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Guest Editorial
From Counting to Understanding: The Evolving Epidemiologic Approach to Dementia
Ian McDowell, PhD
(PDF)

In Review
More Than the Epidemiology of Alzheimer’s Disease: Contributions of the Canadian Study of Health and Aging
Joan Lindsay, Elizabeth Sykes, Ian McDowell, René Verreault, Danielle Laurin
(PDF)

Alzheimer’s Disease, Genes, and Environment: The Value of International Studies
Hugh C Hendrie, Kathleen S Hall, Adesola Ogunniyi, Sujuan Gao
(PDF)

Original Research
Hidden Cardiac Lesions and Psychotropic Drugs as a Possible Cause of Sudden Death in Psychiatric Patients: A Report of 14 Cases and Review of the Literature
Dominique Frassati, Alain Tabib, Bernard Lachaux, Natalie Giloux, Jean Daléry, François Vittori, Dorothée Charvet, Cécile Barel, Bernard Bui-Xuan, Rachel Mégard, Louis Pierre Jenoudet, Jacques Descotes, Thierry Vial, Quadiri Timour
(PDF)

The 5-Factor Model of Personality and Antidepressant Medication Compliance
Nicole L Cohen, Erin C Ross, R Michael Bagby, Peter Farvolden, Sidney H Kennedy
(PDF)

Social, Demographic, and Clinical Factors Related to Disruptive Behaviour in Hospital
Andrea K Boggild, Marnin J Heisel, Paul S Links
(PDF)

The Course of Depressive Illness in General Practice
Frédéric Limosin, PhD, Jean-Yves Loze, Myriam Zylberman-Bouhassira, Mark E Schmidt, Eléna Perrin, Frédéric Rouillon
(PDF)

Review Paper
Prevalence and Incidence Studies of Mood Disorders: A Systematic Review of the Literature
Paul Waraich, Elliot M Goldner, Julian M Somers, Lorena Hsu
(PDF)

Brief Communication
Bupropion Sustained Release Treatment Reduces Fatigue in Cancer Patients
Jodi L Cullum, Agnieszka E Wojciechowski, Guy Pelletier, J Steven A Simpson
(PDF)

Patient Factors Associated With Missed Appointments in Persons With Schizophrenia
Shalom Coodin, Douglas Staley, Barb Cortens, Rob Desrochers, Sandy McLandress
(PDF)

Book Reviews
(PDF)

The Treatment of Anxiety Disorders: Clinical Guides and Patient Manuals. 2nd ed Reviewed by
Richard Swinson, MD

Cognitive-Behavioral Group Therapy for Social Phobia: Basic Mechanisms and Clinical Strategies
Reviewed by
Michael Van Ameringen, MD, FRCPC

Letters to the Editor
(PDF)

Aripirazole–Olanzapine Combination for Treatment of Schizophrenia

Improvement of Torticollis With Quetiapine in a Schizophrenia Patient

Internalizing Antecedents of Conduct Disorder

Travel Time and the Use of Psychiatric Outpatient Clinic Services in Coastal Northern Norway

Respiratory Panic Disorder Treatment With Clonidine

In Review

More Than the Epidemiology of Alzheimer’s Disease: Contributions of the Canadian Study of Health and Aging

Joan Lindsay, PhD¹, Elizabeth Sykes, BA², Ian McDowell, PhD³, René Verreault, MD, PhD⁴, Danielle Laurin, PhD⁵

Twenty years ago, there were very few published studies of the epidemiology of Alzheimer’s disease (AD) or other dementias. As concern grew over the aging of the population in many countries, several large-scale, longitudinal studies were undertaken, including the Canadian Study of Health and Aging (CSHA). The CSHA initially focused on prevalence and incidence of dementia (principally AD and vascular dementia), on risk factors for AD and vascular dementia, and on caring for people with dementia. However, in the second and third phases of the study the objectives broadened to include healthy aging, frailty, disability, predictors of institutional admission and mortality, and cognitive impairment not meeting the criteria for dementia (CIND). The third phase focused on early detection of dementia, including predictors of the transition from CIND to dementia. Detailed clinical and neuro- psychological data collected for a subset of the study sample permitted the establishment of norms for cognitively healthy seniors, as well as analyses of topics relevant to seniors’ health, including medication use and other medical conditions, such as depression. We highlight results of several of the analyses conducted to date. Some topics are omitted owing to space and time constraints—not because we lack appreciation of the importance of these analyses. We also discuss the study’s current directions.

