Drug Burden Index Is a Modifiable Predictor of 30-Day Hospitalization in Community-Dwelling Older Adults With Complex Care Needs: Machine Learning Analysis of InterRAI Data.

BACKGROUND: Older adults (≥65 years) account for a disproportionately high proportion of hospitalization and in-hospital mortality, some of which may be avoidable. Although machine learning (ML) models have already been built and validated for predicting hospitalization and mortality, there remains a significant need to optimize ML models further. Accurately predicting hospitalization may tremendously affect the clinical care of older adults as preventative measures can be implemented to improve clinical outcomes for the patient. METHODS: In this retrospective cohort study, a data set of 14 198 community-dwelling older adults (≥65 years) with complex care needs from the International Resident Assessment Instrument-Home Care database was used to develop and optimize 3 ML models to predict 30-day hospitalization. The models developed and optimized were Random Forest (RF), XGBoost (XGB), and Logistic Regression (LR). Variable importance plots were generated for all 3 models to identify key predictors of 30-day hospitalization. RESULTS: The area under the receiver-operating characteristics curve for the RF, XGB, and LR models were 0.97, 0.90, and 0.72, respectively. Variable importance plots identified the Drug Burden Index and alcohol consumption as important, immediately potentially modifiable variables in predicting 30-day hospitalization. CONCLUSIONS: Identifying immediately potentially modifiable risk factors such as the Drug Burden Index and alcohol consumption is of high clinical relevance. If clinicians can influence these variables, they could proactively lower the risk of 30-day hospitalization. ML holds promise to improve the clinical care of older adults. It is crucial that these models undergo extensive validation through large-scale clinical studies before being utilized in the clinical setting.

Using interRAI Assessment for Research: Developing a National Research Agenda in Aotearoa New Zealand.

interRAI provides a suite of standardized, validated instruments used to assess health and psychosocial well-being, and to inform person-centered care planning. Data obtained from these standardized tools can also be used at a population level for research and to inform policy, and interRAI is currently used in more than 40 countries globally. We present a brief overview of the use of interRAI internationally within research and policy settings, and then introduce how interRAI is used within the universal public health system in Aotearoa New Zealand (NZ), including considerations relating to Maori, the Indigenous people of NZ. In NZ, improvement in interRAI data utilization for research purposes was called for from aged care, health providers, and researchers, to better use these data for quality improvement and health advancement for New Zealanders. A national research network has been established, providing a medium for researchers to form relationships and collaborate on interRAI research with a goal of translating routinely collected interRAI data to improve clinical care, patient experience, service development, and quality improvement. In 2023, the network members met (hybrid: in-person and online) and identified research priorities. These were collated and developed into a national interRAI research agenda by the NZ interRAI Research Network Working Group. Research priorities included reviewing the interRAI assessment processes, improving methods for data linkage to national data sets, exploring how Indigenous Data Sovereignty can be upheld, as well as a variety of clinically focused research topics. Implications for Practice, Policy, and Research: This appears to be the first time national interRAI research priorities have been formally identified. Priorities identified have the potential to inform quality and clinical improvement activities and are likely of international relevance. The methodology described to cocreate the research priorities will also be of wider significance for those looking to do so in other countries.

A multistate transition model of changes in loneliness and carer stress among community-dwelling older adults in Aotearoa New Zealand.

OBJECTIVES: To identify changes in loneliness and carer stress between two time points for older people of different ethnicities who had repeated interRAI home care assessments. METHODS: Participants consisted of community-dwelling older adults across New Zealand who received two interRAI-HC assessments between 5 July 2012 and 31 December 2019. Two multistate models were developed: the first model was not lonely versus lonely, and the second model was no carer stress versus carer stress. The one-year transition probabilities were calculated. Mean sojourn times were calculated for each state except death. Paired t-tests assessed the differences in transition probabilities between the different ethnic groups. RESULTS: The mean age of the cohort was 82.5 years (SD 7.7 years). At first assessment, 14,646 (21%) older people stated they were lonely and 26,789 carers (38%) experienced stress. The most common first transition type was not lonely to not lonely: Maori 42%, Pacific 54%, Asian, 48% and Other 40%. The highest one-year transition probability in the loneliness model was living in aged residential care to death (0.79). The most common first transition type for the carer stress was no carer stress to no carer stress: Maori 35%, Pacific, 46%, Asian, 43% and Other 33%. The highest one-year transition probability in the carer stress model was living in aged residential care to death (0.80). The statuses not lonely and no carer stress had a mean sojourn time of approximately one year, and eight months to one year, respectively. CONCLUSIONS: Loneliness can change over time due to circumstances and an individual's perception of loneliness at the time of assessment. Carer stress is enduring and has a low probability of improvement.

