Transitioning Towards a Virtual Falls Prevention Program for Frail Seniors: Learning from the Experiences of Older Adults During the COVID-19 Pandemic.

Background: The literature to date is unable to clearly characterize the appropriateness of virtual care for falls prevention services from the patient perspective. In response to COVID-19, the Falls Prevention Program (FPP) at Sunnybrook Health Sciences Centre was modified to include virtual components. We set out to uncover the experiences of this unique older-adult patient population to inform FPP quality improvement and appropriate incorporation of technology post-pandemic. Methods: FPP patients during the COVID-19 pandemic (February 2020 - February 2022) and their primary caregivers met inclusion criteria. Out of 18 eligible patients, 10 consented to participate in 20-minute, semi-structured telephone interviews conducted and transcribed by the first author. Inductive coding followed by theme generation occurred through collaborative analysis. Results: The participants (n=10) were 60% female, mean age 84 years (SD 5.8), 60% living alone, and 70% university educated. We generated three main themes: 1) First Steps First, revealed a common desire for physical and mental support and the perceived essentials of a successful FPP highlighting the importance of program length and individualized attention; 2) Overcoming Obstacles, highlighted participants' experiences overcoming barriers with technology in the context of an isolating pandemic; and 3) Advancing Care Post-Pandemic, elaborated on the appropriateness of virtual care and delved into the importance of program personalization. Conclusion: The interviewed older adults revealed agreement on the FPP's necessity and the importance of increasing program length, one-on-one interaction, and program flexibility for unique patient needs. Incorporating virtual assessment prior to in-person exercises was largely favoured and should be considered as an appropriate use of technology post-pandemic.

Interventions that have potential to help older adults living with social frailty: a systematic scoping review.

BACKGROUND: The impact of social frailty on older adults is profound including mortality risk, functional decline, falls, and disability. However, effective strategies that respond to the needs of socially frail older adults are lacking and few studies have unpacked how social determinants operate or how interventions can be adapted during periods requiring social distancing and isolation such as the COVID-19 pandemic. To address these gaps, we conducted a scoping review using JBI methodology to identify interventions that have the best potential to help socially frail older adults (age ≥65 years). METHODS: We searched MEDLINE, CINAHL (EPSCO), EMBASE and COVID-19 databases and the grey literature. Eligibility criteria were developed using the PICOS framework. Our results were summarized descriptively according to study, patient, intervention and outcome characteristics. Data synthesis involved charting and categorizing identified interventions using a social frailty framework.  RESULTS: Of 263 included studies, we identified 495 interventions involving ~124,498 older adults who were mostly female. The largest proportion of older adults (40.5%) had a mean age range of 70-79 years. The 495 interventions were spread across four social frailty domains: social resource (40%), self-management (32%), social behavioural activity (28%), and general resource (0.4%). Of these, 189 interventions were effective for improving loneliness, social and health and wellbeing outcomes across psychological self-management, self-management education, leisure activity, physical activity, Information Communication Technology and socially assistive robot interventions. Sixty-three interventions were identified as feasible to be adapted during infectious disease outbreaks (e.g., COVID-19, flu) to help socially frail older adults. CONCLUSIONS: Our scoping review identified promising interventions with the best potential to help older adults living with social frailty.

Outcomes of critically ill older adults with COVID-19: a multicentre retrospective cohort study.

PURPOSE: Older adults with COVID-19 have a high prevalence of complications and mortality during hospitalization. Given the large proportion of older adults requiring admission to an intensive care unit (ICU), we aimed to describe the management and outcomes of older adults with COVID-19 requiring ICU care and identify predictors of hospital mortality. METHODS: We included consecutive patients ≥ 65 yr of age who were admitted between 11 March 2020 and 30 June 2021 to one of five Toronto (ON, Canada) ICUs with a primary diagnosis of SARS-CoV-2 infection in a retrospective cohort study. Patient characteristics, ICU treatment, and outcomes were recorded. We used multivariable logistic regression to identify predictors of in-hospital mortality. RESULTS: Of the 273 patients, the median [interquartile range] age was 74 [69-80] yr, 104 (38.1%) were female, and 164 (60.1%) required invasive mechanical ventilation. One hundred and forty-two patients (52.0%) survived their hospital stay. Compared with survivors, nonsurvivors were older (74 [70-82] yr vs 73 [68-78] yr; P = 0.03), and a smaller proportion was female (39/131, 29.8% vs 65/142, 45.8%; P = 0.01). Patients had long hospital (19 [11-35] days) and ICU (9 [5-22] days) stays, with no significant differences in ICU length of stay or duration of invasive mechanical ventilation between the two groups. Higher APACHE II score, increasing age, and the need for organ support were independently associated with higher in-hospital mortality while female sex was associated with lower mortality. CONCLUSIONS: Older critically ill COVID-19 patients had long ICU and hospital stays, and approximately half died in hospital. Further research is needed to identify individuals who will benefit most from an ICU admission and to evaluate posthospitalization outcomes.

