Clinical Complexity and Use of Antipsychotics and Restraints in Long-Term Care Residents with Parkinson’s Disease

Abstract

Background: Patients with Parkinson’s disease (PD) and/or Parkinsonism are affected by a complex burden of comorbidity. Many ultimately require institutional care, where they may be subject to the application of physical restraints or the prescription of antipsychotic medications, making them more vulnerable to adverse outcomes.

Objectives: The objectives of this paper are to: 1) describe the clinical complexity of older institutionalized persons with PD; and 2) examine patterns and predictors of restraint use and prescription of antipsychotics in this population.

Methods: Population-based cross-sectional cohort study. Residents with PD and/or Parkinsonism living in long-term care (LTC) facilities in 6 Canadian provinces and 1 Northern Territory and Complex Continuing Care (CCC) facilities in Manitoba and Ontario, Canada. The RAI MDS 2.0 instrument was used to assess all LTC residents and CCC residents. Clinical characteristics and the prevalence of major comorbidities were examined. Multivariate modeling was used to identify the characteristics of PD residents most associated with the prescription of antipsychotics and the use of restraints in LTC and CCC facilities.

Results: Residents with PD in LTC and CCC exhibit a high prevalence of dementia, major psychiatric disorders, stroke, heart failure, chronic obstructive pulmonary disease and diabetes mellitus. More than 90% of LTC and CCC residents with PD had cognitive impairment; with more than half having moderate to severe impairment. Residents with PD were more likely to receive antipsychotics than those without PD. Antipsychotic use was associated with psychosis and aggressive behaviours, but also with unsteady gait and higher comorbidity and medication count. Similarly, although more common in CCC than LTC facilities, both psychosis and aggressive behaviours were associated with restraint use, as was greater cognitive and functional impairment, and urinary incontinence. Younger age, male gender, and lower physician access were all associated with greater antipsychotic and restraint use.

Conclusions: LTC and CCC residents with PD are very complex medically. Use of antipsychotics and restraints is common, and their use is often associated with factors other than psychosis or aggression.

Keywords

Parkinson’s disease Resident Assessment Instrument minimum data set nursing home restraints antipsychotics

INTRODUCTION

Parkinson’s disease (PD) is a progressive movement disorder that is often complicated by neuropsychiatric manifestations (including dementia, depression, anxiety, sleep disturbance and psychosis) and autonomic dysfunction (including constipation, urinary frequency, erectile dysfunction, and orthostatic hypotension) [1]. PD is the second most common neurodegenerative disorder after Alzheimer’s disease, with an overall lifetime risk of 1.5% [1]. PD primarily affects older individuals, with a sharply rising incidence after the age of 60 years, and its prevalence continues to increase with population aging [2]. PD results in impaired quality of life, disability, caregiver burden, greater health care utilization and costs (drug costs, home care, physician visits and hospitalization), and an increased risk of mortality [3 –11]. The care of persons with PD is further complicated by a rising burden of age-associated comorbidities such as cardiovascular disease, diabetes, and arthritis, and geriatric syndromes such as falls and fractures, urinary incontinence, and frailty [3 , 12–17].

Ultimately, many persons with PD are admitted into Long Term Care (LTC) homes. Between 5 and 10% of LTC residents have a diagnosis of PD, with admission often associated with cognitive impairment, hallucinations and functional impairment [2]. Residents with PD are typically younger on average than others, suffer from a greater burden of comorbidities, cognitive impairment and psychosis, and are more likely to experience poorer quality of life and accelerated functional decline [2]. The mortality rate of LTC residents with PD is approximately 50% at three years, risk factors for which include cognitive and functional impairment, pneumonia and heart failure [2, 18]. There is evidence to suggest that poor outcomes experienced by persons with PD may, at least in part, reflect suboptimal management and associated comorbidities [2, 19].

The management of PD can lead to therapeutic competition, an adverse drug event whereby the treatment of one symptom or disease feature leads to a side-effect, the treatment of which exacerbates the initial symptom or feature [20]. In PD, dopaminergic agents, prescribed to improve mobility, may precipitate psychosis, leading to the prescription of an antipsychotic, which then may counter the motor effect of dopaminergic agents. Up to 50% of persons with PD are eventually prescribed an antipsychotic drug, and studies among LTC residents with PD show that prescribing rates range from 15% to almost 40% [21 –27]. Justification for the use of antipsychotics is often lacking, with some studies showing that psychosis is documented in as few as a quarter of recipients, who are thus unnecessarily exposed to a high risk of adverse events [27 –30].

