Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis.

BACKGROUND: Chronic non-cancer pain is common among older residents of long-term care (LTC) homes and often poorly recognized and treated. With heightened concerns regarding opioid prescribing in recent years, it is important to examine the current prevalence of opioid use and its association with resident characteristics to help identify those potentially at risk of medication harms as well as suboptimal pain management. OBJECTIVES: The aims were to estimate the prevalence and correlates of opioid use among non-palliative LTC residents and explore variation in opioid prevalence and correlates across strata defined by pain frequency and intensity. METHODS: We conducted a population-based cross-sectional study of all older (aged > 65 years) LTC residents (excluding those with cancer or receiving palliative care) in Ontario, Canada during 2018-2019. Health administrative databases were linked with standardized clinical assessment data to ascertain residents' health and pain characteristics and their opioid and other medication use. Modified Poisson regression models estimated unadjusted and adjusted associations between residents' characteristics and opioid use, overall and across strata capturing pain frequency and intensity. RESULTS: Among 75,020 eligible residents (mean age 85.1 years; 70% female), the prevalence of opioid use was 18.5% and pain was 29.4%. Opioid use ranged from 12.2% for residents with no current pain to 55.7% for those with severe pain. In adjusted models, residents newly admitted to LTC (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI] 0.57-0.62) and with moderate to severe cognitive impairment (aRR = 0.69, 95% CI 0.66-0.72) or dementia (aRR = 0.76, 95% CI 0.74-0.79) were significantly less likely to receive an opioid, whereas residents with select conditions (e.g., arthritis, aRR = 1.37, 95% CI 1.32-1.41) and concurrently using gabapentinoids (aRR = 1.80, 95% CI 1.74-1.86), benzodiazepines (aRR = 1.33, 95% CI 1.28-1.38), or antidepressants (aRR = 1.31, 95% CI 1.27-1.35) were significantly more likely to receive an opioid. The associations observed for residents newly admitted, with dementia, and concurrently using gabapentinoids, benzodiazepines, or antidepressants were largely consistent across all pain strata. CONCLUSIONS: Our findings describe resident sub-groups at potentially higher risk of adverse health outcomes in relation to both opioid use and non-use. LTC clinical and policy changes informed by research are required to ensure the appropriate recognition and management of non-cancer pain in this setting.

Integration of a Palliative Approach in the Care of Older Adults with Dementia in Primary Care Settings: A Scoping Review.

A palliative approach to care aims to meet the needs of patients and caregivers throughout a chronic disease trajectory and can be delivered by non-palliative specialists. There is an important gap in understanding the perspectives and experiences of primary care providers on an integrated palliative approach in dementia care and the impact of existing programs and models to this end. To address these, we undertook a scoping review. We searched five databases; and used descriptive numerical summary and narrative synthesizing approaches for data analysis. We found that: (1) difficulty with prognostication and a lack of interdisciplinary and intersectoral collaboration are obstacles to using a palliative approach in primary care; and (2) a palliative approach results in statistically and clinically significant impacts on community-dwelling individuals, specifically those with later stages of dementia. There is a need for high-quality research studies examining the integrated palliative approach models and initiation of these models sooner in the care trajectory for persons living with mild and moderate stages of dementia in the community.

Health and social interventions to restore physical function of older adults post-hip fracture: a scoping review.

OBJECTIVES: Despite inpatient rehabilitation, many older adults post-hip fracture have difficulty returning to their prefracture levels of function and activity. This scoping review aims to identify interventions for community-dwelling older adults discharged from inpatient rehabilitation and examine the function and activity outcomes associated with these interventions. DESIGN: This scoping review followed Arksey and O'Malley's five-stage framework. DATA SOURCES: We searched MEDLINE, CINAHL, PsycINFO, EMBASE and Ageline electronic databases for English-language articles published between January 1946 and January 2020. ELIGIBILITY CRITERIA: We included studies with health and social interventions involving community-dwelling older adults and their caregivers after hip fracture and inpatient rehabilitation. The interventions were selected if initiated within 60 days post-hip fracture surgery. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened abstracts and full texts and extracted the data based on the inclusion criteria. A third reviewer adjudicated any disagreement and collated the extracted data. RESULTS: Of the 24 studies included in the review, most studies (79%) used exercise-based interventions, over half (63%) included activities of daily living training and/or home assessment and environment modification as intervention components, and three studies used social intervention components. Over half of the interventions (58%) were initiated in the inpatient setting and physiotherapists provided 83% of the interventions. Only seven studies (29%) involved tailored interventions based on the older adults' unique needs and progress in exercise training. Six studies (25%) enrolled patients with cognitive impairment, and only one study examined caregiver-related outcomes. Exercise-based interventions led to improved function and activity outcomes. 29 different outcome measures were reported. CONCLUSION: While exercise-based multicomponent interventions have evidence for improving outcomes in this population, there is a paucity of studies, including social interventions. Further, studies with standardised outcome measures are needed, particularly focusing on supporting caregivers and the recovery of older adults with cognitive impairment.

