Screening for frailty in primary care: Accuracy of gait speed and hand-grip strength.

OBJECTIVE: To examine the accuracy of individual Fried frailty phenotype measures in identifying the Fried frailty phenotype in primary care. DESIGN: Retrospective chart review. SETTING: A community-based primary care practice in Kitchener, Ont. PARTICIPANTS: A total of 516 patients 75 years of age and older who underwent frailty screening. MAIN OUTCOME MEASURES: Using modified Fried frailty phenotype measures, frailty criteria included gait speed, hand-grip strength as measured by a dynamometer, and self-reported exhaustion, low physical activity, and unintended weight loss. Sensitivity, specificity, accuracy, and precision were calculated for single-trait and dual-trait markers. RESULTS: Complete frailty screening data were available for 383 patients. The overall prevalence of frailty based on the presence of 3 or more frailty criteria was 6.5%. The overall prevalence of individual Fried frailty phenotype markers ranged from 2.1% to 19.6%. The individual criteria all showed sensitivity and specificity of more than 80%, with the exception of weight loss (8.3% and 97.4%, respectively). The positive predictive value of the single-item criteria in predicting the Fried frailty phenotype ranged from 12.5% to 52.5%. When gait speed and hand-grip strength were combined as a dual measure, the positive predictive value increased to 87.5%. CONCLUSION: There is a need for frailty measures that are psychometrically sound and feasible to administer in primary care. While use of gait speed or grip strength alone was found to be sensitive and specific as a proxy for the Fried frailty phenotype, use of both measures together was found to be accurate, precise, specific, and more sensitive than other possible combinations. Assessing both measures is feasible within primary care.

Use of potentially inappropriate medications among ambulatory home-dwelling elderly patients with dementia: A review of the literature.

BACKGROUND: Older adults with dementia are at high risk for drug-related adverse outcomes. While much is known about potentially inappropriate medication use in older adults, its prevalence and characteristics among those with dementia are not as well elucidated. We conducted a literature review to examine the prevalence of potentially inappropriate medication use among home-dwelling older adults with dementia. Our secondary aim was to determine the most frequently implicated medications and factors associated with potentially inappropriate medication use. METHODS: MEDLINE, EMBASE, CINAHL, and International Pharmaceutical Abstracts were searched between 1946 and 2014 for articles that referenced potentially inappropriate medication use and types of dementia. One reviewer screened all titles and abstracts from the initial search and full-text articles after the initial screen for eligibility, then 2 reviewers independently abstracted data from included studies. RESULTS: Searches yielded 81 articles, of which 7 met inclusion criteria. Prevalence of potentially inappropriate medication use varied from 15% to 46.8%. No single drug or drug class was reported consistently across all studies as the most frequent potentially inappropriate medication, but anticholinergics and benzodiazepines, drugs that affect cognition, were among the most common medications or pharmacological classes listed. DISCUSSION: Older adults with dementia may be particularly vulnerable to potentially inappropriate medications because of cognitive impairment from their condition and the greater likelihood of experiencing adverse events from medications. Given this population's greater susceptibility to adverse events, more intense medication and patient monitoring may be warranted, especially among those taking anticholinergics and benzodiazepines, as these drugs can contribute to cognitive impairment.

Multispecialty Interprofessional Team Memory Clinics: Enhancing Collaborative Practice and Health Care Providers' Experience of Dementia Care.

This study explored whether working within Multispecialty INterprofessional Team (MINT) memory clinics has an impact on health care professionals' perceptions of the challenges, attitudes, and level of collaboration associated with providing dementia care. Surveys were completed by MINT memory clinic members pre- and 6-months post-clinic launch. A total of 228 pre-and-post-training surveys were matched for analysis. After working in the MINT memory clinics for 6 months, there were significant reductions in mean ratings of the level of challenge associated with various aspects of dementia care, and significant increases in the frequency with which respondents experienced enthusiasm, inspiration, and pride in their work in dementia care and in ratings of the extent of collaboration for dementia care. This study provides some insights into the effect of collaborative, interprofessional approaches on health care professionals' perceptions of the challenges and attitudes associated with providing dementia care and level of collaboration with other health professionals.

Improving primary care for persons with spinal cord injury: Development of a toolkit to guide care.

