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1.  Health information technologies in geriatrics and gerontology: a mixed systematic review 
Objective
To review, categorize, and synthesize findings from the literature about the application of health information technologies in geriatrics and gerontology (GGHIT).
Materials and Methods
This mixed-method systematic review is based on a comprehensive search of Medline, Embase, PsychInfo and ABI/Inform Global. Study selection and coding were performed independently by two researchers and were followed by a narrative synthesis. To move beyond a simple description of the technologies, we employed and adapted the diffusion of innovation theory (DOI).
Results
112 papers were included. Analysis revealed five main types of GGHIT: (1) telecare technologies (representing half of the studies); (2) electronic health records; (3) decision support systems; (4) web-based packages for patients and/or family caregivers; and (5) assistive information technologies. On aggregate, the most consistent finding proves to be the positive outcomes of GGHIT in terms of clinical processes. Although less frequently studied, positive impacts were found on patients’ health, productivity, efficiency and costs, clinicians’ satisfaction, patients’ satisfaction and patients’ empowerment.
Discussion
Further efforts should focus on improving the characteristics of such technologies in terms of compatibility and simplicity. Implementation strategies also should be improved as trialability and observability are insufficient.
Conclusions
Our results will help organizations in making decisions regarding the choice, planning and diffusion of GGHIT implemented for the care of older adults.
doi:10.1136/amiajnl-2013-001705
PMCID: PMC3822120  PMID: 23666776
Health information technology; chronic disease; diffusion of innovation; geriatrics; gerontology
2.  Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 
Canadian Family Physician  2014;60(5):433-438.
Abstract
Objective
To revise diagnostic strategies for Alzheimer disease (AD), update recommendations on symptomatic treatment of dementia, and provide an approach to rapidly progressive and early-onset dementias.
Composition of the committee
Experts and delegates representing relevant disciplines from diverse regions across Canada discussed and agreed upon revisions to the 2006 guidelines.
Methods
The GRADE (grading of recommendations, assessment, development, and evaluation) system was used to evaluate consensus on recommendations, which was defined as when 80% or more of participants voted for the recommendation. Evidence grades are reported where possible.
Report
Important for FPs, despite advances in liquid biomarkers and neuroimaging, the diagnosis of dementia in Canada remains fundamentally clinical. New core clinical criteria for the diagnosis of AD now recognize less common, nonamnestic forms. Early-onset dementia, a rare but important condition, should prompt referral to specialists with access to genetic counselors. Rapidly progressive dementia, poorly defined in the literature, is described to facilitate detection of this rare but important condition. There are new expanded indications for cholinesterase inhibitors beyond AD, as well as guidelines for their discontinuation, which had not been previously described. New evidence regarding use of memantine, antidepressants, and other psychotropic medications in dementia care is presented.
Conclusion
Several recommendations from the Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia are relevant to FPs. For guidelines to remain useful, family physicians should participate in all stages of the ongoing development process, including topic selection.
PMCID: PMC4020644  PMID: 24829003
3.  Quatrième conférence consensuelle sur le diagnostic et le traitement de la démence 
Canadian Family Physician  2014;60(5):e244-e250.
Résumé
Objectif
Revoir les stratégies diagnostiques de la maladie d’Alzheimer, actualiser les recommandations concernant le traitement des symptômes de démence et proposer une approche thérapeutique à la démence d’apparition précoce et d’évolution rapide.
Composition du comité
Des spécialistes et des délégués de diverses régions du Canada et représentant diverses disciplines pertinentes ont discuté et se sont mis d’accord sur les révisions à apporter aux lignes directrices de 2006.
Méthodologie
On a eu recours au système GRADE (grading of recommendations, assessment, development, and evaluation) pour évaluer le consensus concernant les recommandations, lequel était défini comme suit : lorsque 80 % ou plus des participants ont voté en faveur de la recommandation. La cote des données probantes est rapportée lorsque cela est possible.
Rapport
important pour les médecins de famille, malgré les progrès effectués dans les domaines des biomarqueurs liquidiens et de la neuro-imagerie, le diagnostic de démence au Canada demeure fondamentalement clinique. De nouveaux critères cliniques essentiels de diagnostic de la maladie d’Alzheimer en reconnaissent dorénavant les formes moins fréquentes et non amnestiques. La démence précoce, une affection rare, mais importante, devrait inciter les médecins à aiguiller les patients vers un spécialiste ayant accès à des conseillers en génétique. La démence d’évolution rapide, mal définie dans la littérature, faciliterait le dépistage de cette affection rare, mais importante. Les inhibiteurs de la cholinestérase sont maintenant indiqués pour le traitement d’affections autres que la maladie d’Alzheimer. Des lignes directrices concernant l’arrêt du traitement, lesquelles n’existaient pas auparavant, sont également apparues. De nouvelles données probantes sur le recours à la mémantine, aux antidépresseurs et à d’autres agents psychotropes dans le traitement de la démence sont aussi présentées.
