The Canadian Stroke Best Practice Recommendations (CSPR) 7th edition includes this new module on the diagnosis and management of vascular cognitive impairment (VCI) with or without neurodegenerative disease. An expert writing group and people with VCI lived experience (PWLE) reviewed current evidence. Existing recommendations were reviewed and revised, and new recommendations added. Sections include definitions, signs and symptoms, screening, assessment, diagnosis, pharmacological and non-pharmacological management, secondary prevention, rehabilitation, and end-of-life care. PWLE were actively involved in all aspects of the development, ensuring their experiences are integrated. A unique VCI journey map, developed by PWLE, is included, and helped to motivate and anchor the recommendations. We encourage it to be displayed across healthcare settings to raise awareness and support persons with VCI. These VCI CSBPRs emphasize the need for integrated multidisciplinary care across the continuum. Evidence for the diagnosis and management of VCI continues to emerge and gaps in knowledge should drive future research.Highlights This Canadian Stroke Best Practice Recommendations module focuses specifically on VCI using a structured framework and validated methodology. A comprehensive set of evidence-based recommendations is presented that addresses the continuum from symptom onset to diagnosis, management, and end of life. The recommendations consider individuals who experience VCI because of stroke or because of other vascular pathologies such as atrial fibrillation or heart failure. A journey map of an individual's experience with VCI has been developed by individuals with lived experience. It is a valuable guide to inform educational content, approaches to caring for individuals and families with VCI, and systems planning.

Improving supports to enhance wellbeing of people living with dementia is a priority. Engaging people living with dementia, care partners, and other stakeholders in development of interventions increases the likelihood they will be relevant and impactful. We describe the participatory approach used to co-design the Dementia Lifestyle Intervention for Getting Healthy Together (DELIGHT) program, which aims to promote the health and wellbeing of people living with dementia and care partners. The DELIGHT project was guided by a team of researchers, people living with dementia, care partners, and an Alzheimer Society representative. The co-design team included additional people living with dementia, care partners, exercise professionals, dietitians, health care professionals, and community service providers (n = 29). The co-design was planned for in-person but was transitioned to six online, 1.5-h sessions due to COVID-19 related restrictions. We used breakout rooms for discussion, with people living with dementia in each breakout room. Co-design meetings focused on identifying target population and outcomes and developing program components and structure. Two or three guiding questions focused discussion in each meeting. The final co-design session focused on the overall structure of the DELIGHT program. Program resources were iteratively designed with the research team, co-design team, and other external stakeholders. The result of the co-design process was the DELIGHT program, an 8-week, twice weekly program designed to promote living well with dementia for people living with dementia and care partners. Each session includes 50-60 minutes of exercise and 20-30 minutes of facilitated, shared learning with an associated resource. A healthy snack may be offered. Shared learning focuses on healthy eating, sleeping well, mental well-being, social connection, and physical activity. Our vision is that the co-designed DELIGHT program will promote the health and wellbeing of people living with dementia and care partners, increasing the likelihood of living well with dementia.

Background During the pandemic, there has been significant social media attention focused on the increased COVID-19 risks and impacts for people with dementia and their care partners. However, these messages can perpetuate misconceptions, false information, and stigma. Objective This study used Twitter data to understand stigma against people with dementia propagated during the COVID-19 pandemic. Methods We collected 1743 stigma-related tweets using the GetOldTweets application in Python from February 15 to September 7, 2020. Thematic analysis was used to analyze the tweets. Results Based on our analysis, 4 main themes were identified: (1) ageism and devaluing the lives of people with dementia, (2) misinformation and false beliefs about dementia and COVID-19, (3) dementia used as an insult for political ridicule, and (4) challenging stigma against dementia. Social media has been used to spread stigma, but it can also be used to challenge negative beliefs, stereotypes, and false information. Conclusions Dementia education and awareness campaigns are urgently needed on social media to address COVID-19-related stigma. When stigmatizing discourse on dementia is widely shared and consumed amongst the public, it has public health implications. How we talk about dementia shapes how policymakers, clinicians, and the public value the lives of people with dementia. Stigma perpetuates misinformation, pejorative language, and patronizing attitudes that can lead to discriminatory actions, such as the limited provision of lifesaving supports and health services for people with dementia during the pandemic. COVID-19 policies and public health messages should focus on precautions and preventive measures rather than labeling specific population groups.

