JCCC 2012 Issue 1
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New Year, New Initiatives!
I hope you enjoy this issue of the Journal. Feedback and discussion, as always, is welcomed. 2012 Canadian Consensus Conference on Dementia
On May 4th and 5th the fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4) took place in Montreal. First started in 1989, the goal of the conference and its contributors, participants and authors is to review the evidence on various critical aspects of dementia and produce a series of papers summarizing the evidence. After the papers are written by a team of physician experts in the field of study, then are posted on the consensus website and conference participants are invited to add comments, then vote on a series of recommendations which are formulated by the authors, based on the best available evidence that can be gleaned from the English and French language medical literature. The conference is attended by the papers’ authors, the steering committee of the conference and delegates from across Canada representing as much as possible all the fields addressed by the papers. This resulted in 27 attendees at the Montreal conference, from neurology, geriatric psychiatry, geriatric medicine, care of the elderly family medicine, genetics, neuroimaging and the major organizations that deal with those populations often living with or at risk for dementia that included the Canadian Academy of Geriatric Psychiatry, Canadian Geriatrics Society, College of Family Physicians of Canada and the Alzheimer’s Society. The topics chosen for the focus of the papers from which evidence was gleaned to formulate the many recommendations were divided into the following categories: Definitions, Pharmacology and Therapeutics, Neuroimaging, Rapidly Progressive Dementia, Liquid Biomarkers, Early Onset Dementia, Knowledge translation in Dementia and Translation into Primary Care. As can be seen from the list, not every conceivable component of dementia care was covered, but those areas that are dependent on a body of literature from which evidence as to the consistency, efficacy and outcomes could be reasonably gleaned were the primary focus of the conference as has been the case in the past. When there was nothing new from the literature, we endorsed previous recommendations. For example, we did not recommend any changes to the laboratory work up for all cases of suspected dementia. There was also recognition that the areas chosen for review have a substantial impact on the practice of dementia-related medical care and public health care policy. All the papers were also explored for the ethical and resource allocation impact of the proposed recommendations. At the end of each paper presentation by one or more of the authors, the results of the online voting was reviewed. Further, robust and far-reaching discussion of the recommendations often resulted in some modifications of the wording or conclusions. The strength of the recommendations (strong, weak) and levels of supporting evidence (A= most persuasive, B= moderate, C= weakest) resulted in suggestions for practice that were then subjected to the conference participants’ final vote. While most recommendations reached consensus agreement, some were rejected as being inappropriate or not supported by sufficient evidence. The next step is that the results of the conference and the final recommendations will be submitted to a number of journals directed to the whole spectrum of physicians involved in dementia care. This includes primary care physicians, specialist physicians both community-based and academic, of which the latter often function within the milieu of tertiary level memory and dementia programs and clinics. After the recommendations are published in the medical literature, HealthPlexus will play an important role in the dissemination and the process of translation of the recommendations into clinical practice with the goal of assisting primary care physicians in the evaluation, investigation, and care of their patients afflicted with the wide range of cognitive impairments, and the caregivers and families who support them. We will endeavour to help family physicians through various modalities of presentations including the possibility of case-based presentations that can be addressed through the lens of the new recommendations so that our HealthPlexus readership can assimilate the new recommendations into the very practical challenges of primary care. As the editor of the dementia section of HealthPlexus, and member of the steering committee, and ethics consultant to the Consensus conference, I am very pleased that we can play an active role in helping front-line primary care physicians utilize the recommendations of the Conference to guide the every day challenges of their practice.
Michael Gordon, MD, MSc, FRCPC
Thoughts on the WHO's Dementia Report
One of the comments that caught the eye of the media about Canada's approach is that unlike Australia, Denmark, France, Japan, Korea, the Netherlands, Norway and the United Kingdom which all have some sort of a national strategy for dementia, Canada does not. This apparent lack by the Canadian federal government became a focus for criticism by many Canadian organizations including the Alzheimer Society of Canada which used the term, "a wake up call" to the federal government to take action.
