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Dorothy Forbes

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Associate Professor

Dorothy Forbes

Nursing

Email: dorothy.forbes@ualberta.ca
Tel: 780-492-4709
Fax: 780-492-2551

  • Associate Professor

  • Dementia care
  • Systematic reviews

http://hdl.handle.net/10402/era.22506

Subject areas and related deposits

  • Aging

    • Family members providing home-based palliative care to older adults: The enactment of multiple roles

      Canadians are experiencing increased life expectancy and chronic illness requiring end-of-life care. There is limited research on the multiple roles for family members providing home-based palliative care. Based on a larger ethnographic study of client-family-provider relationships in home-based palliative care, this qualitative secondary analysis explores the enactment of multiple roles for family members providing home-based palliative care to seniors with advanced cancer. Family members had multiple expectations to provide care but felt their expectations of services were unmet. The process of enacting multiple roles was depicted by three interrelated themes: balancing, re-prioritizing, and evolving. Positive and negative health responses resulted from attempts to minimize personal health while simultaneously maintaining health. "True" family-centred care was found to be lacking, but should be a goal of health professionals involved in end-of-life care.

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    • Rural and urban Canadians with dementia: Use of health care services

      The purpose of this research was to examine the characteristics of older Canadians with dementia (compared to those without dementia), their use of health care services, and the impact of place (rural/urban) on use of services. Andersen and Newman's Behavioural Model of Health Services Use (1973) guided the study. A cross-sectional design used data from the Canadian Community Health Survey (CCHS) Cycle 1.1 (N=49,995 older Canadians; those with dementia = 313). Results indicated that among Canadian females between the ages of 50 and 64, those with dementia were more likely than those without dementia to live in rural areas. Among females 80 years of age and over, those with dementia had higher levels of education and income than those without dementia. In addition, a higher proportion of white than of visible minority Canadians was afflicted with dementia. The results further suggest that Canadians with dementia primarily required support services and that they were more likely than persons without dementia to report that their health care needs were unmet. It is recommended that publicly funded national home care programs be expanded to ensure that the supportive services needed by this population are available.

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  • Alzheimer Disease

  • Alzheimer’s disease

  • Antioxidants (therapeutic use)

    • Melatonin for the treatment of dementia (Review)

      Background There are a number of studies that suggest a relationship between decline of melatonin function and the symptoms of dementia. Objectives The review assessed the evidence of clinical effectiveness of melatonin in the treatment of symptoms of dementia. Relevant primary outcomes were cognition, mood, behaviour, functions of daily living, and safety of melatonin use and secondary outcomes were quality of life, morbidity, mortality and length of time to institutionalization and caregiver stress. Search methods The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library,MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 29 June 2009 using the terms: MELATONIN and N-ACETYL-5- METHOXYTRYPTAMINE. The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. The search of June 2009 retrieved several studies for consideration by the authors. Selection criteria All relevant, randomized controlled trials in which orally administered melatonin in any dosage was compared with a control group for the effect on managing cognitive, behavioral (excluding sleep), and mood disturbances of people with dementia of any degree of severity. Data collection and analysis Two to three reviewers independently assessed the retrieved articles for relevance and risk of bias, and extracted data from the selected studies. Statistically significant differences in end-points or changes in outcomes frombaseline to end of treatment between themelatonin and control groups were examined. Each study was summarized using a measure of effect (e.g. mean difference) and meta-analyses were conducted when appropriate. Main results Five studies met the inclusion criteria. The pooled estimates of MMSE cognitive and ADAS-cognitive change scores from three of these studies revealed non-significant cognitive effects for melatonin treatment. In two of these studies, significant improvements in psychopathological behaviours (e.g., decreased mood symptoms of depression, anxiety and apathy and decreased behavior symptoms of hallucinations, delusions, agitation, irritability, and appetite disturbances), were found from meta-analysis of the change scores from the NPI (7 weeks, 2.5 mg melatonin), and ADAS non-cognitive (4 weeks, 3 mg melatonin) scales. Sensitivity analyses found similar results to those of the original meta-analyses, and thus, supported the effect estimates for non-significant cognitive outcomes. Individual study estimates for treatment effect of 2.5 mg melatonin at one year demonstrated a significant worsening of mood (e.g. decrease in positive affect) as measured by the Philadelphia Geriatric Centre Affect Rating Scale (positive). The remainder of the treatment effects for mood, behavior, and function of daily living were non-significant. There were no reported adverse effects associated with melatonin use. Authors’ conclusions The analyses did not support the use of melatonin for treatment of cognitive impairment associated with dementia. Meta-analysis of psychopathologic behavior scale scores suggested that melatonin may be effective in treating these dementia-related disturbances. P L A I N L A N G U A G E S U M M A R Y Melatonin treatment may be effective for the treatment of dementia-related behavior disturbances There are a number of studies that suggest a relationship between decline of melatonin function and the symptoms of dementia. Metaanalysis was conducted on data from three randomised, placebo controlled trials that were designed to evaluate melatonin for managing dementia-related cognitive changes; data also were pooled from two of these trials that evaluated melatonin for managing mood and behavioral disturbances. Significantly improved outcomes were found from the meta-analysis of psychopathologic behavior and mood scale scores. Melatonin treatment may be effective for the treatment of dementia-related psychopathologic behavior disturbances. No evidence was found to support the effectiveness of melatonin for the treatment of cognitive impairment.

