of dementia. The creation of a bond between professionals, relatives, and older adults was perceived as an emotional health care device fundamental for monitoring dementia cases.

An integrative review of system-level factors influencing dementia detection in primary care

BACKGROUND AND PURPOSE

The incidence of Alzheimer disease (AD) is increasing in the United States, yet more than half of the people with AD are diagnosed late in the course of the disease. Most are identified outside primary care. New approaches to prevention and treatment mean that early detection of AD may improve the quality of life of those affected by the disease. Nurse practitioners (NPs) have an important role in increasing early diagnosis of AD.The purpose of this systematic literature review is to identify health care system factors that contribute to missed or delayed diagnosis of dementia by primary care providers.

METHODS

Articles were identified through a systematic electronic search of the following databases: MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Results indicate considerable variation in the diagnostic accuracy of dementia by primary care providers. Missed or underdiagnosis of dementia results from organizational, provider, and patient factors. New treatments are under investigation that may slow the progression of AD much better than current therapy, emphasizing the need to improve early detection by clinicians, especially primary care NPs.

Outcomes of Medication Misadventure Among People With Cognitive Impairment or Dementia: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate mortality and hospitalization outcomes associated with medication misadventure (including medication errors [MEs], such as the use of potentially inappropriate medications [PIMs], and adverse drug events [ADEs]) among people with cognitive impairment or dementia.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, Ovid International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched from inception to December 2019.

STUDY SELECTION AND DATA EXTRACTION

Relevant studies using any study design were included. Reviewers independently performed critical appraisal and extracted relevant data.

DATA SYNTHESIS

The systematic review included 10 studies that reported the outcomes of mortality or hospitalization associated with medication misadventure, including PIMs (n=5), ADEs (n=2), a combination of MEs and ADEs (n=2), and drug interactions (n=1). Five studies examining the association between PIMs and mortality/hospitalization were included in the meta-analyses. Exposure to PIMs was not associated with either mortality (odds ratio [OR]=1.36; 95%CI=0.79-2.35) or hospitalization (OR=1.02; 95%CI=0.83-1.26). In contrast, single studies indicated that ADEs with cholinesterase inhibitors were associated with mortality and hospitalization.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Individuals with cognitive impairment or dementia are at increased risk of medication misadventure; based on relatively limited published data, this does not necessarily translate to increased mortality and hospitalization.

CONCLUSIONS

Overall, medication misadventure was not associated with mortality or hospitalization in people with cognitive impairment or dementia, noting the limited number of studies, difficulty in controlling potential confounding variables, and that most studies focus on PIMs.

Primary Care Physicians' Perceived Barriers to Optimal Dementia Care: A Systematic Review

BACKGROUND AND OBJECTIVES

Primary care physicians (PCPs) have a key role in providing care for people with dementia and their carers, however, a range of barriers prevent them from delivering optimal care. We reviewed studies on PCPs' perceptions of barriers to providing optimal dementia care, including their methodological quality, whether they focused on barriers related to diagnosis and/or management, and the patient-, provider-, and system-level barriers identified.

RESEARCH DESIGN AND METHODS

Studies were included if they were quantitative studies published since 2006 which reported on PCPs' perceptions of the barriers to providing dementia care. The methodological quality of identified studies was assessed using an adapted version of accepted rating criteria for quantitative studies. Data were extracted from studies which were rated as "moderate" or "strong" quality.

RESULTS

A total of 20 studies were identified, 16 of which were rated as "moderate" or "strong" methodological quality. Patient-related barriers included a reluctance to acknowledge cognitive decline and patient nonadherence to management plans. Provider-related barriers included a lack of training and confidence. System-related barriers included a lack of time during consultations and lack of support services.

DISCUSSION AND IMPLICATIONS

This review highlights a range of barriers to dementia diagnosis and management from studies rated as being methodologically adequate. Future studies should also utilize theory-driven approaches to exploring a comprehensive range of barriers to optimal dementia care across the care trajectory.

Temporal and Geographic Variation in the Incidence of Alzheimer's Disease Diagnosis in the US between 2007 and 2014

OBJECTIVES

Our aim was to describe the incidence of Alzheimer's disease (AD) in the United States, overall and by geographic region.

