A Proposed Curricular Framework for an Interprofessional Approach to Deprescribing.

Deprescribing involves reducing or stopping medications that are causing more harm than good or are no longer needed. It is an important approach to managing polypharmacy, yet healthcare professionals identify many barriers. We present a proposed pre-licensure competency framework that describes essential knowledge, teaching strategies, and assessment protocols to promote interprofessional deprescribing skills. The framework considers how to involve patients and care partners in deprescribing decisions. An action plan and example curriculum mapping exercise are included to help educators assess their curricula, and select and implement these concepts and strategies within their programs to ensure learners graduate with competencies to manage increasingly complex medication regimens as people age. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01704-9.

Goals of Care Conversations in Long-Term Care during the First Wave of the COVID-19 Pandemic.

Goals of care discussions typically focus on decision maker preference and underemphasize prognosis and outcomes related to frailty, resulting in poorly informed decisions. Our objective was to determine whether navigated care planning with nursing home residents or their decision makers changed care plans during the first wave of the COVID-19 pandemic. The MED-LTC virtual consultation service, led by internal medicine specialists, conducted care planning conversations that balanced information-giving/physician guidance with resident autonomy. Consultation included (1) the assessment of co-morbidities, frailty, health trajectory, and capacity; (2) in-depth discussion with decision makers about health status and expected outcomes; and (3) co-development of a care plan. Non-parametric tests and logistic regression determined the significance and factors associated with a change in care plan. Sixty-three residents received virtual consultations to review care goals. Consultation resulted in less aggressive care decisions for 52 residents (83%), while 10 (16%) remained the same. One resident escalated their care plan after a mistaken diagnosis of dementia was corrected. Pre-consultation, 50 residents would have accepted intubation compared to 9 post-consultation. The de-escalation of care plans was associated with dementia, COVID-19 positive status, and advanced frailty. We conclude that during the COVID-19 pandemic, a specialist-led consultation service for frail nursing home residents significantly influenced decisions towards less aggressive care.

Evaluation of an initiative to improve advance care planning for a home-based primary care service.

BACKGROUND: Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future. There is evidence that ACP reduces hospital-based interventions, especially at the end of life. ACP for frail older adults is especially important as this population is more likely to use hospital services but less likely to benefit from resource intensive care. Our study goal was to evaluate whether an approach to ACP developed for frail older adults, known as the Palliative and Therapeutic Harmonization or PATH, demonstrated an improvement in ACP. METHODS: The PATH approach was adapted to a primary care service for homebound older adults in Vancouver, Canada. This retrospective chart review collected surrogate measures related to ACP from 200 randomly selected patients enrolled in the service at baseline (prior to June 22, 2017), and 114 consecutive patients admitted to the program after implementation of the PATH ACP initiative (October 1, 2017 to May 1, 2018). We compared the following surrogate markers of ACP before and after implementation of the PATH model, chart documentation of: frailty stage, substitute decision-maker, resuscitation decision, and hospitalization decision. A composite ACP documentation score that ascribed one point for each of the above four measures (range 0 to 4) was also compared. For those with documented resuscitation and hospitalization decisions, the study examined patient/ substitute decision-maker expressed preferences for do-not-resuscitate and do-not-hospitalize, before and after implementation. RESULTS: We found the following changes in ACP-related documentation before and after implementation: frailty stage (27.0% versus 74.6%, p < .0001); substitute decision-maker (63.5% versus 71.9%, p = 0.128); resuscitation decision documented (79.5% versus 67.5%, p = 0.018); and hospitalization decision documented (61.5% versus 100.0%, p < .0001); mean (standard deviation) composite ACP documentation score (2.32 (1.16) versus 3.14 (1.11), p < .0001). The adjusted odds ratios (95% confidence intervals) for an expressed preference of do-not-resuscitate and do-not-hospitalize after implementation were 0.87 (0.35, 2.15) and 3.14 (1.78, 5.55), respectively. CONCLUSIONS: Results suggest partial success in implementing the PATH approach to ACP in home-based primary care. Key contextual enablers and barriers are important considerations for successful implementation.

