Gary Naglie

Content validity for dementia of three generic preference based health related quality of life instruments

A semi-structured interview was conducted with dementia patients and their caregivers in order to explore which aspects of quality of life were perceived as relevant and important. These aspects of quality of life were compared with the content of three generic utility-based quality of life instruments: European Quality of Life Instrument, Health Utilities Index, and Quality of Well-Being (QWB) Scale. Twenty patients with mild dementia and 20 caregiver volunteers provided narrative data derived from interviews that were analyzed using a modified Grounded Theory method of analysis. Essential attributes of dementia quality of life identified by the respondents were missing in the three utility-based quality of life instruments selected for the study. Patients provided a wider range of attributes than the instruments including some attributes not described by caregivers. Of the three utility-based measures, the QWB scale included the largest number of quality of life attributes but still missed many. Compared to the respondent generated attributes all three utility-based quality of life instruments have important shortcomings in content validity.

Comparison studies of cholinesterase inhibitors for Alzheimer's disease

There is uncertainty about which of the three available cholinesterase inhibitors should be prescribed as initial therapy for patients with Alzheimers disease. We have assessed the reports of three trials that directly compared cholinesterase inhibitors. They were reviewed for sponsorship, authorship, main results, proportions of individuals who achieved maximum daily doses of the study cholinesterase inhibitors, and how the studies dealt with items on the CONSORT checklist for randomised controlled trials. All studies were funded by pharmaceutical companies, coauthored by their employees, and reported results that favoured the sponsors product. In two studies, a significantly lower proportion of people achieved the target maximum daily dose for the comparator drug than for the sponsors product. Between 27% and 55% of CONSORT items per study were rated as inadequately reported. The methodological limitations of these studies reduce our confidence in the validity of the conclusions drawn in the published reports.

Older Driver Estimates of Driving Exposure Compared to In-Vehicle Data in the Candrive II Study

Objective: Most studies on older adults’ driving practices have relied on self-reported information. With technological advances it is now possible to objectively measure the everyday driving of older adults in their own vehicles over time. The purpose of this study was to examine the ability of older drivers to accurately estimate their kilometers driven over one year relative to objectively measured driving exposure. Methods: A subsample (n = 159 of 928; 50.9% male) of Candrive II participants (age ≥ 70 years of age) was used in these analyses based on strict criteria for data collected from questionnaires as well as an OttoView-CD Autonomous Data Logging Device installed in their vehicle, over the first year of the prospective cohort study. Results: Although there was no significant difference overall between the self-reported and objectively measured distance categories, only moderate agreement was found (weighted kappa = 0.57; 95% confidence interval, 0.47–0.67). Almost half (45.3%) chose the wrong distance category, and some people misestimated their distance driven by up to 20,000 km. Those who misjudged in the low mileage group (≤5000 km) consistently underestimated, whereas the reverse was found for those in the high distance categories (≥ 20,000); that is, they always overestimated their driving distance. Conclusions: Although self-reported driving distance categories may be adequate for studies entailing broad group comparisons, caution should be used in interpreting results. Use of self-reported estimates for individual assessments should be discouraged.

An inpatient rehabilitation model of care targeting patients with cognitive impairment

BackgroundThe 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/DesignA 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 6u2009months 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.DiscussionEvaluation of this model of care is timely given the increasing proportion of persons with cognitive impairment and hip fractures.Trial registrationThe study is registered at http://clinicaltrials.gov, Identifier NCT01566136.

Clinical pharmacy services in the home: Canadian case studies.

OBJECTIVESnTo describe clinical home care services provided by Canadian pharmacists and to identify facilitators of and barriers to the provision of these services.nnnDESIGNnHome care practices in Canada were identified using key informant and snowball sampling methods. Case descriptions of each pharmacy were composed using data obtained via a faxed questionnaire and a follow-up telephone interview.nnnSETTINGnCommunity and institutional pharmacies across Canada.nnnPARTICIPANTSnSixteen pharmacists with practices that met three criteria: at least one home visit conducted per week, visits conducted specifically for clinical purposes beyond routine prescription counseling, and documentation of home care services.nnnINTERVENTIONnFaxed questionnaire and follow-up telephone interview.nnnMAIN OUTCOME MEASURESnPharmacist characteristics, pharmacy characteristics, types of clinical home care services, home care-related products and dispensing services, referral system, reimbursement, barriers and facilitators, and evaluative strategies.nnnRESULTSnTwelve practices were in community pharmacies, nine of them independents. Home care services were provided primarily to address noncompliance and at the request of other health professionals. Elderly patients were the predominant service recipients. Services provided in most practices included compliance support, medication regimen review, monitoring of new medications, and patient education and training. Less than one-third of practices compiled evaluative data on these services. Most practices did not bill for services rendered. Lack of reimbursement was cited as the most important practice barrier, and having other sources of funding, such as high prescription revenues, was viewed as the major facilitator.nnnCONCLUSIONnClinical home care practice is rare in Canadian pharmacy; reimbursement is a major barrier. Practices described in these case studies were initiated to address a perceived important patient need. To enable further dissemination of clinical home care practice, pharmacists need to establish formal linkages with other home care providers, evaluate their services, and use the data obtained to develop marketing and reimbursement strategies.

