Identifying the areas of low self-reported confidence of internal medicine residents in geriatrics: a descriptive study of findings from a structured geriatrics skills assessment survey.

BACKGROUND: Currently, no standardized methods exist to assess the geriatric skills and training needs of internal medicine trainees to enable them to become confident in caring for older patients. This study aimed to describe the self-reported confidence and training requirements in core geriatric skills amongst internal medicine residents in Toronto, Ontario using a standardized assessment tool. METHODS: This study used a novel self-rating instrument, known as the Geriatric Skills Assessment Tool (GSAT), among incoming and current internal medicine residents at the University of Toronto, to describe self-reported confidence in performing, teaching and interest in further training with regard to 15 core geriatric skills previously identified by the American Board of Internal Medicine. RESULTS: 190 (75.1%) out of 253 eligible incoming (Year 0) and current internal medicine residents (Years 1-3) completed the GSAT. Year 1-3 internal medicine residents who had completed a geriatric rotation reported being significantly more confident in performing 13/15 (P < 0.001 to P = 0.04) and in teaching 9/15 GSAT skills (P < 0.001 to P = 0.04). Overall, the residents surveyed identified their highest confidence in administering the Mini-Mental Status Examination and lowest confidence in assessing fall risk using a gait and balance tool, and in evaluating and managing chronic pain. CONCLUSION: A structured needs assessment like the GSAT can be valuable in identifying the geriatric training needs of internal medicine trainees based on their reported levels of self-confidence. Residents in internal medicine could further benefit from completing a mandatory geriatric rotation early in their training, since this may improve their overall confidence in providing care for the mostly older patients they will work with during their residency and beyond.

A systematic review and qualitative analysis of geriatric models of care for rural and remote populations.

INTRODUCTION: Much is known about the healthcare needs of rural and remote communities; however, understanding how to best deliver geriatric models of care in these settings has received less attention. The purpose of this systematic review was to identify necessary key components of existing models of geriatric care serving rural or remote populations. METHODS: A systematic literature review was conducted using MEDLINE, CINAHL and EMBASE databases to identify articles that described models of geriatric care serving rural or remote populations. A qualitative case study and key component analysis approach was used to identify necessary model components. RESULTS: Eight articles were included. We identified eight distinct components that may improve the successful delivery of models of geriatric care serving rural or remote populations. Environmental assessments were done in six of eight models. Model integration with the local healthcare system, local provider leadership, and local provider education in geriatrics were present in five of eight models. Three of eight models used high-risk screening principles and included geriatrician consultation. One model described active community engagement, and one used telemedicine. CONCLUSION: Future geriatric care delivery models designed to serve rural or remote populations are encouraged to use an evidence-based framework based on eight distinct model characteristics found in the literature that aim to support the ideal provision of effective and accessible geriatric medical care.

Reflecting on the Journey to Develop New National Long-Term Care Standards.

Samir K. Sinha - Implementation Science Team lead and chair of the Health Standards Organization's National Long-Term Care Services Standard Technical Committee - sheds light on the development of the long-term care national standards. Sinha also discusses what the standards hope to achieve for improved quality of care and quality of life across the sector.

Risk factors for outbreaks of SARS-CoV-2 infection at retirement homes in Ontario, Canada: a population-level cohort study.

BACKGROUND: The epidemiology of SARS-CoV-2 infection in retirement homes (also known as assisted living facilities) is largely unknown. We examined the association between home-and community-level characteristics and the risk of outbreaks of SARS-CoV-2 infection in retirement homes since the beginning of the first wave of the COVID-19 pandemic. METHODS: We conducted a population-based, retrospective cohort study of licensed retirement homes in Ontario, Canada, from Mar. 1 to Dec. 18, 2020. Our primary outcome was an outbreak of SARS-CoV-2 infection (≥ 1 resident or staff case confirmed by validated nucleic acid amplification assay). We used time-dependent proportional hazards methods to model the associations between retirement home- and community-level characteristics and outbreaks of SARS-CoV-2 infection. RESULTS: Our cohort included all 770 licensed retirement homes in Ontario, which housed 56 491 residents. There were 273 (35.5%) retirement homes with 1 or more outbreaks of SARS-CoV-2 infection, involving 1944 (3.5%) residents and 1101 staff (3.0%). Cases of SARS-CoV-2 infection were distributed unevenly across retirement homes, with 2487 (81.7%) resident and staff cases occurring in 77 (10%) homes. The adjusted hazard of an outbreak of SARS-CoV-2 infection in a retirement home was positively associated with homes that had a large resident capacity, were co-located with a long-term care facility, were part of larger chains, offered many services onsite, saw increases in regional incidence of SARS-CoV-2 infection, and were located in a region with a higher community-level ethnic concentration. INTERPRETATION: Readily identifiable characteristics of retirement homes are independently associated with outbreaks of SARS-CoV-2 infection and can support risk identification and priority for vaccination.