RéSUMé: OBJECTIF: Les personnes âgées atteintes de la COVID-19 ont une prévalence élevée de complications et de mortalité pendant l'hospitalisation. Compte tenu de la forte proportion de personnes âgées nécessitant une admission dans une unité de soins intensifs (USI), nous avons cherché à décrire la prise en charge et les devenirs des personnes âgées atteintes de COVID-19 nécessitant des soins intensifs et à identifier les prédicteurs de mortalité hospitalière. MéTHODE: Nous avons inclus des patient·es consécutif·ves âgé·es de ≥ 65 ans admis·es entre le 11 mars 2020 et le 30 juin 2021 dans l'une des cinq unités de soins intensifs de Toronto (ON, Canada) avec un diagnostic primaire d'infection par le SRAS-CoV-2 dans une étude de cohorte rétrospective. Les caractéristiques des patient·es, le traitement en USI et les devenirs ont été enregistrés. Nous avons utilisé une régression logistique multivariable pour identifier les prédicteurs de mortalité hospitalière. RéSULTATS: Parmi les 273 patient·es, l'âge médian [écart interquartile] était de 74 [69-80] ans, 104 (38,1 %) étaient des femmes et 164 (60,1 %) ont nécessité une ventilation mécanique invasive. Cent quarante-deux personnes (52,0 %) ont survécu à leur séjour à l'hôpital. Comparativement aux personnes survivantes, les personnes qui n'ont pas survécu étaient plus âgées (74 [70-82] ans vs 73 [68­78] ans; P = 0,03), et une plus faible proportion était de sexe féminin (39/131, 29,8 % vs 65/142, 45,8 %; P = 0,01). Les séjours des patient·es à l'hôpital (19 [11-35] jours) et à l'USI (9 [5-22] jours) étaient longs, sans différence significative dans la durée du séjour en USI ou la durée de la ventilation mécanique invasive entre les deux groupes. Un score APACHE II plus élevé, un âge plus avancé et le besoin de mesures de soutien d'organes étaient indépendamment associés à une mortalité plus élevée à l'hôpital, tandis que le sexe féminin était associé à une mortalité plus faible. CONCLUSION : Les personnes plus âgées gravement malades atteintes de la COVID-19 ont eu de longs séjours en soins intensifs et à l'hôpital, et environ la moitié sont décédées à l'hôpital. D'autres recherches sont nécessaires pour identifier les personnes qui bénéficieraient le plus d'une admission à l'USI et pour évaluer les devenirs post-hospitalisation.

Virtual fall program assessment for frail Canadian community-dwelling older adults: Examining equitable accessibility.

