CONECT-6: a case-finding tool to identify patients with complex health needs.

BACKGROUND: Early identification of patients with chronic conditions and complex health needs in emergency departments (ED) would enable the provision of services better suited to their needs, such as case management. A case-finding tool would ultimately support ED teams to this end and could reduce the cost of services due to avoidable ED visits and hospitalizations. The aim of this study was to develop and validate a short self-administered case-finding tool in EDs to identify patients with chronic conditions and complex health needs in an adult population. METHODS: This prospective development and initial validation study of a case-finding tool was conducted in four EDs in the province of Quebec (Canada). Adult patients with chronic conditions were approached at their third or more visit to the ED within 12 months to complete a self-administered questionnaire, which included socio-demographics, a comorbidity index, the reference standard INTERMED self-assessment, and 12 questions to develop the case-finding tool. Significant variables in bivariate analysis were included in a multivariate logistic regression analysis and a backward elimination procedure was applied. A receiver operating characteristic (ROC) curve was developed to identify the most appropriate threshold score to identify patients with complex health needs. RESULTS: Two hundred ninety patients participated in the study. The multivariate analysis yielded a six-question tool, COmplex NEeds Case-finding Tool - 6 (CONECT-6), which evaluates the following variables: low perceived health; limitations due to pain; unmet needs; high self-perceived complexity; low income; and poor social support. With a threshold of two or more positive answers, the sensitivity was 90% and specificity 66%. The positive and negative predictive values were 49 and 75% respectively. CONCLUSIONS: The case-finding process is the essential characteristic of case management effectiveness. This study presents the first case-finding tool to identify adult patients with chronic conditions and complex health needs in ED.

Risk of Frequent Emergency Department Use Among an Ambulatory Care Sensitive Condition Population: A Population-based Cohort Study.

BACKGROUND: A small fraction of patients use a disproportionately large amount of emergency department (ED) resources. Identifying these patients, especially those with ambulatory care sensitive conditions (ACSC), would allow health care professionals to enhance their outpatient care. OBJECTIVE: The objectives of the study were to determine predictive factors associated with frequent ED use in a Quebec adult population with ACSCs and to compare several models predicting the risk of becoming an ED frequent user following an ED visit. RESEARCH DESIGN: This was an observational population-based cohort study extracted from Quebec's administrative data. SUBJECTS: The cohort included 451,775 adult patients, living in nonremote areas, with an ED visit between January 2012 and December 2013 (index visit), and previously diagnosed with an ACSC but not dementia. MEASURES: The outcome was frequent ED use (≥4 visits) during the year following the index visit. Predictors included sociodemographics, physical and mental comorbidities, and prior use of health services. We developed several logistic models (with different sets of predictors) on a derivation cohort (2012 cohort) and tested them on a validation cohort (2013 cohort). RESULTS: Frequent ED users represented 5% of the cohort and accounted for 36% of all ED visits. A simple 2-variable prediction model incorporating history of hospitalization and number of previous ED use accurately predicted future frequent ED use. The full model with all sets of predictors performed only slightly better than the simple model (area under the receiver-operating characteristic curve: 0.786 vs. 0.759, respectively; similar positive predictive value and number needed to evaluate curves). CONCLUSIONS: The ability to identify frequent ED users based only on previous ED and hospitalization use provides an opportunity to rapidly target this population for appropriate interventions.

Factors associated with frequent use of emergency-department services in a geriatric population: a systematic review.

