David B. Hogan

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.

Measurement, Correlates, and Health Outcomes of Medication Adherence Among Seniors

OBJECTIVE To provide a comprehensive review of the literature on the measurement, correlates, and health outcomes of medication adherence among community-dwelling older adults. DATA SOURCES Searches of MEDLINE, PubMed, and International Pharmaceutical Abstracts databases for English-language literature (1966–December 2002) were conducted using one or more of the following terms: elderly, adherence/nonadherence, compliance/noncompliance, medication/drug, methodology/measurement, and hospitalization. STUDY SELECTION AND DATA EXTRACTION From the above search, studies of medication adherence in community-dwelling seniors were selected for review along with relevant publications from the reference lists of articles identified in the initial database search. DATA SYNTHESIS Although several methods are available for the assessment of adherence, accurate measurement continues to be difficult. The available evidence suggests that polypharmacy and poor patient–healthcare provider relationships (including the use of multiple providers) may be major determinants of nonadherence among older persons, with the impact of most sociodemographic factors being negligible. There is little consensus regarding other determinants of nonadherence. Relatively few high-quality investigations have examined the associations between nonadherence and subsequent health outcomes. Available data provide some support for increased health risks with nonadherence. However, interventions to improve adherence have seldom demonstrated positive effects on health outcomes. CONCLUSIONS There are few empirical data to support a simple systematic descriptor of the nonadherent patient. The inconsistencies across studies may be attributable, in part, to the inherent difficulties involved in the measurement of a behavioral risk factor such as nonadherence. Future research in this area would be strengthened by incorporation of detailed assessments of patient-reported reasons for nonadherence, the appropriateness of drug regimens, and the effect of nonadherence on health outcomes.

Models, Definitions, and Criteria of Frailty

This chapter will examine the current state of research on frailty. A number of competing and complementary models for its development will be described. This will be followed by a working definition of frailty. Finally, criteria for the identification of frailty in older individuals will be discussed. Promising future directions for research will be noted throughout the chapter. The aim is to provide useful background information about frailty for researchers interested in the field. It is an area of inquiry still early in its evolution.

Prevalence and types of dementia in the very old Results from the Canadian Study of Health and Aging

We report on the prevalence of dementia in Canadians age 85 years and older. The purpose of this study was to determine whether the prevalence of dementia continued to increase in the very old, and to define the types of dementia and their relative proportions in this age group. We collected data as part of the Canadian Study of Health and Aging (1990 to 1992), which consisted of a sample of 1,835 subjects from a population of 283,510 Canadians who were 85 years of age and older residing in the community or in institutions. The prevalence of dementia in the 85 years and older group was 28.5%, more than twice that of the 75- to 84-years cohort. The prevalence of dementia of 23% in the 85- to 89-years sample (n= 1,332) increased to 40% in the 90 to 94 years group (n = 371) and, in the 95 years and older sample (n = 104), reached 58%. Overall, Alzheimers disease (AD; probable or possible) accounted for 75% of all dementias; a vascular etiology alone accounted for 13% of dementias. The proportion of clinically diagnosed AD cases to vascular dementia cases increased significantly after age 65 and was higher in the 85+ group than in a younger cohort (65 to 84 years).

Conceptualisation and Measurement of Frailty in Elderly People

The use of the term ‘frailty’ has shown tremendous growth in the last 15 years, but this has not been accompanied by a widely accepted definition, let alone agreed-upon measures. In this paper, we review approaches to the definition and measurement of frailty and discuss the relationship between frailty, aging and disability. Two trends are evident in definitions, which often trade off comprehensiveness for precision: frailty can be seen as being synonymous with a single-system problem or as a multisystem problem. The essential feature of frailty is the notion of risk due to instability (itself suggesting a balance of many factors), and has been only poorly measured to date. Future models of frailty should incorporate more precise operationalisation of the probability of frailty and better explain the relationship between disease, disability and frailty.

