Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study.

BACKGROUND: Health system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada. METHODS: Group concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan. RESULTS: Forty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument's ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance. CONCLUSIONS: Many person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.

Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life.

BACKGROUND: Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals. METHODS: Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life. RESULTS: Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04). CONCLUSIONS: Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.

High-intensity exercise does not protect against orthostatic intolerance following bedrest in 55- to 65-yr-old men and women.

Prolonged bedrest provokes orthostatic hypotension and intolerance of upright posture. Limited data are available on the cardiovascular responses of older adults to head-up tilt following bedrest, with no studies examining the potential benefits of exercise to mitigate intolerance in this age group. This randomized controlled trial of head-down bedrest (HDBR) in 55- to 65-yr-old men and women investigated if exercise could avert post-HDBR orthostatic intolerance. Twenty-two healthy older adults (11 female) underwent a strict 14-day HDBR and were assigned to either an exercise (EX) or control (CON) group. The exercise intervention included high-intensity, aerobic, and resistance exercises. Head-up tilt-testing to a maximum of 15 minutes was performed at baseline (Pre-Bedrest) and immediately after HDBR (R1), as well as 6 days (R6) and 4 weeks (R4wk) later. At Pre-Bedrest, three participants did not complete the full 15 minutes of tilt. At R1, 18 did not finish, with no difference in tilt end time between CON (422 ± 287 s) and EX (409 ± 346 s). No differences between CON and EX were observed at R6 or R4wk. At R1, just 1 participant self-terminated the test with symptoms, while 12 others reported symptoms only after physiological test termination criteria were reached. Finishers on R1 protected arterial pressure with higher total peripheral resistance relative to Pre-Bedrest. Cerebral blood velocity decreased linearly with reductions in arterial pressure, end-tidal CO2, and cardiac output. High-intensity interval exercise did not benefit post-HDBR orthostatic tolerance in older adults. Multiple factors were associated with the reduction in cerebral blood velocity leading to intolerance.

External validation of the hospital frailty risk score among hospitalised home care clients in Canada: a retrospective cohort study.

BACKGROUND: The Hospital Frailty Risk Score (HFRS) is scored using ICD-10 diagnostic codes in administrative hospital records. Home care clients in Canada are routinely assessed with Resident Assessment Instrument-Home Care (RAI-HC) which can calculate the Clinical Frailty Scale (CFS) and the Frailty Index (FI). OBJECTIVE: Measure the correlation between the HFRS, CFS and FI and compare prognostic utility for frailty-related outcomes. DESIGN: Retrospective cohort study. SETTING: Alberta, British Columbia and Ontario, Canada. SUBJECTS: Home care clients aged 65+ admitted to hospital within 180 days (median 65 days) of a RAI-HC assessment (n = 167,316). METHODS: Correlation between the HFRS, CFS and FI was measured using the Spearman correlation coefficient. Prognostic utility of each measure was assessed by comparing measures of association, discrimination and calibration for mortality (30 days), prolonged hospital stay (10+ days), unplanned hospital readmission (30 days) and long-term care admission (1 year). RESULTS: The HFRS was weakly correlated with the FI (ρ 0.21) and CFS (ρ 0.28). Unlike the FI and CFS, the HFRS was unable to discriminate for 30-day mortality (area under the receiver operator characteristic curve (AUC) 0.506; confidence interval (CI) 0.502-0.511). It was the only measure that could discriminate for prolonged hospital stay (AUC 0.666; CI 0.661-0.673). The HFRS operated like the FI and CFI when predicting unplanned readmission (AUC 0.530 CI 0.526-0.536) and long-term care admission (AUC 0.600; CI 0.593-0.606). CONCLUSIONS: The HFRS identifies a different subset of older adult home care clients as frail than the CFS and FI. It has prognostic utility for several frailty-related outcomes in this population, except short-term mortality.

The association between frailty, long-term care home characteristics and COVID-19 mortality before and after SARS-CoV-2 vaccination: a retrospective cohort study.

