Deprescribing Anticholinergic and Sedative Drugs to Reduce Polypharmacy in Frail Older Adults Living in the Community: A Randomized Controlled Trial.

BACKGROUND: Polypharmacy is associated with poor outcomes in older adults. Targeted deprescribing of anticholinergic and sedative medications may improve health outcomes for frail older adults. Our pharmacist-led deprescribing intervention was a pragmatic 2-arm randomized controlled trial stratified by frailty. We compared usual care (control) with the intervention of pharmacists providing deprescribing recommendations to general practitioners. METHODS: Community-based older adults (≥65 years) from 2 New Zealand district health boards were recruited following a standardized interRAI needs assessment. The Drug Burden Index (DBI) was used to quantify the use of sedative and anticholinergic medications for each participant. The trial was stratified into low, medium, and high-frailty. We hypothesized that the intervention would increase the proportion of participants with a reduction in DBI ≥ 0.5 within 6 months. RESULTS: Of 363 participants, 21 (12.7%) in the control group and 21 (12.2%) in the intervention group had a reduction in DBI ≥ 0.5. The difference in the proportion of -0.4% (95% confidence interval [CI]: -7.9% to 7.0%) provided no evidence of efficacy for the intervention. Similarly, there was no evidence to suggest the effectiveness of this intervention for participants of any frailty level. CONCLUSION: Our pharmacist-led medication review of frail older participants did not reduce the anticholinergic/sedative load within 6 months. Coronavirus disease 2019 (COVID-19) lockdown measures required modification of the intervention. Subgroup analyses pre- and post-lockdown showed no impact on outcomes. Reviewing this and other deprescribing trials through the lens of implementation science may aid an understanding of the contextual determinants preventing or enabling successful deprescribing implementation strategies.

Performance of the Cognitive Performance Scale of the Resident Assessment Instrument (interRAI) for Detecting Dementia amongst Older Adults in the Community.

The Cognitive Performance Scale (CPS) in the widely used interRAI suite of instruments is of interest to clinicians and policy makers as a potential screening mechanism for detecting dementia. However, there has been little evaluation of the CPS in home care settings. This retrospective diagnostic study included 134 older adults (age ≥ 65) who were discharged from two acute psychogeriatric inpatient units or assessed in two memory clinics. The reference test was a diagnosis of clinical dementia, and the index test was interRAI CPS measured within 90 days of discharge. The overall accuracy of the CPS was good, with an area under the Receiver Operating Characteristic curve of 0.82 (95% CI = 0.75-0.89). The optimal cut point was 1/2, coinciding with the recommended cut point, with good sensitivity (0.90, 95% CI = 0.81-0.96) but poor specificity (0.60, 95% CI = 0.46-0.72). Positive predictive value improved from 0.72 (95% CI = 0.66-0.78) to 0.89 (95% CI = 0.75-0.96) when using a cut point of 2/3 instead of 1/2. If the results of the present study are replicated with more generalisable interRAI samples, older adults with a CPS of 3 or above, but without a formal diagnosis of dementia, should be referred for further cognitive assessment.

It's about who they are and what they can do: Maori perspectives on frailty in later life.

AIM: This study aimed to explore Maori (the indigenous people of Aotearoa New Zealand) understandings of frailty. METHOD: Focus groups were held with older Maori in supported living, health professionals working with older Maori and a rural community. A qualitative thematic analysis was conducted. RESULTS: Two interlinked, overarching themes emerged: (1) Frailty is a multidimensional experience, not simply a physical one. (2) The experience of frailty is a balance between deficits and strengths. The Waikare o te Waka o Meihana model provided a useful framework for structuring the thematic results. CONCLUSIONS: Culturally appropriate and comprehensive support and care for older Maori with frailty will be facilitated by a rounded strength-based approach and listening skills.

What Is Frailty? Perspectives from Chinese Clinicians and Older Immigrants in New Zealand.

This qualitative study explores the meanings of frailty held by Chinese New Zealanders and Chinese health care professionals with the aim of identifying commonalities as well as potential differences. Two guided focus groups with Mandarin and Cantonese speaking older adults (n = 10), one individual interview with a English speaking older Chinese, and one focus group with Chinese New Zealand health care professionals (n = 7) were held to obtain views on frailty in older adults, followed by transcribing and a thematic qualitative analysis. Three main themes emerged: (1) Frailty is marked by ill-health, multiple chronic and unstable medical comorbidities, and is a linked with polypharmacy; (2) Frailty can involve physical weakness, decline in physical function such as reduced mobility or poor balance, and declining cognitive function; and (3) Frailty is associated with psychological and social health including depression, reduced motivation, social isolation, and loss of confidence. The perspectives of frailty that emerged are congruent with a multi-dimensional concept of frailty that has been described in both Chinese and non-Chinese medical research literature.

