Public Health Sciences (School of)

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This is the collection for the University of Waterloo's School of Public Health Sciences. The School was known as the Department of Public Health and Health Systems until January 2021.

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Heart Failure in Older Persons: Considerations For The Primary Care Physician
(Canadian Geriatrics Society, 2012-04-18) Glenny, Christine; Heckman, George A.; McKelvie, Robert S.
Heart failure (HF) affects over 500,000 Canadians, with 50,000 new patients diagnosed each year. While mortality from cardiovascular diseases has progressively declined in Canada, the burden of HF is expected to continue rising as a result of population aging and improved survival of patients with other cardiovascular diseases. HF is the leading cause of hospitalization and death among those aged 65 years and over, with a mortality rate of up to 50% within 5 years of diagnosis. Elderly HF patients are complex: a recent Ontario study of home care recipients with HF found that these clients had more health instability, took more medications, and had more co-morbidities compared with other home care clients. Optimal management of HF in “complex seniors” requires that clinicians understand the interactions between HF and age-associated syndromes such as frailty, cognitive impairment, and functional decline. As the majority of Canadian patients with HF are treated by primary care providers (PCPs), this article is directed at PCPs caring for older adults with HF. It is meant as a brief overview and discusses how the Canadian Cardiovascular Society (CCS) Consensus Guidelines on HF can be applied in daily practice.
Meeting the Challenge of Managing Seniors With Multiple Complex Conditions: The Central Role of Primary Care
(Canadian Geriatrics Society, 2012-09-28) Lee, Linda; Heckman, George A.
With the aging population, primary care physicians will be increasingly challenged to manage more seniors with complex chronic conditions. The North American population aged 65 years and above is projected to increase from 14% in 2009 to 24% by 2036, and, by 2050, the average life span worldwide is expected to extend another 10 years. Three quarters of seniors have one or more chronic conditions; in one Canadian study, nearly half of patients had five or more types of chronic disease. It is well established that chronic diseases contribute to disability, diminished quality of life, as well as increased health costs. Yet currently, Canadian seniors with chronic disease receive suboptimal quality of care. Most primary care physicians do not appear able to properly manage chronic illness although most of the visits for chronic conditions are provided in primary care. Continued poor management of chronic conditions is expected to have a profound impact on health system utilization and quality of life for these persons and their families. This article reviews evidence that can help to inform the development of future programs aimed at improving care for seniors with chronic illnesses.
Understanding organizational context and heart failure management in long term care homes in Ontario, Canada
(Scientific Research Publishing, 2012-10-01) Marcella, Jill; Nadarajah, Jayanthini; Kelley, Mary Lou; Heckman, George A.; Kaasalainen, Sharon; Strachan, Patricia H.; McKelvie, Robert S.; Newhouse, Ian; McAiney, Carrie A.; Demers, Catherine; Stolee, Paul
This study examined the prevalence of Control Intervention (CI) use in adult in-patient psychiatric units/hospitals in Ontario and developed a profile of those patients who had CI use during their admission between April 2006 and March 2010. Control intervention types included mechanical/physical, chair prevents rising, acute control medications, and seclusion. The profiles of patients with control intervention use included an examination of sociodemographic, mental health service use, and mental health clinical characteristics.
Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study
(BioMed Central, 2013-06-22) Doran, Diane M.; Hirdes, John P.; Blais, Régis; Baker, G. Ross; Poss, Jeffrey W.; Li, Xiaoqiang; Dill, Donna; Gruneir, Andrea; Heckman, George A.; Lacroix, Hélène; Mitchell, Lori; O'Beirne, Maeve; White, Nancy; Droppo, Lisa; Foebel, Andrea Dawn; Qian, Gan; Nahm, Sang-Myong; Yim, Odilia; McIsaac, Corrine; Jantzi, Micaela
Background: Home care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario. Methods: A retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences. Results: The study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death. Conclusions: Our study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.