BACKGROUND: Frequent geriatric users of emergency departments (EDs) constitute a small group of individuals accounting for a disproportionately high number of ED visits. In addition to overcrowding, this situation might result in a less appropriate response to health needs and negative health impacts. Geriatric patients turn to EDs for a variety of reasons. A better understanding of the variables associated with frequent ED use will help implement interventions best suited for their needs. OBJECTIVE: This review aimed at identifying variables associated with frequent ED use by older adults. METHODS: For this systematic review, we searched Medline, CINAHL, Healthstar, and PsyINFO (before June 2018). Articles written in English or French meeting these criteria were included: targeting a population aged 65 years or older, reporting on frequent ED use, using an observational study design and multivariate regression analysis. The search was supplemented by manually examining the reference lists of relevant studies. Independent reviewers identified articles for inclusion, extracted data, and assessed quality with the JBI Critical Appraisal Checklist for Studies Reporting Prevalence. A narrative synthesis was done to combine the study results. A sensitivity analysis was performed to evaluate the effect of removing the studies not meeting the quality criteria. RESULTS: Out of 5096 references, 8 met our inclusion criteria. A high number of past hospital and ED admissions, living in a rural area adjacent to an urban center, low income, a high number of prescribed drugs, and a history of heart disease were associated with frequent ED use among older adults. In addition, having a principal-care physician and living in a remote rural area were associated with fewer ED visits. Some variables recognized in the literature as influencing ED use among older adults received scant consideration, such as comorbidity, dementia, and considerations related to primary-care and community settings. CONCLUSION: Further studies should bridge the gap in understanding and give a more global portrait by adding important personal variables such as dementia, organizational variables such as use of community and primary care, and contextual variables such as social and economic frailty.

Development and validation of clinical profiles of patients hospitalized due to behavioral and psychological symptoms of dementia.

BACKGROUND: Patients hospitalized on acute psychogeriatric wards are a heterogeneous population. Cluster analysis is a useful statistical method for partitioning a sample of patients into well separated groups of patients who present common characteristics. Several patient profile studies exist, but they are not adapted to acutely hospitalized psychogeriatric patients with cognitive impairment. The present study aims to partition patients hospitalized due to behavioral and psychological symptoms of dementia into profiles based on a global evaluation of mental health using cluster analysis. METHODS: Using nine of the 13 items from the Health of the Nation Outcome Scales for elderly people (HoNOS65+), data were collected from a sample of 542 inpatients with dementia who were hospitalized between 2011 and 2014 in acute psychogeriatric wards of a Swiss university hospital. An optimal clustering solution was generated to represent various profiles, by using a mixed approach combining hierarchical and non-hierarchical (k-means) cluster analyses associated with a split-sample cross-validation. The quality of the clustering solution was evaluated based on a cross-validation, on a k-means method with 100 random initial seeds, on validation indexes, and on clinical interpretation. RESULTS: The final solution consisted of four clinically distinct and homogeneous profiles labeled (1) BPSD-affective, (2) BPSD-functional, (3) BPSD-somatic and (4) BPSD-psychotic according to their predominant clinical features. The four profiles differed in cognitive status, length of hospital stay, and legal admission status. CONCLUSION: In the present study, clustering methods allowed us to identify four profiles with distinctive characteristics. This clustering solution may be developed into a classification system that may allow clinicians to differentiate patient needs in order to promptly identify tailored interventions and promote better allocation of available resources.

[From daily care to expert consensus: state of evidence of nursing interventions and their prioritization according to the clinical profiles of older people hospitalized due to behavioral and psychological symptoms of dementia]. / Du soin pratiqué au quotidien au consensus d'experts : état de I'évidence sur les interventions infirmières et leur priorisation selon le profil clinique des personnes âgées hospitalisées our des symptômes comportementaux et psychologiques de la démence.

The description of the different profiles of somatic, psychiatric and socio-relational comorbidites of psychogeriatric inpatient hospitalized due to behavioral and psychological symptoms of dementia and their associated nursing interventions are poorly documented. This study aimed to describe the observations and interventions given to patients from the four LPCI clinical profiles and to reach a consensus of experts on relevant interventions per profile. A content analysis was conducted on computerized nursing notes of 40 patients. By combining individual and collective production phase, the TRIAGE method allowed reaching an expert consensus on relevant interventions. The results showed that the current practices are generally similar for all patients while appropriate interventions from the expert consensus varied depending on the profile. Also, some problems remain poorly invested, such as screening, assessment and treatment of depressive symptoms and the maintenance of functional autonomy. Since most interventions have been tested in long- term institutions, the development of studies to test interventions tailored to acute psychogeriatric environment and the implementation of evidence-based practices are needed.

Does regulating private long-term care facilities lead to better care? A study from Quebec, Canada.