The use of restraints is also common in LTC, usually with the aim of preventing falls and managing behavioural disturbances among residents [31]. While evidence of benefit is lacking, substantial evidence shows that restraint use can result in harm, including agitation, anxiety, depression, delirium, functional decline, pressure ulcers, aspiration, falls, fractures, and death [32 –39].

The optimal management of PD in LTC homes may thus be complicated by the clinical complexity of affected residents, resulting in excessive use of antipsychotics and restraints. To date, the small number of studies to examine characteristics of PD in LTC homes have been limited by small samples or have only been analyzed on a regional level. Moreover, available data on antipsychotic use are limited and there have been no studies to our knowledge on restraint use in LTC settings in persons with PD. The objectives of this paper are to 1) characterize the clinical complexity of older persons with PD living in LTC and Complex Continuing Care (CCC) facilities in Canada; 2) estimate the prevalence of antipsychotic prescribing and restraint use in this population; and 3) identify correlates of antipsychotic and restraint use in this population.

METHODS

Design and sample

This is a cross-sectional study undertaken as part of a larger research initiative designed to provide estimates on the prevalence, health and social characteristics, quality of care and related needs of persons living with selected neurological conditions and who are receiving community- and facility-based care services across Canada. This initiative, called the Innovations in Data, Evidence, and Applications for Persons with Neurological Conditions (ideasPNC) [40], aimed to provide detailed clinical profiles of 11 prioritized neurological conditions and is part of the National Population Health Study of Neurological Conditions lead by Neurological Health Charities Canada and the Public Health Agency of Canada [41]. This study uses data from individuals identified as having Parkinson’s disease or Parkinsonism.

Data for this study were drawn from the Continuing Care Reporting System (CCRS), a database built and maintained by the Canadian Institute for Health Information (CIHI), and based on the interRAI’s Resident Assessment Instrument 2.0 (RAI 2.0) instrument [42, 43]. The RAI 2.0 instrument is widely used in Canadian Long Term Care (LTC) and Complex Continuing Care (CCC) settings and contains information on demographic, clinical, functional, and resource use characteristics of persons expected to receive care in these settings for more than fourteen days [44]. The RAI 2.0 also includes care planning, outcome measurement, quality improvement and case mix–based funding applications [45 –47]. All possible sources of information are used by trained assessors to complete RAI 2.0 assessments, including interviews with, and observation of, the person, discussions with other staff and family, and facility chart review. Data quality for the CCRS has been demonstrated to be good based on a variety of indicators of reliability, validity, logical consistency and completeness [48]. The University of Waterloo houses de-identified copies of CCRS data as part of a license agreement between interRAI and the Canadian Institute for Health Information. These data holdings are governed by regulations to protect personal privacy (including prohibited release of small cell estimates) but do not require individual client consent beyond that already obtained as part of routine care. The study received research ethics approval from the University of Waterloo’s Office of Research Ethics (project #17045).

Long term care

The CCRS includes quarterly and full annual assessments conducted in long term care/nursing home settings by trained clinicians using the RAI 2.0 in six of ten Canadian provinces and one of three northern territories. The number of years of data available and the number of reporting facilities varies by province due to different RAI 2.0 implementation phases. As a result, not all facilities may have contributed data in all years. For the present study, 635 facilities in Ontario contributed data in the period from July 1, 2003 to March 31st, 2011, with all facilities contributing after the RAI 2.0 was fully mandated in all Ontario LTC homes in July, 2010. Eight facilities from Nova Scotia provided data during the same period. British Columbia submitted data from 126 facilities for the period 2006 – 2011. From 2008–2011, Saskatchewan had data from 168 facilities, Manitoba contributed data from 38 facilities, Newfoundland from seven facilities and the Yukon from two facilities.

Complex Continuing Care

The term Complex Continuing Care (CCC) refers to a post-acute hospital setting that provides medically complex and specialized health services to patients with chronic illnesses and disabilities, often over extended periods of time, including the provision of skilled, technology-based care not available in the community or in LTC [49]. CCC patients are more medically complex and use more health resources than those in LTC. Similarly, mandated quarterly and full assessments conducted in 173 CCC units/hospitals by trained clinicians using the RAI 2.0 from April 1996 to March 31 2011 in CCC hospitals/units in Ontario were included in the analysis. Clients receive a quarterly assessment every 90 days, and one full assessment yearly. Persons from one Manitoba CCC hospital/unit were also included, where data collection began mid-year 2008.

