Perspectives on the representation of frailty in the electronic frailty index.

BACKGROUND: Frailty is a state of increased vulnerability from physical, social, and cognitive factors resulting in greater risk of negative health-related outcomes and increased healthcare expenditure. A 36-factor electronic frailty index (eFI) developed in the United Kingdom calculates frailty scores using electronic medical record data. There is currently no standardization of frailty screening in Canadian primary care. In order to implement the eFI in a Canadian context, adaptation of the tool is necessary because frailty is represented by different clinical terminologies in the UK and Canada. In considering the promise of implementing an eFI in British Columbia, Canada, we first looked at the content validation of the 36-factor eFI. Our research question was: Does the eFI represent frailty from the perspectives of primary care clinicians and older adults in British Columbia? METHODS: A modified Delphi using three rounds of questionnaires with a panel of 23 experts (five family physicians, five nurse practitioners, five nurses, four allied health professionals, four older adults) reviewed and provided feedback on the 36-factor eFI. These professional groups were chosen because they closely work as interprofessional teams within primary care settings with older adults. Older adults provide real life context and experiences. Questionnaires involved rating the importance of each frailty factor on a 0-10 scale and providing rationale for ratings. Panelists were also given the opportunity to suggest additional factors that ought to be included in the screening tool. Suggested factors were similarly rated in two Delphi rounds. RESULTS: Thirty-three of the 36 eFI factors achieved consensus (> 80% of panelists provided a rating of ≥ 8). Factors that did not achieve consensus were hypertension, thyroid disorder and peptic ulcer. These factors were perceived as easily treatable or manageable and/or not considered reflective of frailty on their own. Additional factors suggested by panelists that achieved consensus included: cancer, challenges to healthcare access, chronic pain, communication challenges, fecal incontinence, food insecurity, liver failure/cirrhosis, mental health challenges, medication noncompliance, poverty/financial difficulties, race/ethnic disparity, sedentary/low activity levels, and substance use/misuse. There was a 100% retention rate in each of the three Delphi rounds. CONCLUSIONS AND NEXT STEPS: Three key findings emerged from this study: the conceptualization of frailty varied across participants, identification of frailty in community/primary care remains challenging, and social determinants of health affect clinicians' assessments and perceptions of frailty status. This study will inform the next phase of a broader mixed-method sequential study to build a frailty screening tool that could ultimately become a standard of practice for frailty screening in Canadian primary care. Early detection of frailty can help tailor decision making, frame discussions about goals of care, prevent advancement on the frailty trajectory, and ultimately decrease health expenditures, leading to improved patient and system level outcomes.

Population-level use of gynecological health services by female youth with intellectual/developmental disabilities in British Columbia Canada.

BACKGROUND: There is evidence that female youth with intellectual/developmental disabilities (IDD) experience poorer gynecological care compared to female youth without disabilities. OBJECTIVE: The objective of this study was to obtain baseline data on visits to a health care provider for a gynecological issue for females with IDD and compare that information to the experiences of female youth without IDD. METHODS: This study is a retrospective cohort study using population-level administrative health data from 2010 to 2019 for females aged 15-24 years, with and without IDD. RESULTS: 6452 female youth with IDD and 637,627 female youth without IDD were identified in the data. Over the ten-year period, 53.77% of youth with IDD and 53.68% of youth without IDD had a visit to a physician for a gynecological issue. However, as females with IDD aged, the number of people seeing a physician for a gynecological issue decreased. In the group aged 20-24 years, 15.25% of females with IDD and 24.47% of females without IDD (p < 0.0001) had a Pap test done at any time; 25.94% of females with IDD had a visit for contraception management and 28.38% of females (p < 0.0001) without IDD had a visit for contraception management. Gynecological care also varied by type of IDD. CONCLUSIONS: Females with IDD had a similar number of visits for a gynecological issue as female youth without IDD. However, the reasons for visits and the age at which visits occurred differed between youth with and without IDD. As females with IDD transition into adulthood, gynecological care must be maintained and improved.

