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Multiple transitions across care settings can be disruptive for older adults with dementia and their care partners, and can lead to fragmented care with adverse outcomes. This scoping review was conducted to identify and classify care trajectories across multiple settings for people with dementia, and to understand the prevalence of multiple transitions and associated factors at the individual and organizational levels. Searches of three databases, limited to peer-reviewed studies published between 2007 and 2017, provided 33 articles for inclusion. We identified 26 distinct care trajectories. Common trajectories involved hospital readmission or discharge from hospital to long-term care. Factors associated with transitions were identified mainly at the level of demographic and medical characteristics. Findings suggest a need for investing in stronger community-based systems of care that may reduce transitions. Further research is recommended to address knowledge gaps about complex and longitudinal care trajectories and trajectories experienced by sub-populations of people living with dementia.
Canada, like other countries around the world, has an ageing population and growing numbers of people with dementia. Although rural Canada makes up 95 per cent of the country's land mass (Moazzami, 2014), Canada is becoming increasingly urbanised as cities grow and the proportion of people living in rural areas has declined and aged (Statistics Canada, 2017a). These changes have socioeconomic impacts on rural communities, including ability to deliver health and social services for ageing rural populations. The challenges of ageing in rural communities, such as disparities in access to services (Keating et al, 2011) are compounded when living with dementia. This chapter reviews the Canadian dementia care context, issues and challenges in rural dementia care, and Canadian research addressing these issues. The chapter provides an overview of the Rural Dementia Action Research (RaDAR) programme based in Saskatchewan, Canada, which has focused on rural dementia care for over 20 years.
Dementia in Canada
The number of people over age 65 in Canada is projected to increase from 17 per cent in 2017 to 23 per cent by 2031 (Statistics Canada, 2017a). The number of people with dementia is also projected to increase, from 564,000 in 2016 to around one million by 2033 (ASC, 2016). A number of Canadian initiatives have been implemented to address growing dementia care needs. Most of the ten provinces in Canada have established dementia strategies, some as early as 2002, and a national dementia strategy was released in 2019 (Public Health Agency of Canada). A 2016 report by the Senate of Canada included 29 recommendations to inform development of the national strategy (Senate of Canada, 2016). The Alzheimer Society of Canada has published several studies of projected prevalence and monetary costs using different data sources and intervention scenarios (ASC, 2010, 2016). The Canadian Institutes of Health Research Dementia Research Strategy included C$32 million in federal funding over five years for Phase I of the Canadian Consortium on Neurodegeneration in Aging (CCNA) and C$46 million for Phase 2 (2019– 24). This network of 20 research teams involves over 350 researchers conducting research in dementia prevention, treatment and quality of life (CCNA, 2019). The Canadian Chronic Disease Surveillance System was expanded to include dementia in 2011, creating national data on dementia incidence and prevalence to support planning and evaluation of policies and services (Public Health Agency of Canada, 2017; CIHI, 2018).
This study is aimed at developing a Rural Primary Health Care (PHC) Model for delivering comprehensive PHC for dementia in rural settings and addressing the gap in knowledge about disseminating and implementing evidence-based dementia care in a rural PHC context.
Limited access to specialists and services in rural areas leads to increased responsibility for dementia diagnosis and management in PHC, yet a gap exists in evidence-based best practices for rural dementia care.
Elements of the Rural PHC Model for Dementia were based on seven principles of effective PHC for dementia identified from published research and organized into three domains: team-based care, decision support, and specialist-to-provider support. Since 2013 the researchers have collaborated with a rural PHC team in a community of 1000 people in the Canadian province of Saskatchewan to operationalize these elements in ways that were feasible in the local context. The five-step approach included: building relationships; conducting a problem analysis/needs assessment; identifying core and adaptable elements of a decision support tool embedded in the model and resolving applicability issues; implementing and adapting the intervention with local stakeholders; and sustaining the model while incrementally scaling up.