Background:Patient and public involvement/engagement in research on dementia is not new, but it is becoming increasingly common. The objective of this study was to describe researchers' knowledge, attitudes, and activities related to engaging people with lived experience of dementia in research, and how these differ by research theme.Methods:Data were from an online, anonymous survey of researchers within the Canadian Consortium on Neurodegeneration in Aging.Results:Of the 84 researchers who completed the survey (response rate: 27%), 89% agreed they understood the meaning of engaging people with lived experience in research, although this was lower among biomedical researchers. Almost all (93%) agreed that people with lived experience could contribute meaningfully to research, and nearly two-thirds were already incorporating engagement in their research. Some engagement practices reported differed by research theme. Irrespective of the type of research they conduct, researchers were most often motivated by improving the relevance and quality of their research.Conclusions:These findings support an optimistic outlook for engaging people with lived experience of dementia in research, but identify differences across research themes. Understanding approaches to incorporate, evaluate, and adapt engagement activities across research disciplines are needed to enable researchers, as well as others involved in research, to develop and target strategies for patient and public involvement/engagement in research on dementia.

OBJECTIVE:In recognition that engagement in physical activities for persons living with dementia can be challenging in rural and northern communities, the objective of this study was to explore the factors influencing physical activity participation among persons living with dementia in rural/northern communities and to identify the locally-driven mitigation strategies participants used to address barriers to physical activity. SETTING:Interviews and focus groups were conducted in two locations in northern British Columbia, Canada including a rural community (<10 000 persons) and a medium-sized geographically isolated city (<80 000 persons). Both communities are located at substantial distances (>700 km) from larger urban centres. PARTICIPANTS:Twenty-nine individuals participated including healthcare providers (n=8), community exercise professionals (n=12), persons living with dementia (n=4) and care partners (n=5). RESULTS:Rural and northern contextual factors including aspects of the built and natural environment were the main drivers of physical activity for persons living with dementia. Limited capacity in the health system to support physical activity due to a lack of referrals, poor communication mechanisms and limited resources for programming created challenges for physical activity participation. At the community level, local champions filled gaps in physical activity programming by leveraging informal networks to organise opportunities. Programme-level factors included a lack of consistency in staff, and challenges defining programme scope given limited population size and the fear of stigma for persons living with dementia. CONCLUSIONS:Environmental context and limited access to specialised programming affect the opportunities for persons living with dementia to engage in physical activities. Rural and northern communities showed resiliency in providing physical activity opportunities yet remained fragile due to human resource challenges. Without reliable resources and sustained support from the health system, local champions remain vulnerable to burnout. Enhancing support for local champions may provide greater stability and support to physical activity promotion in rural and northern communities.

BACKGROUND:Continuing professional development (CPD) for opioid agonist therapy (OAT) has been identified as a key health policy strategy to improve care for people living with opioid use disorder (OUD) and to address rising opioid-related harms. To design and deliver effective CPD programs, there is a need to clarify how they work within complex health system and policy contexts. This review synthesizes the literature on OAT CPD programs and educational theory to clarify which interventions work, for whom, and in what contexts.METHODS:A systematic review and realist synthesis of evaluations of CPD programs focused on OAT was conducted. This included record identification and screening, theory familiarization, data collection, analysis, expert consultation, and iterative context-intervention-mechanism-outcome (CIMO) configuration development.RESULTS:Twenty-four reports comprising 21 evaluation studies from 5 countries for 3373 providers were reviewed. Through iterative testing of included studies with relevant theory, five CIMO configurations were developed. The programs were categorized by who drove the learning outcomes (i.e., system/policy, instructor, learner) and their spheres of influence (i.e., micro, meso, macro). There was a predominance of instructor-driven programs driving change at the micro level, with few policy-driven macro-influential programs, inconsistent with the promotion of CPD as a clear opioid crisis policy-level intervention.CONCLUSION:OAT CPD is challenged by mismatches in program justifications, objectives, activities, and outcomes. Depending on how these program factors interact, OAT CPD can operate as a barrier or facilitator to OUD care. With more deliberate planning and consideration of program theory, programs more directly addressing diverse learner and system needs may be developed and delivered. OAT CPD as drug policy does not operate in isolation; programs may feed into each other and intercalate with other policy initiatives to have micro, meso, and macro impacts on educational and population health outcomes.