OBJECTIVE: In the province of Quebec, Canada, long-term residential care is provided by two types of facilities: publicly funded accredited facilities and privately owned facilities in which care is privately financed and delivered. Following evidence that private facilities were delivering inadequate care, the provincial government decided to regulate this industry. We assessed the impact of regulation on care quality by comparing quality assessments made before and after regulation. In both periods, public facilities served as a comparison group. DESIGN: A cross-sectional study conducted in 2010-12 that incorporates data collected in 1995-2000. SETTINGS: Random samples of private and public facilities from two regions of Quebec. PARTICIPANTS: Random samples of disabled residents aged 65 years and over. In total, 451 residents from 145 care settings assessed in 1995-2000 were compared with 329 residents from 102 care settings assessed in 2010-12. INTERVENTION: Regulation introduced by the province in 2005, effective February 2007. MAIN OUTCOME MEASURE: Quality of care measured with the QUALCARE Scale. RESULTS: After regulation, fewer small-size facilities were in operation in the private market. Between the two study periods, the proportion of residents with severe disabilities decreased in private facilities whereas it remained >80% in their public counterparts. Meanwhile, quality of care improved significantly in private facilities, while worsening in their public counterparts, even after controlling for confounding. CONCLUSIONS: The private industry now provides better care to its residents. Improvement in care quality likely results in part from the closure of small homes and change in resident case-mix.

Identifying psychosocial variables for home care services and how to measure them.

A Delphi-type expert consultation founded on the RAND/UCLA Appropriateness method was used to select variables related to older adults and environment characteristics perceived essential in assessing psychosocial needs and that could influence the social work workload in home care services. After two rounds of consultation, the 60 experts reached a consensus on 97 variables out of the 160 considered. A focus group made up of 10 experts identified tools that would allow us to measure the variables in a clinical context. Eighty-three percent of the variables selected could be measured with five instruments identified by the focus group experts.

[Development of decision support guidance of people in loss of autonomy in the care system in the Canton of Geneva's healthcare system]. / Développement d'algorithmes de soutien à la décision d'orientation des personnes en perte d'autonomie dans le réseau de soins du Canton de Genève.

AIM: The objective of this study is to use Iso-SMAF functional autonomy profiles (SMAF: French acronym for Functional autonomy measurement system) and other clinical and sociodemographic characteristics to develop algorithms that would support decision-making in orienting disabled people that would be adapted to current and future options available to a healthcare system in the Canton of Geneva. METHODS: A modified Delphi expert consultation, including the RAND/UCLA method, was used. After two rounds of consultations in which the experts responded to Web-based questionnaires, a nominal group completed the study. RESULTS: A total of 108 experts took part in the online consultation during the two rounds of consultation; 13 took part in the nominal group. In addition to belonging to various disciplines, the participants came from the different care structures within the Canton of Geneva. The findings made it possible to develop 14 decision-making algorithms, eight of which received consensus support in the first round of consultation. The second round and nominal group achieved consensus for others. The profiles with moderate to severe cognitive impairment were those for which the orientation options required several rounds of voting. CONCLUSION: Since the orientation choices suggested by the algorithms were relatively standardized, they constitute recommendations that can guide professionals in orienting people.

Profiles of frequent emergency department users with chronic conditions: a latent class analysis.

OBJECTIVES: Frequent emergency department users represent a small proportion of users while cumulating many visits. Previously identified factors of frequent use include high physical comorbidity, mental health disorders, poor socioeconomic status and substance abuse. However, frequent users do not necessarily exhibit all these characteristics and they constitute a heterogeneous population. This study aims to establish profiles of frequent emergency department users in an adult population with chronic conditions. DESIGN: This is a retrospective cohort study using administrative databases. SETTING: All adults who visited the emergency department between 2012 and 2013 (index date) in the province of Quebec (Canada), diagnosed with at least one chronic condition, and without dementia were included. Patients living in remote areas and who died in the year following their index date were excluded. We used latent class analysis, a probability-based model to establish profiles of frequent emergency department users. Frequent use was defined as having five visits or more during 1 year. Patient characteristics included sociodemographic characteristics, physical and mental comorbidities and prior healthcare utilisation. RESULTS: Out of 4 51 775 patients who visited emergency departments at least once in 2012-2013, 13 676 (3.03%) were frequent users. Four groups were identified: (1) 'low morbidity' (n=5501, 40.2%), (2) 'high physical comorbidity' (n=3202, 23.4%), (3) 'injury or chronic non-cancer pain' (n=2313, 19.5%) and (4) 'mental health or alcohol/substance abuse' (n=2660, 16.9%). CONCLUSIONS: The four profiles have distinct medical and socioeconomic characteristics. These profiles provide useful information for developing tailored interventions that would address the specific needs of each type of frequent emergency department users.