BACKGROUND: The relative contributions of long-term care (LTC) resident frailty and home-level characteristics on COVID-19 mortality has not been well studied. We examined the association between resident frailty and home-level characteristics with 30-day COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination in LTC. METHODS: We conducted a population-based retrospective cohort study of LTC residents with confirmed SARS-CoV-2 infection in Ontario, Canada. We used multi-level multivariable logistic regression to examine associations between 30-day COVID-19 mortality, the Hubbard Frailty Index (FI), and resident and home-level characteristics. We compared explanatory models before and after vaccine availability. RESULTS: There were 11,179 and 3,655 COVID-19 cases in the pre- and post-vaccine period, respectively. The 30-day COVID-19 mortality was 25.9 and 20.0% during the same periods. The median odds ratios for 30-day COVID-19 mortality between LTC homes were 1.50 (95% credible interval [CrI]: 1.41-1.65) and 1.62 (95% CrI: 1.46-1.96), respectively. In the pre-vaccine period, 30-day COVID-19 mortality was higher for males and those of greater age. For every 0.1 increase in the Hubbard FI, the odds of death were 1.49 (95% CI: 1.42-1.56) times higher. The association between frailty and mortality remained consistent in the post-vaccine period, but sex and age were partly attenuated. Despite the substantial home-level variation, no home-level characteristic examined was significantly associated with 30-day COVID-19 mortality during either period. INTERPRETATION: Frailty is consistently associated with COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination. Home-level characteristics previously attributed to COVID-19 outcomes do not explain significant home-to-home variation in COVID-19 mortality.

Frailty prevalence and efficient screening in primary care-based memory clinics.

BACKGROUND: Little is known about the prevalence of frailty among patients with memory concerns attending a primary care-based memory clinic. OBJECTIVE: This study aims to describe the prevalence of frailty among patients attending a primary care-based memory clinic and to determine if prevalence rates differ based on the screening tool that is used. METHODS: We conducted a retrospective medical record review for all consecutive patients assessed in a primary care-based memory clinic over 8 months. Frailty was measured in 258 patients using the Fried frailty criteria, which relies on physical measures, and the Clinical Frailty Scale (CFS), which relies on functional status. Weighted kappa statistics were calculated to compare the Fried frailty and the CFS. RESULTS: The prevalence of frailty was 16% by Fried criteria and 48% by the CFS. Agreement between Fried frailty and CFS was fair for CFS 5+ (kappa = 0.22; 95% confidence interval: 0.13, 0.32) and moderate for CFS 6+ (kappa = 0.47; 0.34, 0.61). Dual-trait measures of hand grip strength with gait speed were found to be a valid proxy for Fried frailty phenotype. CONCLUSIONS: Among primary care patients with memory concerns, frailty prevalence rates differed based on the measure used. Screening for frailty in this population using measures relying on physical performance may be a more efficient approach for persons already at risk of further health instability from cognitive impairment. Our findings demonstrate how measure selection should be based on the objectives and context in which frailty screening occurs.

There is some evidence that frailty and dementia are inter-related. This study aimed to describe the prevalence of frailty among patients attending a primary care-based memory clinic using 2 commonly used frailty measures: the Fried frailty phenotype criteria and the Clinical Frailty Scale (CFS). Frailty prevalence in patients with memory concerns is at least double that of regular primary care practice; prevalence is 16% when the Fried frailty phenotype is used, which incorporates physical frailty measures, as compared with prevalence of 48% when the more function-based measure of CFS is used. Screening tools should be selected considering the objectives and context in which they are used. Within primary care-based memory clinics, physical frailty measures may be most optimal. Using hand grip and gait speed screening as a valid proxy for Fried frailty phenotype offers a feasible and practical way of identifying frailty relating more to physical underlying conditions. Based on our study findings, frailty screening within primary care-based memory clinics is justified for patients 65 years+; early identification and intervention may prevent further decline and adverse outcomes. Further research in this area will increase our understanding of frailty and dementia in this context and how to best plan care.

Predictors of improvement in urinary incontinence in the postacute setting: A Canadian cohort study.

