Health utility in community-dwelling adults with dysvascular lower limb loss.

PURPOSE: Adults with dysvascular lower extremity amputation (LEA) experience a large number of secondary health conditions yet there is a gap in the literature on health utility scores for this population. A health utility score relates to a person's state of well-being, and is a single metric anchored at 0 (death) and 1 (perfect health). This study aimed to provide a descriptive account of health utility scores in community-dwelling adults with dysvascular LEA. METHODS: Participants were adults with dysvascular LEA who were 3 months post-amputation. Data collected included socio-demographic characteristics, the Special Interest Group in Amputee Medicine (SIGAM) grades, the dysvascular conditions scale (DCS), which is a scale developed for this study, and the Short Form-36 (SF-36). SF-6D health utility scores were derived from the SF-36 using a software algorithm. Participants were grouped into low-impact and high-impact groups based on self-reported severity of symptoms using the DCS. Health utility scores were compared between the low-impact and high-impact groups using independent t-tests. RESULTS: A total of 231 participants were enrolled in the study. The mean SF-6D health utility score was 0.689 (0.127). A significant association was found between health utility score and SIGAM grade (p < 0.001, η2 = .09). Health utility was positively associated with age (r = 0.137, p = 0.037) and months post-amputation (r = 0.141, p = 0.032), and negatively associated with DCS severity (r = -0.526, p < 0.001). Health utility scores were lower for participants in the DCS high-impact groups for conditions such as diabetes mellitus, phantom limb pain, musculoskeletal pain, back pain, psychological distress, depression, vision problems, and other pain. CONCLUSION: Cost-utility analyses rely on health utility estimates and our findings provide data for future economic evaluations that may assist policy makers in evidence informed allocation of healthcare resources for this population.

Reporting of Rehabilitation Outcomes in the Traumatic Lower Limb Amputation Literature: A Systematic Review.

OBJECTIVE: To synthesize the outcomes reported in the rehabilitation and community literature for adults with traumatic lower limb amputation (LLA). DATA SOURCES: The search strategy was conducted in 3 databases (Medline, EMBASE, and CINAHL) from inception to April 2022. STUDY SELECTION: To be eligible, articles could be of any design but were required to have at least 50% adult individuals with traumatic LLA and had to report on interventions and outcomes in either a rehabilitation or community setting. DATA EXTRACTION: The extracted outcomes were classified using Dodd's framework, which is designed for organizing research outcomes. Heterogeneity was observed in the outcome measures (OMs) used for evaluation. Two reviewers independently conducted the data extraction, which was verified by a third reviewer. DATA SYNTHESIS: Of the 7,834 articles screened, 47 articles reporting data on 692 individuals with traumatic LLA, met our inclusion criteria. Four core areas encompassing 355 OMs/indicators were identified: life effect (63.4%), physiological/clinical (30.1%), resource use (5.1%), and adverse events (1.4%). Physical functioning (eg, gait, mobility) was the most frequently reported outcome domain across studies, followed by nervous system outcomes (eg, pain) and psychiatric outcomes (eg, depression, anxiety). Domains such as global quality of life and role/emotional functioning were seldomly reported. CONCLUSION: The study provides a list of outcome indicators explicitly published for adults with traumatic LLA, highlighting inconsistent reporting of outcome indicators. The lack of a standardized set of OMs is a barrier to performing meta-analyses on interventions, preventing the identification of effective care models and clinical pathways. Developing a core outcome set that includes OMs relevant to the needs of the traumatic LLA population may address these issues.

The process of implementing culture change across a city-operated long-term care home and the importance of stakeholder engagement.

