A profile of older community-dwelling home care clients with heart failure in Ontario.

INTRODUCTION: The aging of the Canadian population is associated with a rising burden of heart failure (HF), a condition associated with significant morbidity, mortality and health service use. METHODS: We used data from the Ontario Resident Assessment Instrument-Home Care database for all long-stay home care clients aged 65 years or older to (1) describe the demographic and clinical characteristics of home care clients with HF and (2) examine service use among home care clients with HF to promote management at home with appropriate services. RESULTS: Compared with other home care clients, HF clients exhibit more health instability, take more medications, experience more comorbid conditions and receive significantly more nursing, homemaking and meal services. They are hospitalized more frequently, have significantly more emergency department visits and use more emergent care. DISCUSSION: HF clients are a more complex group than home care clients in general. Patient self-care must be tailored to the clinical characteristics, patterns of service use and barriers to self-care of the client. This is particularly true for older, frail and medically complex HF patients, many of whom require home care services. This work provides a background upon which to base initiatives to help these higher-needs clients manage their HF at home with appropriate support and services.

A care planning strategy for traumatic life events in community mental health and inpatient psychiatry based on the InterRAI assessment instruments.

Clinical triggers from the Traumatic Life Events Clinical Assessment Protocol (CAP) identify individuals who might benefit from formal services or additional supports targeted towards trauma treatment. The Traumatic Life Events CAP identifies two groups who have experienced one or more potentially traumatic life events: (1) those who are in immediate danger due to current abuse/criminal victimization; (2) those who have experienced one or more traumatic events that evoked an intense sense of horror or fear. Descriptive analysis was conducted across psychiatric hospital and community-based mental health service settings to compare the two triggered groups to those without traumatic experiences (the not-triggered group). The Traumatic Life Events CAP identified subpopulations with unrecognized and untreated traumatic-stress-related symptoms, which are of great concern for those in community-based mental health services who are in immediate danger due to current abuse.

Moving Towards Common Data Elements and Core Outcome Measures in Frailty Research.

With aging populations around the world, frailty is becoming more prevalent increasing the need for health systems and social systems to deliver optimal evidence based care. However, in spite of the growing number of frailty publications, high-quality evidence for decision making is often lacking. Inadequate descriptions of the populations enrolled including frailty severity and frailty conceptualization, lack of use of validated frailty assessment tools, utilization of different frailty instruments between studies, and variation in reported outcomes impairs the ability to interpret, generalize and implement the research findings. The utilization of common data elements (CDEs) and core outcome measures (COMs) in clinical trials is increasingly being adopted to address such concerns. To catalyze the development and use of CDEs and COMs for future frailty studies, the Canadian Frailty Network (www.cfn-nce.ca; CFN), a not-for-profit pan-Canadian nationally-funded research network, convened an international group of experts to examine the issue and plan the path forward. The meeting was structured to allow for an examination of current frailty evidence, ability to learn from other COMs and CDEs initiatives, discussions about specific considerations for frailty COMs and CDEs and finally the identification of the necessary steps for a COMs and CDEs consensus initiative going forward. It was agreed at the onset of the meeting that a statement based on the meeting would be published and herein we report the statement.

A review of evidence on the reliability and validity of Minimum Data Set data.

This paper reviews the reliability and validity of the Minimum Data Set (MDS) assessment, which is being used increasingly in Canadian nursing homes and continuing care facilities. The central issues that surround the development and implementation of a standardized assessment such as the MDS are presented, including implications for health care managers in how to approach data quality concerns. With other sectors such as home care and inpatient psychiatry using MDS for national reporting, these issues have importance in and beyond residential care management.

Implementing Frailty Measures in the Canadian Healthcare System.

