William B. Dalziel

What is a health expectation? Developing a pragmatic conceptual model from psychological theory

Introduction  Examination of the existing literature in respect of health expectations revealed both ambiguity in relation to terminology, and relatively little work in respect of how abstract theories of expectancy in the psychological literature might be used in empirical research into the influence of expectations on attitudes and behaviours in the real world. This paper presents a conceptual model for the development of health expectations with specific reference to Alzheimers disease.

Why health expectations and hopes are different: the development of a conceptual model

Background  In the literature, ‘hope’ has often been thought of as an ideal expectation. However, we believe the classification of hope as a type of expectation is problematic. Although both hopes and expectations are future‐oriented cognitions, expectations are distinct in that they are an individual’s probability‐driven assessment of the most likely outcomes, while hopes are an assessment of the most desirable – but not necessarily the most probable – outcomes.

A Review of Barriers and Enablers to Diagnosis and Management of Persons with Dementia in Primary Care

Background With the rise in the prevalence of dementia disorders and the growing critical impact of dementia on health-care resources, the provision of dementia care has increasingly come under scrutiny, with primary care physicians (PCP) being at the centre of such attention. Purpose To critically examine barriers and enablers to timely diagnosis and optimal management of community living persons with dementia (PWD) in primary care. Methods An interpretive scoping review was used to synthesize and analyze an extensive body of heterogeneous Western literature published over the past decade. Results The current primary care systems in many Western countries, including Canada, face many challenges in providing responsive, comprehensive, safe, and cost-effective dementia care. This paper has identified a multitude of highly inter-related obstacles to optimal primary dementia care, including challenges related to: a) the complex biomedical, psychosocial, and ethical nature of the condition; b) the gaps in knowledge, skills, attitudes, and resources of PWD/caregivers and their primary care providers; and c) the broader systemic and structural barriers negatively affecting the context of dementia care. Conclusions Further progress will require a coordinated campaign and significantly increased levels of commitment and effort, which should be ideally orchestrated by national dementia strategies focusing on the barriers and enablers identified in this paper.

Pathways to diagnosis: exploring the experiences of problem recognition and obtaining a dementia diagnosis among Anglo-Canadians.

Increasing evidence suggests that early diagnosis and management of dementia-related symptoms may improve the quality of life for patients and their families. However, individuals may wait from 1-3 years from the onset of symptoms before receiving a diagnosis. The objective of this qualitative study was to explore the perceptions and experiences of problem recognition, and the process of obtaining a diagnosis among individuals with early-stage dementia and their primary carers. From 2006-2009, six Anglo-Canadians with dementia and seven of their carers were recruited from the Alzheimers Society of Calgary to participate in semi-structured interviews. Using an inductive, thematic approach to the analysis, five major themes were identified: becoming aware of memory problems, attributing meanings to symptoms, initiating help-seeking, acknowledging the severity of cognitive changes and finally obtaining a definitive diagnosis. Individuals with dementia reported noticing memory difficulties earlier than their carers. However, initial symptoms were perceived as ambiguous, and were normalised and attributed to concurrent health problems. The diagnostic process was typically characterised by multiple visits and interactions with health professionals, and a diagnosis was obtained as more severe cognitive deficits emerged. Throughout the diagnostic pathway, carers played dynamic roles. Carers initially served as a source of encouragement to seek help, but they eventually became actively involved over concerns about alternative diagnoses and illness management. A better understanding of the pre-diagnosis period, and the complex interactions between peoples beliefs and attributions about symptoms, may elucidate some of the barriers as well as strategies to promote a timelier dementia diagnosis.

Symbolic meaning of relocation to a residential care facility for persons with dementia

Objectives: This study explored the perspectives of persons with dementia (PWD) on the meanings and experiences associated with relocation to a residential care facility (RCF). Methods: A qualitative design was employed, which involved in-depth interviews with 16 PWD at their homes within two months prior to relocation. The work of Strauss and Corbin guided the analysis process. Results: Participants viewed relocation to an RCF as a major residential change and life transition requiring significant adaptive efforts. The experience clearly had a profound personal meaning for the participating PWD, shaped by their unique personal identities, psycho-environmental histories and current living circumstances. However, despite individual variations, four major themes captured the common perspectives and experiences in the sample. Relocation to an RCF: (a) symbolized the end of an era and a long-established way of life; (b) signaled the inevitable downward trajectory of old age; (c) meant living a more protected, dependent, structured and communal lifestyle in a place that is associated with ‘hospitality’ and ‘rest’; and (d) presented a life course challenge that could be dealt with by drawing on ones sense of identity as a ‘survivor’. Conclusion: The findings raise awareness of the subjective meanings of residential transitions in the experience of aging with dementia, and inform supportive interventions to optimize housing decisions for PWD in order to promote successful adaptation to their new living environments.

Persistence with cholinesterase inhibitor therapy for dementia: an observational administrative health database study.