Advance Care Planning and Decision-Making in a Home-Based Primary Care Service in a Canadian Urban Centre.

BACKGROUND: Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future, and has been shown to reduce hospital-based interventions at the end of life. Our goal was to describe the current state of ACP in a home-based primary care program for frail homebound older people in Vancouver, Canada. We did this by identifying four key elements that should be essential to ACP in this program: frailty stage, documentation of substitute decision-makers, and decision-making with regard to both resuscitation (i.e., do not resuscitate (DNR)) and hospitalization (i.e., do not hospitalize (DNH)). While these elements are an important part of the ACP process, they are often excluded from common practice. METHODS: This was a cross-sectional, observational study of data abstracted from 200 randomly selected patient electronic medical records between July 1 and September 30, 2017. We describe the association between demographic characteristics, comorbidities, and four key elements of ACP documentation and decision-making as documented in the clinical record using bivariate comparison, a logistic regression model and multiple logistic regression analysis. RESULTS: In 73% (n=146) of the patient records, there was no explicit documentation of frailty stage. Sixty-four per cent had documentation of a substitute decision-maker. Of those who had their preferences documented, 90.6% (n=144/159) indicated a preference for DNR, and 23.6% (n=29/123) indicated a preference for DNH. In multiple regression modeling, a diagnosis of dementia and older age were associated with documentation of a DNR preference, adjusted odds ratio (AOR) = 4.79 (95% CI 1.37, 16.71) and AOR = 1.14 (95% CI 1.05, 1.24), respectively. Older age, male sex, and English identified as the main language spoken were associated with a DNH preference. AOR = 1.17 (95% CI 1.06, 1.28), AOR = 4.19 (95% CI 1.41, 12.42), and AOR = 3.42 (95% CI 1.14, 10.20), respectively. CONCLUSIONS: Clinician documentation of some elements of ACP, such as identification of a substitute decision-maker and resuscitation status, have been widely adopted, while other elements that should be considered essential components of ACP, such as frailty staging and preferences around hospitalization, are infrequent and provide an opportunity for practice improvement initiatives. The significant association between language and ACP decisions suggests an important role for supporting cross-cultural fluency in the ACP process.

Systematic review and meta-analysis of second-generation antidepressants for the treatment of older adults with depression: questionable benefit and considerations for frailty.

BACKGROUND: Frail older adults are commonly prescribed antidepressants. Yet, there is little evidence to determine the efficacy and safety of antidepressants to treat depression with concomitant frailty. To better understand this issue, we examined the efficacy and safety of second-generation antidepressants for the treatment of older adults with depression and then considered implications for frailty. METHODS: Due to the absence of therapeutic studies of frail older adults with depression, we conducted a systematic review and meta-analysis of double-blind, randomized controlled trials that compared antidepressants versus placebo for adults with depression, age 65 years or older. We searched PubMed/MEDLINE, Cochrane Library, reference lists from meta-analyses/studies, hand searches of publication lists, and related articles on PubMed. Outcomes included rates of response, remission, and adverse events. After evaluating the data, we applied a frailty-informed framework to consider how the evidence could be applied to frailty. RESULTS: Nine trials were included in the meta-analysis (n = 2704). Subjects had moderate to severe depression. For older adults with depression, there was no statistically significant difference in response or remission to second-generation antidepressants compared to placebo. Response occurred in 45.3% of subjects receiving an antidepressant compared to 40.5% receiving placebo (RR 1.15, 95% CI: 0.96 - 1.37, p = 0.12, I2 = 71%). Remission occurred in 33.1% with antidepressant versus 31.3% with placebo (RR 1.10, 95% CI: 0.92 - 1.31, p = 0.30, I2 = 56%) (Figure 2 and 3). There were more withdrawals due to adverse events with antidepressants, 13% versus 5.8% (RR 2.30, 95% CI: 1.45-3.63; p < 0.001; I2 = 61%; NNH 14, 95% CI:10-28). IMPLICATIONS FOR FRAILTY: Subjects in the meta-analysis did not have obvious characteristics of frailty. Using framework questions to consider the implications of frailty, we hypothesize that, like older adults, frail individuals with depression may not respond to antidepressants. Further, observational studies suggest that those who are frail may be less responsive to antidepressants compared to the non-frail. Given the vulnerability of frailty, adverse events may be more burdensome. CONCLUSIONS: Second-generation antidepressants have uncertain benefit for older adults with depression and cause more adverse events compared to placebo. Until further research clarifies benefit, careful consideration of antidepressant prescribing with frailty is warranted.

