Feasibility, Acceptability, and Impact of a self-guided e-learning Memory and Brain Health Promotion Program for Healthy Older Adults.

OBJECTIVES: To examine the feasibility (e.g., completion rate), acceptability (e.g., satisfaction), and participant-reported impact (e.g., memory concerns, behavior change, goal attainment) of a self-guided, e-learning adaptation of a validated, facilitator-guided, in-person memory intervention for older adults. METHODS: Participants were 139 healthy older adults (mean age: 73 ± 7, 73% women). Participation tracking and pre/post questionnaires embedded within the e-learning program were used to assess feasibility, acceptability, and impact. RESULTS: Sixty-eight percent of participants completed the program. Anonymous feedback data indicated a high level of satisfaction with the program, the pace and clarity of the learning modules, and the user interface. Suggested improvements included offering more interaction with others and addressing minor platform glitches. There was a 41% decrease in the prevalence of concern about memory changes from baseline to posttest. The majority of participants reported an increase in use of memory strategies and uptake of health-promoting lifestyle behaviors. All participants reported moderate-to-high satisfaction with personal goal attainment. CONCLUSIONS: The program demonstrated good feasibility, acceptability, and lead to reduction in age-related memory concerns. CLINICAL IMPLICATIONS: Self-guided, e-learning programming shows promise for fostering positive adaptation to age-related memory changes and improving the uptake of evidence-based strategies to promote brain health among older adults.

How Long Should GPS Recording Lengths Be to Capture the Community Mobility of An Older Clinical Population? A Parkinson's Example.

Wearable global position system (GPS) technology can help those working with older populations and people living with movement disorders monitor and maintain their mobility level. Health research using GPS often employs inconsistent recording lengths due to the lack of a standard minimum GPS recording length for a clinical context. Our work aimed to recommend a GPS recording length for an older clinical population. Over 14 days, 70 older adults with Parkinson's disease wore the wireless inertial motion unit with GPS (WIMU-GPS) during waking hours to capture daily "time outside", "trip count", "hotspots count" and "area size travelled". The longest recording length accounting for weekend and weekdays was ≥7 days of ≥800 daily minutes of data (14 participants with 156, 483.9 min recorded). We compared the error rate generated when using data based on recording lengths shorter than this sample. The smallest percentage errors were observed across all outcomes, except "hotspots count", with daily recordings ≥500 min (8.3 h). Eight recording days will capture mobility variability throughout days of the week. This study adds empirical evidence to the sensor literature on the required minimum duration of GPS recording.

Perspectives on ageing: a qualitative study of the expectations, priorities, needs and values of older people from two Canadian provinces.

BACKGROUND: Understanding the needs and values of older people is vital to build responsive policies, services and research agendas in this time of demographic transition. Older peoples' expectations and priorities for ageing, as well as their beliefs regarding challenges facing ageing societies, are multi-faceted and require regular updates as populations' age. OBJECTIVE: To develop an understanding of self-perceptions of ageing and societal ageing among Canadian retirees of the education sector to define a meaningful health research agenda. METHODS: We conducted four qualitative focus groups among 27 members of a Canadian retired educators' organisation. Data were analysed using an inductive thematic approach. RESULTS: We identified four overarching themes: (1) vulnerability to health challenges despite a healthier generation, (2) maintaining health and social connection for optimal ageing, (3) strengthening person-centred healthcare for ageing societies and (4) mobilising a critical mass to enact change. Participants' preconceptions of ageing differed from their personal experiences. They prioritised maintaining health and social connections and felt that current healthcare practices disempowered them to manage and optimise their health. Although the sheer size of their demographic instilled optimism of their potential to garner positive change, participants felt they lacked mechanisms to contribute to developing solutions to address this transition. CONCLUSION: Our findings suggest a need for health research that improves perceptions of ageing and supports health system transformations to deliver person-centred care. Opportunities exist to harness their activism to engage older people as partners in shaping solution-oriented research that can support planning for an ageing society.

Depression, anxiety, and personal recovery outcomes after group vs individual transdiagnostic therapy: a brief report.

Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is an evidence-informed treatment utilizing Cognitive Behavioural Therapy (CBT) treatment principles. UP has demonstrated promising treatment effects comparable to single disorder protocol across several mental disorders. Its impact on personal recovery in anxiety and depression has not been examined. This study compares clinical and personal recovery outcomes of UP treatment for depression and anxiety disorders when delivered in a group vs. individual format. Retrospective chart review of outcomes was conducted for outpatients receiving 12-week individual (n = 65) and group (n = 62) UP treatment in a specialized psychiatric hospital. Descriptive and repeated measures ANOVA analyses were conducted on outcomes on Overall Depression Severity and Impairment Scale, Overall Anxiety Severity and Impairment Scale, Recovery Assessment Scale administered pre and post treatment. On average, participants in both group and individual UP treatment showed improvements in anxiety, depression, and recovery scores. Greater proportion of group participants showed improvements on two interpersonal-focused domains of personal recovery. Results indicate group UP treatment is comparably effective compared to individual UP in improving clinical and recovery outcomes, and treatment modality affects the degree of personal recovery. Overall findings offer important clinical promise of UP treatment as a transdiagnostic treatment option for individuals with anxiety and depression.

Prevention of poststroke depression: does prophylactic pharmacotherapy work?

BACKGROUND: Given the negative influence of poststroke depression (PSD) on functional recovery, cognition, social participation, quality of life, and risk for mortality, the early initiation of antidepressant therapy to prevent its development has been investigated; however, individual studies have offered conflicting evidence. The present systematic review and meta-analysis examined available evidence from published randomized controlled trials (RCTs) evaluating the effectiveness of pharmacotherapy for the prevention of PSD to provide updated pooled analyses. METHODS: Literature searches of 6 databases were performed for the years 1990 to 2011. RCTs meeting study inclusion criteria were evaluated for methodologic quality. Data extracted included the antidepressant therapy used, treatment timing and duration, method(s) of assessment, and study results pertaining to the onset of PSD. Pooled analyses were conducted. RESULTS: Eight RCTs were identified for inclusion. Pooled analyses demonstrated reduced odds for the development of PSD associated with pharmacologic treatment (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.22-0.53; P<.001), a treatment duration of 1 year (OR 0.31; 95% CI 0.18-0.56; P<.001), and the use of a selective serotonin reuptake inhibitor (OR 0.37; 95% CI 0.22-0.61; P<.001). CONCLUSIONS: The early initiation of antidepressant therapy, in nondepressed stroke patients, may reduce the odds for development of PSD. Optimum timing and duration for treatment and the identification of the most appropriate recipients for a program of indicated prevention require additional examination.

Development of a dynamic machine learning algorithm to predict clinical pregnancy and live birth rate with embryo morphokinetics.

Objective: To evaluate the feasibility of generating a center-specific embryo morphokinetic algorithm by time-lapse microscopy to predict clinical pregnancy rates. Design: A retrospective cohort analysis. Setting: Academic fertility clinic in a tertiary hospital setting. Patients: Patients who underwent in vitro fertilization with embryos that underwent EmbryoScope time-lapse microscopy and subsequent transfer between 2014 and 2018. Interventions: None. Main Outcome Measures: Clinical pregnancy. Results: A supervised, random forest learning algorithm from 367 embryos successfully predicted clinical pregnancy from a training set with overall 65% sensitivity and 74% positive predictive value, with an area under the curve of 0.7 for the test set. Similar results were achieved for live birth outcomes. For the secondary analysis, embryo growth morphokinetics were grouped into five clusters using unsupervised clustering. The clusters that had the fastest morphokinetics (time to blastocyst = 97 hours) had pregnancy rates of 54%, whereas a cluster that had the slowest morphokinetics (time to blastocyst = 122 hours) had a pregnancy rate of 71%, although the differences were not statistically significant (P=.356). Other clusters had pregnancy rates of 51%-60%. Conclusions: This study shows the feasibility of a clinic-specific, noninvasive embryo morphokinetic simple machine learning model to predict clinical pregnancy rates.

Canada's health human resource challenges: what is the fate of our healthcare heroes?