This article describes the Quality Improvement (QI) initiative of a culture change model, CareTO. CareTO is a made-in-Toronto, resident-driven, person-centred approach to care that was implemented across all units of a City of Toronto-operated Long-Term Care (LTC) home during the COVID-19 pandemic. The City of Toronto's Seniors Services and Long-Term Care (SSLTC) Division partnered with an external QI team to support the implementation of CareTO at the pilot site. This team employed a multi-method approach (fact-gathering conversations, stakeholder survey, and meeting) to understand how residents, families, and professionals defined CareTO, and identified implementation facilitators, barriers, and priorities. Emerging findings were shared with SSLTC to inform the delivery of CareTO in real time. Results suggested that stakeholder engagement, and collaborations between external partners and municipal governments are an effective means of mobilizing implementation initiatives by encouraging reflection, developing a shared understanding, and refining objectives.

Housing Satisfaction Among Older Adults Living in Low-Income Seniors' Housing.

Tenant experience surveys are a key tool for social housing landlords to gauge their success in providing high quality housing. This paper examines feedback from a tenant experience survey facilitated in a low-income housing seniors' housing community to: (1) examine their perceptions of their housing across key domains related to tenant satisfaction; and (2) identify opportunities they felt would improve their housing experience. A total of 1,114 households completed the survey. Results showed that tenants generally had high satisfaction with property management, safety and security, communication with staff, access to services, community support, and tenancy management. However, open-ended comments from tenants highlighted specific situations that negatively impacted their housing, including maintenance issues, safety concerns, and limited access to health and social programs. Findings point to several suggestions for social housing providers to enhance their services to foster inclusive, supportive, and safe housing environments for low-income older adults.

Designing and Implementing a New Seniors Services Coordinator Role for Low-Income Housing: A Qualitative Study.

Older adults living in social housing are disproportionally impacted by poverty, social isolation, and chronic health conditions that negatively impact their housing stability. In response, service coordination models of care that provide proactive case management have seen widespread adoption across low-income seniors housing communities. We examined the design and implementation of a new "seniors services coordinator" (SSC) role that was introduced by a social housing provider in Toronto, Canada. We conducted qualitative focus groups with tenants (n = 16), housing and policy staff (n = 16), and government-funded care coordinators (n = 16) to understand how the new SSC position formed relationships with tenants, assessed tenant needs and coordinated services, and built partnerships with government-funded system navigators. Since staff were assigned to specific buildings and had smaller caseloads, stakeholders felt that the SSC would be well positioned to build relationships of trust with tenants. Histories of mistrust, boundaries and time management, role conflicts, and system-level barriers, however, made it difficult for SSCs to fully carry out their role. Our findings highlight several design and implementation considerations that may impact the success of tenant-facing support staff such as SSCs, which can serve as a roadmap for other housing providers looking to implement similar initiatives.

Infection prevention and control across the continuum of COVID-19 care: A qualitative study of patients', caregivers' and providers' experiences.

INTRODUCTION: Healthcare facilities adopted restrictive visitor policies as a result of the COVID-19 (COVID) pandemic. Though these measures were necessary to promote the safety of patients, families and healthcare providers, it led to isolation and loneliness amongst acute care inpatients that can undermine patient rehabilitation and recovery. The study objectives were to (1) explore how infection prevention and control (IP&C) measures impacted stakeholders' perceptions of care quality and interactions with others and (2) investigate how these experiences and perceptions varied across stakeholder groups and care settings. METHODS: A qualitative descriptive study was conducted. Patients and their families from an inpatient COVID rehabilitation hospital and healthcare providers from an acute or rehabilitation COVID hospital were interviewed between August 2020 and February 2021. RESULTS: A total of 10 patients, 5 family members and 12 healthcare providers were interviewed. Four major themes were identified: (1) IP&C measures challenged the psychosocial health of all stakeholders across care settings; (2): IP&C measures precipitated a need for greater relational care from HCPs; (3) infection prevention tenets perpetuated COVID-related stigma that stakeholders experienced across care settings; and (4) technology was used to facilitate human connection when IP&C limited physical presence. CONCLUSION: IP&C measures challenged psychosocial health and maintenance of vital human connections. Loneliness and isolation were felt by all stakeholders due to physical distancing and COVID-related stigma. Some isolation was mitigated by the relational care provided by HCPs and technological innovations used. The findings of the study underscore the need to balance safety with psychosocial well-being across care settings and beyond the patient-provider dyad. PATIENT AND PUBLIC CONTRIBUTION: This study was informed by the Patient-Oriented Research Agenda and developed through consultations with patients and family caregivers to identify priority areas for rehabilitation research. Priority areas identified that informed the current study were (1) the need to focus on the psychosocial aspects of recovery from illness and injury and (2) the importance of exploring patients' recovery experiences and needs across the continuum of care. The study protocol, ethics submission, analysis and manuscript preparation were all informed by healthcare providers with lived experience of working in COVID care settings.