The Drug Burden Index and Level of Frailty as Determinants of Healthcare Costs in a Cohort of Older Frail Adults in New Zealand.

OBJECTIVES: Frailty is common in older people and is associated with increased use of healthcare services and ongoing use of multiple medications. This study provides insights into the healthcare cost structure of a frail group of older adults in Aotearoa, New Zealand. Furthermore, we investigated the relationship between participants' anticholinergic and sedative medication burden and their total healthcare costs to explore the viability of deprescribing interventions within this cohort. METHODS: Healthcare cost analysis was conducted using data collected during a randomized controlled trial within a frail, older cohort. The collected information included participant demographics, medications used, frailty, cost of service use of aged residential care and outpatient hospital services, hospital admissions, and dispensed medications. RESULTS: Data from 338 study participants recruited between 25 September 2018 and 30 October 2020 with a mean age of 80 years were analyzed. The total cost of healthcare per participant ranged from New Zealand $15 (US dollar $10) to New Zealand $270 681 (US dollar $175 943) over 6 months postrecruitment into the study. Four individuals accounted for 26% of this cohort's total healthcare cost. We found frailty to be associated with increased healthcare costs, whereas the drug burden was only associated with increased pharmaceutical costs, not overall healthcare costs. CONCLUSIONS: With no relationship found between a patient's anticholinergic and sedative medication burden and their total healthcare costs, more research is required to understand how and where to unlock healthcare cost savings within frail, older populations.

Falls Risk in Long-Term Care Residents With Cognitive Impairment: Effects of COVID-19 Pandemic.

OBJECTIVES: The aim of this study was to investigate the impact of the COVID-19 pandemic on falls rates in long-term care residents with cognitive impairment. DESIGN: An observational study using routinely collected national interRAI data. SETTING AND PARTICIPANTS: Participants were from long-term care residents (age ≥60 years) who received an interRAI Long Term Care Facility assessment anywhere in New Zealand between August 17, 2018, and August 16, 2022. METHODS: The primary outcome was "At least 1 fall in the last 30 days." Based on the Cognitive Performance Scale (CPS), cognitive impairment was categorized into 3 levels: intact or borderline intact (0-1), mild to moderate impairment (2-3), and moderately to very severe impairment (4-6). The COVID-19 pandemic was divided into 3 periods (First wave: March 21, 2020, to June 8, 2020; Varying level of community outbreaks: June 9, 2020 to August 16, 2021; and Delta-Omicron wave: August 17, 2021, to August 16, 2021) and compared to a pre-COVID-19 period (August 17, 2018, to March 20, 2020). Cox regression modeling was used to study falls and interactions between CPS and COVID-19 pandemic periods, along with other established falls risk factors in the literature. RESULTS: A total of 282,518 interRAI-LTCF assessments from 75,132 unique residents were included. Interactions between CPS and COVID-19 pandemic periods found that cognitive impairment was associated with a higher hazard ratio (ranged from 1.22 to 1.37) in each of the 3 COVID-19 pandemic periods. We also found unstable health, unsteady gait, wandering, and moderate to severe ADL dependency were the strongest risk factors for falls. CONCLUSIONS AND IMPLICATIONS: Cognitively impaired long-term care residents had an increased risk for falls during the COVID-19 pandemic. This risk was influenced by several factors. In future pandemic or infection control related isolation, residents who are most at risk can be identified for targeted falls prevention programs.

Multimorbidity associated with urinary incontinence among older women and men with complex needs in Aotearoa | New Zealand.