Objective: In response to COVID-19, the fall prevention program (FPP) at Sunnybrook Health Sciences Centre was modified to be delivered virtually. We compared patient populations assessed for the FPP virtually versus in-person to explore equitable accessibility. Methods: A retrospective chart review was performed. All patients assessed virtually from the beginning of the COVID-19 pandemic until the end of abstraction (April 25, 2022) were compared to a historic sample of patients assessed in-person beginning in January 2019. Demographics, measures of frailty, co-morbidity, and cognition were abstracted. Wilcoxon Rank Sum tests and Fisher's Exact tests were used for continuous and categorical variables, respectively. Results: Thirty patients were assessed virtually and compared to 30 in-person historic controls. Median age was 80 years (interquartile range 75-85), 82% were female, 70% were university educated, the median Clinical Frailty Score was 5 out of 9, and 87% used >5 medications. Once normalized, frailty scores showed no difference (p = 0.446). The virtual cohort showed significantly higher outdoor walking aid use (p = 0.015), reduced accuracy with clock drawing (p = 0.020), and nonsignificant trends toward using >10 medications, requiring assistance with >3 instrumental activities of daily living (IADLs), and higher treatment attendance. No significant differences were seen for time-to-treat (p = 0.423). Conclusion: Patients assessed virtually were similarly frail as the in-person controls but had increased use of walking aids, medications, IADL assistance, and cognitive impairment. In a Canadian context, frail and high socioeconomic status older adults continued to access treatment through virtual FPP assessments during the COVID-19 pandemic highlighting both the benefits of virtual care and potential inequity.

Developing a fall prevention intervention economic model.

PURPOSE: Model-based economic evaluations require conceptualization of the model structure. Our objectives were to identify important health states, events, and patient attributes to be included in a model-based cost-effectiveness analysis of fall prevention interventions, to develop a model structure to examine cost-effectiveness of fall prevention interventions, and to assess the face validity of the model structure. METHODS: An expert panel comprising clinicians, health service researchers, health economists, a patient partner, and policy makers completed two rounds of online surveys to gain consensus on health states, events, and patient attributes important for fall prevention interventions. The surveys were informed by a literature search on fall prevention interventions for older adults (≥65 years) including economic evaluations and clinical practice guidelines. The results of the Delphi surveys and subsequent discussions can support the face validity of a state-transition model for an economic evaluation of fall prevention interventions. RESULTS: In total, 11 experts rated 24 health states/events and 41 patient attributes. Consensus was achieved on 14 health states/events and 26 patient characteristics. The proposed model structure incorporated 12 of the 14 selected health states/events. Panelists confirmed the face validity of the model structure during teleconferences. CONCLUSIONS: There is a dearth of studies presenting the model conceptualization process; consequently, this study involving multiple end user partners with opportunities for input at several stages adds to the literature as another case study. This process is an example of how a fall prevention economic model was developed using a modified Delphi process and assessed for face validity.

Chemical and physical restraint use during acute care hospitalization of older adults: A retrospective cohort study and time series analysis.

BACKGROUND: Chemical and physical restraints are associated with harm in older adults, but our understanding of their use during acute care hospitalizations is limited. OBJECTIVES: To (1) describe restraint use during acute care hospitalizations of older adults at the onset of the COVID-19 pandemic compared to pre-pandemic levels and (2) describe between-hospital variability in restraint use. DESIGN: Retrospective cohort study with a time series analysis. PARTICIPANTS: Acute care hospital inpatients, aged 65 years or older, who were discharged from one of four Alberta hospitals or six Ontario hospitals in Canada, between November 1, 2019, and June 30, 2020. MAIN MEASURES: We used autoregressive linear models with restricted cubic splines to compare proportions of chemical restraint (that is, psychotropic medications, namely antipsychotics, benzodiazepines, and trazodone) and physical restraint (e.g., mittens) use immediately after the onset of the COVID-19 pandemic with pre-pandemic levels. We describe between-hospital variability in restraint use using intraclass correlation coefficients (ICC) and median odds ratios (OR). KEY RESULTS: We included 71,004 hospitalizations. Adjusted for the prevalence of dementia and psychotic disorders, chemical restraint use increased in Ontario hospitals from a pre-pandemic average of 27.1% to 30.8% (p<0.001) before returning to pre-pandemic levels within eight weeks. Physical restraint orders in Ontario increased from 5.9% to 8.3% (p = 0.012) and remained elevated at eight weeks. No significant changes in restraint use were observed in Alberta. There was moderate between-hospital variability in chemical restraint use (ICC 0.041 and median OR 1.43). Variability in physical restraint use was higher (ICC 0.11 and median OR 1.83). CONCLUSIONS: The COVID-19 pandemic impacted in-hospital use of chemical and physical restraints among older adults in Ontario but not Alberta. Substantial differences in chemical and physical restraint use by region and hospital suggests there are opportunities to improve best practices in geriatric care. Future research must support implementation of evidence-informed interventions that standardize appropriate restraint use.