Cohort definitions

The total number of RAI 2.0 assessments available in the CCRS database was 1,278,419 from LTC and 468,206 from CCC. From these, the most recent assessment for each individual was selected, for a total of 190,011 individuals from LTC and 181,846 from CCC. From these, 1,561 LTC and 164 CCC assessments were missing data related to the PHAC neurological conditions and were excluded, leaving final cohort sizes of 188,450 for LTC and 181,682 for CCC. Within the RAI 2.0, disease diagnoses can be recorded using a check-box for 47 different diseases (section I1), or by free-text and ICD-10-CA code (section I3). Diagnoses are to be recorded if they “have a relationship to current activities of daily living (ADL) status, cognitive status, mood and behaviour status, medical treatments, nurse monitoring, or risk of death”, meaning that inactive diagnoses are not recorded [50]. All neurological conditions of interest were available from the RAI 2.0 data, and both pick list items and ICD-10-CA codes were used to identify cases (see Supplementary Table 1). We previously showed that that the sensitivity and specificity of the RAI 2.0 for diagnoses of Parkinson’s disease is 0.85 and 0.98, respectively, compared to the validated Discharge Abstract Database maintained by the Canadian Institute for Health Information [40 , 51–53].

The cohort of patients with Parkinson’s disease (PD) was defined as including any individual with a documented diagnosis in the RAI 2.0 with “Parkinson’s disease or Parkinsonism.” Major comorbidity categories, based on other studies of older PD patients and which have been shown to be the most common reasons for hospitalization among older Canadians [3 , 54], were included in the model and defined as:

Dementia;

Mental health comorbidities: defined as a diagnosis of any anxiety disorder, depression, manic depression or schizophrenia, a Depression Rating Scale score equal or greater to 3 [55], or the documentation of delusions or hallucinations during the last seven days prior to assessment;

Major cardiac comorbidities: defined as a diagnosis of Atherosclerotic Heart Disease, Coronary Artery Disease, or Congestive Heart Failure;

Stroke;

COPD; and

Diabetes mellitus.

Covariates and other outcome measures

A number of validated scales derived from the RAI 2.0 instrument were examined including the i) the Cognitive Performance Scale (CPS) (range 0–6) [56, 57]; (ii) the Activities of Daily Living (ADL) Self-Performance Hierarchy Scale (range 0–6) [58]; (iii) the Changes in Health, End-stage Disease, and Signs and Symptoms (CHESS) Scale (range 0–5) [59, 60]; (iv) the Depression Rating Scale (DRS) (range 0–14) [55]; (v) the Pain scale (range 0–3) [61, 62], and (vi) the Aggressive Behaviour Scale (ABS) [63]. Higher scores on all these scales indicate more severe impairment (see Supplementary Table 2). In addition, we examined specific individual RAI 2.0 items including age, gender, delusions or hallucinations, behavioural symptoms, vision impairment, falls, unsteady gait and bladder incontinence. Finally, we assessed indicators of clinical activity recorded in the RAI 2.0 assessments, including hospital visits in the ninety days prior to a RAI 2.0 assessment, physician visits in the prior 14 days (any vs. none), prescription of an antipsychotic, and use of restraints in the prior 7 days (defined as any use of trunk or limb restraints, or the use of a chair device to prevent a resident from rising) [46].

Analysis

Descriptive analysis was conducted to examine the age and gender distribution of residents with PD in both LTC and CCC. Descriptive analysis was also conducted to examine the distribution of comorbidities, interRAI scales, items and outcomes defined above, among cohorts of LTC and CCC residents with PD. Multivariate logistic regression models were used to determine the associations of antipsychotic prescribing and restraint use in LTC and CCC facilities with clinical variables, selected primarily based on clinical and published relevance [2 , 30–32], as well as Canadian Province of residence, physician visits, the intensity of physician contact, comorbidities and medication use. All analyses were conducted using SAS version 9.2 (SAS Institute Inc. The SAS System for Windows. Cary, NC: SAS Institute Inc: 2009).

