Dementia In Canada Research Articles

Prevalence and population attributable fractions of potentially modifiable risk factors for dementia in Canada: A cross-sectional analysis of the Canadian Longitudinal Study on Aging.

We investigated the prevalence and population attributable fraction (PAF) of 12 potentially modifiable risk factors for dementia in middle-aged and older Canadians. We conducted a cross-sectional study of 30,097 adults aged 45 to 85 with baseline data from the Canadian Longitudinal Study on Aging (2011‒2015). Risk factors and associated relative risks were taken from a highly cited systematic review. We calculated the prevalence of each risk factor using sampling weights. Individual PAFs were calculated both crudely and weighted for communality, and combined PAFs were calculated using both multiplicative and additive assumptions. Analyses were stratified by household income and repeated at CLSA's first follow-up (2015‒2018). The most prevalent risk factors were physical inactivity (63.8%; 95% CI, 62.8-64.9), hypertension (32.8%; 31.7-33.8), and obesity (30.8%; 29.7-31.8). The highest crude PAFs were physical inactivity (19.9%), traumatic brain injury (16.7%), and hypertension (16.6%). The highest weighted PAFs were physical inactivity (11.6%), depression (7.7%), and hypertension (6.0%). We estimated that the 12 risk factors combined accounted for 43.4% (37.3‒49.0) of dementia cases assuming weighted multiplicative interactions and 60.9% (55.7‒65.5) assuming additive interactions. There was a clear gradient of increasing prevalence and PAF with decreasing income for 9 of the 12 risk factors. The findings of this study can inform individual- and population-level dementia prevention strategies in Canada. Differences in the impact of individual risk factors between this study and other international and regional studies highlight the importance of tailoring national dementia strategies to the local distribution of risk factors.

Operationalizing the Intolerable Suffering Criterion in Advance Requests for Medical Assistance in Dying for People Living with Dementia in Canada.

In Canada, there is interest in expanding medical assistance in dying (MAID) to include advance requests (AR) for people living with dementia (PLWD). However, operationalizing the intolerable suffering criterion for MAID in ARs for PLWD is complicated by the Canadian legal context-in which MAID is understood as a medical intervention and suffering is conceptualized as subjective-and the degenerative nature of dementia. ARs that express a wish to receive MAID when the PLWD develops pre-specified impairments are problematic because people are unlikely to accurately predict the conditions that will cause intolerable suffering. ARs that express a wish to receive MAID when the PLWD exhibits pre-specified behaviors that likely represent suffering are problematic because they are inconsistent with the subjective conceptualization of suffering. Further research is required to determine whether adopting an objective conceptualization of suffering is justified in these cases and, if so, how to reliably identify intolerable suffering in PLWD.

THE MANY FACES OF DEMENTIA IN CANADA: EXAMINING SEX, ETHNICITY, AND AGE OF ONSET IN THE LANDMARK STUDY

Abstract With the rapidly increasing size of the dementia population, it is important to enhance our understanding of the similarities and differences that are found across the people living with condition. This work takes a closer look at the many faces of dementia in Canada by highlighting the diversity that is found within the national population projections for dementia. To conduct these forecasts, a simulation model was developed using demographic characteristics and risk factors for dementia to estimate the numbers of people living with dementia in Canada from 2020-2050. From the results of the Landmark Study, we will highlight findings related to sex, Indigenous Peoples, ethnic origins, and young-onset dementia. In 2020, 61.3% of dementia diagnoses were in females and this sex ratio is projected to stay constant over the three decades. For Indigenous Peoples of Canada, dementia numbers are estimated to increase by 273% (2020: 10,800; 2050: 40,300). People of Asian origin will increase from 8% of people living with dementia in 2020 to 24% by 2050. The changes are driven both by future immigration, and by people who have already immigrated to Canada in the past few decades. The Landmark Study also projects that there could be over 40,000 people under the age of 65 living with dementia in Canada by 2050.These findings illustrate the changing landscape of people living with dementia in Canada. These demographic characteristics, as well as other distinctions across population groups, profoundly affect the way in which dementia is experienced and their care needs.