Methods

The CSHA is a large national longitudinal study of people aged 65 years and over. It began in 1991–1992, with follow- ups in 1996–1997 and in 2001–2002. Across Canada, 18 field centres participated in this study, which was coordinated jointly by the University of Ottawa and Health Canada. The ethics review committees in the coordinating centre and in each participating study centre approved all 3 phases. Figure 1 shows the flow of participants through all 3 study phases, Table 1 summarizes the extensive data collected, and Table 2 shows the participation rates for the different study phases and components.

Initial Assessment (CSHA-1)
In 1991–1992, data were collected from representative samples of men and women aged 65 years and over in 36 urban and surrounding rural areas covering all 10 Canadian provinces (1). Of the 10 263 participants, 9008 lived in the community, and 1255 were residents in institutions. Those in the community were interviewed about their health, the presence of specific disorders, and limitations they had in performing basic and instrumental activities of daily living according to a standard scale (2). All participants were screened for dementia with the Modified Mini-Mental State Examination (3MS) (3,4). People with a 3MS score below 78/100, plus a random sample of those who screened negative (78/100 and over) and all who lived in institutions, were invited to attend an extensive clinical evaluation that followed a 3-stage protocol. First, a nurse readministered the 3MS and collected information on medication use, as well as on the participant’s medical and family history. Next, a physician took a history and conducted a standardized physical and neurological examination. Laboratory tests were undertaken, and blood samples were collected for genetic and other analyses. Finally, for those deemed testable (that is, those with 3MS score ³ 50), a psychometrist administered a series of neuropsychological tests that were later interpreted by a neuropsychologist. The physician and neuropsychologist made independent preliminary diagnoses; these were followed by a case conference wherein a consensus diagnosis was reached according to DSM-III-R criteria for dementia (5), National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) criteria for AD (6), and other specific criteria for cognitive impairment and vascular dementia. Diagnoses comprised no cognitive impairment, CIND, probable AD, possible AD, vascular dementia, other specific dementia, and unclassifiable dementia. The diagnosis formed the basis for estimating the prevalence of dementia. Case–control risk factor studies were also undertaken.

Table 1  Numbers of study participants and number of variables in the various Canadian Study of Health and Aging (CSHA) data sets
CSHA-1 (1991)	Maintaining contact (1993)	CSHA-2 (1996)	CSHA-3 (2001)
Community interview  192 variables  n = 9008	Telephone interview  n = 8512	Community interview  254 variables  n = 5703	Community interview  292 variables  n  » 3334
Neuropsychological tests  66 variables  n = 1879	—	Neuropsychological tests  321 variables  n = 1399	Neuropsychological tests  133 variables  n = 1484
Clinical examination  633 variables  n = 2914	—	Clinical examination  1515 variables  n = 2305	Clinical examination  853 variables  n » 1386
Caregiver interview  427 variables  n = 1686	—	Caregiver interview  683 variables  n = 1129	Caregiver interview  332 variables  n = 1137
Self-completed risk factor questionnaire  413 variables  n = 6628	—	—	—
—	—	—	Informant interview  113 variables  n = 1495
Proxy risk factor questionnaire  413 variables  n = 2560	—	—	—
—	—	Decedent dataset  74 variables  n = 2614	Decedent dataset  111 variables  n = 2084
—	—	Institutional interview  34 variables  n = 1025	Institutional interview  35 variables  n = 645
Linking file, 85 variables, n » 10 263
Death certificate information, n » 4476