Psychosocial Constructs as Possible Moderators of Self-Reported Driving Restrictions

Les associations entre les variables psychosociaux et les comportements de conduite ont été examinés seulement en coupe transversale à ce jour. Dans cette étude, nous avons utilisé trois vagues de données recueillies chaque année de 928 conducteurs âgés (âge moyen = 76.21 ans; 62% d’hommes) s’inscrits pour la cohorte Candrive II, afin de déterminer si des changements dans les attitudes et les perceptions à l’égard de conduire (l’équilibre décisionnel et le confort à la conduite de jour comme de nuit) ont été associés à des limitations à la conduite rapportées chez les aînés et de leurs capacités perçues à conduire. Des modèles à plusieurs niveaux ont révélé que plus de personnes âgées qui ont montré une augmentation des attitudes négatives à l’égard de conduite étaient plus susceptibles de déclarer la pratique de plus en plus restreinte (on évite souvent des situations difficiles de conduite) et des baisses perçues dans la capacité de conduire, par rapport aux individus dont les attitudes envers la conduite restaient stable au cours de deux années. Ce travail confirme les résultats précédents et offre une nouvelle compréhension de la façon dont les attitudes ont trait aux perceptions de conduite (c’est-à-dire, le confort), et l’auto-régulation chez les personnes âgées au fil du temps. To date, associations between psychosocial driving variables and behaviour have been examined only cross-sectionally. Using three waves of data collected annually from 928 older drivers (mean age = 76.21 years; 62% male) enrolled in the Candrive II cohort, we examined in this study whether changes in attitudes and perceptions towards driving (decisional balance and day and night driving comfort) were associated with changes in older adults’ reported restrictions in driving practices and perceived driving abilities. Multi-level models revealed that older adults who showed an increase in negative attitudes towards driving over time were more likely to report more-restricted practices (greater avoidance of challenging driving situations) and perceived declines in driving abilities compared to individuals whose attitudes towards driving remained stable across two years. This work supports previous findings and offers a new understanding of how attitudes relate to driving perceptions (e.g., comfort) and self-regulation in older adults over time.

The impact of subclinical sleep problems on self-reported driving patterns and perceived driving abilities in a cohort of active older drivers

The present study sought to investigate the influence of subclinical sleep disturbances on driving practices and driver perceptions in a large cohort of healthy older drivers. Participants from the Candrive II prospective cohort study were investigated. Self-reported measures of sleep problems were used to determine the influence of sleep disturbance on self-reported driving practices and perceived driving abilities, as measured by the Situational Driving Frequency, Situational Driving Avoidance, and Perceived Driving Abilities scales. Hierarchical regression analyses were used to estimate whether mild self-reported sleep problems were predictive of driving restrictions and perceived abilities, while controlling for a variety of health-related factors and demographic variables known to mediate sleep problems or to impact driving. Cross-sectional analysis of baseline data from the Candrive II study suggests that subclinical sleep problems do not significantly influence self-reported driving patterns or perceived driving abilities in older drivers once control variables are considered. The relationship between sleep problems, driving frequency, avoidance and perceived abilities is better explained by mediating demographic, health, and cognitive factors. Further research examining sleep disturbances and driving should include objective measures of driving practices (exposure, patterns) and outcomes (crashes, violations) and should take in consideration the severity of sleep problems.

Comparison of Older Adults' and Occupational Therapists' Awareness of Functional Abilities at Discharge from Rehabilitation with Actual Performance in the Home

Objectives: To compare older adults and occupational therapists (OTs) awareness of patients functional abilities at discharge from inpatient rehabilitation using patient performance in the home as the criterion for functional abilities. Design: A prospective cohort study. Setting: Inpatient rehabilitation unit of a large community hospital followed by observation at home. Participants: Thirty-four older adult patients who live alone and had acute hospital admission for orthopedic, medical, or cardiopulmonary primary diagnoses followed by inpatient rehabilitation. Measurements: Patients and OTs perceptions of patients abilities at hospital discharge were recorded for basic and instrumental activities of daily living (ADLs) and mobility using the Functional Autonomy Measuring System. One week following discharge, patients functional performance was measured at home. Awareness was calculated as the difference between perceptions and performance. Results: There was greater than 82% exact agreement between patients and OTs perceptions for: eating, bathing, dressing, toileting, transferring and walking, but only 52% agreement for meal preparation. Patients awareness for all ADLs and mobility was about 80% accurate except for stair-climbing, meal preparation, and medication management. OTs awareness was greatest for tasks routinely assessed while in hospital (e.g., eating, dressing, toileting, transferring, walking and stair-climbing) and for telephone use and meal preparation. Overall patients awareness was equal to or higher than OTs awareness for all activities except stair-climbing, meal preparation, telephone use, and medication management. Conclusions: Awareness of functional abilities varies by activity and rater and is an important element of discharge planning for community living.