Adverse Events Associated with Hospitalization or Detected through the RAI-HC Assessment among Canadian Home Care Clients
(Longwoods Publishing, 2013-08-19) Doran, Diane M.; Hirdes, John P.; Blais, Régis; Baker, G. Ross; Poss, Jeffrey W.; Li, Xiaoqiang; Dill, Donna; Gruneir, Andrea; Heckman, George A.; Lacroix, Hélène; Mitchell, Lori; O’Beirne, Maeve; Foebel, Andrea Dawn; White, Nancy; Qian, Gan; Nahm, Sang-Myong; Yim, Odilia; Droppo, Lisa; McIsaac, Corrine
Background: The occurrence of adverse events (AEs) in care settings is a patient safety concern that has significant consequences across healthcare systems. Patient safety problems have been well documented in acute care settings; however, similar data for clients in home care (HC) settings in Canada are limited. The purpose of this Canadian study was to investigate AEs in HC, specifically those associated with hospitalization or detected through the Resident Assessment Instrument for Home Care (RAI-HC). Method: A retrospective cohort design was used. The cohort consisted of HC clients from the provinces of Nova Scotia, Ontario, British Columbia and the Winnipeg Regional Health Authority. Results: The overall incidence rate of AEs associated with hospitalization ranged from 6% to 9%. The incidence rate of AEs determined from the RAI-HC was 4%. Injurious falls, injuries from other than fall and medication-related events were the most frequent AEs associated with hospitalization, whereas new caregiver distress was the most frequent AE identified through the RAI-HC. Conclusion: The incidence of AEs from all sources of data ranged from 4% to 9%. More resources are needed to target strategies for addressing safety risks in HC in a broader context. Tools such as the RAI-HC and its Clinical Assessment Protocols, already available in Canada, could be very useful in the assessment and management of HC clients who are at safety risk.
Diagnostic data for neurological conditions in interRAI assessments in home care, nursing home and mental health care settings: a validity study
(BioMed Central, 2013-11-01) Foebel, Andrea Dawn; Hirdes, John P.; Heckman, George A.; Kergoat, Marie-Jeanne; Patten, Scott; Marrie, Ruth Ann
Background: The interRAI suite of assessment instruments can provide valuable information to support person-specific care planning across the continuum of care. Comprehensive clinical information is collected with these instruments, including disease diagnoses. In Canada, interRAI data holdings represent some of the largest repositories of clinical information in the country for persons with neurological conditions. This study examined the accuracy of the diagnostic information captured by interRAI instruments designed for use in the home care, long-term care and mental health care settings as compared with national administrative databases. Methods: The interRAI assessments were matched with an inpatient hospital record and emergency department (ED) visit record in the preceding 90 days. Diagnoses captured on the interRAI instruments were compared to those recorded in either administrative record for each individual. Diagnostic validity was examined through sensitivity, specificity and positive predictive value analysis for the following conditions: multiple sclerosis, epilepsy, Alzheimer's disease and other dementias, Parkinson's disease, traumatic brain injury, stroke, diabetes mellitus, heart failure and reactive airway disease. Results: In the three large study samples (home care: n = 128,448; long-term care: n = 26,644; mental health: n = 13,812), interRAI diagnoses demonstrated high specificity when compared to administrative records, for both neurological conditions (range 0.80 - 1.00) and comparative chronic diseases (range 0.83 - 1.00). Sensitivity and positive predictive values (PPV) were more varied by specific diagnosis, with sensitivities and PPV for neurological conditions ranging from 0.23 to 0.94 and 0.14 to 0.77, respectively. The interRAI assessments routinely captured more cases of the diagnoses of interest than the administrative records. Conclusions: The interRAI assessment collected accurate information about disease diagnoses when compared to administrative records within three months. Such information is likely relevant to day-to-day care in these three environments and can be used to inform care planning and resource allocation decisions.