First Follow-Up (CSHA-2)
In 1996–1997, all subjects who could be contacted and who agreed to participate were interviewed to measure changes in health status and functioning, on average, 5 years after CSHA-1 (7). The diagnostic process was the same as in CSHA-1, including the screening test, the nurse evaluation, and the clinical evaluation. A consensus conference assigned 2 diagnoses for each person examined, one according to the criteria used in CSHA-1 and the other according to the more recent DSM-IV criteria for AD (8) and National Institute of Neurological Disorders and Stroke–Association internationale pour la recherche et l’enseignement en neurosciences (NINDS–AIREN) criteria for vascular dementia (9). Blood samples were collected from some of those who were clinically examined, and apolipoprotein E (apoE) status and levels of omega-3 fatty acids were determined (10,11). Where participants had died before or during the follow-up study, the date and cause of death were obtained from the relevant provincial registrar of vital statistics; as well, a relative or other informant was interviewed to assess the subject’s physical and cognitive status 3 months prior to death.

Second Follow-Up (CSHA-3)
The study methods in 2001–2002 were generally the same as previously, except that the 3MS cut point was set at 89/90 to screen for CIND rather than dementia, and the neuro- psychological evaluation determined which participants received a clinical examination.

Risk Factor Component
Detailed information about potential risk factors was gathered in a questionnaire covering sociodemographic characteristics, occupational and environmental exposures, lifestyle (that is, smoking habits, alcohol use, selected food items, and exercise), and family and medical history (that is, prior head injury, chronic diseases, and medication use). As part of CSHA-1, case–control risk factor studies were conducted for AD (12) and for vascular dementia (13). For subjects diagnosed with dementia, information was collected from a proxy; for comparability, we also interviewed a proxy for the control subjects. In CSHA-2, a prospective analysis of risk factors for AD was undertaken (14), based on risk factor data collected in the self-administered version of the questionnaire completed by those without dementia at CSHA-1. The analyses included those who screened negative or were clinically diagnosed as cognitively normal at baseline and those diagnosed with incident AD at CSHA-2. A similar prospective analysis was conducted for risk factors for vascular dementia (15).

Caregiver Component
The caregiver studies selected subgroups of CSHA participants according to their cognitive status and then interviewed their primary caregivers. The CSHA-1 caregiver sample included the caregivers of 1048 study participants diagnosed with dementia; a comparison group included 638 caregivers of people who were cognitively normal (this group included some who were physically frail). At CSHA-2, we reinterviewed 1057 of the informal caregivers from the CSHA-1 caregiver study. The CSHA-3 caregiver study was cross-sectional; it compared caregivers of people suffering from incident dementia with caregivers of people having CIND and with caregivers of cognitively normal participants with and without functional limitations.

Results and Discussion

By fall 2003, slightly more than 200 journal articles had arisen from the CSHA. They have focused on cognitive impairment and dementia, although many other health topics and methodological issues have been reported. The following paragraphs offer a brief summary of some of the salient findings. A full listing of published articles with Web links to text copies is available at www.csha.ca.