Family physicians' and trainees' experiences regarding cancer screening with patients with intellectual disability: An interpretive description study.

People with intellectual disability receive breast, cervical, and colorectal cancer screening at lower rates relative to the general population, although the reasons for this disparity are largely unknown. Research, both with the general population and specific to people with intellectual disability, has revealed that a family physician's recommendation for cancer screening or continuity of primary care may increase screening rates. We interviewed family physicians and family medicine trainees regarding their experiences recommending cancer screening to patients with intellectual disability. We concluded that the decision to recommend cancer screening is complex, and includes physicians weighing their clinical judgement as to the best provision of care for patients with a patient's eligibility for screening, while continuing to respect patients' autonomy. This patient-physician interaction occurs within the larger medical environment. Further research with experienced family physicians is warranted to better understand this complex phenomenon.

Exploring New Use of Cannabis among Older Adults.

Objectives: In Canada, cannabis prohibition ended in October 2018. Older adults are the fastest growing group of cannabis users and are out-pacing other groups as new users. Clinical evidence indicates that cannabis may be helpful for select medicinal purposes in this population. Yet there is limited research about older adults experiences of starting to use cannabis in later life. The purpose of this study was to begin to address this gap. Methods: This study employed qualitative description. A convenience sample of Canadian community-dwelling older adults who were new users of cannabis were recruited. Data were collected using semi-structured interviews. Data analysis was inductive and thematic. Results: Twelve older adults between the ages of 71 and 85 participated. All of the participants used cannabis for medicinal reasons, however, only one had a prescription. The main reasons for using were: pain management, alternative to prescription or over-the-counter medication, and sleep aide. Most participants obtained cannabis from non-licensed stores. Eleven discussed cannabis use with their family physicians, however, none received prescriptions from them. The main sources of information were friends, cannabis store staff, and the media. Conclusions: Older adults who begin using cannabis are likely using for what they perceive to be medicinal purposes for a range of issues. However, they receive minimal guidance from their family physicians and instead obtain information from non-clinician sources. Clinical implications: Cannabis screening should be included in geriatric assessments and medicine reconciliation. Continuing education for clinicians needs to address knowledge gaps about cannabis use among older adults.

Avoidance of urinary catheterization to minimize in-hospital complications after transcatheter aortic valve implantation: An observational study.

BACKGROUND: Contemporary transcatheter aortic valve implantation (TAVI) devices and approach present opportunities to review historical practices initially informed by early treatment development and cardiac surgery. The avoidance of urinary catheterization in the older TAVI population is a strategy to minimize in-hospital complications. The purpose of the study was to explore elimination-related complications following the phased implementation of a default strategy of avoiding urinary catheterization in patients undergoing transfemoral (TF) TAVI. METHODS: We conducted an observational study using a retrospective chart review of patients treated between 2011 and 2013 to identify patient characteristics, peri-procedure details, in-hospital outcomes and elimination-related complications in patients who did or did not receive a peri-procedure indwelling catheter. Descriptive analyses were used to report differences between the groups; we conducted a regression analysis to explore the relationship between the practice of urinary catheterization and total procedure time. RESULTS: Of the 408 patients who underwent TF TAVR, 188 (46.1%) received a peri-procedure indwelling urinary catheter and 220 (53.9%) did not. There was no difference in in-hospital mortality (2.2%), disabling stroke (0.5%), or other major cardiac adverse events. The avoidance of a urinary catheter resulted in significantly lower rates of urinary tract infection requiring a new antibiotic regimen (1.4% versus 6.1%, p = 0.014), haematuria documented by medicine or nursing (3.7% versus 17.6%, p = 0.001), and the need for continuous bladder irrigation (2.7% versus 0%, p = 0.027). CONCLUSION: The avoidance of a urinary catheter may contribute to improved outcomes in patients undergoing TAVI. The intervention should be further evaluated within the broader study of minimalist TAVI.

Transition to palliative care when transcatheter aortic valve implantation is not an option: opportunities and recommendations.