"We could be good partners if we work together": the perspectives of health and social service providers on the barriers to forming collaborative partnerships with social housing providers for older adults.

BACKGROUND: Many older adults are aging-at-home in social housing. However, the lack of integration between housing and health services makes it difficult for older tenants to access needed supports. We examined barriers and facilitators health and social service providers face providing on-site services to older tenants. METHODS: We conducted semi-structured qualitative interviews and focus groups with health and social service professionals (n = 58) in Toronto, Canada who provide community programs in support of older tenants who live in non-profit, rent-geared-to-income social housing. Interviews examined the barriers they faced in providing on-site services to older tenants. FINDINGS: Service providers strongly believed that collaboration with on-site housing staff led to better health and housing outcomes for older tenants. Despite the recognized benefits of partnering with housing staff, service providers felt that their ability to work effectively in the building was dependent on the staff (particularly the superintendent) assigned to that building. They also identified other barriers that made it difficult to work collaboratively with the housing provider, including staffing challenges such as high staff turnover and confusion about staff roles, a lack of understanding among housing staff about the link between housing and health, challenges sharing confidential information across sectors, and complex and inefficient partnership processes. CONCLUSION: Older adult tenants are increasingly vulnerable and in need of supports but the housing provider has a long history of ineffective partnerships with service providers driven by complex and inefficient staffing models, and an organizational culture that questions the role of and need for partnerships. Findings highlight the need for more effective integration of housing and health services. Simplified processes for establishing partnerships with service agencies and more opportunities for communication and collaboration with housing staff would ensure that services are reaching the most vulnerable tenants.

Examination of the Relationships Among Social Networks and Loneliness on Health and Life Satisfaction in People with Spinal Cord Injury/Dysfunction.

OBJECTIVE: To examine the associations among social networks and loneliness on health and life satisfaction in adults with chronic spinal cord injury/dysfunction (SCI/D). DESIGN: Cross-sectional telephone survey study. SETTING: Tertiary spinal cord injury rehabilitation center in Ontario, Canada. PARTICIPANTS: Community-dwelling adults with chronic SCI/D (N=170). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The main outcome measures were the Short-Form 36 to assess health and the Life Satisfaction-11 to assess life satisfaction. RESULTS: A hierarchical regression model predicting physical health accounted for 24% (P<.001) of the variance. The only social network variable to significantly contribute to the model was having a higher proportion of network members living in one's household (P<.05). A model predicting mental health accounted for 44% (P<.001) of the variance, with having a higher proportion of network members living in one's household (P<.05) and lower feelings of loneliness (P<.001) associated with better mental health. Finally, the model predicting life satisfaction accounted for 62% (P<.001) of the variance, with lower greater levels of social network intimacy (P<.01) and lower feelings of loneliness (P<.001) being significant predictors. CONCLUSIONS: These findings highlight the importance of having access to network members in one's home for better physical and mental health after SCI/D as well as the negative association between loneliness and mental health and life satisfaction. There is a need for approaches to ensure that people with SCI/D in the community feel supported to mitigate feelings of loneliness to optimize their health and wellbeing.

Prevalence of Prescribed Opioid Claims Among Persons With Traumatic Spinal Cord Injury in Ontario, Canada: A Population-Based Retrospective Cohort Study.