Scoping study of definitions and instruments measuring vulnerability in older adults.

BACKGROUND: It is important to foster social participation and health equity, especially for older adults in situations of vulnerability. Despite growing interest in vulnerability, there is no consensus regarding how to define or measure this concept. This paper provides an inventory and synthesis of definitions of and instruments measuring vulnerability in older adults. METHODS: Using a scoping study framework, eight databases (Abstracts in Social Gerontology, Academic Search Complete, AgeLine, CINAHL, MEDLINE, SocINDEX, PsycInfo, Scopus) were searched with relevant keywords [Vulnerab* AND (Concept*, Defin*, Meaning, Terminology, Measurement, Assessment*, Indicator*, Instrument*, Scale*, Questionnaire* OR Test*) AND (Aging, Aging, Elder*, Gerontolog*, Older OR Senior*)]. RESULTS: Thirty-one original definitions and five measuring instruments were identified, content-analyzed, and compared. Vulnerability definitions mostly focused on people under conditions that increased their risk of harm because of individual physical factors, the environment, and their interaction. Considering these definitions, experts in the field of aging, including two representing older adults, participated in a workshop, and a consensus was reached to define a situation of vulnerability as "a set of circumstances in which one or more individuals experience, at a specific moment in time, one or multiple physiological, psychological, socioeconomic or social difficulties that may interact to increase their risk of being harmed or having coping challenges that have a negative impact on their life." Although none of the measures fully targeted this definition, the Perceived Vulnerability Scale (PVS) is one of the most complete measures, with 22 items considering feelings of vulnerability toward personal and environmental factors, and good psychometric properties. CONCLUSIONS: The proposed definition and the PVS help to provide a common language and measure in health and social sciences research, policy and practice identifying and reaching older adults in situations of vulnerability and intervening to foster social participation and health equity.

Meeting the home-care needs of disabled older persons living in the community: does integrated services delivery make a difference?

BACKGROUND: The PRISMA Model is an innovative coordination-type integrated-service-delivery (ISD) network designed to manage and better match resources to the complex and evolving needs of elders. The goal of this study was to examine the impact of this ISD network on unmet needs among disabled older persons living in the community. METHODS: Using data from the PRISMA study, we compared unmet needs of elders living in the community in areas with or without an ISD network. Disabilities and unmet needs were assessed with the Functional Autonomy Measurement System (SMAF). We used growth-curve analysis to examine changes in unmet needs over time and the variables associated with initial status and change. Sociodemographic characteristics, level of disability, self-perceived health status, cognitive functioning, level of empowerment, and the hours of care received were investigated as covariates. Lastly, we report the prevalence of needs and unmet needs for 29 activities in both areas at the end of the study. RESULTS: On average, participants were 83 years old; 62% were women. They had a moderate level of disability and mild cognitive problems. On average, they received 2.07 hours/day (SD = 1.08) of disability-related care, mostly provided by family. The findings from growth-curve analysis suggest that elders living in the area where ISD was implemented and those with higher levels of disability experience better fulfillment of their needs over time. Besides the area, being a woman, living alone, having a higher level of disability, more cognitive impairments, and a lower level of empowerment were linked to initial unmet needs (r2 = 0.25; p < 0.001). At the end of the study, 35% (95% CI: 31% to 40%) of elders with needs living in the ISD area had at least one unmet need, compared to 67% (95% CI: 62% to 71%) in the other area. In general, unmet needs were highest for bathing, grooming, urinary incontinence, walking outside, seeing, hearing, preparing meals, and taking medications. CONCLUSIONS: In spite of more than 30 years of home-care services in the province of Quebec, disabled older adults living in the community still have unmet needs. ISD networks such as the PRISMA Model, however, appear to offer an effective response to the long-term-care needs of the elderly.