The Value of Admission Clinical Data for Diagnosing Heart Failure in Long-term Care
(Canadian Geriatrics Society, 2013-12-03) Heckman, George A.; Foebel, Andrea Dawn; Dubin, Joel A.; Ng, Jennifer; Turpie, Irene D.; Hussack, Patricia; McKelvie, Robert S.
Background Heart failure (HF) is common in long-term care (LTC). Diagnostic uncertainty is important barrier to optimal HF management, stemming from inadequate health information transfer upon LTC admission. We determine the utility of admission clinical information to confirm a HF diagnosis in new LTC residents. Methods This was a prospective cohort study. From February 2004 to November 2006, information about new residents from 41 LTC homes in Ontario, Canada, was collected from residents and caregivers, and all available health records. A prior HF diagnosis was confirmed by consensus review of available data by two independent experts. Multivariate modelling was utilized to determine the utility of the admission clinical assessment in confirming a prior HF diagnosis. Results A total of 449 residents were included for analysis, aged84.3±6.5 years, and 21.6% had a prior HF diagnosis. The most useful clinical item for diagnosing HF was a “history of HF”. The final model included “history of HF’ (OR [odds ratio] 13.66, 95% CI 6.61–28.24), “fluid on the lungs” (OR 2.01, 95% CI 1.04–3.89), “orthopnea” (OR 1.76, 95% CI 0.93–3.33), “taking β-blocker” (OR 2.09, 95% CI 1.10– 3.94), “taking loop diuretics” (OR 2.11, 95% CI 1.12–3.98), and “history of coronary artery disease” (OR 2.83, 95% CI 1.42–5.64). Conclusion Elements of the clinical assessment for new LTC residents can help confirm a prior HF diagnosis. An admission history of HF is highly predictive
Geriatric Medicine Leadership of Health Care Transformation: To Be or Not To Be?
(Canadian Geriatrics Society, 2013-12-03) Heckman, George A.; Molnar, Frank J.; Lee, Linda
Geriatric Medicine is well-suited to inform and lead healthcare system redesign to address the needs of seniors with complex conditions. We posit that geriatricians must urgently consider how to “brand” Geriatric Medicine in a manner that garners active support from those outside the specialty, including how to adapt practice patterns to better meet the needs of patients and of the health-care system.
Addressing Health Care Needs For Frail Seniors In Canada: The Role of InterRAI Instruments
(Canadian Geriatrics Society, 2013-12-30) Heckman, George A.; Gray, Leonard C.; Hirdes, John P.
Fiscal pressure on the Canadian health care system results from rising numbers of frail seniors with multiple concurrent medical co-morbidities and geriatric syndromes. Improving outcomes in such seniors is contingent on a comprehensive geriatric assessment (CGA) to identify strengths and deficits and to facilitate the development of a comprehensive care plan. InterRAI instruments are standardized, reliable, and validated suites of tools to conduct CGAs; they offer several benefits, including helping clinicians identify important health issues among patients, develop appropriate care plans, and monitor patient progess. These instruments also provide several benefits beyond the bedside, including quality indicators to assess care quality, and case-mix classification algorithms to facilitate funding of health services. Finally, interRAI instruments, which are implemented in several health care settings across Canada and abroad, provide a standardized and common language that is compatible with electronic medical records and will facilitate greater integration of the health care system.
The effect of interior bezel presence and width on magnitude judgement
(Canadian Human-Computer Communications Society, 2014-05) Wallace, James R.; Vogel, Daniel; Lank, Edward
Large displays are often constructed by tiling multiple small displays, creating visual discontinuities from inner bezels that may affect human perception of data. Our work investigates how bezels impact magnitude judgement, a fundamental aspect of perception. Two studies are described which control for bezel presence, bezel width, and user-to-display distance. Our findings form three implications for the design of tiled displays. Bezels wider than 0.5cm introduce a 4-7% increase in judgement error from a distance, which we simplify to a 5% rule of thumb when assessing display hardware. Length judgements made at arm's length are most affected by wider bezels, and are an important use case to consider. At arm's length, bezel compensation techniques provide a limited benefit in terms of judgement accuracy. Copyright held by authors.