AIMS: To investigate the association between multimorbidity and urinary incontinence (UI) among community living older adults with complex needs in sex-specific crude and adjusted analyses. METHODS: Since 2012 in Aotearoa | New Zealand (NZ) all community-living older people with complex needs who require publicly funded assistance undergo a comprehensive standardized geriatric needs assessment using the interRAI-HC instrument. Consenting adults aged ≥65 years who undertook this assessment between July 5, 2012 and December 31, 2020 were investigated. Multimorbidity was defined as having ≥2 chronic conditions. Recent bladder incontinence episodes were elicited and UI dichotomized into continent and incontinent groups. RESULTS: The study included 140 401 participants with an average age of 82.0 years (range: 65-107 years), of whom 85 746 (61.1%) were female. Overall, 36 185 (42.2%) females and 17 988 (32.9%) males reported UI. Participants had a median of 3 (range: 0-12) chronic conditions, with 109 135 (77.9%) classified as having multimorbidity. In adjusted modified Poisson regression analyses, the prevalence ratio for UI was 1.21 (95% confidence interval [CI]: 1.19, 1.24) times higher in females and 1.18 (95% CI: 1.14, 1.22) times higher for males with multimorbidity compared to those without multimorbidity. CONCLUSIONS: Although significant, the estimated sex-specific effect sizes were modest for the association between multimorbidity and UI in this population. However, despite using the comprehensive interRAI-HC instrument, several potentially core chronic conditions were not adequately captured. Although increasingly recognized as an important and growing public health issue, capturing all relevant chronic conditions challenges many epidemiological investigations into multimorbidity.

Utility of Big Data to Explore Medication Adherence in Maori and Non-Maori Community-Dwelling Older Adults with Heart Failure in Aotearoa New Zealand: A Cross-sectional Study.

BACKGROUND: Medication adherence improves morbidity and mortality-related outcomes in heart failure, and knowledge of patterns of medication adherence supports patient and clinician decision-making. Routinely collected national data facilitate the exploration of medication adherence and associated factors in older adults with heart failure, including the association between ethnicity and adherence. There are known inequities in access to medicines between Maori (Indigenous People of Aotearoa New Zealand) and non-Maori, yet ethnic variation in medicines adherence in community-dwelling older adults with heart failure has not been explored. OBJECTIVE: Here we identify medication adherence rates for community-dwelling older adults diagnosed with heart failure and differences in adherence rates between Maori and non-Maori. METHODS: Cross-sectional analysis of interRAI (comprehensive standardised assessment) data in a continuously recruited national cohort from 2012 to 2019. RESULTS: Overall, 13,743 assessments (Maori N = 1526) for older community-dwelling adults with heart failure diagnoses were included. The mean age of participants was 74.5 years [standard deviation (SD) 9.1 years] for Maori and 82.3 years (SD 7.8 years) non-Maori. In the Maori cohort, 21.8% did not adhere fully to their medication regimen, whereas in the non-Maori cohort, this figure was 12.8%. After adjusting for confounders, the Maori cohort were more likely to be medication non-adherent than non-Maori [prevalence ratio 1.53, 95% confidence interval (CI) 1.36-1.73]. CONCLUSIONS: There was a significant disparity between Maori and non-Maori concerning medication adherence. Given the international use of the interRAI-HC assessment tool, these results have significant transferability to other countries and allow the identification of underserved ethnic groups for which culturally appropriate interventions can be targeted.

Post Hoc Analyses of a Randomized Controlled Trial for the Effect of Pharmacist Deprescribing Intervention on the Anticholinergic Burden in Frail Community-Dwelling Older Adults.