Computerized Care-Pathways (CCPs) System to Support Person-Centered, Integrated, and Proactive Care in Home-Care Settings.

This paper describes the software design/development process leading to an improved computerized clinical/management solution-RSIPA (2016 version)-integrating care pathways (CPs) specifically designed to meet the needs of frail and disabled older adults in home care. The development methodology used Soft Systems Methodology (SSM) for the initial system design and participatory design (PD) to involve stakeholders and end users, along with AGILE SCRUM methodology to provide rapid iterations in adapting to new requests. Given scarce project resources, we opted to combine methodologies to efficiently deliver a fully functional system for three of the five CP clinical phases. The development methodology aggregated assessment-based data to identify risk factors and assist in needs prioritization leading to care plans and addressed in the current system. The new Quebec RSIPA solution incorporating CCPs is a promising example of technologies that support person-centered care, clinical and management processes, and proactive care in home-care settings.

Profiles of Frequent Geriatric Users of Emergency Departments: A Latent Class Analysis.

BACKGROUND/OBJECTIVES: Frequent geriatric users of emergency departments (EDs) represent a complex and heterogeneous population. Identifying their specific subgroups would allow the development of interventions better customized to their needs and characteristics. Thus, this study aimed to develop profiles of frequent geriatric ED users using the individual characteristics of patients. DESIGN: This was a retrospective cohort study. SETTING: Databases from the Régie de l'assurance maladie du Québec (RAMQ) were utilized. PARTICIPANTSThis study included individuals aged 65 years or older living in the community in the Province of Quebec (Canada), who consulted in an ED at least four times in the year after an ED index date (an ED visit, chosen randomly, during an index period of January 1, 2012 to December 31, 2013) and who had received a diagnosis of ambulatory care-sensitive conditions (ACSCs) in the 2 years preceding the index date. MEASUREMENTS: A latent class analysis was used to identify subgroups of frequent geriatric ED users according to their individual characteristics, including ACSC type, dementia, mental health disorders, cancer diagnosis, and comorbidity index. RESULTS: The study cohort consisted of 21,393 frequent geriatric ED users. Four groups of frequent geriatric ED users were identified: people with low comorbidity (39.0%), comprising the individuals with the lowest number of physical and mental health conditions; people with cancer (32.7%); people with pulmonaryand cardiac diseases (18.1%); and people with dementia or mental health disorders (10.2%), composed of individuals with the highest proportion of common and severe mental health disease, as well as dementia. This group accounts for the highest use of overall healthcare services. CONCLUSION: These profiles will be useful in developing customized interventions addressing the needs of each subgroup of frequent geriatric ED users. More research is needed to bridge the remaining gaps, especially regarding the healthiest frequent geriatric users of EDs.

Frequent emergency department use by older adults with ambulatory care sensitive conditions: A population-based cohort study.

AIM: To identify factors associated with frequent emergency department (ED) use among older adults with ambulatory care sensitive conditions. METHODS: This was a retrospective cohort study using databases from the Régie de l'assurance maladie du Québec. We included community-dwelling individuals aged ≥65 years in the Province of Quebec (Canada), who consulted in ED at least once between 2012 and 2013 (index period), and were diagnosed with at least one ambulatory care sensitive condition in the 2 years preceding and including the index date (n = 264 473). We used a multivariate logistic regression model to evaluate the association between independent variables and being a frequent geriatric ED user, defined as four or more visits during the year after the index date. RESULTS: Out of the total study population, 17 332 (6.6%) individuals were considered frequent ED users in the year after the index date, accounting for 38% of ED uses for this period. The main variables associated with frequent geriatric ED use were older age, presence of chronic obstructive pulmonary disorder or diabetes, higher comorbidity index, common mental health disorders, polypharmacy, higher number of past ED and specialist visits, rural residence, and higher material and social deprivation. Dementia was inversely associated with frequent ED use. CONCLUSIONS: Frequent geriatric ED users constitute a complex population whose characteristics need to be managed thoroughly in order to enhance the quality and efficiency of their care. Further studies should address their description in administrative databases so as to combine self-perceived and professionally evaluated variables. Geriatr Gerontol Int 2020; 20: 317-323.

Persistent frequent emergency department users with chronic conditions: A population-based cohort study.