Effect of Bezel Presence and Width on Visual Search
(Association for Computing Machinery, 2014-06) Wallace, James R.; Vogel, Daniel; Lank, Edward
We investigate how the presence and width of interior bezels impacts visual search performance across tiled displays. In spite of a potential benefit from structured segmentation, we do not find significant differences in visual search time, and note a small effect size of less than 0.5% for bezel width. However, we find participants are more accurate when searching for targets spanning a bezel. Based on these findings, we suggest two implications for the design of tiled displays: 1) that additional costs associated with thinner bezels may not provide significant return on investment; and 2) that bezels may act as visual anchors, and be useful for the placement of interface elements.
Use of the interRAI CHESS Scale to Predict Mortality among Persons with Neurological Conditions in Three Care Settings
(Public LIbrary of Science, 2014-06-10) Hirdes, John P.; Poss, Jeffrey W.; Mitchell, Lori; Korngut, Lawrence; Heckman, George A.
Background: Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions. Methods: Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories. Results: CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings. Conclusions: CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.
Dysregulation of Phosphate Metabolism and Conditions Associated With Phosphate Toxicity
(Nature, 2015-06-03) Brown, Ronald B; Razzaque, Mohammed S
Phosphate homeostasis is coordinated and regulated by complex cross-organ talk through delicate hormonal networks. Parathyroid hormone (PTH), secreted in response to low serum calcium, has an important role in maintaining phosphate homeostasis by influencing renal synthesis of 1,25-dihydroxyvitamin D, thereby increasing intestinal phosphate absorption. Moreover, PTH can increase phosphate efflux from bone and contribute to renal phosphate homeostasis through phosphaturic effects. In addition, PTH can induce skeletal synthesis of another potent phosphaturic hormone, fibroblast growth factor 23 (FGF23), which is able to inhibit renal tubular phosphate reabsorption, thereby increasing urinary phosphate excretion. FGF23 can also fine-tune vitamin D homeostasis by suppressing renal expression of 1-alpha hydroxylase (1α(OH)ase). This review briefly discusses how FGF23, by forming a bone-kidney axis, regulates phosphate homeostasis, and how its dysregulation can lead to phosphate toxicity that induces widespread tissue injury. We also provide evidence to explain how phosphate toxicity related to dietary phosphorus overload may facilitate incidence of noncommunicable diseases including kidney disease, cardiovascular disease, cancers and skeletal disorders.
Identifying Feasible Physical Activity Programs for Long-Term Care Homes in the Ontario Context
(Canadian Geriatrics Society, 2015-06-30) Shakeel, Saad; Newhouse, Ian; Malik, Ali; Heckman, George A.
Background Structured exercise programs for frail institutionalized seniors have shown improvement in physical, functional, and psychological health of this population. However, the ‘feasibility’ of implementation of such programs in real settings is seldom discussed. The purpose of this systematic review was to gauge feasibility of exercise and falls prevention programs from the perspective of long-term care homes in Ontario, given the recent changes in funding for publically funded physiotherapy services. Method Six electronic databases were searched by two independent researchers for randomized controlled trials that targeted longterm care residents and included exercise as an independent component of the intervention. Results A total of 39 studies were included in this review. A majority of these interventions were led by physiotherapist(s), carried out three times per week for 30–45 minutes per session. However, a few group-based interventions that were led by long-term care staff, volunteers, or trained non-exercise specialists were identified that also required minimal equipment. Conclusion This systematic review has identified ‘feasible’ physical activity and falls prevention programs that required minimal investment in staff and equipment, and demonstrated positive outcomes. Implementation of such programs represents cost-effective means of providing long-term care residents with meaningful gains in physical, psychological, and social health.