A Palliative Approach to Falls in Advanced Dementia.

Falls are viewed as a preventable cause of injury, functional loss, and death in older adults with dementia, and have been used as a marker of quality of care in long-term care facilities. Despite intensive intervention around fall prevention in these settings, falls and injury remain frequent, particularly among residents in the advanced stages of dementia. In this clinical review, we consider the common challenges and pitfalls in both the management of falls and the provision of palliative care in advanced dementia. We then describe a palliative approach to falls in advanced dementia that involves identifying individuals who would benefit from this care approach, framing falls and loss of mobility as a quality of life issue, and devising an individualized symptom assessment and management plan. A palliative approach can lead to recognition and acceptance that recurrent falls are often symptomatic of advanced dementia, and that not all falls are preventable. We conclude that falls in the advanced stage of dementia can be sentinel events indicating the need for a palliative approach to care. Rather than replace falls prevention activities, a palliative approach to falls prompts us to select dementia stage-appropriate interventions with a focus on symptom management, comfort, and dignity.

Potentially Inappropriate Medications and the Time to Full Functional Recovery After Hip Fracture.

BACKGROUND: Older adults after hip fracture are at increased risk of being prescribed potentially inappropriate medications, and may be particularly vulnerable to their adverse effects. OBJECTIVE: The objective of this study was to examine the association of potentially inappropriate medication use with the time to full functional recovery within 1 year of hip fracture repair. METHODS: We conducted a secondary analysis of a prospective longitudinal study of eight hospitals in St. Louis, MO, USA. The participants were older adults (n = 477) aged 60 years or older who had undergone surgical repair of a hip fracture free of delirium, dementia or depression at baseline. Drugs at baseline were categorised using the American Geriatrics Society 2012 Beers criteria. The outcome was the Functional Recovery Scale total score measured at four time points during a 12-month period of observation. Cox proportional hazards models examined the time to 95% recovery of function ('full recovery'), adjusting for demographics, cognition, depression, medical co-morbidity, pre-fracture functioning and pain as covariates. RESULTS: Potentially inappropriate medication use was common following hip fracture, with 51% of participants prescribed at least one potentially inappropriate medication and 17.4% prescribed two or more potentially inappropriate medications. Potentially inappropriate medication use was significantly associated with a longer time to achieve full recovery with a hazard ratio of 0.69 (95% confidence interval 0.52-0.92; p = 0.012) and this association was stronger for two or more potentially inappropriate medications compared with one potentially inappropriate medication (hazard ratio = 0.60; 95% confidence interval 0.40-0.90; p = 0.014). CONCLUSION: Potentially inappropriate medication use was associated with a longer time to full functional recovery in older adults who underwent surgery for a hip fracture, particularly in those using two or more potentially inappropriate medications at baseline.

Changing Pattern of Sedative Use in Older Adults: A Population-Based Cohort Study.

BACKGROUND: Benzodiazepine medications have well-documented side effects, and their prescription rates in older adults have been declining. Trazodone and quetiapine are medications with sedative properties when used at low doses and are commonly used off-label for sleep or behavioral symptoms in older adults. OBJECTIVE: Our objective was to describe the shifting patterns of sedative prescription in older adults over time by comparing changes in benzodiazepine, trazodone, and quetiapine dispensing between community and long-term care settings. METHODS: We conducted a population-based serial cross-sectional study to compare the patterns of sedative dispensing (specifically, benzodiazepines, trazodone, and quetiapine) to individuals aged ≥66 years between 1 January 2002 and 31 March 2013 in Ontario, Canada. We compared rates of use between long-term care and community settings and used linear regression models to characterize the magnitude and direction of the rate of change in sedative use by age, sex, and dementia status. RESULTS: The dispensing of trazodone and quetiapine increased over time, and this coincided with a decrease in benzodiazepine dispensing. This pattern was particularly apparent in the oldest cohort and in those with dementia. Benzodiazepines, trazodone, and quetiapine were associated with high rates of psychotropic polypharmacy. Overall trends were similar in long-term care and the community. CONCLUSIONS: While benzodiazepine prescribing is declining among older adults in Ontario over time, there is a corresponding shift towards low-dose, off-label prescribing of trazodone and quetiapine and psychotropic polypharmacy. These prescribing trends highlight sedative substitution and reinforce the need to confirm efficacy and safety of this practice.