Developing and sustaining relationships at regional and PHC team levels was critical. A comprehensive needs assessment identified challenges related to all domains of the Rural PHC Model. An existing decision support tool for dementia diagnosis and management was adapted and embedded in the team’s electronic medical record. Strategies for operationalizing other model elements included integrating team-based care co-ordination into the decision support tool and family-centered case conferences. Research team specialists provided educational sessions on topics identified by the PHC team. This paper provides an example of a community-based process for adapting evidence-based practice principles to a real-world setting.
The study purpose was to provide evidence of validity for the Primary Health Care Engagement (PHCE) Scale, based on exploratory factor analysis and reliability findings from a large national survey of regulated nurses residing and working in rural and remote Canadian communities.
There are currently no published provider-level instruments to adequately assess delivery of community-based primary health care, relevant to ongoing primary health care (PHC) reform strategies across Canada and elsewhere. The PHCE Scale reflects a contemporary approach that emphasizes community-oriented and community-based elements of PHC delivery.
Data from the pan-Canadian Nursing Practice in Rural and Remote Canada II (RRNII) survey were used to conduct an exploratory factor analysis and evaluate the internal consistency reliability of the final PHCE Scale.
The RRNII survey sample included 1587 registered nurses, nurse practitioners, licensed practical nurses, and registered psychiatric nurses residing and working in rural and remote Canada. Exploratory factor analysis identified an eight-factor structure across 28 items overall, and good internal consistency reliability was indicated by an α estimate of 0.89 for the final scale. The final 28-item PHCE Scale includes three of four elements in a contemporary approach to PHC (accessibility/availability, community participation, and intersectoral team) and most community-oriented/based elements of PHC (interdisciplinary collaboration, person-centred, continuity, population orientation, and quality improvement). We recommend additional psychometric testing in a range of health care providers and settings, as the PHCE Scale shows promise as a tool for health care planners and researchers to test interventions and track progress in primary health care reform.
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.
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).
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.
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.
To report the development and psychometric evaluation of a scale to measure rural and remote (rural/remote) nurses’ perceptions of the engagement of their workplaces in key dimensions of primary health care (PHC).
Amidst ongoing PHC reforms, a comprehensive instrument is needed to evaluate the degree to which rural/remote health care settings are involved in the key dimensions that characterize PHC delivery, particularly from the perspective of professionals delivering care.
This study followed a three-phase process of instrument development and psychometric evaluation. A literature review and expert consultation informed instrument development in the first phase, followed by an iterative process of content evaluation in the second phase. In the final phase, a pilot survey was undertaken and item discrimination analysis employed to evaluate the internal consistency reliability of each subscale in the preliminary 60-item Primary Health Care Engagement (PHCE) Scale. The 60-item scale was subsequently refined to a 40-item instrument.
The pilot survey sample included 89 nurses in current practice who had experience in rural/remote practice settings. Participants completed either a web-based or paper survey from September to December, 2013. Following item discrimination analysis, the 60-item instrument was refined to a 40-item PHCE Scale consisting of 10 subscales, each including three to five items. Alpha estimates of the 10 refined subscales ranged from 0.61 to 0.83, with seven of the subscales demonstrating acceptable reliability (α⩾0.70). The refined 40-item instrument exhibited good internal consistency reliability (α=0.91). The 40-item PHCE Scale may be considered for use in future studies regardless of locale, to measure the extent to which health care professionals perceive their workplaces to be engaged in key dimensions of PHC.
Nursing homes have become complex care environments where residents have significant needs and most have age-related dementia. Building on research by Hirdes et al. (2011), we describe a resident profile in a representative sample of 30 urban nursing homes in the prairie provinces using Resident Assessment Instrument – Minimum Data Set 2.0 data from 5,196 resident assessments completed between 1 October 2007 and 31 December 2011. Residents were chiefly over age 85, female, and with an age-related dementia. We compared facility support and related services and resident characteristics by province, owner-operator model, and number of facility units. We observed differences in support and related services by both unit count and province. We also found that public facilities tend to care for residents with more demanding characteristics: notably cognitive impairment, aggressive behaviours, and incontinence. No clear trends associating the number of units in a facility with resident characteristics were observed.