Conclusion
Plusieurs recommandations de la Quatrième conférence consensuelle sur le diagnostic et le traitement de la démence intéresseront les médecins de famille. Pour assurer l’utilité des lignes directrices, les médecins de famille devraient participer à toutes les étapes du processus de formulation continu, y compris à la sélection des sujets.
PMCID: PMC4020660
4.  A life-course approach to healthy ageing: maintaining physical capability 
Research on healthy ageing lacks an agreed conceptual framework and has not adequately taken into account the growing evidence that social and biological factors from early life onwards affect later health. We conceptualise healthy ageing within a life-course framework, separating healthy biological ageing (in terms of optimal physical and cognitive functioning, delaying the onset of chronic diseases, and extending length of life for as long as possible) from changes in psychological and social wellbeing. We summarise the findings of a review of healthy ageing indicators, focusing on objective measures of physical capability, such as tests of grip strength, walking speed, chair rises and standing balance, which aim to capture physical functioning at the individual level, assessing the capacity to undertake the physical tasks of daily living. There is robust evidence that higher scores on these measures are associated with lower rates of mortality, and more limited evidence of lower risk of morbidity, and of age-related patterns of change. Drawing on a research collaboration of UK cohort studies, we summarise what is known about the influences on physical capability in terms of lifetime socioeconomic position, body size and lifestyle, and underlying physiology and genetics; the evidence to date supports a broad set of factors already identified as risk factors for chronic diseases. We identify a need for larger longitudinal studies to investigate age-related change and ethnic diversity in these objective measures, the dynamic relationships between them, and how they relate to other component measures of healthy ageing. Robust evidence across cohort studies, using standardised measures within a clear conceptual framework, will benefit policy and practice to promote healthy ageing.
doi:10.1017/S0029665113003923
PMCID: PMC3981474  PMID: 24456831
Life course; Epidemiology; Healthy ageing; Physical capability; Cohort studies
5.  Searching for an Operational Definition of Frailty: A Delphi Method Based Consensus Statement. The Frailty Operative Definition-Consensus Conference Project 
Background.
There is no consensus regarding the definition of frailty for clinical uses.
Methods.
A modified Delphi process was used to attempt to achieve consensus definition. Experts were selected from different fields and organized into five Focus Groups. A questionnaire was developed and sent to experts in the area of frailty. Responses and comments were analyzed using a pre-established strategy. Statements with an agreement more than or equal to 80% were accepted.
Results.
Overall, 44% of the statements regarding the concept of frailty and 18% of the statements regarding diagnostic criteria were accepted. There was consensus on the value of screening for frailty and about the identification of six domains of frailty for inclusion in a clinical definition, but no agreement was reached concerning a specific set of clinical/laboratory biomarkers useful for diagnosis.
Conclusions.
There is agreement on the usefulness of defining frailty in clinical settings as well as on its main dimensions. However, additional research is needed before an operative definition of frailty can be established.
doi:10.1093/gerona/gls119
PMCID: PMC3598366  PMID: 22511289
Frailty; Consensus definition; Older people; Biomarkers
6.  Preoperative Anxiety as a Predictor of Mortality and Major Morbidity in Patients >70 Years of Age Undergoing Cardiac Surgery 
The American journal of cardiology  2013;111(1):137-142.
This study examined the association between patient-reported anxiety and post-cardiac surgery mortality and major morbidity. Frailty ABC'S was a prospective multicenter cohort study of elderly patients undergoing cardiac surgery (coronary artery bypass surgery and/or valve repair or replacement) at 4 tertiary care hospitals between 2008 and 2009. Patients were evaluated a mean of 2 days preoperatively with the Hospital Anxiety and Depression Scale (HADS), a validated questionnaire assessing depression and anxiety in hospitalized patients. The primary predictor variable was high levels of anxiety, defined by HADS score ≥11. The main outcome measure was all-cause mortality or major morbidity (stroke, renal failure, prolonged ventilation, deep sternal wound infection, or reoperation) occurring during the index hospitalization. Multivariable logistic regression examined the association between high preoperative anxiety and all-cause mortality/major morbidity, adjusting for Society of Thoracic Surgeons (STS) predicted risk, age, gender, and depression symptoms. A total of 148 patients (mean age 75.8 ± 4.4 years; 34% women) completed the HADS-A. High levels of preoperative anxiety were present in 7% of patients. There were no differences in type of surgery and STS predicted risk across preoperative levels of anxiety. After adjusting for Society of Thoracic Surgeons predicted risk, age, gender, and symptoms of depression, preoperative anxiety remained independently predictive of postoperative mortality or major morbidity (OR 5.1; 95% CI 1.3, 20.2; p=0.02). In conclusion, although high levels of anxiety were present in a minority of patients anticipating cardiac surgery, this conferred a strong and independent heightened risk of mortality or major morbidity.