Initiation of Antidepressant Medication After Hip Fracture in Community-Dwelling Older Adults.

OBJECTIVE: To evaluate the incidence, characteristics, and correlates of antidepressant drug therapy initiation among community-dwelling older adults following hip fracture. DESIGN: Retrospective cohort study using linked, population-based administrative data. SETTING: Province of Ontario, Canada. PARTICIPANTS: Older adults, aged 65 years or older, with a hip fracture and hip fracture surgery between April 1, 2003, and February 28, 2011. The study sample was restricted to individuals who returned home following surgery and who had not been dispensed an antidepressant in the year prior to their fracture (N=25,436). MEASUREMENTS: We determined the incidence of new antidepressant use defined by the dispensing of antidepressant drug therapy within 90 days of discharge home. We identified independent correlates of antidepressant initiation using multivariate regression. RESULTS: Overall, antidepressants were newly initiated in 8.8% of older adults with hip fracture in the 90 days following hospital discharge. There was a statistically significant, 1.3-fold increase in incidence of antidepressant prescribing from 2003 to 2010. Trazodone, frequently prescribed at a low dose, accounted for 39.0% of newly dispensed antidepressants, followed by selective serotonin reuptake inhibitors (36.9%). Rehabilitation admission, psychiatric evaluation, a diagnosis of dementia, and baseline benzodiazepine use were the strongest independent correlates of antidepressant initiation. CONCLUSION: The period after a hip fracture is associated with a high rate of initiation of antidepressant therapy. The data raise the possibility that antidepressants are frequently prescribed off-label in these patients. Further research is needed to investigate the safety and efficacy of antidepressant use in this vulnerable population.

Fatigue in systemic lupus erythematosus: contributions of disordered sleep, sleepiness, and depression.

OBJECTIVE: To clarify the role of sleep disorders, sleepiness, and depression in patients with systemic lupus erythematosus (SLE) who complain of disabling tiredness. METHODS: Patients with SLE (31 women, 4 men) with disabling tiredness were evaluated with the Epworth Sleepiness Scale (ESS) and overnight polysomnography, followed by daytime multiple sleep latency tests (MSLT) and the Beck Depression Inventory (BDI). Their polysomnography was compared with 17 healthy, asymptomatic controls. RESULTS: Polysomnography of the patients in comparison with healthy controls showed impaired sleep efficiency (p < 0.02), high arousal frequencies (p < 0.01), increased stage 1 sleep (p < 0.02), decreased stage 3/4 slow-wave sleep (p < 0.02), and a high percentage (77% of patients) with increased alpha-EEG non-REM sleep. In 23% of patients periodic limb movement (PLM) disorder was observed (mean PLM index 31.1 +/- 15); 26% of patients had obstructive sleep apnea (mean apnea/hypopnea index 19.3 +/- 10), and one patient had narcolepsy-cataplexy. Remarkably, 51% of patients were excessively sleepy on both the ESS and MSLT (mean sleep latency < 10 min). This excessive daytime sleepiness was not related to sleep restriction. There was no association between sleepiness and SLE disease features such as neuropsychiatric SLE, medications, fibromyalgia, or disease activity. As a whole, the study group reported mild to moderate depression (mean BDI = 15.8 +/- 9.9). Within the group, the sleepy patients had lower BDI scores than the non-sleepy patients (p < 0.02), and fewer of the sleepy patients were depressed (p < 0.04). CONCLUSION: Primary sleep disorders, sleepiness, and depression are common in tired SLE patients. Tiredness in SLE that is the result of excessive daytime sleepiness can be distinguished from tiredness of depression. Such distinctions will help identify appropriate treatment for tired patients with SLE.

The interaction properties of costimulatory molecules revisited.

B7-1 and B7-2 are generally thought to have comparable structures and affinities for their receptors, CD28 and CTLA-4, each of which is assumed to be bivalent. We show instead (1) that B7-2 binds the two receptors more weakly than B7-1, (2) that, relative to its CTLA-4 binding affinity, B7-2 binds CD28 2- to 3-fold more effectively than B7-1, (3) that, unlike B7-1, B7-2 does not self-associate, and (4) that, in contrast to CTLA-4 homodimers, which are bivalent, CD28 homodimers are monovalent. Our results indicate that B7-1 markedly favors CTLA-4 over CD28 engagement, whereas B7-2 exhibits much less bias. We propose that the distinct structures and binding properties of B7-1 and B7-2 account for their overlapping but distinct effects on T cell responses.