Paramedic-Initiated Home Care Referrals and Use of Home Care and Emergency Medical Services.

OBJECTIVE: We examined the association between paramedic-initiated home care referrals and utilization of home care, 9-1-1, and Emergency Department (ED) services. METHODS: This was a retrospective cohort study of individuals who received a paramedic-initiated home care referral after a 9-1-1 call between January 1, 2011 and December 31, 2012 in Toronto, Ontario, Canada. Home care, 9-1-1, and ED utilization were compared in the 6 months before and after home care referral. Nonparametric longitudinal regression was performed to assess changes in hours of home care service use and zero-inflated Poisson regression was performed to assess changes in the number of 9-1-1 calls and ambulance transports to ED. RESULTS: During the 24-month study period, 2,382 individuals received a paramedic-initiated home care referral. After excluding individuals who died, were hospitalized, or were admitted to a nursing home, the final study cohort was 1,851. The proportion of the study population receiving home care services increased from 18.2% to 42.5% after referral, representing 450 additional people receiving services. In longitudinal regression analysis, there was an increase of 17.4 hours in total services per person in the six months after referral (95% CI: 1.7-33.1, p = 0.03). The mean number of 9-1-1 calls per person was 1.44 (SD 9.58) before home care referral and 1.20 (SD 7.04) after home care referral in the overall study cohort. This represented a 10% reduction in 9-1-1 calls (95% CI: 7-13%, p < 0.001) in Poisson regression analysis. The mean number of ambulance transports to ED per person was 0.91 (SD 8.90) before home care referral and 0.79 (SD 6.27) after home care referral, representing a 7% reduction (95% CI: 3-11%, p < 0.001) in Poisson regression analysis. When only the participants with complete paramedic and home care records were included in the analysis, the reductions in 9-1-1 calls and ambulance transports to ED were attenuated but remained statistically significant. CONCLUSIONS: Paramedic-initiated home care referrals in Toronto were associated with improved access to and use of home care services and may have been associated with reduced 9-1-1 calls and ambulance transports to ED.

Clinical characteristics associated with the onset of delirium among long-term nursing home residents.

BACKGROUND: Nursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Most of the existing evidence base on delirium is derived from studies in the acute in-patient population. We examine the association between clinical characteristics and medication use with the incidence of delirium during the nursing home stay. METHODS: This is a retrospective cohort study of 1571 residents from 12 nursing homes operated by a single care provider in Ontario, Canada. Residents were over the age of 55 and admitted between February 2010 and December 2015 with no baseline delirium and a minimum stay of 180 days. Residents with moderate or worse cognitive impairment at baseline were excluded. The baseline and follow-up characteristics of residents were collected from the Resident Assessment Instrument-Minimal Data Set 2.0 completed at admission and repeated quarterly until death or discharge. Multivariate logistic regression was used to identify characteristics and medication use associated with the onset of delirium. RESULTS: The incidence of delirium was 40.4% over the nursing home stay (mean LOS: 32 months). A diagnosis of dementia (OR: 2.54, p < .001), the presence of pain (OR: 1.64, p < .001), and the use of antipsychotics (OR: 1.87, p < .001) were significantly associated with the onset of delirium. Compared to residents who did not develop delirium, residents who developed a delirium had a greater increase in the use of antipsychotics and antidepressants over the nursing home stay. CONCLUSIONS: Dementia, the presence of pain, and the use of antipsychotics were associated with the onset of delirium. Pain monitoring and treatment may be important to decrease delirium in nursing homes. Future studies are necessary to examine the prescribing patterns in nursing homes and their association with delirium.