The Effects of Photovoice as a Comprehensive School Health Intervention in Grade 5 Classrooms
(University of Waterloo, 2015-07-24) Soni, Shilpa
Objective: The primary goal of the study was to explore the effects of a photovoice intervention within a Comprehensive School Health (CSH) framework. The objectives of the study were to: understand the context of each case with respect to school readiness; understand healthy eating and physical activity influences (facilitators and barriers) within a school, from the perspective of a participating students; determine if photovoice enhanced students understanding of healthy school environments and CSH pillars; and determine key factors for success of a CSH facilitator to enhance school environments. Methods: This study employed an embedded and descriptive case study approach. One grade 5 and one 5/6 class from different schools were selected to participate in the PV intervention. Schools were purposively selected from a broader facilitated school health intervention. The study used a mixed methods approach that included both quantitative and qualitative methods of data analysis. Quantitative data sources included the Healthy School Planner survey to assess school readiness. Qualitative data sources included facilitator interviews and email exchanges with the researcher, and photovoice data (pictures and discussion transcripts). The study utilized a framework analysis approach to manage the large amounts of qualitative data. Results: Quantitative analyses showed that School 1 scored higher across all indicator scores, suggesting greater readiness for a CSH intervention. Of the 345 photovoice pictures submitted, 220 were analysed using NVivo 10. Also analysed were 3 facilitator interview transcripts, 4 photovoice non-verbatim discussion transcripts and email exchanges between the facilitator and researcher. The final analytical framework identified three overarching themes: CSH Pillars (what is happening in schools to support healthy environments); how to create healthy school environments; and barriers. Facilitator data identified key factors for successful facilitation, which included creating action plans, enhancing buy-in, communicating, enhancing engagement and supporting sustainability. At the student-level, participating photovoice students demonstrated an increase in references to CSH pillars from time 1 to time 2, suggesting an increase in engagement and understanding of CSH pillars. Finally, time and dose were identified as large barriers to successful facilitation for a school health program. Conclusion: This study suggests that student engagement interventions can enhance students’ understanding of the theoretical grounding driving a school health program (i.e., CSH Pillars). This may result in increased engagement in policy and individual-level behaviour outcomes. Furthermore, key factors for successful facilitation were identified and should be considered for future CSH facilitation. Recommendations of smaller facilitator to school doses, longer interventions and more touch points may enhance CSH results and should also be considered in future research. Finally, this study also identified lessons learned for implementing photovoice as a student engagement intervention within a CSH context.
Does a High-Fat Diet Cause Inflammation in Female Rat Brain?
(University of Waterloo, 2015-08-12) Yeung, Derrick
Obesity results from a disruption of normal energy homeostasis, and leads to a state of chronic low-grade inflammation. Given that inflammatory cytokines can disrupt synaptic activity and that obesity has been shown to cause cognitive impairment, I hypothesized that diet-induced obesity may cause an inflammatory response in regions of the brain important for learning and memory. Notably, previous diet-induced obesity studies have tended to focus on male animals, but sexual dimorphism in response to a high-fat diet (HFD) has been suggested; as a result, female rats were randomly assigned to either a control diet (CD; 10% kcal from fat), or a HFD (45% kcal from fat) at post-natal day 28. After 10 weeks, the hippocampus and pre-frontal cortex were extracted from each animal and homogenized. Immunoblotting was used to determine if a HFD affected levels of pro/anti-inflammatory cytokines, glial cells, and proteins involved in leptin signal transduction. A HFD was found to cause enhanced expression of anti-inflammatory IL-1ra in the prefrontal cortex, but no cytokine-related changes in the hippocampus (although levels of the leptin receptor and AKT/PKB were reduced in the hippocampus, but not the pre-frontal cortex). Although the data demonstrate that our protocol did not induce obvious proinflammatory changes, the possibility exists that the elevated IL-1ra levels reflect a compensatory response to an earlier period of inflammation caused by the HFD. Future work should expand on my current findings with the inclusion of male animals to allow for a direct sex comparison of the effects of the HFD. Our model could also be expanded with an immune challenge via lipopolysaccharide injection, or leptin stimulation in order to tease out potential differences not observed under basal conditions. Transgenerational effects should also be explored by examining the effects a maternal HFD may have on the expression of similar proteins in the offspring.