CASE SCENARIOS OF CANADIAN MEDIC-ALERT SUBSCRIBERS WITH DEMENTIA WHO GO MISSING

Abstract With the increasing prevalence of dementia worldwide, it is expected that incidences of getting lost and going missing among persons living with dementia due to wayfinding challenges will also increase. Despite this, there is currently a gap in accessible education materials specific to risk factors and incidents of getting lost and going missing, aimed at first responders and family care partners. Case scenarios can effectively convey the circumstances of recurring events while also accounting for lived experiences. The purpose of this project was to develop case scenarios informed by real-life missing incidents that involve persons living with dementia in Canada. Qualitative description and conventional content analysis were used to analyze summary notes of missing incidents (n=515) obtained from Medic-Alert Foundation Canada hotline database. Summary notes contained: demographics of the missing person, their living situation and circle of support, events leading up to incident, by whom and where they were found, their health condition, and how they were re-united with their care partners. Case scenarios were developed that reflected the common (e.g., going missing while on foot, being found on the street) as well as less common (e.g., going missing while driving, being found seriously injured). Five experts (person living with dementia, care partner, health care professional, support providers) reviewed these scenarios to ensure relevance. Case scenarios can raise awareness of the circumstances encountered during missing incidents. The scenarios can be used by first responders and care partners to learn how to respond to missing incidents and receive support.

The Many Faces of Dementia in Canada: Findings from the Landmark Study

AbstractBackgroundWith the rapidly increasing size of the dementia population, it is important to get a better understanding of the similarities and differences that are found across the people living with dementia. This work expands on the first report from the Landmark Study and takes a closer look at the many faces of dementia in Canada by highlighting some of the diversity that is found within the national projections for dementia.MethodUsing the Canadian Centre for Economic Analysis’s socio‐economic statistical analysis platform, a simulation model was developed using demographic characteristics and risk factors for dementia to forecast the numbers of people living with dementia in Canada from 2020‐2050. Here, we will examine findings related to sex, Indigenous Peoples, ethnic origins, and young‐onset dementia.ResultIn 2020, 61.3% of dementia diagnoses were in females and this sex ratio is projected to stay relatively constant over the three decades. By 2050, 1.08 million females and 637,000 males are projected to be living with dementia. For Indigenous Peoples of Canada, dementia numbers are estimated to increase by 273% (2020: 10,800; 2050: 40,300). By 2050, the ethnic background of people living with dementia will be quite different than today. People of Asian origin will increase from 8% of people living with dementia in 2020 to 24% by 2050. The changes are driven both by future immigration, and by people who have already immigrated to Canada in the past few decades. While most cases of dementia are found in older age groups, by 2050, the Landmark Study projects that there could be over 40,000 people under the age of 65 living with dementia in Canada, compared to the 28,000 in 2020.ConclusionThis study illustrates the changing landscape of dementia in Canada. The characteristics examined in this study, as well as other distinctions between people, can profoundly affect the way in which dementia is experienced and their care needs. When it comes to these differences, we propose that the best way forward is to examine them, generate evidence, listen closely to the recommendations that come from these communities, and collectively advocate for systemic change.

What are the most prevalent combinations of modifiable dementia risk factors that can be targeted in multidomain lifestyle intervention in Canada?