Turning evidence into action using a senior friendly hospital framework and a collaborative network.

The Senior Friendly Hospital Accelerating Change Together in Ontario program linked the Collaborative Network Model and the Senior Friendly Hospital Framework in a unique multi-hospital knowledge-to-practice initiative to improve care for hospitalized older adults. The design enabled teams from 78 Ontario hospitals to close a shared skills and knowledge gap while meeting the varied needs of their diverse contexts. Results suggest that this design meant to reduce unnecessary redundancy, while preserving requisite diversity, was successful in achieving its specific objectives: to build a collaborative network and increase the confidence, knowledge, and skills of its members sufficient to lead sustainable improvements in their unique hospital settings. Findings with special relevance to process improvement specialists, health system leaders, and hospital administrators and managers are discussed.

Characteristics, treatment and delirium incidence of older adults hospitalized with COVID-19: a multicentre retrospective cohort study.

BACKGROUND: The COVID-19 pandemic has affected older adults disproportionately, and delirium is a concerning consequence; however, the relationship between delirium and corticosteroid use is uncertain. The objective of the present study was to describe patient characteristics, treatments and outcomes among older adults hospitalized with COVID-19, with a focus on dexamethasone use and delirium incidence. METHODS: We completed this retrospective cohort study at 7 sites (including acute care, rehabilitation and long-term care settings) in Toronto, Ontario, Canada. We included adults aged 65 years or older, consecutively hospitalized with confirmed SARS-CoV-2 infection, between Mar. 11, 2020, and Apr. 30, 2021. We abstracted patient characteristics and outcomes from charts and analyzed them descriptively. We used a logistic regression model to determine the association between dexamethasone use and delirium incidence. RESULTS: During the study period, 927 patients were admitted to the acute care hospitals with COVID-19. Patients' median age was 79.0 years (interquartile range [IQR] 72.0-87.0), and 417 (45.0%) were female. Most patients were frail (61.9%), based on a Clinical Frailty Scale score of 5 or greater. The prevalence of delirium was 53.6%, and the incidence was 33.1%. Use of restraints was documented in 20.4% of patients. In rehabilitation and long-term care settings (n = 115), patients' median age was 86.0 years (IQR 78.5-91.0), 72 (62.6%) were female and delirium occurred in 17 patients (14.8%). In patients admitted to acute care during wave 2 of the pandemic (Aug. 1, 2020, to Feb. 20, 2021), dexamethasone use had a nonsignificant association with delirium incidence (adjusted odds ratio 1.38, 95% confidence interval 0.77-2.50). Overall, in-hospital death occurred in 262 (28.4%) patients in acute care settings and 28 (24.3%) patients in rehabilitation or long-term care settings. INTERPRETATION: In-hospital death, delirium and use of restraints were common in older adults admitted to hospital with COVID-19. Further research should be directed to improving the quality of care for this population with known vulnerabilities during continued waves of the COVID-19 pandemic.

Mortality in hospitalized older adults with COVID-19 during three waves: A multicenter retrospective cohort study.

Background: The waves of COVID-19 infections in Ontario, Canada, were marked by differences in patient characteristics and treatment. Our objectives were to (i) describe patient characteristics, treatment, and outcomes of hospitalized older adults with COVID-19 between waves 1, 2, and 3, (ii) determine if there was an improvement in in-hospital mortality in waves 2 and 3 after adjusting for covariates. Methods: This retrospective cohort study was done in five acute care hospitals in Toronto, Ontario. Consecutive hospitalized older adults aged ≥65 years with confirmed COVID-19 infection were included. Wave 1 extended from March 11 to July 31, 2020, wave 2 from August 1, 2020 to February 20, 2021, and wave 3 from February 21 to June 30, 2021. Patient characteristics and outcomes were abstracted from charts. A logistic regression model was used to determine the association between COVID-19 and in-hospital mortality in waves 2 and 3 compared with wave 1. Results: Of the 1671 patients admitted to acute care, 297 (17.8%) were admitted in wave 1, 751 (44.9%) in wave 2, and 623 (37.3%) in wave 3. The median age of our cohort was 77.0 years (interquartile range: 71.0-85.0) and 775 (46.4%) were female. The prevalence of frailty declined in progressive waves. The use of dexamethasone, remdesivir, and tocilizumab was significantly higher in waves 2 and 3 compared with wave 1. In the unadjusted analysis, in-hospital mortality was unchanged between waves 1 and 2, but it was lower in wave 3 (18.3% vs. 27.4% in wave 1). After adjustment, in-hospital mortality was unchanged in waves 2 and 3 compared with wave 1. Conclusion: In-hospital mortality in hospitalized older adults with COVID-19 was similar between waves 1 and 3. Further research should be done to determine if COVID-19 therapies have similar benefits for older adults compared with younger adults.