DESIGN

We conducted retrospective analyses of administrative claims data for a 5% random sample of US Medicare beneficiaries aged 65 years or older. AD incidence, defined as a diagnosis for AD (International Classification of Disease, Ninth Revision, Clinical Modification code 331.0×) in a given year, with no AD diagnosis in the beneficiary's entire medical history, was estimated for each calendar year between 2007 and 2014. Beneficiaries were required to be enrolled in Medicare for the calendar year of evaluation as well as the preceding 12 months. In addition, a cross-sectional assessment of geographic variation in AD incidence was conducted for 2014. For each population area (specifically, core-based statistical area, as defined by the US Census Bureau), AD incidence was estimated overall, as well as adjusted for differences in underlying patient demographics and metrics of access to care and quality of care. Changes in AD incidence from 2007 were also estimated.

SETTING

US fee-for-service Medicare.

PARTICIPANTS

US Medicare beneficiaries aged 65 years or older with no history of AD.

RESULTS

Overall, the diagnosed incidence of AD decreased over time, from 1.53% in 2007 to 1.09% in 2014; trends were similar for most population areas. In 2014, the rates of AD incidence ranged from 0% to more than 3% across population areas, with the highest observed incidence rates in areas of the Midwest and the South. Statistical models explain little of the geographic variation, although following adjustment, the incidence rates increased the most (in relative terms) in rural areas of western states.

CONCLUSION

Our findings are consistent with previously reported estimates of incidence of AD in the United States and its recent declining trend. Additionally, the study highlights the considerable geographic variation in the incidence of AD in the United States and suggests that further research is needed to better understand the determinants of this geographic variation. J Am Geriatr Soc 68:346-353, 2020.

Empowering Patients with Alzheimer's Disease To Avoid Unwanted Medical Care: A Look At The Dementia Care Triad

Patients with Alzheimer's disease and other types of dementia with acute medical problems, who have lost capacity and are without advance directives, are at risk of being over treated inhospitals. To deal with this growing demographic and ethical crisis, patients with dementia need to plan for their future medical care while they have capacity to do so. This article will examine the role of each member of the dementia care triad and how to empower the patient to participate in planning future medical care. A case will be made that physicians have the same professional disclosure obligations to dementia patients as they do to all other capable patients with terminal illnesses. Because there is little consensus about what facts should be included in a diagnostic disclosure, this article will offer a proposal to empower newly diagnosed patients with dementia with capacity to plan for their future medical care.

Communicating a diagnosis of dementia: A systematic mixed studies review of attitudes and practices of health practitioners

The aim of this study is to systematically review practitioners’ practices and attitudes in regards to communicating a diagnosis of dementia. A systematic search was conducted of Scopus, Web of Science and PubMed for English language original empirical papers. A sequential explanatory mixed studies analysis approach was used. Twenty-five quantitative descriptive, two intervention, six mixed methods descriptive and 21 qualitative studies were included. Pooled analysis showed that 34% of GPs and 48% of specialists usually/routinely tell the person with dementia their diagnosis, and 89% of GPs and 97% specialists usually/routinely tell the family the diagnosis. Euphemistic terms such as ‘memory problems’ are more often used to describe dementia than medical terms. Practitioners’ decision to diagnose and communicate the diagnosis of dementia are influenced by (a) their own beliefs regarding dementia and treatment efficacy and their confidence in diagnosis and communication; (b) patient circumstances including level of awareness, level of severity and family support; (c) the health and social care system including access to specialist and diagnostic services, reimbursement for diagnosis/management and availability of services and (d) cultural norms in relation to dementia including stigma, labels, and common clinical practice. The diagnosis and communication of diagnosis of dementia are intertwined processes and should be concurrently addressed in interventions. Multicomponent approaches to address these practices could include guideline development, practitioner education, anti-stigma public health campaigns, offering post-diagnosis treatments and support and sufficient reimbursement for practitioners for time spent managing dementia.

Knowledge, Attitudes, and Clinical Practices for Patients With Dementia Among Mental Health Providers in China: City and Town Differences

Mental health providers are the major resource families rely on when experiencing the effects of dementia. However, mental health resources and manpower are inadequate and unevenly distributed between cities and towns in China. This study was conducted to examine similarities and differences in knowledge, attitudes, and clinical practices concerning dementia and working with family caregivers from mental health providers' perspectives in city versus town settings. Data were collected during focus group discussions with 40 mental health providers in the Xicheng (city) and Daxing (town) districts in Beijing, China in 2011. Regional disparities between providers' knowledge of early diagnosis of dementia and related counseling skills were identified. Regional similarities included training needs, dementia-related stigma, and low awareness of dementia among family caregivers. Culturally sensitive education specific to dementia for mental health providers and a specialized dementia care model for people with dementia and their family caregivers are urgently needed. Implications for geriatric practitioners and educators are discussed.