Canadian healthcare is changing to include individuals living with frailty, but frailty must be better operationalized and better framed by sound data standards and policy. Frailty results from deficit accumulation in multiple body systems, with exaggerated vulnerability to external stressors. A growing consensus on defining frailty sets the stage for consensus on operationalization and widespread implementation in care settings. Frailty measurement is not yet integrated into daily clinical practice in Canada. Here, we will present how this integration might occur. We hope to demonstrate that implementation must appeal to inter-professional practice needs in different settings or circumstances. In some settings, methods for frailty case finding are expected to evolve as deemed to be most appropriate to the front-line users. In this "hands-off" approach, care providers, supported by emerging knowledge translation on frailty operationalization, would be informed by their setting and local practices to establish patterns of ad hoc case finding and component definition of frailty. This more nimble case finding strategy would be opportunistic, and would appeal to expert clinicians and self-directed teams who emphasize an individualized health care experience for their patients. In other settings, we can shape frailty case finding by building care algorithms around existing standardized practices and data repositories, leading to a systematic application of frailty measures and a more coordinated process of component definition and care protocols. Here, recommended instruments and data standards must be endorsed by health networks locally, provincially and nationally. The interRAI suite of assessment instruments has pan-Canadian standards in place and its pervasiveness makes it the most obvious starting point, especially in home care and long-term care. We anticipate the evolution of an integrated model informed by stakeholders and settings, where policy makers focus on system supports for frailty case finding, while front-line clinicians use case finding strategies to pinpoint and act on key frailty components.

Comparing the care needs of people living with and without HIV in Canadian home and long-term care settings.

BACKGROUND: With the advent of highly active antiretroviral therapy (HAART), HIV has become a manageable chronic infection and individuals with it are living longer. Older individuals with HIV will begin to seek services across the continuum of health care. Whether their care needs differ from those who are HIV negative has not been well-characterized. OBJECTIVES: To compare the demographic characteristics, chronic conditions, presence of infections, and mental health issues among HIV-positive versus HIV-negative individuals in home care, long-term care and complex continuing care settings across Canada. METHODS: This cross-sectional study used interRAI data to compare characteristics of HIV-positive and HIV-negative individuals in long-term care, complex continuing care and home care settings. Chi-square analyses explored differences between groups on co-infections, chronic disease and mental health issues. RESULTS: Data from 1,200,073 people were analyzed of whom 1,608 (0.13%) had HIV. Overall, HIV-positive individuals had more co-infections but fewer chronic diseases than their HIV-negative counterparts. Depression, social isolation and the use of psychotropic medications were generally more prevalent in the HIV-positive cohort. CONCLUSION: People living with HIV make up a small cohort of people with complex needs in home care and institutional settings and their care needs differ from those who are HIV negative. As HIV-positive people age, a better understanding of the context in which these issues are experienced will support appropriate interventions.

The importance of social relationships, socioeconomic status and health practices with respect to mortality among healthy Ontario males.

The associations of social relationships, socioeconomic status and health practices with 20-year mortality were examined in a cohort of 2000 Ontario males. A social relationships index comprised of marital status, number of children, family contact and participation in voluntary associations had a strong association with mortality (adjusted relative risk of 0.30, 95% CI 0.11-0.83, comparing the highest 10% with the lowest 10% scores of the index). Among indicators of socioeconomic status, only income was significantly related to mortality with an adjusted relative risk of 0.41 (95% CI 0.23-0.72) for the highest 20% compared with the lowest 20% income group. The adjusted relative risk for smokers compared with non-smokers was 2.26 (95% CI 1.51-3.37). The joint effects of a relatively high score in the social relationships index, high income and being a non-smoker is estimated to represent an approximately 18-fold reduction in the risk of mortality during the follow-up period.

The relationship between aging and disease: geriatric ideology and myths of senility.

An ongoing debate in gerontology concerns the relationship between aging and disease. Goodwin, as part of a discussion on the importance of geriatric ideology, argues that age-related disorders like senile dementia of the Alzheimer's type (SDAT) should be regarded as an aging process, while others suggest it is more appropriate to consider it as a disease. This paper comments on the arguments presented by Goodwin and develops these by providing a review of the underlying assumptions concerning aging and disease. The policy relevance and implications for future research are also outlined.

Comprehensive clinical assessment in community setting: applicability of the MDS-HC.

OBJECTIVE: To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC. DESIGN: Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients. SETTING AND PARTICIPANTS: Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States. MEASUREMENTS: The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications. RESULTS: Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels. CONCLUSION: Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.

