Evidence summaries (decision boxes) to prepare clinicians for shared decision-making with patients: a mixed methods implementation study

Background: Decision boxes (Dboxes) provide clinicians with research evidence about management options for medical questions that have no single best answer. Dboxes fulfil a need for rapid clinical training tools to prepare clinicians for clinician-patient communication and shared decision-making. We studied the barriers and facilitators to using the Dbox information in clinical practice. Methods: We used a mixed methods study with sequential explanatory design. We recruited family physicians, residents, and nurses from six primary health-care clinics. Participants received eight Dboxes covering various questions by email (one per week). For each Dbox, they completed a web questionnaire to rate clinical relevance and cognitive impact and to assess the determinants of their intention to use what they learned from the Dbox to explain to their patients the advantages and disadvantages of the options, based on the theory of planned behaviour (TPB). Following the 8-week delivery period, we conducted focus groups with clinicians and interviews with clinic administrators to explore contextual factors influencing the use of the Dbox information. Results: One hundred clinicians completed the web surveys. In 54% of the 496 questionnaires completed, they reported that their practice would be improved after having read the Dboxes, and in 40%, they stated that they would use this information for their patients. Of those who would use the information for their patients, 89% expected it would benefit their patients, especially in that it would allow the patient to make a decision more in keeping with his/her personal circumstances, values, and preferences. They intended to use the Dboxes in practice (mean 5.6 ± 1.2, scale 1–7, with 7 being “high”), and their intention was significantly related to social norm, perceived behavioural control, and attitude according to the TPB (P < 0.0001). In focus groups, clinicians mentioned that co-interventions such as patient decision aids and training in shared decision-making would facilitate the use of the Dbox information. Some participants would have liked a clear “bottom line” statement for each Dbox and access to printed Dboxes in consultation rooms. Conclusions: Dboxes are valued by clinicians. Tailoring of Dboxes to their needs would facilitate their implementation in practic

Vitamin D status, cognitive decline and incident dementia : the Canadian Study of Health and Aging

Objective: Vitamin D could prevent cognitive decline because of its neuroprotective, anti-inflammatory and antioxidant properties. This study aimed to evaluate the associations of plasma 25-hydroxyvitamin D (25(OH)D) concentrations with global cognitive function and incident dementia, including Alzheimer’s disease (AD). Methods: The Canadian Study of Health and Aging is a 10-year cohort study of a representative sample of individuals aged 65years or older. A total of 661 subjects initially without dementia with frozen blood samples and follow-up data were included. Global cognitive function was measured using the validated Modified Mini-Mental State (3MS) examination. A consensus diagnosis of all-cause dementia and AD was made between the physician and the neuropsychologist according to published criteria. Cognitive decline for a 5-year increase in age at specific 25(OH)D concentrations was obtained using linear mixedmodels with repeated measures. Hazard ratios of incident dementia and AD were obtained using semi-parametric proportionalhazards models with age as time scale. Results: Over a mean follow-up of 5.4 years, 141 subjects developed dementia of which 100 were AD. Overall, no significant association was found between 25(OH)D and cognitive decline, dementia or AD. Higher 25(OH)D concentrations were associated with an increased risk of dementia and AD in women, but not in men. Conclusion: This study does not support a protective effect of vitamin D status on cognitive function. Further research is needed toclarify the relation by sex.Objectif : La vitamine D pourrait avoir un effet protecteur sur le déclin cognitif en raison de ses propriétés neuroprotectrices, anti-inflammatoires et antioxydantes. L’objectif de cette étude était d’évaluer les associations entre la concentration plasmatique de 25-hydroxyvitamine D (25(OH)D), la fonction cognitive globale et l’incidence de la démence incluant la maladie d’Alzheimer (MA). Méthodes: L’Étude sur la santé et le vieillissement au Canada est une étude de cohorte de 10 ans réalisée dans un échantillon représentatif des Canadiens âgés de 65 ans et plus. Un total de 661 participants sans démence, pour lesquels un échantillon sanguin congelé et des données au suivi étaient disponibles, ont été inclus dans l’analyse. La fonction cognitive globale a été mesurée à l’aide d’un outil validé, le Modified Mini-Mental State(3MS) Examination. Les diagnostics de démence toutes cause set de MA ont été obtenus par consensus entre un médecin généraliste et un neuropsychologue selon des critères publiés. Le déclin cognitif pour chaque augmentation de 5 ans d’âge à des concentrations spécifiques de 25(OH)D a été mesuré à l’aide de modèles linéaires mixtes avec données répétées. Des rapports de risques de la démence et de la MA ont été obtenus à l’aide de modèles à risques proportionnels semi-paramétriques en utilisant l’âge comme échelle du temps. Résultats : En cours de suivi (moyenne : 5,4 ans), 141 individus ont développé une démence dont 100 étaient la MA. Globalement, aucune association statistiquement significative n’a été observée entre le 25(OH)D et le déclin cognitif, la démence ou la MA. Des concentrations plus élevées de 25(OH)D étaient associées à une augmentation du risque de démence et de MA chez les femmes, mais pas chez les hommes. Conclusion : Cette étude n’appuie pas l’hypothèse d’un effet protecteur de la vitamine D sur la fonction cognitive. D’autres études seraient nécessaires pour clarifier la relation selon le sexe