OBJECTIVES: Anticholinergic burden is detrimental to cognitive health. Multiple studies found that a high anticholinergic burden is associated with an increased risk for dementia, changes to the brain structure, function, and cognitive decline. We performed a post hoc analysis of a randomized controlled deprescribing trial. We compared the effect of the intervention on baseline anticholinergic burden across the treatment and control groups and the time of recruitment before and after a lockdown due to the COVID pandemic with subgroup analyses by baseline frailty index. DESIGN: Randomized controlled trial. SETTINGS AND PARTICIPANTS: We analyzed data from a de-prescribing trial of older adults (>65 years) previously conducted in New Zealand that was focused on reducing the Drug Burden Index (DBI). METHODS: We used the anticholinergic cognitive burden (ACB) to quantify the impact of the intervention on reducing the anticholinergic burden. Participants not taking anticholinergics at the start of the trial were excluded. The primary outcome for this subgroup analysis was a change in ACB, measured with the gHedges statistic describing the difference in standard deviation units of this change between intervention and control. For this analysis, the trial participants were stratified into low, medium, and high frailty and timing into prior- and post-lockdown (public health measures for COVID-19). RESULTS: Among the 295 participants in this analysis, the median (IQR) age was 79 (74, 85), and 67% were women. For the primary outcome gHedges = -0.04 (95% CI -0.26 to 0.19) with a -0.23 mean reduction in ACB in the intervention arm and -0.19 in the control arm. Before lockdown gHedges = -0.38 (95% CI -0.84 to 0.04) and post-lockdown gHedges = 0.07 (95% CI -0.19 to 0.33). The mean change in ACB for each of the frailty strata was as follows: low frailty (-0.02; 95% CI -0.65 to 0.18); medium frailty (0.05; 95% CI -0.28 to 0.38); high frailty (0.08; 95% CI -0.40 to 0.56). CONCLUSIONS AND IMPLICATIONS: The study did not provide evidence for the effect of pharmacist deprescribing intervention on reducing the anticholinergic burden. However, this post hoc analysis examined the impact of COVID on the effectiveness of the intervention, and further research in this area may be warranted.

Dementia and cataract surgery in Australia and New Zealand.

BACKGROUND: Cataract surgery improves quality of life and reduces cognitive deterioration. OBJECTIVES: This paper discusses the health implications of low vision, commonly related to cataracts, in older adults. A recent publication reported that cataract surgery reduces the risk of dementia by 30% over 10 years. METHODS: We searched Medline from inception to January 2023. We also conducted backward and forward citation searches of included studies and set up alerts to identify studies published after the search date. We performed discussion groups with multidisciplinary experts. RESULTS: This article provides a broad description of the importance of vision for cognitive function. We discuss access to public-funded cataract surgery in Australia and New Zealand and how this impacts population benefits. CONCLUSIONS: We have evidence that cataract surgery can decrease the risk of dementia. This is an important topic that deserves recognition as part of an overall ageing response by policymakers and health professionals.

Chronic health conditions and mortality among older adults with complex care needs in Aotearoa New Zealand.

BACKGROUND: Older people have more comorbidities than younger groups and multimorbidity will increase. Often chronic conditions affect quality of life, functional ability and social participation. Our study aim was to quantify the prevalence of chronic conditions over a three-year period and their association with mortality after accounting for demographics. METHODS: We conducted a retrospective cohort study using routinely collected health data including community-dwelling older adults in New Zealand who had an interRAI Home Care assessment between 1 January 2017 and 31 December 2017. Descriptive statistics and differences between variables of interest among ethnic groups were reported. Cumulative density plots of mortality were developed. Logistic regression models adjusted for age and sex to estimate mortality were created independently for each combination of ethnicity and disease diagnosis. RESULTS: The study cohort consisted of 31,704 people with a mean (SD) age of 82.3 years (8.0), and of whom 18,997 (59.9%) were female. Participants were followed for a median 1.1 (range 0 to 3) years. By the end of the follow-up period 15,678 (49.5%) people had died. Nearly 62% of Maori and Pacific older adults and 57% of other ethnicities had cognitive impairment. Diabetes the next most prevalent amongst Maori and Pacific peoples, and coronary heart disease amongst Non-Maori/Non-Pacific individuals. Of the 5,184 (16.3%) who had congestive heart failure (CHF), 3,450 (66.6%) died. This was the highest mortality rate of any of the diseases. There was a decrease in mortality rate with age for both sexes and all ethnicities for those with cancer. CONCLUSIONS: Cognitive impairment was the most common condition in community dwelling older adults who had an interRAI assessment. Cardiovascular disease (CVD) has the highest mortality risk for all ethnic groups, and in non-Maori/non-Pacific group of advanced age, risk of mortality with cognitive impairment is as high as CVD risk. We observed an inverse for cancer mortality risk with age. Important differences between ethnic groups are reported.

The association between anticholinergic burden and mobility: a systematic review and meta-analyses.