OBJECTIVES: To examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use. DESIGN: Retrospective cohort study using population-level administrative data. SETTING: Ontario, Canada. PARTICIPANTS: Individuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Proportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period). RESULTS: A total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity. CONCLUSIONS: A large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.

Prevalence of prescribed opioid claims among persons with nontraumatic spinal cord dysfunction in Ontario, Canada: a population-based retrospective cohort study.

STUDY DESIGN: Cohort study. OBJECTIVE: To determine the prevalence and to identify predictors of prescription opioid use among persons with nontraumatic spinal cord dysfunction within 1 year after discharge from inpatient rehabilitation. SETTING: Ontario, Canada. METHODS: We conducted a retrospective cohort study using administrative data to determine predictors of receiving prescription opioids during the 1 year after discharge from inpatient rehabilitation among persons with nontraumatic spinal cord dysfunction between April 1, 2004 and March 31, 2015. We modeled the outcome using a Poisson multivariable regression and reported relative risks with 95% confidence intervals. RESULTS: We identified 3468 individuals with nontraumatic spinal cord dysfunction (50% male) with 67% who were aged ≥66. Over half of the cohort (60%) received opioids during the observation period. Older adults (≥66 years old) were significantly more likely to experience comorbidities (p < 0.05) but less likely to be dispensed opioids following rehabilitation discharge. Being female, previous opioid use before rehabilitation, experiencing lower continuity of care, increasing comorbidity level, low functional status, and having a previous diagnosis of osteoarthritis or mental illness were significant risk factors for receiving opioids after discharge, as shown in a multivariable analysis. Increasing length of rehabilitation stay and higher income were protective against opioid receipt after discharge. CONCLUSION: Many individuals with nontraumatic spinal cord dysfunction in Ontario are prescribed opioids after discharge from inpatient rehabilitation. This may be problematic due to the number of severe complications that may arise from opioid use and their use in this population warrants future research.

Prescription medications dispensed following a nontraumatic spinal cord dysfunction: a retrospective population-based study in Ontario, Canada.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To examine the prevalence of polypharmacy for individuals with nontraumatic spinal cord dysfunction (NTSCD) following inpatient rehabilitation and to determine associated risk factors. SETTING: Ontario, Canada. METHODS: Administrative data housed at ICES, Toronto, Ontario were used. Between 2004 and 2015, we investigated prescription medications dispensed over a 1-year period for persons following an NTSCD-related inpatient rehabilitation admission. Descriptive and analytical statistics were conducted. Using a robust Poisson multivariable regression model, relative risks related to polypharmacy (ten or more drug classes) were calculated. Main independent variables were sex, age, income quintile, and continuity of care with outpatient physician visits. RESULTS: We identified 3468 persons with NTSCD during the observation window. The mean number of drug classes taken post-inpatient rehabilitation was 11.7 (SD = 6.0), with 4.0 different prescribers (SD = 2.5) and 1.8 unique pharmacies (SD = 1.0). Significant predictors for post-discharge polypharmacy were: being female, lower income, higher comorbidities prior to admission, lower Functional Independence Measure at discharge, previous number of medication classes dispensed in year prior to admission, and lower continuity of care with outpatient physician visits. The most common drugs dispensed post-inpatient rehabilitation were antihypertensives (70.0%), laxatives (61.6%), opioids (59.5%), and antibiotics (57.8%). CONCLUSION: Similar to previous research with traumatic spinal cord injury, our results indicate that polypharmacy is prevalent among persons with NTSCD. Additional research examining medication therapy management for NTSCD is suggested.

"The strategies are the same, the problems may be different": a qualitative study exploring the experiences of healthcare and service providers with medication therapy management for individuals with spinal cord injury/dysfunction.