"We could be good partners if we work together": the perspectives of health and social service providers on the barriers to forming collaborative partnerships with social housing providers for older adults.

BACKGROUND: Many older adults are aging-at-home in social housing. However, the lack of integration between housing and health services makes it difficult for older tenants to access needed supports. We examined barriers and facilitators health and social service providers face providing on-site services to older tenants. METHODS: We conducted semi-structured qualitative interviews and focus groups with health and social service professionals (n = 58) in Toronto, Canada who provide community programs in support of older tenants who live in non-profit, rent-geared-to-income social housing. Interviews examined the barriers they faced in providing on-site services to older tenants. FINDINGS: Service providers strongly believed that collaboration with on-site housing staff led to better health and housing outcomes for older tenants. Despite the recognized benefits of partnering with housing staff, service providers felt that their ability to work effectively in the building was dependent on the staff (particularly the superintendent) assigned to that building. They also identified other barriers that made it difficult to work collaboratively with the housing provider, including staffing challenges such as high staff turnover and confusion about staff roles, a lack of understanding among housing staff about the link between housing and health, challenges sharing confidential information across sectors, and complex and inefficient partnership processes. CONCLUSION: Older adult tenants are increasingly vulnerable and in need of supports but the housing provider has a long history of ineffective partnerships with service providers driven by complex and inefficient staffing models, and an organizational culture that questions the role of and need for partnerships. Findings highlight the need for more effective integration of housing and health services. Simplified processes for establishing partnerships with service agencies and more opportunities for communication and collaboration with housing staff would ensure that services are reaching the most vulnerable tenants.

Reducing Sedative-Hypnotics Among Hospitalized Patients: a Multi-centered Study.

BACKGROUND: Sedative-hypnotics are frequently prescribed for insomnia in hospital but are associated with preventable harms. OBJECTIVE, DESIGN, AND PARTICIPANTS: We aimed to examine whether a sedative-hypnotic reduction quality improvement bundle decreases the rate of sedative-hypnotic use among hospitalized patients, who were previously naïve to sedative-hypnotics. This interrupted time series study occurred between May 2016 and January 2019. Control data for 1 year prior to implementation and intervention data for at least 16 months were collected. The study occurred on 7 inpatient wards (general medicine, cardiology, nephrology, general surgery, and cardiovascular surgery wards) across 5 teaching hospitals in Toronto, Canada. INTERVENTION: Participating wards implemented a sedative-hypnotic reduction bundle (i.e., order set changes, audit-feedback, pharmacist-enabled medication reviews, sleep hygiene, daily sleep huddles, and staff/patient/family education) aimed to reduce in-hospital sedative-hypnotic initiation for insomnia in patients who were previously naïve to sedative-hypnotics. Each inpatient ward adapted the bundle prior to sustaining the intervention for a minimum of 16 months. MAIN MEASURES: The primary outcome measure was the proportion of sedative-hypnotic-naïve inpatients newly prescribed a sedative-hypnotic for sleep in hospital. Secondary measures include prescribing rates of other sedating medications, fall rates, length of stay, and mortality. KEY RESULTS: We included 8,970 patient discharges in the control period and 10,120 in the intervention period. Adjusted sedative-hypnotic prescriptions among naïve patients decreased from 15.48% (95% CI: 6.09-19.42) to 9.08% (p<0.001) (adjusted OR 0.814; 95% CI: 0.667-0.993, p=0.042). Unchanged secondary outcomes included mortality (adjusted OR 1.089; 95% CI: 0.786-1.508, p=0.608), falls (adjusted rate ratio 0.819; 95% CI: 0.625-1.073, p=0.148), or other sedating drug prescriptions (adjusted OR 1.046; 95% CI: 0.873-1.252, p=0.627). CONCLUSIONS: A sedative-hypnotic reduction quality improvement bundle implemented across 5 hospitals was associated with a sustained reduction in sedative-hypnotic prescriptions.