AbstractBackgroundNot all risk factors have the same weight in dementia development, and the combinations of common risk factors differs across individuals and populations. The goal of this study is to estimate the potential population impact of modifiable risk factors for dementia in Canada, and to identify the combinations of the modifiable risk factors that could prevent many dementia cases in Canadian adults.MethodThis is a secondary analysis of data from the Canadian Longitudinal Study on Aging Comprehensive Cohort (n = 30,009). The prevalence and population attributable fraction (PAF) of 12 modifiable lifestyle risk factors established in the Lancet Commission Report 2020 were calculated using baseline data. The prevalence of every possible dyad, triad, and tetrad combination of the risk factors was estimated. All analyses were stratified by 2 sex strata (male, female) and 4 age strata (45‐54, 55‐64, 65‐74, 75+).ResultThe combined PAF of the 12 lifestyle risk factors was 49% in the Canadian population. The single risk factors that contributed the most were physical inactivity (11.3%), hearing loss (6.9%), and obesity (6.9%) in Canada, whereas social isolation (0.4%), alcohol (1.1%), and smoking (1.4%) had substantially smaller effects (Table 1). The most prevalent risk factor dyad was physical inactivity and sleep disturbance (34%). Obesity, physical inactivity, and sleep disturbance was the most prevalent risk factor triad (14%). The tetrad of hearing loss, obesity, physical inactivity, and sleep disturbance had the highest prevalence (4.9%). The prevalent risk factor combinations were similar in the two younger age groups and both sexes, but not in the two older age groups (Table 2).ConclusionNearly 50% of dementia cases in Canada can be prevented by modifying 12 lifestyle risk factors. The most prevalent combinations of risk factors differ before and after the age of 65, but not by sex. The most prevalent risk factor combinations consist of physical inactivity, sleep disturbance and obesity in the two younger age groups, and hearing loss, sleep disturbance and obesity in the two older age groups. These findings may help strategically target tailoring multidomain dementia intervention programs to have the greatest impact in the Canadian population.

Situating support for people living with rarer forms of dementia

BackgroundAwareness of a multitude of diseases that can cause neurodegenerative decline and their unique symptom profiles in the dementia care and support sectors remains limited. Obtaining an accurate diagnosis and post-diagnostic care and support is a challenge for many people and their families. As part of a larger study examining multi-component forms of support for people living with rarer dementias, the aim of this present study was to examine how rare dementia was situated within the complex social groupings, their organization and embedded discursive constructions that broadly form dementia care and support delivery.MethodsAdopting a situational analysis approach, we undertook an examination of public documents and organizational websites within the support sector for people living with dementia in Canada, England, and Wales. We also surveyed professionals to further explore the situation at the point of care and support delivery. Consistent with our approach, data collection and analysis occurred concurrently including the development of a series of analytic maps.ResultsRecognizing the complexities within the situation, our findings provided new insights on the situated structures for support action and the discursive representations that illuminate both the limitations of the current support landscape and possibilities for a more flexible and tailored rare dementia support. Alongside, the predominant universal versus tailored support positionings within our data reinforced the complexity from which a promising new social space for people living with rarer dementias is being cultivated.ConclusionsThe social worlds engaged in supportive action with people living with rare dementia are less visible within the shadow of a universally constructed dementia support milieu and appear to be negotiated within this powerful arena. However, their evolving organization and discursive constructions point to an emerging new social space for people living with rarer conditions.

Can we improve care of people with mild cognitive impairment or dementia in Canada?

Can we improve care of people with mild cognitive impairment or dementia in Canada?

Canada’s changing dementia landscape: Preliminary findings from The Landmark Study

AbstractBackgroundAs with many nations, the prevalence of dementia in Canada is expected to rise dramatically in the upcoming decades as the population ages. The Landmark Study is aimed at updating these estimates and the broader population changes associated for the Canadian population made in the 2010 Rising Tide Report.MethodUsing the Canadian Centre for Economic Analysis’s socio‐economic statistical analysis platform, a simulation model was developed using demographic characteristics (age, sex, ethnicity) and risk factors for dementia to forecast the burden of dementia in Canada over the next 30 years. This approach allows for comparisons across sex, ethnicity, provinces, while accounting for population dynamics including immigration. The model was also used to examine how a delay in incidence (1‐year, 5‐years, 10‐years) would impact prevalence and incident cases.ResultAs expected, the model forecasts the number of Canadians with dementia to more than double in the next 30 years: 493,718 (2020; 59.6% female) to 1,296,707(2050; 61.2% female; Figure 1). With changing immigration patterns, the ethnic background of people with dementia will be quite different than today. People with Asian origin could increase from 8% of people with dementia today to 24% by 2050 (Figure 2). The changes are driven both by future immigration, and people who have already immigrated to Canada in the past. Delays in onset of 1 year would avoid over 300K cases, whereas a deferred incidence of 10 years would bring Canadian dementia rates to lower than where it is today (Figure 3). With the increase in prevalence of dementia, comes an increase in the number of informal caregivers and the number of hours providing care to persons living with dementia. The number of informal caregivers in 2020 (349,551; 472.6 million hours/year) is projected to increase in 2050 to 1,005,815 (1,386 million hours/year; Figure 4).ConclusionThis study forecasts rising dementia prevalence in Canada, illustrates the changing landscape of ethnicity in Canadians living with dementia, and estimates the population‐level impacts of interventions that delay onset of dementia would have on prevalence, incidence, and informal care.