doi:10.1016/j.amjcard.2012.08.060
PMCID: PMC3677723  PMID: 23245838
geriatric; cardiac surgery; outcomes; anxiety
7.  Implementing frailty into clinical practice: a cautionary tale 
Background
Little is known about the contribution of frailty in improving patient-level prediction beyond readily available clinical information. The objective of this study is to compare the predictive ability of 129 combinations of 7 frailty markers (cognition, energy, mobility, mood, nutrition, physical activity, and strength) and quantify their contribution to predictive accuracy beyond age, sex and number of chronic diseases.
Methods
Two cohorts from the Established Populations for Epidemiologic Studies of the Elderly were used. The model with the best predictive fit in predicting 6-year incidence of disability was determined using the Akaike Information Criterion. Predictive accuracy was measured by the C statistic.
Results
Incident disability was 23% in one cohort and 20% in the other cohort. The “best model” in each cohort was found to be a model including between 5 and 7 frailty markers including cognition, mobility, nutrition, physical activity and strength. Predictive accuracy of the 129 models ranged from 0.73 to 0.77 across both cohorts. Adding frailty markers to age, sex and chronic disease increased predictive accuracy by up to 3% in both cohorts (P< .001). The contribution of frailty increased up to 9% in the oldest age group.
Conclusions
Adding frailty markers provided a modest increase in patient-level prediction of disability. Such a modest increase may still be worthwhile because while age, sex and the number of chronic diseases are not modifiable, frailty may be. Further studies examining the contribution of frailty in improving prediction are needed before adopting frailty as a prognostic tool.
doi:10.1093/gerona/glt053
PMCID: PMC3806754  PMID: 23640761 CAMSID: cams2968
8.  Contribution of Frailty Markers in Explaining Differences Among Individuals in Five Samples of Older Persons 
Background.
There has been little research on the relative importance of frailty markers. The objective was to investigate the association among seven frailty domains (nutrition, physical activity, mobility, strength, energy, cognition, and mood) and their relative contribution in explaining differences among individuals in five samples of older persons.
Methods.
Data from five studies of aging were analyzed using multiple correspondence analysis. Aggregation of frailty markers was evaluated using graphical output. Decomposition of variability was used to assess the relative contribution of each marker in each sample. Results were combined across the samples to assess the average contribution.
Results.
Frailty markers were found to consistently aggregate in each sample, suggesting a possible underlying construct. Physical strength had the highest contribution on average in explaining differences among individuals. Mobility and energy also had large contributions. Nutrition and cognition had the smallest contributions.
Conclusions.
Our results provide further evidence supporting the notion that frailty domains may belong to a common construct. Physical strength may be the most important discriminating characteristic.
doi:10.1093/gerona/gls084
PMCID: PMC3668388  PMID: 22459619
Frailty; Multivariate analyses; Older adults
9.  Correspondence analysis is a useful tool to uncover the relationships among categorical variables 
Journal of clinical epidemiology  2009;63(6):638-646.
Objective
Correspondence Analysis (CA) is a multivariate graphical technique designed to explore relationships among categorical variables. Epidemiologists frequently collect data on multiple categorical variables with to the goal of examining associations amongst these variables. Nevertheless, despite its usefulness in this context, CA appears to be an underused technique in epidemiology. The objective of this paper is to present the utility of CA in an epidemiological context.
Study Design and Setting
The theory and interpretation of CA in the case of two variables and more than two variables is illustrated through two examples.
Results
The outcome from correspondence analysis is a graphical display of the rows and columns of a contingency table that is designed to permit visualization of the salient relationships among the variable responses in a low-dimensional space. Such a representation reveals a more global picture of the relationships among row-column pairs which would otherwise not be detected through a pairwise analysis.
