Recommendations of the Canadian Consensus Conference on Dementia--dissemination, implementation, and evaluation of impact.

BACKGROUND: Subsequent to the development of consensus statements on a clinical topic, it is vital to establish a plan for dissemination, implementation and evaluation of impact. Consensus statements can be used for both guiding continuing medical education (CME) and producing clinical practice guidelines (CPGs). Insufficient attention to dissemination can lead to a failure to change physician behaviour and improve patient outcomes. METHODS: A plan to disseminate the conclusions of the Canadian Consensus Conference on Dementia (CCCD) was developed. This plan was based on a literature review of CME and CPGs. A Medline search was performed on the dissemination and evaluation of the 1989 Canadian Consensus Conference on the Assessment of Dementia (CCCAD) and other published guides for physicians on dementia care. CCCD dissemination that has occurred to date (June, 2000) was reviewed in this paper. RESULTS: Lectures and unsolicited printed material are weak forms of CME. Small-group interactive CME that provides practice opportunities appears to be the most effective way to change physician behaviour. The ability of CPGs to change physician behaviour is uncertain. It appears that inadequate attention has been placed on CPG dissemination and implementation. The CCCAD had a modest impact on clinical practice in Canada. While dissemination of the conclusions of the CCCD has taken place, evaluation of the impact of the CCCD has yet to be done. Local initiatives utilizing the conclusions of the CCCD are on-going. CONCLUSIONS: Further work is needed on how to optimize the impact of consensus statements and CPGs. While dissemination of the CCCD has occurred, it is currently unknown whether it has led to any change in physician practices.

Office management of elderly hypertensive patients. Focusing on cognition and function.

OBJECTIVE: To review office management of elderly hypertensive patients and to focus on cognition and function both as ways to stratify who gets treated and as end points for treatment. QUALITY OF EVIDENCE: Relevant papers were identified through a MEDLINE search from January 1994 to March 2000, using the MeSH terms hypertension, aged, aged 80 and over, cognition, activities of daily living, therapeutics, hypotension orthostatic, and dementia. Many well conducted randomized controlled trials were found and are included. MAIN MESSAGE: Treatment of combined and systolic hypertension up to age 80 is clearly worthwhile; beyond age 85, other factors (chiefly cognitive and functional impairment) mitigate most routine recommendations. Successful treatment is individualized, taking into account comorbid conditions and their effect on cognition and function. Age is useful for thinking about groups, not individuals: as people age, risk of cognitive and functional impairment increases, but even very elderly people (> 85 years) with no impairment should be treated as younger patients are. Elderly people with signs of having a "brain at risk" should be managed with special vigilance. CONCLUSION: Good evidence supports treating elderly people, who are otherwise well and are cognitively and functionally intact, when their blood pressure is > 160 mm Hg systolic or > 105 mm Hg diastolic. There is insufficient evidence for carrying out routine recommendations for frail elderly people. Treatment of comorbid illnesses dictates choice of therapeutic agent.

Relationship between timed 'up and go' and gait time in an elderly orthopaedic rehabilitation population.

OBJECTIVE: To analyse the relationship between the timed 'up and go' (TUG) and gait time in an elderly orthopaedic population, in order to determine whether additional useful information is obtained by measuring both. DESIGN: Observational study. SETTING: Jewish Rehabilitation Hospital, Laval, Quebec. SUBJECTS: Seventy-nine consecutive inpatients in the orthopaedic programme with a primary admitting diagnosis of either total hip replacement (THR), total knee replacement (TKR), or hip fracture repair. OUTCOME MEASURES: Timed 'up and go' and time to walk 10 metres. RESULTS: The admission correlation between gait time and TUG was r= 0.745. The correlation at discharge (r= 0.816) was higher than that seen on admission. The relationship between gait time and TUG was linear both at admission and discharge. The correlation between gait time and TUG was strong for patients with TKR at admission (r= 0.868) and discharge (r= 0.878), and for patients with THR, both at admission (r= 0.809) and discharge (r= 0.879). However, the correlation on admission was weaker for patients with hip fracture (r= 0.497). For slow walkers (people with a gait speed below 0.5 m/s) on admission, the correlation was moderate (r= 0.649). However, for those with gait speeds faster than or equal to 0.5 m/s, the correlation was weaker (r= 0.484). This discrepancy was no longer evident on discharge. Likewise, for patients with a fast TUG score (< 30 seconds) on admission, there was virtually no relationship between TUG and gait time (r= 0.084), although a good correlation was present for those with 'up and go' times longer than 30 seconds (r = 0.634). As with gait speed, this difference disappeared by discharge. CONCLUSIONS: The relationship between gait time and TUG in an elderly orthopaedic rehabilitation population is good, and its strength varies by specific diagnosis, mobility, and time point in the course of therapy. The two measures are not redundant in this population.