Magnitude of the Problem of Dementia Including AD
Prevalence and Incidence of Dementia.The study found the prevalence of dementia to be 8% in the Canadian population aged 65 years and over, a total of 252 600 people in 1991 (1). Prevalence rates rose dramatically with age: they were 2.4% in those aged 65 to 74 years, 11.1% in those aged 75 to 84 years, and 34.5% in those aged 85 years and over. Almost two-thirds (64%) of prevalent cases were AD, while vascular dementia accounted for almost one-fifth (19%) of cases. Roughly equal numbers of people with dementia lived in the community and in institutions, with institutional care being more common for the more severe cases. Because there are more elderly women in the population and because they live longer with dementia, more than twice as many women had dementia than men (171 400 vs 81 200). As a percentage of their respective populations, however, there was less difference (8.6% vs 6.9%). We estimated that in 2001 the number of people with dementia had increased to 364 000 and that by 2021 there will be 592 000 seniors with dementia. About 2% of the population aged 65 years and over developed dementia each year from 1991 to 1996 (7). There was little difference in incidence rates for men and women. However, the numbers of women diagnosed with dementia were considerably higher, with a total of 36 320 women per annum in the early 1990s, compared with 23 830 men. Our prevalence and incidence rates lie toward the upper end of the range identified in other recent studies (16). This may reflect our inclusion of both institutional and community samples and our inclusion of cases of early-stage dementia. It may also be partly due to our inclusion of decedents classified as having dementia or not at the time of death.

Prevalence of CIND. The CIND diagnostic category was created during CSHA-1 to include an admittedly heterogeneous group of people who were not cognitively normal but who did not meet the criteria for dementia (17). Diagnostic criteria for CIND were clarified at CSHA-2. A conservative estimate of the prevalence of CIND is 16.8% of the population aged 65 years and over. We screened for dementia, not CIND, so some cases of CIND will have been missed (18). In seniors, therefore, CIND is more than twice as common as dementia (8%). Not all CIND is irreversible: about one-third of people classified with mild cognitive impairment (a subcategory of CIND) at CSHA-1 showed improvement at CSHA-2 (19).

Institutionalization and Mortality. Rockwood and others (20) identified the following factors associated with admission to long-term care institutions: being a woman, being unmarried, the absence of a caregiver, the presence of cognitive impairment (including all types of dementia), functional impairment, diabetes mellitus, stroke, and Parkinson’s disease. Factors that predicted institutionalization of people with dementia included type of dementia (notably AD), increasing severity of dementia, caregiver age over 60 years, caregiver not being the spouse or a child, and severe caregiver burden (20). Institutionalization and mortality rates at CSHA-2 were higher among those who had lower self-reported health ratings at CSHA-1 (21). St John and others found that low cognitive test scores predicted mortality and institutionalization, even among those in the low normal range (22). Those with dementia who lived alone at home were not more likely to be institutionalized or to die than were those who lived with others, even though they were viewed as being at higher risk (23) and placing them in an institution was more likely to have been considered (24).

Hill and others (25) and Østbye and others (26,27) documented the mean survival of people with dementia, comparing it with survival of those who were cognitively normal. The odds of death within 5 years increased with institution- alization and with increasing cognitive and physical impairment. Wolfson and others argued that studies might have underestimated dementia’s impact on reducing survival by failing to consider people with rapidly progressive disease who died before they could be included in a study (28).

Patterns of Caring for People With Dementia. In 1991, caregivers of those with dementia tended to make relatively little use of community services, although this changed considerably by 1996, mainly among child, as opposed to spouse, caregivers (29,30). Caregivers of healthy elders reported fewer personal health problems than did caregivers of people with dementia or frailty, but the latter groups did not differ significantly (30). In our longitudinal analysis, death of the care recipient or admission to institutional care did not have a consistent impact on caregiver health. Additional reports from the CSHA have documented the use of community health services, as well as negative and positive aspects of caregiving (31–35).

Economic Costs of Dementia and Vascular Cognitive Impairment. The CSHA has begun to provide estimates of the cost of dementia. This work will continue as we link our data to provincial health services use data that include costs of care. qstbye and others placed the annual cost of dementia in Canada at over $3.9 billion in 1991 (36), but this figure may be conservative (37). Hux and others showed that costs increased significantly with the severity of AD, both for those in the community and for those in institutions (38). Rockwood and others found that the yearly costs for those with vascular cognitive impairment were not substantially lower than for those with AD and that they varied by disease severity in a manner similar to AD (39).

