Geriatric care physicians' perspectives on providing virtual care: a reflexive thematic synthesis of their online survey responses from Ontario, Canada.

BACKGROUND: During the COVID-19 pandemic, telemedicine was widely implemented to minimise viral spread. However, its use in the older adult patient population was not well understood. OBJECTIVE: To understand the perspectives of geriatric care providers on using telemedicine with older adults through telephone, videoconferencing and eConsults. DESIGN: Qualitative online survey study. SETTING AND PARTICIPANTS: We recruited geriatric care physicians, defined as those certified in Geriatric Medicine, Care of the Elderly (family physicians with enhanced skills training) or who were the most responsible physician in a long-term care home, in Ontario, Canada between 22 December 2020 and 30 April 2021. METHODS: We collected participants' perspectives on using telemedicine with older adults in their practice using an online survey. Two researchers jointly analysed free-text responses using the 6-phase reflexive thematic analysis. RESULTS: We recruited 29 participants. Participants identified difficulty using technology, patient sensory impairment, lack of hospital support and pre-existing high patient volumes as barriers against using telemedicine, whereas the presence of a caregiver and administrative support were facilitators. Perceived benefits of telemedicine included improved time efficiency, reduced travel, and provision of visual information through videoconferencing. Ultimately, participants felt telemedicine served various purposes in geriatric care, including improving accessibility of care, providing follow-up and obtaining collateral history. Main limitations are the absence of, or incomplete physical exams and cognitive testing. CONCLUSIONS: Geriatric care physicians identify a role for virtual care in their practice but acknowledge its limitations. Further work is required to ensure equitable access to virtual care for older adults.

Geriatric Specialists' Perspectives on Telemedicine during the COVID-19 Pandemic: a Concurrent Triangulation Mixed-Methods Study.

During the COVID-19 pandemic, physicians provided virtual care to minimize viral transmission. This concurrent triangulation mixed-methods study assesses the use of synchronous telephone and video visits with patients and asynchronous eConsults by geriatric providers, and explores their perspectives on telemedicine use during the pandemic. Participants included physicians practicing in Ontario, Canada who were certified in Geriatric Medicine, or Care of the Elderly, or who were the most responsible physician in a long-term care for at least 10 patients. Participants' perspectives were solicited using an online survey and themes were generated through a reflexive thematic analysis of survey responses. We assessed the current use of each telemedicine tool and compared the proportion of participants using telemedicine before the pandemic with self-predicted use after the pandemic. We received 29 surveys from eligible respondents (87.9% completion rate), with 75.9% being geriatricians. The telephone was most used (96.6%), followed by video (86.2%) and eConsults (64%). Most participants using telephone and video visits had newly implemented them during the pandemic and intend to continue using these tools post-pandemic. Our thematic analysis revealed that telemedicine plays an important role in the continuity of care during the pandemic, with increased self-reported positive perspectives and openness towards use of virtual care tools, although limited by inadequate physical exams or cognitive testing. Its ongoing use depends on the availability of continued remuneration.

Barriers and facilitators for optimizing oral anticoagulant management: Perspectives of patients, caregivers, and providers.

BACKGROUND: Oral anticoagulants (OACs) are very commonly prescribed for prevention of serious vascular events, but are also associated with serious medication-related bleeding. Mitigation of harm is believed to require high-quality OAC management. This study aimed to identify barriers and facilitators for optimal OAC management from the perspective of patients, caregivers and healthcare providers. METHODS: Using a qualitative descriptive study design, we conducted five focus groups, three with patients and caregivers and two with health care providers, in two health regions in Southwestern Ontario. An expert facilitator led the discussions using a semi-structured interview guide. Each session was digitally recorded, transcribed verbatim and anonymized. Transcripts were analyzed in duplicate using conventional content analysis. RESULTS: Forty-two (19 patients, 7 caregivers, and 16 providers including physicians, nurses and pharmacists) participated. More than half of the patients received OAC for the treatment of venous thromboembolism (57.9%) and the majority (94.7%) were on chronic therapy (defined as >3 years). Data analysis organized codes describing barriers and facilitators into 4 main themes-medication-related, patient-related, provider-related, and system-related. Barriers highlighted were problems with medication access due to cost, patient difficulties with adherence, knowledge and adjusting their lifestyles to OAC therapy, provider expertise, time for adequate communication amongst providers and their patients, and health care system inadequacies in supporting communications and monitoring. Facilitators identified generally addressed these barriers. CONCLUSIONS: Many barriers to optimal OAC management exist even in the era of DOACs, many of which are amenable to facilitators of improved care coordination, patient education, and adherence monitoring.

Canadian Guidelines on Benzodiazepine Receptor Agonist Use Disorder Among Older Adults Title.

