Impact of a national dementia research consortium: The Canadian Consortium on Neurodegeneration in Aging (CCNA)

Howard Chertkow^{1

2

3

4}, Natalie Phillips⁵, Kenneth Rockwood⁶, Nicole Anderson^{7

3}, Melissa K Andrew^{6

8}, Robert Bartha^{9

10}, Camille Beaudoin¹¹, Nathalie Bélanger¹, Pierre Bellec^{12

13}, Sylvie Belleville^{12

13}, Howard Bergman^{1

14

15}, Sarah Best¹⁶, Jennifer Bethell¹⁷, Louis Bherer^{12

18

19}, Sandra Black^{2

20

21}, Michael Borrie^{22

16

23}, Richard Camicioli^{24

25

26}, Julie Carrier^{13

27}, Neil Cashman^{28

29}, Senny Chan³⁰, Lynden Crowshoe³¹, Claudio Cuello^{32

33}, Max Cynader³⁴, Thanh Dang-Vu^{35

12}, Samir Das¹¹, Roger A Dixon^{36

37

38}, Simon Ducharme^{39

39}, Gillian Einstein^{40

7

30}, Alan C Evans^{32

11

41

42}, Margaret Fahnestock^{43

44}, Howard Feldman^{45

46

29}, Guylaine Ferland⁴⁷, Elizabeth Finger⁴⁸, John D Fisk⁴⁹, Jennifer Fogarty¹⁶, Edward Fon^{32