Guidance for hospital and community-based health services for older adults: The senior friendly care framework.

To meet the needs of a population of older adults at risk of becoming frail in the context of known limitations to current practice, frameworks have emerged to guide health service development. Typically these frameworks have developed in the hospital sector despite the need for hospital/community sector co-development and adoption. In the present study one such framework - the Senior Friendly Hospital (SFH1) Framework - is examined with an intersectoral lens. The study included a scoping review of literature addressing system-based approaches to improving healthcare of older people as well as a modified Delphi process to incorporate these findings into an expanded framework. Qualitative analysis of the data extracted from the scoping review resulted in the identification of "senior friendly" excerpts that were charted using an apriori matrix provided by the SFH Framework. Researchers conducted thematic analysis of the excerpts to avoid redundancy and wrote statements to optimize thematic clarity. In a modified Delphi process, the statements were subsequently rated for perceived importance, clarity and fit by an intersectoral panel of experts resulting in a refined Senior Friendly Care (sfCare2) Framework comprising 31 statements and 7 guiding principles to consider when implementing improvements in the care of older adults. Finally, a panel of stakeholders were consulted for feedback on the clarity of the framework's intent and its anticipated impact on care. The sfCare Framework is now available to guide hospital and community-based health service development for older adults.

Effectiveness of an eHealth self-management tool for older adults with multimorbidity (KeepWell): protocol for a hybrid effectiveness-implementation randomised controlled trial.

INTRODUCTION: In response to the burden of chronic disease among older adults, different chronic disease self-management tools have been created to optimise disease management. However, these seldom consider all aspects of disease management are not usually developed specifically for seniors or created for sustained use and are primarily focused on a single disease. We created an eHealth self-management application called 'KeepWell' that supports seniors with complex care needs in their homes. It incorporates the care for two or more chronic conditions from among the most prevalent high-burden chronic diseases. METHODS AND ANALYSIS: We will evaluate the effectiveness, cost and uptake of KeepWell in a 6-month, pragmatic, hybrid effectiveness-implementation randomised controlled trial. Older adults age ≥65 years with one or more chronic conditions who are English speaking are able to consent and have access to a computer or tablet device, internet and an email address will be eligible. All consenting participants will be randomly assigned to KeepWell or control. The allocation sequence will be determined using a random number generator.Primary outcome is perceived self-efficacy at 6 months. Secondary outcomes include quality of life, health background/status, lifestyle (nutrition, physical activity, caffeine, alcohol, smoking and bladder health), social engagement and connections, eHealth literacy; all collected via a Health Risk Questionnaire embedded within KeepWell (intervention) or a survey platform (control). Implementation outcomes will include reach, effectiveness, adoption, fidelity, implementation cost and sustainability. ETHICS AND DISSEMINATION: Ethics approval has been received from the North York General Hospital Research and Ethics Board. The study is funded by the Canadian Institutes of Health Research and the Ontario Ministry of Health. We will work with our team to develop a dissemination strategy which will include publications, presentations, plain language summaries and an end-of-grant meeting. TRIAL REGISTRATION NUMBER: NCT04437238.

Evaluating quality of overall care among older adults with diabetes with comorbidities in Ontario, Canada: a retrospective cohort study.