PURPOSE: To determine factors associated with improvement in urinary incontinence (UI) for long-stay postacute, complex continuing care (CCC) patients. DESIGN: A retrospective cohort investigation of patients in a CCC setting using data obtained from the Canadian Institute for Health Information's Continuing Care Reporting System collected with interRAI Minimum Data Set 2.0. SETTING AND PARTICIPANTS: Individuals aged 18 years and older, were admitted to CCC hospitals in Ontario, Canada, between 2010 and 2018. METHODS: Multivariable logistic regression was used to determine the independent effects of predictors on UI improvement, for patients who were somewhat or completely incontinent on admission and therefore had the potential for improvement. RESULTS: The study cohort consisted of 18 584 patients, 74% (13 779) of which were somewhat or completely incontinent upon admission. Among those patients with potential for improvement, receiving bladder training, starting a new medication 90 days prior (odds ratio, OR: 1.54 [95% confidence interval, CI: 1.36-1.75]), and triggering the interRAI Urinary Incontinence Clinical Assessment Protocol to facilitate improvement (OR: 1.36 [95% CI: 1.08-1.71]) or to prevent decline (OR: 1.32 [95% CI: 1.13-1.53]) were the strongest predictors of improvement. Conversely, being totally dependent on others for transfer (OR: 0.62 [95% CI: 0.42-0.92]), is rarely or never understood (OR: 0.65 [95% CI: 0.50-0.85]), having a major comorbidity count of ≥3 (OR: 0.72 [95% CI: 0.59-0.88]), Parkinson's disease, OR: 0.77 (95% CI: 0.62-0.95), Alzheimer/other dementia, OR: 0.83 (95% CI: 0.74-0.93), and respiratory infections, OR: 0.57 (95% CI: 0.39-0.85) independently predicted less likelihood of improvement in UI. CONCLUSIONS AND IMPLICATIONS: Findings of this study suggest that improving physical function, including bed mobility, and providing bladder retraining have strong positive impacts on improvement in UI for postacute care patients. Evidence generated from this study provides useful care planning information for care providers in identifying patients and targeting the care that may lead to better success with the management of UI.

BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial.

BACKGROUND: Nursing home (NH) residents should have the opportunity to consider, discuss and document their healthcare wishes. However, such advance care planning (ACP) is frequently suboptimal. OBJECTIVE: Assess a comprehensive, person-centred ACP approach. DESIGN: Unblinded, cluster randomised trial. SETTING: Fourteen control and 15 intervention NHs in three Canadian provinces, 2018-2020. SUBJECTS: 713 residents (442 control, 271 intervention) aged ≥65 years, with elevated mortality risk. METHODS: The intervention was a structured, $\sim$60-min discussion between a resident, substitute decision-maker (SDM) and nursing home staff to: (i) confirm SDMs' identities and role; (ii) prepare SDMs for medical emergencies; (iii) explain residents' clinical condition and prognosis; (iv) ascertain residents' preferred philosophy to guide decision-making and (v) identify residents' preferred options for specific medical emergencies. Control NHs continued their usual ACP processes. Co-primary outcomes were: (a) comprehensiveness of advance care planning, assessed using the Audit of Advance Care Planning, and (b) Comfort Assessment in Dying. Ten secondary outcomes were assessed. P-values were adjusted for all 12 outcomes using the false discovery rate method. RESULTS: The intervention resulted in 5.21-fold higher odds of respondents rating ACP comprehensiveness as being better (95% confidence interval [CI] 3.53, 7.61). Comfort in dying did not differ (difference = -0.61; 95% CI -2.2, 1.0). Among the secondary outcomes, antimicrobial use was significantly lower in intervention homes (rate ratio = 0.79, 95% CI 0.66, 0.94). CONCLUSIONS: Superior comprehensiveness of the BABEL approach to ACP underscores the importance of allowing adequate time to address all important aspects of ACP and may reduce unwanted interventions towards the end of life.

Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?

BACKGROUND: Residents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes. METHODS: In this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015. RESULTS: We report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65-0.69), 0.63 (0.61-0.65), and 0.47 (0.43-0.52) for residents with low, moderate and high health instability, respectively. CONCLUSION: Even though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.

The predictive utility of functional status at discharge: a population-level cohort analysis.

