Joint effect of stroke and APOE 4 on dementia risk: the Canadian Study of Health and Aging.

BACKGROUND: Although stroke and APOE 4 are independent risk factors for dementia, their combined effect remains uncertain. We assessed their joint effect on dementia risk. METHODS: Subjects participated in Phases 1 and 2 of the Canadian Study of Health and Aging (CSHA). Dementia was diagnosed by consensus, and stroke was diagnosed by history or clinical examination. Analyses were first conducted among clinical participants only, and then rerun with the screening sample included as well. RESULTS: Analyses included 949 participants from CSHA-1 and 1,413 from CSHA-2. During a median 4.6-year follow-up, 740 were included in the CSHA-1 to -2 incidence study. Among clinical participants, the highest prevalence (40.6% for CSHA-1 and 57.6% for CSHA-2) and incidence (8.4 per 100 person-years) of dementia occurred in elderly having both stroke and APOE 4; the lowest prevalence (19.8% for CSHA-1 and 23.3% for CSHA-2) and incidence (4.3 per 100 person-years) were among persons having neither. These findings held true when the screening sample was included. The adjusted hazard ratios of incident dementia, relative to elderly with neither stroke nor APOE 4, were 1.33 (95% CI 0.73 to 2.43) for stroke alone, 2.06 (95% CI 1.42 to 2.99) for APOE 4 alone, and 2.57 (95% CI 1.11 to 5.94) for both. No interaction on additive or multiplicative scales was suggested. CONCLUSIONS: The joint presence of stroke and APOE 4 was associated with a greater risk of dementia compared with absence of these two factors. The effect of stroke on dementia does not seem to be modified by APOE 4.

Effectiveness of case-based on-line learning of evidence-based practice guidelines.

BACKGROUND: Traditional continuing medical education (CME) has not been successful in improving physicians'practice. This project evaluated the use of e-mail to deliver evidence-based moderated case discussions to family physicians. METHODS: In a randomized controlled trial, 58 southwestern Ontario physicians were recruited and randomly assigned to receive two evidence-based cases (type 2 diabetes, prevention) or were put on a waiting list to receive the same. On-line discussions took place about each case. Data were collected using two knowledge questionnaires, charts audits, and standardized patient visits for each of the two cases. RESULTS: The two groups were similar except for rural/urban and solo versus group practice. The latter was related to outcomes, and analyses were controlled for this variable. The intervention group showed statistically significant improvements compared to the control group for knowledge and chart-audit scores for one of the two cases. CONCLUSIONS: Using a randomized control design, this e-mail CME method demonstrated mixed effectiveness.

Preventive health information on the Internet. Qualitative study of consumers' perspectives.

OBJECTIVE: To explore how best to make high-quality preventive health information available to consumers on the Internet. DESIGN: Focus groups. SETTING: Three urban workplaces and one local hospital with patients from a rural family medical practice. PARTICIPANTS: Twenty-two men and 17 women patients. METHOD: Qualitative survey of four focus groups, analysis of transcripts and researchers' notes. MAIN FINDINGS: Five themes characterized participants' perceptions of a consumer website of evidence-based preventive guidelines: content expectations, website design, trustworthiness of content, marketing, and the implications of consumer health information on the Internet. CONCLUSION: Consumers want preventive health information both for taking care of themselves and for participating in a more informed way in their health care when they see a physician. Findings of this study reveal some ways in which consumers' use of Internet health information can affect physicians' and other health professionals' work.

Evidence-based preventive practice guidelines. Qualitative study of useful resources on the Internet.

OBJECTIVE: To explore family physicians' perspectives on how best to provide evidence-based preventive clinical practice guidelines (CPGs) to physicians on the Internet. DESIGN: Focus groups. SETTING: A large, urban centre and a rural community hospital. PARTICIPANTS: Thirty-four of more than 150 family physicians who subscribed to an e-mail discussion group. METHOD: Qualitative survey of four focus groups, analysis of transcripts and researchers' notes. MAIN FINDINGS: Four themes characterized participants' preferences for disseminating preventive CPGs on the Internet: content expectations; quick, easy access to information; trustworthiness of information; and implications for clinical practice. CONCLUSION: Physicians want quick, easy access to trustworthy information. A website for preventive CPGs with these characteristics would be a useful resource.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia.