BACKGROUND: Persons with spinal cord injury/dysfunction (SCI/D) often take multiple medications to treat their secondary complications and chronic conditions (multimorbidity). Multiple healthcare and service providers are often involved in care, which can result in increased risk of fragmentation of care. Optimal medication therapy management (MTM) is essential to ensure therapeutic benefit from medication regimens. However, little is known about the experiences of providers in supporting persons with SCI/D with MTM. METHODS: Telephone interviews were conducted to explore healthcare and service providers' experiences with MTM for persons with SCI/D. Participants were recruited through clinical organizations and researchers' personal contacts. Participants were purposefully selected for diversity in profession and were required to be English speaking and to have provided care to at least one person with SCI/D. The qualitative interviews followed a semi-structured interview guide. Data display matrices were used in a constant comparative process for descriptive and interpretive analysis. RESULTS: Thirty-two interviews were conducted from April to December 2018. Each profession had distinct views on their roles in facilitating MTM for persons with SCI/D, which aligned with their respective scopes of practice. Shared provider tasks included tailoring medications, providing education, and exploring medication alternatives. Most participants felt that the care they provided for persons with SCI/D was similar to the care that they provided to other patients, with some differences relating to the physical limitations and medical complexity associated with SCI/D. Five factors were identified that impacted participants' abilities to provide MTM for persons with SCI/D: patient self-management skills, provider knowledge and confidence, provider-patient relationships, interprofessional collaboration, and provider funding models including the use of technology-supported consultations. CONCLUSION: While participants described commonalities in the barriers and enablers associated with providing MTM to persons with SCI/D and other populations, there were unique considerations identified. These SCI/D-specific considerations resulted in recommendations for improvements in MTM for this population. Future research should include perspectives from persons with SCI/D.

Scoping Review on Rehabilitation Scoping Reviews.

OBJECTIVE: To examine the extent, scope, and methodological quality of rehabilitation scoping reviews. DATA SOURCES: A comprehensive list of scoping reviews conducted in the broader health field (inception to July 2014), with a further update of that list (up to February 2017) using similar methods, including searching 9 electronic databases. STUDY SELECTION: Articles were included if they were scoping reviews within rehabilitation. Established review methods were used including (1) a PubMed filter detecting rehabilitation content and (2) title-and-abstract screening by 2 independent reviewers applied sequentially to articles from the existing list of scoping reviews and to the updated search results. Full-text articles were reviewed by 1 reviewer, with discrepancies resolved by another after pilot screening with > 80% agreement. Remaining discrepancies were resolved by external experts. DATA EXTRACTION: Two independent reviewers used piloted and standardized data extraction forms. DATA SYNTHESIS: We screened 1823 records, including 992 full texts, to identify 251 rehabilitation-related scoping reviews. Rehabilitation scoping reviews had an exponential yearly increase since 2008 (r2=0.89; P<.01). The literature addressed diverse topics (eg, spread over 43 condition groupings); 43% were published in Canada. Examples of methodological limitations included: 39% of reviews did not cite the use of a methodological framework, 96% did not include the appropriate flow diagram, 8% did not report eligibility criteria, and 57% did not report data extraction details. CONCLUSIONS: The increasing popularity of scoping reviews in rehabilitation has not been met by high standards in methodological quality. To increase the value of rehabilitation scoping reviews, rehabilitation stakeholders need to use existing methodological standards for the conduct, reporting, and appraisal of scoping reviews.

Development of a novel neurogenic bowel patient reported outcome measure: the Spinal Cord Injury Patient Reported Outcome Measure of Bowel Function & Evacuation (SCI-PROBE).