BACKGROUND: Functional status is a patient-important, patient-centered measurement. The utility of functional status measures to inform post-discharge patient needs is unknown. We sought to examine the utility of routinely collected functional status measures gathered from older hospitalized patients to predict a panel of post-discharge outcomes. METHODS: In this population-based retrospective cohort study, Adults 65+ discharged from an acute hospitalization between 4 November 2008 and 18 March 2016 in Ontario, Canada and received an assessment of functional status at discharge using the Health Outcomes for Better Information and Care tool were included. Multivariable regression analysis was used to determine the relationship between functional status and emergency department (ED) re-presentation, hospital readmission, long term care facility (LTCF) admission or wait listing ('LTCF readiness'), and death at 180 days from discharge. RESULTS: A total of 80 020 discharges were included. 38 928 (48.6%) re-presented to the ED, 24 222 (30.3%) were re-admitted, 5 037 (6.3%) were LTCF ready, and 9 047 (11.3%) died at 180 days. Beyond age, diminished functional status at discharge was the factor most associated with LTCF readiness (adjusted Odds Ratio [OR] 4.11 for those who are completely dependent for activities of daily living compared to those who are independent; 95% Confidence Interval [CI]: 3.70-4.57) and death (OR 3.99; 95% CI: 3.67-4.35). Functional status also had a graded relationship with each outcome and improved the discriminability of the models predicting death and LTCF readiness (p<0.01) but not ED re-presentation or hospital re-admission. CONCLUSION: Routinely collected functional status at discharge meaningfully improves the prediction of long term care home readiness and death. The routine assessment of functional status can inform post-discharge care and planning for older adults.

Prevalence of prescription and non-prescription polypharmacy by frailty and sex among middle-aged and older Canadians.

Background: Estimates of polypharmacy have primarily been derived from prescription claims, and less is known about the use of non-prescription medications (alone or in combination with prescription medications) across the frailty spectrum or by sex. Our objectives were to estimate the prevalence of polypharmacy (total, prescription, non-prescription, and concurrent prescription and non-prescription) overall, and by frailty, sex and broad age group. Data: Canadian Health Measures Survey, Cycle 5, 2016 to 2017. Methods: Among Canadians aged 40 to 79 years, all prescription and non-prescription medications used in the month prior to the survey were documented. Polypharmacy was defined as using five or more medications total (prescription and non-prescription), prescription only and non-prescription only. Concurrent prescription and non-prescription use was defined as two or more and three or more of each. Frailty was defined using a 31-item frailty index (FI) and categorized as non-frail (FI ≤ 0.1) and pre-frail or frail (FI > 0.1). Survey-weighted descriptive statistics were calculated overall and age standardized. Results: We analyzed 2,039 respondents, representing 16,638,026 Canadians (mean age of 56.9 years; 51% women). Overall, 52.4% (95% confidence interval [CI] = 47.3 to 57.4) were defined as pre-frail or frail. Age-standardized estimates of total polypharmacy, prescription polypharmacy and concurrent prescription and non-prescription medication use were significantly higher among pre-frail or frail versus non-frail adults (e.g., total polypharmacy: 64.1% versus 31.8%, respectively). Polypharmacy with non-prescription medications was common overall (20.5% [95% CI = 16.1 to 25.8]) and greater among women, but did not differ significantly by frailty. Interpretation: Polypharmacy and concurrent prescription and non-prescription medication use were common among Canadian adults, especially those who were pre-frail or frail. Our findings highlight the importance of considering non-prescribed medications when measuring the exposure to medications and the potential risk for adverse outcomes.

Effective Chronic Disease Interventions in Nursing Homes: A Scoping Review Based on the Knowledge-to-Action Framework.

Objectives: The purpose of this scoping review was two-fold: 1) to identify effective intervention studies addressing chronic disease for seniors living in nursing homes (e.x. chronic heart failure, diabetes, dementia, etc.), and 2) to describe how consistently the studies' reported their stages of the Knowledge-to-Action framework (2006).Methods: This scoping review involved a systematic search of CINAHL, EMBASE, PubMed and Scopus of intervention studies, published in English and French between 1997 and 2018, that focused on the development, implementation and/or evaluation of a chronic disease management guideline or best practice for older adults 65+ residing within a nursing home (NH). Authors abstracted information specific to the seven stages of the Knowledge-to-Action framework (identifying problem, tailoring to local context, barriers and facilitators to intervention delivery, implementation, monitoring, outcome criteria, and sustainability).Results: Six studies met the inclusion criteria. Procedures for monitoring knowledge use and outcome evaluation were thoroughly described. Other stages of the Knowledge-to-Action framework were not consistently reported, including problem identification related to older adults' needs and within the context of NHs, intervention implementation, evaluation, and sustainability. Of the six studies included, only two met all the pre-defined evaluation outcomes.Conclusions: Given the need for chronic disease management in NHs, researchers are encouraged to report on intervention studies using the Knowledge-to-Action framework to optimize the likelihood that interventions will be suitable for the context of their delivery and introduce sustainable change.Clinical implications: To answer what interventions should be introduced to residents in long-term care, research must clearly demonstrate efficacy, provide enough detail for methods to be reproducible in applied contexts, and consider strategies for sustainability and the holistic needs of residents.