RESULTS

Characteristics of LTC and CCC residents with PD are shown in Table 1. There were 12,206 LTC residents and 7,851 CCC residents with a recorded diagnosis of PD, for prevalence figures of 6.5% and 4.3%, respectively. The mean ages of LTC and CCC residents with PD were 82.6 years (95% confidence interval 82.4, 82.7) and 79.6 (95% confidence interval 79.4, 79.6) years, respectively, with the overwhelming majority being over the age of 75 years. There were significantly fewer CCC compared to LTC residents in the 85 years-and-over age category, including those with PD, and fewer women with PD compared to those without PD.

The most frequent comorbidities in the entire sample, also shown in Table 1, were dementia, followed by cardiovascular conditions and stroke, depression, arthritis, diabetes mellitus and COPD. Residents received on average over 10 medications each. Dementia, hypertension, arthritis, and depression were more common in LTC residents than among CCC residents, whereas major cardiac diseases, cancer and renal insufficiency were more common in CCC. Compared to residents without PD, those with PD were significantly more likely to be diagnosed with dementia, depression, and less likely to be diagnosed with stroke, arteriosclerotic heart disease, heart failure, arrhythmia, PVD, CRF and COPD.

Among mental health indicators, residents with PD were more likely to have more severe cognitive impairment than those without, according to CPS scores, with those in LTC being more severely impaired than those in CCC. In all, approximately 90% of residents in LTC and CCC had some degree of cognitive impairment. Further, over half of residents had at least moderate to severe cognitive impairment, particularly among CCC facilities (61% of PD versus 46% all other residents) as indicated by a CPS score of at least 3 or greater. Those with PD were more likely to manifest indicators of worsening cognitive decline than those without. Clinically meaningful symptoms of depression, as indicated by DRS scores of 3 or greater, were common with rates of 28.8% in LTC and 23.1% in CCC facilities, respectively. Over half of LTC residents and 70% of those in CCC had significant behavioural symptoms. Residents with PD were significantly more likely than those without PD to exhibit delusions and hallucinations, though overall the prevalence of these symptoms was low at 7.9% and 11% in LTC and CCC, respectively.

Among functional and health indicators, fewer than 5% of residents in either LTC or CCC facilities had no documented ADL impairment, with a large majority of those in both sectors having moderate to severe ADL impairment. Residents with PD were significantly more likely to exhibit more severe functional impairment, and were particularly more likely to have urinary incontinence than those without PD. Daily pain was documented in 45% of LTC residents with PD and over two thirds of those in CCC, though only a small proportion were documented to suffer from severe daily pain. There were no significant differences in health instability between residents with or without PD according to CHESS score distributions, though residents of CCC generally exhibited a greater degree of medical complexity than those in LTC. Finally, residents with PD were more likely than those without PD to experience falls and gait abnormalities, and more so in CCC than in LTC.

Prescription of antipsychotics

As shown in Table 1, residents with PD were more likely than those without PD to be prescribed an antipsychotic medication, particularly in CCC facilities. Antipsychotics were prescribed to over one third of LTC residents with PD and almost a quarter of CCC residents with PD. As shown in Table 2, the use of antipsychotics among residents with PD was associated with the presence of psychotic symptoms, aggressive behaviours, unsteady gait, as well as higher comorbidity and medication count. Younger age, male gender, and lower physician access were all associated with greater antipsychotic and restraint use. Antipsychotic use was significantly greater in LTC than it was in CCC. There appeared to be variability in the use of antipsychotics according to jurisdiction but none of these differences achieved statistical significance. More physician visits was modestly associated with lower use of antipsychotics.

Use of restraints

Restraints were used in over one quarter of residents with PD, a rate that was substantially greater than among residents without PD (see Table 1). Use of restraints was modestly greater in LTC than it was in CCC. Limb restraints were used rarely, with chair restraints being used slightly more often than trunk restraints. As shown in Table 2, age and female gender were associated with a lower likelihood of being restrained. A history of falls was associated with the use of restraints, though the presence of an unsteady gait was associated with less restraint use. Other factors associated with the use of restraints include greater cognitive impairment, the presence of aggressive behaviour, delusions or hallucinations, or other behavioural symptoms, functional impairment and urinary incontinence. Restraints were used more often in CCC than in LTC. Variability in restraint use across jurisdictions was also noted, and was statistically significantly higher in Nova Scotia and Saskatchewan. More physician visits and a greater number of comorbidities were associated with less restraint use.

