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It is a positive step for all of us trying to care for those living with dementia and their families to learn that the World Health Organization (WHO) has produced a far-reaching report outlining the world-wide challenge faced by nations whose populations will be affected by increasing numbers of those afflicted with Alzheimer's disease and other causes of dementia. The report entitled, "Dementia: A Public Health Priority",  gives a world-wide perspective and reiterates the already known Canadian statistics which estimates about half a million people living with some sort of dementia in 2010 with an estimated increase to 1.1 million by 2025 if nothing dramatic happens in terms of preventative treatments over the coming years.

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.

The problem in Canada with expecting the federal government to embark on a national strategy is that unlike the nations cited as having national strategies which in fact have national health services, Canada does not really have a national health service. Rather it has a nationally mandated framework for provincially run-health care systems under the umbrella legislation known as the Canada Health Act, often referred to as Canadian Medicare. In essence what Canada has are provincial health care systems, all of which share commonalities, but which differ enormously in the spectrum of services provided beyond the federally mandated (through the Canada Health Act) physician and hospital services. Therefore each province has its own approach to home care, long-term care, pharmacare, and family support systems for those experiencing a wide range of ailments of which dementia is just one of many that can have a devastating effect on individuals and their families.

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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
Editor-in-Chief, Dementia Educational Resource
www.healthplexus.net and the Journal of Clinical Care

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.

Liesel-Ann Meusel¹, PhD, Ekaterina Tchistiakova^2,3, BSc, William Yuen^4,5, BSc, Bradley J Macintosh^2,3, PhD, Nicole D Anderson^1,6, PhD, and Carol E Greenwood^4,5, PhD
¹Rotman Research Institute, Baycrest Centre, Toronto, ON. ²HSF Centre for Stroke Recovery, Sunnybrook Research Institute, Toronto, ON. ³Department of Medical Biophysics, Faculty of Medicine, University of Toronto, Toronto, ON.
⁴Kunin-Lunenfeld Applied and Evaluative Research Unit, Baycrest Centre, Toronto, ON. ⁵Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON. ⁶Departments of Psychology and Psychiatry, University of Toronto, Toronto, ON.

Abstract
Type 2 diabetes mellitus is increasingly common, and previously unrecognized complications are emerging; namely, cognitive impairment and dementia. The mechanisms that link these factors together are still unknown, but likely result from the interplay of several variables, including vascular change, poor glycemic control, inflammation, and hypothalamic pituitary adrenal overactivity. At present, it is still too early to propose best practices related to the management of diabetes-induced cognitive change. All things considered, however, patients should be aware that proper management of metabolic and vascular complications may minimize the adverse effects of type 2 diabetes on cognitive function and quality of life.
Keywords: type 2 diabetes, cognition, dementia, vascular, metabolic.

D’Arcy Little, MD, CCFP, FRCPC, Medical Director, JCCC and www.healthplexus.net

There have been some significant developments at Health Plexus, the publisher of this Journal. At the beginning of the year we launched our first “specialty” channel—the Dementia Educational Resource. Considering that the founding members of Health Plexus have deep historical roots in Geriatrics, it was only natural to build a dedicated team to address the tremendous interest of our readership in the area of Dementia. Dr. Michael Gordon has assumed responsibility of Editor-in-Chief for the Dementia Educational Resource. Please see Dr. Barry Goldlist’s interview with Dr. Michael Gordon in this issue and stay tuned for further announcements on similar launches of other specialty channels. I have a hint for you, the next has something to do with the skin...

The Journal of Current Clinical Care and www.healthplexus.net are innovative educational platforms and social forums for knowledge transfer and are a medium for sharing ideas. We encourage dialogue and are asking our readers to step in and participate in the development of content. We also welcome individuals or professional groups to lead the development of specialty channels where they would be able to share their expertise.

I have the pleasure of introducing the first issue of 2012 of the Journal of Current Clinical Care. This issue addresses a variety of interesting and clinically relevant topics.

Dr. Andrew Johnson et al., present the topic The Hidden Cost of Cognition: Examining the Link Between Dual-Task Interference and Falls. The article acknowledges that falls are a leading contributor to mortality and morbidity in older adults. Cognition is important factor in falls, as individuals who are unable to orient an appropriate amount of attention to the task of maintaining safe and stable balance are more likely to fall. They describe several strategies to address falls prevention in this context.

Dr. Yoav Keynan et al., present a case study of a Diffuse Rash in an HIV Infected Patient, reminding us that syphilis incidence is currently increasing in North America, and that HIV infection is present in 1/5 of individuals diagnosed with syphilis.

In his article, Helping Families Worried about Developing Dementia: Strategies to ease the Burden Stress, Fear and Guilt, Dr. Michael Gordon presents some of the challenges of and some practical strategies for caregivers of patients with dementia.

Type 2 diabetes mellitus is increasingly common, and previously unrecognized complications are emerging, including cognitive impairment and dementia. The article, Vascular and Metabolic Contributions to Cognitive Decline and Dementia Risk in Older Adults with Type 2 Diabetes, by Liesel-Ann Meusel et al., emphasizes that proper management of metabolic and vascular complications of diabetes may minimize the adverse effects on cognitive function and quality of life.