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  • Caregiving

    • Making care decisions in home-based dementia care: Why context matters

      The hours of unpaid elder care by family members are projected to triple by 2038. Because living with dementia can inhibit decision-making abilities, family members are often besought to assist in this process. In this ethnographic study, relationships within home-based dementia care were critically examined through face-to-face interviews and participant observations with clients, family caregivers, and home care providers (n = 51). The findings revealed how the formalized home care system contextually imposes decisions, and revealed three themes: (1) accommodating clinically defined competence/incompetence, (2) making untimely decisions, and (3) reinforcing exclusion in decision making. These themes shed light on how cultural values (competency), beliefs (immutability of the system), and practices (timing of decisions) of the home care system are ultimately deterministic in decision making for persons with dementia and caregivers. Additional attention to the collaborative and inclusive practices of all family members in dementia home care is imperative in order to optimize health.

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  • Cochrane Library

    • The Cochrane Library can answer your nursing care effectiveness questions.

      Systematic reviews help nurses to manage the overwhelming volume of available information by synthesizing valid data from primary studies and summarizing the results of interventions. One reliable source of systematic reviews of healthcare interventions is the Cochrane Library.This paper brie y describes the Cochrane Collaboration and the Cochrane Library. It also encourages nurse clinicians and nurse administrators to use the Cochrane Library and encourages nurse researchers to contribute to the Cochrane Library by conducting systematic reviews in the Ž eld of nursing care effectiveness.

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  • Dementia

    • Canadians with dementia: Gender differences in use and availability of home- and community-based health services.

      The purpose was to examine the use and availability of home and communitybased services by men and women with dementia using data from the 2003 Canadian Community Health Survey.Variables of interest were based on the Andersen and Newman model and included predisposing, enabling, need, and use of health service variables, perceived unmet health and home care needs, and availability of home and community-based health services.Women reported better health and received more supportive care yet had more unmet home care needs than men.Thus, the caregivers of men with dementia (often their wives) were particularly vulnerable to negative outcomes, as their care recipients had poorer health yet received fewer services.These gender differences should be considered when policies and programs are developed, the needs of care recipients and caregivers are assessed, and services are provided.

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    • Dementia home care resources: How are we managing?

      With the number of people living with dementia expected to more than double within the next 25 years, the demand for dementia home care services will increase. In this critical ethnographic study, we drew upon interview and participant data with persons with dementia, family caregivers, in-home providers, and case managers in nine dementia care networks to examine the management of dementia home care resources. Three interrelated, dialectical themes were identified: (1) finite formal care-inexhaustible familial care, (2) accessible resources rhetoric-Iinaccessible resources reality, and (3) diminishing care resources-increasing care needs. The development of policies and practices that provide available, accessible, and appropriate resources, ensuring equitable, not necessarily equal, distribution of dementia care resources is required if we are to meet the goal of aging in place now and in the future.

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    • Exercise programs for people with dementia.