Policy programs and service delivery models for older adults and their caregivers: Comparing three provinces and two states.

Despite an increase in prevalence of complex chronic conditions and dementia, long-term care services are being continuously pushed out of institutional settings and into the home and community. The majority of people living with dementia in Canada and the United States (U.S.) live at home with support provided by family, friends or other unpaid caregivers. Ten dementia care policy programs and service delivery models across five different North American jurisdictions in Canada and the U.S. are compared deductively using a comparative policy framework originally developed by Richard Rose. One aim of this research was to understand how different jurisdictions have worked to reduce the fragmentation of dementia care. Another aim is to assess, relying on the theory of smart policy layering, the extent to which these policy efforts 'patch' health system structures or add to system redundancies. We find that these programs were introduced in a manner that did not fully consider how to patch current programs and services and thus risk creating further system redundancies. The implementation of these policy programs may have led to policy layers, and potentially to tension among different policies and unintended consequences. One approach to reducing these negative impacts is to implement evaluative efforts that assess 'goodness of fit'. The degree to which these programs have embedded these efforts into an existing policy infrastructure successfully is low, with the possible exception of one program in NY.

Comparative Analysis of Dementia Care Programs and Delivery Models

Dementia has significant social and economic impacts for those living with dementia and their caregivers. Despite an increase in prevalence of complex chronic conditions and dementia, long-term care services are continuously pushed out of institutional settings and into the home and community. The majority of people living with dementia in Canada and the United States (U.S.) live at home with support provided by family, friends, or other unpaid caregivers. Ten dementia care programs and service delivery models across five different North American jurisdictions in Canada and the U.S. are compared using a deductive analytical approach using a comparative policy framework developed by Richard Rose. The policy efforts included in this research attempt to improve health system flow and access for vulnerable populations. One common theme among all jurisdictions are long-standing institutional barriers that can make change difficult. These barriers can prevent the ability for systems to be flexible and adapt to meet the changing needs of populations. Incrementalism is often considered an appropriate approach to health system reform. Yet, incremental change efforts lead to policy layers and these layers can lead to tension between different policy mixes and unintended consequences. These programs were introduced in a manner that did not fully consider how to patch current structures and risk creating further system redundancies. One approach to reduce this risk is to combine evaluative efforts that assess ‘goodness of fit’. The degree to which these programs have embedded these efforts successfully is low, with the possible exception of DSRIP from NY.

Monitoring dementia and stroke comorbidity in Canada: Prevalence and mortality time trends among individuals aged 65+, from 2003–2004 to 2016–2017