The prevalence of smoking and implications for quality of life among the community-based elderly.

Although the adverse health consequences associated with smoking among middle-aged adults are well known, the significance of smoking among the elderly is less clear. We used data from three national surveys with representative samples of the noninstitutionalized Canadian population 15 years of age and older to investigate the prevalence and consequences of smoking among the elderly. The results showed a lower prevalence of smoking among older age groups, a higher prevalence and higher consumption rates among elderly men than among elderly women, a greater likelihood among elderly nonsmokers for men to be former smokers and for women never to have smoked, and lower consumption rates among elderly men and women than among younger individuals. Results from multivariate logistic regression models suggested an increased risk among elderly male and female smokers for poorer health ratings, respiratory problems, and selected medication use. These models also showed an increased risk for impairment in mobility and high life stress among elderly male smokers and for low happiness and dissatisfaction with social relationships among elderly female smokers, compared with persons who had never smoked. These preliminary findings suggest that smoking among elderly persons may be associated with several negative quality-of-life outcomes, but the direction of this relationship is not clear. Nonetheless, these results provide support for the initiation of smoking cessation programs for elderly individuals.

Traffic-related fatalities among older drivers and passengers: past and future trends.

PURPOSE OF THE STUDY: This study was initiated to forecast the number of older drivers and passengers who may be fatally injured in traffic crashes in future years. DESIGN AND METHODS: The study was based on data from the U.S. Fatality Analysis Reporting System covering the period from 1975 to 1998. Projections were based on least squares regression models. RESULTS: About 35,000 drivers and passengers died in traffic crashes each year from 1975 to 1998. Older adults (65 and older) accounted for 10% of all fatalities in 1975, 17% in 1998, and a projected 27% by 2015, the same proportion predicted for drivers and passengers aged younger than 30. On the basis of these projections, the number of fatally injured women and men aged 65 and older will increase respectively by 373% and 271% between 1975 and 2015. IMPLICATIONS: If current trends continue, the number of fatalities among older drivers and passengers and those aged younger than 30, may be equivalent early in this century. These projections call for further research into conditions that may lead to crashes involving older drivers and for the development and implementation of initiatives to curb traffic-related fatalities among older adults.

The balance of exchange in instrumental support with network members outside the household.

The exchange of six types of instrumental support with individuals outside the household was examined using data from the 1990 Canadian General Social Survey. The balance of exchange within the network as a whole was considered in relation to age, gender, social class, availability of social relationships, and health status. The findings reveal the complexity of examining the provision and receipt of support simultaneously. Results are generally consistent with propositions under exchange theory regarding the association between age and reciprocity, depending on assumptions made about the nature of exchange. Implications for future research are discussed.

Smoking cessation and quality of life outcomes among older adults in the Campbell's Survey on Well-Being.

Most research regarding the health effects of smoking has focussed on mortality and on relatively young populations. Less is known about the consequences of smoking and the benefits of cessation among older adults. Improvements in quality of life are likely to represent more salient reasons to motivate older adults to stop smoking. Multivariate results from the Campbell's Survey on Well-Being indicate that long-term cessation among older adults yielded odds ratios comparable to never smokers in eight of 13 quality of life outcomes. Conversely, current smokers had elevated risks in 11 of 13 areas. Short-term benefits of smoking cessation were less clear in this subsample, and a number of possible explanations for this finding are explored.

Pain and cognitive status among nursing home residents in Canada.