Background Successful best practice implementation is influenced by access to peer support and knowledge exchange. The Toronto Stroke Networks Virtual Community of Practice, a secure social media platform, is a knowledge translation tool supporting dissemination and adoption of stroke best practices for interprofessional stroke stakeholders. Objective The aim of this study is to evaluate the use of a virtual community of practice (VCoP) in supporting regional stroke care best practice implementation in an urban context. Methods A mixed methods approach was used. Qualitative data were collected through focus groups and interviews with stroke care provider members of the VCoP working in acute and rehabilitation settings. Thematic analysis was completed, and the Wenger Value Creation Model and developmental evaluation were used to reflect practice change. Quantitative data were collected and analyzed using website analytics on VCoP use. Results A year after implementation, the VCoP had 379 members. Analysis of web analytics data and transcripts from focus groups and interviews conducted with 26 VCoP members indicated that the VCoP provided immediate value in supporting user networking, community activities, and interactions. Skill acquisition and changes in perspective acquired through discussion and project work on the VCoP were valued by members, with potential value for supporting practice change. Learning about new stroke best practices through the VCoP was a starting point for individuals and teams to contemplate change. Conclusions These findings suggest that the VCoP supports the early stages of practice change and stroke best practice implementation. Future research should examine how VCoPs can support higher levels of value creation for implementing stroke best practices.

Exercise improves functional abilities of persons living with dementia (PLWD) and provides an opportunity for social engagement, support, and inclusion. Yet, there are few exercise programs available to PLWD, especially in smaller communities. The goal of the Dementia-Inclusive Choices for Exercise (DICE) project was to use participatory processes to create evidence-informed knowledge translation (KT) resources to increase the number and quality of exercise opportunities for PLWD.The DICE core team includes PLWD, a family care partner (CP), exercise providers (EPs), dementia service providers (DSPs), health care professionals, and researchers. In the early project stages, we confirmed objectives and conducted 1 survey, 2 interviews, 16 focus groups to better understand barriers to and supports needed for exercise among PLWD. Results led to the prioritizing of primary (EPs) and secondary (PLWD & CP) target audiences for the KT resources. Co-creation of the KT resources followed several steps: 1) drafting content and possible formats for resources over several core team meetings; 2) conducting a one-day workshop with additional PLWD, CPs, EPs, and DSPs to develop a comprehensive plan for the content and format for each resource, target audience, and dissemination strategies; 3) using iterative design among the core team, resource developers, and additional PLWD, CPs, EPs, and DSPs to develop resources; and 4) usability testing.Key information to be translated included understanding the diversity of dementia, rights of PLWD to inclusion, physical activity guidelines/benefits, and dementia-inclusive communication, practices, and design. This information is delivered through the DICE toolkit, which includes a website, on-line training modules and manual targeted at exercise providers, destigmatizing videos that show the stories of PLWD, and resources for PLWD and their CPs to increase knowledge and confidence regarding exercise. Subsequent usability testing among EPs, PLWD, and CPs (n=7) identified design and content adjustments. Collaborative and inclusive decision making created improved relationships and ongoing learning between all stakeholders.The participatory approach of the DICE project enabled stakeholders to identify and share perspectives and needs throughout the co-creation process. Working collaboratively and iteratively with a diverse team ensured that the DICE toolkit is relevant and usable to EPs, PLWD, and CPs.

In February 2021, France had more than 76,000 deaths due to COVID-19 and older adults were heavily affected. Most measures taken to reduce the impact of COVID-19 (quarantine, visit ban in nursing home, etc.) significantly influenced the lives of older adults. Yet they were rarely consulted about their implementation. Exclusion of and discrimination against older adults has been accentuated during the COVID-19 pandemic. While many articles discussing COVID-19 also mention ageism, few actually incorporate the perspectives and opinions of older adults. Our research aims to assess the ageism experienced by older adults during the COVID-19 pandemic. We conducted interviews with older adults (63–92 years, mean age = 76 years) in an urban area of France. Participants reported experiencing more ageism during the COVID-19 pandemic, including hostile and benevolent ageism from older adults' families. Despite reports of experiencing ageist attitudes and behaviors from others, however, older adults also identified positive signs of intergenerational solidarity during this COVID-19 crisis.

