Assessing Determinants of Perceived Quality in Transitions for People with Dementia: a Prospective Observational Study.

BACKGROUND: The trajectory of dementia through time is characterized by common transitions which are difficult for persons with dementia (PWDs) and their families and friends. Our study sought to identify determinants for the quality of transition outcomes. METHOD: A 24-month, prospective, longitudinal design identified specific transitions as they occurred in 108 person-with-dementia/caregiver dyads, and assessed the perceived transition quality from the perspective of the caregiver and what we denote as the 'summative' transition quality outcome variable (as explained in the Data Processing section under Methods). RESULTS: Among caregivers and during the authors' deliberations of the summative transition quality outcomes, good transition quality was associated with the PWD's baseline Disability Assessment for Dementia (OR 1.04, 95% CI 1.02-1.06 per increase in percent score based on summative assessments), and with the PWD's higher baseline quality of life scores (OR 1.11, 95% CI 1.05-1.18 per increase in unit of score in QOL-AD based on summative assessments). Caregiver-perceived better outcome quality was associated with lower caregiver burden, (OR 0.97, 95% CI 0.95-0.99 per unit CBI score increase). CONCLUSION: Identifying determinants of successful transitions is feasible and may be translated into practical guidance for use in clinical encounters. Those with worse prior quality of life or worse performance in activities of daily living appear to require specific support during transitions, as do those whose caregivers report higher levels of burden.

Antidepressant and antipsychotic prescribing in primary care for people with dementia.

OBJECTIVE: To use data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) to evaluate the prevalence of antidepressant and antipsychotic prescriptions among patients with no previous depression or psychosis diagnoses, and to identify the factors associated with the use of these drugs in this population. DESIGN: Retrospective cohort study using data derived from CPCSSN. SETTING: Primary care practices associated with CPCSSN. PARTICIPANTS: Patients who were born before 1949; who were associated with a CPCSSN primary care practitioner between October 1, 2007, and September 30, 2013; and whose electronic medical records contained data from at least 6 months before and 12 months after the date of dementia diagnosis. MAIN OUTCOME MEASURES: Prescription for an antidepressant or antipsychotic medication in the absence of a depression or psychosis diagnosis. Multivariable models were fitted to determine estimated odds ratios (ORs) and were adjusted for age and sex. RESULTS: Of the 3252 patients without a depression diagnosis, 8.5% received a new prescription for an antidepressant in the 12 months following their diagnosis of dementia. Prescribing was reduced in association with older age (OR of 0.86 per 5-year age increase, P=.001) and male sex (OR=0.77, P=.056), and prescribing increased in association with prescription of cholinesterase inhibitor medications (OR=1.57, P=.003). Of the 4262 patients without a diagnosis of psychosis, 6.1% received a new prescription for an antipsychotic in the 12 months following their diagnosis of dementia. Higher rates of antipsychotic prescriptions were reported in men (OR=1.31, P=.046), those receiving a prescription for steroids (OR=1.90, P=.037), and those diagnosed with Parkinson disease (OR 1.58, P=.051). CONCLUSION: A substantial number of patients with dementia are being prescribed antidepressant or antipsychotic medications by their primary care practitioners without evidence of depression or psychosis in their electronic medical records.

Provision of dementia-related services in Canada: a comparative study.

BACKGROUND: Dementia is common, particularly among older adults, and is one of the major causes of dependency later in life. We sought to provide an overview and comparison of key services related to dementia care as the disease progresses in three large Canadian healthcare centres. METHODS: We identified family physicians, geriatric specialists, and dementia case managers from three major population centres in Canada with universal healthcare coverage. Using a standardized longitudinal dementia case vignette, participants were interviewed on services they would provide at each stage of the disease. We used principles of content analysis to generate codes and identify themes; appropriate time frames from the vignette fitting the necessary provision of services were derived from the Canadian consensus statement and determined in consultation with clinical experts. Proportions of participants that identified dementia-related care services were analyzed at each time point of the vignette using chi-square tests. RESULTS: Thirty-four healthcare providers from Calgary (Alberta), Edmonton (Alberta), and Ottawa (Ontario) participated. Review of our data identified seven overarching themes of dementia-related care services. Services provided in the community setting include future planning and related services, educational and social support services, and home care and respite services. Although all providers consistently identified educational and social support services (e.g. the Alzheimer Society) within the appropriate time frame, the provision of other services was variable. The proportion of providers reporting potential access of future planning services was significantly different across the three sites (Calgary, 91.7 %; Edmonton; 58.3 %; and Ottawa, 30.0 %), p = 0.012. Also, the proportion of providers that identified day program services were significantly different across the three sites (Calgary, 100.0 %; Edmonton, 91.7 %; and Ottawa, 60.0 %), p = 0.023 according to a chi-square test. CONCLUSIONS: We found important types of variability in service delivery among different regions in Canada for a typical patient with dementia and their family caregiver. Health systems can be calibrated by aligning services from different settings to appropriate time points in the vignette, which illustrates the dynamic course of service delivery and opportunities for improvement throughout the disease trajectory.

