Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy.

BACKGROUND: Polypharmacy is associated with poorer health outcomes in older adults. Other than the associated multimorbidity, factors contributing to this association could include medication adverse effects and interactions, difficulties in managing complicated medication regimes, and reduced medication adherence. It is unknown how reversible these negative associations may be if polypharmacy is reduced. The purpose of this study was to determine the feasibility of implementing an operationalized clinical pathway aimed to reduce polypharmacy in primary care and to pilot measurement tools suitable for assessing change in health outcomes in a larger randomized controlled trial (RCT). METHODS: We randomized consenting patients ≥ 70 years old on ≥ 5 long-term medications into intervention or control groups. We collected baseline demographic information and research outcome measures at baseline and 6 months. We assessed four categories of feasibility outcomes: process, resource, management, and scientific. The intervention group received TAPER (team approach to polypharmacy evaluation and reduction), a clinical pathway for reducing polypharmacy using "pause and monitor" drug holiday approach. TAPER integrates patients' goals, priorities, and preferences with an evidence-based "machine screen" to identify potentially problematic medications and support a tapering and monitoring process, all supported by a web-based system, TaperMD. Patients met with a clinical pharmacist and then with their family physician to finalize a plan for optimization of medications using TaperMD. The control group received usual care and were offered TAPER after follow-up at 6 months. RESULTS: All 9 criteria for feasibility were met across the 4 feasibility outcome domains. Of 85 patients screened for eligibility, 39 eligible patients were recruited and randomized; two were excluded post hoc for not meeting the age requirement. Withdrawals (2) and losses to follow-up (3) were small and evenly distributed between arms. Areas for intervention and research process improvement were identified. In general, outcome measures performed well and appeared suitable for assessing change in a larger RCT. CONCLUSIONS: Results from this feasibility study indicate that TAPER as a clinical pathway is feasible to implement in a primary care team setting and in an RCT research framework. Outcome trends suggest effectiveness. A large-scale RCT will be conducted to investigate the effectiveness of TAPER on reducing polypharmacy and improving health outcomes. TRIAL REGISTRATION: clinicaltrials.gov NCT02562352 , Registered September 29, 2015.

Cognitive and social well-being in older adulthood: The CoSoWELL corpus of written life stories.

This paper presents the Cognitive and Social WELL-being (CoSoWELL) project that consists of two components. One is a large corpus of narratives written by over 1000 North American older adults (55+ years old) in five test sessions before and during the first year of the COVID-19 pandemic. The other component is a rich collection of socio-demographic data collected through a survey from the same participants. This paper introduces the first release of the corpus consisting of 1.3 million tokens and the survey data (CoSoWELL version 1.0). It also presents a series of analyses validating design decisions for creating the corpus of narratives written about personal life events that took place in the distant past, recent past (yesterday) and future, along with control narratives. We report results of computational topic modeling and linguistic analyses of the narratives in the corpus, which track the time-locked impact of the COVID-19 pandemic on the content of autobiographical memories before and during the COVID-19 pandemic. The main findings demonstrate a high validity of our analytical approach to unique narrative data and point to both the locus of topical shifts (narratives about recent past and future) and their detailed timeline. We make the CoSoWELL corpus and survey data available to researchers and discuss implications of our findings in the framework of research on aging and autobiographical memories under stress.

Parent Survey Identifies Low-Cost Emotional and Educational Supports in NICU and Beyond.

BACKGROUND: Families face significant mental health challenges after preterm birth. However, there are few low-cost and sustainable services to help with mental health challenges. PURPOSE: To understand suggestions for low-cost and sustainable mental health supports to help families. METHODS: This was an internet-based survey made available to preterm families through the Canadian Premature Babies Foundation social media (Facebook private parents' group). RESULTS: Families reported that peer support, such as connecting with other parents and families who experience preterm birth, was most beneficial. Parents also reported ways to allow families to access the existing mental health services, such as providing child care options and improving advertisement of available resources. IMPLICATIONS: Our results can help implement beneficial low-cost and sustainable mental health supports across many contexts (eg, hospitals and community organization) both in-person and online.

Personhood and aging: Exploring the written narratives of older adults as articulations of personhood in later life.