AbstractBackgroundDementia and stroke are debilitating and interrelated conditions. This study describes the time trends in prevalence and mortality of comorbid stroke and dementia in Canada, among individuals aged 65+.MethodUsing data from the Canadian Chronic Disease Surveillance System (CCDSS) for Canadians aged 65+, Joinpoint analyses were conducted to estimate change over time (2003–2004 to 2016–2017) in the age‐standardized prevalence and all‐cause mortality of comorbid dementia and stroke. Validated case definitions were applied to longitudinal CCDSS linked administrative health data to identify comorbid cases (regardless of the sequence of disease identification). Diagnosed cases for both conditions were identified since 1996–1997, but a run‐in period was applied until 2003–2004 to allow a better capture of prevalent cases. Time trends were significant (unless otherwise noted), but differences between sexes were not significant.ResultFrom 2003–2004 to 2016–2017, the age‐standardized prevalence of the comorbidity increased from 1.4% (∼64,000 individuals) to 1.7% (∼110,000 individuals), representing an average annual percent change (AAPC) of 1.1% (females: 1.0%; males: 1.3%). The increase was more pronounced at the beginning of the period and among those aged 80‐84, 85‐89 and 90+. In contrast, during the same period, the age‐standardized prevalence rate among individuals with dementia/without stroke increased with an AAPC of 1.5% (females: 1.5%; males 1.7%), but only with an AAPC of 0.2% (not statistically significant) among those with stroke/without dementia.Following the general declining mortality pattern observed in the Canadian population, the age‐standardized all‐cause mortality rate for those with the comorbidity decreased (AAPC ‐1.4%; females: ‐1.2%; males: ‐1.7%), with a steeper reduction over the first portion of the period. However, Canadians without the comorbidity benefited from a greater decline in all‐cause mortality (AAPC ‐2.2%; females: ‐2.1%; males: ‐2.5%).ConclusionThis surveillance analysis explores the prevalence and all‐cause mortality of dementia and stroke comorbidity, by highlighting its evolution over time in older Canadians. Although further research is needed to explain the drivers of these trends, such public health surveillance data can inform health care policies and programs. Other countries could consider the CCDSS model for enhancing surveillance of dementia and its comorbidities.

Justification for Integrated Care of Dementia and Presbycusis: Focused on National Dementia Policy

Dementia management has become one of essential factors in the national policy globally in terms of the elderly health care service. In the brief communication, we compared various national reports from other countries to see whether current care service for the dementia had integrative approach for the patients with hearing loss in Korea. We also discussed a need of systematic hearing care for the elderly with dementia who was also a suspected case of aged-related hearing loss because many studies had confirmed that untreated hearing loss has a negative effect on dementia and vice versa. After analyzing the national policy from several countries, we found that the systems had been well established to screen dementia patients by using various clinical tests in UK, Canada, and Japan who provided appropriate services by classifying types of the dementia. Remarkably, the hearing test was included as the testing protocol for the dementia in Canada and the experts such as speech pathologists and music therapists had worked in a non-pharmacotherapy program for the elderly with dementia in France. Unfortunately, the dementia policy of Korea needs to be refined when considering the hearing care/management in that the integrated management of hearing and dementia are important. In addition, the clinicians who work for the dementia care home need to know audiological knowledge. Since the auditory training and rehabilitation for the elderly can reduce increased rate of cognitive decline, we strongly recommend that auditory training should be a part of the cognitive rehabilitation programs in the dementia care home.

A story of innovation: Building a national surveillance system for dementia in Canada

AbstractBackgroundAccurately capturing cases of dementia at the population‐level is complex, given the nature of the condition. Over the past decade, Canada has focused on this challenge, evolving and improving dementia surveillance in collaboration with multiple stakeholders.MethodOriginally based on self‐reported data, dementia data in Canada were limited to the prevalence of the condition and were significantly underestimating its burden. Canada sought to develop an innovative and systematic approach to enhance dementia surveillance by, initially, undertaking the National Population Health Study of Neurological Conditions and, then, exploring the feasibility of using linked health administrative data. The Canadian Chronic Disease Surveillance System (CCDSS), a network of provincial/territorial surveillance systems supported by the Public Health Agency of Canada, since became the core platform to support national reporting on dementia.ResultA validated case definition, incorporating data from hospitalizations, physician claims and drug prescriptions, was developed and applied to the CCDSS linked databases. As a result, since 2016, national and provincial/territorial estimates of dementia incidence, prevalence, and mortality over time (dating back to 2002) are released annually. With the recent adoption of Canada’s National Dementia Strategy in 2019, other innovative methods are being explored to enhance surveillance, including: analysing the trajectory of the condition, with the development of comorbidities and impacts on health outcomes; creating new data linkages to enrich the sociodemographic information on individuals living with dementia; assessing the feasibility to monitor early onset dementia.ConclusionUtilizing the unique capacity of the CCDSS, a new national surveillance system for dementia in Canada has been implemented. The evolution and innovation of dementia surveillance over the course of the past decade can provide valuable lessons for the surveillance of dementia and other complex conditions in other countries.