      This is an update of our previous 2008 review. Several recent trials and systematic reviews of the impact of exercise on people with dementia are reporting promising findings. Objectives Primary: Do exercise programs for older people with dementia improve cognition, activities of daily living (ADLs), challenging behaviour, depression, and mortality in older people with dementia? Secondary: Do exercise programs for older people with dementia have an indirect impact on family caregivers’ burden, quality of life, and mortality? Do exercise programs for older people with dementia reduce the use of healthcare services (e.g. visits to the emergency department) by participants and their family caregivers? Search methods We identified trials for inclusion in the review by searching ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group’s Specialised Register, on 4 September 2011, and again on 13 August 2012. The search terms used were: ’physical activity’ OR exercise OR cycling OR swim* OR gym* OR walk* OR danc* OR yoga OR ‘tai chi’. Selection criteria In this review, we included randomized controlled trials in which older people, diagnosed with dementia, were allocated either to exercise programs or to control groups (usual care or social contact/activities) with the aim of improving cognition, ADLs, behaviour, depression, and mortality. Secondary outcomes related to the family caregiver(s) and included caregiver burden, quality of life,mortality, and use of healthcare services.Data collection and analysis Independently, at least two authors assessed the retrieved articles for inclusion, assessed methodological quality, and extracted data. Data were analysed for summary effects using RevMan 5.1 software. We calculated mean differences or standardized mean difference (SMD) for continuous data, and synthesized data for each outcome using a fixed-effect model, unless there was substantial heterogeneity between studies,when we used a random-effects model. We planned to explore heterogeneity in relation to severity and type of dementia, and type, frequency, and duration of exercise program. We also evaluated adverse events. Main results Sixteen trials with 937 participants met the inclusion criteria. However, the required data from three trials and some of the data from a fourth trial were not published and not made available. The included trials were highly heterogeneous in terms of subtype and severity of participants’ dementia, and type, duration and frequency of exercise. Only two trials included participants living at home. Our meta-analysis suggested that exercise programs might have a significant impact on improving cognitive functioning (eight trials, 329 participants; SMD 0.55, 95% confidence interval (CI) 0.02 to 1.09). However, there was substantial heterogeneity between trials (I2 value 80%), most of which we were unable to explain. We repeated the analysis omitting one trial, an outlier, that included only participants with moderate or severe dementia. This reduced the heterogeneity somewhat (I2 value 68%), and produced a result that was no longer significant (seven trials, 308 participants; SMD 0.31, 95% CI -0.11 to 0.74). We found a significant effect of exercise programs on the ability of people with dementia to perform ADLs (six studies, 289 participants; SMD 0.68, 95% CI 0.08 to 1.27). However, again we observed considerable unexplained statistical heterogeneity (I2 value 77%) in this meta-analysis. This means that there is a need for caution in interpreting these findings. In further analyses, we found that the burden experienced by informal caregivers providing care in the home may be reduced when they supervise the participation of the family member with dementia in an exercise program (one study, 40 participants;MD-15.30, 95%CI -24.73 to -5.87), but we found no significant effect of exercise on challenging behaviours (one study, 110 participants; MD -0.60, 95% CI -4.22 to 3.02), or depression (six studies, 341 participants; MD -0.14, 95% CI -0.36 to 0.07) . We could not examine the remaining outcomes, quality of life, mortality, and healthcare costs, as either the appropriate data were not reported, or we did not retrieve trials that examined these outcomes. Authors’ conclusions There is promising evidence that exercise programs can have a significant impact in improving ability to perform ADLs and possibly in improving cognition in people with dementia, although some caution is advised in interpreting these findings. The programs revealed no significant effect on challenging behaviours or depression. There was little or no evidence regarding the remaining outcomes of interest.

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    • Formal dementia care among First Nations in Southwestern Ontario

      This article explores how dementia care is provided to First Nations communities in southwestern Ontario. Data were collected through in-depth interviews with health care providers and analysed using a constructivist grounded-theory methodology. Two interrelated frameworks for understanding dementia care were identified: a care delivery framework and a knowledge framework. The care delivery framework identified care goals, care elements being provided, care barriers, and strategies and solutions to deliver care and overcome barriers. The knowledge framework defined four groups of knowledge stakeholders: persons with dementia, informal care providers, formal care providers, and the First Nations community. It identified the knowledge each stakeholder held or needed and processes of sharing - or failing to share - knowledge in dementia care. Several barriers, many created by a lack of knowledge, negatively impacted dementia care. However, health care professionals had effective strategies for providing care, designed to overcome barriers and which encompassed elements of knowledge sharing.

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  • Depression

    • Reducing depression in older home care clients: Design of a prospective study of a nurse-led interprofessional mental health promotion intervention

      Background: Very little research has been conducted in the area of depression among older home care clients using personal support services. These older adults are particularly vulnerable to depression because of decreased cognition, comorbid chronic conditions, functional limitations, lack of social support, and reduced access to health services. To date, research has focused on collaborative, nurse-led depression care programs among older adults in primary care settings. Optimal management of depression among older home care clients is not currently known. The objective of this study is to evaluate the feasibility, acceptability and effectiveness of a 6-month nurse-led, interprofessional mental health promotion intervention aimed at older home care clients with depressive symptoms using personal support services. Methods/Design: This one-group pre-test post-test study aims to recruit a total of 250 long-stay (> 60 days) home care clients, 70 years or older, with depressive symptoms who are receiving personal support services through a home care program in Ontario, Canada. The nurse-led intervention is a multi-faceted 6-month program led by a Registered Nurse that involves regular home visits, monthly case conferences, and evidence-based assessment and management of depression using an interprofessional approach. The primary outcome is the change in severity of depressive symptoms from baseline to 6 months using the Centre for Epidemiological Studies in Depression Scale. Secondary outcomes include changes in the prevalence of depressive symptoms and anxiety, health-related quality of life, cognitive function, and the rate and appropriateness of depression treatment from baseline to 12 months. Changes in the costs of use of health services will be assessed from a societal perspective. Descriptive and qualitative data will be collected to examine the feasibility and acceptability of the intervention and identify barriers and facilitators to implementation. Discussion: Data collection began in May 2010 and is expected to be completed by July 2012. A collaborative nurse-led strategy may provide a feasible, acceptable and effective means for improving the health of older home care clients by improving the prevention, recognition, and management of depression in this vulnerable population. The challenges involved in designing a practical, transferable and sustainable nurse-led intervention in home care are also discussed.

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  • Home care services

    • Individual determinants of home-care nursing and housework assistance.

