Improving the integration of informal caregiving in long-term residential care

Informal caregiving is defined as care provided by family and friends to a relative or friend residing in a long-term residential care (LTRC) situation. The role of informal caregivers is significant. Informal caregivers contribute more than 44 million hours of care work in LTRC facilities each year; a number that will more than double to 107 million hours in 2038 (source: Canadian Alzheimer Society). These contributions are essential given the current pressures on LTRC, which include an increasingly acute and medically/socially complex resident population and staffing levels that are typically below industry standards. Dr. Jennifer Baumbusch is conducting a series of studies focused on understanding how informal caregivers currently participate in LTRC. Dr. Baumbusch is asking the following research questions in order to better understand the role of informal caregiving and to develop and refine policies and practices to improve the integration of informal caregiving in LTRC. In what ways do informal caregivers contribute to the care of their relative? In what ways do informal caregivers contribute to the care of other residents? How do the informal caregivers’ contributions affect the everyday facility routines, such as recreational activities and meal times? Research will take place on regular units and on Special Care Units for residents with Alzheimer disease and related dementias and will recognize the unique needs of this specialized population. This program will incorporate ethnographic approaches and will be guided by input from community stakeholders. Research findings will be consolidated with existing literature to provide the basis for knowledge translation activities which will include policy forums that foster a national dialogue about caregiving in LTRC, collaborative knowledge translation research, and arts-based knowledge translation approaches. The aim of this program is to improve the integration and recognize the unique contributions of both informal caregivers and formal caregivers (staff) to care provision. Generating new policy directions will contribute to more effective healthcare services within LTRC and will ultimately improve the health of aging Canadians living in LTRC.

An investigation of cognitive behavioural therapy, mindfulness, and predictors of psychological treatment response among women with provoked vestibulodynia

Provoked vestibulodynia (PVD) is severe pain at the vaginal opening and the most common form of chronic genital pain in women. Although as many as 14 per cent of Canadian women and 20 per cent of adolescents are affected by this condition, it is frequently underdiagnosed and undertreated, and as a result, many women experience sexual difficulties, emotional distress, and multiple medical visits. Although different types of treatment exist, ranging from medication to psychological therapy, the best treatments to reduce PVD pain and distress, and which patients will benefit the most, are not known. Evidence indicates that psychological therapies such as cognitive behavioural therapy (CBT) and mindfulness-based therapy (MBT) are effective at reducing pain and sex-related distress for women with PVD. CBT is designed to challenge thoughts and uses active strategies (e.g. progressive muscle relaxation to decrease muscle tension) to change one’s experience, whereas MBT teaches individuals to be nonjudgmental and accepting of their experience and to learn to live without reacting to pain. Dr. Kelly Smith’s aim is to determine whether CBT or MBT is the most effective approach for reducing PVD pain and improving women’s quality of life, and she will determine which patient characteristics are associated with better responses to these treatments. She will be examining personal and medical characteristics for women with PVD who participated in the Multidisciplinary Vulvodynia Program, a treatment program based at Vancouver General Hospital for women with chronic genital pain. She will then study whether CBT or MBT is related to greater pain reduction and improvements in sexual function/emotional distress in a group of 70 women participating in an 8-session CBT or MBT group program. At the end of the study, women will be interviewed to assess their satisfaction with the program and provide feedback on how to improve the program. Dr. Smith’s studies will be the first to provide information on which of these psychological treatments works best for specific types of women with PVD. This information will provide clinicians with evidence-based guidance regarding potential treatment recommendations and will be essential in helping to reduce the health and economic burdens associated with PVD. Dr. Smith’s final results will be communicated to physicians and other health providers in British Columbia, and her findings will be submitted for publication in professional, wide-reaching health journals.

Effects of Adult Aging on Neural Control and Muscle Fatigue

Individuals 65 years of age and older constitute the fastest growing age group in Canada. With natural adult aging, the neuromuscular system (the muscles of the body and the nerves that supply them) undergo degenerative changes that are characterized by reductions in strength and power due to decreased muscle size. This age-related muscle weakness and overall decline in muscle function is referred to as sarcopenia. Sarcopenia not only interferes with tasks as lifting and carrying groceries, navigating stairs, and performing smooth complex movements, it is highly linked to physical disabilities and risk of falls. Sarcopenia is caused by a decrease in the number and function of motor units (MU), which consists of a single nerve branch and all of the muscle fibres it supplies. During the aging process, some of the MUs die off, while other MUs change structurally to compensate. As a result, there are fewer MUs present, but each one supports more muscle fibers. This MU remodeling process is a compensatory mechanism that acts to maintain muscle strength until a critical threshold is reached and strength decreases at an accelerated rate, usually by the eighth decade of life.