DISCUSSION

The results of this large cross-sectional study, conducted across multiple Canadian jurisdictions, illustrate well the substantial clinical complexity of LTC and CCC residents with PD. With population ageing and changing admission criteria for LTC homes, this complexity will continue to grow. The prevalence of PD in this sample is consistent with previous literature, as are the findings related to age and gender [2, 3]. Not unexpectedly, health instability, as indicated by the CHESS scale, was greater among CCC residents than those in LTC.

Cognitive and psychiatric comorbidities were common and were characterized by significant symptom burden. These findings are also consistent with previous literature and reflect the neuropsychiatric complications of PD [1]. Medical comorbidities, including major cardiovascular disease, arthritis, diabetes, and COPD were also very common, although less common than those without PD. These conditions are associated with a significant burden of disability and health service utilization among seniors, both in the community and in institutional settings [54 , 64–66]. Cardiovascular comorbidities may be particularly problematic in persons with PD, in whom a predisposition to orthostatic hypotension and falls may be especially exacerbated by comorbid cardiovascular conditions and associated medications [67 –69]. Further, comorbid COPD may predispose to further respiratory complications in a population with significant pulmonary compromise arising from PD [37, 66].

More than one third (34%) and nearly a quarter (24%) of LTC and CCC residents with PD were prescribed antipsychotics, respectively. A 2003 study of LTC homes in 5 countries found a prevalence of antipsychotic use ranging from 11 to 38%, with no consistent associations shown to explain this variability. Recently published data from the 2004 US National Nursing Home Survey showed that the prevalence of antipsychotic use in LTC residents with PD was 31% [28]. In that study, the use of two or more psychotropic medications was associated with the presence of depression, schizophrenia, psychosis and anxiety. Specific predictors of antipsychotic use were not identified. Despite using more recent data, we found that antipsychotic use remains very common still. However, several provincial and national initiatives to reduce inappropriate antipsychotic use are now underway based on interRAI quality indicators drawn from the RAI 2.0 [70].

Guidelines recommend that the use of antipsychotic medications in persons with dementia be limited to those exhibiting agitation, aggression or psychosis of such severity that there is risk of harm to them or to others [71], and only after non-pharmacological measures have failed to reduce this risk. In our sample, the presence of delusions or hallucinations was a strong predictor of antipsychotic use, as was the presence of aggressive behaviour. However, the prevalence of antipsychotic use was far greater than that of severe aggression and psychosis combined, and was associated with other resident characteristics including cognitive impairment, depression, greater comorbidity and medication counts, male gender, younger age and preserved functional capacity. Given the risks associated with the use of antipsychotics in patients with PD, which include worsening mobility, falls, cognitive impairment, infections and mortality, the prescription of antipsychotics without clear justification of benefit is concerning [22, 29].

The prevalence of restraint use in this study is also cause for concern. A 2003 study of 14,504 LTC homes in 5 countries found that rates of restraint use varied from 6 to 31%, with much of the variability remaining unexplained [72]. Whereas evidence suggests that rates of restraint use of no more than 5% should be achievable in LTC homes [38], our study found that one quarter of LTC and CCC residents with PD were restrained, rates that were substantially higher than those among residents without PD. In addition to falls, multiple resident characteristics were associated with restraint use, including male gender, functional and cognitive impairment, depression, urinary incontinence, psychotic symptoms and aggressive behaviour. There was marked inter-jurisdictional variability and again, physician visits were modestly protective.

These findings suggest that LTC residents with PD do not receive optimal care and that many are exposed to serious risks associated with antipsychotics and restraint use despite the absence of clear indications. Residents with less access to physicians in LTC and CCC facilities are more likely to receive antipsychotics and be restrained. In addition, the data suggest that men of younger age are more likely to be prescribed antipsychotics or restraints. Younger men may be perceived as more dangerous than older men, and in the absence of behavioural support programs, may be prescribed antipsychotics or restraints with the aim to protect staff, other residents or individuals themselves. Similar gender findings were seen in a cross-sectional study of restraint use in inpatient mental health settings [73]. Further, other symptoms such as incontinence may be exacerbated, significantly decreasing quality of life.