Associations between circulating cardiovascular disease risk factors and cognitive performance in cognitively healthy older adults from the NuAge study

IntroductionCardiovascular disease risk factors (CVRFs) contribute to the development of cognitive impairment and dementia.MethodsThis study examined the associations between circulating CVRF biomarkers and cognition in 386 cognitively healthy older adults (mean age = 78 ± 4 years, 53% females) selected from the Quebec Longitudinal Study on Nutrition and Successful Aging (NuAge). Memory, executive function, and processing speed were assessed at baseline and 2-year follow-up. CVRF biomarkers included total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), triglycerides, glucose, insulin, high sensitivity C-reactive protein (hs-CRP), homocysteine, protein carbonyls, and cortisol. Linear mixed models were used to determine associations between individual CVRF biomarkers and cognition at both time points.ResultsHDL-C was most consistently associated with cognition with higher values related to better performance across several domains. Overall, stronger and more consistent relationships between CVRF biomarkers and cognition were observed in females relative to males.DiscussionFindings suggest that increases in the majority of circulating CVRFs are not associated with worse cognition in cognitively healthy older adults

Detection of delirium by nurses among long-term care residents with dementia

<p>Abstract</p> <p>Background</p> <p>Delirium is a prevalent problem in long-term care (LTC) facilities where advanced age and cognitive impairment represent two important risk factors for this condition. Delirium is associated with numerous negative outcomes including increased morbidity and mortality. Despite its clinical importance, delirium often goes unrecognized by nurses. Although rates of nurse-detected delirium have been studied among hospitalized older patients, this issue has been largely neglected among demented older residents in LTC settings. The goals of this study were to determine detection rates of delirium and delirium symptoms by nurses among elderly residents with dementia and to identify factors associated with undetected cases of delirium.</p> <p>Methods</p> <p>In this prospective study (N = 156), nurse ratings of delirium were compared to researcher ratings of delirium. This procedure was repeated for 6 delirium symptoms. Sensitivity, specificity, positive and negative predictive values were computed. Logistic regressions were conducted to identify factors associated with delirium that is undetected by nurses.</p> <p>Results</p> <p>Despite a high prevalence of delirium in this cohort (71.5%), nurses were able to detect the delirium in only a minority of cases (13%). Of the 134 residents not identified by nurses as having delirium, only 29.9% of them were correctly classified. Detection rates for the 6 delirium symptoms varied between 39.1% and 58.1%, indicating an overall under-recognition of symptoms of delirium. Only the age of the residents (≥ 85 yrs) was associated with undetected delirium (OR: 4.1; 90% CI: [1.5–11.0]).</p> <p>Conclusion</p> <p>Detection of delirium is a major issue for nurses that clearly needs to be addressed. Strategies to improve recognition of delirium could result in a reduction of adverse outcomes for this very vulnerable population.</p

Blood n-3 fatty acid levels and total and cause-specific mortality from 17 prospective studies.

The health effects of omega-3 fatty acids have been controversial. Here we report the results of a de novo pooled analysis conducted with data from 17 prospective cohort studies examining the associations between blood omega-3 fatty acid levels and risk for all-cause mortality. Over a median of 16 years of follow-up, 15,720 deaths occurred among 42,466 individuals. We found that, after multivariable adjustment for relevant risk factors, risk for death from all causes was significantly lower (by 15-18%, at least p < 0.003) in the highest vs the lowest quintile for circulating long chain (20-22 carbon) omega-3 fatty acids (eicosapentaenoic, docosapentaenoic, and docosahexaenoic acids). Similar relationships were seen for death from cardiovascular disease, cancer and other causes. No associations were seen with the 18-carbon omega-3, alpha-linolenic acid. These findings suggest that higher circulating levels of marine n-3 PUFA are associated with a lower risk of premature death.The EPIC Norfolk study (DOI 10.22025/2019.10.105.00004) has received funding from the Medical Research Council (MR/N003284/1 and MC-UU_12015/1) and Cancer Research UK (C864/A14136). NJW, NGF, and FI were supported by the Medical Research Council Epidemiology Unit core funding [MC_UU_12015/1 and MC_UU_12015/5]. NJW and NGF acknowledge support from the National Institute for Health Research Cambridge Biomedical Research Centre [IS-BRC-1215-20014] and NJW is an NIHR Senior Investigator