To understand the underlying biological mechanisms of MU remodeling, Dr. Brian Dalton is using a technique called single-unit microneurography. This research tool uses tiny electrodes inserted through the skin and into a peripheral nerve to stimulate and record signals from individual MUs. Using this technique, he will measure the integrity of functioning MUs in aged adult volunteers to determine if MU remodeling impairs neuromuscular function and muscle performance in the older adult. This work will help build a more comprehensive understanding of the neuromuscular system, specifically the process of sarcopenia and how it impacts natural adult human aging. The information gained from this study will aid in the design of functional training programs to improve and maintain muscle function — and quality of life — in older adults.

Adherence to Immunomodulators in Multiple Sclerosis: Prevalence and Clinical Impact (The AIMS Study)

Taking prescribed medications as intended, or “”adherence”” is an important strategy for the management of chronic diseases. Half of the individuals with a chronic disease have poor medication adherence, and research has shown that people with poor medication adherence often have more health problems, higher hospitalization rates and a higher risk of death. Not surprisingly, medication non-adherence is extremely expensive, and is estimated to cost the Canadian health care system $8 – 10 billion every year. With an estimated 75,000 Canadians affected, and three new people being diagnosed every day, Canada has one of the highest rates of MS in the world. Multiple sclerosis (MS) is a chronic disease of the brain and spinal cord, leading to disability, severe fatigue and coordination problems. Although there is no known cure, immunomodulatory drugs (IMDs), are now commonly prescribed for MS and can lead to a substantial improvement in the health of people with MS. The benefits of IMD therapy might not be realized in people who have poor adherence; currently very little information is known about adherence to these medications. Dr. Charity Evans is working to determine how many individuals with MS have good adherence to these medications, and if people with poor adherence have higher rates of hospitalizations or worsening of the disease. She will also work to identify any time periods during therapy when an individual is more likely to be non-adherent to their IMD. Dr. Evans will be using administrative health data from three provinces (British Columbia, Saskatchewan and Manitoba), and will be studying those individuals with MS who have received an IMD between 1995 and 2008. The results of this research study will be important to determine the impact that non-adherence may have on patient health outcomes in MS, and will also help identify factors to optimize adherence to MS therapies. These methods will also be applicable to the study of adherence in other chronic diseases requiring similar drug therapies.

The anti-inflammatory effects of exercise in patients with chronic obstructive pulmonary disease

The number of individuals suffering from chronic obstructive pulmonary disease, or COPD is on the rise in Canada and around the world. COPD, is an inflammatory disease primarily associated with lung inflammation. Inflammation also extends beyond the lungs, and the presence of inflammatory factors in the blood causes blood vessel and heart disease, increasing a COPD patient’s risk of heart attack and stroke. Exercise training is known to have anti-inflammatory effects that are beneficial in the treatment and prevention of a number of chronic conditions. However, the effects of exercise on inflammation in the airways and blood of COPD patients is not well understood. It is also unknown whether exercise training can reverse some of the detrimental effects of inflammation in the blood vessels and brains of patients with COPD and reduce their risk of having a heart attack or stroke. To answer these important questions, Dr. Neil Eves will be conducting two studies. His first study will investigate how exercise training affects the airway and blood inflammation of patients with COPD. His second study will investigate how exercise training improves blood vessel function in patients with COPD and whether these improvements are related to changes in inflammation. Reducing inflammation with exercise in patients with COPD could greatly improve the health of these patients and reduce secondary morbidities associated with the disease.

Investigating pharmaceutical policies, coverage, and costs

Prescription medicines play a key role in the treatment and prevention of disease, as evidenced by the fact they are the second-largest and fastest-growing component of health care expenditures in British Columbia. Dr. Michael Law's research program includes studies on the broad themes of pharmaceutical policies, coverage, and costs. Pharmaceutical Policies. In January 2009, a policy change in British Columbia gave pharmacists the authority to independently modify and renew prescriptions. While this policy was intended to improve patient access to drugs and reduce the already heavy burden on primary care physicians, concerns have been raised about potential negative effects on patient safety due and reduced continuity of care. This policy has not been rigorously evaluated.

Dr. Law is currently studying the effects of this policy change on drug utilization and costs, patient adherence to medication, and the number of visits patients make to physicians and hospitals. Pharmaceutical Coverage. Canadians pay for prescription drugs through a patchwork of mechanisms, including public drug programs, private drug insurance, and out-of-pocket payments. In 2008, private insurers paid $9.3 billion in drug costs, representing 31% of overall expenditure. Despite this, we have little sense for how private health benefits plans are changing in light of tough economic times. He is currently leading an investigation into private drug insurance benefits in Canada. Pharmaceutical Costs.

