A formative evaluation of a nurse practitioner-led interprofessional geriatric outpatient clinic.

The number of older adults with multiple complex comorbidities and frailty is expected to increase dramatically in the coming decades, which will necessitate a concomitant increase in the need for skilled clinicians who are able to manage complex geriatric needs. Many physicians, however, lack the required formal training, often leading to long wait-lists for specialist clinics. Yet, clinics led by non-physician professionals specialising in geriatric care could decrease these delays. This article describes the development and evaluation of a nurse practitioner-led interprofessional geriatric outpatient clinic (Inter-D Clinic). A combination of semi-structured clinician interviews, post-clinic follow-up phone calls, satisfaction surveys, and information from the hospital workload management system served as data sources for this formative programme evaluation. Between January 2013 and December 2014, 293 patients were seen in the clinic with the majority being referred for either memory issues (49%) or functional decline (35%). The clinic assessment frequently uncovered other issues, which led to guidance around falls prevention, improved nutrition, medication management, and referrals to available community supports. Both patients and referring physicians were very satisfied with this model of care, which is likely transferable to other locations provided the needed clinical expertise and community support services are available.

Understanding bladder management on a palliative care unit: a grounded theory study.

BACKGROUND: Research regarding factors associated with nursing-initiated changes to bladder management at end-of-life is sparse. OBJECTIVES: To explore the process of Palliative Care Unit (PCU) nurses' approach to bladder management changes. METHODS: Nursing staff from one PCU in London, Canada were interviewed regarding bladder management care practices. A constructivist grounded theory was generated. RESULTS: Four interconnected themes emerged: humanity (compassionate support of patients); journey (making the most of a finite timeline); health condition (illness, functional decline); and context (orders, policies, supplies). These overlapping themes must be considered in light of ongoing changes which prompt recycling through the framework. While bladder management necessitates shared decision-making and individualised care, nurses' phronetic experience may serve to detect the presence of change and the need to consider other alternatives. CONCLUSION: End-of-life bladder management requires nurses to continually reconsider the significance of humanity, journey, health condition and context in light of ongoing changes.

Taoist Tai Chi® and Memory Intervention for Individuals with Mild Cognitive Impairment.

OBJECTIVE: It was hypothesized that a combined Taoist Tai Chi (TTC) and a memory intervention program (MIP) would be superior to a MIP alone in improving everyday memory behaviors in individuals with amnestic mild cognitive impairment (aMCI). A secondary hypothesis was that TTC would improve cognition, self-reported health status, gait, and balance. METHOD: A total of 48 individuals were randomly assigned to take part in MIP + TTC or MIP alone. The TTC intervention consisted of twenty 90 min sessions. Outcome measures were given at baseline, and after 10 and 22 weeks. RESULTS: Both groups significantly increased their memory strategy knowledge and use, ratings of physical health, processing speed, everyday memory, and visual attention. No preferential benefit was found for individuals in the MIP + TTC group on cognition, gait, or balance measures. CONCLUSIONS: Contrary to expectations, TTC exercise did not specifically improve cognition or physical mobility. Explanations for null findings are explored.

The South West Local Health Integration Network Behavioural Supports Ontario Experience.

Creating a seamless system of care with improved system and patient outcomes is imperative to the estimated 35,000 older adults living with mental health problems and addictions in the South West Local Health Integration Network. Building on existing investments and those offered through the Behavioural Supports Ontario program, strategies to improve system coordination were put in place, cross-sectoral partnerships were fostered, interdisciplinary teams from across the care continuum were linked, and educational opportunities were promoted. This evolving, co-created system has resulted in a decrease in alternate level of care cases among those with behavioural specialized needs and improved client/family perceptions of care. Also, in fiscal year 2014/15, it provided more than 7,000 care providers with learning opportunities.

Creating an Ethnodrama to Catalyze Dialogue in Home-Based Dementia Care.