BACKGROUND: As people age, they accumulate several health conditions, requiring the use of multiple medications (polypharmacy) to treat them. One of the challenges with polypharmacy is the associated increase in anticholinergic exposure to older adults. In addition, several studies suggest an association between anticholinergic burden and declining physical function in older adults. OBJECTIVE/PURPOSE: This systematic review aimed to synthesise data from published studies regarding the association between anticholinergic burden and mobility. The studies were critically appraised for the strength of their evidence. METHODS: A systematic literature search was conducted across five electronic databases, EMBASE, CINAHL, PSYCHINFO, Cochrane CENTRAL and MEDLINE, from inception to December 2021, to identify studies on the association of anticholinergic burden with mobility. The search was performed following a strategy that converted concepts in the PECO elements into search terms, focusing on terms most likely to be found in the title and abstracts of the studies. For observational studies, the risk of bias was assessed using the Newcastle Ottawa Scale, and the Cochrane risk of bias tool was used for randomised trials. The GRADE criteria was used to rate confidence in evidence and conclusions. For the meta-analyses, we explored the heterogeneity using the Q test and I2 test and the publication bias using the funnel plot and Egger's regression test. The meta-analyses were performed using Jeffreys's Amazing Statistics Program (JASP). RESULTS: Sixteen studies satisfied the inclusion criteria from an initial 496 studies. Fifteen studies identified a significant negative association of anticholinergic burden with mobility measures. One study did not find an association between anticholinergic intervention and mobility measures. Five studies included in the meta-analyses showed that anticholinergic burden significantly decreased walking speed (0.079 m/s ± 0.035 MD ± SE,95% CI: 0.010 to 0.149, p = 0.026), whilst a meta-analysis of four studies showed that anticholinergic burden significantly decreased physical function as measured by three variations of the Instrumental Activities of Daily Living (IADL) instrument 0.27 ± 0.12 (SMD ± SE,95% CI: 0.03 to 0.52), p = 0.027. The results of both meta-analyses had an I2 statistic of 99% for study heterogeneity. Egger's test did not reveal publication bias. CONCLUSION: There is consensus in published literature suggesting a clear association between anticholinergic burden and mobility. Consideration of cognitive anticholinergic effects may be important in interpreting results regarding the association of anticholinergic burden and mobility as anticholinergic drugs may affect mobility through cognitive effects.

Deprescribing Anticholinergic and Sedative Drugs to Reduce Polypharmacy in Frail Older Adults Living in the Community: A Randomized Controlled Trial.

BACKGROUND: Polypharmacy is associated with poor outcomes in older adults. Targeted deprescribing of anticholinergic and sedative medications may improve health outcomes for frail older adults. Our pharmacist-led deprescribing intervention was a pragmatic 2-arm randomized controlled trial stratified by frailty. We compared usual care (control) with the intervention of pharmacists providing deprescribing recommendations to general practitioners. METHODS: Community-based older adults (≥65 years) from 2 New Zealand district health boards were recruited following a standardized interRAI needs assessment. The Drug Burden Index (DBI) was used to quantify the use of sedative and anticholinergic medications for each participant. The trial was stratified into low, medium, and high-frailty. We hypothesized that the intervention would increase the proportion of participants with a reduction in DBI ≥ 0.5 within 6 months. RESULTS: Of 363 participants, 21 (12.7%) in the control group and 21 (12.2%) in the intervention group had a reduction in DBI ≥ 0.5. The difference in the proportion of -0.4% (95% confidence interval [CI]: -7.9% to 7.0%) provided no evidence of efficacy for the intervention. Similarly, there was no evidence to suggest the effectiveness of this intervention for participants of any frailty level. CONCLUSION: Our pharmacist-led medication review of frail older participants did not reduce the anticholinergic/sedative load within 6 months. Coronavirus disease 2019 (COVID-19) lockdown measures required modification of the intervention. Subgroup analyses pre- and post-lockdown showed no impact on outcomes. Reviewing this and other deprescribing trials through the lens of implementation science may aid an understanding of the contextual determinants preventing or enabling successful deprescribing implementation strategies.

Carer distress among community living older adults with complex needs in the pre- and post-COVID-19 era: a national population study.