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

Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Jeffrey D. Holmes, MSc(OT), PhD, Assistant Professor, School of Occupational Therapy, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Kevin Wood, BHSc, Research Assistant, Health and Rehabilitation Sciences, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Mary E. Jenkins, BSc(PT), BEd, MD, FRCPC, Associate Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.

Abstract
“Accidents” (specifically falls) are a major contributor to death among older adults (defined as individuals over the age of 65). Falls contribute to ongoing mobility issues, and make it difficult for individuals that have sustained a fall, or who are at significant risk for a fall, to live independently.
Keywords: cognition, falls, dual-task interference

Many 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.

Keywords: 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.

On physical examination: in no apparent distress, vital signs were within normal limits.

Notable finding on the examination included multiple small and non-tender anterior cervical, posterior cervical, axillary and inguinal lymph nodes. Genital examination revealed a healed lesion on the glans penis. A macular skin rash was widely distributed over face, trunk and extremities with several lesions on palms and soles (figure 1. and 2.)

1. What is your diagnosis?
2. Would you obtain a lumbar puncture?

by Michael Gordon, MD, MSc, FRCPC, FACP, FRCPEdin
with Natalie Baker, BA, MSc
Publisher: iUniverse Publishing
Reviewed by: D’Arcy Little, MD, CCFP, FRCPC

Modern medicine may offer seemingly promising treatments, but eventually, the impact of Alzheimer's disease and other ailments of dementia can cause profound deterioration in the patient's quality of life. The focus must eventually shift to compassionate end-of-life care.

Michael Gordon in his new book “Late-Stage Dementia: Promoting Comfort, Compassion, and Care” shares his extensive experience with health care professionals and families struggling with these poignant and difficult decisions.

If you are a health care professional who is responsible for caring for frail elders and agrees with the sentiment: “I want to provide the best care possible” or you are a family member of a patient with later stages of dementia and trying to ensure the most compassionate care for your loved one and struggle with painful decisions when confronting the inevitable while providing love, compassion and care, you may want to source this book. It is available online at Amazon.ca and Chapters.

And here you may read and watch what Dr. Gordon says about his latest book himself:  Dealing with difficult choices in end-stage dementia

Kaitlyn Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia, Kelowna, BC.
Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Mary E. Jenkins, BSc(PT), BEd, MD, FRCPC, Associate Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.

Abstract
Burden is a psychological concept, a subjective interpretation by caregivers of the extent to which the caregiving experience impacts on one's health, social life, or financial status. In this article, we examine some of the predictors of caregiver burden, and look specifically at the burden experienced by caregivers of individuals with Parkinson's disease.
Keywords: Parkinson's disease, psychological health, physical health, caregiver burden

Fatemeh Akbarian, MD, Research Fellow, University of Toronto, Toronto, ON.
Hatim Al Lawati, MD, FRCPC, Cardiology Resident, Division of Cardiology, Faculty of Medicine, University of Toronto, Toronto, ON.
Mohammad Ali Shafiee, MD, FRCPC, General Internist, Nephrologist, Department of Medicine, Toronto General Hospital, University Health Network; Clinician Teacher, University of Toronto, Toronto, ON.

Abstract
Proteinuria can create one of the greatest challenges in primary practice, especially in the geriatric population. It is typically detected by dipstick urinalysis, an ordinary, non-invasive test. Proteinuria is frequently a marker of unsuspected kidney disease, progressive atherosclerosis or a systemic disease. There is a strong correlation between urinary protein excretion and progression of renal failure. Furthermore, Proteinuria is a strong and independent predictor of increased risk for cardiovascular disease and death, especially in people with diabetes, hypertension, chronic kidney disease, and the elderly. This article will review the clinical significance of proteinuria in adults, especially in the elderly population, and provide a practical diagnostic approach in addition to a summary of non-specific antiproteinuric therapy.
Keywords: Proteinuria, Microalbuminuria, Macroalbuminuria, elderly, Risk Factor.

Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario,
London, ON.
H. Christopher Hyson, MD, FRCPC, Assistant Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.
Kaitlyn P. Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia Okanagan, Kelowna, BC.

Abstract
Although Parkinson’s disease is primarily considered to be a motor disorder, it has inarguable effects on cognition and personality. The cluster of neuropsychiatric sequelae known as impulse-control disorders has been of particular interest in recent years, perhaps owing to the potentially disastrous effects that such behaviors can have on individuals and families. Research has suggested that impulse control disorders are significantly more prevalent among individuals with Parkinson’s disease, particularly with regards to pathological gambling and hypersexuality, and has further suggested that these disorders are significantly and substantively affected by the use of dopamine agonists. Treatment options for impulse control disorders tend to revolve around dopamine agonist dose reduction or cessation. The use of psychosocial strategies, or deep-brain stimulation of the subthalamic nucleus may also be considered in the management of patients with impulse control disorders.
Keywords: Impulse control disorders, Parkinson’s disease, dopamine agonists service use.