This article describes the development of a theater script derived from a critical ethnographic study that followed people living with dementia--and their family and professional caregivers--over an 18-month period. Analysis of the ethnographic data yielded four themes that characterized home-based dementia care relationships: managing care resources, making care decisions, evaluating care practices, and reifying care norms. The research team expanded to include a colleague with playwright experience, who used these themes to write a script. A theater director was included to cast and direct the play, and finally, a videography company filmed the actors on a realistic set. To contribute to the qualitative health research and the research-based theater knowledge translation literatures, this article describes and explains the creative decisions taken as part of our effort to disseminate research focused on home-based dementia care in a way that catalyzes and fosters critical (actionable) dialogue.

Correcting the MoCA for education: effect on sensitivity.

OBJECTIVE: The goal of this study was to quantify the impact of the suggested education correction on the sensitivity and specificity of the Montreal Cognitive Assessment (MoCA). METHOD: Twenty-five outpatients with dementia and 39 with amnestic mild cognitive impairment (aMCI) underwent a diagnostic evaluation, which included the MoCA. Thirty-seven healthy controls also completed the MoCA and psychiatric, medical, neurological, functional, and cognitive difficulties were ruled out. RESULTS: For the total MoCA score, unadjusted for education, a cut-off score of 26 yielded the best balance between sensitivity and specificity (80% and 89% respectively) in identifying cognitive impairment (people with either dementia or aMCI, versus controls). When applying the education correction, sensitivity decreased from 80% to 69% for a small specificity increase (89% to 92%). The cut-off score yielding the best balance between sensitivity and specificity for the education adjusted MoCA score fell to 25 (61% and 97%, respectively). CONCLUSIONS: Adjusting the MoCA total score for education had a detrimental effect on sensitivity with only a slight increase in specificity. Clinically, this loss in sensitivity can lead to an increased number of false negatives, as education level does not always correlate to premorbid intellectual function. Clinical judgment about premorbid status should guide interpretation. However, as this effect may be cohort specific, age and education corrected norms and cut-offs should be developed to help guide MoCA interpretation.

An exploration of risk for recurrent falls in two geriatric care settings.

BACKGROUND: Fall events were examined in two distinct geriatric populations to identify factors associated with repeat fallers, and to examine whether patients who use gait aids, specifically a walker, were more likely to experience repeat falls. Each unit already had a generic program for falls prevention in place. METHODS: Secondary data analysis was conducted on information collected during the pilot testing of a new quality assurance Incident Reporting Tool between October 2006 and September 2008. The study settings included an in-patient geriatric rehabilitation unit (GRU) and a long stay veterans' unit (LSVU) in a rehabilitation and long-stay hospital in Ontario. Participants were two hundred and twenty three individuals, aged 65 years or older on these two units, who experienced one or more fall incidents during the study period. RESULTS: Logistic regression analyses showed that on the GRU age was significantly associated with repeat falls. On the LSVU first falls in the morning or late evening were associated with repeat falling. Walker as a gait aid listed at time of first fall was not associated with repeat falls. CONCLUSIONS: This study suggests that different intervention may be necessary in different geriatric settings to identify, for secondary prevention, certain individuals for which the generic programs prove inadequate. Information collection with a specific focus on the issue of repeat falls may be necessary for greater insight.

Effectiveness of Cell-Based Quadrivalent Seasonal Influenza Vaccine: A Systematic Review and Meta-Analysis.

Cell-based seasonal influenza vaccine viruses may more closely match recommended vaccine strains than egg-based options. We sought to evaluate the effectiveness of seasonal cell-based quadrivalent influenza vaccine (QIVc), as reported in the published literature. A systematic literature review was conducted (PROSPERO CRD42020160851) to identify publications reporting on the effectiveness of QIVc in persons aged ≥6 months relative to no vaccination or to standard-dose, egg-based quadrivalent or trivalent influenza vaccines (QIVe/TIVe). Publications from between 1 January 2016 and 25 February 2022 were considered. The review identified 18 relevant publications spanning three influenza seasons from the 2017-2020 period, with an overall pooled relative vaccine effectiveness (rVE) of 8.4% (95% CI, 6.5-10.2%) for QIVc vs. QIVe/TIVe. Among persons aged 4-64 years, the pooled rVE was 16.2% (95% CI, 7.6-24.8%) for 2017-2018, 6.1% (4.9-7.3%) for 2018-2019, and 10.1% (6.3-14.0%) for 2019-2020. For adults aged ≥65 years, the pooled rVE was 9.9% (95% CI, 6.9-12.9%) in the egg-adapted 2017-2018 season, whereas there was no significant difference in 2018-2019. For persons aged 4-64 years, QIVc was consistently more effective than QIVe/TIVe over the three influenza seasons. For persons aged ≥65 years, protection with QIVc was greater than QIVe or TIVe during the 2017-2018 season and comparable in 2018-2019.

