Julie Kosteniuk

Dementia care in rural and remote settings: A systematic review of formal or paid care

OBJECTIVES The purpose of this review is to critically evaluate the available evidence from the published scientific literature on dementia care and service provision in rural and remote settings from the perspective of formal/paid caregiving, in order to assess the current state of knowledge, identify policy and practice implications, and make recommendations for future research. METHODS A systematic review of the literature indexed in ISI Web of Knowledge, PsychInfo, Medline, Healthstar, CINAHL, EMBASE, and Sociological Abstracts was conducted. Data were extracted from papers meeting inclusion criteria: peer-reviewed papers that focused on dementia or Alzheimers disease (AD), examined care or service provision in relation to persons with AD or dementia, and relevant to rural or remote care or services. RESULTS The search identified 872 articles for review, reduced to 72 after removing duplicates and articles not meeting criteria. Of the 72 remaining, 46 are included in this current review focusing on formal or paid care. A future review will focus on the 26 studies on informal/unpaid care. Six themes that correspond to the current state of knowledge in rural dementia care in the 46 included studies were: diagnostic processes, service provision, service models and programs, staff education and support needs, use of technology, and long-term care. CONCLUSIONS Despite the growing body of evidence over the 20 years covered by this review, much of the research is descriptive and/or based on small sample sizes, and distributed across the care continuum. Hence the body of evidence on which to base policy and program decisions remains limited. More research is needed that would support the development of comprehensive rural dementia care models.

Moving on? Predictors of intent to leave among rural and remote RNs in Canada

CONTEXT Examination of factors related to the retention or voluntary turnover of Registered Nurses (RNs) has mainly focused on urban, acute care settings. PURPOSE This paper explored predictors of intent to leave (ITL) a nursing position in all rural and remote practice settings in Canada. Based on the conceptual framework developed for this project, potential predictors of ITL were related to the individual RN worker, the workplace, the community context, and satisfaction related to both the workplace and the community(s) within which the RN lived and worked. METHODS A national cross-sectional mail survey of RNs in rural and remote Canada provided the data (n = 3,051) for the logistic regression analysis of predictors of ITL. FINDINGS We found that RNs were more likely to plan to leave their nursing position within the next 12 months if they: were male, reported higher perceived stress, did not have dependent children or relatives, had higher education, were employed by their primary agency for a shorter time, had lower community satisfaction, had greater dissatisfaction with job scheduling, had lower satisfaction with their autonomy in the workplace, were required to be on call, performed advanced decisions or practice, and worked in a remote setting. CONCLUSIONS The statistical evidence for predictors of ITL supported our framework with determinants related to the individual, the workplace, the community, and satisfaction levels. The importance of community makes this framework uniquely relevant to the rural health context. Our findings should guide policy makers and employers in developing retention strategies.

Use and perceptions of information among family physicians: sources considered accessible, relevant, and reliable

OBJECTIVES The research determined (1) the information sources that family physicians (FPs) most commonly use to update their general medical knowledge and to make specific clinical decisions, and (2) the information sources FPs found to be most physically accessible, intellectually accessible (easy to understand), reliable (trustworthy), and relevant to their needs. METHODS A cross-sectional postal survey of 792 FPs and locum tenens, in full-time or part-time medical practice, currently practicing or on leave of absence in the Canadian province of Saskatchewan was conducted during the period of January to April 2008. RESULTS Of 666 eligible physicians, 331 completed and returned surveys, resulting in a response rate of 49.7% (331/666). Medical textbooks and colleagues in the main patient care setting were the top 2 sources for the purpose of making specific clinical decisions. Medical textbooks were most frequently considered by FPs to be reliable (trustworthy), and colleagues in the main patient care setting were most physically accessible (easy to access). CONCLUSIONS When making specific clinical decisions, FPs were most likely to use information from sources that they considered to be reliable and generally physically accessible, suggesting that FPs can best be supported by facilitating easy and convenient access to high-quality information.