Is benzodiazepine use associated with the risk of dementia and cognitive impairment-not dementia in older persons? The Canadian study of health and aging

Background : The use of benzodiazepines in relation to cognitive decline remains an area of controversy in aging populations. Objective: This study aims to evaluate the risk of cognitive impairment–not dementia (CIND), Alzheimer disease (AD), and all-cause dementia with benzodiazepine use. The effect modification by sex was also investigated. Methods : Data come from the Canadian Study of Health and Aging, a 10-year multicentric study involving 10 263 participants randomly selected, 65 years and older, living in the community and in institutions. Current exposure to benzodiazepines was assessed in a face-to-face interview or self-reported in a questionnaire. Cox proportional hazard regression models, using age as time scale, were conducted to estimate hazard ratios, with adjustment for sex, education, smoking, alcohol intake, depression, physical activity, nonsteroidal anti-inflammatory drug use, and vascular comorbidities. Results : Data sets included 5281 participants for dementia as the outcome, 5015 for AD, and 4187 for CIND. Compared with nonusers, current use of benzodiazepines was associated with an increased risk of CIND (hazard ratio = 1.36; 95% CI = 1.08-1.72) in the simplest model. Results remained similar in the fully adjusted model (hazard ratio = 1.32; 95% CI = 1.04-1.68). There was no association between benzodiazepine use and the risk of dementia or AD. All these effects were similar between men and women. Conclusion and Relevance : Benzodiazepine use in older people from the general population is related to subsequent occurrence of cognitive dysfunction but not implicated in the pathogenesis of dementia or AD. Caution should be exercised when prescribing benzodiazepines to preserve global cognitive function

Differentiation of the pattern of cognitive impairment between depressed and non-depressed patients with dementia living in long-term care facilities

Objective: The principal objective of this study is to examine the cognitive profile of patients with dementia plus (Dþ group) and without (D group) concomitant depression. Method: The Dþ (N ¼ 61) and D (N ¼ 89) patients were recruited in long-term care facilities. The depression status of the participants was determined using the Cornell Scale for Depression in Dementia. Cognitive functioning was assessed using the Hierarchic Dementia Scale (HDS). Results: The analyses first indicated that on the total HDS score, patients of the Dþ group exhibited more severe cognitive impairment compared to those of the D group. Further analyses revealed that the difference between groups pertained to perception, attention/memory, calculation, and language functions. Moreover, secondary analyses revealed that the cognitive deficits of the Dþ group were associated with behavioral (agitation and retardation, in particular), but not with mood-related, symptoms of depression. Interestingly, ideational symptoms of depression (suicide and self-depreciation, in particular) were positively correlated with cognitive impairment. Conclusion: These findings add to those of previous studies showing that Dþ and D patients differ not only regarding the presence or absence of depressive symptoms, but also regarding cognitive manifestations. This study thus reinforces the need to detect and treat accurately depression in dementia

Treatment with rivastigmine or galantamine and risk of urinary incontinence : results from a Dutch database study

Treatment of Alzheimer disease (AD) with cholinesterase inhibitors (ChEIs) may increase the risk of urinary incontinence (UI). Objective: To assess whether ChEI use was associated with the risk of UI among older patients with AD. Methods: A crossover cohort study using the PHARMO Record Linkage System included 10years of data on drug dispensing histories for over two million Dutch residents. Included patients were aged 50 +, free of UI for the last 6months, received a first ChEI prescription during the study period, had at least 12months prior drug exposure history and one subsequent prescription of any drug. UI was defined as a first dispensing of a urinary spasmolytic or of incontinence products for at least 30days. Cox regression with time-varying covariates and multivariate adjustment allowed assessing whether UI incidence was associated with ChEI exposure. Results: Among 3154 patients there were 657 UI cases during a mean follow-up of 5.1years before a first ChEI dispensing, and 499 cases after ChEI initiation, during a mean follow-up of 2.0years. Among the 2700 participants free of UI one year before ChEI initiation, the adjusted hazard ratio (HR) for UI was 1.13 (95% CI: 0.97-1.32) when periods with ChEI use were compared to periods without ChEI use. Sensitivity analyses may suggest an increased risk in the 1st month after ChEI initiation (HR: 1.72, p=0.09) Conclusion: Worsening AD may increase incidence of UI, but no firm association between ChEI treatment and risk of UI could be shown from these data