Is Dementia Screening of Apparently Healthy Individuals Justified?

Despite efforts to raise awareness and develop guidelines for care of individuals with dementia, reports of poor detection and inadequate management persist. This has led to a call for more identification of people with dementia, that is, screening individuals who may or may not complain of symptoms of dementia in both acute settings and primary care. The following should be considered before recommending screening for dementia among individuals in the general population. Dementia Tests. Low prevalence reduces positive predictive value of tests and screening tests will miss people who have dementia and identify people who do not have dementia in substantial numbers. Clinical Issues. The clinical course of dementia has not yet been shown to be amenable to intervention. Misdiagnosis and overdiagnosis can have significant long-term effects including stigmatization, loss of employment, and autonomy. Economic Issues. Health systems do not have the capacity to respond to increased demand resulting from screening. In conclusion, at present attention to life-course risk reduction and support in the community for frail and cognitively impaired older adults is a better use of limited healthcare resources than introduction of unevaluated dementia screening programs.Peer Reviewe

The inheritance of loss: Caspase-6 activity and effect in human neurons caused by familial Alzheimer's Disease associated mutants

Active Caspase 6 associates with the neuropathological hallmarks of sporadic Alzheimer disease (SAD), indirectly increases amyloid beta (A-Beta) and cleaves Tau and other cytoskeleton proteins. Given the similar neuropathology of SAD and familial AD (FAD), my objective is to assess if FAD-associated amyloid precursor protein (APP) mutations activate Caspase 6 in human neurons. Human neurons were transfected with a bigenic vector expressing enhanced green florescent protein (EGFP) and either wild type APP, the Swedish or London mutations. Normally diffuse EGFP beads in neurons over-expressing APP or APP mutants in an A-Beta independent manner and appears to co-localize with beaded Tau and Ubiquitin. Additionally, the number of EGFP-positive APP or APP mutant-transfected neurons decreases with time in culture and undergoes A-Beta dependent cell death. Treatment with a caspase 6 inhibitor or dominant negative Caspase 6 attenuates EGFP beading, EGFP-positive neuronal dropout and cell death. Therefore, FAD-mutants and APP over-expression activate Caspase 6 in human neurons resulting in morphological changes and A-Beta dependent cell death that may contribute to the neuropathological features of FAD.La forme active de la Caspase 6 est impliquée dans les effets neuropathologiques typiques de la forme sporadique de la maladie d'Alzheimer (SAD) en augmentant indirectement la production du peptide amyloïde-bêta (A-Beta) et en clivant Tau ainsi que d'autres protéines du cyotoskelette. Compte tenu des neuropathologies similaires de SAD et de la forme familiale de la maladie d'Alzheimer (FAD), mon objectif était de déterminer si les mutations de la protéine précurseur de l'amyloïde (APP) associées à FAD, activent la Caspase 6 dans les neurones humains. Les neurones humains ont été transfectés avec un vecteur bigénique exprimant la protéine fluorescente verte (EGFP; Enhanced Green Fluorescent Protein) et soit l'APP sauvage ou sa forme mutée associée a FAD soit la mutation Suédoise ou la mutation de Londre. Normalement présente sous forme diffuse dan le neurone, l'EGFP forme des agrégats dan les neurites del cellules qui sur experiment en présence de l'APP sauvage ou les mutants. La protein Tau et d'Ubiquitine semble se co-localiser avec les agrégations EGFP. Notons que cette accumulation ne dépend pas de la présence de A-Beta. De plus, le nombre de neurones exprimant une forme ou l'autre d'APP où EGFP est visible diminue et il y a augmentation de la mort cellulaire chez ces cellules liée à la présence de A-Beta. Le traitement avec l'inhibiteur de la Caspase 6 ou un mutant dominant négatif de la Caspase 6 atténue la formation d'agrégats d'EGFP, la diminution du nombre de neurones positifs à l'EGFP et la mort cellulaire. Par conséquent, les mutants FAD activent la caspase 6 dans les neurones humains et mènent à des changements de morphol

Diagnosis & disruption : understanding guideline-consistent dementia care and patterns of transitions experienced by individuals with dementia