Marijuana Use in Canada: Patterns of Use Among Medical Marijuana Users
(University of Waterloo, 2015-08-20) Shiplo, Samantha
Research evidence supports the use of marijuana for the purpose of relieving medical symptoms and, therefore, the Canadian courts granted Canadians legal access to marijuana for medical purposes. More than 40,000 Canadians are currently approved to use medical marijuana, with an additional 400,000 Canadians reporting use of marijuana for medical purposes. During the study period, Marihuana for Medical Purposes Regulations (MMPR) was the medical marijuana regulation in effect in Canada, which allowed patients with a medical document from a physician to purchase dried marijuana from a Health Canada licensed producer. Medical marijuana regulations infer how medical marijuana is to be accessed and used. The mode of delivery—whether marijuana is smoked, vapourized, or consumed—may have important implications for potential therapeutic efficacy, as well as health risks. Anecdotal evidence suggests that the use of alternative and innovative modes of delivery is on the rise; however, there is very little evidence on current patterns of use among Canadian medical marijuana users, particularly with respect to modes of delivery. The primary objective of the current research was to examine patterns of use among Canadians using marijuana for medical purposes. The study had five specific aims: 1) To estimate the prevalence of different modes of delivery, 2) To examine perceptions and importance of various factors for different modes of delivery, 3) To estimate the prevalence of different forms of marijuana, 4) To examine the reasons for using different forms of marijuana, and 5) To assess prevalence and perceptions of different sources for obtaining medical marijuana. An overall sample of 364 approved adult Canadian medical marijuana users completed an online cross-sectional survey between April 29 and June 8, 2015. Participants were recruited through a convenience sample from Health Canada licensed producers. Nine Health Canada licensed producers from across Canada helped recruit participants mainly through email. The results showed that using a vapourizer was the most popular mode of delivery currently used (53%), even more so than smoking a joint (47%), indicating a possible increase in the use of vapourizers among approved medical users since the introduction of the MMPR. The main reason participants reported using a vapourizer was to reduce negative health consequences associated with smoking. Furthermore, current use of a vapourizer was associated with fewer respiratory symptoms (OR=1.28, 95%CI: 1.05-1.56, p=0.01) supporting that the use of vapourizers may be less harmful than smoking. Overall, 75% of participants reported using dried herb due to it’s easy accessibility, as it was the only legal form of marijuana available for purchase from licensed producers. It is important to note that accessibility of the forms of marijuana may change due to the recent revision to the MMPR allowing alternative forms of marijuana, in addition to dried herb, to be sold by licensed producers. Licensed producers, as the only legal source for obtaining medical marijuana at the time, was preferred by most approved users (44%). However, the city of Vancouver did not agree that licensed producers were a sufficient source for obtaining medical marijuana, thus, against federal medical marijuana law, decided to allow dispensaries and clubs to sell marijuana. Monitoring implications of such current and future changes to medical marijuana regulations may be beneficial to policymakers. Specifically, continuing to monitor and track medical marijuana use trends in terms of modes, forms, and sources in light of the present data. Overall, the current study addressed an important evidence gap on patterns of medical marijuana use in Canada following the introduction of the MMPR as it is critical to understand the population of medical users in order to inform marijuana policy.