Prospective Validation of the Ottawa 3DY Scale by Geriatric Emergency Management Nurses to Identify Impaired Cognition in Older Emergency Department Patients.

STUDY OBJECTIVE: Assessment of older emergency department (ED) patients with cognitive impairment is challenging because few tools exist that can be quickly administered by front-line practitioners. Our objective is to validate the Ottawa 3DY Scale, a 4-question screening tool for cognitive impairment, in older ED patients and compare its performance with that of the Animal Fluency Test. METHODS: We conducted a prospective cohort study in 2 EDs and enrolled a convenience sample of patients aged 75 years or older with no history of cognitive impairment. Eligible patients were assessed by geriatric emergency management nurses who administered the Mini-Mental State Examination, ordered with the Ottawa 3DY Scale questions first, followed by the Animal Fluency Test. Mini-Mental State Examination score less than 25 was our criterion standard for cognitive impairment. RESULTS: Study patients (N=238) had a mean age of 81.9 years and were 60.1% women, and 26.5% were admitted to the hospital. The Ottawa 3DY Scale and Mini-Mental State Examination were in agreement for 75.6% of cases, with a sensitivity of 93.8% (95% confidence interval [CI] 77.8% to 98.9%) and specificity of 72.8% (95% CI 66.1% to 78.7%). The Animal Fluency Test score less than 15 and Mini-Mental State Examination score were in agreement for 46.2% of cases, with sensitivity 90.6% (95% CI 73.8% to 97.5%) and specificity 39.3% (95% CI 32.7% to 46.4%). CONCLUSION: Both the Ottawa 3DY Scale and the Animal Fluency Test demonstrated excellent sensitivity versus the Mini-Mental State Examination; however, the Animal Fluency Test exhibited poor specificity. The Ottawa 3DY Scale is an effective tool to screen for cognitive impairment in older ED patients, and its use may facilitate improved care in this vulnerable population.

Role expectations in dementia care among family physicians and specialists.

BACKGROUND: The assessment and ongoing management of dementia falls largely on family physicians. This pilot study explored perceived roles and attitudes towards the provision of dementia care from the perspectives of family physicians and specialists. METHODS: Semi-structured, one-to-one interviews were conducted with six family physicians and six specialists (three geriatric psychiatrists, two geriatricians, and one neurologist) from University of Toronto-affiliated hospitals. Transcripts were subjected to thematic content analysis. RESULTS: Physicians' clinical experience averaged 16 years. Both physician groups acknowledged that family physicians are more confident in diagnosing/treating uncomplicated dementia than a decade ago. They agreed on care management issues that warranted specialist involvement. Driving competency was contentious, and specialists willingly played the "bad cop" to resolve disputes and preserve long-standing therapeutic relationships. While patient/caregiver education and support were deemed essential, most physicians commented that community resources were fragmented and difficult to access. Improving collaboration and communication between physician groups, and clarifying the roles of other multi-disciplinary team members in dementia care were also discussed. CONCLUSIONS: Future research could further explore physicians' and other multi-disciplinary members' perceived roles and responsibilities in dementia care, given that different health-care system-wide dementia care strategies and initiatives are being developed and implemented across Ontario.

The pathway to diagnosis of dementia for francophones living in a minority situation.