Prevalence and management of dementia in primary care practices with electronic medical records: a report from the Canadian Primary Care Sentinel Surveillance Network

BACKGROUND

The proportion of Canadians living with Alzheimer disease and related dementias is projected to rise, with an increased burden on the primary health care system in particular. Our objective was to describe the prevalence and management of dementia in a community-dwelling sample using electronic medical record (EMR) data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), which consists of validated, national, point-of-care data from primary care practices.

METHODS

We used CPCSSN data as of Dec. 31, 2012, for patients 65 years and older with at least 1 clinical encounter in the previous 2 years. A validated case definition for dementia was used to calculate the national and provincial prevalence rates, to examine variations in prevalence according to age, sex, body mass index, rural or urban residence, and select comorbid conditions, and to describe patterns in the pharmacologic management of dementia over time at the provincial level.

RESULTS

The age-standardized prevalence of dementia among community-dwelling patients 65 years and older was 7.3%. Prevalence estimates increased with age; they also varied between provinces, and upward trends were observed. Dementia was found to be associated with comorbid diabetes, depression, epilepsy and parkinsonism. Most of the patients with dementia did not have a prescription for a dementia-related medication recorded in their EMR between 2008 and 2012 inclusive. Those who had a prescription were most often prescribed donepezil by their primary care provider.

INTERPRETATION

Overall prevalence estimates for dementia based on EMR data in this sample managed in primary care were generally in line with previous estimates based on administrative data, survey results or clinical sources.

Optimizing person-centered transitions in the dementia journey: a comparison of national dementia strategies

The journey for people with Alzheimer's disease or another dementia involves the need for increasing levels of support, with transitions across care settings. Although transitional care has received increasing attention in the health care arena, no widely accepted transitions typology exists for the dementia journey. At the same time, national dementia strategies are proliferating. We developed a typology containing six transitions that cover the dementia journey from symptom recognition to end-of-life care. We then critically evaluated whether and how the national dementia strategies of Australia, England, France, the Netherlands, Norway, Scotland, and the United States addressed each transition. Adopting a person-centered perspective, we found that most or all of the national strategies adequately address earlier transitions in the journey, but fewer strategies address the later transitions. We recommend that next-generation national dementia strategies focus on later transitions, specify how care coordination and workforce training should make transitions more person centered, and use person-centered outcomes in evaluating the success of the strategies' implementation and dissemination.

Strengthening the dementia care triad: identifying knowledge gaps and linking to resources

This article describes a project to identify the needs of family caregivers and health care providers caring for persons with dementia. Participants included 128 caregivers, who completed a survey, and 27 health care providers, who participated in a focus group and completed a survey. Caregivers reported their primary source of information about the disease was the doctor; however, the majority also reported they were primarily informed of medications and not about needed resources. Health care providers identified limited time with patients and families, and lack of awareness of community services, as their main challenges. Recommendations include strengthening the partnership between physicians, patients, and caregivers (the dementia care triad) through additional support and training for physicians and caregivers, increasing awareness of the Alzheimer's Association, and utilization of technology for families and professionals to track the needs of persons with dementia.

Role expectations in dementia care among family physicians and specialists

BACKGROUND

The assessment and ongoing management of dementia falls largely on family physicians. This pilot study explored perceived roles and attitudes towards the provision of dementia care from the perspectives of family physicians and specialists.

METHODS

Semi-structured, one-to-one interviews were conducted with six family physicians and six specialists (three geriatric psychiatrists, two geriatricians, and one neurologist) from University of Toronto-affiliated hospitals. Transcripts were subjected to thematic content analysis.

RESULTS

Physicians' clinical experience averaged 16 years. Both physician groups acknowledged that family physicians are more confident in diagnosing/treating uncomplicated dementia than a decade ago. They agreed on care management issues that warranted specialist involvement. Driving competency was contentious, and specialists willingly played the "bad cop" to resolve disputes and preserve long-standing therapeutic relationships. While patient/caregiver education and support were deemed essential, most physicians commented that community resources were fragmented and difficult to access. Improving collaboration and communication between physician groups, and clarifying the roles of other multi-disciplinary team members in dementia care were also discussed.

CONCLUSIONS

Future research could further explore physicians' and other multi-disciplinary members' perceived roles and responsibilities in dementia care, given that different health-care system-wide dementia care strategies and initiatives are being developed and implemented across Ontario.