PURPOSE OF REVIEW: Transcatheter aortic valve implantation (TAVI) is the recommended treatment for most patients with symptomatic aortic stenosis at high surgical risk. However, TAVI may be clinically futile for patients who have multiple comorbidities and excessive frailty. This group benefits from transition to palliative care to maximize quality of life, improve symptoms, and ensure continuity of health services. We discuss the clinical determination of utility and futility, explore the current evidence guiding the integration of palliative care in procedure-focused cardiac programs, and outline recommendations for TAVI programs. RECENT FINDINGS: The determination of futility of treatment in elderly patients with aortic stenosis is challenging. There is a paucity of research available to guide best practices when TAVI is not an option. Opportunities exist to build on the evidence gained in the management of end of life and heart failure. TAVI programs and primary care providers can facilitate improved communication and processes of care to provide decision support and transition to palliative care. SUMMARY: The increased availability of transcatheter options for the management of valvular heart disease will increase the assessment of people with life-limiting conditions for whom treatment may not be an option. It is pivotal to bridge cardiac innovation and palliation to optimize patient outcomes.

Exploring changes in functional status while waiting for transcatheter aortic valve implantation.

BACKGROUND: Aortic stenosis (AS) is a structural heart disease primarily associated with ageing. For people with multiple co-morbidities, surgical treatment may not be a safe or feasible option. Transcatheter aortic valve implantation (TAVI) is indicated for patients with symptomatic AS who are at excessive risk for surgical valve replacement and are likely to derive significant benefit. Functional status can deteriorate during the time between referral and procedure because of the rapid disease progression of severe AS and varying wait-times for treatment in Canada. AIMS: The purpose of this study was to examine changes in functional status between time of eligibility assessment and TAVI procedure date. METHODS: An exploratory prospective cohort study was conducted to evaluate changes in functional status including gait speed, frailty scores and cognitive status. RESULTS: Thirty-two patients participated in the study with median age 81 years. Functional status declined between time of eligibility assessment and time of TAVI: gait speed increased by an average of 0.53 s (standard deviation (SD)=1.0, p=0.01) and frailty scores increased by an average of 0.31 (SD=0.64, p=0.01). Patients waiting longer than six weeks for TAVI had a larger decline in gait speed than patients waiting less than six weeks (p=0.02). Patients living alone had a larger increase in frailty scores compared to patients living with another adult (p=0.05). CONCLUSION: Older adults with life-limiting AS are vulnerable to changes in functional status. In the absence of TAVI wait-time benchmarks, findings may be used to facilitate individualized care and management strategies and inform health-care policy.

Integrating a palliative approach in a transcatheter heart valve program: bridging innovations in the management of severe aortic stenosis and best end-of-life practice.

Severe aortic stenosis (AS) is the most prevalent structural heart disease and affects primarily older adults in their last decade of life. If the risk for surgery is high, transcatheter aortic valve implantation (TAVI) is the treatment of choice for many patients with suitable anatomy who are likely to derive significant benefit from this innovative and minimally invasive approach. In a large transcatheter heart valve (THV) centre that offers TAVI as one of the treatment options, of 565 consecutive referrals for the assessment of eligibility for TAVI over 18 months, 78 (14%) were deemed unsuitable candidates for TAVI or higher risk surgery by the interdisciplinary Heart Team because of their advanced disease, excessive frailty or comorbid burden. Concerns were raised for patients for whom TAVI is not an option. The integration of a palliative approach in a THV program offers opportunities to adopt best end-of-life practices while promoting innovative approaches for treatment. An integrated palliative approach to care focuses on meeting a patient's full range of physical, psychosocial and spiritual needs at all stages of a life-limiting illness, and is well suited for the severe AS and TAVI population. A series of interventions that reflect best practices and current evidence were adopted in collaboration with the Palliative Care Team and are currently under evaluation in a large TAVI centre. Changes include the introduction of a palliative approach in patient assessment and education, the measurement of symptoms, improved clarity about responsibility for communication and follow-up, and triggering referrals to palliative care services.