Why physicians and nurses ask (or don't) about partner violence: a qualitative analysis.

BACKGROUND: Intimate partner violence (IPV) against women is a serious public health issue and is associated with significant adverse health outcomes. The current study was undertaken to: 1) explore physicians' and nurses' experiences, both professional and personal, when asking about IPV; 2) determine the variations by discipline; and 3) identify implications for practice, workplace policy and curriculum development. METHODS: Physicians and nurses working in Ontario, Canada were randomly selected from recognized discipline-specific professional directories to complete a 43-item mailed survey about IPV, which included two open-ended questions about barriers and facilitators to asking about IPV. Text from the open-ended questions was transcribed and analyzed using inductive content analysis. In addition, frequencies were calculated for commonly described categories and the Fisher's Exact Test was performed to determine statistical significance when examining nurse/physician differences. RESULTS: Of the 931 respondents who completed the survey, 769 (527 nurses, 238 physicians, four whose discipline was not stated) provided written responses to the open-ended questions. Overall, the top barriers to asking about IPV were lack of time, behaviours attributed to women living with abuse, lack of training, language/cultural practices and partner presence. The most frequently reported facilitators were training, community resources and professional tools/protocols/policies. The need for additional training was a concern described by both groups, yet more so by nurses. There were statistically significant differences between nurses and physicians regarding both barriers and facilitators, most likely related to differences in role expectations and work environments. CONCLUSIONS: This research provides new insights into the complexities of IPV inquiry and the inter-relationships among barriers and facilitators faced by physicians and nurses. The experiences of these nurses and physicians suggest that more supports (e.g., supportive work environments, training, mentors, consultations, community resources, etc.) are needed by practitioners. These findings reflect the results of previous research yet offer perspectives on why barriers persist. Multifaceted and intersectoral approaches that address individual, interpersonal, workplace and systemic issues faced by nurses and physicians when inquiring about IPV are required. Comprehensive frameworks are needed to further explore the many issues associated with IPV inquiry and the interplay across these issues.

Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial.

BACKGROUND: Disturbance in the metabolism of tryptophan and tryptophan-derived compounds (e.g., melatonin) may have a role in the pathogenesis of delirium. OBJECTIVE: To evaluate the efficacy of low dose exogenous melatonin in decreasing delirium. DESIGN: A randomized, double-blinded, placebo-controlled study. SETTING: An Internal Medicine service in a tertiary care centre in London, Ontario, Canada. PARTICIPANTS: 145 individuals aged 65 years or over admitted through the emergency department to a medical unit in a tertiary care hospital. INTERVENTION: Patients were randomized to receive either 0.5 mg of melatonin or placebo every night for 14 days or until discharge. MEASUREMENTS: The primary outcome was the occurrence of delirium as determined by Confusion Assessment Method (CAM) criteria. RESULTS: Of a total of 145 individuals (mean age (standard deviation): 84.5 (6.1) years) 72 were randomly assigned to the melatonin group and 73 to the placebo group. Melatonin was associated with a lower risk of delirium (12.0% vs. 31.0%, p = 0.014), with an odds ratio (OR), adjusted for dementia and co-morbidities of 0.19 (95% confidence intervals (CI): 0.06-0.62). Results were not different when patients with prevalent delirium were excluded. LIMITATION: An intention to treat analysis was not possible due to loss to follow-up. CONCLUSION: Exogenous low dose melatonin administered nightly to elderly patients admitted to acute care may represent a potential protective agent against delirium.

Collaborative Development of an Older Adult Experience Survey for Specialized Geriatric Services.