Dementia Services Mini-Screen: a simple method to identify patients and caregivers in need of enhanced dementia care services

OBJECTIVE

Improving dementia care in health systems requires estimates of need in the population served. We explored whether dementia-specific service needs and gaps for patients and caregivers could be predicted by simple information readily captured in routine care settings.

METHOD

Primary family caregivers (n = 215) rated their own current stress, challenging patient behaviors, and prior-year needs and gaps in 16 medical and psychosocial services. These were evaluated with other patient and caregiver characteristics in multivariate regressions to identify unique predictors of service needs and gaps.

RESULTS

Caregiver stress and patient behavior problems together accounted for an average of 24% of the whole-sample variance in total needs and gaps. All other variables combined (comorbid chronic disease, dementia severity, age, caregiver relationship, and residence) accounted for a mean of 3%, with none yielding more than 4% in any equation. We combined stress and behavior problem indicators into a simple screen. In early/mild dementia dyads (n = 111) typical in primary care settings, the screen identified gaps in total (84%) and psychosocial (77%) care services for high stress/high behavior problem dyads vs. 25% and 23%, respectively, of low stress/low behavior problem dyads. Medical care gaps were dramatically higher in high stress/high behavior problem dyads (66%) than all others (12%).

CONCLUSION

The Dementia Services Mini-Screen is a simple tool that could help clinicians and health systems rapidly identify dyads needing enhanced dementia care, track key patient and caregiver outcomes of interventions, and estimate population needs for new service development.

Variations in self-reported practice of physicians providing clinical care to individuals with dementia: a systematic review

OBJECTIVES

To determine to what extent actual practice as reported in the literature is consistent with clinical guidelines for dementia care.

DESIGN

A systematic review of empirical studies of clinical services provided by physicians to older adults with a diagnosis of dementia.

SETTING

All settings involving primary care physicians in which a diagnosis of dementia is provided.

PARTICIPANTS

Physicians providing care to individuals aged 60 and older with a primary or secondary diagnosis of dementia.

INTERVENTION

Seven dementia care processes recommended by guidelines: formal memory testing, imaging, laboratory testing, interventions, counseling, community service, and specialist referrals.

MEASUREMENTS

Web of Knowledge, PubMed, Science Direct, MedLine, PsychINFO, EMBASE, and Google Scholar databases were searched for articles in English published before March 1, 2012.

RESULTS

Twelve studies met the final inclusion criteria, all of which were self-reported cross-sectional surveys. There was broad variation in the proportion of physicians who reported conducting each dementia care process, with the widest variation in formal memory testing (4-96%). Recently published studies reflected a shift in scope of care, reporting that high proportions of physicians provided interventions, counseling, and referrals to specialist.

CONCLUSION

Despite the availability and dissemination of established best practice guidelines, there is still wide variation in physician practice patterns in dementia care. The quality of currently available studies limits the ability to draw strong conclusions. Better information on practice patterns and their relationship to outcomes for individuals with dementia and their caregivers using more-robust study designs is needed to address the needs of the increasing number of individuals who will require dementia care.

Assessing factors related to the pharmacologic management of laryngeal diseases and disorders

OBJECTIVES/HYPOTHESIS

To examine how age, gender, comorbidity, geography, provider type, and laryngeal pathology influence the use of pharmacological treatment in managing patients with laryngeal disorders.

STUDY DESIGN

Retrospective analysis of data from a large, nationally representative, administrative, US claims database.

METHODS

Patients with a laryngeal disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004 to December 31, 2008, seen as an outpatient by a primary care physician (PCP), otolaryngologist, or both and continuously enrolled for 12 months were included. Data regarding pharmacy claims, age, gender, geographic location, comorbid conditions, provider type, and laryngeal diagnosis were collected. To identify factors that influenced whether a patient received a medication or not, a logistic regression was performed.

RESULTS

Of almost 55 million individuals in the database, 258,705 had a laryngeal diagnosis 12 months post-index date follow-up and an outpatient encounter with a PCP, otolaryngologist, or both. A total of 135,973 (52.6%) unique patients, mean age 47.4 years (22.2 standard deviation [SD]), with 61.9% female, received a medication, and 122,732 (47.4%), mean age 47.4 years (19.8 SD), with 65.8% female, did not. Higher odds ratios for medication treatment were associated with PCPs versus otolaryngologists, acute laryngitis, the South region, and patients with comorbid conditions. Variable prescription patterns were also observed for age and gender.

