Treatment of Adult Distal Humerus Fracture with Fishtail Deformity: A Case Report.

CASE: We report a single case of a closed intra-articular distal humerus fracture in a 28-year-old man with a preexisting fishtail deformity characterized by concavity of the central trochlea and corresponding deformity of the olecranon. The patient was treated with open reduction and internal fixation. CONCLUSION: The case highlights the diagnosis and challenges of treatment. Conventional fixation choices and imaging techniques may need to be altered when treating a fracture with this deformity.

Computed Tomography Scans and Fixation Rates for Trimalleolar Ankle Fractures Over 10 Years at a Level 1 Trauma Center.

Background: The posterior malleolus component of the trimalleolar ankle fracture has posed a controversial topic for diagnostic imaging and surgical management. Preoperative computed tomography (CT) scans are used to better appreciate fracture morphology and may affect management techniques. No prior study has investigated the trend in preoperative CT scan use and the rates of posterior and syndesmotic fixation for trimalleolar injuries. Methods: This retrospective cohort study evaluated the use of preoperative CT scans and the rates of posterior and syndesmotic fixation for trimalleolar ankle fractures over a 10-year period at an adult level 1 trauma center. Patients surgically managed for ankle fractures with OTA/AO classifications of 44B3, 44C3.3, 44C1.3, 44C2.3, and 44A3 were identified and included using Current Procedural Terminology codes and a prospectively collected fracture registry. Demographic information, comorbidities, fixation methods, and use of preoperative CT scan were recorded. Comparative analyses were performed to assess for yearly differences in demographic characteristics along with changes in trends of preoperative CT scans and posterior and syndesmotic fixation. Results: A total of 1191 patients were included in the analyses. OTA/AO 44B3.2 fractures were the most common injuries (yearly range of 59.4%-80.1%). The rate of posterior fixation did not significantly increase during the study interval (1.4% growth per year [95% CI -0.27, 3.07]). However, the rate of preoperative CT scan use significantly increased by 2.76% (95% CI 1.99, 3.52) per year and the rate of syndesmotic fixation increased by 2.58% (95% CI 1.17, 3.99) per year. Fixation methods for both the syndesmosis and posterior malleolus changed during the study timeline. Conclusion: Despite a relatively stable rate of posterior fixation, the frequency of preoperative CT scans and use of syndesmotic fixation increased significantly over a 10-year study period. Level of Evidence: Level IV, descriptive pilot study.

Medicolegal pitfalls when assessing decision-making capacity in people with cognitive impairment.

BACKGROUND: The global population of older adults will double over the next three decades, and one in 10 will have dementia. OBJECTIVE: This article examines medicolegal pitfalls when assessing the decision-making capacity of cognitively impaired patients. DISCUSSION: Be aware of the pitfalls while completing the five steps of the assessment. Step 1, the request for a capacity assessment, alerts the clinician that this is more than an administrative form-filling task and that the consultation is not therapeutic. Step 2, initiation of the consultation, requires being prepared for a new diagnosis of dementia, explicitly obtaining consent and understanding the expectations of all involved. Step 3, the clinical assessment, requires avoiding assumptions about the patient and the law, completing tests of cognition, including executive function, and ensuring a detailed understanding of the matter requiring a decision. Step 4, the formulation of opinion and documentation, requires documenting and addressing the legal questions about function and impairment. Step 5, review and reflect assuming somebody will contest the opinion.

Delay to Surgical Treatment in Geriatric Hip Fracture Patients.

Background: Hip fractures in the geriatric population are frequently encountered. There is increasing focus on minimizing the delay to surgery in these patients. This study was designed to evaluate factors responsible for a delay to surgery in a geriatric hip fracture population and how time to surgery affects mortality. Methods: A retrospective cohort of patients sustaining low energy geriatric hip fractures in either an American College of Surgeons (ACS) verified Level 1 trauma center or a local university affiliated community teaching hospital were reviewed. The following variables were evaluated as independent risk factors for delay to surgery: demographic data, surgical details, use of cardiology resources, treatment center, and comorbidities. As a secondary objective, the effect of time to surgery on 1 year mortality was analyzed. Results: 1157 patients met inclusion criteria. The following factors increased the risk of delay to surgery greater than 48 hours: male sex, treatment in a community hospital (versus trauma center), older age, multiple comorbidities (eg, cardiovascular-related conditions or other fractures), cardiology consultation, and an American Society of Anesthesiologists physical status score of 3 or 4. Cardiology consultation was the strongest independent predictor of risk for delay to surgery of >48 hours (odds ratio, 6.68; 95% confidence interval, 4.40 to 10.14; P < .001). The 1-year mortality of patients did not differ when surgical treatment occurred before 48 hours or after 48 hours (Log-rank test P = .109). Conclusion: The presence of cardiovascular comorbidities and cardiology consultations can delay surgical treatments for hip fractures in patients greater than 65 years old, but the delay did not influence 1-year all-cause mortality. Level of Evidence: Level IV.

