Associations between specialized dementia care, COVID-19 and central nervous system medication use in assisted living: a population-based repeated cross-sectional study.

BACKGROUND: Assisted living (AL) is an increasingly common residential setting for persons with dementia; yet concerns exist about sub-optimal care of this population in AL given its lower levels of staffing and services. Our objectives were to (i) examine associations between AL setting (dementia care vs. other), COVID-19 pandemic waves, and prevalent antipsychotic, antidepressant, anti-dementia, benzodiazepine, and anticonvulsant drug use among residents with dementia/cognitive impairment, and (ii) explore associations between resident and home characteristics and prevalent medication use. METHODS: We conducted a population-based, repeated cross-sectional study using linked clinical and health administrative databases for all publicly funded AL homes in Alberta, Canada, examined between January 2018 - December 2021. The quarterly proportion of residents dispensed a study medication was examined for each setting and period (pandemic vs. comparable historical [2018/2019 combined]) focusing on four pandemic waves (March-May 2020, September 2020-February 2021, March-May 2021, September-December 2021). Log-binomial GEE models estimated prevalence ratios (PR) for period (pandemic vs. historical periods), setting (dementia care vs. other) and period-setting interactions, adjusting for resident (age, sex) and home (COVID-19 cases, health region, ownership) characteristics. RESULTS: On March 1, 2020, there were 2,779 dementia care and 3,013 other AL residents (mean age 83, 69% female) with dementia/cognitive impairment. Antipsychotic use increased during waves 2-4 in both settings, but this was more pronounced in dementia care than other AL during waves 3 and 4 (e.g., adjusted [adj]PR 1.20, 95% CI 1.14-1.27 vs. adjPR 1.09, 95% CI 1.02-1.17, interaction p = 0.023, wave 3). Both settings showed a statistically significant but modest increase in antidepressant use and decrease in benzodiazepine use. For dementia care AL residents only, there was a statistically significant increase in gabapentinoid use during several waves (e.g., adjPR 1.32, 95% CI 1.10-1.59, wave 3). Other than a modest decrease in prevalent anti-dementia drug use for both settings in wave 2, no other significant pandemic effects were observed. CONCLUSIONS: The persistence of the pandemic-associated increase in antipsychotic and antidepressant use in AL residents coupled with a greater increase in antipsychotic and gabapentinoid use for dementia care settings raises concerns about the attendant risks for residents with cognitive impairment.

Comparison of hospitalization events among residents of assisted living and nursing homes during COVID-19: Do settings respond differently during public health crises?

BACKGROUND: COVID-19 and resulting health system and policy decisions led to significant changes in healthcare use by nursing homes (NH) residents. It is unclear whether healthcare outcomes were similarly affected among older adults in assisted living (AL). This study compared hospitalization events in AL and NHs during COVID-19 pandemic waves 1 through 4, relative to historical periods. METHODS: This was a population-based, repeated cross-sectional study using linked clinical and health administrative databases (January 2018 to December 2021) for residents of all publicly subsidized AL and NH settings in Alberta, Canada. Setting-specific monthly cohorts were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods. Monthly rates (per 100 person-days) of all-cause hospitalization, hospitalization with delayed discharge, and hospitalization with death were plotted and rate ratios (RR) estimated for period (pandemic wave vs historical comparison), setting (AL vs NH) and period-setting interactions, using Poisson regression with generalized estimating equations, adjusting for resident and home characteristics. RESULTS: On March 1, 2020, there were 9,485 AL and 14,319 NH residents, comparable in age (mean 81 years), sex (>60% female) and dementia prevalence (58-62%). All-cause hospitalization rates declined in both settings during waves 1 (AL: adjusted RR 0.60, 95%CI 0.51-0.71; NH: 0.74, 0.64-0.85) and 4 (AL: 0.76, 0.66-0.88; NH: 0.65, 0.56-0.75) but unlike NHs, AL rates were not significantly lower during wave 2 (and increased 27% vs NH, January 2021). Hospitalization with delayed discharge increased in NHs only (during and immediately after wave 1). Both settings showed a significant increase in hospitalization with death in wave 2, this increase was larger and persisted longer for AL. CONCLUSIONS: Pandemic-related changes in hospitalization events differed for AL and NH residents and by wave, suggesting unique system and setting factors driving healthcare use and outcomes in these settings in response to this external stress.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic.