Diagnosis and treatment of dementia: 5. Nonpharmacologic and pharmacologic therapy for mild to moderate dementia

Background: Practising physicians frequently seek advice on the most effective interventions for dementia. In this article, we provide practical guidance on nonpharmacologic and pharmacologic interventions for the management of mild to moderate dementia based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. Methods: We developed evidence-based guidelines using systematic literature searches, with specific criteria for the selection and quality assessment of articles, and a clear and transparent decision-making process. We selected articles published from January 1996 to December 2005 that dealt with the management of mild to moderate stages of Alzheimer disease and other forms of dementia. Recommendations based on the literature review were drafted and voted on. Consensus required 80% or more agreement by participants. Subsequent to the conference, we searched for additional articles published from January 2006 to April 2008 using the same major keywords and secondary search terms. We graded the strength of the evidence using the criteria of the Canadian Task Force on Preventive Health Care. Results: We identified 1615 articles, of which 954 were selected for further study. From a synthesis of the evidence in these studies, we made 48 recommendations for the management of mild to moderate dementia (28) and dementia with a cerebrovascular component (8) as well as recommendations for addressing ethical issues (e.g., disclosure of the diagnosis) (12). The updated literature review did not change these recommendations. An exercise program is recommended for patients with mild to moderate dementia. Physicians should decide whether to prescribe a cholinesterase inhibitor on an individual basis, balancing anticipated benefits with the potential for harm. For mild mood and behavioural concerns, nonpharmacologic approaches should be considered first. Interpretation: Although the available therapies for dementia can help with the management of symptoms, there is a need to develop more effective interventions.

A canadian cohort study of cognitive impairment and related dementias (ACCORD): Study methods and baseline results

The overall objective of the Canadian Collaborative Cohort of Related Dementias (ACCORD) study is to describe the diagnostic distribution, natural history and treatment outcomes of individuals referred from the community to dementia clinics in Canada. Between 1997 and 1999, an inception cohort of 1,136 subjects entered into this longitudinal study. At the baseline assessment, 10.9% of the subjects were classified as ‘not cognitively impaired’ (NCI), 30.1% as ‘cognitively impaired not demented’ (CIND), and 59% as demented. A subclassification of CIND included amnestic 25.1%, vascular cognitive impairment 18.1%, psychiatric 17.2%, neurologic 7.3%, medical/toxic metabolic 3.5%, mixed 7.6% and not specified 19.0%. The percentage of the cohort referred with dementia increased progressively each decade, while the proportions of CIND and NCI decreased. Within the dementia group, Alzheimer’s disease accounted for 47.2% of the subjects, mixed dementias 33.7%, vascular dementia 8.7%, frontotemporal degenerations 5.4%, dementia with Lewy bodies 2.5%, and unclassifiable 1.8%. The ACCORD cohort will allow a detailed study of the longitudinal course of CIND, and the longer-term outcomes of both treated and untreated dementia subjects.

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.

The prevalence and management of current daily pain among older home care clients

&NA; The aim of this cross‐sectional study was to examine the prevalence and correlates of pharmacotherapy for current daily pain in older home care clients, focusing on analgesic type and potential contraindications to treatment. The sample included 2779 clients aged 65 + years receiving services from Community Care Access Centres in Ontario during 1999–2001. Clients were assessed with the Resident Assessment Instrument‐Home Care (RAI‐HC). Prescription and over‐the‐counter (OTC) medications listed on the RAI‐HC were used to categorize analgesic treatment into two groups (relative to no analgesic use): use of non‐opioids (acetaminophen or non‐steroidal anti‐inflammatory drugs only); and, use of opioids alone or in combination with non‐opioids. Associations between client characteristics and analgesic treatment among those in current daily pain were examined using multivariable multinomial logistic regression. Approximately 48% (n = 1,329) of clients had daily pain and one‐fifth (21.6%) of this group received no analgesic. In multivariable analyses, clients aged 75 + years and those with congestive heart failure, diabetes, other disease‐related contraindications, cognitive impairment and/or requiring an interpreter were significantly less likely to receive an opioid alone or in combination with a non‐opioid. Clients with congestive heart failure and without a diagnosis of arthritis were significantly less likely to receive a non‐opioid alone. A diagnosis of arthritis or cancer and use of nine or more medications were significantly associated with opioid use. The findings provide evidence of both rational prescribing practices and potential treatment bias in the pharmacotherapeutic management of daily pain in older home care clients.

Management of mild to moderate Alzheimer’s disease and dementia

The authors were charged with making a series of evidence‐based recommendations that would provide concrete advice on all aspects of the management of mild to moderate stages of dementia and Alzheimers disease (AD). The recommendations were primarily targeted to primary care physicians practicing in Canada. The assigned topic area did not include either the assessment of a patient with suspected dementia or the prevention of AD and other dementias. An extensive examination of the available literature was conducted. Explicit criteria for grading the strength of recommendations and the level of evidence supporting them were used. The 28 evidence‐based recommendations agreed on are presented in this article.