Little is known about the views of rural family physicians (FPs) regarding collaborative care models for patients with dementia. The study aims were to explore FPs’ views regarding this issue, their role in providing dementia care, and the implications of providing dementia care in a rural setting. This study employed an exploratory qualitative design with a sample of 15 FPs. All rural FPs indicated acceptance of collaborative models. The main disadvantages of practicing rural were accessing urban-based health care and related services and a shortage of local health care resources. The primary benefit of practicing rural was FPs’ social proximity to patients, families, and some health care workers. Rural FPs provided care for patients with dementia that took into account the emotional and practical needs of caregivers and families. FPs described positive and negative implications of rural dementia care, and all were receptive to models of care that included other health care professionals.
The physical and social environments are recognized as important therapeutic tools in the care of nursing home residents with dementia, yet little is known about the environments of rural nursing homes. This study was conducted in one rural health authority (16,000 km 2) in the province of Saskatchewan. Long-term institutional care was provided in seven small (15 to 35 beds), publicly funded nursing homes, none of which had separate dementia special care units (SCUs). The Physical Environmental Assessment Protocol (PEAP) was used to evaluate the facilities on nine key dimensions of dementia care environments. Facilities were most supportive in provision of privacy and least supportive on maximizing awareness and orientation. Focus groups were conducted with registered nurses, nursing aides, and activity workers. Staff caregivers identified six special needs of residents with dementia that were difficult to meet in the nursing homes, two of which were related to the physical environment (safety and a calm, quiet environment) and four of which were related to the social environment (meaningful activity and one-to-one contact, opportunity to use remaining abilities, flexible policy, and knowledgeable caregivers who enjoy working with persons with dementia). Staff suggested separate dementia SCUs as one approach to managing dementia care but also identified challenges in creating dementia units in small rural facilities. Results provide support for conceptual models of dementia care settings that emphasize the interaction of organizational, social, and physical factors.
The opening of a new Special Care Unit provided the opportunity to study the effect of reduced social density (fewer residents) and spatial density (more area per person) on the behaviour of residents with dementia. Two groups (N = 64) were observed at three periods spaced six months apart. As hypothesized, there was a greater improvement in Disruptive and Nondisruptive behaviour in the experimental group (move from high to low density) compared to the comparison group (constant high density). Findings suggest that unit density is an important determinant of behaviour in elderly residents with dementia.
1. Eighty-five samples from fifteen different legume seed lines generally available inthe UK were examined by measurements of their net protein utilization by rats and by haemagglutination tests with erythrocytes from a number of different animal species. From these results the seeds were classified into four broad groups.
2. Group a seeds from most varieties of kidney (Phaseolus vulgaris), runner (Phaseolus coccineus) and tepary (Phaseolus acutifolius) beans showed high reactivity with all cell types and were also highly toxic.
3. Group b, which contained seeds from lima or butter beans (Phaseolus lunatus) and winged bean (Psophocarpus tetragonolobus), agglutinated only human and pronase-treated rat erythrocytes. These seeds did not support proper growth of the ratsalthough the animals survived the 10 d experimental period.
4. Group c consisted of seeds from lentils (Lens culinaris), peas (Pisum sativum), chick-peas (Cicer arietinum), blackeyed peas (Vigna sinensis), pigeon peas (Cajanus cajan), mung beans (Phaseolus aureus), field orbroad beans (Vicia faba) and aduki beans (Phaseolus angularis). These generally had low reactivity with all cells and were non-toxic.
5. Group d, represented by soya (Glycine max) and pinto (Phaseolus vulgaris) beans, generally had low reactivity with all cells but caused growth depression atcertain dietary concentrations. This growth depression was probably mainly due to antinutritional factors other than lectins.
6. Lectins from group a seeds showed many structural and immunological similarities. However the subunit composition of the lectin from the tepary bean samples was different from that of the other bean lectins in this or any other groups.
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