Personhood is a complex concept in gerontological research. It is often used to explore the maintenance or reconstruction of self-identity. Narrative analysis has commonly explored how the stories that older individuals living with cognitive impairment(s) produce preserve the personhood that is perceived to be threatened by cognitive decline. This article moves beyond this exploration by focusing on the experiences of aging more generally to better understand how non-cognitively impaired older adults construct personhood through narrative writing. This article uses thematic narrative analysis and argues that older adults articulate personhood through written narratives by creating coherent constructions of self. Importantly, it demonstrates that older adults are concerned with maintaining a sense of self rather than embracing changed aspects of identity in accordance with popularized conceptualizations of personhood as well as ideals of coherence and consistency promoted in successful and active aging discourses.

The World Mental Health International College Student Survey in Canada: Protocol for a Mental Health and Substance Use Trend Study.

BACKGROUND: The World Health Organization World Mental Health International College Student (WMH-ICS) initiative aims to screen for mental health and substance use problems among postsecondary students on a global scale as well as to develop and evaluate evidence-based preventive and ameliorative interventions for this population. This protocol paper presents the Canadian version of the WMH-ICS survey, detailing the adapted survey instrument, the unique weekly cross-sectional administration, the multitiered recruitment strategy, and the associated risk mitigation protocols. OBJECTIVE: This paper aims to provide a methodological resource for researchers conducting cross-national comparisons of WMH-ICS data, as well as to serve as a useful guide for those interested in replicating the outlined cross-sectional methodology to better understand how mental health and substance use vary over time among university students. METHODS: The online survey is based on the WMH-ICS survey instrument, modified to the Canadian context by the addition of questions pertaining to Canadian-based guidelines and the translation of the survey to Canadian French. The survey is administered through the Qualtrics survey platform and is sent to an independent stratified random sample of 350 students per site weekly, followed by two reminder emails. Upon survey closure every week, a random subsample of 70 nonresponders are followed up with via phone or through a personal email in an effort to decrease nonresponder bias. The survey is accompanied by an extensive risk mitigation protocol that stratifies respondents by the level of need and provides tailored service recommendations, including a facilitated expedited appointment to student counseling services for those at increased risk of suicide. The anticipated sample size is approximately 5500 students per site per year. RESULTS: In February 2020, the Canadian survey was deployed at the University of British Columbia. This was followed by deployment at Simon Fraser University (November 2020), McMaster University (January 2021), and the University of Toronto (January 2022). Data collection at all 4 sites is ongoing. As of May 6, 2022, 29,503 responses have been collected. CONCLUSIONS: Based on international collaboration, the Canadian version of the WMH-ICS survey incorporates a novel methodological approach centered on the weekly administration of a comprehensive cross-sectional survey to independent stratified random samples of university students. After 27 months of consecutive survey administration, we have developed and refined a survey protocol that has proven effective in engaging students at four Canadian institutions, allowing us to track how mental health and substance use vary over time using an internationally developed university student survey based on the criteria from the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/35168.

Team approach to polypharmacy evaluation and reduction: study protocol for a randomized controlled trial.

BACKGROUND: Polypharmacy in older adults can be associated with negative outcomes including falls, impaired cognition, reduced quality of life, and general and functional decline. It is not clear to what extent these are reversible if the number of medications is reduced. Primary care does not have a systematic approach for reducing inappropriate polypharmacy, and there are few, if any, approaches that account for the patient's priorities and preferences. The primary objective of this study is to test the effect of TAPER (Team Approach to Polypharmacy Evaluation and Reduction), a structured operationalized clinical pathway focused on reducing inappropriate polypharmacy. TAPER integrates evidence tools for identifying potentially inappropriate medications, tapering, and monitoring guidance and explicit elicitation of patient priorities and preferences. We aim to determine the effect of TAPER on the number of medications (primary outcome) and health-related outcomes associated with polypharmacy in older adults. METHODS: We designed a multi-center randomized controlled trial, with the lead implementation site in Hamilton, Ontario. Older adults aged 70 years or older who are on five or more medications will be eligible to participate. A total of 360 participants will be recruited. Participants will be assigned to either the control or intervention arm. The intervention involves a comprehensive multidisciplinary medication review by pharmacists and physicians in partnership with patients. This review will be focused on reducing medication burden, with the assumption that this will reduce the risks and harms of polypharmacy. The control group is a wait list, and control patients will be given appointments for the TAPER intervention at a date after the final outcome assessment. All patients will be followed up and outcomes measured in both groups at baseline and 6 months. DISCUSSION: Our trial is unique in its design in that it aims to introduce an operationalized structured clinical pathway aimed to reduce polypharmacy in a primary care setting while at the same time recording patient's goals and priorities for treatment. TRIAL REGISTRATION: Clinical Trials.gov NCT02942927. First registered on October 24, 2016.