450 - Exploring staff perspectives on the role of physical environment in dementia care facilities in Sweden and Canada

This study explored staff perceptions of the role of physical environment in dementia care facilities in affecting resident’s behaviors and staff care practice. We used focus group method (Krueger & Casey, 2000; Krueger, 1998) to elicit staff’s shared perceptions on the impact of the physical environment on residents’ behaviors and on their own care practice. A total of 24 staff members from four facilities, two in Sweden and two in Canada, participated. Discussions in the focus groups generated rich and inter-subjective accounts via dynamic and interactive exchange among participants. Participants were explained that the researchers were particularly interested in three aspects of the physical environment: architecture or spatial layout of the setting (e.g. corridor length, bath room size, etc.), interior design aspects (e.g. lighting, flooring, furnishing, etc.) and sensory aspects (e.g. noise, smell, tactile properties, etc.). Staff in both countries reported similar physical environmental characteristics that enabled and hindered them from delivering good care. This study yielded three environmental themes that have a substantial effect on the social interaction and care practice: design ambience, space arrangement, and sensory stimuli. The deficits in the physical environmental characteristics prevented staff from providing effective person-centred care. Our findings identified substantial differences between the facilities of the two countries, although it is possible that greater differences might exist between the range of facilities in each country about the quality of environment and care. The quality of environment contributed to a high job satisfaction reported by staff in Sweden. The unsupportive and problematic features of the physical environment seemed to be the primary factor that triggers agitation among the residents with dementia in Canada.

Dementia Care in Canada: Nursing Recommendations.

ABSTRACTThe prevention and management of dementia in Canada is at a crossroads. Despite the low diagnosis rates, the number of persons living with dementia continues to increase. Yet, Canada's health care policies have resulted in more people living with dementia living at home, and with most of their care being provided by family, friends, and significant others. This Policy Note provides an overview of a joint submission from the Canadian Gerontological Nursing Association (CGNA) and the Registered Nurses' Association of Ontario (RNAO) to the Standing Senate Committee on Social Affairs, Science, and Technology. This article outlines the background and recommendations in five key areas of dementia care in Canada: health system resources, education and training of health providers, housing, care partners, and the integration of health and social supports. Based on these five key areas, a number of health and social policy interventions are discussed.

Utilizing population-based clinical and administrative data to estimate the incremental healthcare costs of dementia and frailty among community-residing care recipients.

IntroductionCurrent cost estimates for dementia in Canada are lacking and no studies have yet to examine the incremental healthcare costs associated with both dementia and frailty, despite evidence of increasing prevalence of both conditions and their bidirectional association. These data are essential for informed clinical and public policy programs.
 Objectives and ApproachUsing linked clinical and health administrative databases in Ontario, we conducted a cohort study of all long-stay home care clients aged 50+ years with a clinical assessment between April 2014 and March 2015 (n=160,209). We defined dementia using a validated algorithm, and frailty categories (robust, pre-frail, frail) using a modified frailty index from clinical assessment data. Clients were followed prospectively for 1-year, for which we obtained total- and sector-specific healthcare costs for all encounters. We calculated cost differences (in $2015CAD) between dementia-frailty groups using a survival- and covariate-adjusted cost estimator described by Manning and Basu (2010) that included dementia-frailty interactions.
 ResultsIn this population-based cohort of long-stay home care recipients, the prevalence of dementia was 26.8% and 33.3% of these clients were frail (vs. 26.9% among clients without dementia). Approximately 15% of the cohort died over the 1-year follow-up. The average 1-year estimated total health system cost was $26,965. On average, home care clients with dementia categorized as frail incurred $14,291 (SE=$139) more in charges than similar robust clients ($35,381 vs. $21,091, respectively). In contrast, frail persons without dementia incurred $12,796 (SE=$95) more in charges that similar robust clients ($33,659 vs. $20,864, respectively). Among frail persons, those with dementia incurred $1,722 (SE=$149) more in expenditures, on average. Wide variation in sector-specific costs were also observed by dementia and frailty strata.
 Conclusion/ImplicationsDementia and frailty pose significant challenges to healthcare systems. Our findings illustrate large incremental costs associated with frailty, regardless of dementia status. Further research using the linked clinical assessment and administrative data is needed to inform variations in, and to delineate key drivers of, formal healthcare and informal care costs associated with dementia and frailty.