Conclusion
When the study variables of interest are categorical, CA is an appropriate technique to explore relationships amongst variable response categories and can play a complementary role in analyzing epidemiological data.
doi:10.1016/j.jclinepi.2009.08.008
PMCID: PMC3718710  PMID: 19896800 CAMSID: cams2970
Correspondence analysis; multivariate graphical analysis; categorical data; relationship; epidemiology; information dissemination methods
10.  A graphical analysis revealed frailty deficits aggregate and are multidimensional 
Journal of clinical epidemiology  2009;63(6):647-654.
Objective
To examine the relationships among seven frailty domains: nutrition, physical activity, mobility, strength, energy, cognition, and mood, using data from three studies.
Study Design and Setting
Data from three studies were separately analyzed using Multiple Correspondence Analysis (MCA). The graphical output of MCA was used to assess 1) if the presence of deficits in the frailty domains separate from the absence of deficits on the graph, 2) the dimensionality of the domains, 3) the clustering of domains within each dimension and 4) their relationship with age, sex and disability. Results were compared across the studies.
Results
In two studies, presence of deficits for all domains separated from absence of deficits. In the third study, there was separation in all domains except cognition. Three main dimensions were retained in each study however assigned dimensionality of domains differed. The clustering of mobility with energy and/or strength was consistent across studies. Deficits were associated with older age, female sex and disability.
Conclusion
Our results suggest that frailty is a multidimensional concept for which the relationships among domains differ according to the population characteristics. These domains, with the possible exception of cognition, appear to aggregate together and share a common underlying construct.
doi:10.1016/j.jclinepi.2009.08.007
PMCID: PMC3718711  PMID: 19880286 CAMSID: cams2969
Frailty; Domains of frailty; Older persons; Multiple correspondence analysis; Association; Epidemiology
11.  Predicting missing biomarker data in a longitudinal study of Alzheimer disease 
Lo, Raymond Y. | Jagust, William J. | Aisen, Paul | Jack, Clifford R. | Toga, Arthur W. | Beckett, Laurel | Gamst, Anthony | Soares, Holly | C. Green, Robert | Montine, Tom | Thomas, Ronald G. | Donohue, Michael | Walter, Sarah | Dale, Anders | Bernstein, Matthew | Felmlee, Joel | Fox, Nick | Thompson, Paul | Schuff, Norbert | Alexander, Gene | DeCarli, Charles | Bandy, Dan | Chen, Kewei | Morris, John | Lee, Virginia M.-Y. | Korecka, Magdalena | Crawford, Karen | Neu, Scott | Harvey, Danielle | Kornak, John | Saykin, Andrew J. | Foroud, Tatiana M. | Potkin, Steven | Shen, Li | Buckholtz, Neil | Kaye, Jeffrey | Dolen, Sara | Quinn, Joseph | Schneider, Lon | Pawluczyk, Sonia | Spann, Bryan M. | Brewer, James | Vanderswag, Helen | Heidebrink, Judith L. | Lord, Joanne L. | Petersen, Ronald | Johnson, Kris | Doody, Rachelle S. | Villanueva-Meyer, Javier | Chowdhury, Munir | Stern, Yaakov | Honig, Lawrence S. | Bell, Karen L. | Morris, John C. | Mintun, Mark A. | Schneider, Stacy | Marson, Daniel | Griffith, Randall | Clark, David | Grossman, Hillel | Tang, Cheuk | Marzloff, George | Toledo-Morrell, Leylade | Shah, Raj C. | Duara, Ranjan | Varon, Daniel | Roberts, Peggy | Albert, Marilyn S. | Pedroso, Julia | Toroney, Jaimie | Rusinek, Henry | de Leon, Mony J | De Santi, Susan M | Doraiswamy, P. Murali | Petrella, Jeffrey R. | Aiello, Marilyn | Clark, Christopher M. | Pham, Cassie | Nunez, Jessica | Smith, Charles D. | Given, Curtis A. | Hardy, Peter | Lopez, Oscar L. | Oakley, MaryAnn | Simpson, Donna M. | Ismail, M. Saleem | Brand, Connie | Richard, Jennifer | Mulnard, Ruth A. | Thai, Gaby | Mc-Adams-Ortiz, Catherine | Diaz-Arrastia, Ramon | Martin-Cook, Kristen | DeVous, Michael | Levey, Allan I. | Lah, James J. | Cellar, Janet S. | Burns, Jeffrey M. | Anderson, Heather S. | Laubinger, Mary M. | Bartzokis, George | Silverman, Daniel H.S. | Lu, Po H. | Graff-Radford MBBCH, Neill R | Parfitt, Francine | Johnson, Heather | Farlow, Martin | Herring, Scott | Hake, Ann