Understanding care transitions from the perspectives of persons with dementia and their caregivers: A grounded theory
(University of Waterloo, 2015-08-24) Ashbourne, Jessica
Introduction: The proportion of the Canadian population living with dementia is rising. Since persons with dementia are intensive health care service users, they have many contact points with various health care providers and settings. Consequently, they may be required to navigate through an often-fragmented care system. Transitional care, which involves the coordination and continuity of care for patients moving within or between care settings, has the potential to improve transitions for persons with dementia and their caregivers. Despite being recognized as a policy and research priority, transitional care for persons with dementia and their caregivers is poorly understood. Objective: This study aimed to fill gaps in the understanding of care transitions from the perspectives of individuals with dementia and their informal caregivers through the development of a theoretical framework outlining factors that contribute to the processes care transitions in this population. Research questions addressed what was important to persons with dementia and their caregivers as they moved throughout the health care system as well as the challenges that they faced during health care system transitions. Methods: Constructivist grounded theory methods were used to build an understanding of the care transitions of persons with dementia and their caregivers. Individual or dyad interviews were conducted, recorded, and transcribed verbatim. Through initial and focused coding, themes and relationships between themes emerged and framework development began. Data collection and analysis occurred iteratively until saturation was reached. Results and Discussion: A three-part theoretical framework outlining the context, processes and influencing factors of care transitions emerged from the data. Elements of context included the existence of multiple realities and goals among those involved in transitions, the broader community, and the parallel experiences of others navigating the system. Phases of transition processes experienced during the dementia journey were a transition into the dementia care system, a continuous process of management and follow-up, and the adjustment to a new home. Four categories of influencing factors were described by participants: catalysts (causes of transitions), buffers (intermediary actions to ease future transitions), facilitators (factors that help transitions), and obstacles (factors that hinder transitions). This study suggests that transitions are complex; there is no single, simple remedy for the challenges of transitions. However, gaining an in depth understanding of the care transitions of individuals with dementia is an important step in improving transitions for this population. Knowledge translation and significance: The results of the study may be useful in the creation of recommendations for improving the care transition experiences of individuals with dementia and their caregivers. Furthermore, the consultations contributed to dementia strategy development in Ontario. Transitional periods represent a time of risk for adverse events and a high level of caregiver stress; therefore, this study has the potential to improve the quality of care and quality of life of persons with dementia and their informal caregivers.
High-Risk Medication Use, Frailty and Hospitalization among Older Assisted Living Residents
(University of Waterloo, 2015-09-11) Stock, Kathryn
Background: With substantial comorbidity, high levels of medication use and age-related physiological changes, older adults are at an increased risk of drug-related errors and adverse events. Of particular concern are (i) antipsychotic medications, which are often prescribed off-label to individuals with dementia; and (ii) high-risk (HR) drugs (anticoagulants, oral antiplatelet agents, insulins, and oral hypoglycemic agents), which have been shown to be responsible for the majority of drug-related hospital admissions. Given the risk associated with these medications, medication management and monitoring are particularly important for older individuals at risk of adverse drug events. However, assisted living (AL) facilities, increasingly popular residential options for older adults requiring supportive care, are often characterized by lower levels of staffing and professional service, raising concerns about the care and oversight of vulnerable older adults in these settings. The concept of frailty offers a promising avenue for identifying vulnerable older adults who may require increased monitoring when using high-risk medications; however, frailty has been relatively unexplored in this context or setting. Objectives: The present research addresses knowledge gaps with respect to frailty and medication use by: (i) estimating the baseline prevalence of HR (anticoagulants, oral antiplatelet agents, insulins, and