Persons living with dementia (PLWD) and family care partners (CPs) want to improve their health, maintain independence, and enhance well-being. Multi-domain interventions towards this goal are needed, but few are available and fewer were co-created with PLWD, CPs, and program providers. The objective of the DELIGHT project is to use a participatory approach to co-design a feasible, effective multi-domain intervention (the DELIGHT program) that meets the health and well-being goals of PLWD and CPs.Using a participatory approach, the DELIGHT project is guided by a core team of researchers, PLWD, CPs, and an Alzheimer Society representative. The co-design team included the core team and additional PLWD/CPs, exercise professionals, dietitians, health care professionals, and community service providers (n=29). Due to COVID-19, research team meetings have been virtual since May 2020. The co-design was planned for four in-person, half-day sessions but was transitioned to six online, 1.5-hour sessions, using small breakout rooms for discussion. The co-design meetings focused on identifying target population, key outcomes of the program and developing program components and structure. During co-design meetings, two or three guiding questions were set to focus discussion on a specific topic (e.g., exercise). The final co-design session focused on the overall structure of the DELIGHT program. The core team then reflected on co-design discussions and decisions and made final decisions on program structure. Program resources were iteratively designed with the core team, co-design team, and other external stakeholders (including an illustrator).The DELIGHT program is designed to promote well-being among PLWD and CP. Engagement soon after diagnosis is a goal. The program will meet twice per week for one hour of exercise and thirty minutes of facilitated discussion/education with a healthy snack and social engagement. Education will focus on healthy eating, sleeping well, mental well-being, social connection, and physical activity. Program resources and manual are in development.The DELIGHT program was co-created by PLWD, CPs, researchers, and community stakeholders to meet the health and well-being goals of PLWD and CPs. The on-line and in-person program options will be piloted and evaluated in fall 2021.

Engaged research involves stakeholders as active partners in the research process, not just as research participants. Engaged dementia research can improve the relevance and quality of research, empower persons living dementia (PLWD) and family care partners, and acknowledge their expertise gained through lived experience. Conducting engaged research is challenging during COVID-19 when in-person interactions are difficult or impossible. The Dementia Lifestyle Intervention for Getting Health Together (DELIGHT) project used an online, engaged research approach to co-design the DELIGHT program, a 12-week program to support the health and well-being goals of PLWD and care partners. Here, we used mixed-methods to evaluate the DELIGHT co-design process, its alignment with an Authentic Partnership approach, and experiences, satisfaction, and suggestions for future online co-design processes. The DELIGHT project engaged 29 people in the co-design process during Summer 2020, including PLWD, care partners, service/program providers, healthcare providers, and researchers. The co-design team met over six, 1.5-hour online meetings (via Zoom) to develop the program. Although the co-design process is on-going, evaluation focused on this first phase of the co-design process. A 17-item survey assessed alignment with an Authentic Partnerships approach. Focus groups and interviews used a semi-structured guide to assess experiences, satisfaction, and suggestions for future on-line co-design. Surveys were completed by 11 co-design members, and 11 co-design members participated in interviews or focus groups (not all completed both). Initial analysis of survey results indicates co-design members felt respected and safe in the co-design process, felt their perspectives and opinions were valued, and valued the contributions of other members (100% agreed or strongly agreed). All survey respondents felt they gained knowledge and strategies for living well with dementia during the co-design process. All survey respondents also strongly agreed that the DELIGHT program, when implemented, will have a positive impact on PLWD and care partners. Analysis of interviews/focus groups is ongoing and will be available in Spring 2021. Co-design members expressed high satisfaction with the process and felt their experiences were valued and heard. All members expressed a strong belief that the program developed will benefit PLWD and care partners.