      The purpose of this study was to examine individual determinants of use of publicly funded home-care nursing and housework assistance by Canadians 18 years and older from 1994 to 1999. Andersen and Newman's Behavioural Model of Health Services Use guided the selection of variables, analyses, and interpretation of the findings. Descriptive, correlation, and multiple logistic regression analyses were completed in each of the first 3 cross-sectional cycles of Statistics Canada's National Population Health Surveys. The determinants of use of housework assistance were older age, female, living alone, lower income, activity restriction, needing help with housework, not hospitalized in the previous year, and having at least 1 chronic condition. The determinants for home nursing tended to be the opposite of those for housework assistance. Between 1994 and 1999, use of housework assistance appeared to decrease and use of nursing services appeared to remain relatively stable. The findings underscore the need to target these 2 discrete subgroups of home-care users and ensure that funding is directed at support services as well as nursing services.

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  • Knowledge translation

    • Accelerating client-driven care: Pilot study for a social interaction approach to knowledge translation.

      This study piloted a knowledge translation (KT) intervention promoting evidence-based home care through social interaction.A total of 33 providers organized into 5 heterogeneous, geographically defined action groups participated in 5 researcher-facilitated meetings based on the participatory action model.The KT evidence reflects an empowering partnership approach to service delivery. Exploratory investigation included quantitative pre-post measurement of outcomes and qualitative description of data, presented herein. The critical reflections of the groups reveal macro-, meso-, and micro-level barriers to and facilitators of KT as well as recommendations for achieving KT. Insights gleaned from the findings have informed the evolution of the KT intervention to engage all 3 levels in addressing barriers and facilitators, with a conscious effort to transcend “push” and “pull” tendencies and enact transformative leadership.The findings suggest the merit of a more prolonged longitudinal investigation with expanded participation.

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  • Long-term care

    • Knowledge-to-action processes in SHRTN Collaborative Communities of Practice: a study protocol

      Background: The Seniors Health Research Transfer Network (SHRTN) Collaborative is a network of networks that work together to improve the health and health care of Ontario seniors. The collaborative facilitates knowledge exchange through a library service, knowledge brokers (KBs), local implementation teams, collaborative technology, and, most importantly, Communities of Practice (CoPs) whose members work together to identify innovations, translate evidence, and help implement changes. This project aims to increase our understanding of knowledge-to-action (KTA) processes mobilized through SHRTN CoPs that are working to improve the health of Ontario seniors. For this research, KTA refers to the movement of research and experience-based knowledge between social contexts, and the use of that knowledge to improve practice. We will examine the KTA processes themselves, as well as the role of human agents within those processes. The conceptual framework we have adopted to inform our research is the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Methods/design: This study will use a multiple case study design (minimum of nine cases over three years) to investigate how SHRTN CoPs work and pursue knowledge exchange in different situations. Each case will yield a unique narrative, framed around the three PARIHS dimensions: evidence, context, and facilitation. Together, the cases will shed light on how SHRTN CoPs approach their knowledge exchange initiatives, and how they respond to challenges and achieve their objectives. Data will be collected using interviews, document analysis, and ethnographic observation. Discussion: This research will generate new knowledge about the defining characteristics of CoPs operating in the health system, on leadership roles in CoPs, and on the nature of interaction processes, relationships, and knowledge exchange mechanisms. Our work will yield a better understanding of the factors that contribute to the success or failure of KTA initiatives, and create a better understanding of how local caregiving contexts interact with specific initiatives. Our participatory design will allow stakeholders to influence the practical usefulness of our findings and contribute to improved health services delivery for seniors.

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  • Melatonin

    • Melatonin for cognitive impairment (Protocol)

      This is the protocol for a review and there is no abstract. The objectives are as follows: The primary objective is a systematic review of evidence relating to clinical efficacy and safety of melatonin in treatment of manifestations of dementia or cognitive impairment (CI).

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    • Melatonin for cognitive impairment (Protocol)

      This is the protocol for a review and there is no abstract. The objectives are as follows: The primary objective is a systematic review of evidence relating to the clinical efficacy and safety of melatonin in the treatment of manifestations of dementia or cognitive impairment (CI).

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  • Mental health/pyschosocial

    • Depression in nurses.

      Patient outcomes are reliant on nursing calibre, which in turn is dependent on the health of work environments and practice settings. The National Survey of the Work and Health of Nurses (NSWHN) examined a broad spectrum of nurses’ work and health, with one finding of particular concern: Nurses have a higher rate of depression (1 in 10) than their counterparts (as found in other national surveys). This secondary analysis of the data focused on the outcome of depression in a subsample of the nurses surveyed by the NSWHN and examined associations between depression and work-related variables such as job strain, role overload, respect, social and employer supports, and nurses’ perception of the quality of the care they provided. A multivariate logistic regression found an increased risk of depression in nurses experiencing job strain, role overload, and a lack of respect.

