Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.
 

Learning Objectives

When it comes to dementia much of the focus is related to diagnosis and treatment(s). A terminal phase is not always considered with conditions that cause dementia-but must be to properly plan care.

To address clinical and ethical challenges that face health care providers and families for this population and to provide health care providers with processes by which to address such ethical dilemmas.

Keywords: dementia, caregiving, end-of-life planning

I
have the pleasure of introducing the latest edition of the Journal Of Current Clinical Care. As always there are a multitude of noteworthy developments to report and
a variety of interesting and clinically relevant topics that are covered in this issue.

As hinted in my last editorial, I am pleased to welcome Dr. Charles Lynde as Editor-in-Chief for the Dermatology Educational Resource @HealthPlexus and the Journal of Current Clinical Care. Dr. Lynde with the help of his fellow editors Drs. Anne
Goodfellow, John Kraft and Francesca Cheung, will spearhead a Dermatology
section on www.healthplexus.net and the Journal of Current Clinical Care. For this edition, Shahana Nathwani and Dr. Joseph Lam from the University of British Columbia provide an approach to ‘lumps and bumps’ in the pediatric population. There are
a number of conditions that present clinically as ‘lumps and bumps’ in this age group.
Some of these follow a benign course and can be safely observed, and others are more
concerning and require definitive therapy and may even result in serious complications.
A helpful feature of the article is a practice helper tool: A menu of cutaneous lesions in
the pediatric population categorized according to colour.

I am also happy to introduce our new department called Infographics. Going
forward we will select a topic and present the information and facts in an exciting and
visually informative format. In this issue our choice of condition to present as an infographic is Ulcerative Colitis, an important topic for which we are also developing a
CME program that is scheduled for release later this year.

Another first that we are introducing in this issue is a Lecture Series department.
Dr. Michael Gordon, the Medical Program Director at Baycrest Geriatric Health
Care System at the University of Toronto, is one our regular contributors, and is the
Editor-in-Chief of our Dementia Educational Resource, gives an engaging talk on Later
Stage Dementia and focusing on Promotion of Comfort, Compassion and Care, complete with video and slides.

Also in this issue, Dr. Michael Gordon in his article When to Have the Critical
Conversation? Issues in Planning for Persons with Dementia and their Caregivers,
uses a poignant family vignette to remind us that as health care providers we should
encourage families and our patients to initiate conversations early regarding treatment
at the end of life.

Drs. Lovingly Quitania Park and Sarah Tomaszewski Farias from the
Department of Neurology at the University of California at Davis review the concept of
Functional Limitations Predict Future Decline in Mild Cognitive Impairment (MCI).
MCI is a term used to describe a transitional stage between normal aging and dementia.
In MCI there are subtle changes in everyday activities that may indicate the presence
of an under lying neurodegenerative condition, however patient independence is maintained. The authors review how to assess for cognitive impairment in this population
and the prognostic implications of on subsequent conversion to dementia and the rate
of progression of dementia.

The effects of caregiver burden are often expressed as a decline in psychological and
physical health, as well as an increase in physician visits. In the article, Identifying and
Managing Caregiver Burden Among Spouses of Individuals with Parkinson’s Disease Dr. Andrew Johnson et al., examines some of the predictors of caregiver burden,
with a specific emphasis on the burden experienced by caregivers of individuals with
Parkinson’s disease. Helpful strategies for relieving caregiver burden are also reviewed.

I hope you enjoy this edition of the journal. As always, your comments and questions are welcomed.

Skin is the body’s largest organ. It acts as a protective layer between the insides and the rest of the world, helps regulate body temperature, acts as a natural filter and is constantly growing. It’s affected by every aspect of our life, by what we eat and the environment. Skin that is healthy is able to resist signs of aging, heals faster and can even stave off potential disease. It often manifests some underlying diseases and when it’s visually altered or damaged can make a profound effect on one’ quality of life.

As the newly appointed Editor-in-Chief for the Dermatology Educational Resource @HealthPlexus and the Journal of Current Clinical Care and with the help of my fellow editors Drs. Anne Goodfellow, John Kraft, and Francesca Cheung, we will solicit, organize and present to you educational materials of relevance to primary care practitioners and specialists alike by asking for contributions from recognized Key Opinion Leaders in the field of Dermatology on evidence-based best practices and treatment options.