Etiologic Analyses: Risk Factors for AD and Vascular Dementia. The prospective risk factor analysis (14) showed increased risk of AD with age, lower education, and the apoE e4 allele. Use of nonsteroidal antiinflammatory drugs, wine consumption, coffee consumption, regular physical activity (40), and past exposure to vaccines (41) were all associated with a reduced risk of AD. The prospective analysis found no association between family history of dementia and AD, although this association had been seen in the case–control analysis (12). No association was observed between AD and smoking or history of depression. For vascular dementia, the prospective analysis identified age, the apoE e4 allele, depression, diabetes, hypertension for women, heart problems for men, taking aspirin, rural residence, and occupational exposure to pesticides or fertilizers as significant predictors (15). Protective factors included eating shellfish and regular physical activity for women. There was no relation with sex, education, cigarette smoking, or alcohol use. CSHA data did not support the hypothesis of a protective effect of omega-3 fatty acids for dementia (11). The CSHA was one of the first studies to identify regular physical activity as being protective; the effect was seen more clearly for women than for men (40). A protective effect of regular physical activity holds important implications for preventing cognitive impairment and all forms of dementia. The CSHA was also the first study to report a protective effect of past exposure to vaccines. Further research is needed to verify these associations.

Clinical Contributions of the CSHA

Screening for Dementia:Translation, Validation, and Comparison of the 3MS with the Mini-Mental State Exam (MMSE). Hébert and others validated the French translation of the 3MS (4). However, minor inconsistencies in results between the English and French versions of the 3MS suggest possible issues either with the translation, with the cultural equivalence of the test, or with other factors (42). While we used the 3MS to screen for dementia and, for CSHA-3, to screen for cognitive impairment, we included questions from the MMSE (43) so that the tests could be compared. Tombaugh and others found that the main advantage of the 3MS over the MMSE was the inclusion of a verbal fluency test (44). The 2 tests gave comparable reliability estimates: fewer years of education decreased specificity and increased sensitivity, while increasing age reduced specificity. These researchers developed norms for the cognitively normal, stratified by age and education. McDowell and others found the 3MS to be an improvement over the MMSE, although neither test adequately identified mild cognitive impairment (42). Bravo and Hébert concurred that the 3MS was slightly more reproducible than the MMSE and that the reproducibility was greater in English than in French (45). Rockwood and others found that adding measures of physical function did not improve the validity of the 3MS in screening for cognitive impairment (46).

CIND. By CSHA-2, those diagnosed with CIND at CSHA-1 were more likely to die than those who were cognitively normal (49% and 30%, respectively), to be admitted to long-term care (29% and 14%, respectively), and to be diagnosed with dementia (47% and 15%, respectively) (47). People with CIND are of particular interest because about one-half develop dementia and one-half do not. The ability to predict which people with CIND will develop dementia is critical to identifying those who would benefit most from treatment at the earliest possible stages of cognitive decline. This is the focus of CSHA-3.

Risk factors for vascular cognitive impairment (a subgroup of CIND) are potentially reversible—a factor that may reduce not only the risk of vascular dementia but also the risk of other adverse health outcomes (48).

Standardizing the Diagnosis of Dementia. Standardizing clinical diagnoses is both difficult and important in a large multicentre study such as the CSHA. As part of CSHA-1, we measured the consistency of the diagnosis, interrater reliability, and the impact of neuropsychological data on the diagnosis of dementia (49). There was 98% concordance with the DSM-III-R criteria for dementia and 92% concordance with the NINCDS-ADRDA criteria for AD. Interrater agreement was high for diagnosis of dementia vs no dementia (kappa = 0.81) and for diagnosis of normal vs CIND (kappa = 0.74). The impact of the neuropsychological data was strongest in cases on the borderline between these diagnostic categories. Factors associated with inconsistent diagnosis of dementia between physicians and neuropsychologists included lower scores on the 3MS, depression reported by an informant, and identification of short-term memory impairment or constructional impairment. Conversely, higher education and identification of long-term memory impairment by the neuropsychologist increased agreement (50).