Qualité des soins dans les établissements de soins de longue durée canadiens accueillant différents groupes linguistiques.

OBJECTIVES: Canada has two official languages (English and French) that vary in usage by province/territory and other smaller geographic units. The objective of this study was to compare the characteristics of persons receiving care in long-term care homes serving different language groups and to examine the extent to which data quality and distributional properties of indicators vary between homes. METHODS: We used routinely collected interRAI Minimum Data Set (MDS) 2.0 assessment data from nine Canadian provinces and territories to classify 1,333 long-term care homes into predominately English, French, and mixed language groups. We compared resident characteristics, risk-adjusted quality indicator performance, and assessment data quality by facility language group. RESULTS: In these data, eighteen (1.35%) long-term care homes served predominately French-speaking residents. An additional 274 (20.54%) homes were classified as mixed language homes, where 20% or more residents spoke a language other than English or French. The remaining homes (1,042; 78.11%) were classified as English homes. We did not observe substantial differences between facility language groups in terms of resident characteristics, quality indicator performance, and data quality. CONCLUSIONS: Despite linguistic differences, long-term care homes in Canada serving residents that speak predominately French and other languages can be compared directly with homes serving predominantly English-speaking residents. These findings support language-agnostic benchmarking of quality of care among long-term care homes situated across Canada, particularly in officially bilingual provinces.

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.

Outcomes of vulnerable elderly patients undergoing elective major surgery: a prospective cohort study.

PURPOSE: Identifying patients at risk of postoperative complications and trying to prevent these complications are the essence of preoperative evaluation. While not overtly frail or disabled, vulnerable patients with mild frailty may be missed by routine assessments and may still have a worse postoperative course. METHODS: We performed a prospective cohort study evaluating vulnerability in older patients undergoing elective surgery. Vulnerability was assessed using the Clinical Frailty Scale. Our primary outcome was postoperative hospital length of stay (LOS) and our secondary outcome was non-home hospital discharge. We performed multivariable analyses to assess the association between vulnerability and our primary and secondary outcome. RESULTS: Between 1 January 2017 and 1 January 2018, 271 older patients with a median [interquartile range (IQR)] age of 72 [69-76] yr underwent frailty assessment prior to surgery. Eighty-eight (32.5%) of the cohort were classified as vulnerable. The median [IQR] duration of hospital LOS was 4 [2-7] days for vulnerable patients, 4 [2-6] days for robust patients, and 7 [3-10] days for frail patients. After adjusting for confounders, hospital LOS was not longer for vulnerable patients than for robust patients, but was associated with a higher rate of non-home discharge (odds ratio, 3.7; 95% confidence interval, 1.1 to 12.9; P = 0.04). CONCLUSIONS: Vulnerability was not associated with a longer hospital LOS but with higher risk of non-home discharge. Vulnerable patients might benefit from early identification and advanced planning with earlier transfer to rehabilitation centres.