BACKGROUND: Frequent emergency department users are patients cumulating at least four visits per year. Few studies have focused on persistent frequent users, who maintain their frequent user status for multiple consecutive years. This study targets an adult population with chronic conditions, and its aims are: 1) to estimate the prevalence of persistent frequent ED use; 2) to identify factors associated with persistent frequent ED use (frequent use for three consecutive years) and compare their importance with those associated with occasional frequent ED use (frequent use during the year following the index date); and 3) to compare characteristics of "persistent frequent users" to "occasional frequent users" and to "users other than persistent frequent users". METHODS: This is a retrospective cohort study using Quebec administrative databases. All adult patients who visited the emergency department in 2012, diagnosed with chronic conditions, and living in non-remote areas were included. Patients who died in the three years following their index date were excluded. The main outcome was persistent frequent use (≥4 visits per year during three consecutive years). Potential predictors included sociodemographic characteristics, physical and mental comorbidities, and prior healthcare utilization. Odds ratios were computed using multivariable logistic regression. RESULTS: Out of 297,182 patients who visited ED at least once in 2012, 3,357 (1.10%) were persistent frequent users. Their main characteristics included poor socioeconomic status, mental and physical comorbidity, and substance abuse. Those characteristics were also present for occasional frequent users, although with higher percentages for the persistent user group. The number of previous visits to the emergency department was the most important factor in the regression model. The occasional frequent users' attrition rate was higher between the first and second year of follow-up than between the second and third year. CONCLUSIONS: Persistent frequent users are a subpopulation of frequent users with whom they share characteristics, such as physical and mental comorbidities, though the former are poorer and younger. More research is needed in order to better understand what factors can contribute to persistent frequent use.

Correlates of the perceived need for institutionalisation among older adults without cognitive impairment.

BACKGROUND: While many studies investigate the factors that influence the institutionalisation of older persons, only a few consider one of its most important predictors, namely, the perceived need for institutionalisation. Also referred to as 'desire for institutionalisation', it has mainly been investigated for informal caregivers of older adults suffering from dementia. Not many studies target caregivers of people without dementia; even fewer have been interested in the older adult's own perceived need. OBJECTIVE: To measure the prevalence and identify the correlates of the perceived need for institutionalisation among community-dwelling older adults without cognitive impairment. METHODS: During the fourth wave of the longitudinal PRISMA study, cognitive-impairment-free participants (78 years or older and at risk of functional decline) were presented with three questions assessing their perceived need for institutionalisation. Correlates were identified through multivariable logistic regression analyses. Analyses were conducted separately for two types of home living arrangements: individual and collective dwellings. RESULTS: 27% of the older adults at least thought about institutionalisation, irrespective of their current living arrangements. For homeowners/tenants, age ranging from 80 to 85, transfer and vision problems, the absence or advanced age of the informal caregiver, and the use of the ER or help for home maintenance during the past year led them to think about institutionalisation. Seniors living in collective dwellings think about institutionalisation after experiencing a recent highly significant functional decline, when feeling that their current environment fails to meet needs, and after requiring the use of voluntary services during the past year. CONCLUSIONS: The percentage of community-dwelling older adults considering institutionalisation is the same for people currently in individual or collective settings. Factors related to physical disabilities and insufficiencies of resources are important correlates, with specific factors differing between the two types of current living arrangements.

The social support experiences of major junior ice hockey players in a physically removed region of Canada.

The present report from a larger project overviews the sources and types of social support resourced by 10 major junior athletes while they performed out of one physically removed Canadian region. Retrospective interviews and content analysis were conducted during three stages (3, 3, and 4 respondents). The data were segmented into meaning units, coded into a hierarchy of themes, and verified by each respondent and an expert panel (former athlete, coach, parent of former athlete). The respondents sought out three types of social support from four different sources (providers) that were adapted to their remote location, including teachers and general community support. Implications are considered in terms of applied research and practice with aspiring adolescent athletes located in removed locations. Key pointsThe study extends knowledge about the sources and types of social support resourced by elite major junior ice hockey players located in one physically removed Canadian region.From the respondents' views, three types of social support were sought from four different sources.Implications are considered in terms of sport psychology research and applied practice.

