An inpatient rehabilitation model of care targeting patients with cognitive impairment

BACKGROUND: The course and outcomes of hip fracture patients are often complicated by the presence of dementia and delirium, referred to as cognitive impairment (CI), which limits access to in-patient rehabilitation. In response to this concern, members of our team developed and piloted an in-patient rehabilitation model of care (Patient-Centred Rehabilitation Model; PCRM) targeting patients with hip fracture and CI (PCRM-CI). We are now conducting a 3-year study comparing an inpatient rehabilitation model of care for community dwelling individuals with hip fracture and CI (PCRM-CI) to usual care to determine whether it results in improved mobility at the time of discharge from inpatient rehabilitation. METHODS/DESIGN: A non-equivalent pre-post design is being used to evaluate the PCRM-CI compared to usual care. All community dwelling (private home or retirement home) patients following a hip fracture are eligible to participate. Recruitment of both cohorts is taking place at two facilities. Target accrual is 70 hip fracture patients in the PCRM-CI cohort and 70 patients in the usual care cohort. We are also recruiting 70 health care providers (HCPs), who are being trained to implement the PCRM-CI, and their unit managers. Patient data are collected at baseline, discharge, and 6 months post-discharge from an inpatient rehabilitation program. Evaluations include mobility, physical function, and living arrangement. Additional outcome variables are being collected from medical records and from the patients via their proxies. Data on the prevalence and severity of dementia and delirium are being collected. Staff data are collected at baseline and one year after implementation of the model to determine change in staff knowledge and attitudes toward patients with hip fracture and CI. Bi-monthly semi-structured interviews with unit managers have been conducted to examine factors and barriers influencing the model implementation. Data collection began in 2009 and is expected to be completed in 2012. The control cohort of 70 patients has been recruited, and 45 patients have been accrued to the intervention group to date. DISCUSSION: Evaluation of this model of care is timely given the increasing proportion of persons with cognitive impairment and hip fractures. TRIAL REGISTRATION: The study is registered at http://clinicaltrials.gov, Identifier NCT01566136

Structural Brain Magnetic Resonance Imaging to Rule out Comorbid Pathology in the Assessment of Alzheimer\u27s Disease Dementia: Findings from the Ontario Neurodegenerative Disease Research Initiative (ONDRI) Study and Clinical Trials over the Past 10 Years

Background/Objective: Structural brain magnetic resonance imaging (MRI) is not mandatory in Alzheimer\u27s disease (AD) research or clinical guidelines. We aimed to explore the use of structural brain MRI in AD/mild cognitive impairment (MCI) trials over the past 10 years and determine the frequency with which inclusion of standardized structural MRI acquisitions detects comorbid vascular and non-vascular pathologies. Methods: We systematically searched ClinicalTrials.gov for AD clinical trials to determine their neuroimaging criteria and then used data from an AD/MCI cohort who underwent standardized MRI protocols, to determine type and incidence of clinically relevant comorbid pathologies. Results: Of 210 AD clinical trials, 105 (50%) included structural brain imaging in their eligibility criteria. Only 58 (27.6%) required MRI. 16,479 of 53,755 (30.7%) AD participants were in trials requiring MRI. In the observational AD/MCI cohort, 141 patients met clinical criteria; 22 (15.6%) had relevant MRI findings, of which 15 (10.6%) were exclusionary for the study. Discussion: In AD clinical trials over the last 10 years, over two-thirds of participants could have been enrolled without brain MRI and half without even a brain CT. In a study sample, relevant comorbid pathology was found in 15% of participants, despite careful screening. Standardized structural MRI should be incorporated into NIA-AA diagnostic guidelines (when available) and research frameworks routinely to reduce diagnostic heterogeneity

Family Physicians’ Attitudes and Practices Regarding Assessments of Medical Fitness to Drive in Older Persons

BACKGROUND: Higher crash rates per mile driven in older drivers have focused attention on the assessment of older drivers. OBJECTIVE: To examine the attitudes and practices of family physicians regarding fitness-to-drive issues in older persons. DESIGN: Survey questionnaire. PARTICIPANTS: The questionnaire was sent to 1,000 randomly selected Canadian family physicians. Four hundred sixty eligible physicians returned completed questionnaires. MEASUREMENTS: Self-reported attitudes and practices towards driving assessments and the reporting of medically unsafe drivers. RESULTS: Over 45% of physicians are not confident in assessing driving fitness and do not consider themselves to be the most qualified professionals to do so. The majority (88.6%) feel that they would benefit from further education in this area. About 75% feel that reporting a patient as an unsafe driver places them in a conflict of interest and negatively impacts on the patient and the physician–patient relationship. Nevertheless, most (72.4%) agree that physicians should be legally responsible for reporting unsafe drivers to the licensing authorities. Physicians from provinces with mandatory versus discretionary reporting requirements are more likely to report unsafe drivers (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.58 to 4.91), but less likely to perform driving assessments (OR, 0.58; 95% CI, 0.39 to 0.85). Most driving assessments take between 10 and 30 minutes, with much variability in the components included. CONCLUSIONS: Family physicians lack confidence in performing driving assessments and note many negative consequences of reporting unsafe drivers. Education about assessing driving fitness and approaches that protect the physician–patient relationship when reporting occurs are needed

A Patient-Based Needs Assessment for Living Well with Parkinson Disease: Implementation via Nominal Group Technique

Background. Parkinson’s disease (PD) is a neurodegenerative condition with complex subtleties, making it challenging for physicians to fully inform their patients. Given that approximately 50% of Americans access the Internet for health information, the development of a multimedia, web-based application emphasizing targeted needs of people with Parkinson’s disease (PwP) has the potential to change patient’s lives. Objectives. To determine what information PwP perceive could enhance their quality of life. Methods. Group sessions utilizing nominal group technique (NGT) were conducted. Participants were asked “what information do you want to know about that would help you live well with PD?” Silent generation of ideas preceded discussion followed by anonymous ranking of items. A “summary score” (sum of rank × frequency) was calculated. Results. 36 individual items were collapsed into 9 categories. Coping with emotions, changing relationships, and social implications of PD were ranked as most important. Financial supports and skills for self-advocacy were also highly ranked. Conclusions. Qualitative research methodology was utilized to determine the unmet needs of PwP. Results of this survey will inform the development of a patient-oriented, online resource, the goal will be to provide information and strategies to improve symptom management, reduce disability and address all relevant concerns important to those affected by PD.Peer Reviewe