Introduction Early detection and management, as outlined in dementia guidelines, can improve outcomes and potentially reduce the number of transitions experienced between care-facilities. The objectives of this thesis were to : conduct a critical assessment of the literature on actual versus guideline-consistent dementia care; use population-level data to examine variations in receipt of guideline-consistent dementia care; understand longitudinal patterns of transitions and the factors that contribute to transitions; and assess if receipt of guideline-consistent dementia care and/or high quality primary care are associated with the number of transitions experienced. Method Population-level administrative data in British Columbia were used to identify cohorts of individuals newly diagnosed with dementia in 2001/02 and 2009/10. Dementia guidelines were used to characterize clinical care individuals could receive. The proportion of patients diagnosed with dementia in 2009/10 who received guideline-consistent dementia care and the probability that patient characteristics affected the likelihood of receiving each process was assessed. Those diagnosed with dementia in 2001/02 were followed forward 10-years after the first point of diagnosis and points of care when transitions were highest as well as factors that contribute to those transitions were assessed. The association of receipt of guideline-consistent dementia care and/or high quality primary care with the number of transitions experienced in the year of diagnosis was assessed using negative binomial regression. Results Older patients were less likely to receive guideline-consistent dementia care. A quarter of the cohort received an antipsychotic or non-recommended benzodiazepine. Individuals living within rural health-authorities or of low income were more likely to receive antipsychotic treatment. Transitions were highest in the year of diagnosis and at end-of-life, driven by acute hospitalizations. Higher morbidity, living within rural health-authorities, and having behavioural symptoms associated with dementia were strongly associated with the number of transitions experienced. Lastly, receipt of guideline-consistent dementia care and high quality primary care, independently, were associated with fewer transitions across care settings. Conclusion Patterns of inequality by age and income may signal barriers to guideline-consistent dementia care. The spike in transitions in the year following diagnosis highlights a distressing period for individuals with dementia, but suggests a useful target for interventions.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Is Dementia Screening of Apparently Healthy Individuals Justified?

Despite efforts to raise awareness and develop guidelines for care of individuals with dementia, reports of poor detection and inadequate management persist. This has led to a call for more identification of people with dementia, that is, screening individuals who may or may not complain of symptoms of dementia in both acute settings and primary care. The following should be considered before recommending screening for dementia among individuals in the general population. Dementia Tests. Low prevalence reduces positive predictive value of tests and screening tests will miss people who have dementia and identify people who do not have dementia in substantial numbers. Clinical Issues. The clinical course of dementia has not yet been shown to be amenable to intervention. Misdiagnosis and overdiagnosis can have significant long-term effects including stigmatization, loss of employment, and autonomy. Economic Issues. Health systems do not have the capacity to respond to increased demand resulting from screening. In conclusion, at present attention to life-course risk reduction and support in the community for frail and cognitively impaired older adults is a better use of limited healthcare resources than introduction of unevaluated dementia screening programs

Designation, diligence and drift: understanding laboratory expenditure increases in British Columbia, 1996/97 to 2005/06

Abstract Background Laboratory testing is one of the fastest growing areas of health services spending in Canada. We examine the extent to which increases in laboratory expenditures might be explained by testing that is consistent with guidelines for the management of chronic conditions, by analyzing fee-for-service physician payment data in British Columbia from 1996/97 and 2005/06. Method We used direct standardization to quantify the effect on laboratory expenditures from changes in: fee levels; population growth; population aging; treatment prevalence; expenditure on recommended tests for those conditions; and expenditure on other tests. The chronic conditions selected were those with guidelines containing laboratory recommendations developed by the BC Guidelines and Protocol Advisory Committee: diabetes, hypertension, congestive heart failure, renal failure, liver disease, rheumatoid arthritis, osteoarthritis and dementia. Result Laboratory service expenditures increased by $98 million in 2005/06 compared to 1996/97, or 3.6% per year after controlling for population growth and aging. Testing consistent with guideline-recommended care for chronic conditions explained one-third (1.2% per year) of this growth. Changes in treatment prevalence were just as important, contributing 1.5% per year. Hypertension was the most common condition, but renal failure and dementia showed the largest changes in prevalence over time. Changes in other laboratory expenditure including for those without chronic conditions accounted for the remaining 0.9% growth per year. Conclusion Increases in treatment prevalence were the largest driver of laboratory cost increases between 1996/97 and 2005/06. There are several possible contributors to increasing treatment prevalence, all of which can be expected to continue to put pressure on health care expenditures.</p

