Jocelyn Charles

Risk Factors for Harm in Cognitively Impaired Seniors Who Live Alone: A Prospective Study

Objectives: To identify risk factors for harm due to self‐neglect or behaviors related to disorientation in cognitively impaired seniors who live alone that can be used in primary care.

A comparison of the effects of oral conjugated equine estrogen and transdermal estradiol-17β combined with an oral progestin on quality of life in postmenopausal women

OBJECTIVE To compare the effect of transdermal estradiol-17 beta and oral conjugated equine estrogen when combined with an oral progestin on quality of life in post-menopausal women. DESIGN Randomized controlled double-blind trial. A randomization error lead to the exclusion of six subjects but the soundness of the remaining randomization was confirmed. SETTING Large urban community. PATIENTS Women 2-7 years after menopause with a uterus and ovaries, and not currently using hormone replacement therapy. Seventy-four women completed the trial. INTERVENTIONS After baseline measures of quality of life, subjects were randomly assigned to either continuous oral conjugated equine estrogen 0.625 mg daily or continuous transdermal estradiol-17 beta 50 mcg twice weekly, for four 4-week cycles. Medroxyprogesterone acetate 10 mg oral tablets was administered to both groups for the last 12 days of each cycle. OUTCOMES MEASURED Quality of life was determined using the Menopause-Specific Quality of Life Questionnaire. Tolerability was determined by a specifically designed list of adverse effects. Both measures were recorded at base-line and in mid-cycle during the second, third and fourth cycles of treatment. RESULTS There were no statistically significant differences in any of the domains at baseline between the oral and transdermal treatment groups. In the vasomotor domain-scores for the oral and transdermal groups improved from baseline levels of 3.14 and 3.09, respectively, to 1.32 and 1.23; physical domain scores improved from 2.45 and 2.73 to 2.04 and 1.78; psychosocial domain scores improved from 2.72 and 3.04 to 2.21 and 1.94; sexual domain scores improved from 2.32 and 2.16 to 1.64 and 1.30. There were no statistically significant group differences or time/group interactions. Both forms of therapy were equally well tolerated. CONCLUSIONS Improvement in all domains, measured by the Menopause-Specific Quality of Life Questionnaire, was observed in both the oral and transdermal groups. In the absence of a placebo control group, the improvements observed cannot be attributed solely to the therapy. Neither form of therapy offered an advantage over the other in respect to improvement in quality of life.

Risk factors for medication nonadherence in older adults with cognitive impairment who live alone

The aim of this study was to prospectively examine the influence of cognitive, medical, behavioral, and social risk factors on medication nonadherence in community‐dwelling older adults with cognitive impairment.

Identification of Those at Greatest Risk of Harm Among Cognitively Impaired People Who Live Alone

Our purpose was to determine whether we could predict, from among seniors with cognitive impairment who lived alone, those at highest risk of experiencing harm or needing emergency services. Specifically, our focus was on the problems that occurred as a result of negligence due to cognitive impairment. We assessed 139 people, 65 years of age and older, who lived alone in a large urban centre and who showed cognitive impairment on a screening test. On average, participants were 83-year-olds, had 11 years of education, and a Mini-Mental State Score of 23. A total of 39% met diagnostic criteria for dementia. All underwent assessment of their neuropsychological abilities, behavioural characteristics and social supports. A study informant was identified for each participant who, together with the family physician, provided detailed information regarding the participants’ use of emergency medical, fire or police services, their experience of harm or loss of property over the last 12 months. We determined that negligence due to cognitive impairment caused harm or the need for emergency services based on informants’ and primary care physicians’ reports and by three independent raters. Logistic regression analyses indicated that the best predictors of harm or use of emergency services were male sex, self-care deficits, and poor performance on the Trail Making Test, Part B. The sensitivity of this three-variable regression model was 81% and the specificity was 66%. The likelihood ratio of both the positive and negative tests for harm represented a small but meaningful change in pretest to posttest probability of harm. These results indicate that we can estimate an individual’s probability of harm based on performance on these three variables. The next step is to confirm the findings with prospectively collected data.

Feasibility and validity of the self-administered computerized assessment of mild cognitive impairment with older primary care patients.

We investigated whether a validated computerized cognitive test, the Computerized Assessment of Mild Cognitive Impairment (CAMCI), could be independently completed by older primary care patients. We also determined the optimal cut-off for the CAMCI global risk score for mild cognitive impairment against an independent neuropsychological reference standard. All eligible patients aged 65 years and older, seen consecutively over 2 months by 1 family practice of 13 primary care physicians, were invited to participate. Patients with a diagnosis or previous work-up for dementia were excluded. Primary care physicians indicated whether they, the patient, or family had concerns about each patient’s cognition. A total of 130 patients with cognitive concerns and a matched sample of 133 without cognitive concerns were enrolled. The CAMCI was individually administered after instructions to work independently. Comments were recorded verbatim. A total of 259 (98.5%) completed the entire CAMCI. Two hundred and forty-one (91.6%) completed it without any questions or after simple acknowledgment of their question. Lack of computer experience was the only patient characteristic that decreased the odds of independent CAMCI completion. These results support the feasibility of using self-administered computerized cognitive tests with older primary care patients, given the increasing reliance on computers by people of all ages. The optimal cut-off score had a sensitivity of 80% and specificity of 74%.