PURPOSE OF THE STUDY: As the prevalence of dementia increases, the pressure to make early diagnoses also increases. Although patients must be able to identify the symptoms to access appropriate services, they may not be equally accessible to all citizens in a multicultural society. Health care professionals and patients may lack a common "first language." This study explores the experience of francophone persons with dementia (PWD) and their caregivers during the peri-diagnostic period. DESIGN AND METHODS: Individual interviews were undertaken to elicit information regarding symptoms, the role of the family and friends, and the access to formal services. Seven PWD and their caregivers who spoke French as their primary language but who lived in a primarily English-speaking region completed the interviews. RESULTS AND IMPLICATIONS: No single symptom seemed sufficient to alert participants that dementia might be present. Participants communicated that there was a dire need to inform the public about the signs of dementia; they spoke of the role of the family physician and the importance of having a long-standing relationship with a health professional. For some, having similar personal characteristics, such as language and culture, might accentuate the strength of the relationship and facilitate the process of diagnosis.

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.

When it is time to hang up the keys: the driving and dementia toolkit - for persons with dementia (PWD) and caregivers - a practical resource.

BACKGROUND: The aim of this project was to develop a toolkit to assist persons with dementia (PWD) and their caregivers, in planning for retirement from driving. The information gathered was used to develop a tool that can assist reflection about, and make sound decisions in this challenging area of the dementia journey. The purpose is to keep safe drivers on the road and to prepare those who are moving towards being at risk of being involved in crashes, to eventually stop driving when they are unsafe.The toolkit was prepared to address the concerns of both the PWD as well as the caregivers. Strategies and solutions are presented for both the PWD and the caregivers. A grief insert was also developed that can assist caregivers in supporting the PWD in the grief process that can accompany losing one's driving privileges.

Geriatrics, interprofessional practice, and interorganizational collaboration: a knowledge-to-practice intervention for primary care teams.

INTRODUCTION: Caring for frail seniors requires health professionals with skills and knowledge in 3 core competencies: geriatrics, interprofessional practice, and interorganizational collaboration. Despite a growing population of frail seniors in all developed countries, significant gaps exist in preparation of health professionals in these skills. To help close these gaps, a knowledge-to-practice (KTP) process was undertaken to increase the capacity of newly created family health teams and longer standing Community Health Centers in the Province of Ontario, Canada. METHODS: Each team identified a staff member to become its facilitator in the 3 core skill sets. Guided by a KTP framework, a set of training modules were created, compiled into a digital toolkit for transfer into practice, translated in a multimethods workshop, and implemented using a variety of strategies to optimize practice change. RESULTS: Staff from 82% of the targeted primary care teams learned to use the toolkit in a train-the-facilitator process that was highly valued, and prompted a range of changes in personal and team practice. A digital toolkit for primary care teams remains an enduring and often used resource. DISCUSSION: Closing the knowledge gap in the core competencies for frailty focused care is complex. A KTP framework helped guide a staged multimethod process that produced both individual and team practice change and on online toolkit that has a continuing influence.

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.

Effect of nurse practitioner and pharmacist counseling on inappropriate medication use in family practice.

OBJECTIVE: To measure the effect of nurse practitioner and pharmacist consultations on the appropriate use of medications by patients. DESIGN: We studied patients in the intervention arm of a randomized controlled trial. The main trial intervention was provision of multidisciplinary team care and the main outcome was quality and processes of care for chronic disease management. SETTING: Patients were recruited from a single publicly funded family health network practice of 8 family physicians and associated staff serving 10 000 patients in a rural area near Ottawa, Ont. PARTICIPANTS: A total of 120 patients 50 years of age or older who were on the practice roster and who were considered by their family physicians to be at risk of experiencing adverse health outcomes. INTERVENTION: A pharmacist and 1 of 3 nurse practitioners visited each patient at his or her home, conducted a comprehensive medication review, and developed a tailored plan to optimize medication use. The plan was developed in consultation with the patient and the patient's doctor. We assessed medication appropriateness at the study baseline and again 12 to 18 months later. MAIN OUTCOME MEASURES: We used the medication appropriateness index to assess medication use. We examined associations between personal characteristics and inappropriate use at baseline and with improvements in medication use at the follow-up assessment. We recorded all drug problems encountered during the trial. RESULTS: At baseline, 27.2% of medications were inappropriate in some way and 77.7% of patients were receiving at least 1 medication that was inappropriate in some way. At the follow-up assessments these percentages had dropped to 8.9% and 38.6%, respectively (P < .001). Patient characteristics that were associated with receiving inappropriate medication at baseline were being older than 80 years of age (odds ratio [OR] = 5.00, 95% CI 1.19 to 20.50), receiving more than 4 medications (OR = 6.64, 95% CI 2.54 to 17.4), and not having a university-level education (OR = 4.55, 95% CI 1.69 to 12.50). CONCLUSION: We observed large improvements in the appropriate use of medications during this trial. This might provide a mechanism to explain some of the reductions in mortality and morbidity observed in other trials of counseling and advice provided by pharmacists and nurses. TRIAL REGISTRATION NUMBER: NCT00238836 (ClinicalTrials.gov).