A key concern appears to be related to physician access. The majority of physician services for LTC residents are provided by family physicians, with a recent Ontario study showing that over 90% of care to over 50,000 LTC residents was provided by 628 family physicians, most of whom are also aging [74, 75]. However, most Canadian family physicians receive limited exposure to geriatric medicine or neurology during residency training, and furthermore, the number of family physicians practicing in Canadian LTC settings is at risk of declining [75, 76]. Other studies have shown that the involvement of specialists in the care provided to persons with PD may result in a more accurate diagnosis and potentially slower functional decline and fewer hip fractures [77, 78]. However, recent evidence suggests that, at least in the ambulatory care setting, ageing seniors with multiple comorbidities are less likely to receive care from specialists [79]. Access to specialist care may be even more restricted in institutional settings [80]. In Canada, only 32% of the approximately 240 geriatricians in the country provide services to LTC homes [81, 82]. However, greater access to specialist care alone may be insufficient to improve the quality of care provided to institutionalized seniors with PD. For example, evidence suggests that neurologists may be limited in their ability to recognize the neuropsychiatric complications of PD [83].

There is widespread recognition of the importance of generalist oversight in the management of complex patients with multiple comorbidities, and that primary care providers can play an important and effective role in the management of these patients, including those with PD [84 –88]. The management of patients with complex chronic conditions must be rooted and sustained in primary care and involve a truly collaborative shared-care approach between primary care clinicians, specialists, and inter-professional health providers [89]. Emerging data from other settings suggest that shared care approaches involving specialized and primary care, ideally co-located, can lead to more optimal management and improved outcomes among community-dwelling patients with complex conditions such as heart failure, dementia, or frailty [89 –94]. Similar approaches must be explored for institutionalized seniors with PD. An example of a successful inter-professional shared care model, in which full use was made of the clinical planning capabilities of the interRAI LTCF (the updated version of the MDS 2.0 used in this study) [95], was evaluated in a cluster randomized controlled trial in Dutch LTC homes [96]. Intervention homes saw an overall improvement in care quality, as measured by a sum score of 32 risk-adjusted quality indicators, and overall better pain control, reduced frequency of problematic behaviours, and less antipsychotic use.

The examination of a large population-based sample of LTC and CCC residents and the comprehensive nature of the RAI 2.0 data are important strengths of this study, and the findings reflect the true complexity of the health characteristics of a real world sample of institutionalized persons with PD. However, some limitations should be noted. The contents of the CCRS database are limited to representing jurisdictions that routinely collect RAI 2.0 data. This precludes a truly representative national sample. Further, as the RAI 2.0 has been mandated in Ontario since 2003, the majority of cases in our sample are from this province. Nevertheless, the prevalence and similarities between our sample and those from previous studies does attest to the representativeness and generalizability of our results. The RAI 2.0 item “Parkinson’s disease or Parkinsonism” does not permit the distinction between idiopathic Parkinson’s disease and other etiologies of Parkinsonism. However, work done earlier in the context of this ideasPNC project compared this RAI 2.0 item to the validated Discharge Admission Database maintained by the Canadian Institute of Health Information, and showed a very high specificity and very good sensitivity for Parkinson’s disease [40]. Moreover, the use of antipsychotics and restraints is concerning for any patient with Parkinsonism. Finally, the cross-sectional design limits any definite interpretation regarding the direction of observed associations. Specifically, the quality of care provided in LTC or CCC reflects more than simply physician availability. However, the apparent inverse relationship between the extent of physician contact and the use of restraints strongly suggests the importance of access to physicians in the quality of care provided.

CONCLUSIONS

Residents with PD and who reside in LTC and CCC are affected by a substantial burden of comorbidities, both associated to PD itself, and also associated with ageing itself. Our data suggest that the care of these patients may be suboptimal, potentially due to limited access to physicians. Integrated and inter-professional shared-care approaches, centered on the full clinical care planning capabilities of interRAI instruments, may offer a solution towards improved care of this complex patient population.

CONFLICT OF INTEREST

Drs. Heckman, Kergoat and Hirdes are fellows of interRAI, an international not-for-profit research consortium. Otherwise, the authors have no conflict of interest to report.

Footnotes

ACKNOWLEDGMENTS

This study is part of the National Population Health Study of Neurological Conditions. We wish to acknowledge the membership of Neurological Health Charities Canada and the Public Health Agency of Canada for their contribution to the success of this initiative. Funding for this publication was provided by the Public Health Agency of Canada. The opinions expressed in this publication are those of the authors/researchers and do not necessarily reflect the official views of the Public Health Agency of Canada. Dr. Heckman holds the Schlegel Research Chair for Geriatric Medicine at the Research Institute for Aging and University of Waterloo. Dr. Jette holds a Canada Research Chair in Neurological Health Services Research.

Appendix

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