M. | van Dyck, Christopher H. | MacAvoy, Martha G. | Benincasa, Amanda L. | Chertkow, Howard | Bergman, Howard | Hosein, Chris | Black, Sandra | Graham, Simon | Caldwell, Curtis | Hsiung, Ging-Yuek Robin | Feldman, Howard | Assaly, Michele | Kertesz, Andrew | Rogers, John | Trost, Dick | Bernick, Charles | Munic, Donna | Wu, Chuang-Kuo | Johnson, Nancy | Mesulam, Marsel | Sadowsky, Carl | Martinez, Walter | Villena, Teresa | Turner, Scott | Johnson, Kathleen B. | Behan, Kelly E. | Sperling, Reisa A. | Rentz, Dorene M. | Johnson, Keith A. | Rosen, Allyson | Tinklenberg, Jared | Ashford, Wes | Sabbagh, Marwan | Connor, Donald | Jacobson, Sandra | Killiany, Ronald | Norbash, Alexander | Nair, Anil | Obisesan, Thomas O. | Jayam-Trouth, Annapurni | Wang, Paul | Lerner, Alan | Hudson, Leon | Ogrocki, Paula | DeCarli, Charles | Fletcher, Evan | Carmichael, Owen | Kittur, Smita | Mirje, Seema | Borrie, Michael | Lee, T-Y | Bartha, Dr Rob | Johnson, Sterling | Asthana, Sanjay | Carlsson, Cynthia M. | Potkin, Steven G. | Preda, Adrian | Nguyen, Dana | Tariot, Pierre | Fleisher, Adam | Reeder, Stephanie | Bates, Vernice | Capote, Horacio | Rainka, Michelle | Hendin, Barry A. | Scharre, Douglas W. | Kataki, Maria | Zimmerman, Earl A. | Celmins, Dzintra | Brown, Alice D. | Gandy, Sam | Marenberg, Marjorie E. | Rovner, Barry W. | Pearlson, Godfrey | Anderson, Karen | Saykin, Andrew J. | Santulli, Robert B. | Englert, Jessica | Williamson, Jeff D. | Sink, Kaycee M. | Watkins, Franklin | Ott, Brian R. | Wu, Chuang-Kuo | Cohen, Ronald | Salloway, Stephen | Malloy, Paul | Correia, Stephen | Rosen, Howard J. | Miller, Bruce L. | Mintzer, Jacobo
Neurology  2012;78(18):1376-1382.
Objective:
To investigate predictors of missing data in a longitudinal study of Alzheimer disease (AD).
Methods:
The Alzheimer's Disease Neuroimaging Initiative (ADNI) is a clinic-based, multicenter, longitudinal study with blood, CSF, PET, and MRI scans repeatedly measured in 229 participants with normal cognition (NC), 397 with mild cognitive impairment (MCI), and 193 with mild AD during 2005–2007. We used univariate and multivariable logistic regression models to examine the associations between baseline demographic/clinical features and loss of biomarker follow-ups in ADNI.
Results:
CSF studies tended to recruit and retain patients with MCI with more AD-like features, including lower levels of baseline CSF Aβ42. Depression was the major predictor for MCI dropouts, while family history of AD kept more patients with AD enrolled in PET and MRI studies. Poor cognitive performance was associated with loss of follow-up in most biomarker studies, even among NC participants. The presence of vascular risk factors seemed more critical than cognitive function for predicting dropouts in AD.
Conclusion:
The missing data are not missing completely at random in ADNI and likely conditional on certain features in addition to cognitive function. Missing data predictors vary across biomarkers and even MCI and AD groups do not share the same missing data pattern. Understanding the missing data structure may help in the design of future longitudinal studies and clinical trials in AD.
doi:10.1212/WNL.0b013e318253d5b3
PMCID: PMC3345787  PMID: 22491869
12.  Are non-attenders a concern for primary care practice? 
The article by Eshel et al. describes major differences, in terms of demography and health status, between elderly patients who did and those who did not visit primary care physicians for general health check-ups. The authors conclude that non-attenders are not at risk for developing health conditions.
While this study by Eshel et al. provides a better understanding of the primary care population, the conclusion (no need for reaching out to the non-attenders) should be viewed with caution. In this study, non-attenders ‘have a higher probability of being women, older, not married and from a lower socio-economic’ segment of the population, a population that is known to be at higher risk for chronic disease. In addition, outreach programs in primary care would be key in providing essential preventive measures for this vulnerable population (e.g., osteoporosis prevention, vaccination, lifestyle, etc.).