We would like to hear from you: This means that for there to be a meaningful and robust approach to the challenges of dementia from original and basic research to the clinical domains of care through the spectrum of stages and venues where care will be provided to the very late stages of dementia where palliative and end-of-life considerations become paramount, it will likely be at the individual provincial level. This will take place with local organizations including universities and their affiliated research centres and individual health care settings from acute to long-term care that will ultimately define, explore and experiment with the range of interventions that might be useful in either thwarting the disease or providing appropriate care and support to patients and their families. The federal government can be of great assistance whether through a formal national 'strategy' or through extensions of already existing mechanisms by promoting and encouraging (which usually means funding) research across many domains of dementia scientific enquiry, from the basic science aspects, to pharmaceutical research to health care systems and delivery studies. It can also find ways to support the range of care provision aspects at the individual and organizational approaches again through funding, grants, tax incentives, and other levels that work at the federal level that augment, but do not conflict with the provincial mandates of providing care in the local jurisdictional level. That dementia is a "ticking time bomb" is clear from the current statistics and the projections should nothing dramatic occur. But that can change with a combination of concerted effort, use of best brains and technologies and a modicum of good fortune in the world of research endeavors which often comes up with solutions either from expected or unexpected sources. Canada and each of the provinces cannot ignore the implications of the WHO report and the impact that the factors outlined in the report will have on the populations living in the country. All ways possible must be found to support each of the provinces as they try to cope with the local challenges of their populations affected by the "ticking time bomb" through their own provincial initiatives along with close scrutiny of the world-wide evidence on novel approaches along with cooperation across all the provinces and the sectors within the country. Canadians deserve no less from their federal and provincial governments.
Michael Gordon, MD, MSc, FRCPC
Helping Families Worried About Developing DementiaMichael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.
One of the challenges faced by those of us who practice geriatric medicine or through another specialty is helping family members understand the hodgepodge of medical literature especially as it is reported by internet/Google searches rather than careful reviews of the peer reviewed literature. Even in the latter there is a wide range of opinions which even for physicians sometimes presents a challenge in how we make our recommendations. This is especially the case when dealing with dementia. Cognitive Decline and Dementia Risk in Type 2 Diabetes
Abstract The Launch of the Dementia Educational Resource: Interview With the Editor-in-Chief Dr. Michael Gordon
Following on the footsteps of the recent announcement of the launch of the Dementia Educational Resource, www.HealthPlexus.net recently interviewed Dr. Michael Gordon who was appointed as Editor-in-Chief for the newly re-focused educational channel. Dr. Barry Goldlist asked Dr. Gordon a few questions about the format and the plans for this project. The Hidden Cost of Cognition: Examining the Link Between Dual-Task Interference and Falls
Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Abstract Assault as Treatment: Mythology of CPR in End-of-Life Dementia CareMany people have come to view cardiopulmonary resuscitation (CPR) as a routine intervention following cardiac arrest, and they insist on CPR for their loved ones even when the physician explains its likely futility. Physicians who refuse a family member’s request to perform unwarranted CPR risk becoming the center of media, legal, and disciplinary scrutiny. Although CPR is largely perceived as a benign life-saving intervention, it inflicts indignity and possibly pain on a dying patient and should not be used when it is unlikely to succeed or to benefit the patient if successful. The growing acceptance of do-not-resuscitate orders for patients with advanced cancer has not spread to families of patients suffering from the late stages of other degenerative or terminal illnesses. Having blunt discussions about the true consequences and risks of CPR might foster greater willingness to abstain from administering CPR to patients unlikely to benefit. This article was originally published by HMP Communications LLC (Annals of Long-Term Care: Clinical Care and Aging), 05/16/2011. A Diffuse Rash in a Patient Infected with HIVKeywords: Syphilis; Treponema pallidum; HIV.
A 27-year-old MSM, presented to care with a rash. The rash appeared several weeks prior to presentation and involved the face, chest and back, arms and legs and was not accompanied by pruritus. He denied fever, chills, but complained of fatigue. No respiratory, gastrointestinal or urinary symptoms were present. He disclosed a diagnosis of HIV infection a year earlier, but has not kept his follow up appointments and was not receiving anti-retroviral medications or opportunistic infection prophylaxis. His most recent CD4 count was 109/mm3. He admitted sexual encounters with several male partners with inconsistent condom usage, and recalled a penile lesion that was present several weeks before the rash had appeared. The lesion has healed without specific therapy.
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There have been some significant developments at Health Plexus, the publisher of this Journal. At the beginning of the year we 