OBJECTIVE: i) To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians towards the recognition, assessment and management of dementing disorders; ii) to disseminate and evaluate the impact of these statements and guidelines built on these statements. OPTIONS: Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral; management of complications (especially behaviour problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations, neuroimaging and referrals; appropriate use of cognitive enhancing agents. EVIDENCE: Authors of each background paper were entrusted to: perform a literature search, discover additional relevant material including references cited in retrieved articles; consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based upon this evidence, consensus statements were developed by a group of experts, guided by a steering committee of eight individuals from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems. VALUES: Recommendations have been developed with particular attention to the context of primary care and are intended to support family physicians in their ongoing assessment and care of patients with dementia. BENEFITS, HARMS AND COSTS: Potential for improved clinical care of individuals with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations. RECOMMENDATIONS: See text. VALIDATION: Four other sets of consensus statements and/or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia.

OBJECTIVE: To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians toward the recognition, assessment and management of dementing disorders and to disseminate and evaluate the impact of these statements and guidelines built on these statements. OPTIONS: Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral, management of complications (especially behavioural problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations; neuroimaging and referrals; and appropriate use of cognitive enhancing agents. EVIDENCE: Authors of each background paper were entrusted to perform a literature search, discover additional relevant material, including references cited in retrieved articles, consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based on this evidence, consensus statements were developed by a group of experts, guided by a steering committee of 8 individuals, from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems. VALUES: Recommendations have been developed with particular attention to the context of primary care, and are intended to support family physicians in their ongoing assessment and care of patients with dementia. BENEFITS HARM AND COSTS: Potential for improved clinical care of people with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations. RECOMMENDATIONS: Forty-eight recommendations are offered that address the following aspects of dementia care: early recognition; importance of careful history and examination in making a positive diagnosis; essential laboratory tests; rules for neuroimaging and referral; disclosure of diagnosis; importance of monitoring and providing support to caregivers; cultural aspects; detection and treatment of depression; observation and management of behavioural disturbances; detection and reporting of unsafe motor vehicle driving; genetic factors and opportunities for preventing dementia; pharmacological treatment with particular emphasis on cognitive enhancing agents. VALIDATION: Four other sets of consensus statement or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

Periodic health examination, 1999 update: 1. Detection, prevention and treatment of obesity. Canadian Task Force on Preventive Health Care.

OBJECTIVES: (1) To evaluate the evidence relating to the effectiveness of methods to prevent and treat obesity, and (2) to provide recommendations for the prevention and treatment of obesity in adults aged 18 to 65 years and for the measurement of the body mass index (BMI) as part of a periodic health examination. OPTIONS: In adults with obesity (BMI greater than 27) management options include weight reduction, prevention of further weight gain or no intervention. OUTCOMES: The long-term (more than 2 years) effectiveness of (a) methods to prevent obesity and (b) methods to treat obesity. EVIDENCE: MEDLINE was searched for articles published from 1966 to April 1998 that related to the prevention and treatment of obesity; additional articles were identified from the bibliographies of review articles and the listings of Current Contents. Selection criteria were used to limit the analysis to prospective studies with at least 2 years' follow-up. BENEFITS, HARM AND COSTS: Health benefits of weight reduction were evaluated in terms of alleviation of symptoms, improved management of obesity-related diseases and a reduction in major clinical outcomes. The health risk of weight-reduction methods were briefly evaluated in terms of increased mortality and morbidity. VALUES: The recommendations of this report reflect the commitment of the Canadian Task Force on Preventive Health Care to provide a structured, evidence-based appraisal of whether a manoeuvre should be part of a periodic health examination. RECOMMENDATIONS: (1) PREVENTION: There is insufficient evidence to recommend in favour of or against community-based obesity prevention programs; however, because of considerable health risks associated with obesity and the limited long-term effectiveness of weight-reduction methods, the prevention of obesity should be a high priority for health care providers (grade C recommendation). (2) TREATMENT: (a) For obese adults without obesity-related diseases, there is insufficient evidence to recommend in favour of or against weight-reduction therapy because of a lack of evidence supporting the long-term effectiveness of weight-reduction methods (grade C recommendation); (b) for obese adults with obesity-related diseases (e.g., diabetes mellitus, hypertension), weight reduction is recommended because it can alleviate symptoms and reduce drug therapy requirements, at least in the short term (grade B recommendation). (3) Detection: (a) for people without obesity-related diseases, there is insufficient evidence to recommend the inclusion or exclusion of BMI measurement as part of a periodic health examination, and therefore BMI measurement is left to the discretion of individual health care providers (grade C recommendation); (b) for people with obesity-related diseases, BMI measurement is recommended because weight reduction should be considered with a BMI of more than 27 (grade B recommendation). VALIDATION: The findings of this analysis were reviewed through an iterative process by the members of the Canadian Task Force on Preventive Health Care. SPONSORS: The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.