Each year, the Canadian health education system graduates thousands of health professionals who have the best intentions of practising to their full scope of knowledge and skills to help improve the patient care experience in this country. However, a recent research study points to the fact that members of the healthcare team may be practising in a challenging environment in which only a limited number of their skills are actually being used. The Michener Institute for Applied Health Sciences believes that these issues, which include increased role specialization, limited scopes of practice, rapidly advancing technology, and challenges transitioning from hospital to community settings, have broader health education and health system implications that need to be addressed by policy makers, educators, and healthcare system leaders in order to enhance health professional education as well as patient care.

Comparing GPS-Based Community Mobility Measures with Self-report Assessments in Older Adults with Parkinson's Disease.

BACKGROUND: Real-life community mobility (CM) measures for older adults, especially those with Parkinson's disease (PD), are important tools when helping individuals maintain optimal function and quality of life. This is one of the first studies to compare an objective global positioning system (GPS) sensor and subjective self-report CM measures in an older clinical population. METHODS: Over 14 days, 54 people in Ontario, Canada with early to mid-stage PD (mean age = 67.5 ± 6.3 years; 47 men; 46 retired) wore a wireless inertial measurement unit with GPS (WIMU-GPS), and completed the Life Space Assessment and mobility diaries. We assessed the convergent validity, reliability and agreement on mobility outcomes using Spearman's correlation, intraclass correlation coefficient, and Bland-Altman analyses, respectively. RESULTS: Convergent validity was attained by the WIMU-GPS for trip frequency (rs = .69, 95% confidence interval [CI] = 0.52-0.81) and duration outside (rs = .43, 95% CI = 0.18-0.62), but not for life space size (rs = .39, 95% CI = 0.14-0.60). The Life Space Assessment exhibited floor and ceiling effects. Moderate agreements were observed between WIMU-GPS and diary for trip frequency and duration (intraclass correlation coefficients = 0.71, 95% CI = 0.51-0.82; 0.67, 95% CI = 0.42-0.82, respectively). Disagreement was more common among nonretired individuals. CONCLUSIONS: WIMU-GPS could replace diaries for trip frequency and duration assessments in older adults with PD. Both assessments are best used for retired persons. However, the Life Space Assessment may not reflect actual mobility.

Health Forums and Twitter for Dementia Research: Opportunities and Considerations.

BACKGROUND/OBJECTIVES: Social media platforms are promising sources for large quantities of participant-driven research data and circumvent some common challenges when conducting dementia research. This study provides a summary of key considerations and recommendations about using these platforms as research tools for dementia. DESIGN: Mixed methods. SETTING: Alzheimer's Society's online Dementia Talking Point forum from inception to April 17, 2018, and Twitter in February and March 2018. PARTICIPANTS: All users of Dementia Talking Point who posted in subforums labeled "I have dementia" and "I care for a person with dementia," and Twitter users whose posts contained the keywords "dementia," "Alzheimer," or "Alzheimer's." MEASUREMENTS: We quantified the average daily number of dementia-related posts on each platform and number of words per post. Guided by a codebook, we conducted thematic content analysis of 5% of the 15,513 posts collected from Dementia Talking Point, and 10% of the 25,948 comprehensible posts from Twitter containing "dementia," "Alzheimer," or "Alzheimer's." We also summarized research-relevant characteristics inherent to platforms and posts. RESULTS: On average, Dementia Talking Point provided less than two new daily dementia-related posts with 213.5 to 241.5 words, compared with 7,883 new daily Twitter posts with 14.5 words. Persons with dementia (PWDs) commonly shared dementia-related concerns (75.7%), experiences (68.6%), and requests for, as well as offers of, information and support (44.3% and 38.6%, respectively). Caregivers commonly shared caregiving experience (67.0%) and requests for information and support (52.5%). Most common dementia-related Twitter posts were derogatory use of the term dementia (14.5%), advocacy, fundraising, and awareness (11.6%), and research dissemination (8.0%). Recommendations about these platforms' unique technical and ethical considerations are outlined. CONCLUSIONS: Understanding the priorities of PWDs and their caregivers remains important to understand how clinicians can best support them. This study will help clinicians and researcher to better leverage online health forums and Twitter for such dementia-related information.

Does Physician Retirement Affect Patients? A Systematic Review.