50}, Ziv Gan-Or^{32

50}, Serge Gauthier^{32

39

51}, Carol Greenwood⁵², Charlie Henri-Bellemare¹¹, Nathan Herrmann^{20

53}, David B Hogan^{54

55}, Robin Hsiung^{28

37}, Inbal Itzhak¹, Kristen Jacklin⁵⁶, Krista Lanctôt^{20

53

57}, Andrew Lim^{20

58}, Ian MacKenzie⁵⁹, Mario Masellis^{2

20}, Colleen Maxwell^{60

61

62}, Carrie McAiney^{60

63}, Katherine McGilton^{64

17

65}, JoAnne McLaurin^{20

66}, Alex Mihailidis^{17

67}, Zia Mohades¹¹, Manuel Montero-Odasso^{16

68

69}, Debra Morgan⁷⁰, Gary Naglie^{71

72}, Haakon Nygaard^{28

29}, Megan O'Connell^{70

73}, Ron Petersen⁷⁴, Randi Pilon¹, Maria Natasha Rajah⁷⁵, Mark Rapoport^{20

53}, Pamela Roach^{55

76}, Julie M Robillard^{77

28}, Ekaterina Rogaeva⁷⁸, Pedro Rosa-Neto^{32

39

51}, Jane Rylett^{79

80}, Joel Sadavoy^{58

81}, Peter St George-Hyslop⁷⁸, Dallas Seitz^{55

82}, Eric Smith^{55

83}, Bojana Stefanovic^{20

84}, Isabelle Vedel^{1

15}, Jennifer D Walker^{85

86}, Cheryl Wellington^{59

29}, Victor Whitehead¹, Walter Wittich⁸⁷

Affiliations

¹ Lady Davis Institute for Medical Research, Montréal, Québec, Canada.
² Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada.
³ Rotman Research Institute, Baycrest Academy for Research & Education, Toronto, Ontario, Canada.
⁴ Affiliate Member, Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada.
⁵ Department of Psychology, Concordia University, Montréal, Québec, Canada.
⁶ Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
⁷ Department of Psychology, University of Toronto, Toronto, Ontario, Canada.
⁸ Division of Geriatric Medicine, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
⁹ Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.
¹⁰ The Brain and Mind Institute, University of Western Ontario, London, Ontario, Canada.
¹¹ McGill Centre for Integrative Neuroscience, Montréal, Québec, Canada.
¹² Centre de recherche IUGM, Institut universitaire de gériatrie de Montréal, Montréal, Québec, Canada.
¹³ Département de psychologie, Université de Montréal, Montréal, Québec, Canada.
¹⁴ Department of Medicine (Geriatrics) and Oncology, McGill University, Montréal, Québec, Canada.
¹⁵ Department of Family Medicine, McGill University, Montréal, Québec, Canada.
¹⁶ Lawson Health Research Institute, London, Ontario, Canada.
¹⁷ KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.
¹⁸ Département de médecine, Université de Montréal, Montréal, Québec, Canada.
¹⁹ Institut de Cardiologie de Montréal-Montreal Heart Institute, Montréal, Québec, Canada.
²⁰ Sunnybrook Research Institute, Toronto, Ontario, Canada.
²¹ Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada.
²² Schulich School of Medicine & Dentistry, Department of Medicine and Division of Geriatric Medicine, University of Western Ontario, London, Ontario, Canada.
²³ Schulich School of Medicine & Dentistry, Department of Medicine and Division of Geriatric Medicine, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada.
²⁴ Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. Neuroscience and Mental Health Institute, Edmonton, Alberta, Canada.
²⁵ Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
²⁶ Neuroscience and Mental Health Institute, Edmonton, Alberta, Canada.
²⁷ Center for Advanced Research in Sleep Medicine (CARSM), Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.
²⁸ Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
²⁹ Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada.
³⁰ Rotman Research Institute, Baycrest Hospital, Toronto, Ontario, Canada.
³¹ Department of Family Medicine & Indigenous, Local and Global Health Office, University of Calgary, Calgary, Alberta, Canada.
³² Department of Neurology and Neurosurgery, McGill University, Montréal, Qikb1uébec, Canada.
³³ Department of Pharmacology & Therapeutics, McGill University, Montréal, Québec, Canada.
³⁴ Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
³⁵ Department of Health, Kinesiology and Applied Physiology, Concordia University, Montréal, Québec, Canada.
³⁶ Department of Psychology (Science), University of Alberta, Edmonton, Alberta, Canada. Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada.
³⁷ Department of Psychology (Science), University of Alberta, Edmonton, Alberta, Canada.
³⁸ Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada.
³⁹ Department of Psychiatry, McGill University, Montréal, Québec, Canada.
⁴⁰ Department of Psychology, University of Toronto, Toronto, Ontario, Canada. Rotman Research Institute, Baycrest Hospital, Toronto, Ontario, Canada.
⁴¹ Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada. McGill Centre for Integrative Neuroscience, Montréal, Québec, Canada. McConnell Brain Imaging Centre (BIC), McGill University, Montréal, Québec, Canada.
⁴² McConnell Brain Imaging Centre (BIC), McGill University, Montréal, Québec, Canada.
⁴³ McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada.
⁴⁴ Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada.
⁴⁵ Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
⁴⁶ Department of Neurosciences, University of California, San Diego, CA, USA.
⁴⁷ Département de nutrition, Faculté de médecine, Université de Montréal, Montréal, Québec, Canada.
⁴⁸ Department of Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada.
⁴⁹ Nova Scotia Health and the Department of Psychiatry, Division of Geriatric Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
⁵⁰ Montreal Neurological Institute, Montréal, Québec, Canada.
⁵¹ McGill Center for Studies in Aging, Douglas Hospital, McGill University, Montréal, Québec, Canada.
⁵² Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.
⁵³ Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
⁵⁴ Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
⁵⁵ Hotchkiss Brain Institute, Calgary, Alberta, Canada.
⁵⁶ Department of Family Medicine and Biobehavioral Health, University of Minnesota, Minneapolis, MN, USA.
⁵⁷ Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
⁵⁸ Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.
⁵⁹ Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
⁶⁰ School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada.
⁶¹ School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada.
⁶² ICES, Toronto, Ontario, Canada.
⁶³ Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada.
⁶⁴ Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
⁶⁵ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
⁶⁶ Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.
⁶⁷ Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada.
⁶⁸ Gait and Brain Lab, Parkwood Institute, University of Western Ontario, London, Ontario, Canada.
⁶⁹ Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada.
⁷⁰ Canadian Centre for Health and Safety in Agriculture (CCHSA), University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
⁷¹ Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
⁷² Department of Medicine and Rotman Research Institute, Baycrest Hospital, Toronto, Ontario, Canada.
⁷³ Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
⁷⁴ Cora Kanow Professor of Alzheimer Disease Research and Professor of Neurology, Mayo Clinic Dept. of Neurology, Mayo Clinic, Rochester, NY, USA.
⁷⁵ Department of Psychology, Toronto Metropolitan University, Toronto, Canada.
⁷⁶ Department of Family Medicine, University of Calgary, Calgary, Alberta Canada.
⁷⁷ Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
⁷⁸ Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada.
⁷⁹ Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.
⁸⁰ Schulich School of Medicine & Dentistry, Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada.
⁸¹ Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada.
⁸² Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.
⁸³ Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
⁸⁴ Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.
⁸⁵ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
⁸⁶ McMaster Indigenous Research Institute, McMaster University, Hamilton, Ontario, Canada.
⁸⁷ École d'optométrie, Université de Montréal, Montréal, Québec, Canada.