International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position Statement and 10 Recommendations for Action.

Globally, the number of drug prescriptions is increasing causing more adverse drug events, which is now a significant cause of mortality, morbidity, and disability that has reached epidemic proportions. The risk of adverse drug events is correlated to very old age, multiple co-morbidities, dementia, frailty, and limited life expectancy, with the major contributor being polypharmacy. Each characteristic alters the risk-benefit balance of medications, typically reducing anticipated benefits and amplifying risk. Current clinical guidelines are based on evidence proven in younger/healthier adult populations using a single disease model and their application to older adults with multimorbidity, in whom testing has not been conducted, yields a different risk-benefit prospect and makes inappropriate medication use and polypharmacy inevitable. Applying inappropriate clinical practice guidelines to older adults is antithetical to good healthcare, is likely to increase health inequity, and is associated with substantial negative clinical, economic, and social implications for health systems. The casualties are on the scale of a war or epidemic, yet are usually invisible in measures of healthcare quality and formal recommendations. Radical and rapid action is required to achieve a better quality of life for older populations and to remain true to the principles of medical professionalism and evidence-based medicine that place patients' interests and autonomy at the fore. This first International Group for Reducing Inappropriate Medication Use & Polypharmacy position statement briefly details the causes, consequences, and extent of inappropriate medication use and polypharmacy. This article outlines current strategies to reduce inappropriate medication use, provides evidence for their effect, and then proposes recommendations for moving forward with 10 recommendations for action and 12 recommendations for research. We conclude that an urgent integrated effort to reduce inappropriate medication use and polypharmacy should be a leading global target of the highest priority. The cornerstone of this position statement from the International Group for Reducing Inappropriate Medication Use & Polypharmacy is the understanding that without evidence of definite relevant benefit, when it comes to prescribing, for many older patients 'less is more'. This approach differs from most other current recommendations and guidance in medical care, as the focus is on what, when, and how to stop, rather than on when to start medications/interventions. Disrupting the framework that indiscriminately applies standard guidelines to older adults requires a new approach that better serves patients with multimorbidity. This transition requires a shift in medical education, research, and diagnostic frameworks, and re-examination of the measures used as quality indicators. In achieving this objective, we promote a return to some of the original concepts of evidence-based medicine: which considers scientific data (where it exists), clinical judgment, patient/family preference, and context. A shift is needed: from the current model that focuses on single conditions to one that simultaneously considers multiple conditions and patient priorities. This approach reframes the clinician's role as a professional providing care, rather than a disease technician.

Using the Frailty Assessment for Care Planning Tool (FACT) to screen elderly chronic kidney disease patients for frailty: the nurse experience.