This is a commentary on http://www.ijhpr.org/content/2/1/7.
doi:10.1186/2045-4015-2-13
PMCID: PMC3635887  PMID: 23537209
13.  Prevalence and correlates of frailty among community-dwelling older men and women: findings from the Hertfordshire Cohort Study 
Age and ageing  2009;39(2):197-203.
Background
frailty, a multi-dimensional geriatric syndrome, confers a high risk for falls, disability, hospitalisation and mortality. The prevalence and correlates of frailty in the UK are unknown.
Methods
frailty, defined by Fried, was examined among community-dwelling young-old (64-74 years) men (n = 320) and women (n = 318) who participated in the Hertfordshire Cohort Study, UK.
Results
the prevalence of frailty was 8.5% among women and 4.1% among men (P = 0.02). Among men, older age (P = 0.009), younger age of leaving education (P = 0.05), not owning/mortgaging one’s home (odds ratio [OR] for frailty 3.45 [95% confidence interval {CI} 1.01-11.81], P = 0.05, in comparison with owner/mortgage occupiers) and reduced car availability (OR for frailty 3.57 per unit decrease in number of cars available [95% CI 1.32, 10.0], P = 0.01) were associated with increased odds of frailty. Among women, not owning/mortgaging one’s home (P = 0.02) was associated with frailty. With the exception of car availability among men (P = 0.03), all associations were non-significant (P > 0.05) after adjustment for co-morbidity.
Conclusions
frailty is not uncommon even among community-dwelling young-old men and women in the UK. There are social inequalities in frailty which appear to be mediated by co-morbidity.
doi:10.1093/ageing/afp204
PMCID: PMC3546311  PMID: 20007127
frailty; prevalence; older people; social inequalities; co-morbidity; elderly
14.  Diffusion of a collaborative care model in primary care: a longitudinal qualitative study 
BMC Family Practice  2013;14:3.
Background
Although collaborative team models (CTM) improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians (PCPs). The objectives of this study are to understand: (1) how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2) the model's diffusion process.
Methods
We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 PCPs and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics.
Results
Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM's diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM's compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices). Opinion leaders played a key role in the diffusion of the CTM among PCPs.
Conclusion
CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians.
doi:10.1186/1471-2296-14-3
PMCID: PMC3558442  PMID: 23289966
Primary care; Primary care physician; Nurses; Chronic disease; Collaboration; Health service research; Diffusion of innovation
15.  Understanding and Meeting the Needs of the Older Population: A Global Challenge 
Canadian Geriatrics Journal  2013;16(2):61-65.
Background
In the past century, there has been a significant rise in life expectancy in almost all regions of the world, contributing to an increasingly older population. The aging of the population, in conjunction with urbanization and industrialization, has resulted in an important epidemiological transition marked by a widespread increase in the prevalence of chronic diseases and their sequelae. Current trends suggest that the transition will have a greater impact on developing countries compared to developed countries. An adequate response to the transition requires a strong emphasis on primary prevention and adequate resource allocation.
doi:10.5770/cgj.16.60
PMCID: PMC3671014  PMID: 23737931
aged; health service needs and demands; world health; chronic disease
16.  Predictors of Patient Self-Ratings of Quality of Life in Alzheimer’s Disease: Cross-Sectional Results from the Canadian Alzheimer’s Disease Quality of Life (CADQOL) Study 
Objectives
To assess whether the core symptoms of Alzheimer’s disease (AD) consistently predict patient self-rated quality of life (QOL) as assessed by a variety of QOL measures in a large national sample of AD patients.
Design
Cross-sectional.
Setting
Fifteen dementia and geriatric clinics across Canada.
Participants
Community-living patients with AD (n = 370) with Mini-Mental State Examination (MMSE) scores > 10.
Measurements
Patients rated their QOL using two utility indexes, the EQ-5D, the Quality of Well-Being Scale, a global QOL visual analogue scale, and the disease-specific QOL-AD instrument. Cognition was assessed with the AD Assessment Scale-Cognitive subscale and MMSE, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory (NPI) and the Geriatric Depression Scale (GDS). One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between core dementia symptoms and QOL ratings.
Results
The QOL measures had only small to moderate correlations with each other. For all QOL measures, patient ratings were significantly lower among patients with more depressive symptoms. In multivariable analyses, the GDS score was the only significant independent predictor of patient self-ratings for all four QOL measures.