Carer distress is one important negative impact of caregiving and likely exacerbated by the novel coronavirus disease 2019 (COVID-19) pandemic, yet little population-based epidemiological information exists. Using national data from repeated standardized comprehensive geriatric needs assessments, this study aims to: describe the pattern of caregiver distress among those providing informal care to community-living adults aged ≥ 65 years with complex needs in New Zealand over time; estimate the COVID-19 effect on this temporal pattern; and, investigate relationships between participants' sociodemographic and selected health measures on caregiver distress. Fractional polynomial regression and multivariable multilevel mixed-effects models were employed. Overall, 231,277 assessments from 144,358 participants were analysed. At first assessment, average age was 82.0 years (range 65-107 years), and 85,676 (59.4%) were female. Carer distress prevalence increased from 35.1% on 5 July 2012 to a peak of 48.5% on 21 March 2020, when the New Zealand Government announced a national lock-down. However, the population attributional fraction associated with the COVID-19 period was small, estimated at 0.56% (95% CI 0.35%, 0.77%). Carer distress is common and has rapidly increased in recent years. While significant, the COVID-19 impact has been relatively small. Policies and services providing efficacious on-going strategies to support caregivers deserves specific attention.

Evaluation of the added value of Brain Natriuretic Peptide to a validated mortality risk-prediction model in older people using a standardised international clinical assessment tool.

The ability to accurately predict the one-year survival of older adults is challenging for clinicians as they endeavour to provide the most appropriate care. Standardised clinical needs assessments are routine in many countries and some enable application of mortality prediction models. The added value of blood biomarkers to these models is largely unknown. We undertook a proof of concept study to assess if adding biomarkers to needs assessments is of value. Assessment of the incremental value of a blood biomarker, Brain Naturetic Peptide (BNP), to a one year mortality risk prediction model, RiskOP, previously developed from data from the international interRAI-HomeCare (interRAI-HC) needs assessment. Participants were aged ≥65 years and had completed an interRAI-HC assessment between 1 January 2013 and 21 August 2021 in Canterbury, New Zealand. Inclusion criteria was a BNP test within 90 days of the date of interRAI-HC assessment. The primary outcome was one-year mortality. Incremental value was assessed by change in Area Under the Receiver Operating Characteristic Curve (AUC) and Brier Skill, and the calibration of the final model. Of 14,713 individuals with an interRAI-HC assessment 1,537 had a BNP within 90 days preceding the assessment and all data necessary for RiskOP. 553 (36.0%) died within 1-year. The mean age was 82.6 years. Adding BNP improved the overall AUC by 0.015 (95% CI:0.004 to 0.028) and improved predictability by 1.9% (0.26% to 3.4%). In those with no Congestive Heart Failure the improvements were 0.029 (0.004 to 0.057) and 4.0% (0.68% to 7.6%). Adding a biomarker to a risk model based on standardised needs assessment of older people improved prediction of 1-year mortality. BNP added value to a risk prediction model based on the interRAI-HC assessment in those patients without a diagnosis of congestive heart failure.

Development and validation of a frailty index compatible with three interRAI assessment instruments.

BACKGROUND: a Frailty Index (FI) calculated by the accumulation of deficits is often used to quantify the extent of frailty in individuals in specific settings. This study aimed to derive a FI that can be applied across three standardised international Residential Assessment Instrument assessments (interRAI), used at different stages of ageing and the corresponding increase in support needs. METHODS: deficit items common to the interRAI Contact Assessment (CA), Home Care (HC) or Long-Term Care Facilities assessment (LTCF) were identified and recoded to form a cumulative deficit FI. The index was validated using a large dataset of needs assessments of older people in New Zealand against mortality prediction using Kaplan Meier curves and logistic regression models. The index was further validated by comparing its performance with a previously validated index in the HC cohort. RESULTS: the index comprised 15 questions across seven domains. The assessment cohort and their mean frailty (SD) were: 89,506 CA with 0.26 (0.15), 151,270 HC with 0.36 (0.15) and 83,473 LTCF with 0.41 (0.17). The index predicted 1-year mortality for each of the CA, HC and LTCF, cohorts with area under the receiver operating characteristic curves (AUCs) of 0.741 (95% confidence interval, CI: 0.718-0.762), 0.687 (95%CI: 0.684-0.690) and 0.674 (95%CI: 0.670-0.678), respectively. CONCLUSIONS: the results for this multi-instrument FI are congruent with the differences in frailty expected for people in the target settings for these instruments and appropriately associated with mortality at each stage of the journey of progressive ageing.

An interRAI derived frailty index predicts acute hospitalizations in older adults residing in retirement villages: A prospective cohort study.