PURPOSE: Recent evidence supports the prognostic significance of frailty for functional decline and poor health outcomes in patients with chronic kidney disease. Yet, despite the development of clinical tools to screen for frailty, little is known about the experiential impact of screening for frailty in this setting. The Frailty Assessment for Care Planning Tool (FACT) evaluates frailty across 4 domains: mobility, function, social circumstances, and cognition. The purpose of this qualitative study was as follows: 1) explore the nurse experience of screening for frailty using the FACT tool in a specialized outpatient renal clinic; 2) determine how, if at all, provider perceptions of frailty changed after implementation of the frailty screening tool; and 3) determine the perceived factors that influence uptake and administration of the FACT screening tool in a specialized clinical setting. METHODS: A semi-structured interview of 5 nurses from the Nova Scotia Health Authority, Central Zone Renal Clinic was conducted. A grounded theory approach was used to generate thematic categories and analysis models. RESULTS: Four primary themes emerged in the data analysis: "we were skeptical", "we made it work", "we learned how", and "we understand". As the renal nurses gained a sense of confidence in their ability to implement the FACT tool, initial barriers to implementation were attenuated. Implementation factors - such as realistic goals, clear guidelines, and ongoing training - were important factors for successful uptake of the frailty screening initiative. CONCLUSION: Nurse participants reported an overall positive experience using the FACT method to screen for frailty and indicated that their understanding of the multiple dimensions and subtleties of "frailty" were enhanced. Future nurse-led FACT screening initiatives should incorporate those factors identified as being integral to program success: realistic goals, clear guidelines, and ongoing training. Adopting the evaluation of frailty as a priority within clinical departments will encourage sustainability.

Evaluating the Implementation and Feasibility of a Web-Based Tool to Support Timely Identification and Care for the Frail Population in Primary Healthcare Settings.

BACKGROUND: Understanding and addressing the needs of frail persons is an emerging health priority for Nova Scotia and internationally. Primary healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not standard practice and, in general, there is a lack of awareness about how to identify and respond to frailty. A web-based tool called the Frailty Portal was developed to aid in identifying, screening, and providing care for frail patients in PHC settings. In this study, we will assess the implementation feasibility and impact of the Frailty Portal to: (1) support increased awareness of frailty among providers and patients, (2) identify the degree of frailty within individual patients, and (3) develop and deliver actions to respond to frailtyl in community PHC practice. METHODS: This study will be approached using a convergent mixed method design where quantitative and qualitative data are collected concurrently, in this case, over a 9-month period, analyzed separately, and then merged to summarize, interpret and produce a more comprehensive understanding of the initiative's feasibility and scalability. Methods will be informed by the 'Implementing the Frailty Portal in Community Primary Care Practice' logic model and questions will be guided by domains and constructs from an implementation science framework, the Consolidated Framework for Implementation Research (CFIR). DISCUSSION: The 'Frailty Portal' aims to improve access to, and coordination of, primary care services for persons experiencing frailty. It also aims to increase primary care providers' ability to care for patients in the context of their frailty. Our goal is to help optimize care in the community by helping community providers gain the knowledge they may lack about frailty both in general and in their practice, support improved identification of frailty with the use of screening tools, offer evidence based severity-specific care goals and connect providers with local available community supports.

Severely frail elderly patients do not need lipid-lowering drugs.

After performing a systematic review, members of the Palliative and Therapeutic Harmonization (PATH) program and the Dalhousie Academic Detailing Service found that evidence does not support lipid-lowering therapy for severely frail elderly patients.

Proceedings of the Canadian Frailty Network Summit: Medication Optimization for Frail Older Canadians, Toronto, Monday April 24, 2017.

Appropriate and optimal use of medication and polypharmacy are especially relevant to the care of older Canadians living with frailty, often impacting their health outcomes and quality of life. A majority (two thirds) of older adults (65 or older) are prescribed five or more drug classes and over one-quarter are prescribed 10 or more drugs. The risk of adverse drug-induced events is even greater for those aged 85 or older where 40% are estimated to take drugs from 10 or more drug classes. The Canadian Frailty Network (CFN), a pan-Canadian non-for-profit organization funded by the Government of Canada through the Networks of Centres of Excellence Program (NCE), is dedicated to improving the care of older Canadian living with frailty and, as part of its mandate, convened a meeting of stakeholders from across Canada to seek their perspectives on appropriate medication prescription. The CFN Medication Optimization Summit identified priorities to help inform the design of future research and knowledge mobilization efforts to facilitate optimal medication prescribing in older adults living with frailty. The priorities were developed and selected through a modified Delphi process commencing before and concluding during the summit. Herein we describe the overall approach/process to the summit, a summary of all the presentations and discussions, and the top ten priorities selected by the participants.

End of Life Care in Frailty.