In this issue, we are featuring the first article in our dermatology section titled Common Lumps and Bumps in Children: A Colour-coded Differential. Dr. Joseph Lam and Shahana Nathwani examine the many conditions that present as ‘lumps and bumps’ in the pediatric population. While some follow a benign course, others require definitive therapy or carry the potential for serious complications. Their review presents and categorizes common pediatric cutaneous lesions according to colours as a tool to help the general practitioner recognize and remember these lesions.

If you have questions, interested in serving as a contributor or peer-reviewer please reach out to us at contactus@healthplexus.net

I hope you enjoy this issue of the Journal. Feedback and discussion, as always, is welcomed.

Kelly J. Murphy, PhD, C.Psych., Neuropsychologist, Neuropsychology & Cognitive Health, Baycrest; Assistant Professor, Psychology, University of Toronto.
Angela K. Troyer, PhD, C.Psych, Professional Practice, Chief of Psychology, Baycrest, Assistant Professor, Psychology, University of Toronto.

Abstract
Dementia is characterized by multiple cognitive impairments that cause significant functional decline. Based on this brief definition, the initial expectation might be that recognizing dementia in a patient is straightforward. Not true. Recognizing dementia can be tricky, particularly in patients who present as alert, socially appropriate, and capable of providing reasonable answers to questions. We briefly outline signs on casual observation that would prompt investigation into a patient's current cognitive and functional status to determine the presence of dementia during a routine visit. Approaches to screening for cognitive and functional decline are described along with first-step recommendations to connect patients and families with resources. The front-line clinician plays a pivotal role in identifying dementia with earlier intervention having the most potential to offset the burden on patients, families, and society.
Keywords: dementia, activities of daily living, functional decline, cognitive decline.

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.

Of the many challenges that face families when looking after their older loved ones, of the most difficult is deciding on end-of-life decisions. The accepting or rejecting artificial nutrition and hydration, apparently life-saving antibiotic intervention for an aspiration pneumonia or urinary tract infection or the implementation of theoretically life-saving cardio-pulmonary resuscitation are among the many decisions that substitute decision-makers, who are often close family members, have to make. More often than not, these types of decisions are required in urgent situations where a time-consuming deliberative process that might be expected for a well-thought out decision to be reached is not possible because of the pressures of the potentially fatal clinical situation. Proper preparation for such eventualities usually requires time and thought that includes exploration of personal values and wishes in what ideally should occur during conversations between older loved ones at risk of or in the throes of dementia when discussions might still take place. These revealing communications must occur with those that are responsible for making these very personal and potentially life-altering clinical decisions.

On May 4^th and 5^th 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
Editor-in-Chief, Dementia Educational Resource
www.healthplexus.net and the Journal of Clinical Care
and
Member of CCCDTD2012 Steering Committee
Ethics Consultant to the Committee

About Health Plexus:
Comprised of 1000s of clinical reviews, CMEs, bio-medical illustrations and animations and other resources, all organized in the 34 condition zones, our vision is to provide physicians and allied healthcare professionals with access to credible, timely and multi-disciplinary continuing medical education from anywhere and on any media consumption device. The Dementia Educational Resource is the compilation of high quality clinical reviews, online CME programs, library of original visual aids, interviews, roundtable discussions and related conference reports.

Shahana Nathwani, BHK, Faculty of Medicine, University of British Columbia, Vancouver, BC.
Joseph M Lam, MD, FRCP(C), Clinical Assistant Professor, Department of Pediatrics, Associate Member, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, BC.

Abstract
Many conditions present as 'lumps and bumps' in the pediatric population. Some follow a benign course and can be safely observed with parental education and reassurance. Others require definitive therapy or carry the potential for serious complications. Understanding and recognizing the different lesions will help guide the care, counseling and management of patients with these common 'lumps and bumps'. This review presents and categorizes common pediatric cutaneous lesions according to colours as a tool to help the general practitioner recognize and remember these lesions.
Keywords: benign; pediatric; tumours; vascular; hemangioma; nevus.