Designation, diligence and drift: understanding laboratory expenditure increases in British Columbia, 1996/97 to 2005/06

Background: Laboratory testing is one of the fastest growing areas of health services spending in Canada. We examine the extent to which increases in laboratory expenditures might be explained by testing that is consistent with guidelines for the management of chronic conditions, by analyzing fee-for-service physician payment data in British Columbia from 1996/97 and 2005/06. Method We used direct standardization to quantify the effect on laboratory expenditures from changes in: fee levels; population growth; population aging; treatment prevalence; expenditure on recommended tests for those conditions; and expenditure on other tests. The chronic conditions selected were those with guidelines containing laboratory recommendations developed by the BC Guidelines and Protocol Advisory Committee: diabetes, hypertension, congestive heart failure, renal failure, liver disease, rheumatoid arthritis, osteoarthritis and dementia. Result Laboratory service expenditures increased by $98 million in 2005/06 compared to 1996/97, or 3.6% per year after controlling for population growth and aging. Testing consistent with guideline-recommended care for chronic conditions explained one-third (1.2% per year) of this growth. Changes in treatment prevalence were just as important, contributing 1.5% per year. Hypertension was the most common condition, but renal failure and dementia showed the largest changes in prevalence over time. Changes in other laboratory expenditure including for those without chronic conditions accounted for the remaining 0.9% growth per year. Conclusion Increases in treatment prevalence were the largest driver of laboratory cost increases between 1996/97 and 2005/06. There are several possible contributors to increasing treatment prevalence, all of which can be expected to continue to put pressure on health care expenditures.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofReviewedFacult

Defining and measuring full service family practice in BC, 1991-2006

Ongoing primary care reform in Canada is in part a response to concerns that Canadians lack timely access to a regular source of primary care. While the supply of general practice physicians per capita has been stable, changes in practice patterns including abandonment of specific areas of practice (such as obstetrics, anesthesia, or provision of services in hospitals, homes, or long-term care facilities) and movement to walk-in style clinics may shape accessibility of primary care as perceived and experienced by patients. In British Columbia (BC), the General Practice Services Committee (GPSC) has spearheaded reform efforts. Founded in 2003, the GPSC is a joint committee composed of the BC Ministry of Health, the BC Medical Association, and the Society of General Practitioners of BC. Its mandate is to support full service family practice and benefit patients. This report seeks to operationalize the GPSC definition of full service family practice using administrative data, and to track changes in physician practice patterns consistent with that definition over time.composed of the BC Ministry of Health, the BC Medical Association, and the Society of General Practitioners of BC. Its mandate is to support full service family practice and benefit patients. This report seeks to operationalize the GPSC definition of full service family practice using administrative data, and to track changes in physician practice patterns consistent with that definition over time.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofUnreviewedFacultyResearcherPostdoctora

Capacity development in health systems and policy research: a survey of the Canadian context

Background: Over the past decade, substantial global investment has been made to support health systems and policy research (HSPR), with considerable resources allocated to training. In Canada, signs point to a larger and more highly skilled HSPR workforce, but little is known about whether growth in HSPR human resource capacity is aligned with investments in other research infrastructure, or what happens to HSPR graduates following training. Methods: We collected data from the Canadian Institutes of Health Research, Canada’s national health research funding agency, and the Canadian Association for Health Services and Policy Research on recent graduates in the HSPR workforce. We also surveyed 45 Canadian HSPR training programs to determine what information they collect on the career experiences of graduates. Results: No university programs are currently engaged in systematic follow-up. Collaborative training programs funded by the national health research funding agency report performing short-term mandated tracking activities, but whether and how data are used is unclear. No programs collected information about whether graduates were using skills obtained in training, though information collected by the national funding agency suggests a minority (<30%) of doctoral-level trainees moving on to academic careers. Conclusions: Significant investments have been made to increase HSPR capacity in Canada and around the world but no systematic attempts to evaluate the impact of these investments have been made. As a research community, we have the expertise and responsibility to evaluate our health research human resources and should strive to build a stronger knowledge base to inform future investment in HSPR research capacity.Non UBCMedicine, Faculty ofPopulation and Public Health (SPPH), School ofReviewedFacult