The increasing prevalence of frailty within the aging population poses challenges to current models of chronic disease management and end-of-life care delivery. As frailty progresses, individuals face an increasing frequency of acute health issues requiring medical attention. The ability of health care systems to recognize and respond to acute health issues in frail patients using a holistic understanding of health and prognosis will play a central role in ensuring their effective and appropriate care, including that at the end of their lives. This chapter reviews the history of palliative care and the elements of frailty that require the modification of current models of palliative care. In addition, tools and models for recognition of end of life in frailty and considerations for symptom management are introduced.

Promoting higher blood pressure targets for frail older adults: a consensus guideline from Canada.

The authors, who are members of the Dalhousie Academic Detailing Service and the Palliative and Therapeutic Harmonization program, recommend that antihypertensive treatment be less intense in elderly patients who are frail. This paper reviews their recommendations and the evidence behind them.

Evidence-informed guidelines for treating frail older adults with type 2 diabetes: from the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) program.

Clinical practice guidelines specific to the medical care of frail older adults have yet to be widely disseminated. Because of the complex conditions associated with frailty, guidelines for frail older patients should be based on careful consideration of the characteristics of this population, balanced against the benefits and harms associated with treatment. In response to this need, the Diabetes Care Program of Nova Scotia (DCPNS) collaborated with the Palliative and Therapeutic Harmonization (PATH) program to develop and disseminate guidelines for the treatment of frail older adults with type 2 diabetes. The DCPNS/PATH guidelines are unique in that they recommend the following: 1. Maintain HbA1c at or above 8% rather than below a specific level, in keeping with the conclusion that lower HbA1c levels are associated with increased hypoglycemic events without accruing meaningful benefit for frail older adults with type 2 diabetes. The guideline supports a wide range of acceptable HbA1c targets so that treatment decisions can focus on whether to aim for HbA1c levels between 8% and 9% or within a higher range (ie, >9% and <12%) based on individual circumstances and symptoms. 2. Simplify treatment by administering basal insulin alone and avoiding administration of regular and rapid-acting insulin when feasible. This recommendation takes into account the variations in oral intake that are commonly associated with frailty. 3. Use neutral protamine Hagedorn (NPH) insulin instead of long-acting insulin analogues, such as insulin glargine (Lantus) or insulin detemir (Levemir), as insulin analogues do not appear to provide clinically meaningful benefit but are significantly more costly. 4. With acceptance of more liberalized blood glucose targets, there is no need for routine blood glucose testing when oral hypoglycemic medications or well-established doses of basal insulin (used alone) are not routinely changed as a result of blood glucose testing.Although these recommendations may appear radical, they are based on careful review of research findings.

Characteristics of patients described as sub-acute in an acute care hospital.

Frail older patients suffer from multiple, complex needs that often go unmet in an acute care setting. Failure to recognize the geriatric giants in frail older adults is resulting in the misclassification of this population. This study investigated "sub-acute" frail, older-adult in-patients in a tertiary care teaching hospital. Although identified as being no longer acutely ill, all participants (n = 62) required active medical and/or nursing care. Frail older patients, often acutely ill, were being misclassified as sub-acute when the acuity of their illness went unrecognized which resulted in equally unrecognized disease presentations. The majority of participants wished to be cared for at or closer to home. The lack of post-acute-care service within our health care system and risk aversion on the part of hospital staff resulted in lengthy hospital stays and/or in patients being funneled into existing services (nursing homes) against their desire to go home.

Palliative and therapeutic harmonization: a model for appropriate decision-making in frail older adults.