OBJECTIVES: To examine the associations between COVID-19 pandemic waves (1-4) and prevalent antipsychotic, antidepressant, benzodiazepine, anticonvulsant, and opioid use among assisted living (AL) residents, by setting (dementia care vs other). DESIGN: Population-based, repeated cross-sectional study. SETTING AND PARTICIPANTS: Linked clinical and health administrative databases for residents of all publicly subsidized AL homes (N = 256) in Alberta, Canada, examined from January 2018 to December 2021. Setting-specific quarterly cohorts of residents were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods. METHODS: The quarterly proportion of residents dispensed an antipsychotic, antidepressant, benzodiazepine, anticonvulsant, or opioid was examined for each setting and period. Log-binomial generalized estimating equations models estimated prevalence ratios (PR) for period (pandemic vs historical quarterly periods), setting (dementia care vs other AL), and period-setting interactions. RESULTS: On March 1, 2020, there were 2874 dementia care and 6611 other AL residents (mean age 82.4 vs 79.9 years, 68.2% vs 66.1% female, 93.5% vs 42.6% with dementia, respectively). Antipsychotic use increased during waves 2 to 4 for residents of both settings, but this increase was significantly greater for dementia care than other AL residents during waves 3 and 4 (eg, wave 3, PR 1.21, 95% CI 1.14-1.27 vs PR 1.12, 95% CI 1.07-1.17, interaction term P = .029). In both settings, there was a significant but modest increase in antidepressant use and a significant decrease in benzodiazepine use during several pandemic waves. For other AL residents only, there was a small statistically significant increase in anticonvulsant use during waves 2 to 4. No significant pandemic effect was observed for prevalent opioid use in either setting. CONCLUSIONS AND IMPLICATIONS: The persistence of the pandemic-associated increase in antipsychotic, antidepressant, and anticonvulsant use in AL residents, and greater increase in antipsychotic use for dementia care settings, raises concerns about the attendant risks for residents, especially those with dementia.

The COVID-19 pandemic did not negatively impact frequency or continuity of outpatient care in Alberta, Canada.

Outpatient care patterns have changed markedly during the COVID-19 pandemic. In this population-based retrospective cohort study, we compared the frequency of outpatient care (whether in-person or virtual) and continuity of care for all community-dwelling adults in Alberta between March 1, 2019 and February 29, 2020 (pre-pandemic) versus March 1, 2020 to February 28, 2021 (pandemic). We calculated provider continuity using Breslau's Usual Provider Continuity (UPC) for patients with at least 2 outpatient encounters. In 2019-20, 594,350 (98.4%) of 603,877 community-dwelling adults with ambulatory care sensitive conditions (ACSC) had [Formula: see text] 1 outpatient visit (median 8 visits, mean UPC score 0.61, SD 0.23), compared to 566,569 (98.6%) of 574,613 (median 8 visits, mean UPC score 0.67, SD 0.23) during the first year of the pandemic. Similar patterns were seen for adults without ACSC: 2,207,710 (93.9%) of 2,350,147 had [Formula: see text] 1 outpatient visit (median 3 visits, mean UPC score 0.61, SD 0.24) pre-pandemic compared to 2,113,239 (93.5%, median 4 visits, mean UPC 0.67, SD 0.24) in the first year of the pandemic. Thus, the COVID-19 pandemic did not impact frequency of follow-up while continuity of care improved both for patients with or without ACSC in Alberta, Canada.

Frequency and Type of Outpatient Visits for Patients With Cardiovascular Ambulatory-Care Sensitive Conditions During the COVID-19 Pandemic and Subsequent Outcomes: A Retrospective Cohort Study.