Treatment and Outcome of a "Floating Fibula" Injury: A Case Report.

CASE: We report a case of a rare "floating fibula" ankle injury characterized by dislocation of the proximal tibiofibular joint (PTFJ), syndesmosis disruption, complete deltoid disruption, and tibiotalar dislocation without fibula fracture in a 44-year-old man. Imaging includes preoperative and postoperative radiographs and CT scans. Treatment involved reduction and screw fixation of the syndesmosis and PTFJ with planned screw removal. A successful clinical and radiographic outcome was achieved at the 15-month follow-up. CONCLUSION: This case highlights the unique features of the "floating fibula" injury and shows that reduction and intraoperative assessment may be more challenging than a typical Maisonneuve injury.

Outcomes of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture Using Uncemented Stems, a Single Center Study.

Background: To evaluate the clinical, functional, radiographic, and survival outcomes in patients undergoing reverse total shoulder arthroplasty (RSA) with uncemented stem fixation for proximal humerus fractures. Materials and Methods: This is a retrospective cohort study that evaluated a consecutive series of patients with proximal humerus fractures undergoing RSA. Clinical data, radiographs, and re-operation rates were reviewed in patients selected for uncemented stem fixation. The same parameters were compared to the remainder of the cohort undergoing cemented stem fixation. Results: The uncemented group (n = 16, median total follow-up = 108 weeks) and cemented group (n = 12, median total follow-up = 223 weeks, p = 0.110) did not differ statistically in pre-operative demographic, post-operative outcomes or incidence of complications. Two patients (12.5%) in the uncemented group required a reoperation (Week 52 and 180) versus none in the cemented group. Conclusion: Uncemented stem fixation in RSA for proximal humerus fractures does not yield worse results than cemented stem fixation in properly selected patients. Prospective non-inferiority trials comparing outcomes are recommended.

Effects of biochar and N-stabilizers on greenhouse gas emissions from a subtropical pasture field applied with organic and inorganic nitrogen fertilizers.

Pasturelands contribute significantly to the global CO2, CH4 and N2O emissions. These gas emissions are influenced by the amount and type of N-fertilizers applied and local climate. Recent studies showed potential of biochar and N-stabilizer compounds in minimizing CO2, CH4 and N2O emissions by regulating N-release from N-fertilizers. The present study was aimed at determining and comparing the effects of biochar and N-(n-butyl) thiophosphoric triamide + dicyandiamide (N-stabilizer) on CO2, N2O and CH4 emissions from a pasture fertilized with cattle manure or urea. The study was conducted during 2015 and 2016 in an established bermudagrass (Cynodon dactylon L. Pers.). Treatments consisted of combination of N-sources (manure, and urea) and two mitigation technologies [pine hardwood biochar (BC) and N-stabilizer] along with control. Emissions of GHGs were measured from each plot using static chamber systems. Both BC and N-stabilizer applications with manure applied to the hay field significantly decreased N2O emissions by 42% and 45%, respectively, in the year-2, and emission factors compared to manure only treatment. Addition of N-stabilizer to urea had significantly decreased N2O emissions compared to urea alone, while BC had statistically insignificant effect although numerically lowered N2O emissions in both the years. Application of manure to the soil resulted in significantly higher CO2 emissions in both years and CH4 emissions in 2016 compared to unfertilized soil. Urea application had significant effect on CO2 emissions in 2016, while no effect on CH4 emissions compared to control. Application of either biochar or N-stabilizer did not significantly affect CO2 and CH4 emissions.

The impact of reducing signal acquisition specifications on neuronal spike sorting.