Conclusions
Self-rated symptoms of depression were a consistent independent predictor of patient-rated QOL across diverse QOL measures, while performance-based measures of cognition and informant-based functional status were not. These findings confirm the importance of identifying and treating depression in patients with AD and endorse the use of measures of self-rated depressive symptoms and QOL as outcomes in AD clinical trials.
doi:10.1097/JGP.0b013e3182006a67
PMCID: PMC3267777  PMID: 21946804 CAMSID: cams2069
Alzheimer’s disease; dementia; quality of life; utility; depression
17.  Predictors of Family Caregiver Ratings of Patient Quality of Life in Alzheimer’s Disease: Cross-Sectional Results from the Canadian Alzheimer’s Disease Quality of Life (CADQOL) Study 
Objectives
To assess whether the core symptoms of Alzheimer’s disease (AD) and caregiver factors consistently predict family caregiver ratings of patient quality of life (QOL) as assessed by a variety of QOL measures in a large national sample.
Design
Cross-sectional.
Setting
Fifteen dementia and geriatric clinics across Canada.
Participants
Family caregivers (n = 412) of community-living patients with AD of all severities.
Measurements
Caregiver ratings of patient QOL using three utility indexes, the EQ-5D, Quality of Well-Being Scale and Health Utilities Index, a global QOL visual analogue scale, a disease-specific measure, the QOL-AD, and a generic health status measure, the Short Form-36. Patient cognition was assessed with the AD Assessment Scale-Cognitive Subscale and Mini-Mental State Examination, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory and the Geriatric Depression Scale. Caregiver burden was assessed with the Zarit Burden Interview and caregiver depression with the Center for Epidemiologic Studies-Depression scale. One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between patient dementia symptom and caregiver variables with QOL ratings.
Results
In multivariable analyses, caregiver ratings of patient function and depressive symptoms were the only consistent independent predictors of caregiver-rated QOL across the QOL measures.
Conclusions
Caregiver ratings of patient function and depression were consistent independent predictors of caregiver-rated QOL using a spectrum of QOL measures, while measures of patient cognition and caregiver burden and depression were not. These findings support the continued use of caregiver ratings as an important source of information about patient QOL and endorse the inclusion in AD clinical trials of caregiver-rated measures of patient function, depression and QOL.
doi:10.1097/JGP.0b013e3182006a7f
PMCID: PMC3267778  PMID: 21946805 CAMSID: cams2070
Alzheimer’s disease; dementia; quality of life; utility; family caregiver; depression; function
18.  Word reading threshold and mild cognitive impairment: a validation study 
BMC Geriatrics  2012;12:38.
Background
It was previously found, in a pilot study, that Word Reading Threshold (WRT) test is abnormally prolonged in individuals with Alzheimer’s disease (AD) and Mild Cognitive Impairment (MCI), with high sensitivity and specificity. This validation study examines the WRT test as a prognostic tool in MCI individuals. We wish to confirm in a larger group the sensitivity and specificity of the WRT test and determine whether it is influenced by deterioration on other cognitive domains.
Methods
We measured WRT in 60 MCI individuals, 29 AD patients, and 33 normal elderly control (NE). We followed the MCI individuals over 8 years to monitor who progressed to dementia.
Results
We found a statistically significant difference in WRT scores between the three groups. However, using the same cutoff of 85 milliseconds suggested by Massoud and his colleagues, we found lower diagnostic sensitivity (72%) and specificity (76%) when comparing NC and AD. Furthermore, the test did not clearly differentiate MCI individuals who progressed to dementia from those who did not. WRT was found to correlate to some degree with other cognitive domains, especially attention.
Conclusions
We conclude that the WRT is insufficient alone as a diagnostic tool for prodromal AD.
doi:10.1186/1471-2318-12-38
PMCID: PMC3438131  PMID: 22828205
19.  FRAILTY: A Report from the 3rd Joint Workshop of IAGG/WHO/SFGG, Athens, January 2012 
Frailty represents a growing challenge to modern health-care systems. This paper reports on a conference on frailty held in Athens in January 2012. Papers from 11 groups, including those of the authors, were presented and discussed over two days. Several approaches to frailty and its operationalization (including biomarkers) and to social vulnerability were discussed. The search programs that incorporate multiple measures and allows them to be tested were encouraged.