oral hypoglycemic agents) /antipsychotic medication use and frailty among AL residents using the frailty index (FI), cardiovascular health study (CHS) criteria, and health instability (CHESS) scale (ii) examining the associations of high-risk / antipsychotic medication use and selected frailty measures with risk of inpatient hospitalization over 1 year; and, (iii) examine the role of these 3 frailty measures in modifying the association between high-risk/antipsychotic medication exposure and hospitalization risk over 1 year. Methods: 1,089 residents of 59 Assisted Living (AL) facilities from the Alberta Continuing Care Epidemiological Studies (ACCES) were included as participants (mean age 84.9±7.3; 77% female). Baseline (2006-08) and 1-year follow-up assessments of resident clinical and drug use data were carried out by research nurses using the interRAI-AL. Facility-level data was captured through administrator interviews. Hospitalization events were captured through linkage with provincial health service utilization data from the Alberta Inpatient Discharge Abstract Database. Multivariable Cox proportional hazards models were used to estimate risk of hospitalization associated with frailty, medication exposure, and medication -frailty interaction terms. Results: Among AL residents, the prevalence of pre-frail/frail residents was 38.9%/27.5% for the FI; 55.0%/19.2% for the CHS; and, 29.4%/24.4% for the CHESS scale. The cumulative annual incidence of hospitalization was 38.9% (35.9-41.9%). All 3 frailty measures were significantly associated with hospitalization after adjusting for age, sex and comorbidity, with the highest risk observed for frail (vs. non-frail) residents defined by the CHS criteria (adj. HR=2.11, 95% CI 1.53-2.92). Overall, use of antipsychotics (26.4% [94.0% atypical agents]), and use of any of the specified HR medication classes (63.5% using at least 1 HR medication class) showed no association with hospitalization. However, the FI, and occasionally CHS, acted as effect modifiers of drug-outcome associations for certain medication classes. Relative to non-frail resident using the medication class of interest, pre-frail/frail individuals had an increased risk of hospitalization when using antipsychotic agents (adj. HR=2.30, 95%CI 1.43-3.70 and adj. HR=2.20, 95% CI 1.3-3.74, with frailty defined using FI and CHS, respectively), anticoagulants (adj. HR=1.64, 95% CI 1.06-2.53, with frailty defined using FI) and antiplatelet agents (adj. HR=1.66, 95% CI 1.15-2.38, with frailty defined using FI). The CHESS measure was a weaker effect modifier. Pre-frail/frail residents using antipsychotic agents were also significantly more likely than non-frail antipsychotic users to reside in facilities with no licensed practical and/or registered nurse on site (25.5% vs. 13.6%) and with no pharmacist involvement in the past month (34.4% vs. 19.7%). Conclusions: These findings suggest that frailty (particularly when measured using FI) may be a means of identifying older individuals vulnerable to drug-related adverse events. Clinical and policy-level interventions in AL settings may enhance quality of care and reduce hospitalizations among residents.
Does maternal obesity affect hippocampal-dependent spatial learning and memory retention in offspring?
(University of Waterloo, 2015-10-02) Robb, Jamie-Lee
With a rise in the prevalence of obesity worldwide, behavioural, as well as physiological changes after consumption of a high-fat diet are becoming increasingly recognized. In addition to increased risk of chronic and degenerative diseases, obesity has also been linked with cognitive impairment, particularly in hippocampal-dependent behaviours such as spatial learning and memory retention. Maternal obesity is also becoming an issue across the globe, with an alarmingly high percentage of women of reproductive age who are either overweight, or obese. Past studies have not only revealed that early-life nutrition can impact brain development and subsequent behaviours across the lifespan, but also that exposure to a high-fat diet in utero may be particularly detrimental to susceptible structures such as the hippocampus. The present study hoped to elucidate the effects of a high-fat diet (45% kcal from fat) on spatial learning and memory retention in female Sprague-Dawley rats. Further, we examined whether maternal obesity could have intergenerational effects on spatial learning and memory retention in offspring. Although high-fat diet consumption was sufficient to induce obesity in the female animals, these dams did not demonstrate impaired spatial learning or memory retention in the Morris water maze task. Interestingly, in adolescence, male, but not female offspring of the obese dams were impaired in their performance on the Morris water maze task. However, the difference normalized by adulthood. Future research should aim to examine why females appear to be resilient to diet-induced cognitive impairment.

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