STUDY DESIGN: Outcome measure item generation and reduction. OBJECTIVES: To develop a patient reported outcome measure (PROM) addressing the impact of neurogenic bowel dysfunction (NBD) on individuals living with traumatic or nontraumatic spinal cord injury (SCI). SETTING: Tertiary rehabilitation center in Toronto, Canada. METHODS: A PROM based on the International Classification of Functioning, Disability and Health (ICF) framework was developed using the following steps: (a) item generation, (b) item refinement through iterative review, (c) completion of items by individuals living with SCI and NBD followed by cognitive interviewing, and (d) further item refinement, item reduction, and construction of the preliminary PROM. RESULTS: Following initial item generation and iterative review, the investigative team agreed on 55 initial items. Cognitive interviewing, additional revisions, and item reduction yielded an instrument comprised of 35 items; while ensuring at least two items were retained for each of the 16 previously identified challenges of living with NBD following the onset of a SCI. Scoring for the preliminary PROM ranges from 0 to 140. CONCLUSIONS: A preliminary PROM informed by the ICF for assessing the impact of NBD post-SCI has been devised, which can be used to inform clinicians and decision-makers on optimal ways to treat this serious secondary health complication. Future work will assess the validity and clinimetric properties of the PROM.

Prescription drug claims following a traumatic spinal cord injury for older adults: a retrospective population-based study in Ontario, Canada.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The objectives for this study were to examine the prevalence of polypharmacy for people with traumatic spinal cord injury (SCI) following injury and to determine risk factors. SETTING: Ontario, Canada METHODS: We used provincial-level administrative health services data of publicly funded healthcare encounters housed at the Institute for Clinical Evaluative Sciences, Toronto, Ontario. We examined prescription medications dispensed over a 1 year period post injury for persons 66+ years with an index traumatic SCI between 2004 and 2014. Polypharmacy was defined as being on 10 or more drug classes. Descriptive and analytical statistics were conducted. Relative risks and 95% confidence limits for factors related to polypharmacy were calculated using a robust Poisson multivariate regression model. RESULTS: We identified 418 cases of persons with traumatic SCI during the observation window. A total of 233 patients (56%) were taking at least 10 drug classes in the year following discharge from care for traumatic SCI. The mean number of drug classes taken post injury was 11 (SD = 6). Continuity of care was significantly associated with polypharmacy, with a higher continuity of care (having at least 75% of visits with the same doctor) reducing the risk of polypharmacy. The most common drugs prescribed were laxatives, opioids and cardiovascular-related drugs. CONCLUSION: Findings suggest that polypharmacy is extensive among older adults with traumatic SCI. Persons with better continuity of care are less likely to have polypharmacy compared to those with less continuity. SPONSORSHIP: This project was funded by a Connaught New Investigator Award (University of Toronto), and the Craig H. Neilsen Foundation Psychosocial Research Pilot Grant (Grant #441259).

Study protocol for a scoping review on rehabilitation scoping reviews.

INTRODUCTION: Scoping reviews are increasingly popular in rehabilitation. However, significant variability in scoping review conduct and reporting currently exists, limiting potential for the methodology to advance rehabilitation research, practice and policy. Our aim is to conduct a scoping review of rehabilitation scoping reviews in order to examine the current volume, yearly distribution, proportion, scope and methodological practices involved in the conduct of scoping reviews in rehabilitation. Key areas of methodological improvement will be described. Methods and analysis: We will undertake the review using the Arksey and O'Malley scoping review methodology. Our search will involve two phases. The first will combine a previously conducted scoping review of scoping reviews (not distinct to rehabilitation, with data current to July 2014) together with a rehabilitation keyword search in PubMed. Articles found in the first phase search will undergo a full text review. The second phase will include an update of the previously conducted scoping review of scoping reviews (July 2014 to current). This update will include the search of nine electronic databases, followed by title and abstract screening as well as a full text review. All screening and extraction will be performed independently by two authors. Articles will be included if they are scoping reviews within the field of rehabilitation. A consultation exercise with key targets will inform plans to improve rehabilitation scoping reviews. Ethics and dissemination: Ethics will be required for the consultation phase of our scoping review. Dissemination will include peer-reviewed publication and conferences in rehabilitation-specific contexts.

A systematic review on community-based interventions for elder abuse and neglect.