BACKGROUND: While generic, site, and disease-specific patient experience surveys exist, such surveys have limited relevance to frail, medically complex older adults attending appointment-based specialized geriatric services (SGS). The study objective was to develop and evaluate a patient experience survey specific to this population. METHODS: Using established survey research methods, this study was conducted collaboratively with older adults (patients and family members/friends) at three Ontario sites offering SGS. The study was done in three phases: Phase One-literature review, evidence alignment, and operationalization of core survey items; Phase Two-cognitive interviews and refinement; and Phase Three-pilot testing, survey item analysis, and refinement. RESULTS: Based on an evidence-informed framework, the "Older Adult Experience Survey" includes 12 core items, two global rating items, two open-ended questions, and two demographic questions. The summed 12 core items demonstrated acceptable internal consistency (Cronbach's alpha: 0.83), and the correlation between the summed score and a global question was 0.59, providing evidence of construct validity. The survey also demonstrated face and content validity. CONCLUSION: This open access, collaboratively developed, psychometrically sound patient experience survey can be used to assess, then improve, the clinical experience and quality of care of older adults attending appointment-based SGS clinics/programs.

Quantitative gait analysis under dual-task in older people with mild cognitive impairment: a reliability study.

BACKGROUND: Reliability of quantitative gait assessment while dual-tasking (walking while doing a secondary task such as talking) in people with cognitive impairment is unknown. Dual-tasking gait assessment is becoming highly important for mobility research with older adults since better reflects their performance in the basic activities of daily living. Our purpose was to establish the test-retest reliability of assessing quantitative gait variables using an electronic walkway in older adults with mild cognitive impairment (MCI) under single and dual-task conditions. METHODS: The gait performance of 11 elderly individuals with MCI was evaluated using an electronic walkway (GAITRite System) in two sessions, one week apart. Six gait parameters (gait velocity, step length, stride length, step time, stride time, and double support time) were assessed under two conditions: single-task (sG: usual walking) and dual-task (dG: counting backwards from 100 while walking). Test-retest reliability was determined using intra-class correlation coefficient (ICC). Gait variability was measured using coefficient of variation (CoV). RESULTS: Eleven participants (average age = 76.6 years, SD = 7.3) were assessed. They were high functioning (Clinical Dementia Rating Score = 0.5) with a mean Mini-Mental Status Exam (MMSE) score of 28 (SD = 1.56), and a mean Montreal Cognitive Assessment (MoCA) score of 22.8 (SD = 1.23). Under dual-task conditions, mean gait velocity (GV) decreased significantly (sGV = 119.11 +/- 20.20 cm/s; dGV = 110.88 +/- 19.76 cm/s; p = 0.005). Additionally, under dual-task conditions, higher gait variability was found on stride time, step time, and double support time. Test-retest reliability was high (ICC>0.85) for the six parameters evaluated under both conditions. CONCLUSION: In older people with MCI, variability of time-related gait parameters increased with dual-tasking suggesting cognitive control of gait performance. Assessment of quantitative gait variables using an electronic walkway is highly reliable under single and dual-task conditions. The presence of cognitive impairment did not preclude performance of dual-tasking in our sample supporting that this methodology can be reliably used in cognitive impaired older individuals.

Introduction of solid foods: do mothers follow recommendations?

PURPOSE: Infant age at introduction of solid foods was examined, as were maternal characteristics associated with adherence to recommendations. METHODS: In a telephone survey, 2153 mothers living in Ontario were asked questions about the age at which foods were introduced to their infants. RESULTS: Eighteen percent of respondents introduced infant cereal before age four months, while 5% introduced it at age seven months or later. Mothers who introduced cereal either earlier or later than recommended had a lower household income and were less likely to have attended prenatal classes than were those who followed recommendations. Mothers who introduced cereal before their infants were four months old were more likely than were other mothers to be younger, not to be breastfeeding at three months, to have smoked during pregnancy, and to have someone who smoked inside the home. Mothers who introduced infant cereal after age seven months were more likely to be older, breastfeeding at three months, and mothering their second or later-born child than were mothers who introduced infant cereal as recommended. CONCLUSIONS: Small but distinct groups of mothers are introducing solid foods earlier or later than recommended. Educational and informational initiatives that target these parents may help increase the number of infants being fed as recommended.

Disparities in health outcomes among seniors without a family physician in the North West Local Health Integration Network: a retrospective cohort study.