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

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

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 Alzheimer's 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 people's beliefs and attributions about symptoms, may elucidate some of the barriers as well as strategies to promote a timelier dementia diagnosis.

eLearning, knowledge brokering, and nursing: strengthening collaborative practice in long-term care.

Interprofessional collaboration is vital to the delivery of quality care in long-term care settings; however, caregivers in long-term care face barriers to participating in training programs to improve collaborative practices. Consequently, eLearning can be used to create an environment that combines convenient, individual learning with collaborative experiential learning. Findings of this study revealed that learners enjoyed the flexibility of the Working Together learning resource. They acquired new knowledge and skills that they were able to use in their practice setting to achieve higher levels of collaborative practice. Nurses were identified as team leaders because of their pivotal role in the long-term care home and collaboration with all patient care providers. Nurses are ideal as knowledge brokers for the collaborative practice team. Quantitative findings showed no change in learner's attitudes regarding collaborative practice; however, interviews provided examples of positive changes experienced. Face-to-face collaboration was found to be a challenge, and changes to organizations, systems, and technology need to be made to facilitate this process. The Working Together learning resource is an important first step toward strengthening collaboration in long-term care, and the pilot implementation provides insights that further our understanding of both interprofessional collaboration and effective eLearning.

Effects of rivastigmine on common symptomatology of Alzheimer's disease (EXPLORE).

OBJECTIVE: To evaluate, in a real-world clinical setting, the efficacy of rivastigmine in the management of six symptoms commonly associated with Alzheimer's disease (AD). METHODS: This was a naturalistic, prospective, open-label, multi-centre, post-marketing, observational study. Data were collected by the participating study physicians at their practices across Canada. Subjects had a clinical diagnosis of mild-to-moderate AD and were prescribed rivastigmine by their treating physician. Efficacy was primarily evaluated by a physician-assessed, abbreviated Clinical Global Impression of Change (CGI-C) scale, focusing on six symptoms: attention, apathy, anxiety, agitation, irritability and sleep disturbance. Changes were assessed at months 3, 6 and 12. Several other patient-, physician- and caregiver-related assessments were also included. RESULTS: A total of 4460 patients were recruited by 353 study physicians; 3800 were deemed evaluable, having taken at least one dose of rivastigmine and with at least one post-baseline assessment. At baseline, attention problems were present in 86.0% of evaluable patients, anxiety in 77.3%, apathy in 68.3%, irritability in 64.0%, agitation in 54.6% and sleep disturbance in 54.5%. At both month 6 and month 12, for each symptom, the percentage of patients experiencing an improvement was considerably larger than the percentage of patients who experienced symptom worsening. Among evaluable patients, the proportions improving vs. deteriorating at month 6 were 46.4 vs. 8.8% for attention; 42.8 vs. 7.2% for apathy; 41.1 vs. 9.4% for anxiety; 33.8 vs. 7.7% for agitation; 35.1 vs. 10.1% for irritability; and 30.8 vs. 5.4% for sleep disturbance. LIMITATIONS: Open-label studies have an inherent potential for bias by both the caregiver and the physician. CONCLUSIONS: This study demonstrates that a considerable proportion of rivastigmine-treated patients experience improvements on each of the six symptoms studied. These findings add further support to previous randomised, clinical studies showing benefit of rivastigmine in AD.

Meanings, functions, and experiences of living at home for individuals with dementia at the critical point of relocation.