RéSUMé: OBJECTIF: L'identification des patients à risque de complications postopératoires et la prévention de ces complications constituent le fondement de l'évaluation préopératoire. Sans être ouvertement fragiles ou handicapés, les patients vulnérables avec une fragilité légère pourraient passer entre les mailles des évaluations de routine et tout de même souffrir d'un parcours postopératoire plus difficile. MéTHODE: Nous avons réalisé une étude de cohorte prospective évaluant la vulnérabilité des patients âgés subissant une chirurgie élective. La vulnérabilité a été évaluée à l'aide de l'Échelle Clinical Frailty Scale. Notre critère d'évaluation principal était la durée de séjour hospitalier postopératoire; notre critère d'évaluation secondaire était le congé de l'hôpital sans retour au foyer. Nous avons réalisé des analyses multivariées afin d'évaluer l'association entre la vulnérabilité et nos critères d'évaluation principal et secondaire. RéSULTATS: Entre le 1er janvier 2017 et le 1er janvier 2018, 271 patients d'un âge médian [écart interquartile (ÉIQ)] de 72 [69­76] ans ont passé une évaluation de fragilité avant leur chirurgie. Quatre-vingt-huit personnes (32,5 %) de la cohorte ont été catégorisées comme vulnérables. La durée médiane [ÉIQ] de séjour hospitalier était de 4 [2­7] jours pour les patients vulnérables, 4 [2­6] pour les patients robustes, et 7 [3­10] pour les patients fragiles. Après l'ajustement pour tenir compte des facteurs confondants, la durée de séjour hospitalier n'était pas plus longue pour les patients vulnérables que pour les patients robustes, mais était associée à un taux plus élevé de congé sans retour au foyer (rapport de cotes, 3,7; intervalle de confiance 95 %, 1,1 à 12,9; P = 0,04). CONCLUSION: La vulnérabilité n'a pas été associée à une durée de séjour hospitalier plus longue mais à un risque plus élevé de congé sans retour au foyer. Les patients vulnérables pourraient bénéficier d'une identification précoce et d'une planification avancée avec un transfert plus rapide vers les centres de réadaptation.

Acute reduction in cerebral blood velocity on supine-to-stand transition increases postural instability in young adults.

We tested the hypothesis that transient deficits in cerebral blood flow are associated with postural sway. In 19 young, healthy adults, we examined the association between the drop in cerebral blood flow during supine-to-stand transitions, indexed by transcranial Doppler ultrasound [middle cerebral artery blood velocity at diastole (MCAdv)] and near-infrared spectroscopy [tissue saturation index (TSI)] and the center of pressure displacement while standing. Participants performed transitions under three conditions aimed at progressively increasing the drop in MCAdv, in a randomized order: 1) a control transition (Con); 2) a transition that coincided with deflation of bilateral thigh cuffs; and 3) a transition that coincided with both thigh-cuff deflation and 90 s of prior hyperventilation (HTC). The deficit in diastolic blood velocity (MCAdv deficit) was quantified as the difference between MCAdv and its preceding baseline value, summed over 10 s, beginning at the MCAdv nadir. Compared with Con, HTC led to greater drops in MCAdv (P = 0.003) and TSI (P < 0.001) at nadir. The MCAdv deficit was positively associated with the center of pressure displacement vector-average using repeated-measures correlation (repeated-measures correlation coefficient = 0.56, P < 0.001). An a posteriori analysis identified a sub-group of participants that showed an exaggerated increase in MCAdv deficit and greater postural instability in both the anterior-posterior (P = 0.002) and medial-lateral (P = 0.021) directions in response to the interventions. These findings support the theory that individuals who experience greater initial cerebral hypoperfusion on standing may be at a greater risk for falls.NEW & NOTEWORTHY Dizziness and risk for falls after standing might link directly to reduced delivery of oxygen to the brain. By introducing challenges that increased the drop in brain blood flow in healthy young adults, we have shown for the first time a direct link to greater postural instability. These results point to a need to measure cerebral blood flow and/or oxygenation after postural transitions in populations, such as older adults, to assist in fall risk assessment.

Intermittent antipsychotic medication and mortality in institutionalized older adults: A scoping review.

OBJECTIVE/BACKGROUND: Antipsychotic use appears to increase mortality risk among older adults with dementia. Whether this risk is similar for regular or intermittent use is unknown. This scoping review aims to explore the temporal association between antipsychotic use and mortality risk for older institutionalized adults. METHOD: We conducted a scoping review using Medline (PubMed), EMBASE, CINAHL, and the Cochrane libraries between October 2018 and January 2019. RESULTS: Twenty-eight articles met review criteria. We found that different antipsychotic medications present different safety profiles. The risk of mortality was highest with conventional antipsychotic use and within 40 days of antipsychotic initiation. CONCLUSIONS: Conventional antipsychotic use increases mortality for older institutionalized adults. The evidence for atypical antipsychotics is less clear. Mortality risk appears highest within 30 to 40 days of initiating antipsychotic treatment. This temporal association suggests increased mortality may actually be the result of some previously unrecognized illness, comorbidity, change in health status, or increased frailty, rather than an idiosyncrasy of the antipsychotic itself.