OBJECTIVES: The development of frailty tools from electronically recorded healthcare data allows frailty assessments to be routinely generated, potentially beneficial for individuals and healthcare providers. We wished to assess the predictive validity of a frailty index (FI) derived from interRAI Community Health Assessment (CHA) for outcomes in older adults residing in retirement villages (RVs), elsewhere called continuing care retirement communities. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: 34 RVs across two district health boards in Auckland, Aotearoa New Zealand (NZ). 577 participants, mean age 81 years; 419 (73%) female; 410 (71%) NZ European, 147 (25%) other European, 8 Asian (1%), 7 Maori (1%), 1 Pasifika (<1%), 4 other (<1%). METHODS: interRAI-CHA FI tool was used to stratify participants into fit (0-0.12), mild (>0.12-0.24), moderate (>0.24-0.36) and severe (>0.36) frail groups at baseline (the latter two grouped due to low numbers of severely frail). Primary outcome was acute hospitalization; secondary outcomes included long-term care (LTC) entry and mortality. The relationship between frailty and outcomes were explored with multivariable Cox regression, estimating hazard ratios (HRs) and 95% confidence intervals (95%CIs). RESULTS: Over mean follow-up of 2.5 years, 33% (69/209) of fit, 58% (152/260) mildly frail and 79% (85/108) moderate-severely frail participants at baseline had at least one acute hospitalization. Compared to the fit group, significantly increased risk of acute hospitalization were identified in mildly frail (adjusted HR = 1.88, 95%CI = 1.41-2.51, p<0.001) and moderate-severely frail (adjusted HR = 3.52, 95%CI = 2.53-4.90, p<0.001) groups. Similar increased risk in moderate-severely frail participants was seen in LTC entry (adjusted HR = 5.60 95%CI = 2.47-12.72, p<0.001) and mortality (adjusted HR = 5.06, 95%CI = 1.71-15.02, p = 0.003). CONCLUSIONS AND IMPLICATIONS: The FI derived from interRAI-CHA has robust predictive validity for acute hospitalization, LTC entry and mortality. This adds to the growing literature of use of interRAI tools in this way and may assist healthcare providers with rapid identification of frailty.

Impact of the first wave of COVID-19 on the health and psychosocial well-being of Maori, Pacific Peoples and New Zealand Europeans living in aged residential care.

OBJECTIVE: To investigate the impact of New Zealand's (NZ) first wave of COVID-19, which included a nationwide lockdown, on the health and psychosocial well-being of Maori, Pacific Peoples and NZ Europeans in aged residential care (ARC). METHODS: interRAI assessments of Maori, Pacific Peoples and NZ Europeans (aged 60 years and older) completed between 21/3/2020 and 8/6/2020 were compared with assessments of the same ethnicities during the same period in the previous year (21/3/2019 to 8/6/2019). Physical, cognitive, psychosocial and service utilisation indicators were included in the bivariate analyses. RESULTS: A total of 538 Maori, 276 Pacific Peoples and 11,322 NZ Europeans had an interRAI assessment during the first wave of COVID-19, while there were 549 Maori, 248 Pacific Peoples and 12,367 NZ Europeans in the comparative period. Fewer Maori reported feeling lonely (7.8% vs. 4.5%, p = 0.021), but more NZ Europeans reported severe depressive symptoms (6.9% vs. 6.3%, p = 0.028) during COVID-19. Lower rates of hospitalisation were observed in Maori (7.4% vs. 10.9%, p = 0.046) and NZ Europeans (8.1% vs. 9.4%, p < 0.001) during COVID-19. CONCLUSIONS: We found a lower rate of loneliness in Maori but a higher rate of depression in NZ European ARC populations during the first wave of COVID-19. Further research, including qualitative studies with ARC staff, residents and families, and different ethnic communities, is needed to explain these ethnic group differences. Longer-term effects from the COVID-19 pandemic on ARC populations should also be investigated.

Factors associated with caregiver distress among home care clients in New Zealand: Evidence based on data from interRAI Home Care assessment.