Delivering improved patient and system outcomes for hospitalized older adults through an Acute Care for Elders Strategy.

Acute care hospitals are widely recognized as potentially high-risk environments for older adults. In 2010, Mount Sinai Hospital conceived its Acute Care for Elders (ACE) Strategy as a multi-component intervention to improve the care of hospitalized older adults. In order to determine its effectiveness, we conducted a quasi-experimental time series analysis of 12,008 older patients admitted non-electively for acute medical issues over a 6-year period. Despite a 53% increase in annual admissions of older patients between 2009/2010 and 2014/2015, Mount Sinai decreased total lengths of stay and readmissions and reduced the direct cost of care per patient, leading to net savings of CDN$4.2 million in 2014/2015. This article presents Mount Sinai's ACE Strategy and discusses the benefits of implementing integrated evidence-based models across the continuum of care and how it is supporting the implementation of ACE Strategy models of care and care practices across Canada and beyond.

Facteurs de risque d'éclosion de SRAS-CoV-2 dans les résidences pour aînés en Ontario, au Canada: étude de cohorte à l'échelle de la population.

CONTEXTE: L'épidémiologie de l'infection au SRAS-CoV-2 dans les résidences pour aînés (offrant une aide à la vie autonome), est pour une bonne part inconnue. Nous avons étudié le lien entre les caractéristiques des résidences et des communautés avoisinantes et le risque d'éclosion de SRAS-CoV-2 dans les résidences pour aînés depuis le début de la première vague de la pandémie de COVID-19. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective dans la population des résidences pour aînés certifiées en Ontario, au Canada, entre le 1er mars et le 18 décembre 2020. Notre paramètre principal était toute éclosion de SRAS-CoV-2 (≥ 1 cas confirmé parmi les résidents ou le personnel au moyen d'un test d'amplification des acides nucléiques). Nous avons utilisé la méthode des risques proportionnels avec prédicteurs chronologiques pour modéliser les liens entre les caractéristiques des résidences et des communautés avoisinantes et les éclosions de SRAS-CoV-2. RÉSULTATS: Notre cohorte a inclus l'ensemble des 770 résidences privées pour aînés (RPA) certifiées en Ontario qui hébergeaient 56 491 résidents. On a dénombré 273 (35,5 %) résidences pour aînés qui ont connu 1 éclosion de SRAS-CoV-2 ou plus; 1944 résidents (3,5 %) et 1101 employés (3,0 %) ont contracté l'infection. Ces cas étaient inégalement distribués entre les résidences. En effet, 2487 cas parmi les résidents et le personnel (81,7 %) sont survenus dans 77 résidences (10 %). Le rapport de risque ajusté d'une éclosion de SRAS-CoV-2 dans une résidence a été clairement associé aux établissements qui avaient une grande capacité d'accueil, qui comportaient des unités de soins de longue durée, qui appartenaient à de plus grandes bannières et offraient plusieurs services sur place, qui se trouvaient dans des régions marquées par une hausse de l'incidence régionale de SRAS-CoV-2 et où la concentration ethnique à l'échelle de la communauté était supérieure. INTERPRÉTATION: Certaines caractéristiques facilement identifiables des résidences pour aînés sont associées de manière indépendante aux éclosions de SRAS-CoV-2 et peuvent faciliter l'évaluation des risques et orienter la priorisation de la vaccination.

Without Empowered Patients, Caregivers and Providers, a Community-Based Dementia Care Strategy Will Remain Just That.

In trying to cope with the needs of the growing number of people living with dementia (PLWD), jurisdictions around the world have been implementing a variety of strategies, policies and programs to enable better access to the supports they and those who care for them require. Despite considerable efforts that have been undertaken, PLWD and their caregivers still face considerable challenges in pursuing care pathways and community-based supports that can help them avoid premature institutionalization. Morton-Chang et al. (2016) have comprehensively reviewed jurisdictional approaches towards the development of dementia strategies, policies and programs; there is a growing understanding and consensus around the things we need to do as societies to better meet the needs of PLWD and their caregivers; however, progress to date could be best characterized as top-down, patchy and fragmented. This paper builds on Morton-Chang et al.'s (2016) assertion that the development of a comprehensive person and caregiver-centred community-based dementia strategy in Ontario and other parts of Canada is likely achievable, particularly if implemented using a "ground-up" approach that is well-aligned with other government-related initiatives.