Dr. Law is conducting a series of studies on pharmaceutical costs. This research includes a Health Canada-funded study investigating the factors related to cost-related non-adherence to prescription medicines, an investigation into generic drug prices in Canada compared to international peers, and a continuation of his past work studying the influence of direct-to-consumer advertising on prescribing of medicines. Dr. Law’s research promises to help inform the future design and refinement of important and controversial pharmaceutical policies, provide insights into the trends in private drug insurance benefits in Canada, and create greater understanding of the influence of drug pricing on compliance. This research has the potential to create important changes in the health care system.

Mitigation of hippocampal dysfunction and cognitive deficits in early-symptomatic YAC128 transgenic mice for Huntington’s disease

Huntington's disease is a devastating neurodegenerative disorder affecting between three and 10 individuals per 100,000 in the Western world. It is caused by a mutation in the huntingtin gene, which results in the accumulation of mutated huntingtin protein in the brain and the eventual degeneration of certain types of brain cells. The disease is primarily characterized by the onset of motor deficits; this develops when the striatum region deep within the brain begins to degenerate. However, Huntington’s disease patients commonly show cognitive impairments decades before the onset of the motor symptoms. The hippocampus is a brain region known to be involved both in cognitive (i.e. learning and memory) and emotional (i.e. depression) processes.

Dr. Joana Gil-Mohapel is investigating whether the hippocampus is involved in the early cognitive impairments in Huntington’s disease. She is working with a mouse model of Huntington’s disease, which closely mimics the human condition. These mice demonstrate profound structural and functional deficits in this region; significantly, as seen in Huntington’s disease patients, these deficits can be detected when the animals are still in an early-symptomatic stage, before the onset of motor symptoms. Therefore, the goal of the present research is to gain a better understanding of how this structure is affected in this mouse model.

Dr. Gil-Mohapel will investigate whether relevant cellular pathways are altered in this brain region and whether therapies aimed at promoting hippocampal function can reverse these deficits and be of therapeutic value for Huntington’s disease. She hopes her research will help elucidate novel targets for the mitigation of the cognitive deficits characteristic of early-stage Huntington’s disease patients.

OCD translational multi-modal research program

According to the World Health Organization, obsessive-compulsive disorder (OCD) is one of the top 10 causes of disability. The disorder often begins in childhood and interferes with normal development. This disabling mental illness affects approximately 2 – 3 percent of British Columbians and, although treatable, is often under diagnosed.

The aim of Dr. S. Evelyn Stewart's research program is to improve the lives of BC children and families living with OCD. Her goal is to improve the evaluation and awareness of pediatric OCD in BC by conducting research to guide scientific and clinical understanding of OCD and its management by health professionals, and by establishing national and international linkages, which will lead to future research collaborations. Dr. Stewart's specific objectives for the first five years are to 1) create a unique research program within the new pediatric OCD clinic at BC Children's Hospital that is closely tied with the community, 2) establish a pediatric OCD DNA and research data site for BC, 3) launch a comprehensive patient-assessment method, and 4) investigate the outcomes and effectiveness of the program itself.

This program is unique, as it pulls together expertise from the clinic, the community and the laboratory. One important feature of Dr. Stewart's program is the effective transfer of new information between the clinic and the research lab in order to help the outcomes of practice inform research. Dr. Stewart anticipates this program will help limit the suffering and health-care costs related to OCD. The program is anticipated to develop into the first North American OCD Centre of Excellence.

The role of astrocytes in the brain vascular response to neural activity

Sufficient blood flow to the brain is critical for normal brain function. In response to increased brain activity, a local increase in blood flow to the active area is required to supply extra oxygen and glucose. This increase in blood flow is controlled by signaling molecules, which are released by neurons and astrocytes and can regulate blood vessel diameter. Dr. Clare Howarth will investigate how brain blood flow is controlled in response to increases in brain activity and how this is impaired in disease. In particular, she will be studying the role that astrocytes, a type of brain cell, play in the regulation of brain blood flow. One of the signaling molecules released by astrocytes, prostaglandin E2, can result in blood vessel dilation. Dr. Howarth’s hypothesis is that following a stroke, astrocytes have a decreased ability to produce prostaglandin E2, and this contributes to the long-lasting failure of blood vessels to dilate, leading to increasing neuronal damage. Using multi-photon imaging techniques, she will observe what happens to blood flow in the brain when astrocytes are stimulated with pharmaceutical or light-activated agents under conditions where the production of these signaling molecules is compromised. She will also investigate whether pharmaceutical therapies are able to reverse the effect, allowing blood vessels to dilate and help recover brain function after a stroke. This work will advance our understanding of how brain blood flow is regulated in response to neural activity. This knowledge is essential to understanding normal brain function, functional imaging techniques, and what occurs when the brain energy supply is cut off in disorders such as a stroke.