OBJECTIVE: To identify factors associated with caregiver distress among home care clients in New Zealand. METHODS: The cohort consisted of 105,978 community-dwelling people aged 65 years or older requiring home care services in New Zealand who had at least one informal caregiver. Bivariate and multivariable logistic regression analyses were used to identify factors associated with caregiver distress. RESULTS: Variables associated with risk of caregiver distress included Depression Rating Scale score, aggressive behaviour symptoms, primary informal caregiver relationship to patient, Cognitive Performance Scale score, Changes in Health, End-stage disease, and Signs and Symptoms Scale score, informal care time, secondary informal caregiver relationship to care recipient, activities of daily living hierarchy scale score and any hospitalisation. CONCLUSIONS: The study has identified important characteristics that are associated with caregiver stress. These results suggest that caregiver distress can be relieved by promoting protective factors and aiming to reduce risk factors among home care clients in New Zealand.

Deprescribing to reduce polypharmacy: study protocol for a randomised controlled trial assessing deprescribing of anticholinergic and sedative drugs in a cohort of frail older people living in the community.

BACKGROUND: Targeted deprescribing of anticholinergic and sedative medications in older people may improve their health outcomes. This trial will determine if pharmacist-led reviews lead to general practitioners deprescribing anticholinergic and sedative medications in older people living in the community. METHODS AND ANALYSIS: The standard protocol items: Recommendations for Interventional Trials (SPIRIT) checklist was used to develop and report the protocol. The trial will involve older adults stratified by frailty (low, medium, and high). This will be a pragmatic two-arm randomized controlled trial to test general practitioner uptake of pharmacist recommendations to deprescribe anticholinergic and sedative medications that are causing adverse side effects in patients. STUDY POPULATION: Community-dwelling frail adults, 65 years or older, living in the Canterbury region of New Zealand, seeking publicly funded home support services or admission to aged residential care and taking at least one anticholinergic or sedative medication regularly. INTERVENTION: New Zealand registered pharmacists using peer-reviewed deprescribing guidelines will visit participants at home in the community, review their medications, and recommend anticholinergic and sedative medications that could be deprescribed to the participant's general practitioner. The total use of anticholinergic and sedative medications will be quantified using the Drug Burden Index (DBI). OUTCOMES: The primary outcome will be the change in total DBI between baseline and 6-month follow-up. Secondary outcomes will include entry into aged residential care, prolonged hospitalization, and death. DATA COLLECTION POINTS: Data will be collected at the time of interRAI assessments (T0), at the time of the baseline review (T1), at 6 months following the baseline review (T2), and at the end of the study period, or end of study participation for participants admitted into aged residential care, or who died (T3). ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Human, Disability and Ethics Committee: ethical number (17CEN265). TRIAL REGISTRATION: ClinicalTrials.gov ACTRN12618000729224 . Registered on May 2, 2018, with the Australian New Zealand Clinical Trials Registry.

Risk factors for injuries in New Zealand older adults with complex needs: a national population retrospective study.

BACKGROUND: Falls and falls-related injuries are common among older adults. Injuries in older adults lead to poor outcomes and lower quality of life. The objective of our study was to identify factors associated with fall-related injuries among home care clients in New Zealand. METHODS: The study cohort consisted of 75,484 community-dwelling people aged 65 years or older who underwent an interRAI home care assessment between June 2012 and June 2018 in New Zealand. The injuries included for analysis were fracture of the distal radius, hip fracture, pelvic fracture, proximal humerus fracture, subarachnoid haemorrhage, traumatic subdural haematoma, and vertebral fracture. Unadjusted and adjusted competing risk regression models were used to identify factors associated with fall-related injuries. RESULTS: A total of 7414 (9.8%) people sustained a falls-related injury over the 6-year period, and most injuries sustained were hip fractures (4735 63.9%). The rate of injurious falls was 47 per 1000 person-years. The factors associated with injury were female sex, older age, living alone, Parkinson's disease, stroke/CVA, falls, unsteady gait, tobacco use, and being underweight. Cancer, dyspnoea, high BMI, and a decrease in the amount of food or fluid usually consumed, were associated with a reduced risk of sustaining an injury. After censoring hip fractures the risks associated with other types of injury were sex, age, previous falls, dyspnoea, tobacco use, and BMI. CONCLUSIONS: While it is important to reduce the risk of falls, it is especially important to reduce the risk of falls-related injuries. Knowledge of risk factors associated with these types of injuries can help to develop focused intervention programmes and development of a predictive model to identify those who would benefit from intervention programmes.