ObjectiveTo determine if choice of drug and ease of administration affect persistence of therapy with Cholinesterase inhibitors (ChEIs) for treatment of dementia.MethodsAn observational administrative health database study was conducted in 5622 patients aged ≥65 years who received a new prescription for donepezil (DON), rivastigmine (RIV) or galantamine (GAL) from February to May 2006. Patients were followed for 1 year from initiation of therapy to determine percentage persistence and days of therapy. Once-daily galantamine extended release (GAL-ER) was compared with twice-daily galantamine immediate release (GAL-IR) to determine if ease of administration affected persistence. Previous treatment with ChEIs was also documented.ResultsOne-year persistence rates were significantly different among the ChEIs: GAL-ER 54% (95% CI 51, 57), DON 46% (95% CI 43, 49) and RIV 40% (95% CI 37, 43). Average days of therapy were greater for GAL-ER (293) than for RIV (272), but there were no differences between DON (287) and GAL-ER or DON and RIV. One-year persistence was significantly greater for GAL-ER 54% (95% CI 48, 59) than for GAL-IR 44% (95% CI 39, 50), although there was no significant difference in days of therapy (293 vs 286, respectively). More patients currently treated with RIV (40.5%) or GAL-ER (32.3%) had received previous treatment with a different ChEI than with DON (21.9%).ConclusionAmong possible factors affecting persistence of ChEI therapy for dementia, choice of drug, ease of administration and previous treatment appear to be important.

Targeting frail older adults for outpatient comprehensive geriatric assessment and management services: An overview of concepts and criteria

Comprehensive geriatric assessment (CGA) has been defined as ‘a multidimensional, often interdisciplinary, diagnostic process intended to determine a frail elderly person’s medical, psychosocial, and functional capabilities and problems, with the objective of developing an overall plan for treatment and long-term follow-up’. Evidence from recent meta-analyses of clinical trials of the effectiveness of CGA programmes suggest that older persons may experience a variety of health benefits from these comprehensive services.

Pathways to dementia diagnosis among South Asian Canadians

Urban centers are increasingly ethnically diverse. However, some visible minorities are less likely than their majority counterparts to seek and receive services and treatment for dementia. This study explored experiences of South Asian Canadians, Canada’s largest visible minority group, prior to dementia diagnosis. Six persons with dementia and eight of their family carers described their early perceptions of dementia-related changes, actions taken, including help seeking and diagnosis, and affective responses. Early signs were attributed to aging or personality. Even after cognitive enhancers were prescribed, some respondents continued to believe that the dementia symptoms were ‘normal’. Family carers’ affective responses may be related to their attributions. Before seeking medical attention, family carers modified physical or social environments because of symptoms. Help seeking was delayed up to four years, even with significant dementia symptoms. Recognition of a health problem was influenced by safety concerns, emergence of new symptoms following trauma, and treatment for other health problems. For some, relatives living outside the home or outside Canada were instrumental in recognizing a problem and convincing family carers and persons with dementia to seek medical attention. The pathway to diagnosis might be easier with outreach to help South Asian immigrants differentiate between normal aging and dementia. Symptom recognition by physicians treating other acute conditions was a portal to dementia services for others. Screening and referral in acute care could result in earlier diagnosis and treatment.

Continuing Education for Staff in Long-Term Care Facilities: Corporate Philosophies and Approaches.

The purpose of this study was to determine corporate philosophies of continuing education and approaches to meeting the learning needs of staff who strive to provide for the increasingly challenging care requirements of seniors who reside in long-term care facilities. In-depth interviews lasting approximately 1 hour were conducted with key informants at the administrative level from nine long-term care facilities. Content analysis revealed a commitment to continuing education for staff. While recognizing the importance of organizational responsibility for continuing education, administrators placed emphasis on the individual responsibility of staff. Learning needs were identified as affective, managerial, and physical in nature. Challenges to providing continuing education programs were derived from a general lack of fiscal and human resources. A variety of measures was suggested as important to supporting the continuing learning of staff. Implications of this study point to the need for long-term care facilities to incorporate into their strategic plans measures of ensuring continuing education as a basis for the ongoing competence and development of staff. In addition, there is a need for collaboration between long-term care facilities and other institutions of a long-term care, acute care, and educational nature in the development of strategies to operationalize a philosophy of continuing learning as a basis for the provision of optimal care to residents.

Effectiveness of outpatient geriatric assessment programs: exploring caregiver needs, goals, and outcomes.

In this study, the authors examined the goals and outcomes of 141 caregivers of older adults with cognitive impairment who attended a comprehensive geriatric assessment program (CGA). The vast majority of caregivers expressed at least one assessment goal, suggesting that the concept was relevant to them. Most caregiver goals focused on patient needs, with only 10% expressing goals specifically related to their own coping needs. At follow up, more than two-thirds of caregiver goals were attained. The findings confirm the great potential of CGA programs in promoting positive outcomes and point to the opportunities for nurses to improve the process of care.