BACKGROUND: There is little information available on the rates of pain in institutionalized elderly persons, and this is particularly true for Canada. OBJECTIVES: To provide information about the prevalence and clinical correlates of pain in a sample of Canadian nursing homes, to determine whether residents with cognitive impairment experience lower rates of health conditions associated with pain (eg, arthritis) than residents without cognitive impairment and to determine whether the associations (ie, odds ratios) for pain with such health conditions vary as a function of cognitive status. DESIGN: The study is based on a secondary analysis of data collected with the minimum data set (MDS 2.0). SETTING AND PARTICIPANTS: The study comprised 3195 nursing home residents in Ontario, Manitoba and Saskatchewan. SUBJECTS AND METHODS: All residents were assessed with the MDS 2.0 by trained clinicians (usually nurses). Pain was documented if it had occurred within the seven days before the assessment. Assessors were trained to look for overt signs of discomfort, such as wincing or verbalizations. Self-report ratings were obtained when possible. RESULTS: The overall prevalence of pain in this sample was 49.7%, and 23.7% of residents experienced pain daily. Persons with and persons without cognitive impairments did not differ with respect to the prevalence of conditions likely to cause pain and the associations of pain with such health conditions. Regional differences were found, with Ontario residents having a higher frequency and intensity of pain than their counterparts in Saskatchewan and Manitoba. This may be due, at least in part, to regional differences in nursing home admission criteria. CONCLUSIONS: The findings suggest that the prevalence of identified pain is lower among nursing home residents with higher levels of cognitive impairment. These results do not support the notion that this is a function of lower prevalence rates of pain-causing conditions in nursing home residents with dementia. Furthermore, the results do not support the view that residents with cognitive impairments are less sensitive to pain. This study highlights the need for more comprehensive tools to assess pain in persons with cognitive impairments. Nonetheless, the MDS may be a useful instrument for detecting pain in such populations, because it does not rely exclusively on self-report.

Screening clients for an augmentative and alternative communication clinic: a multitrait-multimethod approach.

The aim of Augmentative and Alternative Communication (AAC) services is to support, enhance, or provide alternative methods of communication for individuals who are not independent verbal communicators. However, relatively little evaluative research has been conducted with adult AAC users. The establishment of Freeport Hospital's AAC Clinic for adults included the development of questionnaires to gather information for the selection and provision of services for its clients. The present study addresses the issue reliability and validity of three novel measures contained within the AAC Clinic's Background Information Questionnaire using a multitrait-multimethod (MTMM) design. Results from this evaluation are discussed in terms of clinical application and policy development.

[Integrated health information system based on Resident Assessment Instruments]. / Geïntegreerd gezondheidsinformatiesysteem op basis van Resident Assessment Instrumenten.

The paper explores the meaning of Resident Assessment Instruments. It gives a summary of existing RAI instruments and derived applications. It argues how all of these form the basis for an integrated health information system for "chain care" (home care, home for the elderly care, nursing home care, mental health care and acute care). The primary application of RAI systems is the assessment of client care needs, followed by an analysis of the required and administered care with the objective to make an optimal individual care plan. On the basis of RAI, however, applications have been derived for reimbursement systems, quality improvement programs, accreditation, benchmarking, best practice comparison and care eligibility systems. These applications have become possible by the development on the basis of the Minimum Data Set of RAI of outcome measures (item scores, scales and indices), case-mix classifications and quality indicators. To illustrate the possibilities of outcome measures of RAI we present a table and a figure with data of six Dutch nursing homes which shows how social engagement is related to ADL and cognition. We argue that RAI/MDS assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

Development of a crosswalk from the Minimum Data Set 2.0 to the Alberta Resident Classification System.

Ontario has mandated the use of the Minimum Data Set 2.0 (MDS) to classify patients in all chronic care hospital beds as of July 1996. The MDS, widely used in several other jurisdictions, has been shown to have several advantages over other assessment systems. However, Ontario currently classifies residents of homes for the aged and nursing homes under the Alberta Resident Classification System (ARCS). Since there is not a single system to assess the elderly in institutional settings, it is not possible to create a funding system for all institutions based on patient rather than facility characteristics. The author reports on the development of a crosswalk algorithm to compute ARCS levels of care based on clinical items from the MDS. This algorithm may be used to support a transitional approach to move to a funding system for long-term care based on Resource Utilization Groups (RUG-III).

Identifying an appropriate case mix measure for chronic care: evidence from an Ontario pilot study.

With the move toward rate-based funding for chronic care hospitals, a case mix measure that describes chronic care patients in a valid and reliable manner is needed. A pilot study was done in Ontario to evaluate the effectiveness of three classification systems that have been implemented elsewhere. It was recommended that work continue on the basis that Ontario will implement the Resource Utilization Groups (RUG-III) system for activity measurement and funding of chronic care patients.