OBJECTIVE: To identify a set of essential components for primary care for patients with spinal cord injury (SCI) for inclusion in a point-of-practice toolkit for primary care practitioners (PCP) and identification of the essential elements of SCI care that are required in primary care and those that should be the focus of specialist care. DESIGN: Modified Delphi consensus process; survey methodology. SETTING: Primary care. PARTICIPANTS: Three family physicians, six specialist physicians, and five inter-disciplinary health professionals completed surveys. OUTCOME MEASURES: Importance of care elements for inclusion in the toolkit (9-point scale: 1 = lowest level of importance, 9 = greatest level of importance) and identification of most responsible physician (family physician, specialist) for completing key categories of care. Open-ended comments were solicited. RESULTS: There was consensus between the respondent groups on the level of importance of various care elements. Mean importance scores were highest for autonomic dysreflexia, pain, and skin care and lowest for preventive care, social issues, and vital signs. Although, there was agreement across all respondents that family physicians should assume responsibility for assessing mental health, there was variability in who should be responsible for other care categories. Comments were related to the need for shared care approaches and capacity building and lack of knowledge and specialized equipment as barriers to optimal care. CONCLUSION: This study identified important components of SCI care to be included in a point-of-practice toolkit to facilitate primary care for persons with SCI.

The Value in Mental Health Screening for Individuals With Spinal Cord Injury: What Patients Tell Us.

OBJECTIVE: To gather consumer perspectives of a mental health screening protocol and to identify the incidence of previously unrecognized mental health concerns (case finding). DESIGN: Pilot study using mixed methods: quantitative (survey) and qualitative (interviews). SETTING: Primary care health team in Kitchener, Ontario, Canada. PARTICIPANTS: Patients (N=15) with spinal cord injury living in the community. Participants ranged in age from 21 to 81 years of age (mean=46); 12 were men, 8 had tetraplegia and 5 paraplegia. The number of years since injury ranged from 1 to 32 (mean=13). INTERVENTION: Implementation of a mental health screening protocol consisting of standardized screening tools for depression, anxiety, substance abuse, social isolation, somatoform disorder, functional status, chronic pain, and cognitive impairment. MAIN OUTCOME MEASURES: Positive results on screening tool, acceptability of the screening process, perceptions of the value of screening, and intentions to follow resulting treatment recommendations. RESULTS: Screening identified 11 of 15 individuals with a chronic pain condition; 1 individual screened positive for depression, 1 for anxiety, 3 for potential substance abuse, and 1 for social isolation. Most of the participants (12/13) rated the screening protocol as very acceptable. All but 1 individual intended to follow resulting treatment recommendations. Interview analyses generated themes related to disclosure of experiences that were incomplete that concealed important information and perceptions that the screening protocol failed to assess resiliency. Although perceived as valuable, participants felt screening tools alone did not capture information important to them. CONCLUSIONS: Screening tools alone may not identify mental health issues. Interviews in addition to screening tools are needed to accurately identify mental health issues in this population. Identification of mental health issues is critical to ensuring access to effective interventions and improving health outcomes and quality of life for individuals with SCI.

Advanced Care Planning for Persons With Dementia in Primary Care: Attitudes and Barriers Among Health-Care Professionals.

BACKGROUND: Advance care planning (ACP) provides clarity on goals and preferences for future health-care decisions, the timeliness of which is critical for persons with dementia. AIM: This study assessed Primary Care Collaborative Memory Clinic (PCCMC) health-care practitioners' desire for more education on ACP, capacity for and attitudes toward ACP, and current ACP practices in their regular family practice and in their PCCMC. METHODS: Primary Care Collaborative Memory Clinic health-care professionals completed a questionnaire in which they rated their interest in learning various ACP-related topics (5-point scale: not at all to very much so), attitudes toward ACP, and the importance of and perceived degree of responsibility for ACP (5-point scale: not at all to extremely). Respondents estimated ACP completion in regular family practice and PCCMC. RESULTS: Two hundred and sixty one surveys were completed. Mean knowledge ratings were moderate (M = 3.0) and mean ratings of interest in ACP topics were all high (median ≥ 4). Despite the perception that ACP is very important (M = 4.9) and the responsibility of PCCMCs (M = 3.7), the majority of respondents estimated that 40% or fewer patients have had ACP. Ratings of willingness to conduct ACP (M = 3.7) and comfort level (M = 3.4) were moderate but significantly exceeded ratings of ability (M = 2.9), comfort (M = 3.5), and confidence (M = 2.8). CONCLUSION: There was a striking disconnect between perceptions of the importance of completing ACP for persons with dementia and actual ACP completion rates. Primary Care Collaborative Memory Clinics may be in an ideal position to support ACP discussions; however, there is a need to improve health-care professionals' knowledge and attitudes toward ACP.