COVID-19 severity and mortality risk are greater for older adults whereas economic impact is deeper for younger adults. Using the Health Belief Model (HBM) as a framework, this study used a web-based survey to examine how perceived COVID-19 susceptibility and severity and perceived efficacy of recommended health behaviors varied by age group and were related to the adoption of health behaviors. Proportional odds logistic regression was used to examine the relationship between age group and perceived COVID-19 susceptibility, severity, impact, and health behavior efficacy and adoption. Structural equation modeling based on HBM constructs examined the relationships between health beliefs and behaviors. Data from 820 participants (Ontario, Canada) were analyzed (age: 42.7, 16.2 years; 79% women). Middle-aged and older adults reported greater concerns about the personal risk of hospitalization and mortality, economic impact, and social impact of COVID-19 than young adults. Middle-aged adults also reported greatest concern for other age groups. Adoption and perceived efficacy of health behaviors was similar across age groups with few exceptions. Both middle-aged and older-adults were more likely to perceive their own and each other's age groups as responding adequately to COVID-19 compared to young adults. Structural equation modeling indicated perceived benefits of health behaviors were the primary driver of behavior uptake, with socioeconomic factors and perceived severity and susceptibility indirectly associated with uptake through their influence on perceived benefits. Overall, these results suggest adoption of health behaviors is very high with few differences between age groups, despite differences in perceived impact of COVID-19. Public health communications should focus on the benefits of health behaviors to drive adoption.

Physical activity (PA) participation provides functional and social benefits for persons with mild cognitive impairment (MCI) and Alzheimer's disease (AD), but PA participation in these populations is low. To support health promotion initiatives for cognitively impaired older adults, this study explored the perceptions, experiences, and beliefs of older adults with cognitive impairment and their caregivers concerning PA. Ten care dyads (community-dwelling adult aged ≥65 years diagnosed with MCI or mild-to-moderate AD and their care partner) participated in semi-structured interviews informed by the Theoretical Domains Framework about their PA perceptions, experiences, and beliefs. Interpretive phenomenological analysis of interview transcripts yielded 4 emergent themes: (1) PA as a meaningful activity, (2) experience versus evidence as motivating, (3) participation is possible despite dementia, and (4) care partners as enablers. Findings from this study address a research gap concerning the PA perceptions, experiences, and beliefs of cognitively impaired older adults and their care partners. Novelty Older adults with MCI/AD want to and are capable of engaging in PA. Care partners are critical supporters of PA participation in MCI/AD. Adapted health promotion strategies could enhance PA in MCI/AD.

The goal of this commentary is to highlight the ageism that has emerged during the COVID-19 pandemic. Over 20 international researchers in the field of ageing have contributed to this document. This commentary discusses how older people are misrepresented and undervalued in the current public discourse surrounding the pandemic. It points to issues in documenting the deaths of older adults, the lack of preparation for such a crisis in long-term care homes, how some ‘protective’ policies can be considered patronising and how the initial perception of the public was that the virus was really an older adult problem. This commentary also calls attention to important intergenerational solidarity that has occurred during this crisis to ensure support and social-inclusion of older adults, even at a distance. Our hope is that with this commentary we can contribute to the discourse on older adults during this pandemic and diminish the ageist attitudes that have circulated.

Purpose For persons who are at risk for, or living with, dementia exercise is recommended, yet many become or remain inactive. Exercise providers play a vital role in promoting and facilitating exercise in these groups by recognizing and being responsive to the needs of persons with mild cognitive impairment (MCI) or dementia in exercise programming. The objective of this study was to explore the experiences, perceptions, and needs of community exercise providers regarding dementia. Materials & methods Five focus groups were held with community exercise providers (n = 30) who deliver exercise to older adults (≥55 years) in municipal, non-profit, for profit, or academic settings. Results Three themes were developed: (1) Unique experiences and diverse perceptions: suggests unique personal experiences with MCI and dementia inform distinct perceptions of dementia; (2) Dementia-Inclusive Practices: learning as you go and adapting for the individual: reflects exercise providers’ approaches to recognizing and accommodating individuals’ unique abilities and preferences; (3) Training and Best Practices, with Flexibility: identifies exercise providers’ desires for MCI- and dementia-specific knowledge and training strategies, which need to recognize dementia heterogeneity between and within persons over time. Conclusions These findings highlight a willingness of exercise providers to support dementia-inclusive exercise, but recognize they have minimal training and lack educational resources to do so. Formal training resources may enhance exercise accessibility and participation for persons with MCI or dementia.