Measuring electrical potentials in the extracellular space of the brain is a popular technique because it can detect action potentials from putative individual neurons. Electrophysiology is undergoing a transformation where the number of recording channels, and thus number of neurons detected, is growing at a dramatic rate. This rapid scaling is paving the way for both new discoveries and commercial applications; however, as the number of channels increases there will be an increasing need to make these systems more power efficient. One area ripe for optimization are the signal acquisition specifications needed to detect and sort action potentials (i.e., "spikes") to putative single neuron sources. In this work, we take existing recordings collected using Intan hardware and modify them in a way that corresponds to reduced recording performance. The accuracy of these degraded recordings to spike sort using MountainSort4 is evaluated by comparing against expert labels. We show that despite reducing signal specifications by a factor of 2 or more, spike sorting accuracy does not change substantially. Specifically, reducing both sample rate and bit depth from 30 kHz and 16 bits to 12 kHz and 12 bits resulted in a 3% drop in spike sorting accuracy. Our results suggest that current neural acquisition systems are over-specified. These results may inform the design of next generation neural acquisition systems enabling higher channel count systems.

Recalcitrant carbon and nitrogen in agriculture soi ls with residue accumulation and fertilization under tropical conditions / Carbono recalcitrante e nitrogênio em solos com acumulação e fertilização de resíduos em condições tropicais

Soil organic matter has a strong relation to total organic carbon, and about 85% of organic carbon consists of humic substances (HS), classified as humin (HU), humic (HA) and fulvic acids (FA), and denominated as recalcitrant carbon in soil. HS are formed by complex, heterogeneous and polydisperse molecules, which have significant influence on the soil physical and chemical characteristics. The study evaluates the hypothesis that agricultural soils treated with organic residues may present higher carbon stocks as presented in forest soils. The aim of this study was to evaluate alterations in recalcitrant carbon and nitrogen stocks in Oxisol (Forest - FL, unfertilized Brachiaria - UB, and fertilized Brachiaria - FB) and Cambisol (Forest - FC, Coastcross - CC, sugarcane - CA, and silage corn - SM) at surface (0.0 - 0.1) and subsurface (0.1 - 0.2 m), in the Zona da Mata in Minas Gerais state, Brazil. Result shows that fertilization, low soil disturbance and residual removal promoted increase of C and N content in HS, being close to native forests. Both, carbon and nitrogen recalcitrant, presented reduction with soil depth. HU ranged from 10.5 to 16.7 g kg-1 and presented the highest concentration compared to FA and HA. In Oxisol, FL and FB presented the highest SH concentration and demonstrate the positive effect of fertilization on carbon stocks improving soil quality in well-managed and productive areas. While, In Cambisol, FC and CC presented higher carbon and nitrogen in HS, mainly for HU and HA fractions, and SM showed the lowest concentrations in all fractions. Our results suggest that soil managements with lower soil disturbance and residual removal promotes increasing of carbon and nitrogen in recalcitrant fraction, with concentration close to native forests. Pasture should be fertilized to improve recalcitrant carbon and nitrogen stocks, avoiding process of degradation in tropical soil. It is an important outcome due to high levels of degraded areas in Brazil caused by inadequate use of soil mainly with pasture.