Simultaneous temporal trends in dementia incidence and prevalence, 2005–2013: a population-based retrospective cohort study in Saskatchewan, Canada

BACKGROUND Original studies published over the last decade regarding time trends in dementia report mixed results. The aims of the present study were to use linked administrative health data for the province of Saskatchewan for the period 2005/2006 to 2012/2013 to: (1) examine simultaneous temporal trends in annual age- and sex-specific dementia incidence and prevalence among individuals aged 45 and older, and (2) stratify the changes in incidence over time by database of identification. METHODS Using a population-based retrospective cohort study design, data were extracted from seven provincial administrative health databases linked by a unique anonymized identification number. Individuals 45 years and older at first identification of dementia between April 1, 2005 and March 31, 2013 were included, based on case definition criteria met within any one of four administrative health databases (hospital, physician, prescription drug, and long-term care). RESULTS Between 2005/2006 and 2012/2013, the 12-month age-standardized incidence rate of dementia declined significantly by 11.07% and the 12-month age-standardized prevalence increased significantly by 30.54%. The number of incident cases decreased from 3,389 to 3,270 and the number of prevalent cases increased from 8,795 to 13,012. Incidence rate reductions were observed in every database of identification. CONCLUSIONS We observed a simultaneous trend of decreasing incidence and increasing prevalence of dementia over a relatively short 8-year time period from 2005/2006 to 2012/2013. These trends indicate that the average survival time of dementia is lengthening. Continued observation of these time trends is warranted given the short study period.

Prevalence and Covariates of Elevated Depressive Symptoms in Rural Memory Clinic Patients with Mild Cognitive Impairment or Dementia

Background/Aims: To estimate the prevalence, severity, and covariates of depressive symptoms in rural memory clinic patients diagnosed with either mild cognitive impairment (MCI) or dementia. Methods: In a cross-sectional study of 216 rural individuals who attended an interdisciplinary memory clinic between March 2004 and July 2012, 51 patients were diagnosed with MCI and 165 with either dementia due to Alzheimers disease (AD) or non-AD dementia. The Center for Epidemiologic Studies of Depression Scale (CES-D) was used to estimate the severity and prevalence of clinically elevated depressive symptomatology. Results: The prevalence of elevated depressive symptoms was 51.0% in the MCI patients and 30.9% in the dementia patients. Depressive symptoms were more severe in the MCI patients than in the dementia patients. Elevated depressive symptoms were statistically associated with younger age for the MCI group, with lower self-rated memory for the dementia group, and with increased alcohol use and lower quality of life ratings for all patients. In the logistic regression models, elevated depressive symptoms remained negatively associated with self-rated memory and quality of life for the patients with dementia, but significant bivariate associations did not persist in the MCI group. Conclusions: The high prevalence and severity of depressive symptoms among rural memory clinic patients diagnosed with either MCI or dementia warrant continued investigation.

Nurses who work in rural and remote communities in Canada: a national survey

BackgroundIn Canada, as in other parts of the world, there is geographic maldistribution of the nursing workforce, and insufficient attention is paid to the strengths and needs of those providing care in rural and remote settings. In order to inform workforce planning, a national study, Nursing Practice in Rural and Remote Canada II, was conducted with the rural and remote regulated nursing workforce (registered nurses, nurse practitioners, licensed or registered practical nurses, and registered psychiatric nurses) with the intent of informing policy and planning about improving nursing services and access to care. In this article, the study methods are described along with an examination of the characteristics of the rural and remote nursing workforce with a focus on important variations among nurse types and regions.MethodsA cross-sectional survey used a mailed questionnaire with persistent follow-up to achieve a stratified systematic sample of 3822 regulated nurses from all provinces and territories, living outside of the commuting zones of large urban centers and in the north of Canada.ResultsRural workforce characteristics reported here suggest the persistence of key characteristics noted in a previous Canada-wide survey of rural registered nurses (2001-2002), namely the aging of the rural nursing workforce, the growth in baccalaureate education for registered nurses, and increasing casualization. Two thirds of the nurses grew up in a community of under 10 000 people. While nurses’ levels of satisfaction with their nursing practice and community are generally high, significant variations were noted by nurse type. Nurses reported coming to rural communities to work for reasons of location, interest in the practice setting, and income, and staying for similar reasons. Important variations were noted by nurse type and region.ConclusionsThe proportion of the rural nursing workforce in Canada is continuing to decline in relation to the proportion of the Canadian population in rural and remote settings. Survey results about the characteristics and practice of the various types of nurses can support workforce planning to improve nursing services and access to care.

Evolution of a community-based participatory approach in a rural and remote dementia care research program.