Despite its importance, persons with mild cognitive impairment (MCI) or dementia in rural and northern communities face numerous challenges to exercise. It is critical to engage persons with MCI/dementia, their caregivers, and exercise providers who live and work in rural and northern communities to design exercise programming to support implementation and sustainability of person-centered health interventions. Our objective was to identify and describe the facilitators and barriers to exercise for persons with MCI/dementia in rural and northern communities. We conducted focus groups and interviews with community-dwelling persons with MCI/dementia, care partners, exercise providers, and health care professionals in two communities in Northern BC, Canada (Prince George, population 74,003; Kitimat, population 8,335). Data was recorded, transcribed verbatim, and analyzed thematically. The twenty-nine participants in interviews and focus groups identified several challenges and solutions unique to rural and northern regions. 1) Health care labour shortages(e.g., physicians, exercise providers) and the transient nature of locum physicians in rural communities restrict the offering and referrals to exercise programs, especially when the family physician is the gatekeeper to programs. To supplement labor force, community healthcare professionals invest in remote student practicum placements. 2) Small towns develop informalsupport systems to overcome barriers specific to persons with MCI/dementia such as informal transportation networks. However, informal solutions are more vulnerable to environmental challenges (e.g., inclement weather and natural disasters) than formal services. Implementation of exercise programs and provider training must recognize and address challenges experienced in rural and northern communities.

Exercise improves physical and mental health among people with mild cognitive impairment (MCI) or dementia, yet many remain inactive. To implement exercise in clinical management, we must address barriers and facilitators in implementation. Our objectives were to: 1) understand barriers and facilitators for exercise among people with MCI/dementia; 2) use this knowledge to identify behavior changes strategies using the Behaviour Change Wheel (BCW). Focus groups and interviews were conducted with community-dwelling people with MCI/dementia (n=14), care partners (n=12), exercise providers (n=35), and health care professionals (n=15) in Ontario and Northern BC (Canada). Audio recordings were transcribed and thematically analyzed. Themes were mapped to capability, opportunity, and motivation domains of the BCW and mapped to interventions. Seventy-six people participated in interviews and focus groups. Barriers and facilitators were identified by BCW domains: 1) Capability: cognitive deficits, physical health, fatigue; 2) Opportunity: access to programs meeting needs of people with MCI/dementia, poor understanding of dementia by exercise providers, stigma of dementia; 3) Motivation: apathy/low intrinsic motivation, encouraging exercise providers, care partner support, social engagement. The primary intervention selected as most appropriate was enablement of exercise through education and training of exercise providers, which would expand group exercise opportunities with the added benefits of modelling and incentivization by social engagement. Training exercise providers to understand, engage with, and meet the needs of people with MCI/dementia could be key to implementation of exercise in clinical management, by increasing the quantity and quality of exercise programs accessible to people with dementia.

Exercise improves physical and mental wellbeing among people with mild cognitive impairment (MCI) or dementia. People with MCI/dementia face significant barriers to exercise, yet we know little about effective exercise supports. We conducted the Centre versus Home-based EXercise (CHEX) study, a 12-week pragmatic, randomized parallel group trial of centre-based (CB) versus home-based (HB) exercise among people with MCI/dementia. Community-dwelling adults (≥50 years) diagnosed with MCI or early dementia (MoCA≥17/MMSE≥22) were randomized at two sites (Toronto, Waterloo Canada). HB participants received an exercise prescription, with monthly calls to assess progress/challenges and adjust exercise prescription. CB also attended weekly 60min small-group exercise sessions. Here, we report feasibility outcomes. Of 97 people screened eligible and invited, 44 people with MCI/early dementia (age 76.3[56-96] years; education 15.9[9-25] years; 12[28%] women) were recruited and randomize to CB (n=25) or HB (n=19). The majority of participants (n=34) were from the Waterloo site. Most who declined participation did so because of transportation/distance to the centre, which was more significant in Toronto (bigger city, longer distances, worse traffic). Of the 44 enrolled, 34 completed the study; dropouts were predominantly from the HB arm (n=9 [90%]) and were more common in Toronto (n=5 [50%]) than Waterloo (n=5 [12%]). No adverse events were reported. People with MCI/dementia are more likely to complete a 12-week CB exercise program than HB. However, the feasibility of CB versus HB exercise depends on environment (distance, traffic) and social support (for transportation). The relative effectiveness warrants study with a preference/needs-based design.