Understanding and Improving the Care of Older Adults Living with Dementia Across Four Canadian Provinces during the COVID-19 Pandemic: A Mixed-Methods Study to Inform Policy and Practices

Introduction: The implications of the COVID-19 pandemic are far reaching for persons living with dementia (PLWD) in the community and in long-term care (LTC), as they are among the most vulnerable. PLWD are at risk for severe COVID-19 and a disruption in accessing supportive and health care due to the confinement measures. Objectives: 1) To measure the impact of the pandemic on health and social services use, mortality, COVID-19 infection where possible of PLWD both in the community and in LTC facilities compared to before the pandemic; 2) To understand PLWDs’ and care partners’ perceived needs, behaviours related to health service use and the experiences of PLWD, care partners, and physicians with health and social services; 3) To generate and disseminate evidence-based and actionable recommendations on effective strategies to address the current pandemic and prepare for subsequent waves. Methods: A convergent mixed-methods design with a participatory approach in 4 Canadian provinces. Objective 1 will use a retrospective observational cohort design to examine administrative health data. Outcomes will include mortality (all-cause; COVID-19 related), health service use and, where possible, infection rates. Objective 2 will use an explanatory multiple case study, with surveys and semi-structured interviews to explore the experiences of PLWD and care partners using health and social services and the role of sociodemographic factors. The third, knowledge translation objective will integrate these results using a deliberative dialogue with key stakeholders (decision-makers, healthcare managers, PLWD, care partners, and clinicians) to develop and disseminate evidence-based recommendations for practice and policy. Impact and conclusion: This project will provide an understanding of the impact of the COVID-19 pandemic on PLWD and care partners in Canada and highlight areas for improvement.Introduction : La pandémie de COVID-19 a eu de graves conséquences pour les personnes qui présentent des vulnérabilités, particulièrement celles avec un trouble neurocognitif majeur (TNM). Ces dernières risquent à la fois d’avoir une infection grave et de voir leur accès aux soins de santé et services sociaux compromis. Objectifs : Décrire le protocole de notre étude qui vise à : 1) Mesurer l’impact de la pandémie sur l’utilisation des services de santé et des services sociaux, la mortalité, l’infection à la COVID-19 des personnes avec un TNM, lorsque possible, à la fois dans la communauté et dans les établissements de soins de longue durée, comparativement à avant la pandémie, 2) Comprendre les besoins perçus et les comportements relatifs à l’utilisation des services de santé des personnes avec un TNM et des proches aidants, et les expériences des personnes avec un TNM, proches aidants et médecins avec les services de santé et sociaux, et 3) Générer et diffuser des recommandations fondées sur des données probantes portant sur des stratégies efficaces pour faire face à la pandémie actuelle et se préparer aux vagues subséquentes. Méthodes : Une étude à méthodes mixtes convergentes avec approche participative réalisée dans 4 provinces canadiennes. Objectif 1 : nous ferons une étude de cohorte observationnelle rétrospective dans laquelle nous mesurerons la mortalité (toutes causes ; liées à COVID-19), l’utilisation des services de santé, et les taux d’infection dans des banques de données administratives. Objectif 2 : nous ferons une étude de cas multiple explicative, dans laquelle nous conduirons des entretiens semi-structurés et des questionnaires auprès des personnes avec TNM, proches aidants et des cliniciens. Objectif 3 : nous intégrerons les résultats des 2 premiers objectifs à l’aide d’une méta-matrice et conduirons un dialogue délibératif avec des décideurs, gestionnaires, personnes avec TNM, proches aidants et, cliniciens. Impact et conclusion : Ce projet permettra de comprendre l’impact de la pandémie sur les personnes avec TNM et proches aidants canadiens et de souligner les domaines à améliorer