Model diagnostics for the proportional hazards model with length-biased data

Length-biased data are frequently encountered in prevalent cohort studies. Many statistical methods have been developed to estimate the covariate effects on the survival outcomes arising from such data while properly adjusting for length-biased sampling. Among them, regression methods based on the proportional hazards model have been widely adopted. However, little work has focused on checking the proportional hazards model assumptions with length-biased data, which is essential to ensure the validity of inference. In this article, we propose a statistical tool for testing the assumed functional form of covariates and the proportional hazards assumption graphically and analytically under the setting of length-biased sampling, through a general class of multiparameter stochastic processes. The finite sample performance is examined through simulation studies, and the proposed methods are illustrated with the data from a cohort study of dementia in Canada.

Antipsychotics and dementia in Canada: a retrospective cross-sectional study of four health sectors

BackgroundAntipsychotic medications are not recommended for the management of symptoms of dementia, particularly among persons with no behavioral or psychological symptoms. We examine patterns of antipsychotic medication use among persons with dementia across health sectors in Canada, with a focus on factors related to use among those without behavioral or psychotic symptoms.MethodsUsing a retrospective cross-sectional design, this study examines antipsychotic use among adults aged 65 or older with dementia in home care (HC), complex continuing care (CCC), long-term care (LTC), and among alternate level care patients in acute hospitals (ALC). Using clinical data from January 1, 2009 to December 31, 2014, the prevalence of antipsychotic medication use was estimated by the presence of behavioral and psychotic symptoms. Logistic regression was used to identify sector specific factors associated with antipsychotic use in the absence of behavioral and psychotic symptoms.ResultsThe total prevalence of antipsychotic use among older adults with dementia was 26% in HC, 54% in ALC, 41% in CCC, and 48% in LTC. This prevalence ranged from 38% (HC) to 73% (ALC) for those with both behavioral and psychotic symptoms and from 15% (HC) to 31% (ALC) among those with no symptoms. The regression models identified a number of variables were related to antipsychotic use in the absence of behavior or psychotic symptoms, such as bipolar disorder (OR = 6.63 in CCC; OR = 5.52 in LTC), anxious complaints (OR = 1.54 in LTC to 2.01 in CCC), and wandering (OR = 1.83 in ALC).ConclusionsPotentially inappropriate use of antipsychotic medications is prevalent among older adults with dementia across health sectors. The variations in prevalence observed from community to facility based care suggests that system issues may exist in appropriately managing persons with dementia.

Analysis of Restricted Mean Survival Time for Length-biased Data

In clinical studies with time-to-event outcomes, the restricted mean survival time (RMST) has attracted substantial attention as a summary measurement for its straightforward clinical interpretation. When the data are subject to length-biased sampling, which is frequently encountered in observational cohort studies, existing methods to estimate the RMST are not applicable. In this article, we consider nonparametric and semiparametric regression methods to estimate the RMST under the setting of length-biased sampling. To assess the covariate effects on the RMST, a semiparametric regression model that directly relates the covariates and the RMST is assumed. Based on the model, we develop unbiased estimating equations to obtain consistent estimators of covariate effects by properly adjusting for informative censoring and length bias. Stochastic process theories are used to establish the asymptotic properties of the proposed estimators. We investigate the finite sample performance through simulations and illustrate the methods by analyzing a prevalent cohort study of dementia in Canada.