A matéria orgânica do solo tem uma forte relação com o carbono orgânico total, cerca de 85% do carbono orgânico é composto por substâncias húmicas (HS), classificadas como humina (HU), ácidos húmicos (HA) e fúlvicos (FA), denominadas como carbono recalcitrante no solo. As HS são formadas por moléculas complexas, heterogêneas e polidispersas, que exercem influência significativa nas características físicas e químicas do solo. O estudo avalia a hipótese de que solos agrícolas tratados com resíduos orgânicos podem apresentar maiores estoques de carbono como os encontrados em solos florestais. O objetivo destetrabalho foi avaliar as alterações nos estoques de carbono e nitrogênio recalcitrantes em Latossolo (Floresta - FL, Brachiaria não fertilizada ­ UB, e Brachiaria fertilizada - FB) e Cambissolo (Floresta - FC, coastcross - CC, cana-de-açúcar e milho para silagem - SM) na superfície (0,0 - 0,1) e sub-superfície (0,1 - 0,2 m), na Zona da Mata em Minas Gerais, Brasil. Os resultados mostram que a adubação, a baixa perturbação do solo e a remoção dos resíduos promoveram aumento do teor de C e N na HS, estando próximos às florestas nativas. Ambos, carbono e nitrogênio recalcitrantes, apresentaram redução com a profundidade do solo. A HU variou de 10,5 a 16,7 g kg-1 e apresentou a maior concentração em relação à FA e HA. Em Latossolo, FL e FB apresentaram a maior concentração de SH e demonstraram o efeito positivo da adubação nos estoques de carbono, melhorando a qualidade do solo em áreas bem manejadas e produtivas. Enquanto, no Cambissolo, FC e CC apresentarammaiores teores de carbono e nitrogênio nas HS, principalmente nas frações HU e HA, e SM apresentou as menores concentrações em todas as frações. Nossos resultados mostram que manejos de solo com menor perturbação e remoção de resíduos promovem o aumento de carbono e nitrogênio em frações recalcitrantes, com concentração próxima às florestas nativas. A pastagem deve ser fertilizada para melhorar o estoque de carbono e nitrogênio recalcitrante, evitando o processo de degradação do solo tropical. Este é um resultado importante devido aos altos níveis de áreas degradadas no Brasil causadas pelo uso inadequado do solo,principalmente com pastagens.

Deaths due to thermal injury from cigarette smoking in a 13-year national cohort of nursing home residents.

OBJECTIVES: To examine the nature and frequency of deaths due to thermal injuries from cigarette smoking reported to Australian coroners and to examine the decisions which surround these deaths. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Residents dwelling in accredited nursing homes whose deaths were reported to coroners between 1 July 2000 and 30 June 2013 and attributed to thermal injuries from cigarette smoking. MEASURES: A descriptive analysis was undertaken to report socio-demographic characteristics of the deceased, medical history, mobility, level of observation, safety equipment provided/used, nursing home location, decision to smoke, timing of incident, time from incident to death, incident findings, mechanism of death, formal reports attached and coroners' recommendations. RESULTS: Ten deaths of nursing home residents due to thermal injury from cigarette smoking were reported in Australia over a 13-year period. The median age of residents was 78 years (IQR = 15.25); nine residents were female and one was male. Seven residents had impaired mobility with three residents being wheelchair bound and one resident bed bound. None of the residents were supervised by staff while they smoked, and none of the residents utilised any safety equipment to minimise harm. Burns/thermal injury was the mechanism of harm in most cases. CONCLUSIONS: This national study confirms that thermal injuries caused by cigarette smoking in nursing homes result in fatalities, particularly in the absence of supervision. It also demonstrates the complex tension arising from balancing autonomy with safety. IMPLICATIONS FOR PRACTICE: Nurses and aged care practitioners should endeavour to give effect to each resident's wishes while mitigating the risk of harm. The supervision requirements for cigarette smoking residents should be tailored to the needs of individual residents and staff should try to ensure that residents who require supervision receive it.

Managing risk for aging patients in long-term care: a narrative review of practices to support communication, documentation, and safe patient care practices.

Resident safety and welfare in long-term care (LTC) is being redefined as the focus shifts to promoting an optimal quality of life especially in LTC. Achieving this requires contemporary practice to improve the organization and staff's ability in identifying, communicating, documenting, and managing the risks that arise from the choices a person makes in pursuit of a better quality of life. This article is a narrative realist style review examining the issues of how to manage risks for older residents living in LTC. The issues are examined in six stages: context, identifying, communicating, documenting, enacting, reviewing and reflecting on how choices are made and risks managed. It is important for individuals to be supported in making an informed choice - this requires identifying, providing, and communicating the available options and the potential consequences. Documenting consent, perhaps with formal risk agreements, provides clarity for all involved and assists in determining how and who is responsible for enacting choices. Reviewing and reflecting upon the decisions and actions to enact choices are familiar to prudent LTC managers who implement and monitor robust governance systems. Learning from these experiences is essential to better meet individual resident, staff, organizational, and community expectations. Improving practice at each of the six steps should reduce adverse professional and legal repercussions and enable the resident, families, and staff to better cope with respecting choices when a known harmful outcome eventuates.

Variations in death notification of nursing home residents to Australian Coroners.