PMID: 39636028
DOI: 10.1177/13872877241290990

Review

Impact of a national dementia research consortium: The Canadian Consortium on Neurodegeneration in Aging (CCNA)

Howard Chertkow et al. J Alzheimers Dis. 2024 Dec.

. 2024 Dec;102(3):535-561.

doi: 10.1177/13872877241290990. Epub 2024 Dec 5.

Authors

Affiliations

¹ Lady Davis Institute for Medical Research, Montréal, Québec, Canada.
² Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada.
³ Rotman Research Institute, Baycrest Academy for Research & Education, Toronto, Ontario, Canada.
⁴ Affiliate Member, Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada.
⁵ Department of Psychology, Concordia University, Montréal, Québec, Canada.
⁶ Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
⁷ Department of Psychology, University of Toronto, Toronto, Ontario, Canada.
⁸ Division of Geriatric Medicine, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
⁹ Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.
¹⁰ The Brain and Mind Institute, University of Western Ontario, London, Ontario, Canada.
¹¹ McGill Centre for Integrative Neuroscience, Montréal, Québec, Canada.
¹² Centre de recherche IUGM, Institut universitaire de gériatrie de Montréal, Montréal, Québec, Canada.
¹³ Département de psychologie, Université de Montréal, Montréal, Québec, Canada.
¹⁴ Department of Medicine (Geriatrics) and Oncology, McGill University, Montréal, Québec, Canada.
¹⁵ Department of Family Medicine, McGill University, Montréal, Québec, Canada.
¹⁶ Lawson Health Research Institute, London, Ontario, Canada.
¹⁷ KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.
¹⁸ Département de médecine, Université de Montréal, Montréal, Québec, Canada.
¹⁹ Institut de Cardiologie de Montréal-Montreal Heart Institute, Montréal, Québec, Canada.
²⁰ Sunnybrook Research Institute, Toronto, Ontario, Canada.
²¹ Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada.
²² Schulich School of Medicine & Dentistry, Department of Medicine and Division of Geriatric Medicine, University of Western Ontario, London, Ontario, Canada.
²³ Schulich School of Medicine & Dentistry, Department of Medicine and Division of Geriatric Medicine, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada.
²⁴ Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. Neuroscience and Mental Health Institute, Edmonton, Alberta, Canada.
²⁵ Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
²⁶ Neuroscience and Mental Health Institute, Edmonton, Alberta, Canada.
²⁷ Center for Advanced Research in Sleep Medicine (CARSM), Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.
²⁸ Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
²⁹ Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada.
³⁰ Rotman Research Institute, Baycrest Hospital, Toronto, Ontario, Canada.
³¹ Department of Family Medicine & Indigenous, Local and Global Health Office, University of Calgary, Calgary, Alberta, Canada.
³² Department of Neurology and Neurosurgery, McGill University, Montréal, Qikb1uébec, Canada.
³³ Department of Pharmacology & Therapeutics, McGill University, Montréal, Québec, Canada.
³⁴ Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
³⁵ Department of Health, Kinesiology and Applied Physiology, Concordia University, Montréal, Québec, Canada.
³⁶ Department of Psychology (Science), University of Alberta, Edmonton, Alberta, Canada. Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada.
³⁷ Department of Psychology (Science), University of Alberta, Edmonton, Alberta, Canada.
³⁸ Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada.
³⁹ Department of Psychiatry, McGill University, Montréal, Québec, Canada.
⁴⁰ Department of Psychology, University of Toronto, Toronto, Ontario, Canada. Rotman Research Institute, Baycrest Hospital, Toronto, Ontario, Canada.
⁴¹ Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada. McGill Centre for Integrative Neuroscience, Montréal, Québec, Canada. McConnell Brain Imaging Centre (BIC), McGill University, Montréal, Québec, Canada.
⁴² McConnell Brain Imaging Centre (BIC), McGill University, Montréal, Québec, Canada.
⁴³ McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada.
⁴⁴ Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada.
⁴⁵ Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
⁴⁶ Department of Neurosciences, University of California, San Diego, CA, USA.
⁴⁷ Département de nutrition, Faculté de médecine, Université de Montréal, Montréal, Québec, Canada.
⁴⁸ Department of Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada.
⁴⁹ Nova Scotia Health and the Department of Psychiatry, Division of Geriatric Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
⁵⁰ Montreal Neurological Institute, Montréal, Québec, Canada.
⁵¹ McGill Center for Studies in Aging, Douglas Hospital, McGill University, Montréal, Québec, Canada.
⁵² Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.
⁵³ Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
⁵⁴ Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
⁵⁵ Hotchkiss Brain Institute, Calgary, Alberta, Canada.
⁵⁶ Department of Family Medicine and Biobehavioral Health, University of Minnesota, Minneapolis, MN, USA.
⁵⁷ Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
⁵⁸ Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.
⁵⁹ Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
⁶⁰ School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada.
⁶¹ School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada.
⁶² ICES, Toronto, Ontario, Canada.
⁶³ Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada.
⁶⁴ Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
⁶⁵ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
⁶⁶ Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.
⁶⁷ Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada.
⁶⁸ Gait and Brain Lab, Parkwood Institute, University of Western Ontario, London, Ontario, Canada.
⁶⁹ Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada.
⁷⁰ Canadian Centre for Health and Safety in Agriculture (CCHSA), University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
⁷¹ Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
⁷² Department of Medicine and Rotman Research Institute, Baycrest Hospital, Toronto, Ontario, Canada.
⁷³ Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
⁷⁴ Cora Kanow Professor of Alzheimer Disease Research and Professor of Neurology, Mayo Clinic Dept. of Neurology, Mayo Clinic, Rochester, NY, USA.
⁷⁵ Department of Psychology, Toronto Metropolitan University, Toronto, Canada.
⁷⁶ Department of Family Medicine, University of Calgary, Calgary, Alberta Canada.
⁷⁷ Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
⁷⁸ Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada.
⁷⁹ Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.
⁸⁰ Schulich School of Medicine & Dentistry, Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada.
⁸¹ Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada.
⁸² Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.
⁸³ Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
⁸⁴ Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.
⁸⁵ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
⁸⁶ McMaster Indigenous Research Institute, McMaster University, Hamilton, Ontario, Canada.
⁸⁷ École d'optométrie, Université de Montréal, Montréal, Québec, Canada.