Patients' desires and expectations for medical care in primary care clinics.

To explore whether patients' desires for and expectations of medical care differ between the United States and Canada, we surveyed 652 patients and 105 physicians at primary care sites in Michigan and Ontario. Patient desires were similar at both sites, but expectations were higher in Michigan. Michigan physicians gave higher estimates of patient desire than physicians in Ontario. Physicians at both sites, however, similarly underestimated patients' desires. These between-site differences in expectation may reflect differences both in general cultural factors and in patient exposure to different clinical policies within the medical systems.

The early detection and treatment of prostate cancer: the perspective of the Canadian Task Force on the Periodic Health Examination.

Few would challenge the important health burden associated with prostate cancer. This concern, combined with the emergence of a biochemical test that has the potential for early detection, has fueled enthusiasm for concerted efforts aimed at early detection and treatment of prostate cancer. Reflecting the approach and perspective of the Canadian Task Force on the Periodic Health Examination, this report argues for the objective evaluation of evidence to address the question of whether to initiate and promote early detection campaigns for prostate cancer. Specifically, 3 questions are addressed: "what is the goal of early detection?", "how should the existing evidence be evaluated?" and "how should evidence guide our actions and policies?". After reviewing the evidence using its standardized rules of evidence, the Canadian Task Force has concluded that there presently is insufficient evidence to promote the early detection of prostate cancer in asymptomatic men.

Comprehensive care for the elderly.

As older people make up an ever greater percentage of our population, we need a framework for approaching their primary medical care. Prevention, early detection, health promotion, diagnosis, assessment, and treatment are the principal tasks of primary care physicians. To accomplish these tasks, physicians must maintain a broad perspective and call, where necessary, on the expertise of others.

An Approach to Assessing Dementia: Investigations suitable for use in the family physician's office.

Early tell-tale signs of dementia may not be manifest or recognized as significant by the patient or the physician. Often a spouse, relative, or someone close to the patient recognizes changes over time. While it might be argued that little is lost if the cause is irreversible, a small but significant number of cases have reversible causes and suffering can be alleviated. The recommendations of the Canadian Consensus Conference on the Assessment of Dementia take into account the family physician's perspective. This article looks at applications in the office setting.

Early detection of depression by primary care physicians.

The overall prevalence of depression is from 3.5% to 27%. The burden of suffering is high and includes death through suicide. In most cases treatment is effective, but important episodes of depression are being missed. To determine whether a brief, systematic assessment for the early detection of depression should be part of the periodic health examination we searched MEDLINE and the Science Citation Index for randomized controlled trials that evaluated the effectiveness of early detection of depression with a questionnaire. Seven instruments met our quality criteria; the Beck Depression Inventory, the Center for Epidemiologic Studies Depression Scale, the Zung Self-Assessment Depression Scale, the General Health Questionnaire, the Hopkins Symptom Checklist, the Mental Health Inventory and the Hospital Anxiety and Depression Scale. The four randomized controlled trials failed to provide adequate evidence of the benefit of routine screening. Early detection is difficult because of depression's natural history, the role of symptoms, the cultural diversity of Canada and how detection instruments have been developed. Depression deserves careful attention from primary care physicians; however, further research and development is required before the widespread routine use of any detection test can be recommended.

Prevention and early detection in family medicine: where are we?

During the past 10 years, there has been important progress in the development of prevention and early detection of diseases in family medicine. The key feature in this development has been the increasing availability of evidence-guided recommendations. More recently, attention has begun to focus, as well, on challenges of implementing actions of proven benefit, spurred by the recommendations of the Canadian Task Force on the Periodic Health Examination. The author evaluates the current situation and suggests some strategies for family physicians to implement effective preventive manoeuvres.

Knowledge and clinical problem-solving.

A consistent finding in the literature on measures of clinical problem-solving scores is that there are very low correlations across different problems. This phenomenon is commonly labelled 'content-specificity', implying that the scores differ because the content knowledge necessary to solve the problems differs. The present study tests this hypothesis by presenting groups of residents and clinical clerks with a series of simulated patient problems in which content was systematically varied. Each subject also completed a multiple choice test with questions linked to each diagnosis presented in the clinical problems. Three of the four problem-solving scores showed low correlations, even to two presentations of the same problem, and no relationship to content differences. None of the scores were related to performance on the multiple choice test. The results suggest that variability in problem-solving scores is related to factors other than content knowledge, and several possibilities are discussed.