BACKGROUND: Benzodiazepine receptor agonist (BZRA) use disorder among older adults is a relatively common and challenging clinical condition. METHOD: The Canadian Coalition for Seniors' Mental Health, with financial support from Health Canada, has produced evidence-based guidelines on the prevention, identification, assessment, and management of this form of substance use disorder. RESULTS: Inappropriate use of BZRAs should be avoided by considering non-pharmacological approaches to the management of late life insomnia, anxiety, and other common indications for the use of BZRA. Older persons should only be prescribed BZRAs after they are fully informed of alternatives, benefits, and risks associated with their use. Clinicians should have a high index of suspicion for the presence of BZRA use disorders. The full version of these guidelines can be accessed at www.ccsmh.ca. CONCLUSIONS: A person-centred, stepped care approach utilizing gradual dose reductions should be used in the management of BZRA use disorder.

A population-based study of the risk of osteoporosis and fracture with dutasteride and finasteride.

BACKGROUND: Dutasteride is a potent inhibitor of 5-alpha reductase enzymes that reduces concentrations of dihydrotestosterone to a greater extent than finasteride. Whether this has adverse implications for bone health is unknown. We compared the risk of osteoporosis and fractures in older men treated with dutasteride or finasteride. METHODS: We conducted a population-based retrospective cohort study with high-dimensional propensity score matching of Ontario men aged 66 years or older who started treatment with dutasteride or finasteride between January 1, 2006 and December 31, 2012. The primary outcome was a diagnosis of osteoporosis within 2 years of treatment initiation. A secondary outcome was osteoporotic or fragility fractures. RESULTS: We studied 31,615 men treated with dutasteride and an equal number of men treated with finasteride. Dutasteride-treated patients had a lower incidence of osteoporosis than those receiving finasteride [2.2 versus 2.6 per 100 person years; hazard ratio (HR) 0.82; 95% confidence interval (CI) 0.72 to 0.93]. This effect was no longer statistically significant following adjustment for specialty of prescribing physician (HR 0.90; 95% CI 0.78 to 1.02)]. There was no differential risk of fractures with dutasteride (HR 1.04; 95% 0.86 to 1.25). CONCLUSIONS: Despite differential effects on 5-alpha reductase, dutasteride is not associated with an increased risk of osteoporosis or fractures in older men relative to finasteride. These findings suggest that dutasteride does not adversely affect bone health.

Pregabalin and heart failure: A population-based study.

PURPOSE: The anticonvulsant pregabalin is increasingly prescribed for pain, seizures, and psychiatric disorders. Although evidence suggests pregabalin can cause edema and heart failure, its cardiac safety profile in clinical practice is unknown. We sought to examine the risk of heart failure among older patients receiving pregabalin compared to those receiving gabapentin. METHODS: We conducted a population-based cohort study of Ontarians aged 66 and older with a history of seizure who received pregabalin or gabapentin between April 2013 and March 2014. We used propensity scores to match patients commencing pregabalin to those commencing gabapentin. The primary outcome was an emergency department visit or hospitalization for heart failure within 90 days. RESULTS: We studied 9855 patients who initiated pregabalin and an equal number treated with gabapentin. In the primary analysis, we found no difference in the risk of heart failure with pregabalin compared to gabapentin (1.2% versus 1.3%, hazard ratio of 0.77; 95% CI 0.58-1.03). Secondary analyses stratified for baseline history of heart failure yielded similar findings. CONCLUSION: In a large cohort of older patients with a seizure disorder, pregabalin was not associated with an increased risk of heart failure relative to gabapentin.

Risk of serious falls associated with oxybutynin and tolterodine: a population based study.

PURPOSE: We compared the short-term risk of falls among recipients of oxybutynin or tolterodine to treat urinary incontinence. MATERIALS AND METHODS: We conducted a population based, retrospective cohort study with propensity score matching among patients 66 years old or older who commenced treatment with oxybutynin or tolterodine in Ontario, Canada. The primary outcome was a hospital visit for a fall within 90 days of drug initiation. Secondary outcomes included hospital visits for fractures, delirium or all cause mortality. RESULTS: We found no difference in the risk of falls among users of oxybutynin vs tolterodine (adjusted hazard ratio 1.04, 95% CI 0.95 to 1.14). Secondary analyses revealed no differential risk of fractures (aHR 0.96, 95% CI 0.82 to 1.13) or delirium (aHR 0.90, 95% CI 0.66 to 1.23) associated with oxybutynin. However, statistically significant increases in the risk of all cause hospitalization (aHR 1.12, 95% CI 1.07 to 1.17) and death (aHR 1.20, 95% CI 1.07 to 1.35) were seen with oxybutynin. CONCLUSIONS: Oxybutynin was not associated with a short-term increased risk of hospital visit for falls, fractures or delirium compared to tolterodine. Further research is needed to confirm whether oxybutynin is associated with an increased risk of hospitalization or death.