PMID: 39636028
DOI: 10.1177/13872877241290990

Abstract

The Canadian Consortium on Neurodegeneration in Aging (CCNA) was created by the Canadian federal government through its health research funding agency, the Canadian Institutes for Health Research (CIHR), in 2014, as a response to the G7 initiative to fight dementia. Two five-year funding cycles (2014-2019; 2019-2024) have occurred following peer review, and a third cycle (Phase 3) has just begun. A unique construct was mandated, consisting of 20 national teams in Phase I and 19 teams in Phase II (with research topics spanning from basic to clinical science to health resource systems) along with cross-cutting programs to support them. Responding to the needs of researchers within the CCNA teams, a unique sample of 1173 deeply phenotyped patients with various forms of dementia was accrued and studied over eight years (COMPASS-ND). In the second phase of funding (2019-2024), a national dementia prevention program (CAN-THUMBS UP) was set up. In a short time, this prevention program became a member of the World Wide FINGERS prevention consortium. In this article, the challenges, successes, and impacts of CCNA in Canada and internationally are discussed. Short-term deliverables have occurred, along with considerable promise of impacts in the longer term. The creation of synergy, networking, capacity building, engagement of people with lived experience, and economies of scale have contributed to the considerable success of CCNA by all measures. CCNA is evidence that an organized "centrally-organized" approach to dementia research can catalyze important progress nationally and yield significant and measurable results.

Keywords: Alzheimer's disease; cohort; dementia; prevention; research plan; sex; synergy.

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Conflict of interest statement

Declaration of conflicting interestsDrs. Krista Lanctot, Manuel Montero-Odasso, Sylvie Belleville, and Julie Robillard, are Editorial Board Members of this journal but were not involved in the peer-review process of this article nor had access to any information regarding its peer-review.

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Impact of a national dementia research consortium: The Canadian Consortium on Neurodegeneration in Aging (CCNA)

Affiliations

Impact of a national dementia research consortium: The Canadian Consortium on Neurodegeneration in Aging (CCNA)

Authors

Affiliations

Abstract

Conflict of interest statement

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LinkOut - more resources

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Medical