OBJECTIVES: To examine the impact of changes to the reporting requirements in coronial legislation on the nature and frequency of nursing home resident deaths reported to Coroners. DESIGN: National retrospective study of a population cohort of nursing home resident deaths. SETTING: Accredited Australian nursing homes between July 2000 and June 2013. PARTICIPANTS: Residents who died in nursing homes accredited by the Aged Care Standards and Accreditation Agency reported to Coroners. MAIN OUTCOME MEASURES: We explored three death-reporting models in the nursing home setting: comprehensive model, selective 'mechanism of death' model and selective 'age of death' model. These models were examined by manner of death subgroups: natural, falls-related and other external causes using the outcome measure of deaths notified to the Coroner per 1000 residents. We used an interrupted time series analysis using generalised linear regression with a negative binomial probability distribution and a log link function. RESULTS: The comprehensive model showed the proportion of reportable deaths due to natural causes far exceeded those from falls and other external cause. In contrast, the selective notification models reduced the total number of reportable deaths. Similarly, the selective 'age of death' model showed a decline in the reportable external cause deaths. CONCLUSIONS: Variation in the causes, locations and ages of persons whose deaths are legally required to be notified to Coroners impacts the frequency and nature of deaths of nursing home residents investigated by Coroners. This demonstrates that legislation needs to be carefully framed and applied to ensure that the prevention mandate of Coroners in Australia is to be achieved.

Optimising residential respite care in nursing homes: Current problems and solutions for a better future.

AIM: To examine whether residential respite care increases the risk of harm to older people and suggest directions for future research and policy. BACKGROUND: Respite care is a vital part of the aged care system that supports dependent older people and their caregivers to continue residing in the community. There is little research determining whether an older person experiences harm from residential respite. METHODS: This commentary considered conceptual research and existing empirical evidence to determine whether the risk of death was greater during residential respite care for older people. RESULTS: Evidence on the mortality in contemporary respite care is extremely limited with the majority of studies published almost 20 years ago and focussing on planned respite admissions. The evidence available has limitations in design and lacks comparison groups and key variables relevant to outcome and risk stratification. Nonetheless, it provides a theoretical basis supporting that the potential for harm and mortality may be increased during a residential respite care admission. CONCLUSIONS: The question of whether residential respite care presents significant risks to older people remains unanswered. Substantial changes in practice since the last century make the existing empirical evidence redundant. However, there is much to learn by reflecting on omissions of important details from these studies. IMPLICATIONS FOR PRACTICE: A full and objective understanding of the harm associated with residential respite care for older people requires reopening and re-examining this area with robust research. Informed professional nursing practice and policy requires an empirical evidence basis to residential respite care.

A greater risk of premature death in residential respite care: a national cohort study.

Background: the demand for residential respite care for older persons is high yet little is known about the occurrence of harm, including death in this care setting. Objective: to compare the prevalence and nature of deaths among residential respite to permanent nursing home residents. Design: retrospective cohort study. Setting: australian accredited nursing homes between 1 July 2000 and 30 June 2013. Subjects: respite and permanent residents of Australian accredited nursing homes, whose deaths were investigated by Australian coroners. Methods: prevalence of deaths of nursing home residents were calculated using routinely generated coronial data stored in the National Coronial Information System. Odds ratios (OR) were calculated to examine residency (respite or permanent) by cause of death. Results: of the 21,672 residents who died during the study period, 172 (0.8%) were in respite care. The majority of deaths were due to natural causes. A lower proportion occurred in respite (n = 119, 69.2%) than permanent (n = 18,264, 84.9%) residents. Falls-related deaths in respite as a proportion (n = 41, 23.8%) was almost double that in permanent care (n = 2,638, 12.3%). Deaths from other injury-related causes (such as suicide and choking) were significantly more likely in respite residents (OR = 2.0; 95% confidence interval: 1.1-3.6; P = 0.026). Conclusions: this is the first national cohort study examining mortality among respite residents. It established that premature, injury-related deaths do occur during respite care. This is the first step towards better understanding and reducing the risk of harm in respite care.

Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process.

OBJECTIVE: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. METHOD: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. RESULTS: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. DISCUSSION: Mortality in the immediate period following admission may not simply be due to an individual's health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors.

Complicated Total Knee Arthroplasty in a Patient with Klippel-Trenaunay-Weber Syndrome: A Case Report.