Development of an autobiographical memory test for older electroconvulsive therapy candidates.

OBJECTIVES: To develop a test of autobiographical memory for monitoring of older people during a course of electroconvulsive therapy (ECT). METHOD: A list of events commonly experienced in later life was gathered from older people (n = 26) at a psychogeriatric day clinic and from psychiatrists (n = 23) who work with older depressed patients. The most common events were chosen as question domains for an autobiographical memory interview. This was piloted with 12 severely depressed older patients. RESULTS: A list of 15 common life events was developed. After pilot testing, a final 30-item questionnaire covering six common life events was proposed. CONCLUSION: This study developed an autobiographical memory test with good face validity and potential for clinical use. It was modelled on a well-validated scale (The Columbia University Autobiographical Memory Interview, CUAMI-SF) and represented a useful first step in the development of a test for memory loss in older patients receiving ECT. The proposed test may be particularly sensitive to autobiographical memory loss in older people undergoing ECT because it uses recent personal memories, which are relatively commonly experienced in the older depressed population.

"There's More to Frail than That": Older New Zealanders and Health Professionals Talk about Frailty.

There is general agreement that frailty is common and important in later life, but there is less agreement about what frailty is. Little is known about the extent to which practicing health professionals and older people hold a mutual understanding of frailty. Focus groups were held to engage older people and health professionals in discussion about what made them think that someone was frail. Eighteen older people took part across three focus groups, and se'venteen health professionals took part across another three focus groups. Both the health professionals and the older people talked about the experience of frailty as an interplay of physical, psychological, and social dimensions. Older people with frailty were seen as needing help and being vulnerable to adverse outcomes, but accepting help was positioned by older people as an adaptive choice. The experience of frailty was described as being mediated by the individual's psychological mindset, highlighting the importance of approaches that recognise strengths and resilience. A broader and more balanced understanding of frailty may help create more rounded and appropriate approaches to assessment and management.

Predictors for repeat self-harm and suicide among older people within 12 months of a self-harm presentation.

BACKGROUND: A past history of self-harm is a significant risk factor for suicide in older people. The aims of this study are to (i) characterize older people who present with self-harm to emergency departments (EDs); and (ii) determine the predictors for repeat self-harm and suicide. METHODS: Demographic and clinical data were retrospectively collected on older people (age 65+ years), who presented to seven EDs in New Zealand following an episode of self-harm between 1st July 2010 and 30th June 2013. In addition, 12-month follow-up information on repeat self-harm and suicide was collected. RESULTS: The sample included 339 older people (55.2% female) with an age range of 65-96 years (mean age = 75.0; SD = 7.6). Overdose (68.7%) was the most common method of self-harm. 76.4% of the self-harm cases were classified as suicide attempts. Perceived physical illness (47.8%) and family discord (34.5%) were the most common stressors. 12.7% of older people repeated self-harm and 2.1% died by suicide within 12 months. Older people who had a positive blood alcohol reading (OR = 3.87, 95% Cl = 1.35-11.12, p = 0.012) and were already with mental health services at the index self-harm (OR = 2.73, 95% Cl = 1.20-6.25, p = 0.047) were more likely to repeat self-harm/suicide within 12 months. CONCLUSION: Older people who self-harm are at very high risk of repeat self-harm and suicide. Screening and assessment for alcohol use disorders should be routinely performed following a self-harm presentation, along with providing structured psychological treatment as an adjunct to pharmacological treatment for depression and interventions to improve the person's resilience resources.

Perceptions of a cognitive rehabilitation group by older people living with cognitive impairment and their caregivers: A qualitative interview study.

Cognitive rehabilitation has been developed to improve quality of life, activities of daily living and mood for people with cognitive impairment, but the voice of people with cognitive impairment has been underrepresented. This study aimed to understand the experience of people living with cognitive impairment, as well as their caregivers who took part in a cognitive rehabilitation intervention programme. Twelve individuals with cognitive impairment and 15 caregivers participated in individual qualitative interviews. The interview data were analysed in three steps: 1) familiarisation of the transcripts; 2) identification of themes; 3) re-interpretation, refinement and integration of themes with methodological auditors. Both participants living with cognitive impairment and caregivers valued the comfortable environment with friendly, caring and supportive group leaders who taught practical tips and strategies. The participants living with cognitive impairment enjoyed socialising with like others. Caregivers benefited from learning about memory problems and sharing their challenges with other caregivers. The participants living with cognitive impairment emphasised the benefits of relational and practical aspects, whereas the caregivers valued the informational and emotional support. In conclusion, both participants living with cognitive impairment and caregivers found the cognitive rehabilitation group useful.

Convergent Validity, Concurrent Validity, and Diagnostic Accuracy of the interRAI Depression Rating Scale.