Frail older adults face increasingly complex decisions regarding medical care. The Palliative and Therapeutic Harmonization (PATH) model provides a structured approach that places frailty at the forefront of medical and surgical decision-making in older adults. Preliminary data from the first 150 individuals completing the PATH program shows that the population served is frail (mean Clinical Frailty Score = 6.3), has multiple comorbidities (mean 8), and takes many medications (mean = 9). Ninety-two percent of participants were able to complete decision-making for an average of three current or projected health issues, most often (76.7%) with the help of a substitute decision-maker (SDM). Decisions to proceed with scheduled medical or surgical interventions correlated with baseline frailty level and dementia stage, with participants with a greater degree of frailty (odds ratio (OR) = 3.41, 95% confidence interval (CI) = 1.39-8.38) or more-advanced stage of dementia (OR = 1.66, 95% CI = 1.06-2.65) being more likely to choose less-aggressive treatment options. Although the PATH model is in the development stage, further evaluation is ongoing, including a qualitative analysis of the SDM experience of PATH and an assessment of the effectiveness of PATH in long-term care. The results of these studies will inform the design of a larger randomized controlled trial.

Vestibular and motor contributions to mobility: limitations of seniors awaiting discharge from hospital care.

BACKGROUND AND PURPOSE: Following hospitalization, seniors are at risk of impaired mobility and increased risk of falling, which can lead to injuries and re-admission. The primary purpose of this paper was to evaluate the ability of hospitalized seniors to use vestibular inputs for balance control. The secondary purpose was to examine the influence of vestibular function and lower limb muscle strength on mobility. METHODS: Experimental and correlation designs were used. Patients (aged 65-90 years), preparing for discharge from an inpatient geriatric rehabilitation unit, were recruited. Vestibular control of standing balance was measured using the Clinical Test of Sensory Interaction for Balance (CTSIB). Mobility was measured with the Timed Up and Go (TUG) Test. Lower limb muscle maximum voluntary isometric contraction (MVIC) strength was tested with portable dynamometry. Wilcoxon signed rank test, with alpha adjusted for multiple comparisons (p ≤ 0.017), was used to compare relevant components of the CTSIB. Stepwise regression was used to assess the influence of vestibular impairment on TUG score. RESULTS: CTSIB(Test6) (median = 7.1 seconds, range = 0.0-30.0) was less than CTSIB(Test1) (30.0 seconds, 30.0-30.0) and CTSIB(Test4) (30.0 seconds, 10.5-30.0) (W = 136, p < 0.017). MVIC scores (Nm·kg⁻¹, mean ± SD) included hip abduction 0.38 ± 0.2, hip flexion 0.32 ± 0.1, hip extension 0.44 ± 0.2, knee flexion 0.31 ± 0.1, knee extension 0.33 ± 0.2, ankle dorsiflexion 0.12 ± 0.1 and ankle plantarflexion 0.23 ± 0.1. Mean TUG score was 26.1 ± 6.0 seconds. Performance on CTSIB(Test6) explained 55% of the variance in TUG scores, whereas hip extension strength explained an additional 6%. CONCLUSIONS: Seniors awaiting discharge from hospital had impaired vestibular control of balance that was systematically associated with impaired mobility. Evaluating vestibular function prior to discharge from hospital could improve discharge planning with respect to management of impairments that threaten balance and safe mobility.

Specialist physician approaches to discussing cardiopulmonary resuscitation for frail older adults: a qualitative study.

BACKGROUND: Despite the impact and importance of end-of-life discussions, little is known about how physicians discuss cardiopulmonary resuscitation (CPR) with patients and their families. The necessary components for successful communication about CPR are poorly understood and an established framework to structure these conversations is lacking. Here, we were motivated to understand how physicians approach resuscitation planning with families when older patients have limited life expectancy and a high burden of illness. METHOD: Qualitative analysis was conducted of semi-structured interviews of 28 physicians of varying medical sub-specialties in a tertiary care hospital. RESULTS: Most physicians explored the surrogates' goals and values, but few provided explicit information about the patients' overall health status or expected long-term health outcome related to CPR and underlying illnesses. CONCLUSION: There is considerable heterogeneity in physicians' approaches to CPR discussions. The principle of autonomy is dominant with less emphasis on providing adequate information for effective decision-making.

Respecting frailty.

While the medical treatment of older individuals often results in desirable outcomes, indiscriminate use of aggressive treatment at the end-of-life can cause paradoxical harm and suffering. Comprehensive assessment and communication can help foster decisions that consider the effect of frailty on health outcomes.