Predicting Dementia. Hogan and Ebly found that a lower 3MS score, the subject’s age, and an informant’s report of the subject’s memory problems predicted the development of dementia 5 years later (51). They also found that different definitions of mild cognitive impairment resulted in different likelihoods of subsequent dementia. To predict the development of dementia, they recommended looking for significant impairments on age-standardized neuropsychological tests. St John and Montgomery found that memory complaints in cognitively intact seniors predict the development of dementia over 5 years in a small proportion of this group, suggesting that other factors should also be taken into account (52).

Neuropsychological Test Norms and Validation. In seeking to characterize normal cognitive aging, the CSHA has contributed to the establishment of norms, reliability, and validity for several neuropsychological tests (44,45,53–58). Few studies have included such extensive neuropsychological testing of cognitively normal participants.

Medication Use. Of CSHA subjects, 92% were taking at least 1 medication at CSHA-1 (59). The mean number of medications consumed was highest among those living in Ontario (5.7 drugs per person), followed by those living in the prairie provinces (4.9 drugs per person) and British Columbia (4.4 drugs per person). The mean number of medications was lowest in the Atlantic and Quebec regions (3.9 drugs per person). Those living in institutions took more medications than those in the community. The most common classes of medications were analgesics, diuretics, anxiolytics, cardiac drugs, and antihypertensives. Those with higher 3MS scores were more likely to take more medications. Widespread use of potentially inappropriate medications and apparent underuse of indicated drugs were found, with significant regional variations (59). Regional differences were marked for consumption of different categories of medication, such as benzodiazepines, acetaminophen, and complementary and alternative medicines; these were not related to differences in the prevalence of health problems for which the medications might reasonably have been taken (60).

Rockwood and others examined the association between use of lipid-lowering agents and dementia (61). Use of lipid-lowering agents was significantly more common in those aged 65 to 79 years than in older people. It was not associated with other factors indicating a healthy lifestyle but was associated with a history of smoking and hypertension. Use of statins and other lipid-lowering agents was associated with a lower risk of dementia and, specifically, a lower risk of AD in those aged under 80 years, but there was no significant effect in older subjects.

Ebly and others studied adverse outcomes of psychotropic and narcotic drugs and found that, in subjects with mild dementia, use of such medications was not associated with increased adverse outcomes; however, they found that individuals with better cognitive function were at particular risk for adverse effects such as increased prevalence of falls, impaired cognition, and impaired self-care (62).

Maxwell and others examined the association between use of calcium channel blockers and other antihypertensive drugs and cognitive function (63). The proportion of subjects with significant cognitive decline was higher in those using calcium channel blockers than in those using other anti- hypertensives. In a second analysis, the risk of all-cause and cardiac-related mortality in older subjects was significantly higher among nifedipine users, compared with beta blocker users, and increased with average daily dosage and with recent (that is, £ 6 months) initiation of therapy. The risk remained significant for prolonged-action formulations (64).

Newman and others reported a rate of 4.1% for antidepressant use (among those in the community, 3.1%; among those in institutions, 16.5%) (65). The prevalence rate of major depression among elderly Canadians was estimated to be 2.4%; of those who suffered from depression, 9.4% were taking an antidepressant (among those in the community, 4.2%; among those in an institution, 36.0%). Female sex, living in an institution, presence of dementia, and presence of a chronic physical disease, but not presence of depression, were associated with increased antidepressant use. There was some evidence of underuse of antidepressants in the treatment of geriatric depression, especially for those resident in the community.

Hogan and others found that the prevalence of benzodiazepine use was similar at CSHA-1 and CSHA-2 (26.4% and 25.2%, respectively) (66). Benzodiazepine use was significantly related to affect, self-rated health, cognition, function, and incident institutionalization. These researchers concluded that, since benzodiazepines were associated with several adverse outcomes, the relative benefits and risks of their use should be reexamined. Egan and others reached similar conclusions based on an analysis of long-term use of benzo- diazepines in Quebec (67).