Background Because the impact of changes in how outpatient care was delivered during the COVID-19 pandemic is uncertain, we designed this study to examine the frequency and type of outpatient visits between March 1, 2019 to February 29, 2020 (prepandemic) and from March 1, 2020 to February 28, 2021 (pandemic) and specifically compared outcomes after virtual versus in-person outpatient visits during the pandemic. Methods and Results Population-based retrospective cohort study of all 3.8 million adults in Alberta, Canada. We examined all physician visits and 30- and 90-day outcomes, with a focus on those adults with the cardiovascular ambulatory-care sensitive conditions heart failure, hypertension, and diabetes. Our primary outcome was emergency department visit or hospitalization, evaluated using survival analysis accounting for competing risk of death. Although in-person outpatient visits decreased by 38.9% in the year after March 1, 2020 (10 142 184 versus 16 592 599 in the prior year), the introduction of virtual visits (7 152 147; 41.4% of total) meant that total outpatient visits increased by 4.1% in the first year of the pandemic for Albertan adults. Outpatient visit frequency (albeit 41.4% virtual, 58.6% in-person) and prescribing patterns were stable in the first year after pandemic onset for patients with the cardiovascular ambulatory-care sensitive conditions we examined, but laboratory test frequency declined by 20% (serum creatinine) to 47% (glycosylated hemoglobin). In the first year of the pandemic, virtual outpatient visits were associated with fewer subsequent emergency department visits or hospitalizations (compared with in-person visits) for patients with heart failure (adjusted hazard ratio [aHR], 0.90 [95% CI, 0.85-0.96] at 30 days and 0.96 [95% CI, 0.92-1.00] at 90 days), hypertension (aHR, 0.88 [95% CI, 0.85-0.91] and 0.93 [95% CI, 0.91-0.95] at 30 and 90 days), or diabetes (aHR, 0.90 [95% CI, 0.87-0.93] and 0.93 [95% CI, 0.91-0.95] at 30 and 90 days). Conclusions The adoption and rapid uptake of virtual outpatient care during the COVID-19 pandemic did not negatively impact frequency of follow-up, prescribing, or short-term outcomes, and could have potentially positively impacted some of these for adults with heart failure, diabetes, or hypertension in a setting where there was an active reimbursement policy for virtual visits. Given declines in laboratory monitoring and screening activities, further research is needed to evaluate whether long-term outcomes will differ.

Resident loneliness, social isolation and unplanned emergency department visits from supportive living facilities: a population-based study in Alberta, Canada.

BACKGROUND: Supportive living (SL) facilities are intended to provide a residential care setting in a less restrictive and more cost-effective way than nursing homes (NH). SL residents with poor social relationships may be at risk for increased health service use. We describe the demographic and health service use patterns of lonely and socially isolated SL residents and to quantify associations between loneliness and social isolation on unplanned emergency department (ED) visits. METHODS: We conducted a retrospective cohort study using population-based linked health administrative data from Alberta, Canada. All SL residents aged 18 to 105 years who had at least one Resident Assessment Instrument-Home Care (RAI-HC) assessment between April 1, 2013 and March 31, 2018 were observed. Loneliness and social isolation were measured as a resident indicating that he/she feels lonely and if the resident had neither a primary nor secondary caregiver, respectively. Health service use in the 1 year following assessment included unplanned ED visits, hospital admissions, admission to higher levels of SL, admission to NH and death. Multivariable Cox proportional hazard models examined the association between loneliness and social isolation on the time to first unplanned ED visit. RESULTS: We identified 18,191 individuals living in Alberta SL facilities. The prevalence of loneliness was 18% (n = 3238), social isolation was 4% (n = 713). Lonely residents had the greatest overall health service use. Risk of unplanned ED visit increased with loneliness (aHR = 1.10, 95% CI: 1.04-1.15) but did not increase with social isolation (aHR = 0.95, 95% CI: 0.84-1.06). CONCLUSIONS: Lonely residents had a different demographic profile (older, female, cognitively impaired) from socially isolated residents and were more likely to experience an unplanned ED visit. Our findings suggest the need to develop interventions to assist SL care providers with how to identify and address social factors to reduce risk of unplanned ED visits.

Eating a meal is associated with elevations in agreeableness and reductions in dominance and submissiveness.

Many studies have shown that having a meal together with others increases food intake. In contrast, the effects of having a meal on interactions with others have rarely been examined. More specifically, it is unknown if having a social interaction during a meal alters how people feel, behave, and perceive others. In the present study, 98 working individuals provided information on their everyday social interactions over a three-week period by filling in a form soon after each interaction. Record forms included items representing mood state, interpersonal behaviors, and perceptions of interaction partners. Participants also indicated whether interactions took place during a meal. Engaging in an interaction that involved eating a meal was associated with decreased alertness and, particularly in women, with increased pleasant affect, compared to interactions that did not involve eating a meal. Independently of this, during a meal participants reported fewer dominant and submissive behaviors and more agreeable behaviors, and also perceived interaction partners as more agreeable. These results were largely independent of contextual factors such as the gender and role of the primary social interaction partner, the presence of multiple partners, and the location of the interaction. Overall, social interactions during a meal were more positive in terms of how people felt, behaved, and perceived others. At the same time, agentic behaviors were reduced. These results suggest that shared meals are events in which affiliative bonds are strengthened in the context of weakened displays of hierarchy.

Preparing today's cardiovascular trainees to meet the challenges of tomorrow: team research and interdisciplinary training.