BACKGROUND: The relationship between having a family physician and in-hospital and postdischarge health outcomes among older adults is unclear. We ascertained the proportion of seniors who did not have a family physician and were admitted to an Ontario tertiary care centre, and we determined the association between having/not having a family physician and in-hospital mortality, 1-year mortality and readmission after live discharge. METHODS: This was a retrospective cohort study of community-dwelling seniors who were admitted to a medical service at Thunder Bay Regional Health Sciences Centre. We conducted regression analyses adjusted for demographic factors, prior health care utilization, and factors associated with the index admission to determine the association between family physician status and the study outcomes. RESULTS: Among the 12 033 seniors admitted to hospital between Apr. 1, 2004, and Mar. 31, 2013, 40.7% lacked a family physician. Among those without a family physician, 8.0% (390/4899) died during the index admission and 15.8% (714/4509) died in the subsequent year. Adjusted regression models showed that not having a family physician was significantly associated with in-hospital mortality (odds ratio 1.56, 95% confidence interval [CI] 1.33-1.83). Regression models of all-cause 1-year mortality and readmission also suggested that lack of a family physician was associated with detrimental health outcomes (hazard ratio 1.14, 95% CI 1.04-1.26; subdistribution hazard ratio 1.17, 95% CI 1.10-1.24, respectively). INTERPRETATION: Elders without family physicians were disadvantaged during their hospital admission as well as in the subsequent year. Additional interventions aimed at increasing the proportion of seniors admitted to hospital who are connected with a family physician are warranted.

Staff opinions about the components of a good death in long-term care.

AIM: The aim of this study was to identify differences of opinion about the relative importance of different components of a good death among care providers in a long-term care home serving Canadian war veterans. METHODS: The Concept of a Good Death scale (Swartz et al, 2003), with slight adaptations to fit the long-term care context, was made available to all staff. Responses were accepted for a one-month period. FINDINGS: Survey return rate was 30.4%. There was a majority (greater than 50%) opinion that 12 of the 20 items were essential or important to a good death, and that three items were not necessary: 'that death is sudden and unexpected' (64.5%), 'that there be control of bodily functions to the end' (61.8%) and 'that there be mental alertness to the end' (55.3%). There was not a majority opinion on the five remaining items: 'that the dying period be short', 'that death occurs naturally without technical equipment', 'that the person lived until a key event', 'that the ability to communicate be present until death', and 'that death occurs during sleep'. CONCLUSIONS: Detailed analysis of survey results identified differences of opinion that could have implications for consistency and quality of care. The findings suggest ways in which the unique characteristics of the long-term care environment and population influence opinions about the components of a good death.

Geriatric Cooperatives in Southwestern Ontario: A novel way of increasing inter-sectoral partnerships in the care of older adults with responsive behaviours.

Established in 2010, Geriatric Cooperatives support the evolving Behavioural Supports Ontario (BSO) programme in the South West Local Health Integration Network. Geriatric Cooperatives bring together members representing relevant cross-sectoral services and are tasked with identifying system gaps associated with the BSO target population as well as developing work plans specific to their local area, leveraging local capacity, and co-ordinating and improving linkages between sectors and services. The purpose of this study was to evaluate the partnerships formed over time within these Cooperatives in order to inform their ongoing development and sustainability. In 2012 and in 2015, Geriatric Cooperative members were invited to complete the Partnership Self-Assessment Tool (PSAT), a valid and reliable tool for evaluating collaborative processes and identifying areas in need of improvement. Scoring the PSAT involves the calculation of mean scores (ranging from 1 to 5) for each of six dimensions describing effective collaboration; higher mean scores reflect better functioning. Two psychometrically sound versions of the PSAT exist; the shorter version (PSAT-S) scores fewer items in three dimensions. Survey response rates for the three Cooperatives that were evaluated in both 2012 and 2015 were 70% in 2012 and 36% in 2015; 57% of members who completed the survey in 2015 were new Cooperative members. Both years, more than 25% of respondents selected "don't know" for three of the nine items used to score the administration and management dimension. Both PSAT and PSAT-S mean dimension scores across both years reflected that more effort is needed to maximise collaborative potential. Use of the PSAT has promoted a better understanding of how partnerships are functioning. Knowledge of where more work is required along with effective strategies to overcome weak areas and gaps in functioning has the potential to ensure that these Cooperatives are successful.