OBJECTIVES: This study aimed to: (1) explore whether the quality of overall care for older people with diabetes is differentially affected by types and number of comorbid conditions and (2) examine the association between process of care measures and the likelihood of all-cause hospitalisations. DESIGN: A population-based, retrospective cohort study. SETTING: The province of Ontario, Canada. PARTICIPANTS: We identified 673 197 Ontarians aged 65 years and older who had diabetes comorbid with hypertension, chronic ischaemic heart disease, osteoarthritis or depression on 1 April 2010. MAIN OUTCOME MEASURES: The study outcome was the likelihood of having at least one hospital admission in each year, during the study period, from 1 April 2010 to 3 March 2014. Process of care measures specific to older adults with diabetes and these comorbidities, developed by means of a Delphi panel, were used to assess the quality of care. A generalised estimating equations approach was used to examine associations between the process of care measures and the likelihood of hospitalisations. RESULTS: The study findings suggest that patients are at risk of suboptimal care with each additional comorbid condition, while the incidence of hospitalisations and number of prescribed drugs markedly increased in patients with 2 versus 1 selected comorbid condition, especially in those with discordant comorbidities. The median continuity of care score was higher among patients with diabetes-concordant conditions compared with those with diabetes-discordant conditions, and it declined with additional comorbid conditions in both groups. Greater continuity of care was associated with lower hospital utilisation for older diabetes patients with both concordant and discordant conditions. CONCLUSIONS: There is a need for focusing on improving continuity of care and prioritising treatment in older adults with diabetes with any multiple conditions but especially in those with diabetes-discordant conditions (eg, depression).

Development and validation of a screening tool for early identification of bloodstream infection in older patients - a retrospective case-control study.

BACKGROUND: Delayed diagnosis of bloodstream infection (BSI) occurs in > 20% of older patients, with misdiagnosis in 35%. Our objective was to develop and validate a clinically useful screening tool to identify older patients with a high probability of having a BSI. METHODS: Hospitalized patients > 80 years old with BSI (n = 105/group) were evaluated for the tool development in this retrospective matched case-controlled study (learn cohort). The tool was validated in different retrospectively matched case and control patients > 80 years old (n = 120/group) and 65 to 79 years old (n = 250/group) (test cohort). Binary logistic regression was used to develop a screening tool using laboratory and clinical parameters that were significantly associated with BSI (P < 0.05; adjusted odds ratio (OR) > 1); and Classification and Regression Tree (CART) analysis was used to identify parameter breakpoints. Performance metrics were used to evaluate and validate the tool. RESULTS: The significant parameters associated with BSI were maximum temperature (Tmax)(> 37.55C)(OR = 42.575), neutrophils (> 7.95)(OR = 1.923), a change in level of consciousness (LOC) (Yes = 1, No = 0)(OR = 1.571), blood urea nitrogen (BUN)(> 10.05)(OR = 1.359), glucose (> 7.35)(OR = 1.167), albumin (< 33.5)(OR = 1.038) and alanine aminotransferase (ALT) (> 19.5)(OR = 1.005). The optimal screening tool [Ln (odds of BSI) = - 150.299 + 3.751(Tmax) + 0.654(neutrophils) + 0.452(change in LOC) + 0.307(BUN) + 0.154(glucose) + 0.038(albumin) + 0.005(ALT)] had favorable performance metrics in the learn and test cohorts (sensitivity, specificity and accuracy of 95% in the learn cohort and 77, 89, and 81% in the total test cohort); and performed better than using only temperature and neutrophil count. CONCLUSIONS: The validated tool had high predictive value which may improve early identification and management of BSI in older patients.

Scaling-up implementation in community hospitals: a multisite interrupted time series design of the Mobilization of Vulnerable Elders (MOVE) program in Alberta.

BACKGROUND: As the population ages, older hospitalized patients are at increased risk for hospital-acquired morbidity. The Mobilization of Vulnerable Elders (MOVE) program is an evidence-informed early mobilization intervention that was previously evaluated in Ontario, Canada. The program was effective at improving mobilization rates and decreasing length of stay in academic hospitals. The aim of this study was to scale-up the program and conduct a replication study evaluating the impact of the evidence-informed mobilization intervention on various units in community hospitals within a different Canadian province. METHODS: The MOVE program was tailored to the local context at four community hospitals in Alberta, Canada. The study population was patients aged 65 years and older who were admitted to medicine, surgery, rehabilitation and intensive care units between July 2015 and July 2016. The primary outcome was patient mobilization measured by conducting visual audits twice a week, three times a day. The secondary outcomes included hospital length of stay obtained from hospital administrative data, and perceptions of the intervention assessed through a qualitative assessment. Using an interrupted time series design, the intervention was evaluated over three time periods (pre-intervention, during, and post-intervention). RESULTS: A total of 3601 patients [mean age 80.1 years (SD = 8.4 years)] were included in the overall analysis. There was a significant increase in mobilization at the end of the intervention period compared to pre-intervention, with 6% more patients out of bed (95% confidence interval (CI) 1, 11; p-value = 0.0173). A decreasing trend in median length of stay was observed, where patients on average stayed an estimated 3.59 fewer days (95%CI -15.06, 7.88) during the intervention compared to pre-intervention period. CONCLUSIONS: MOVE is a low-cost, effective and adaptable intervention that improves mobilization in older hospitalized patients. This intervention has been replicated and scaled up across various units and hospital settings.