CASE: A 66-year-old Caucasian man with Klippel-Trenaunay-Weber syndrome (KTWS) presented with chronic changes related to the KTWS, along with worsening pain and motion associated with residual damage from an episode of spontaneous septic arthritis that occurred 1 year prior. He underwent total joint arthroplasty with a rotating hinged knee implant. CONCLUSION: Arthroplasty is a treatment option for patients with KTWS; however, there are risks that must be considered. This case report outlines the management of a patient with KTWS and a history of septic arthritis.

Mortality in Nursing Homes Following Emergency Evacuation: A Systematic Review.

OBJECTIVES: To determine the risk associated with mortality among nursing home residents within 6 months following an evacuation because of man-made or natural disasters. DESIGN: A systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement. SETTING: All peer-reviewed studies published in English, French, German, or Spanish between January 1, 2000 and December 31, 2015, examining mortality within 6 months of disaster evacuation from a nursing home. MEASUREMENTS: Extracted information included study and population characteristics, mortality measures, and risk factors. Studies were examined using the disaster management cycle that considers preparedness, response, recovery, and mitigation. RESULTS: The 10 included studies were published between 2010 and 2015 with one-half conducted in the United States. Only 3 studies detailed the preparedness stage, and 4 detailed the response stage of the disaster management cycle. Mortality was measured as an indicator of recovery and was found to be elevated at 1 month [from 0.03% (n = 1088) to 10.5% (n = 75)] 3 months [from 0.08% (n = 3091) to 15.2% (n = 197)], and 6 months [from 14.9% (n = 263) and 16.8% (n = 22)] postevacuation compared with pre-evacuation and sheltering-in-place. Studies identified vulnerable residents as being over 80 years of age, frail, dependent, male residents with multiple comorbidities and, made recommendations on disaster preparedness. CONCLUSIONS: There is little research on the effects of evacuation on nursing home residents, which is surprising considering the elevated risk of mortality postevacuation. Evacuation seems to have a negative effect on the survival of nursing home residents independent of the effect of the disaster. Standard evacuation procedures may be less applicable to this vulnerable population because of extra challenges they face in disasters.

Missed Opportunities to Prevent Workplace Injuries and Fatalities.

Prevention efforts, especially in high-income countries, have reduced work-related death and injury. Despite this, the global incidence of workplace fatalities remains unacceptably high with approximately 317 million incidents occurring on the job annually. Of particular concern is the occurrence and re-occurrence of incidents with a similar cause and circumstance, such as fatalities occurring in agriculture and transport industries. Efforts to reduce workplace fatalities include surveillance and reporting, investigation, and regulation. Challenges remain in all three domains, limiting the prevention of work-related injuries and deaths. In this commentary, the nature of these challenges and recommendations on how to overcome them are described. Examples of incidents of workplace injury and death, as well as injury prevention efforts are provided to ensure contextual understanding. Reflecting on the present enhances key stakeholders, policy and decision-makers' understanding of the opportunities to reducing harm and the associated human, and economic and legal costs.

Chronic disease self-management support for persons with dementia, in a clinical setting.

The burden of chronic disease is greater in individuals with dementia, a patient group that is growing as the population is aging. The cornerstone of optimal management of chronic disease requires effective patient self-management. However, this is particularly challenging in older persons with a comorbid diagnosis of dementia. The impact of dementia on a person's ability to self-manage his/her chronic disease (eg, diabetes mellitus or heart failure) varies according to the cognitive domain(s) affected, severity of impairment and complexity of self-care tasks. A framework is presented that describes how impairment in cognitive domains (attention and information processing, language, visuospatial ability and praxis, learning and memory and executive function) impacts on the five key processes of chronic disease self-management. Recognizing the presence of dementia in a patient with chronic disease may lead to better outcomes. Patients with dementia require individually tailored strategies that accommodate and adjust to the individual and the cognitive domains that are impaired, to optimize their capacity for self-management. Management strategies for clinicians to counter poor self-management due to differentially impaired cognitive domains are also detailed in the presented framework. Clinicians should work in collaboration with patients and care givers to assess a patient's current capabilities, identify potential barriers to successful self-management and make efforts to adjust the provision of information according to the patient's skill set. The increasing prevalence of age-related chronic illness along with a decline in the availability of informal caregivers calls for innovative programs to support self-management at a primary care level.