OBJECTIVES: Older patients that have aged with their doctors will likely experience their physician retiring. It is unclear if this interruption in continuity of care leaves patients at risk for adverse events or whether a new physician improves care. We sought to identify and synthesize findings from all articles examining the association between physician retirement and patient outcomes. DESIGN: Systematic review. We searched English-language articles cataloged in Medline, Embase, Cochrane, and PsycINFO, from database inception to May 4, 2018. PARTICIPANTS: Any patient whose physician (generalist or specialist) retired. INTERVENTION: Physician retirement, defined as voluntary practice closure, death, or departure. MEASUREMENTS: Articles were categorized as anecdotes, qualitative studies, or quantitative studies. Each patient outcome was indexed under one of 11 themes (eg, adverse event, difficulty accessing care) and classified as favorable, neutral, or unfavorable. Patient outcomes included but were not limited to clinical (eg, death), resource utilization (eg, hospitalization), treatment plan adherence (eg, access to medications), and patient satisfaction (eg, expressed frustration). Two reviewers independently assessed study quality. RESULTS: Of 2099 articles screened, 17 met inclusion criteria: 12 anecdotes, 2 qualitative studies, and 3 quantitative studies. Most patient outcomes described were unfavorable. These included feelings of loss, difficulties with transition to a new provider, adverse clinical outcomes, and increased use of high-cost services. The quality of qualitative studies was high, but that of quantitative studies was poor or moderate. CONCLUSION: Current evidence from qualitative studies suggests physician retirement affects patients unfavorably and that patients are vulnerable during this transition of care. High-quality quantitative research is lacking to identify whether this disproportionately affects older adults and whether physician retirement has significant consequences for the broader healthcare system. J Am Geriatr Soc 68:641-649, 2020.

Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension.

Importance: Calcium channel blockers (CCBs) are commonly prescribed agents for hypertension that can cause peripheral edema. A prescribing cascade occurs when the edema is misinterpreted as a new medical condition and a diuretic is subsequently prescribed to treat the edema. The extent to which this prescribing cascade occurs at a population level is not well understood. Objective: To measure the association between being newly dispensed a CCB and subsequent dispensing of a loop diuretic in older adults with hypertension. Design, Setting, and Participants: A population-based cohort study was performed using linked health administrative databases of community-dwelling adults 66 years or older with hypertension and new prescription drug claims from September 30, 2011, to September 30, 2016, in Ontario, Canada. The dates of analysis were September 1, 2018, to May 30, 2019. Exposures: Individuals who were newly dispensed a CCB were compared with the following 2 groups: (1) individuals who were newly dispensed an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker and (2) individuals who were newly dispensed an unrelated medication. Main Outcomes and Measures: Hazard ratios (HRs) with 95% CIs were estimated for individuals who were dispensed a loop diuretic within 90 days of follow-up using Cox proportional hazards regression models. Results: The cohort included 41 086 older adults (≥66 years) with hypertension who were newly dispensed a CCB, 66 494 individuals who were newly dispensed another antihypertensive medication, and 231 439 individuals who were newly dispensed an unrelated medication. At index (ie, the dispensing date), the mean (SD) age was 74.5 (6.9) years, and 191 685 (56.5%) were women. Individuals who were newly dispensed a CCB had a higher cumulative incidence at 90 days of being dispensed a loop diuretic than individuals in both control groups (1.4% vs 0.7% and 0.5%, P < .001). After adjustment, individuals who were newly dispensed a CCB had increased relative rates of being dispensed a loop diuretic compared with individuals who were newly dispensed an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (HR, 1.68; 95% CI, 1.38-2.05 in the first 30 days after index [days 1-30]; 2.26; 95% CI, 1.76-2.92 in the subsequent 30 days [days 31-60]; and 2.40; 95% CI, 1.84-3.13 in the third month of follow-up [days 61-90]) and individuals who were newly dispensed unrelated medications (HR, 2.51; 95% CI, 2.13-2.96 for 1-30 days after index; 2.99; 95% CI, 2.43-3.69 for 31-60 days after index; and 3.89; 95% CI, 3.11-4.87 for 61-90 days after index). This association persisted, although slightly attenuated, from 90 days to up to 1 year of follow-up and when restricted to a subgroup of individuals who were newly dispensed amlodipine. Conclusions and Relevance: Many older adults with hypertension who are newly dispensed a CCB subsequently receive a loop diuretic. Given how widely CCBs are prescribed, interventions are needed to raise clinicians' awareness of this common prescribing cascade to reduce the prescribing of potentially unnecessary medications that may cause harm.