Integrated health information systems based on the RAI/MDS series of instruments.

There is a growing need for an integrated health information system to be used in community, institutional and hospital based settings. For example, changes in the structure, process and venues of service delivery mean that individuals with similar needs may be cared for in a variety of different settings. Moreover, as people make transitions from one sector of the healthcare system to another, there is a need for comparable information to ensure continuity of care and reduced assessment burden. The RAI/MDS series of assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

A comprehensive profile of the sociodemographic, psychosocial and health characteristics of Ontario home care clients with dementia.

INTRODUCTION: This study provides a comprehensive summary of the sociodemographic, psychosocial and health characteristics of a large population-based cohort of Ontario home care clients (aged 50 years and over) with dementia and examines the variation in these characteristics in those with co-existing neurological conditions. METHODS: Clients were assessed with the Resident Assessment Instrument-Home Care (RAI-HC) between January 2003 and December 2010. Descriptive analyses examined the distribution of these characteristics among clients with dementia relative to several comparison groups, as well as clients with other recorded neurological conditions. RESULTS: Approximately 22% of clients (n=104 802) had a diagnosis of dementia (average age 83 years, 64% female) and about one in four within this group had a co-existing neurological condition (most commonly stroke or Parkinson disease). About 43% of those with dementia did not live with their primary caregiver. Relative to several comparison groups, clients with dementia showed considerably higher levels of cognitive and functional impairment, aggression, anxiety, wandering, hallucinations/delusions, caregiver distress and a greater risk for institutionalization. Conversely, they showed a lower prevalence of several chronic conditions and lower levels of recent health service use. Depressive symptoms were relatively common in the dementia and other neurological groups. CONCLUSION: Clients with co-existing neurological conditions exhibited unique clinical profiles illustrating the need for tailored and flexible home care services and enhanced caregiver assistance programs.

TITRE: Profil complet des caractéristiques sociodémographiques, psychosociales et sanitaires des clients des soins à domicile atteints de démence en Ontario. INTRODUCTION: Cette étude fournit une synthèse des caractéristiques sociodémographiques, psychosociales et sanitaires d'une vaste cohorte représentative des clients des soins à domicile en Ontario (âgés de 50 ans ou plus) atteints de démence et elle examine les variations de ces caractéristiques chez les clients atteints de maladies neurologiques concomitantes. MÉTHODOLOGIE: Les clients ont été évalués à l'aide de l'Instrument d'évaluation des résidents ­ Soins à domicile (RAI-HC) entre janvier 2003 et décembre 2010. Les analyses descriptives fournissent la répartition de ces caractéristiques en comparant les clients atteints de démence et ceux de plusieurs autres groupes ainsi que ceux atteints d'autres maladies neurologiques documentées. RÉSULTATS: Environ 22 % des clients (n = 104 802) avaient reçu un diagnostic de démence (âge moyen de 83 ans, 64 % de femmes) et un sur quatre parmi eux était atteint d'une maladie neurologique concomitante (AVC ou maladie de Parkinson la plupart du temps). Environ 43 % des clients atteints de démence n'habitaient pas avec leur principal aidant. Par rapport aux clients des groupes de comparaison, les clients atteints de démence présentaient des taux considérablement plus élevés de déficit cognitif et fonctionnel, d'agressivité, d'anxiété, d'errance et d'hallucinations ou de délire, avaient plus souvent un aidant en détresse et couraient un plus grand risque de placement en établissement. Par contre, ils étaient moins souvent atteints de diverses maladies chroniques et étaient moins nombreux à avoir eu recours à des services de santé récemment. Les symptômes de dépression étaient relativement fréquents chez les clients atteints de démence et chez ceux atteints d'une autre maladie neurologique. CONCLUSION: Les clients atteints de maladies neurologiques concomitantes présentaient des profils cliniques bien particuliers illustrant la nécessité de personnaliser et d'assouplir les services de soins à domicile et d'améliorer les programmes de soutien pour les aidants.