Predictors of restful sleep in a rehabilitation hospital.

The effect of hypnotic use on self-rated quality of sleep and therapist-rated level of alertness was examined in an inpatient rehabilitation setting. We examined what other factors were predictive of a restful sleep in this population. Seventy-five inpatients at the Jewish Rehabilitation Hospital in Montreal were included. Patients were asked to rate the quality of their own sleep on a given night. Night nurses recorded whether sleeping pills had been used and rated patients' sleep and number of awakenings during the same night. Patients were evaluated by their physiotherapists and occupational therapists the next day regarding how well rested they seemed according to three parameters: alertness, fatigue, and level of participation in therapy. Thirty-three percent of the patients received sleeping pills on the study night. Sleeping pill use did not predict patient perception of getting a good night of sleep or the somewhat more objective sleep rating by the night nurse. Whether a sleeping pill was taken was also found not to be predictive of restful sleep as estimated by the physical and occupational therapists. Variables significantly associated with therapists' ratings of apparently restful sleep included number of comorbidities, the nurses' rating of how well the patient had slept, the patients' self-assessment of sleep, and whether the patient felt well rested the morning after sleep. However, the patients' own assessment of sleep quality was negatively related to their performance in rehabilitation therapy. This suggests that patient self-report of sleeping difficulty may not be the best or only guideline to follow when considering intervention such as prescribing sleeping pills, particularly because sleeping pill use seems not to influence either patient perception of sleep or how well rested they seem in therapy.

Prevalence of potentially reversible dementias and actual reversibility in a memory clinic cohort.

BACKGROUND: Although clinics for the evaluation of cognitive dysfunction have typically emphasized the detection and treatment of the reversible causes of dementia, it remains unclear whether the treatment of such causes results in reversal of the dementia. Therefore, the appropriate work-up for dementia is in dispute. METHODS: A chart review was performed with records from an urban tertiary care referral-based memory clinic. The records for 196 patients with dementia or suspected dementia, seen between October 1991 and December 1993, were examined to determine the prevalence of potentially reversible dementias and whether the cognitive dysfunction improved or resolved after treatment. Data abstracted from the medical charts included demographic information, medication use, presence of depression, and results of neuropsychological tests, blood work and neuroimaging. The clinical diagnosis, the response to treatment, if applicable, and the outcome (mean follow-up period 16 months) were analysed. The recommendations of the 1989 Canadian Consensus Conference on the Assessment of Dementia (CCCAD) on the use of CT were retrospectively applied in each case. RESULTS: Of the 196 patients, 45 (23.0%) had a potentially reversible condition identified by history, physical examination, blood testing or CT; in only 7 (3.6% of the total) did treatment result in improvement or resolution of the dementia. These 7 patients had higher results for the Mini-Mental State examination (mean result 26) and exhibited only mild cognitive deficits. Potentially reversible lesions were found in the CT scans of 6 (3.1%) patients: 4 had normal-pressure hydrocephalus and 2 had a brain tumour. If the CCCAD recommendations had been followed, CT would have been performed in 76 (38.8%) of the patients, and 1 of the 6 patients with a lesion would have been missed. INTERPRETATION: Both potential and actual reversibility of dementia was low in these memory clinic patients. The patients whose condition improved with intervention had early and milder cognitive deficits, which suggests that thorough evaluation of early memory loss is warranted.

Pulmonary edema: atypical anaphylactoid reaction to intravenous iron dextran.

Two cases of atypical anaphylactoid reactions to intravenous iron dextran in hemodialysis patients are described. Anaphylactic reactions to iron dextran in dialysis patients are not uncommon. Pulmonary edema is not generally seen in anaphylaxis. Our patients both developed significant pulmonary edema following intravenous infusion of iron dextran, which responded promptly to treatment of anaphylaxis. Potential mechanisms are discussed.

Acute pulmonary edema as the initial hospital presentation of systemic lupus erythematosus.

Acute pulmonary edema is an unusual initial presentation for systemic lupus erythematosus. A 46-year-old woman required intensive care for life-threatening pulmonary edema of unknown etiology, which was unresponsive to conventional treatment. Her condition improved only when pulse corticosteroid therapy was initiated, with clinical and echocardiographic improvement in cardiac function. The diagnosis of systemic lupus erythematosus was then made, based on immunologic tests and renal biopsy. The patient's condition remained stable only with continuation of appropriate therapy for systemic lupus erythematosus.