Background: Community–based participatory research (CBPR) approaches are valuable strategies for addressing complex health and social problems and powerful tools to support effective transformation of social and health policy to better meet the needs of diverse stakeholders.Objectives: Since 1997, our team has utilized CBPR approaches to improve health service delivery for persons with dementia and their caregivers in rural and remote settings. We describe the evolution of our approach, including benefits, challenges, and lessons learned over the last 15 years.Methods: A multistage approach initiated an ongoing CBPR research program in rural dementia care and shaped its direction based on stakeholders’ recommendation to prioritize both community and facility–based care. Strategies to develop and foster collaborative partnerships have included travel to rural and remote regions, province–wide community meetings, stakeholder workshops, creation of a Decision–Maker Advisory Council to provide ongoing direction to the overall program, development of diverse project–specific advisory groups, and a highly successful and much anticipated annual knowledge exchange and team–building event.Lessons Learned: Partnering with stakeholders in the full research process has enhanced the research quality, relevance, application, and sustainability. These benefits have supported the team’s evolution from a relatively traditional focus to an integrated approach guiding all aspects of our research.Conclusions: Developing and sustaining the full range of stakeholder and decision–maker partnerships is resource–and time–intensive, but our experience shows that community–based participatory strategies are highly suited to health services research that is designed to support sustainable service delivery improvements.

Availability and Primary Health Care Orientation of Dementia-Related Services in Rural Saskatchewan, Canada.

Community-based services are important for improving outcomes for individuals with dementia and their caregivers. This study examined: (a) availability of rural dementia-related services in the Canadian province of Saskatchewan, and (b) orientation of services toward six key attributes of primary health care (i.e., information/education, accessibility, population orientation, coordinated care, comprehensiveness, quality of care). Data were collected from 71 rural Home Care Assessors via cross-sectional survey. Basic health services were available in most communities (e.g., pharmacists, family physicians, palliative care, adult day programs, home care, long-term care facilities). Dementia-specific services typically were unavailable (e.g., health promotion, counseling, caregiver support groups, transportation, week-end/night respite). Mean scores on the primary health care orientation scales were low (range 12.4 to 17.5/25). Specific services to address needs of rural individuals with dementia and their caregivers are limited in availability and fit with primary health care attributes.

The Telehealth Satisfaction Scale: Reliability, Validity, and Satisfaction with Telehealth in a Rural Memory Clinic Population

INTRODUCTION Patient satisfaction is a key aspect of quality of care and can inform continuous quality improvement. Of the few studies that have reported on patient satisfaction with telehealth in programs aimed at individuals with memory problems, none has reported on the psychometric properties of the user satisfaction scales used. MATERIALS AND METHODS We evaluated the construct validity and internal consistency reliability of the Telehealth Satisfaction Scale (TeSS), a 10-item scale adapted for use in a rural and remote memory clinic (RRMC). The RRMC is a one-stop interprofessional clinic for rural and remote seniors with suspected dementia, located in a tertiary-care hospital. Telehealth videoconferencing is used for preclinic assessment and for follow-up. Patients and caregivers completed the TeSS after each telehealth appointment. With data from 223 patients, exploratory factor analysis was conducted using the principal components analysis extraction method. RESULTS The eigenvalue for the first factor (5.2) was greater than 1 and much larger than the second eigenvalue (0.92), supporting a one-factor solution that was confirmed by the scree plot. The total variance explained by factor 1 was 52.1%. Factor loadings (range, 0.54-0.84) were above recommended cutoffs. The TeSS items demonstrated high internal consistency reliability (Cronbachs alpha=0.90). Satisfaction scores on the TeSS items ranged from 3.43 to 3.72 on a 4-point Likert scale, indicating high satisfaction with telehealth. CONCLUSIONS The study findings demonstrate high user satisfaction with telehealth in a rural memory clinic and the sound psychometric properties of the TeSS in this population.

Dementia-related work activities of home care nurses and aides: Frequency, perceived competence, and continuing education priorities

ABSTRACT An understanding of the specific dementia learning needs of home care staff is needed to plan relevant continuing education (CE) programs and supports. The study’s objective was to examine frequency and perceived competence in performing 20 dementia-related work activities, and identify CE priorities among home care staff. A cross-sectional survey of all home care staff in a primarily rural health region was used to gather data. Of 111 eligible staff, 82 participated (41 nursing aides, 41 nurses/case managers). To explore the relationship between activity frequency (F) and competence (C), the proportion of nurses and aides in four quadrants for each activity was examined: (1) low F-low C, (2) low F-high C, (3) high F-low C, and (4) high F-high C. Nurses/case managers were significantly more likely than aides to regularly perform 11 activities and to report high competence in 9 activities (p < .05); aides were more likely to assist with two activities (personal care and daily living activities). Thus, nurses/case managers performed a broader range of activities and reported higher competence overall. The top CE topic for both groups was recognizing differences between dementia subtypes, but rankings for most activities varied by group. Aides’ CE priorities indicated a desire to develop competence in low frequency-low competence activities, suggesting an expanded role in supporting dementia patients and their families. Nurses’ CE priority topics were in the high F-high C quadrant, indicating a need to further develop competence in these activities. Findings have implications for planning CE programming for home care providers.