Integrated client care for frail older adults in the community: preliminary report on a system-wide approach.

The Toronto Central Community Care Access Centre is leading a collaborative local health integration network systemic change initiative to implement and evaluate a practical model of integrated care for older adults with complex needs. The approach is embedded in the community where older adults and their families live and is designed to first and foremost improve the quality of care while ultimately bending the cost curve. The model is leveraging and aligning existing system resources by bringing together sectors from across the health system to create ways of working that build capacity in the system to be more responsive to this population. Outcomes to date will be discussed and next steps described. The secondary goal was to understand the key elements of this integration that can be scaled locally and across the province.

The clinical use of personal hearing amplifiers in facilitating accessible patient-provider communication: A scoping review.

BACKGROUND: Older adults with hearing loss struggle to communicate with care providers and experience higher mortality rates when hospitalized (Genther et al., 2015), even after controlling for age and comorbidities. Personal hearing amplifiers (PHAs), (e.g., Pocketalkers™), can improve communication with older patients. METHODS: We conducted a scoping review to identify research gaps and summarize findings on the clinical use of PHAs with patients with hearing loss. After refining search terms relating to hearing loss and PHAs, we searched MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL Complete, Web of Science Core Collection, ERIC (Proquest), PubMed, ClinicalTrials.gov, International Clinical Trials Registry Platform, and the International Standard Randomised Controlled Trial Number Registry. We identified articles published in English between 1980 and 2022 that reported empirical outcomes relating to PHA use in clinical settings. Two reviewers independently extracted data from articles. We then organized data into an evidence map, and a narrative review summarizing outcomes. RESULTS: From 4234 initially identified titles and abstracts, 12 met our criteria as full texts. These included three surveys on clinicians' awareness and use of PHAs, one evaluation of the acoustic output of a PHA, and eight interventions wherein PHAs were provided to patients with hearing loss. These papers used 10 different terms for PHAs and largely did not cite one another. Results showed high levels of satisfaction with PHAs, and consistently improved speech understanding. Despite this, care providers used devices inconsistently, with challenges around provider awareness, and device maintenance and location tracking. CONCLUSIONS: PHAs have a consistent positive effect on patients' ability to understand their care providers despite hearing loss. Barriers and facilitators to their use in clinical settings should be further explored.

Predictors of Pain and Mood Disturbances Among Older People in Custody Using an interRAI Assessment.

The population of people in federal custody in Canada is aging. Those in custody report experiencing poorer health and high rates of chronic health conditions. Two health concerns that are disproportionately higher among those in custody are mood disorders and pain. This cross-sectional study examined health indicators associated with pain and depressive symptoms among older people (50 years and above) from multiple facilities and security levels in federal custody in Canada. Participants were assessed using the interRAI Emergency Department Contact Assessment, which captures key health indicators. Chi square and logistic regression analyses were conducted to describe the population and identify health indicators associated with mood- and pain-related outcomes, respectively. Of the 1,422 participants in this study, the majority (55%) experienced pain and at least 1 out of 5 experienced depressive symptoms. Health indicators associated with depressive symptoms and/or pain were functional measures, including mobility, managing medication(s), and dyspnea. Depressive symptoms and pain are highly prevalent among older adults in federal custody. The relationship between functional health, depressive symptoms, and pain highlights the importance of interprofessional health care and biopsychosocial intervention(s).

Impact of a peer-support programme to improve loneliness and social isolation due to COVID-19: does adding a secure, user friendly video-conference solution work better than telephone support alone? Protocol for a three-arm randomised clinical trial.