The sociophysical home environment is an integral component of everyday coping, self-identity, and well-being for individuals with dementia; however, residential discontinuity is a common experience for many of these individuals. This article examined the meanings, functions, and experiences associated with living at home for individuals with dementia at the critical point of relocation to a residential care facility. Qualitative research methods were used to analyze in-depth interviews with 16 individuals with dementia at their homes within 2 months prior to relocation. At the time of relocation, living at home had become a paradoxical experience for most participants. The findings inform practice and policy interventions at both individual and societal levels to help individuals with dementia age in place for as long as possible and to maximize their efforts to "place" themselves in their new living environments after relocation.

Canadian Alzheimer's disease caregiver survey: baby-boomer caregivers and burden of care.

OBJECTIVE: Alzheimer's disease (AD) burdens not only the person, but also the person's caregiver(s). This burden has been linked to negative health effects for caregivers. To that end, a survey of Canadian caregivers of persons with AD/other dementias was conducted to investigate the social, physical, psychological and financial impact of AD and/or dementia-related conditions on caregivers' quality of life. METHODS: A web-based survey, the Canadian Alzheimer's Disease Caregiver survey, was made available through the Canadian Alzheimer's Society website and 50plus.com, an internet portal for baby boomers (BB) (people aged 50 years or older), as well as through HarrisDecima Research's e-Vox panel. A total of 398 individuals completed the survey between 15 September and 5 November 2006. RESULTS: Of the 398 total respondents, 221 were identified as baby boomers who provided care to an individual with AD/dementia. Respondents identified several areas of burden of care. These included negative effects on emotional health (such as increased depression, more stress and greater fatigue), financial costs and a need to change a working situation (e.g. by retiring early, reducing work hours or refusing a promotion). CONCLUSION: Caregivers of persons with AD/related dementia face important social, physical, psychological and financial pressures. These negatively affect the quality of life of caregivers with a significant increased burden being placed on live-in caregivers versus caregivers who do not co-reside with their care recipients. Interventions that address these pressures will not only improve the health and well-being of caregivers, but likely also the care of persons with AD/dementia.

Detection of cognitive impairment and dementia using the animal fluency test: the DECIDE study.

OBJECTIVES: To evaluate the performance of a one-minute screening test measured against a validated 10-minute screening test for mild cognitive impairment (MCI) in detecting CI in patients aged > or = 65 years with two or more vascular risk factors (VRF). METHODS: Patients (n=1523) aged 65 years or older without documented CI symptoms or dementia with two or more VRF participated in this study set in Canadian primary care practice. Baseline data was collected, followed by the 1-minute animal fluency (AF) test and the 10-minute Montreal Cognitive Assessment (MoCA). Physicians (n=122) completed case reports during patient interviews and reported their diagnostic impression. AF test sensitivity, specificity, and accuracy in predicting a positive MoCA was assessed. RESULTS: Study sample mean age was 79.7 years, 55% were female, 97.6% were Caucasian and 75% had < or = 12 years of education. The AF test and MoCA detected CI in 52 and 56 percent of the study population, respectively. The AF test demonstrated sensitivity, specificity, and accuracy in predicting a positive MoCA of 67 percent each. Physicians diagnostic impression of MCI was reported for 37% of patients, and of dementia for 6%. CONCLUSION: In an elderly population with at least two VRF, using AF can be useful in detecting previously unknown symptoms of CI or dementia. Screening for CI in this high risk population is warranted to assist physician recognition of early CI. The short AF administration time favours its incorporation into clinical practice.

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. AIM: This paper presents a conceptual model of the factors that may serve as common antecedents of hopes and expectations, and a mechanism that may mediate their differentiation. METHOD: Ovid Healthstar and PsycINFO database searches from January 1967 to October 2008 were conducted. An integrative literature review, synthesis and conceptual model development were carried out. Outcome Our model envisages the differentiation of hope from expectation as a dynamic, longitudinal process consisting of three phases: appraisal of possible outcomes, cognitive analysis for achieving hopes and goal pursuit. Key variables such as temporal proximity, controllability, external resources, goals, affect, agency and pathways may moderate the extent of divergence by influencing the perceived probability of achieving desired outcomes. CONCLUSION: Hopes and expectations are distinct, but linked, constructs. This preliminary conceptual model presents how hopes and expectations develop, become differentiated and how social-cognitive factors may moderate this relationship. A better understanding of hopes and expectations may assist health professionals in communicating illness-related expectations while maintaining the integrity of patient hopes.