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  • National Population Health Survey

    • Canadian community-dwelling young-old and old-old: Determinants of satisfaction with health care

      The purpose of the study was to identify the determinants of satisfaction with health care for Canadian community-dwelling older adults. A correlational design was used to examine the relationships between socio-demographic indicators, psychosocial variables, health services utilization, and satisfaction with health care in the young-old and old-old. A subsample (N = 2,413) from the 1994/95 National Population Health Survey Supplement was analysed. Hierarchical regression analyses revealed that socio-demographic variables were the best predictors of satisfaction with the national health care system in the young-old. Consultation with health care professionals was the best predictor of satisfaction with the Canadian health care system in the old-old and of health care personally received in both cohorts. Consultations with alternative practitioners was negatively related to satisfaction with health care in Canada and to care personally received in the old-old. The identification of the best determinants of satisfaction with health care can provide useful direction to policy makers, program planners, and practitioners so that more appropriate and effective services can be made available to this population.

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  • Nursing home residents

    • Physical activity programs for persons with dementia. (Protocol)

      This is the protocol for a review and there is no abstract. The objectives are as follows: 1.To evaluate the effects of physical activity programs on function (e.g., activities of daily [ADLs], physical function), cognition, mood, behaviour, and mortality in older persons with dementia. 2.To evaluate these effects on their unpaid caregiver’s health, quality of life, and mortality. 3.To evaluate the indirect costs (e.g., number and amount of lost wages by caregiver(s) and direct costs (e.g., use of supportive services, medications, supplies) for the person with dementia and their unpaid caregiver. 4. To make recommendations to health care providers, consumers, and researchers on the effectiveness of physical activity programs in managing the symptoms of dementia in older persons with dementia.

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    • Physical activity programs for persons with dementia. (Review)

      Background. There is some evidence that physical activity delays the onset of dementia in healthy older adults and slows down cognitive decline to prevent the onset of cognitive disability. Studies using animal models suggest that physical activity has the potential to attenuate the pathophysiology of dementia. 'Physical activity' refers to 'usual care plus physical activity'. Objectives. Primary: do physical activity programs maintain or improve cognition, function, behaviour, depression, and mortality compared to usual care in older persons with dementia? Secondary: do physical activity programs have an indirect positive impact on family caregivers' health, quality of life, and mortality compared to family caregivers of older persons with dementia who received usual care alone? Do physical activity programs reduce the use of health care services ( e. g., visits to the emergency department) compared to usual care in older persons with dementia and their family caregiver? Search strategy. The trials were identified from searches of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group, The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS on 9 September 2007 using the search terms: exercise OR "physical activity" OR cycling OR swim* OR gym* OR walk* OR danc* OR yoga OR "tai chi". Selection criteria. All relevant, randomized controlled trials in which physical activity programs were compared with usual care for the effect on managing or improving cognition, function, behaviour, depression, and mortality in people with dementia of any type and degree of severity. Secondary outcomes related to the family caregiver(s) included quality of life, mortality, and use of health care services were intended to be examined. Data collection and analysis. Two reviewers independently assessed the retrieved articles for relevance and methodological quality, and extracted data from the selected trials. These were pooled were appropriate. Main results. Four trials met the inclusion criteria. However, only two trials were included in the analyses because the required data from the other two trials were not made available. Only one meta-analysis was conducted. The results from this review suggest that there is insufficient evidence of the effectiveness of physical activity programs in managing or improving cognition, function, behaviour, depression, and mortality in people with dementia. Few trials have examined these important outcomes. In addition, family caregiver outcomes and use of health care services were not reported in any of the included trials. Authors' conclusions. There is insufficient evidence to be able to say whether or not physical activity programs are beneficial for people with dementia.

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  • Participatory action research

    • Evolving the theory and praxis of knowledge translation through social interaction: A social phenomenological study

      Background: As an inherently human process fraught with subjectivity, dynamic interaction, and change, social interaction knowledge translation (KT) invites implementation scientists to explore what might be learned from adopting the academic tradition of social constructivism and an interpretive research approach. This paper presents phenomenological investigation of the second cycle of a participatory action KT intervention in the home care sector to answer the question: What is the nature of the process of implementing KT through social interaction? Methods: Social phenomenology was selected to capture how the social processes of the KT intervention were experienced, with the aim of representing these as typical socially-constituted patterns. Participants ( n = 203), including service providers, case managers, administrators, and researchers organized into nine geographically-determined multidisciplinary action groups, purposefully selected and audiotaped three meetings per group to capture their enactment of the KT process at early, middle, and end-of-cycle timeframes. Data, comprised of 36 hours of transcribed audiotapes augmented by researchers' field notes, were analyzed using social phenomenology strategies and authenticated through member checking and peer review. Results: Four patterns of social interaction representing organization, team, and individual interests were identified: overcoming barriers and optimizing facilitators; integrating 'science push' and 'demand pull' approaches within the social interaction process; synthesizing the research evidence with tacit professional craft and experiential knowledge; and integrating knowledge creation, transfer, and uptake throughout everyday work. Achieved through relational transformative leadership constituted simultaneously by both structure and agency, in keeping with social phenomenology analysis approaches, these four patterns are represented holistically in a typical construction, specifically, a participatory action KT ( PAKT) model. Conclusion: Study findings suggest the relevance of principles and foci from the field of process evaluation related to intervention implementation, further illuminating KT as a structuration process facilitated by evolving transformative leadership in an active and integrated context. The model provides guidance for proactively constructing a 'fit' between content, context, and facilitation in the translation of evidence informing professional craft knowledge.