A Web-Based Social Network Tool (GENIE) for Supporting Self-management Among High Users of the Health Care System: Feasibility and Usability Study.

BACKGROUND: Primary care providers are well positioned to foster self-management through linking patients to community-based health and social services (HSSs). This study evaluated a web-based tool-GENIE (Generating Engagement in Network Involvement)-to support the self-management of adults. GENIE empowers patients to leverage their personal social networks and increase their access to HSSs. GENIE maps patients' personal social networks, elicits preferences, and filters local HSSs from a community service directory based on patient's interests. Trained volunteers (an extension of the primary care team) conducted home visits and conducted surveys related to life and health goals in the context of the Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) program, in which the GENIE tool was implemented. GENIE reports were uploaded to an electronic medical record for care planning by the team. OBJECTIVE: This study aims to explore patients', volunteers', and clinicians' perceptions of the feasibility, usability, and perceived outcomes of GENIE-a tool for community-dwelling adults who are high users of the health care system. METHODS: This study involved 2 primary care clinician focus groups and 1 clinician interview (n=15), 1 volunteer focus group (n=3), patient telephone interviews (n=8), field observations that captured goal-action sequences to complete GENIE, and GENIE utilization statistics. The patients were enrolled in a primary care program-Health TAPESTRY-and Ontario's Health Links Program, which coordinates care for the highest users of the health care system. NVivo 11 (QSR International) was used to support qualitative data analyses related to feasibility and perceived outcomes, and descriptive statistics were used for quantitative data. RESULTS: Most participants reported positive overall perceptions of GENIE. However, feasibility testing showed that participants had a partial understanding of the tool; volunteer facilitation was critical to support the implementation of GENIE; clinicians perceived their navigation ability as superior to that of GENIE supported by volunteers; and tool completion took 39 minutes, which made the home visit too long for some. Usability challenges included difficulties completing some sections of the tool related to medical terminology and unclear instructions, limitations in the quality and quantity of HSSs results, and minor technological challenges. Almost all patients identified a community program or activity of interest. Half of the patients (4/8, 50%) followed up on HSSs and added new members to their network, whereas 1 participant lost a member. Clinicians' strengthened their understanding of patients' personal social networks and needs, and patients felt less social isolation. CONCLUSIONS: This study demonstrated the potential of GENIE, when supported by volunteers, to expand patients' social networks and link them to relevant HSSs. Volunteers require training to implement GENIE for self-management support, which may help overcome the time limitations faced by primary care clinicians. Refining the filtering capability of GENIE to address adults' needs may improve primary care providers' confidence in using such tools.

Mitigating the Challenges and Capitalizing on Opportunities: A Qualitative Investigation of the Public Library's Response to an Aging Population.

Public libraries are community hubs that can both create opportunities and address challenges often associated with later life and population aging. Using a thematic analysis of 18 in-depth interviews with public librarians, this study investigates common practices and challenges experienced while developing programs for older adults. This analysis is augmented by an environmental scan of older-adult programming offered in member libraries of the Canadian Urban Library Council (CULC). Results indicate that public librarians leverage community partnerships and staff training to develop programs that foster digital, financial, language, and health literacy and create opportunities for both intergenerational and peer social connection. At the same time, they face challenges related to limited space, budgets, and staff capacity, difficulty meeting the extensive and often conflicting interests of various groups within the library, and marketing programming to older adults. Findings indicate that public libraries may be key players in mitigating challenges often associated with having an aging population, and indeed highlight the many benefits of valuing and providing services to this population.

Confronting Medicine's Dichotomies: Older Adults' Use of Interpretative Repertoires in Negotiating the Paradoxes of Polypharmacy and Deprescribing.

To address the risks associated with polypharmacy, health care providers are investigating the feasibility of deprescribing programs as part of routine medical care to reduce medication burden to older adults. As older adults are enrolled in these programs, they are confronted with two dominant and legitimate accounts of medications, labeled the medication paradox: medications keep you healthy but they might be making you sick. We investigated how the medication paradox operates in the lives of older adults. In-depth qualitative interviews were conducted and analyzed with older adults aged 70+ to identify the various paradoxes that seniors live through regarding their medications and the narratives that they engage to negotiate these contradictions. Older adults were found to have established interpretative repertoires to make sense of the incongruent narratives of the medication paradox. In this article, we demonstrate older adults' efforts to carve out their unique place in the dichotomized institution of medicine.