There is a growing focus on interdisciplinary team approaches in science and public health research, including cardiology. This trend is apparent in a large body of team publications and the strong interest from the funding agencies to support interdisciplinary research. Despite this increased emphasis on the importance and roles of teams, schools fail to better prepare their students and trainees with skills that allow them to work in or lead teams. In this article, we discuss the strengths and weaknesses of different team models and highlight the training program implemented by the Alberta Heart Failure Etiology and Analysis Research Team (HEART), which involves 24 scientists/mentors across the research and health care spectrum focused on understanding heart failure with preserved ejection fraction.

The influence of light administration on interpersonal behavior and affect in people with mild to moderate seasonality.

Bright light is used to treat winter depression and may also have positive effects on mood in some healthy individuals. However, there is little information on how bright light treatment influences social behavior. We performed a cross-over study in winter comparing the effects of morning bright light administration with placebo (exposure to negative ions) on mood and social behavior in 38 healthy people with mild to moderate seasonality. Each treatment was given for 21days with a washout period of 14days between treatments. An event-contingent recording assessment was used to measure mood, and social behavior along two axes, agreeable-quarrelsome and dominant-submissive, during each 21-day treatment period. During treatments, participants wore a combined light-sensor and accelerometer to test this method for adherence to light treatment self-administered at home. Data were analyzed using multilevel modeling. Bright light improved mood but increased quarrelsome behavior and decreased submissiveness. Data from the light monitor and accelerometer suggested that 21% of the participants did not adhere to bright light treatment; when this group was analyzed separately, there was no change in quarrelsomeness or mood. However, results for individuals who followed the procedure were similar to those reported for the whole sample.

Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study.

BACKGROUND: Although lower urinary tract symptoms have been associated with falls, few studies have been undertaken to understand this relationship in vulnerable community dwelling older adults. The purpose of this study was to describe the relationship over time of falls risk and lower urinary tract symptoms among community based older women receiving home support services. METHODS: A prospective cohort study which took place in an urban setting in western Canada. Participants were 100 older women receiving home care or residing in assisted living with home support services and were followed for six months. Demographic characteristics were collected at baseline, with the Timed Up and Go (TUG), International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), and self-report of falls collected at baseline, 3 and 6 months. Descriptive statistics were used to summarize demographic data. Differences between the three visits were analyzed using the Friedman test with post hoc analysis and associations between variables by the Spearman Rank-Order Correlation Coefficient. RESULTS: One hundred women initially enrolled; 88 and 75 remained at three months and six months. Mean age = 84.3 years; 91% reported at least one urinary symptom at baseline and 35% reported falling in the six months prior to enrollment; 15.9% reported falling between the baseline and three months and 14.6% between three and six months. Mean TUG scores at each time point indicated falls risk (27.21, 29.18 and 27.76 seconds). Significant correlations between TUG and ICIQ-FLUTS (r = 0.33, p < .001; r = 0.39, p < .001) as well as TUG and overactive bladder scores (r = 0.25, p = .005; r = 0.28, p < .008) were found at baseline and three months, but not six months. CONCLUSIONS: The association of lower urinary tract symptoms and falls risk in this group of vulnerable community dwelling older women at baseline and three months has potential clinical relevance. Lack of correlation at six months may be due loss of less robust participants, illuminating the difficulty in following frailer groups over time. Further studies are needed to understand the contribution of urinary symptoms to falls risk, and clinicians should incorporate continence assessment within falls risk assessment.

Home-based secondary prevention programs for patients with coronary artery disease: a meta-analysis of effects on anxiety.

PURPOSE: Anxiety is common among patients with coronary artery disease (CAD). Despite the benefits of home-based CAD prevention interventions on quality of life and atherosclerotic risk factors, the efficacy of home-based programs in reducing patient anxiety is unknown. METHODS: We performed a systematic review and meta-analysis of all randomized trials that examined the effects of home-based interventions on anxiety reduction in patients with CAD published in 18 databases until December 2009. Analyses were based on changes in the standardized mean difference between treatment groups. RESULTS: Eight trials containing intervention means and standard deviations on anxiety were reviewed. Overall quality of the trials was low to moderate. Compared with usual care or center-based cardiac rehabilitation, home-based interventions had a small but significant effect in reducing anxiety (total effect size: -0.13; 95% CI: -0.20 to -0.06; P < .001; I = 66%). CONCLUSIONS: This meta-analysis provides evidence that home-based secondary prevention programs are effective in reducing anxiety level in CAD patients. However, because of the limited number of trials available and high degrees of heterogeneity in the data, further research needs to be done to provide a definitive answer on the benefits of home-based programs on anxiety management in CAD patients.