Aging at home: integrating community-based care for older persons.

Integrating community-based health and social care has grabbed international attention as a way of addressing the needs of aging populations while contributing to health systems' sustainability. However, integrating initiatives in different jurisdictions work (or do not work) within very various institutional and structural dynamics. The question is, what transferable lessons can we learn to guide policy makers and policy innovators at the local level? In this paper, we consider "aging at home" as a policy option in Ontario, and beyond. In the first section, we focus on the problem, in effect, what not to do. Here, we briefly review findings from national and international research literature and from our own research in Ontario that identify the costs and consequences of non-systems of care for older persons. In the second part, we turn to solutions, in effect, what to do. Drawing on our recent scoping review of the international literature, we identify three guiding principles, as well as a number of recommendations, for integrating care for older persons, knowing that important details of how to put such initiatives "on the ground" will be provided by other contributors to this journal edition.

Sex Differences in the Prevalent Use of Oral Formulations of Cholinesterase Inhibitors in Older Adults with Dementia.

BACKGROUND: Cholinesterase inhibitors (ChEIs) are one of only two drug therapies available to manage cognitive decline in dementia. Given sex-specific differences in medication access and effects, it is important to understand how ChEIs are used by women and men. OBJECTIVE: The objective of this study was to provide contemporary sex-stratified evidence on patterns of ChEI use by community-dwelling older adults with dementia to inform opportunities to optimize drug prescribing. METHODS: We conducted a population-based cross-sectional study examining ChEI use in older adults with dementia in Ontario, Canada. We identified all community-dwelling individuals aged 66 years and older with a pre-existing diagnosis of dementia as of 1 April, 2016. We examined the prevalence of ChEI use among women and men separately, and explored the association between ChEI use and age, sex, income status, geographic location of residence, use of palliative care services, comorbidity, and polypharmacy. Concurrent use of drugs known to impair cognition (including antipsychotics, benzodiazepines, and medications with strong anticholinergic properties) was separately assessed among women and men using multivariable analyses and prevalence risk ratios. RESULTS: Of 74,799 women and 52,231 men living with dementia in the community, nearly 30% currently were using a ChEI (29.3% women, 28.6% men). Close to 70% of users were receiving the target therapeutic dose. Compared to men, women were less often taking the target therapeutic dose (67.8% women vs. 71.6% men, p < 0.001). Over 20% of users also were using drugs known to impair cognition, while being treated for cognitive decline using ChEIs. Compared to men, women were more often concurrently using drugs known to impair cognition (23.9% women vs. 21.8% men, p < 0.001). CONCLUSIONS: This is one of the first studies of ChEI use to account for important sex differences. The results remind clinicians and researchers that patterns of ChEI therapy use differ by sex, as women were less likely to receive target therapeutic doses and more vulnerable to potentially problematic polypharmacy than men.

What Is Known About Preventing, Detecting, and Reversing Prescribing Cascades: A Scoping Review.

OBJECTIVES: To systematically describe the resources available on preventing, detecting, and reversing prescribing cascades using a scoping review methodology. MEASUREMENTS: We searched Medline, EMBASE, PsychINFO, CINAHL, Cochrane Library, and Sociological Abstracts from inception until July 2017. Other searches (Google Scholar, hand searches) and expert consultations were performed for resources examining how to prevent, detect, or reverse prescribing cascades. We used these three categories along the prescribing continuum as an organizing framework to categorize and synthesize resources. RESULTS: Of 369 resources identified, 58 met inclusion criteria; 29 of these were categorized as preventing, 20 as detecting, and 9 as reversing prescribing cascades. Resources originated from 14 countries and mostly focused on older adults. The goal of preventing resources was to educate and increase general awareness of the concept of prescribing cascades as a way to prevent inappropriate prescribing and to illustrate application of the concept to specific drugs (e.g., anticholinergics) and conditions (e.g., inflammatory bowel disease). Detecting resources included original investigations or case reports that identified prescribing cascades using health administrative data, patient cohorts, and novel sources such as social media. Reversing prescribing cascade resources focused on the medication review process and deprescribing initiatives. CONCLUSION: Prescribing cascades are a recognized problem internationally. By learning from the range of resources to prevent, detect, and reverse prescribing cascades, this review contributes to improving drug prescribing, especially in older adults. J Am Geriatr Soc 66:2079-2085, 2018.