Characteristics of frequent users of emergency departments living with major neurocognitive disorders: a cohort study / Características dos utilizadores frequentes dos departamentos de emergência que vivem com demência: um estudo de coorte

OBJETIVO: Este estudo teve como objetivo descrever e comparar as características dos adultos idosos, residentes na comunidade, que vivem com demência e que recorreram frequentemente aos departamentos de emergência. METODOLOGIA: Este é um estudo retrospetivo baseado numa análise secundária de dados administrativos provinciais de saúde no Quebeque, Canadá. Incluímos adultos idosos residentes na comunidade do Quebeque considerados utilizadores frequentes dos departamentos de emergência (mínimo de quatro visitas no ano seguinte a uma visita ao departamento de emergência indexada, escolhida aleatoriamente durante o período de 1 de janeiro de 2012 até 31 de dezembro de 2013) e diagnosticados com pelo menos uma condição crônica. Comparamos as características dos utilizadores frequentes que vivem com e sem demência utilizando os testes qui-quadrado e Kruskal-Wallis. RESULTADOS: A coorte do estudo consistiu em 21 393 utilizadores frequentes, dos quais 3051 (14,26%) foram identificados como portadores de demência. Os resultados salientam maior carga de condições crônicas, polifarmácia, uso de antipsicótico e serviços de saúde passados entre esses indivíduos. Os resultados também revelam maior proporção de doenças associadas a síndromes geriátricas como trauma e lesão, desnutrição, hipertensão ortostática e distúrbios de marcha. CONCLUSÃO: Os utilizadores frequentes dos serviços de emergência que vivem com demência representam uma população complexa. Os nossos resultados salientam a importância de abordar sistematicamente as suas necessidades, em contextos apropriados e por meio de intervenções personalizadas. (AU)

OBJECTIVE: This study aimed to describe and compare the characteristics of community-dwelling older adults living with or without major neurocognitive disorders who made frequent use of emergency departments. METHODS: This is a retrospective cohort study based on a secondary analysis of provincial health administrative data in Quebec, Canada. We included community-dwelling older adults from Quebec who were considered frequent emergency department users (a minimum of 4 visits in the year following an index emergency department visit chosen randomly between January 1, 2012, and December 31, 2013) and who had been diagnosed with at least one chronic condition. We compared characteristics of frequent users living with or without major neurocognitive disorders using chi-square and Kruskal-Wallis tests. RESULTS: The study cohort consisted of 21 393 frequent emergency department users, of which 3051 (14.26%) were identified as having a major neurocognitive disorder. The results highlight a higher burden of chronic conditions, polypharmacy, antipsychotic use, and past use of healthcare services among these individuals. The results also reveal a higher proportion of conditions associated with geriatric syndromes such as trauma and injury, malnutrition, orthostatic hypertension, and gait disorders. CONCLUSION: Frequent emergency department users living with major neurocognitive disorders represent a complex population. Our results highlight the importance of systematically addressing their needs in appropriate settings and through customized interventions. (AU)

Disability-based classification system for older people in integrated long-term care services: the Iso-SMAF profiles.

This study was conducted to develop and evaluate a disability-based classification system for management of long-term care (LTC) needs in an integrated service delivery system. We collected cross-sectional data on 29 items of the Functional Autonomy Measurement System (SMAF) from a stratified multistage sampling of 1977 elderly people with disabilities living in different environments. Disability profiles were identified using statistical clustering techniques combined with advice form a panel of experts. Their clinical meaningfulness, stability, reproducibility, homogeneity, heterogeneity and predictive validity were evaluated. The Iso-SMAF classification consisted of 14 homogeneous disability profiles characterized by a gradual progression in the severity of disabilities in instrumental activities of daily living (IADL) and activities of daily living (ADL) accompanied by predominant limitations either in mobility or mental functions. The profiles achieved a Kappa reproducibility coefficient of 0.67 through cross validation. A stable cluster structure emerged when the items were analyzed using different methods. They explained 82% of the variance in nursing care time, 80% of the variance in cost of nursing care (skilled and unskilled) and 57% of the variance in total costs including both formal and informal sources of LTC services. The conclusion recommends their use for planning, managing and predicting LTC service needs in an integrated care system.