"At 80 I Know Myself": Embodied Learning and Older Adults' Experiences of Polypharmacy and Perceptions of Deprescribing.

In response to the risks of polypharmacy for older adults, there are increasing calls for the development and implementation of deprescribing programs. This article examines the forms of expertise that inform older adults' decisions about how to use medications given concerns over polypharmacy and a clinical focus on deprescribing. In-depth interviews with older adults found that diverse knowledge sources underpin decisions regarding polypharmacy and deprescribing. Findings indicate that this knowledge is formed through a lifetime of embodied learning-the production of relevant knowledge through lived experiences of the body. By way of this embodied learning, older adults possess individualized knowledge bases that inform health and health care decisions, especially regarding the use of medications. If deprescribing programs are to be embedded into standard preventive medical care of older adults, then it is valuable for health care providers to be aware of and take seriously the contribution of embodied knowledge.

Reconstructing Aboriginal Identity and the Meaning of the Body in Blood Donation Decisions.

Ethno-cultural disparities in blood and tissue donation patterns have been described as an emergent challenge in the context of the transfusion medicine literature (Boulware et al. in Med Care 40(2):85-95, 2002; Molzahn et al. in Nephrol Nurs J 30(1):17-26, 2003, Can J Nurs Res 36(4):110-128, 2004). In the North American context, much has been written about blood and tissue donation patterns among different religious and cultural groups within the United States. However, there are few available statistics or descriptive research that discusses blood donation decisions among Aboriginal Canadians. In 2001, Aboriginal Canadians represented approximately 4.1% of the total Canadian population, or 1.1 million persons (Birn et al., in Textbook of international health: global health in a dynamic world. Oxford University Press, New York, NY, 2009). Comparatively, Canada Blood Services reports that Aboriginal Canadians represent only 0.9% of registered donors (Canadian Blood Services 2011a). These low donation patterns suggest that blood donation choice among Aboriginal Canadians requires better understanding. This paper discusses several factors that may influence Aboriginal health choices, specifically those associated with blood donation decision-making. Several influential factors will be discussed, including: the meaning of the body and its parts in relationship to the interconnectedness of all things (religio-cultural), the reflexivity of choice and control (political), and relationships with others (social).

What do people living with HIV/AIDS expect from their physicians? Professional expertise and the doctor-patient relationship.

This qualitative study identifies the types of professional expertise that physicians are seen to possess in clinical encounters from the perspective of people living with HIV/AIDS (PLWHA). Respondents looked to their physicians for expert knowledge in 3 key areas: medical/clinical; legal/statutory; and ethical/moral. Physicians were seen to be authorities in each of these areas and their judgments, though not always agreed with, were taken seriously and influenced the health care decisions made by PLWHA. The authority that comes with professional expertise in each of the areas identified was experienced both positively and negatively by PLWHA. Understanding the expectations of patients in the medical encounter can assist physicians in providing optimal care in the management of HIV/AIDS.

Media activism and Internet use by people with HIV/AIDS.

This paper seeks to understand better the media practices of people who are directly affected by an illness or health problem. Internet sites that have been created by people with HIV/AIDS are examined as a strategy for self-representation. This analysis identifies four prominent 'organising themes' in Internet sites: autobiography; expertise; self promotion; and dissent. It is argued that there is a connection between media activism within the contemporary AIDS movement and Internet use among people with HIV/AIDS. This paper discusses the potential of the Internet, as a form of media activism, to raise the private troubles of people with health problems as public issues through a revitalisation of the public sphere in contemporary post-industrial societies.

How people with HIV/AIDS manage and assess their use of complementary therapies: a qualitative analysis.

The objective of this article is to provide a qualitative analysis of the practical concerns that people with HIV/AIDS have with regard to their use of complementary therapies. In-depth semistructured interviews were conducted with a diverse range of people with HIV/AIDS (N = 46). An inductive grounded approach was used to collect and analyze the data. There were five central concerns: (a) selecting which therapies to use, (b) judging which therapies work, (c) combining Western medicine with complementary therapies, (d) assessing the safety of complementary therapies, and (e) dealing with the barriers to the use of complementary therapies. A better understanding of the practical dimensions of complementary therapy use highlights the treatment and care issues that people with HIV/AIDS face and offers insights into the role that nurses might play in addressing some of these issues.