INTRODUCTION: The COVID-19 pandemic has forced the implementation of physical distancing and self-isolation strategies worldwide. However, these measures have significant potential to increase social isolation and loneliness. Among older people, loneliness has increased from 40% to 70% during COVID-19. Previous research indicates loneliness is strongly associated with increased mortality. Thus, strategies to mitigate the unintended consequences of social isolation and loneliness are urgently needed. Following the Obesity-Related Behavioural Intervention Trials model for complex behavioural interventions, we describe a protocol for a three-arm randomised clinical trial to reduce social isolation and loneliness. METHODS AND ANALYSIS: A multicentre, outcome assessor blinded, three-arm randomised controlled trial comparing 12 weeks of: (1) the HOspitals WoRking in Unity ('HOW R U?') weekly volunteer-peer support telephone intervention; (2) 'HOW R U?' deliver using a video-conferencing solution and (3) a standard care group. The study will follow Consolidated Standard of Reporting Trials guidelines.We will recruit 24-26 volunteers who will receive a previously tested half day lay-training session that emphasises a strength-based approach and safety procedures. We will recruit 141 participants ≥70 years of age discharged from two participating emergency departments or referred from hospital family medicine, geriatric or geriatric psychiatry clinics. Eligible participants will have probable baseline loneliness (score ≥2 on the de Jong six-item loneliness scale). We will measure change in loneliness, social isolation (Lubben social network scale), mood (Geriatric Depression Score) and quality of life (EQ-5D-5L) at 12-14 weeks postintervention initiation and again at 24-26 weeks. ETHICS AND DISSEMINATION: Approval has been granted by the participating research ethics boards. Participants randomised to standard care will be offered their choice of telephone or video-conferencing interventions after 12 weeks. Results will be disseminated through journal publications, conference presentations, social media and through the International Federation of Emergency Medicine. TRIAL REGISTRATION NUMBER: NCT05228782.

Commentary: Minding the Gap - Why Wage Parity Is Crucial for the Care of Older Canadians.

Zagrodney and colleagues (2023) have highlighted the pay differences that exist between those working in the home and community care (HCC) sector and other healthcare sectors. The authors argue that achieving wage parity could significantly mitigate the current HCC human resource crisis, support the overall sustainability of Ontario's healthcare system and improve patient outcomes. We build on their argument by highlighting issues that have contributed to wage disparities within healthcare systems and discuss how addressing them can create more equitable systems for both those receiving and those providing care. We further note how other healthcare systems that have wage parity have demonstrated that it is not a "nice to have" but an essential element of establishing a sustainable health human resources strategy. Finally, the new 10-year bilateral healthcare funding agreements that the federal, provincial and territorial governments are currently announcing will not only provide significant new funding but also an opportunity to decisively address the long-standing issue of wage parity in Canada, once and for all.

Exacerbated inequalities: A scoping review of the experiences of older persons during conflict situations.

BACKGROUND: We conducted the first known comprehensive literature review to (1) identify, categorize, and summarize the existing knowledge about the experiences of older persons and their caregivers during conflict situations; (2) identify the support needs of older persons and their caregivers, and; (3) identify gaps in the literature and understanding that may inform future research. METHODS: A scoping review methodology of academic peer-reviewed and gray English language literature was employed using six academic literature databases and one gray literature database. We further performed comprehensive searches of relevant search engines and organization websites and bibliographic hand searches to identify additional academic and gray literature. Two authors screened for eligibility of identified studies and documents. One reviewer extracted data regarding authors, article type, geographic origin, key participant characteristics, aims, study design and data collection method, results, conclusions and limitations. Data were analyzed thematically. RESULTS: 83 documents met this review's inclusion criteria, including 21 academic documents and 62 from the gray literature. Thematic analysis revealed that conflict situations exacerbate existing inequalities experienced by older persons. Within this overarching theme were three interconnected sub-themes: (1) Older adults are particularly vulnerable during conflict situations; (2) Older persons are inadequately supported in conflict situations; (3) In the face of great challenges, many older adults still manage to endure through conflict situations. We identified 15 recommendations from the reviewed documents to better support older adults in conflict situations. CONCLUSIONS: Existing inequalities, such as ageism and ableism, targeted discrimination, and poor health outcomes, become exacerbated during conflict situations, resulting in older persons being less able to flee and meet their daily needs with sufficient access to necessities and healthcare. Little is known of the experiences and needs of family caregivers during conflict situations. We identified several opportunities to improve the experience and support of older persons in conflict situations.

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study.

OBJECTIVE: We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS: Counts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019. RESULTS: There was a 34% relative increase in the resident population size of assisted living facilities (56,9752019 vs 42,6002013). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019. CONCLUSIONS AND IMPLICATIONS: Residents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.