CONCLUSIONS

Multiple factors are associated with the use of medical treatment for laryngeal disorders.

The coming crisis: obtaining care for the growing burden of neurodegenerative conditions

As the U.S. population ages, the burden of neurodegenerative disorders, including Alzheimer disease and Parkinson disease, will increase substantially. However, many of these patients and their families currently do not receive neurologic care. For example, a recent study found that over 40% of Medicare beneficiaries with an incident Parkinson disease diagnosis did not receive neurologist care early after diagnosis and those who did not were more likely to fracture a hip, be placed in a nursing home, and die. While geography, age, race, and sex likely contribute to these observed disparities in care and outcomes, a large barrier may be Medicare's reimbursement policies, which value procedures over care. With further reductions in Medicare reimbursement constantly on the horizon, the devaluing of clinical care will likely continue. Rather than guaranteeing access to care, Medicare's reimbursement policies may increasingly be an impediment to care.

A review of geographic variation and Geographic Information Systems (GIS) applications in prescription drug use research

BACKGROUND

While understanding geography's role in healthcare has been an area of research for over 40 years, the application of geography-based analyses to prescription medication use is limited. The body of literature was reviewed to assess the current state of such studies to demonstrate the scale and scope of projects in order to highlight potential research opportunities.

OBJECTIVE

To review systematically how researchers have applied geography-based analyses to medication use data.

METHODS

Empiric, English language research articles were identified through PubMed and bibliographies. Original research articles were independently reviewed as to the medications or classes studied, data sources, measures of medication exposure, geographic units of analysis, geospatial measures, and statistical approaches.

RESULTS

From 145 publications matching key search terms, forty publications met the inclusion criteria. Cardiovascular and psychotropic classes accounted for the largest proportion of studies. Prescription drug claims were the primary source, and medication exposure was frequently captured as period prevalence. Medication exposure was documented across a variety of geopolitical units such as countries, provinces, regions, states, and postal codes. Most results were descriptive and formal statistical modeling capitalizing on geospatial techniques was rare.

CONCLUSION

Despite the extensive research on small area variation analysis in healthcare, there are a limited number of studies that have examined geographic variation in medication use. Clearly, there is opportunity to collaborate with geographers and GIS professionals to harness the power of GIS technologies and to strengthen future medication studies by applying more robust geospatial statistical methods.

A review of barriers and enablers to diagnosis and management of persons with dementia in primary care

Background

With the rise in the prevalence of dementia disorders and the growing critical impact of dementia on health-care resources, the provision of dementia care has increasingly come under scrutiny, with primary care physicians (PCP) being at the centre of such attention.

Purpose

To critically examine barriers and enablers to timely diagnosis and optimal management of community living persons with dementia (PWD) in primary care.

Methods

An interpretive scoping review was used to synthesize and analyze an extensive body of heterogeneous Western literature published over the past decade.

Results

The current primary care systems in many Western countries, including Canada, face many challenges in providing responsive, comprehensive, safe, and cost-effective dementia care. This paper has identified a multitude of highly inter-related obstacles to optimal primary dementia care, including challenges related to: a) the complex biomedical, psychosocial, and ethical nature of the condition; b) the gaps in knowledge, skills, attitudes, and resources of PWD/caregivers and their primary care providers; and c) the broader systemic and structural barriers negatively affecting the context of dementia care.

Conclusions

Further progress will require a coordinated campaign and significantly increased levels of commitment and effort, which should be ideally orchestrated by national dementia strategies focusing on the barriers and enablers identified in this paper.

Difficult diagnoses: Family caregivers' experiences during and following the diagnostic process for dementia

Diagnosing Alzheimer's disease and related dementias (ADRD) and adequately connecting families with information and supportive services continue to be challenging processes. Definitive diagnoses can take months and there is often little in place to systematically link families with community organizations. In this brief descriptive study, the researchers examined family caregivers' (N = 106) experiences with these processes. While specialists and sophisticated tests were often used, 58% of caregivers reported that a definitive diagnosis still took 3 months or longer, with 12% waiting more than 1 year. Caregivers also indicated that they were not provided with adequate information about the disease or about community resources both at the time of diagnosis and 1-year following the diagnosis. These findings suggest that there is ample opportunity to improve services offered to families affected by ADRD and that additional training, coordination, and cooperation may enhance our ability to help during and following the diagnosis.