Perceptions of family and staff on the role of the environment in long-term care homes for people with dementia.

BACKGROUND Disruptive behaviors are frequent and often the first predictor of institutionalization. The goal of this multi-center study was to explore the perceptions of family and staff members on the potential contribution of environmental factors that influence disruptive behaviors and quality of life of residents with dementia living in long-term care homes. METHODS Data were collected using 15 nominal focus groups with 45 family and 59 staff members from eight care units. Groups discussed and created lists of factors that could either reduce disruptive behaviors and facilitate quality of life or encourage disruptive behaviors and impede the quality of life of residents. Then each participant individually selected the nine most important facilitators and obstacles. Themes were identified from the lists of data and operational categories and definitions were developed for independent coding by four researchers. RESULTS Participants from both family and staff nominal focus groups highlighted facility, staffing, and resident factors to consider when creating optimal environments. Human environments were perceived to be more important than physical environments and flexibility was judged to be essential. Noise was identified as one of the most important factors influencing behavior and quality of life of residents. CONCLUSION Specialized physical design features can be useful for maintaining quality of life and reducing disruptive behaviors, but they are not sufficient. Although they can ease some of the anxieties and set the stage for social interactions, individuals who make up the human environment are just as important in promoting well-being among residents.

Factors associated with primary care physicians' recognition of cognitive impairment in their older patients.

Although there are accurate screens for cognitive impairment, there is as yet no evidence that screening improves outcomes including primary care physicians’ (PCP) medical decision making. PCPs’ recognition of cognitive impairment being suboptimal, we investigated factors associated with improved recognition. Eligible patients were aged 65 years and above, without documented dementia or previous work-up for dementia, seen consecutively over 2 months by one of 13 PCPs. PCPs indicated whether they, the patient, or the family had concerns about each patient’s cognition. We enrolled 130 patients with any cognitive concerns and a matched sample of 133 without cognitive concerns, and administered standardized neuropsychological tests. PCP’s judgments of cognitive concern showed 61% sensitivity and 86% specificity against the neuropsychological standard. When combined with a Mini-Mental State Examination score ⩽26, PCP recognition improved in sensitivity (82%) with some loss in specificity (74%). True positives increased when PCPs’ practices included more cognitively impaired patients and when patients reported poor memory. False positives increased when patients had diabetes, reported poor memory, or no or light alcohol consumption. Medical decision making can be improved by the Mini-Mental State Examination and greater exposure to cognitively impaired patients, but knowledge of certain risk factors for cognitive impairment negatively affected these decisions.

The Effects of Computerized Cognitive Testing of Older Patients on Primary Care Physicians' Approaches to Care: A Canadian Study.

Background: We evaluated effects of providing primary care physicians (PCPs) with reports of their patients’ results on the Computer Assessment of Mild Cognitive Impairment (CAMCI) by examining their documented care approaches after receipt of the report. Methods: Patients were 65 years and above, without a diagnosis or previous workup for dementia, seen consecutively over 2 months by one of 13 PCPs. PCPs indicated whether they, patients, or families had concerns about patients’ cognition. A total of 259 patients individually completed the CAMCI and results were provided to the PCP. Two raters blind to CAMCI results recorded care approaches documented by PCPs at the first visit within 3 months of report (n=181). Results: In total, 28 different care approaches were grouped as related to Cognition or Safety/Self-Care. Negative binomial regression revealed that the number of care approaches was significantly associated with performance on the CAMCI for both Cognition and Safety/Self-care domains. These findings remained significant when covariates included PCPs’ cognitive concern before CAMCI results, and patients’ age, sex, number of comorbidities, and living arrangements. Conclusions: Our findings indicate that PCPs documented more care approaches in patients with greater cognitive impairment based on the CAMCI results and this was independent of their, the patients’, or families’ prior concerns about their patients’ cognition.

Communication technology adoption among older adult veterans: the interplay of social and cognitive factors

ABSTRACT Objectives: InTouch is an electronic communication platform designed to be accessible by computer-naive seniors. The present study explored the process of adoption and use of the application by seniors with and without mild cognitive impairment (MCI) through the lens of Social Cognitive Theory (SCT). Method: We studied adoption and use of InTouch for social communication over a 12-week period in a 475-bed Veterans care facility at Sunnybrook Health Sciences Centre in Toronto, Canada. Eleven older adult veterans participated, six of whom had MCI, as indicated by their Montreal Cognitive Assessment score. Veterans were partnered with volunteers, each was provided with an iPad with the InTouch application. Qualitative data were collected through interviews, field notes, and direct observation. Quantitative data were collected from data logging of the software and medical charts. Data types and sources were triangulated and examined through the lens of SCT. Results: A total of 2361 messages (102 videos, 359 audios, 417 photos, 1438 texts) were sent by 10 of the 11 veterans over the 12-week study period. There was no apparent difference in extent of adoption or use, between participants with and without MCI. Participants used various resources and techniques to learn, provided that they felt motivated to connect with others using the app. Conclusion: This pilot illustrates both the accessibility of InTouch and the promise of using extrinsic motivators such as social bonding to promote learning in institutionalized older adults with and without cognitive impairment, whose intrinsic motivation and self-efficacy may well be suffering.