Ethics of Clinical Decision-Making for Older Drivers: Reporting Health-Related Driving Risk

RÉSUMÉ: Le vieillissement de la population engendre une augmentation du nombre de conducteurs âgés. Les professionnels de la santé ont la responsabilité de fournir des soins en préservant le secret professionnel tout en assurant la sécurité du public. Cet article traite de l’analyse éthique relative à la prise de décisions en lien avec le signalement aux autorités compétentes des conducteurs âgés identifiés comme étant à risque. Des considérations éthiques inhérentes au signalement des conducteurs à risque sont traitées, telles que l’autonomie, le secret professionnel, la relation thérapeutique et l’incertitude associée à l’évaluation de la conduite automobile. Nous abordons également la question de la responsabilité des divers agents moraux. L’incertitude entourant le raisonnement clinique et les concepts liés à l’évaluation du risque sont également traités. Enfin, nous présentons deux cas illustrant certains défis auxquels sont confrontés les professionnels de la santé dans l’atteinte d’un équilibre entre leurs responsabilités face à leurs patients et celles visant à assurer la sécurité du public. ABSTRACT: The number of older drivers will continue to increase as the population ages. Health care professionals have the responsibility of providing care and maintaining confidentiality for their patients while ensuring public safety. This article discusses the ethics of clinical decision-making pertaining to reporting health-related driving risk of older drivers to licensing authorities. Ethical considerations inherent in reporting driving risk, including autonomy, confidentiality, therapeutic relationships, and the uncertainty about determining individual driving safety and risk, are discussed. We also address the moral agency of reporting health-related driving risk and raise the question of whose responsibility it is to report. Issues of uncertainty surrounding clinical reasoning and concepts related to risk assessment are also discussed. Finally, we present two case studies to illustrate some of the issues and challenges faced by health care professionals as they seek to balance their responsibilities for their patients while ensuring road safety for all citizens.

CIHR Candrive Cohort Comparison with Canadian Household Population Holding Valid Driver's Licenses

Nous avons examiné si l’échantillonnage de commodité est une méthode appropriée pour recruter un échantillon de conducteurs âgés représentatif de la population des conducteurs canadiens âgés. En utilisant des tests d’équivalence, nous avons comparé un grand échantillon de commodité de conducteurs âgés (de la cohorte Candrive II) à une population de conducteurs canadiens d’âges similaires. L’échantillon Candrive est constitué de 928 conducteurs âgés habitant dans l’une de sept régions métropolitaines du Canada. Les données démographiques relatives à la population canadienne ont été obtenues à partir de l’Enquête sur la santé dans les collectivités canadiennes–Vieillissement en santé (ESCC-VS), basé sur un échantillon représentatif de Canadiens âgés. Les données pour les conducteurs âgés de 70 ans et plus ont été extraites de la base de données de l’ESCC-VS, pour un total de 3,899 conducteurs canadiens âgés. Les deux échantillons que nous avons comparés se sont avérés équivalents en ce qui a trait aux variables socio-démographiques, relatives à la santé et à la conduite à l’exception de la fréquence d’utilisation de la voiture. Nous concluons qu’en dépit de quelques différences, l’échantillonnage de commodité utilisé dans l’étude Candrive a créé un échantillon suffisamment représentatif des conducteurs âgés au Canada. We investigated whether convenience sampling is a suitable method to generate a sample of older drivers representative of the older-Canadian driver population. Using equivalence testing, we compared a large convenience sample of older drivers (Candrive II prospective cohort study) to a similarly aged population of older Canadian drivers. The Candrive sample consists of 928 community-dwelling older drivers from seven metropolitan areas of Canada. The population data was obtained from the Canadian Community Health Survey–Healthy Aging (CCHS-HA), which is a representative sample of older Canadians. The data for drivers aged 70 and older were extracted from the CCHS-HA database, for a total of 3,899 older Canadian drivers. Two samples were demonstrated as equivalent on socio-demographic, health, and driving variables that we compared, but not on driving frequency. We conclude that convenience sampling used in the Candrive study created a fairly representative sample of Canadian older drivers, with a few exceptions.