A computer-aided procedure for measuring Lashley III maze performance.

As an animal swims through the Lashley III maze, an observer types into a Macintosh computer the path taken. The computer program, Observe Software, then breaks the string of choices into two-step sequences and counts the number of such sequences. These data are then sent to a spreadsheet, where the sequences are sorted into forward and backward responses. Forward choices are Correct Path, T Choice Errors and Cul Entry Errors. All backward choices are errors, by definition. They are classified as T Choices, Cul Entries, Cul Exits, and Return to Start. The animal's behavior is then described by the various error classes plus a measure called Learning Index. Examples of learning by rats and mice are presented.

The dose-response relationship for memory impairment by anticholinergic drugs.

Twelve stabilized chronic schizophrenic outpatients receiving maintenance treatment with fluphenazine decanoate plus anticholinergic antiparkinsonian drugs underwent two challenge sessions receiving, in random sequence and double-blind, injections of either benztropine or glycopyrrolate (a peripherally active anticholinergic agent that penetrates the CNS poorly, used as an active placebo). Performance on free recall testing was significantly worse after benztropine than after glycopyrrolate. It has previously been shown that routine clinical doses of anticholinergic antiparkinsonian drugs impair verbal learning relative to a drug-free baseline. Our results suggest that memory impairment continues to further increase as anticholinergic drugs are pushed to the upper limit of the acceptable clinical range.

Insight and the clinical outcome of schizophrenic patients.

At the time of discharge from their index hospitalizations, 52 schizophrenic patients initially admitted for acute psychotic episodes were assessed on an Insight and Treatment Attitudes Questionnaire. When these patients were followed up 2 1/2 to 3 1/2 years later, adequate information on their clinical courses and outcomes was available in 46 cases. A global assessment of aftercare environment was made in each case, reflecting the degree to which individuals other than the patient were helpfully invested in maintaining the patient in treatment, whether these individuals were in the patient's living or treatment situations. Five factual outcome variables were also assessed: a) compliance with treatment 30 days after discharge; b) long-term compliance; c) whether or not patients were readmitted; d) readmissions per year; and e) percent of time spent in the hospital. As expected, aftercare environment was significantly related to outcome (p = .039). The overall relationship between insight and the outcome variables closely approached statistical significance (p = .053). Patients with more insight were significantly less likely to be readmitted over the course of follow-up. There was a trend for patients with more insight to be compliant with treatment 30 days after discharge. No significant interaction between aftercare environment and insight was found, suggesting that insight may influence outcome independently of aftercare environment.

Why must some schizophrenic patients be involuntarily committed? The role of insight.

Twenty-four of 52 (46%) schizophrenic patients hospitalized because of acute psychotic episodes associated with preadmission medication noncompliance required involuntary commitment. Committed patients were rated as significantly more severely ill than voluntary patients and were significantly more likely to be transferred to extended treatment facilities after acute care. However, committed patients were significantly less likely than were voluntarily admitted patients to acknowledge that they were psychiatrically ill and in need of treatment, i.e., to demonstrate insight. Although psychopathology diminished significantly in both committed and voluntary patients over the course of hospitalization, only in voluntary patients did insight increase significantly. Over a 21/2 to 31/2 year follow-up, those patients who had been involuntarily committed at the index hospitalization were significantly more likely to require involuntary admissions than were the initially voluntary patients. Inability to see the self as ill seems to be a persistent trait in some schizophrenic patients.

Replacement of chronically administered anticholinergic drugs by amantadine in outpatient management of chronic schizophrenia.

Anticholinergic drugs have been shown to impair new memory acquisition. In a double-blind study, 22 chronically schizophrenic patients had the anticholinergic drugs that they had been taking to control the extrapyramidal side effects (EPSE) of neuroleptic drugs discontinued and were randomly assigned to treatment either with benztropine (an anticholinergic) or with amantadine (which has little or no anticholinergic effect). The EPSE of five of the ten patients assigned to amantadine could not be adequately controlled with that drug alone, and these patients were withdrawn from the study prematurely. The five patients who completed the six-week trial on amantadine showed improved performance on tests of memory acquisition in comparison with patients treated with benztropine. Global inspection of the results showed that only 36% of the patients taking benztropine showed improvement in memory acquisition at the four- and six-week assessments, whereas 80% of the amantadine users showed improvement at the four-week assessment. Analysis of covariance, however, revealed that the performance of the latter group decreased almost to baseline at six weeks, as an additional two of the remaining patients developed distressing EPSE.