Comparison of prescribing practices for older adults treated by female versus male physicians: A retrospective cohort study.

IMPORTANCE: Subtle but important differences have been described in the way that male and female physicians care for their patients, with some evidence suggesting women are more likely to adhere to best practice recommendations. OBJECTIVE: To determine if male and female physicians differ in their prescribing practices as measured by the initiation of lower-than-recommended dose cholinesterase inhibitor (ChEI) drug therapy for dementia management. DESIGN, SETTING, AND PARTICIPANTS: All community-dwelling Ontario residents aged 66 years and older with dementia and newly dispensed an oral ChEI drug (donepezil, galantamine, or rivastigmine) between April 1, 2010 and June 30, 2016 were included. MAIN OUTCOME AND MEASURES: The association between physician sex and the initiation of a lower than recommended-dose ChEI was examined using generalized linear mixed regression models, adjusting for patient and physician characteristics. Data were stratified by specialty. Secondary analyses explored the association between physician sex and cardiac screening as well as shorter duration of the initial prescription. RESULTS: The analysis included 3,443 female and 5,811 male physicians and the majority (83%) were family physicians, Female physicians were more likely to initiate ChEI therapy at a lower-than-recommended dose (Adjusted odds ratio = 1.43,95% confidence interval = 1.17 to 1.74). Compared to their male counterparts, female physicians were also more likely to follow other conservative prescribing practices including cardiac screening (55.1% vs. 49.2%, P-value<0.001) around the time of ChEI initiation, and dispensing a shorter duration of initial prescription (41.8% vs 35.5% P-value<0.001). CONCLUSIONS: There is a statistically significant and important difference in ChEI prescribing patterns between female and male physicians, suggesting that female physicians may be more careful and conservative in their approaches. This will inform future research to determine if patients receiving lower-than-recommended initial doses also have better outcomes.

Initial Cholinesterase Inhibitor Therapy Dose and Serious Events in Older Women and Men.

OBJECTIVES: To examine dose-related prescribing and short-term serious events associated with initiation of cholinesterase inhibitor (ChEI) therapy. DESIGN: Retrospective, population-based cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Women (n=47,829) and men (n=32,503) aged 66 and older who initiated a ChEI between April 1, 2010, and June 30, 2016. MEASUREMENTS: All-cause serious events (emergency department (ED) visits, inpatient hospitalizations, death) within 30 days of ChEI initiation. Multivariable Cox proportional hazards models were used to estimate adjusted rates of serious events. RESULTS: Overall, 4.8% of older adults were dispensed a lower-than-recommended ChEI starting dose, 87.9% a recommended dose, and 7.3% a higher-than-recommended starting dose. Eight thousand six hundred seventy-one (10.8%) individuals experienced a serious event within 30 days of initiating therapy, primarily ED visits (8,540, 10.6%). Relative to those initiated on a recommended starting dose, those initiated on a higher dose had a significantly increased rate of serious events (women adjusted hazard ratio (aHR) 1.50, 95% confidence interval (CI) =1.38-1.63; men aHR 1.31, 95% CI=1.19-1.45). Similar patterns were found for ED visits and inpatient hospitalizations but not death. The relative effect of higher-than-recommended starting dose dispensed vs. recommended starting dose dispensed was greater in women than it was in men: the number needed to harm was 22 (95% confidence interval (CI)=18-29) for women and 36 (95% CI= 26-61) for men. CONCLUSION: Serious events immediately after initiation of ChEIs were associated with starting ChEI dose. This association was stronger in women.