Elder abuse and neglect is a societal issue that requires prevention and intervention strategies at the practice and policy level. A systematic review on the efficacy of community-based elder abuse interventions was undertaken to advance the state of knowledge in the field. The peer-reviewed literature between 2009 and December 2015 were searched across four databases. Two raters independently reviewed all articles, assessed their methodological quality, and used a modified Sackett Scale to assign levels of evidence. Four thousand nine hundred and five articles were identified; nine were selected for inclusion. Although there was Level-1 evidence for psychological interventions (n = 2), only one study on strategies for relatives (START) led to a reported decrease in elder abuse. There was Level-4 evidence for conservatorship, an elder abuse intervention/prevention program (ECARE), and a multidisciplinary intervention (n = 4), in which one study yielded significant decreases in elder abuse and/or neglect. The remaining three were classified as Level-5 evidence (n = 3) for elder mediation and multidisciplinary interventions. There are limited studies with high levels of evidence for interventions that decrease elder abuse and neglect. The scarcity of community-based interventions for older adults and caregivers highlights the need for further work to elevate the quality of studies.

Traumatic Brain Injury in Spinal Cord Injury: Frequency and Risk Factors.

BACKGROUND: The frequency of traumatic brain injury (TBI) co-occurring with traumatic spinal cord injury (tSCI) is unclear despite a number of past studies; as well, limited research has examined predictors of co-morbid TBI in tSCI patients. OBJECTIVES: (1a) To summarize past literature on comorbid diagnosis of TBI in tSCI in order to reexamine the frequency of dual diagnosis in a study designed to obviate past methodological limitations; (1b) to compare dual-diagnosis frequency with vs without the inclusion of diagnostically ambiguous cases; and (2) to measure risk factors for tSCI and comorbid TBI. METHODS: Ninety-one of 135 eligible adults with tSCI, 3 to 6 months postinjury, were prospectively recruited from a tertiary inpatient tSCI rehabilitation program. TBI diagnosis was based on comprehensive, validated clinical neurological and neuroimaging measures. RESULTS: Objective 1: 39.6% of the tSCI patients sustained a concomitant TBI, but when ambiguous cases were removed from analysis, frequency rose to 58.1%. Objective 2: Motor vehicle collisions were most likely to yield a comorbid TBI diagnosis, but 31.6% of falls also resulted in TBI. Patients with cervical and thoracic injuries showed a very similar frequency of comorbid TBI. CONCLUSIONS: Varied methodological approaches, particularly the decision to include/exclude ambiguous cases, likely explain disparate past estimates of TBI in tSCI. However, even this study's lower frequency estimate, at nearly 40%, is clinically important. The prevailing assumption that dual diagnosis is less common in thoracic than cervical spine injuries was not supported. Finally, while comorbid TBI most frequently occurred in motor vehicle collisions, nearly a third of tSCIs sustained in falls resulted in comorbid TBI in our sample.

Phenomenological study of neurogenic bowel from the perspective of individuals living with spinal cord injury.

OBJECTIVE: To gain greater insight into the lived experience of individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction (NBD). DESIGN: Qualitative (phenomenologic) interviews and analysis. SETTING: Community. PARTICIPANTS: Individuals with SCI and NBD (N=19) residing in the community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Concerns related to living with NBD after SCI. RESULTS: Challenges related to living with SCI and NBD included costs and requirements, emotional impact, diet, education and employment, intimacy and interpersonal relations, social participation, spontaneity and daily schedule, travel, lack of appropriate and consistent assistance, loss of autonomy (independence, privacy), lack of predictability and fear of incontinence, medical complications, pain or discomfort, physical effort of the bowel routine, physical experience, and time requirements. CONCLUSIONS: Living with NBD presents many challenges. When categorized according to the International Classification of Functioning, Disability and Health, identified domains include body functions and structures, activity, participation, environmental factors, and personal factors. Identified issues have implications for improving clinical management and should be assessed when determining the impact and efficacy of interventions.