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  • Phototherapy

    • Light therapy for managing cognitive, sleep, functional, behavioural, or psychiatric disturbances in dementia (Review)

      Background Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythmgenerated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light. Objectives The review assesses the evidence of effectiveness of light therapy in managing cognitive, sleep, functional, behavioural, or psychiatric disturbances associated with dementia. Search methods The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library,MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 4 March 2008 using the terms: “bright light*”, “light box*”, “light visor*”, “dawn-dusk*”, phototherapy, “photo therapy”, “light therapy” “light treatment”, light* . The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. Selection criteria All relevant, randomized clinical trials in which light therapy, at any intensity and duration, was compared with a control group for the effect on managing cognition, sleep, function, behavioural, or psychiatric disturbances (as well as changes in institutionalization rates or cost of care) in people with dementia of any type and degree of severity. Data collection and analysis Three reviewers independently assessed the retrieved articles for relevance and methodological quality, and extracted data from the selected studies. Statistically significant differences in outcomes between the treatment and control groups at end of treatment and follow-up were examined. Each study was summarized using a measure of effect (e.g. mean difference). Main results Eight trials met the inclusion criteria. However, three of the studies could not be included in the analyses because of inappropriate reported study analyses or inability to retrieve the required data from the investigators. This review revealed no adequate evidence of the effectiveness of light therapy in managing cognition, sleep, function, behaviour, or psychiatric disturbances associated with dementia. Authors’ conclusions There is insufficient evidence to assess the value of light therapy for people with dementia. Most of the available studies are not of high methodological quality and further research is required. P L A I N L A N G U A G E S U M M A R Y There is insufficient evidence to determine whether light therapy is effective in the management of cognitive, sleep, functional, behavioural or psychiatric disturbances in dementia Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light. The light sources in the included studies were: a light box placed approximately one metre away from the participants at a height within their visual fields; a light visor worn on their heads; ceiling mounted light fixtures; or dawn-dusk simulation that mimics outdoor twilight transitions. Eight studies met the inclusion criteria. However, three trials were not included in the analyses because of inappropriately reported analyses or inability to retrieve the required data from the original investigators. The studies included in the analyses revealed no adequate evidence of the effectiveness of light therapy in managing cognitive, sleep, functional, behavioural, or psychiatric disturbances associated with dementia.

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    • Light Therapy for Managing Sleep, Behaviour, and Mood Disturbances in Dementia (Review)

      Background Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythmgenerated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light. Objectives The review assesses the evidence of efficacy of bright light therapy (BLT) inmanaging sleep, behaviour,mood, and cognitive disturbances associated with dementia. Search strategy The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 5 December 2005 using the terms “bright light*”, “light box*”, “light visor*”, “dawn-dusk*”, phototherapy (MESH), phototherapy, “photo therapy”, “light therapy” “light treatment”, light*. Selection criteria All relevant, randomized controlled trials in which BLT, at any intensity and duration, was compared with a control group for the effect on managing sleep, behavioural, mood, or cognitive disturbances (as well as changes in institutionalization rates or cost of care) on people with dementia of any degree of severity. Data collection and analysis Three reviewers independently assessed the retrieved articles for relevance and methodological quality, and extracted data from the selected studies. Statistically significant differences in changes in outcomes from baseline to end of treatment and from baseline to follow-up, between the light therapy and control groups, were examined. Each study was summarized using a measure of effect (e.g. mean difference). Owing to lack of homogeneity between studies, their results were not combined. Main results Five studies met the inclusion criteria. However, only three were included in the analyses because of inappropriate reported study analyses or inability to retrieve the required data from the investigators. This review revealed no adequate evidence of the effectiveness of BLT in managing sleep, behaviour, cognitive, or mood disturbances associated with dementia. Authors’ conclusions There is insufficient evidence to assess the value of BLT for people with dementia. The available studies are of poor quality and further research is required. P L A I N L A N G U A G E S U M M A R Y There is insufficient evidence to determine whether bright light therapy is effective in the management of sleep, behaviour, mood, or cognitive disturbances in dementia. Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light. The light sources in the included studies were: a light box placed approximately one metre away from the subjects at a height within their visual fields; a light visor worn on their heads; or a more acceptable ’naturalistic’ light therapy, known as dawn-dusk simulation that mimics outdoor twilight transitions. Five studies met the inclusion criteria. However, only three were included in this analysis because of inappropriately reported analyses or inability to retrieve the required data from the original investigators. The three studies included in the analysis were of poor quality and revealed no adequate evidence of the effectiveness of bright light therapy (BLT) in managing sleep, behaviour, or mood disturbances associated with dementia.