Frailty and Healthy Aging
The CSHA has contributed to clarifying the definition of frailty. Rockwood and others examined frailty in relation to the risk of institutionalization and proposed a multidimensional formulation rather than simple dependence in activities of daily living (20). They subsequently developed a brief clinical instrument to classify frailty in elderly people (68). Hogan and others showed that disabilities were almost twice as common in those aged 85 years and over, compared with those aged 65 to 84 years, and this trend occurred even in those without disease risk factors (69). They concluded that preventing disease would only partly reduce disability in the very old, because disability occurred even in those without underlying disease. The CSHA has further contributed to knowledge about healthy aging and subjective well-being or lack thereof (70–73), as well as to methods for measuring frailty and fitness (74).

Finally, many papers have been published on topics outside the main study objectives, often associating these with cognitive decline. One example is a study of incontinence. CSHA-1 data were analyzed to determine the prevalence of incontinence and its association with dementia, ambulatory function, and institutional admission (75). Overall, 16.9% of women and 8.0% of men reported incontinence of any level; daily incontinence was reported by 7.0% and 5.2%, respectively. Prevalence increased with age and declining ambulatory function; other predictors included physical immobility at baseline, diabetes mellitus (for men), and a prior stroke. The incidence of incontinence (76) was associated with cognitive decline, and for both sexes, risk increased dramatically with severity of dementia. Especially among men, those in institutions were more likely to develop urinary incontinence.

Conclusions

While the CSHA began as a study of the epidemiology of AD and other dementias, it has covered a range of topics beyond its original scope. At a 1999 workshop held to present CSHA-2 preliminary findings to researchers, policy makers, and service providers, we were struck with the high prevalence of CIND in relation to dementia. This led to the third phase of the study, which focuses on CIND. We are now trying to discriminate between those whose early cognitive decline presages dementia and others whose decline does not continue. This has important implications for targeting the earliest possible treatment to those who would benefit most. We will reanalyze risk factors for AD and vascular dementia, as well as for CIND and cognitive loss, with the 10-year follow-up period and additional incident cases. We are also broadening our database to include neighbourhood and environmental characteristics of the geographic areas in which participants live. This will be valuable when looking at the broader determinants of health and healthy (or successful) aging, including possible contextual factors associated with cognitive decline.

Funding and Support

Phases 1 and 2 of the core study were funded by the Seniors’ Independence Research Program, through Health Canada’s National Health Research and Development Program (NHRDP). The Medical Research Council provided supplementary funding for analysis of the caregiver component. Additional funding was provided by Pfizer Canada Incorporated, through the Medical Research Council/Pharmaceutical Manufacturers Association of Canada Health Activity Program, NHRDP; by Bayer Incorporated; and by the British Columbia Health Research Foundation. Core funding for phase 3 was obtained from the Canadian Institutes for Health Research (CIHR). Supplementary funding for the caregiver component was obtained from CIHR. Merck-Frosst and Janssen-Ortho provided additional funding. The CSHA was coordinated through the University of Ottawa and Health Canada.

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Author(s)

Manuscript received and accepted December 2003.

1. Adjunct Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario; Manager, Aging-Related Diseases, Surveillance and Risk Assessment Division, Centre for Chronic Disease Prevention and Control, Health Canada, Ottawa, Ontario.

2. Research Coordinator, Canadian Study of Health and Aging, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario.

3. Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario.

4. Director, Laval University Geriatric Research Unit, H^pital du St-Sacrement, Quebec, Quebec

5. Professor, Faculty of Pharmacy, Laval University; Researcher, Laval University Geriatric Research Unit, Hôpital du St-Sacrement, Quebec, Quebec.

Address for correspondence: Dr J Lindsay, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5

e-mail: Joan_Lindsay@hc-sc.gc.ca

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