Person-centered risk assessment framework: assessing and managing risk in older adults living with dementia.

AIM: This study pilot-tested the person-centered risk assessment framework (PCRAF), a framework for managing risk among persons living with dementia (PLWD) in primary care. METHODS: Healthcare providers (N = 7) piloting the PCRAF completed a survey, rating their satisfaction with the tool, and an interview to gather their perceptions of the PCRAF. PLWD and care partners (N = 12) completed a survey, rating their satisfaction with safety planning. RESULTS: Care providers were very satisfied with the tool; however, patient or care partner inability to perceive or understand safety risks was a challenge. Use of the PCRAF was perceived as an opportunity to empower self-management, gather PLWD and care partner perspectives, reduce burden for care partners and increase understanding of potential risks. Patients and care partners were very satisfied with the way in which they were included in the risk discussion. CONCLUSION: The PCRAF is a promising new tool to reduce risks associated with dementia.

Persons with dementia and care partners' perspectives on memory clinics in primary care.

AIMS: To understand persons with dementia (PWD) and care partners' experiences with the Primary Care Collaborative Memory Clinic (PCCMC) care model. METHODS: Interviews were conducted with a purposeful sample of PWD (n = 12) and care partners (N = 16) to identify their perspectives of care received in the clinic and suggestions for improvement. RESULTS: PWD and care partners were satisfied with care received within the PCCMC, had positive interactions with and perceived a strong sense of support from team members and felt listened to; the necessity of cognitive testing was recognized but disliked. CONCLUSIONS: The PCCMC care model can address many existing gaps in dementia care as experienced by PWD and care partners.

Frailty Screening and Case-Finding for Complex Chronic Conditions in Older Adults in Primary Care.

With the aging population, escalating demand for seniors' care and limited specialist resources, new care delivery models are needed to improve capacity for primary health care for older adults. This paper describes the "C5-75" (Case-finding for Complex Chronic Conditions in Seniors 75+) program, an innovative care model aimed at identifying frailty and commonly associated geriatric conditions among older adults within a Canadian family practice setting and targeting interventions for identified conditions using a feasible, systematic, evidence-informed multi-disciplinary approach. We screen annually for frailty using gait speed and handgrip strength, screen for previously undiagnosed comorbid conditions, and offer frail older adults multi-faceted interventions that identify and address unrecognized medical and psychosocial needs. To date, we have assessed 965 older adults through this program; 14% were identified as frail based on gait speed alone, and 5% identified as frail based on gait speed with grip strength. The C5-75 program aims to re-conceptualize care from reactive interventions post-diagnosis for single disease states to a more proactive approach aimed at identifying older adults who are at highest risk of poor health outcomes, case-finding for unrecognized co-existing conditions, and targeting interventions to maintain health and well-being and potentially reduce vulnerability and health destabilization.

Identifying frailty in primary care: A systematic review.

AIM: Identification of frailty in the primary care setting could be improved with the availability of easily identifiable markers of frailty. The purpose of this article was to systematically review markers for frailty or risk tools that have been validated in the ambulatory care setting. METHODS: Medline, PubMed, CIHAHL and Embase databases were searched up to March 2016 for studies on frailty markers in community-dwelling individuals 65 years or older. Studies were included for review if they were carried out in primary care or outpatient settings, used a validated definition of frailty, compared two or more markers, and used randomized controlled trial, quasi-experimental or prospective cohort designs. RESULTS: Of the 3405 titles screened, 12 were retained for review. All of the studies were prospective cohort designs. Studies most frequently assessed biological markers, such as immune, inflammation, endocrine biomarkers and metabolic syndrome markers. Not one specific marker was repeatedly identified as a definitive marker for frailty. CONCLUSIONS: There is a lack of psychometrically sound and clinically useful frailty markers. There is a need for further research to identify highly sensitive, specific and accurate markers that are feasible to use in the context of busy primary care practice. Geriatr Gerontol Int 2017; 17: 1358-1377.