AIMS: Depression Rating Scale (DRS) is one of the clinical outcome measures of the International Resident Assessment Instrument (interRAI) assessment. The primary aim of this study is to investigate the diagnostic accuracy and concurrent validity of the 3-day assessment window version of the DRS. METHODS: The performance of DRS was compared with a gold standard clinical diagnosis of depression in 92 patients (age ≥65) who had interRAI version 9.1 Home Care assessment completed within 30 days of discharge from psychogeriatric inpatient care or memory clinic assessment. RESULTS: The DRS had poor diagnostic accuracy for depression diagnosis with an area under the curve of 0.68 (95% confidence interval [CI] = 0.57-0.77). The DRS score had a poor to moderate correlation with the Health of the Nation Outcome Scale 65+ depression item score ( rs = 0.30, 95% CI = 0.09-0.48, P = .006). CONCLUSION: This study and the existing literature raise concerns that the DRS is not an adequate measure of depression.

Infections Caused by Actinomyces neuii: A Case Series and Review of an Unusual Bacterium.

Background. Actinomyces neuii is a Gram-positive bacillus rarely implicated in human infections. However, its occurrence is being increasingly recognized with the use of improved identification systems. Objective. To analyse A. neuii infections in Alberta, Canada, and review the literature regarding this unusual pathogen. Methods. Cases of A. neuii were identified in 2013-2014 in Alberta. Samples were cultured aerobically and anaerobically. A predominant catalase positive Gram-positive coryneform bacillus with no branching was isolated in each case. Testing was initially done with API-CORYNE® (bioMérieux) and isolates were sent to the Provincial Laboratory for Public Health for further testing. Isolates' identities were confirmed by matrix-assisted laser desorption ionization time-of-flight mass spectrometry microbial identification system (MALDI-TOF MS MIS; bioMérieux) and/or DNA sequencing. Results. Six cases of A. neuii infection were identified. All patients had soft tissue infections; typically, incision and drainage were done followed by a course of antibiotics. Agents used included cephalexin, ertapenem, ciprofloxacin, and clindamycin. All had favourable outcomes. Conclusions. While A. neuii is infrequently recognized, it can cause a diverse array of infections. Increased use of MALDI-TOF MS MIS is leading to increased detection; thus, understanding the pathogenicity of this bacterium and its typical susceptibility profile will aid clinical decision-making.

Developing a dementia-friendly Christchurch: Perspectives of people with dementia.

AIM: Christchurch, New Zealand has a unique opportunity to potentially rebuild as a dementia-friendly city in the wake of the 2010 and 2011 earthquakes. The present study gathered insights from people with dementia about what would make it possible for them to live better in Christchurch. METHODS: Twenty-six older people living with dementia were interviewed using a semi-structured questionnaire. Interviews were transcribed for thematic analysis. RESULTS: Participants talked about the importance of being connected and engaged; of accommodation from service providers and others in the community and raising awareness of dementia, and attributes of the physical environment requiring consideration in the rebuild. CONCLUSION: The themes that emerged about what people with dementia seek from dementia-friendly communities reinforce previous research, but with an overlay of the difficulties of living in an earthquake-damaged city.

"Talking in a new way": older individuals' experiences of group work in an acute psychiatric ward.

Group work is frequently used in mental health, however qualitative studies on service-users' views are rare. Semistructured interviews explored 12 participants' experiences of a café-style social group and a mutual-aid group offered on an older persons psychiatric ward in Christchurch, New Zealand. The values of the strengths-based approach underpinning the groups were reflected back in the experience of an affirming environment, an exchange of strengths, and the capacity to change. The appeal of the café-style may be culturally specific to European women however, reinforcing the importance of an awareness of culture and diversity.

Cultural stereotypes and social representations of elders from Chinese and European perspectives.

Hierarchical cluster analyses of a trait sorting task were used to investigate social representations (and cultural stereotypes) of elderly New Zealanders (NZers) of Chinese and European origin, held by young (mean age = 17) and middle-aged (mean age = 46) NZers from both ethnic groups. Consistent with cultural theories of aging in Chinese societies, organizational features for NZ Chinese were: evaluative simplicity, role-governed representations (e.g., division between socio-emotional and task-oriented elders), little differentiation as a consequence of the ethnicity of elders or age group of subject, and an overall structure dominated by good/bad. NZ Europeans' social representations were more evaluatively complex, had fewer subtypes and more differences as a consequence of target person ethnicity. The Curmudgeon and the Nurturant were the most consensual stereotypes across the 8 cluster analyses (2 subject ethnicity x 2 target ethnicity x 2 subject age group), with the most power to organize stereotypical perceptions of elders across cultural groups. Only the majority group, NZ Europeans, displayed out-group homogeneity effects by creating more categories of elderly Europeans than Chinese. Both ethnic groups held representations of elderly Europeans as higher status in society, and both had more contact with European than Chinese elders outside the family.