doi:10.5770/cgj.15.35
PMCID: PMC3516241  PMID: 23259017
frailty; phenotype; index; risk; aged; biomarkers; social vulnerability
20.  The Choices Facing Geriatrics 
doi:10.5770/cgj.15.33
PMCID: PMC3516245  PMID: 23259015
geriatric medicine; health services; education; clinical responsibility
21.  I May Be Frail But I Ain’t No Failure 
The terms “successful aging” and “the frail elderly” are now commonly used in aging research, but biomedical researchers may be unaware of the possible unintended negative consequences of their use. A commonly used operational definition of successful aging (high cognitive and physical function, low probability of disease, and active engagement with life) reflects values not necessarily shared by other cultures or even by older persons in our own culture. Other definitions for “a good old age” have been proposed. The adjective “successful” implies that those who do not meet its definition are unsuccessful or a failure. Labels such as “frail” predispose the person described to the phenomenon of identity spread, whereby the label becomes the master identity. Labels encourage us to regard someone as “other”. Yet only 10–15% of us will die without a significant period of disability. Research has demonstrated that older persons internalize stereotypes of aging, which can have important short- and long-term effects. The language and theories of social scientists can be poorly understood by those outside of their field, yet biomedical clinicians and researchers should be aware of this literature so that unnecessary suffering is not unintentionally inflicted on our patients and our future selves.
PMCID: PMC3516340  PMID: 23251307
successful aging; frailty; functional decline
22.  Ten years of integrated care: backwards and forwards. The case of the province of Québec, Canada 
International Journal of Integrated Care  2011;11(Special 10th Anniversary Edition):e004.
Introduction
Québec’s rapidly growing elderly and chronically ill population represents a major challenge to its healthcare delivery system, attributable in part to the system’s focus on acute care and fragmented delivery.
Description of policy practice
Over the past few years, reforms have been implemented at the provincial policy level to integrate hospital-based, nursing home, homecare and social services in 95 catchment areas. Recent organizational changes in primary care have also resulted in the implementation of family medicine groups and network clinics. Several localized initiatives were also developed to improve integration of care for older persons or persons with chronic diseases.
Conclusion and discussion
Québec has a history of integration of health and social services at the structural level. Recent evaluations of the current reform show that the care provided by various institutions in the healthcare system is becoming better integrated. The Québec health care system nevertheless continues to face three important challenges in its management of chronic diseases: implementing the reorganization of primary care, successfully integrating primary and secondary care at the clinical level, and developing effective governance and change management.
Efforts should focus on strengthening primary care by implementing nurse practitioners, developing a shared information system, and achieving better collaboration between primary and secondary care.
PMCID: PMC3111887  PMID: 21677842
integrated care; health care system; chronic disease; health policy; Quebec/Canada
23.  Diagnostic, design and implementation of an integrated model of care in France: a bottom-up process with a continuous leadership 
Purpose
To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs.
Context
Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs).
Case description
In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase.
Conclusions
The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.
PMCID: PMC3031805
integrated care models; leadership
24.  Diagnostic study, design and implementation of an integrated model of care in France: a bottom-up process with continuous leadership 
Background
Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs).
Purpose
To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs.
Results
In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase.
Conclusion
The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.
PMCID: PMC2834925  PMID: 20216954
bottom-up process; leadership; change practices; services arrangements
25.  A multidisciplinary systematic literature review on frailty: Overview of the methodology used by the Canadian Initiative on Frailty and Aging 
Background
Over the past two decades, there has been a substantial growth in the body of literature on frailty in older persons. However, there is no consensus on its definition or the criteria used to identify frailty. In response to this lack of consensus, the Canadian Initiative on Frailty and Aging carried out a set of systematic reviews of the literature in ten areas of frailty research: biological basis; social basis; prevalence; risk factors; impact; identification; prevention and management; environment and technology; health services; health and social policy. This paper describes the methodology that was developed for the systematic reviews.
Methods
A Central Coordination Group (CCG) was responsible for developing the methodology. This involved the development of search strategies and keywords, article selection processes, quality assessment tools, and guidelines for the synthesis of results. Each review was conducted by two experts in the content area, with the assistance of methodologists and statisticians from the CCG.
Results
Conducting a series of systematic literature reviews involving a range of disciplines on a concept that does not have a universally accepted definition posed several conceptual and methodological challenges. The most important conceptual challenge was determining what would qualify as literature on frailty. The methodological challenges arose from our goal of structuring a consistent methodology for reviewing literature from diverse fields of research. At the outset, certain methodological guidelines were deemed essential to ensure the validity of all the reviews. Nevertheless, it was equally important to permit flexibility in the application of the proposed methodology to capture the essence of frailty research within the given fields.
Conclusion
The results of these reviews allowed us to establish the status of current knowledge on frailty and promote collaboration between disciplines. Conducting systematic literature reviews in health science that involve multiple disciplines is a mechanism to facilitate interdisciplinary collaboration and a more integrated understanding of health. This initiative highlighted the need for further methodological development in the performance of multidisciplinary systematic reviews.
doi:10.1186/1471-2288-9-68
PMCID: PMC2765448  PMID: 19821972

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