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  • Rural

    • Fitting a round peg into a square hole: Exploring issues, challenges, and strategies for solutions in rural home care settings

      While home care has received much attention lately, little research to date has drawn on the experiences of rural multidisciplinary teams providing in-home care. Home care is typically studied in urban areas, with the tendency to expand urban practices to rural settings, often with problematic results. This paper presents findings regarding unique rural multidisciplinary home care issues, challenges, and strategies for solutions. Five focus group interviews were held with each of three rural multidisciplinary home care provider groups (n=19) in southwest Ontario, Canada. Findings revealed practice issues related to time, distance, communication, recruitment and retention, as well as system issues regarding poor understanding and scheduling of rural practice by administrators and urban employers. Study findings indicate that rural home care requires enhanced understanding and changes to policies and practices to provide efficient and effective care to rural residents. Best practice guidelines for home care in rural areas are urgently needed.

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  • Rural health

    • Dementia care in rural and remote areas: The first year of a CIHR New Emerging Team.

      The Canadian Institutes of Health Research (CIHR) New Emerging Team (NET) program was designed to provide 5 years of support for the creation of new teams or the development of existing teams of investigators conducting collaborative multidisciplinary research in identified areas of focus. A NET group at the University of Saskatchewan was funded under the Cognitive Impairment in Aging focus for a project titled Strategies to Improve the Care of Persons with Dementia in Rural and Remote Areas. In this article we describe the research program developed by the team and implemented during the first year of our mandate.

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  • Rural nursing

    • A profile of registered nurses in rural and remote Canada.

      Research on nursing practice issues in rural and remote areas of Canada is very limited. This report describes the method and initial results of a comprehensive survey of registered nurses (RNs) practising outside the commuting zones of large urban centres, designed to determine: who practises nursing in rural and remote Canada; the nature and scope of their nursing practice; and their satisfaction with their work, community, and practice supports. Using a mailed questionnaire with persistent follow-up, the data-collection frame included a stratified random sample of rural RNs and the full population of RNs who worked in the northern territories and outpost ("remote") settings. The analyses focus on regional comparisons of demographics and primary work settings and on provincial comparisons of satisfaction levels related to work and community. The survey is part of a larger multi-method project intended to inform policy on rural nursing practice in Canada.

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    • Registered nurses working alone in rural and remote Canada.

      This paper describes the demographics of Registered Nurses (RNs) who work alone in rural and remote Canada, their workplaces, and the benefits and challenges of this unique nursing employment situation. Data presented are from a national survey, one of 4 principal approaches used in conducting the project The Nature of Nursing Practice in Rural and Remote Canada. Of the total survey sample, 412 nurses (11.5 %) were employed as the only RN in their work setting.Variables of interest included level of education, employment setting, and regional distribution of workplaces. An exploration of predictors of work satisfaction confirmed previous research findings with respect to the importance of continuing education and face-to-face contact with colleagues. Findings from this analysis may inform policy decisions regarding the employment of RNs in rural and remote Canada.

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  • Rural women

    • Canadian rural women's experiences with rural primary health nurse practitioners

      Background: In Canada, one in five women lives in a rural area. These rural women often experience different health challenges than urban women, including lower life expectancy, higher rates of disability and cancer, fewer available health care resources and greater distances to access health care services. Nurse practitioners [NPs] provide important primary health care [PHC] services to rural women. Research Objective: The purpose of this research study was to explore rural women’s experiences with primary health care nurse practitioners [PHCNPs]. Method and Sample: In-depth, face-to-face interviews using interpretive description methodology were conducted with nine rural women, aged 18-80, who used NP services in rural southwest Ontario, Canada. Results: The participants in the study particularly appreciated the nursing knowledge of the NP, the time the NPs spent with them, and the thoroughness of the care provided by NPs. These foundational elements of the participants’ experiences with rural NPs created a sense of trust and respect, which lead to a collaborative partnership between the NP and the rural women. Conclusions: Results of this study suggest that these rural women were overwhelmingly satisfied with the care provided by NPs. In particular, they valued the collaborative partnership with the NP. These findings have important implications for rural health care practice, policy, and education.