Use of the Consultation Letter Rating Scale among Geriatric Medicine Postgraduate Trainees.

OBJECTIVES: The implementation of competency-based evaluations increases the emphasis on in-training assessment. The Consultation Letter Rating Scale (CLRS), published by the Royal College of Physicians and Surgeons of Canada, is a tool that assesses written-communication competencies. This multisite project evaluated the tool's validity, reliability, feasibility, and acceptability for use in postgraduate geriatric medicine training. METHODS: Geriatric medicine trainees provided consultation letters from the 2017-2018 academic year. Geriatricians reviewed a standardized module and completed the tool for all the deidentified letters. The reviewers recorded the time used to complete the tool for each letter and completed a survey on content validity. Trainees completed a survey on the tool's usefulness. Responses were reviewed independently by two authors for thematic content. The unweighted and the weighted κ were used to measure interrater reliability. RESULTS: A total of 10 of 11 (91%) eligible trainees each provided five letters that were reviewed independently by six geriatricians, leading to a total of 300 assessments. A very small portion (4% [N = 12]) of assessments was incomplete. An average of 4.82 minutes (standard deviation = 3.17) was used to complete the tool. There was high interrater agreement for overall scores, with a multiple-rater weighted κ of 83% (95% confidence interval = 76%-89%). The interrater agreement was lower for the individual components. Both raters and trainees found the comments more useful than the numerical ratings. CONCLUSIONS: Our results support the use of the CLRS for facilitating feedback on the quality of consult letters to improve written-communication competencies among geriatric medicine trainees. J Am Geriatr Soc 67:2157-2160, 2019.

Can the effects of the mobilization of vulnerable elders in Ontario (MOVE ON) implementation be replicated in new settings: an interrupted time series design.

BACKGROUND: Bed rest for older hospitalized patients places them at risk for hospital-acquired morbidity. We previously evaluated an early mobilization intervention and found it to be effective at improving mobilization rates and decreasing length of stay on internal medicine units. The aim of this study was to conduct a replication study evaluating the impact of the evidence-informed mobilization intervention on surgery, psychiatry, medicine, and cardiology inpatient units. METHODS: A multi-component early mobilization intervention was tailored to the local context at seven hospitals in Ontario, Canada. The primary outcome was patient mobilization measured by conducting visual audits twice a week, three times a day. Secondary outcomes were hospital length of stay and discharge destination, which were obtained from hospital decision support data. The study population was patients aged 65 years and older who were admitted to surgery, psychiatry, medicine, and cardiology inpatient units between March and August 2014. Using an interrupted time series design, the intervention was evaluated over three time periods-pre-intervention, during, and post-intervention. RESULTS: A total of 3098 patients [mean age 78.46 years (SD 8.38)] were included in the overall analysis. There was a significant increase in mobility immediately after the intervention period compared to pre-intervention with a slope change of 1.91 (95% confidence interval [CI] 0.74-3.08, P-value = 0.0014). A decreasing trend in median length of stay was observed in the majority of the participating sites. Overall, a median length of stay of 26.24 days (95% CI 23.67-28.80) was observed pre-intervention compared to 23.81 days (95% CI 20.13-27.49) during the intervention and 24.69 days (95% CI 22.43-26.95) post-intervention. The overall decrease in median length of stay was associated with the increase in mobility across the sites. CONCLUSIONS: MOVE increased mobilization and these results were replicated across surgery, psychiatry, medicine, and cardiology inpatient units.