Neighbourhood Team Development to promote resident centred approaches in nursing homes: a protocol for a multi component intervention.

BACKGROUND: As the demand for nursing home (NH) services increases, older adults and their families expect exceptional services. Neighbourhood Team Development (NTD) is a multi-component intervention designed to train team members (staff) in the implementation of resident-centered care in NH settings. A neighbourhood is a 32-resident home area within a NH. This paper presents the protocol used to implement and evaluate NTD. The evaluation aimed to 1) examine fidelity with which the NTD was implemented across NHs; 2) explore contextual factors associated with implementation and outcomes of the NTD; and 3) examine effects of NTD on residents, team members, family, and organizational outcomes, and the association between level of implementation fidelity and outcomes. METHODS: The study employed a repeated measure, mixed method design. NTD consisted of a 30-month standardised training and implementation plan to modify the physical environment, organize delivery and services and align staff members to promote inter-professional team collaboration and enhanced resident centeredness. Training was centred in each 32-resident neighbourhood or home area. Quantitative and qualitative data were collected with reliable and valid measures over the course of 3 years from residents (clinical outcomes, quality of life, satisfaction with care, perception of person centeredness, opportunities for social engagement), families (satisfaction with care for relative, person centeredness, relationship opportunities), team members (satisfaction with job, ability to provide person centered care, team relationships) and organizations (retention, turnover, staffing, events) in 6 NHs. Mixed models were used for the analysis. DISCUSSION: The advantages and limitations of the NTD intervention are described. The challenges in implementing and evaluating this multi-component intervention are discussed as related to the complexity of the NH environment. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03415217 (January 30, 2018 - Retrospectively registered).

Quality assurance as a foundational element for an integrated system of dementia care.

PURPOSE: Many countries are developing primary care collaborative memory clinics (PCCMCs) to address the rising challenge of dementia. Previous research suggests that quality assurance should be a foundational element of an integrated system of dementia care. The purpose of this paper is to understand physicians' and specialists' perspectives on such a system and identify barriers to its implementation. DESIGN/METHODOLOGY/APPROACH: The authors used interviews and a constructivist framework to understand the perspectives on a quality assurance framework for dementia care and barriers to its implementation from ten primary care and ten specialist physicians affiliated with PCCMCs. FINDINGS: Interviewees found that the framework reflects quality dementia care, though most could not relate quality assurance to clinical practice. Quality assurance was viewed as an imposition on practitioners rather than as a measure of system integration. Disparities in resources among providers were seen as barriers to quality care. Greater integration with specialists was seen as a potential quality improvement mechanism. Standardized electronic medical records were seen as important to support both quality assurance and clinical care. PRACTICAL IMPLICATIONS: This work identified several challenges to the implementation of a quality assurance framework to support an integrated system of dementia care. Clinicians require education to better understand quality assurance. Additional challenges include inadequate resources, a need for closer collaboration between specialists and PCCMCs, and a need for a standardized electronic medical record. ORIGINALITY/VALUE: Greater health system integration is necessary to provide quality dementia care, and quality assurance could be considered a foundational element driving system integration.

Individualizing the care of older heart failure patients.

PURPOSE OF REVIEW: The heart failure epidemic is driven mainly by population aging and the improving survival of patients with cardiovascular risk factors. Aging heart failure patients are affected by multiple concurrent comorbidities and geriatric syndromes, the most important of which are frailty and cognitive impairment. The purpose of this review is to provide clinicians with practical advice on how to individualize the care of older heart failure patients. RECENT FINDINGS: Frailty and cognitive impairment are common in older heart failure patients. Frailty is increasingly recognized as a key risk factor for functional decline, health service utilization and mortality in aging heart failure patients. Similarly, cognitive impairment impairs patients' ability for self-care and leads to adverse outcomes. Simple and efficient instruments exist to screen for these conditions. Heart failure patients who are frail or cognitively impaired are best looked after in a disease management setting that is deployed in a more integrated healthcare system with access to specialized geriatric consultants. Optimal care planning requires knowledge of these conditions as well as patient and caregiver engagement. SUMMARY: Frailty and cognitive impairment are central features of the heart failure syndrome in aging patients and should be routinely considered in assessment and care planning.