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  • Social inclusion and exclusion

    • "Her world gets smaller and smaller with nothing to look forward to”: Dimensions of social inclusion and exclusion among rural dementia care networks

      The purpose of this research was to critique the nature of rural dementia care from the perspectives of persons with dementia, their family caregivers and home care providers through a social inclusion/exclusion lens. A critical gerontology approach within a human rights framework (Townsend, 2006) was used. Three rural dementia care networks were included consisting of persons with dementia (n=3), spouse caregivers (n=3), adult children (n=9), grandchildren (n=2) and home care providers (n=3). Thematic analysis (Lubrosky, 1994) revealed three overarching inclusion/exclusion themes. Members of the dementia care network were being denied and afforded opportunities with respect to: (i) experiencing quality relationships among network members; (ii) having a voice in dementia care decisions; and (iii) participating in care, social, and work activities. This study contributes evidence that challenges the myth of the idyllic nature of rural places. Findings revealed the diversity of lived experiences within dementia care network members who described both positive (e.g., close community ties, life-long work opportunities) and negative (e.g., stigma of dementia, dangers of rural setting) aspects of the link between living in a rural setting and living with dementia.

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  • Systematic review

    • Interventions for caregivers of persons with dementia: a systematic review.

      The prevalence of dementia in older adults is increasing.Due to cuts in funding for formal support,many families are having to provide care for a loved one with dementia at home.This systematic review gathered and synthesized information on interventions designed to enhance the well-being of caregivers of people with dementia.A search of the literature resulted in 36 relevant studies. Of these, 11 were rated as strong, 11 as moderate, 13 as weak, and 1 as poor.This paper focuses on the strong studies.No one intervention had an overall signiŽ - cant impact on the well-being of caregivers. Although several interventions have been shown to be of beneŽ t to caregivers, non-signiŽ cant Ž ndings were more common. Further investigation is greatly needed. Systematic reviews are an important means of guiding consumers and practitioners in making evidencebased decisions.

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    • A systematic review of screening tools for predicting the development of dementia

      Early detection of dementia is essential to guide front-line health care practitioners in further clinical evaluations and treatments. There is a paucity of literature assessing the effectiveness of screening tools to predict the development of dementia, thus we conducted a systematic review to fill this gap. The purpose of the systematic review was to make recommendations to health care practitioners on which screening tool best predicts the development of dementia and is most feasible in the primary care setting. Ten databases were searched for relevant articles, yielding 751 papers. Of these, 12 met relevance criteria for inclusion. Screening tools were assessed for test accuracy, cognitive domain coverage, predictive ability, and feasibility. Four screening tools were recommended. Addenbrooke's Cognitive Examination (ACE) was considered to be the ideal tool. A revised version of this tool is now used in clinical practice but the psychometric properties of the ACE-R remain to be established.

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  • Systematic reviews

    • Systematic reviews of health care interventions: An essential component of health sciences graduate programs

      Systematic reviews are an objective, rigorous assessment of both published and unpublished research that enable the reviewer to make recommendations to clinicians, policy-makers, consumers, and researchers. The steps in a systematic review include: (a) developing a research question, (b) developing relevance and validity tools, (c) conducting a thorough literature search of published and unpublished studies, (d) using relevance and validity tools to assess the studies, (e) completing data extraction for each study, (f) synthesizing the findings and, (g) writing the report. The purpose of this paper is to demonstrate the value of providing health science graduate students with the opportunity to learn about the conduct of a systematic review. An example of a thesis utilizing the method of a systematic review is presented.

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  • The Cochrane Library

    • Saskatchewan residents’ use of The Cochrane Library

      The Cochrane Library is a source of reliable information on the effects of healthcare interventions for health care practitioners and consumers. In July 2004, Saskatchewan became the first province in Canada to provide all residents with access to The Cochrane Library. The purpose of this study was to evaluate the use of The Cochrane Library. Training sessions were offered to promote the use of The Cochrane Library. Attendees were informed of the evaluation study and invited to participate. Those who consented to participate were telephoned and audio-taped interviews were conducted at three (n=94), six (n=71), nine (n=79), and 12 months (n=72) following the sessions. Usage of The Cochrane Library was also tracked using data available from Wiley-Blackwell. Most participants were librarians (n=31.5%), between 40 to 65 years of age (71.6%) and female (92.4%). Data from Wiley-Blackwell revealed that from October 2004 to September 2007, the component of The Cochrane Library most frequently accessed was The Cochrane Database of Systematic Reviews (abstracts=26,016; full texts =15,934). Telephone interviews with participants revealed that the majority (65.2%) used The Cochrane Library at the three month interview, however this proportion fell to 27.4% at the twelve month interview even though most (83.6%-88.2%) reported that The Cochrane Library was somewhat to very helpful. Most respondents claimed to have learned something from The Cochrane Library; others reported that the knowledge gained helped in their decision-making or confirmed their beliefs. Respondents accessed The Cochrane Library in response to patron requests for information on a variety of health care topics. Information was used to support changes in health care practice and policy and for the preparation of educational papers and presentations. The reported reasons for not using The Cochrane Library were lack of time, limited access to an internet ready computer in the work setting, reliance on dial-up internet in some rural areas, forgetting how to find and navigate the website, and being disappointed with information available. The plain language summaries were well received, however, some reported that the sophisticated language and length of the reviews were more appropriate for researchers and healthcare providers than the general public. This study provides evidence that given the opportunity and appropriate training, people other than medical professionals will also make use of The Cochrane Library.

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