Inter-Rater Reliability of the Retrospectively Assigned Clinical Frailty Scale Score in a Geriatric Outreach Population.

BACKGROUND: Frailty, a common clinical syndrome in older adults associated with increased risk of poor health outcomes, has been retrospectively calculated in previous publications; however, the reliability of retrospectively assigned frailty scores has not been established. The aim of this study was to see if frailty scores, based on chart review data, agreed with clinician-determined scores based on a comprehensive geriatric assessment. METHODS: Per standard practice, all patients seen by one nurse clinician (JW) from the Southwestern Ontario Regional Geriatric Program, a tertiary care-based outreach service, between August 15, 2013 and December 31, 2015 received a comprehensive geriatric assessment which included the assignment of an interview-based Clinical Frailty Scale score (CFS-I). Subsequently, a medical student researcher (JD), blinded to the CFS-I, assigned each consenting patient a frailty score based on chart review data (CFS-C). The inter-rater reliability of the CFS-I and CFS-C was then determined. RESULTS: Of the 41 consented patients, 39 had both a CFS-I and CFSC score. The median CFS score was 6, indicating patients were moderately frail and required assistance for some basic activities of daily living. Cohen's kappa coefficient was 0.64, indicating substantial agreement. CONCLUSION: CFS scores can be reliably assigned retrospectively, thereby strengthening the utility of this measure.

Automated Fall Detection Technology in Inpatient Geriatric Psychiatry: Nurses' Perceptions and Lessons Learned.

ABSTRACTHospitalized older adults are at high risk of falling. The HELPER system is a ceiling-mounted fall detection system that sends an alert to a smartphone when a fall is detected. This article describes the performance of the HELPER system, which was pilot tested in a geriatric mental health hospital. The system's accuracy in detecting falls was measured against the hospital records documenting falls. Following the pilot test, nurses were interviewed regarding their perceptions of this technology. In this study, the HELPER system missed one documented fall but detected four falls that were not documented. Although sensitivity (.80) of the system was high, numerous false alarms brought down positive predictive value (.01). Interviews with nurses provided valuable insights based on the operation of the technology in a real environment; these and other lessons learned will be particularly valuable to engineers developing this and other health and social care technologies.

Factors influencing identification of and response to intimate partner violence: a survey of physicians and nurses.

BACKGROUND: Intimate partner violence against women (IPV) has been identified as a serious public health problem. Although the health care system is an important site for identification and intervention, there have been challenges in determining how health care professionals can best address this issue in practice. We surveyed nurses and physicians in 2004 regarding their attitudes and behaviours with respect to IPV, including whether they routinely inquire about IPV, as well as potentially relevant barriers, facilitators, experiential, and practice-related factors. METHODS: A modified Dillman Tailored Design approach was used to survey 1000 nurses and 1000 physicians by mail in Ontario, Canada. Respondents were randomly selected from professional directories and represented practice areas pre-identified from the literature as those most likely to care for women at the point of initial IPV disclosure: family practice, obstetrics and gynecology, emergency care, maternal/newborn care, and public health. The survey instrument had a case-based scenario followed by 43 questions asking about behaviours and resources specific to woman abuse. RESULTS: In total, 931 questionnaires were returned; 597 by nurses (59.7% response rate) and 328 by physicians (32.8% response rate). Overall, 32% of nurses and 42% of physicians reported routinely initiating the topic of IPV in practice. Principal components analysis identified eight constructs related to whether routine inquiry was conducted: preparedness, self-confidence, professional supports, abuse inquiry, practitioner consequences of asking, comfort following disclosure, practitioner lack of control, and practice pressures. Each construct was analyzed according to a number of related issues, including clinician training and experience with woman abuse, area of practice, and type of health care provider. Preparedness emerged as a key construct related to whether respondents routinely initiated the topic of IPV. CONCLUSION: The present study provides new insight into the factors that facilitate and impede clinicians' decisions to address the issue of IPV with their female patients. Inadequate preparation, both educational and experiential, emerged as a key barrier to routine inquiry, as did the importance of the "real world" pressures associated with the daily context of primary care practice.