Potentially Modifiable Risk Factors for Dementia and Mild Cognitive Impairment: An Umbrella Review and Meta-Analysis.

INTRODUCTION: The prevalence of mild and major neurocognitive disorders (NCDs), also referred to as mild cognitive impairment and dementia, is rising globally. The prevention of NCDs is a major global public health interest. We sought to synthesize the literature on potentially modifiable risk factors for NCDs. METHODS: We conducted an umbrella review using a systematic search across multiple databases to identify relevant systematic reviews and meta-analyses. Eligible reviews examined potentially modifiable risk factors for mild or major NCDs. We used a random-effects multi-level meta-analytic approach to synthesize risk ratios for each risk factor while accounting for overlap in the reviews. We further examined risk factors for major NCD due to two common etiologies: Alzheimer's disease and vascular dementia. RESULTS: A total of 45 reviews with 212 meta-analyses were synthesized. We identified fourteen broadly defined modifiable risk factors that were significantly associated with these disorders: alcohol consumption, body weight, depression, diabetes mellitus, diet, hypertension, less education, physical inactivity, sensory loss, sleep disturbance, smoking, social isolation, traumatic brain injury, and vitamin D deficiency. All 14 factors were associated with the risk of major NCD, and five were associated with mild NCD. We found considerably less research for vascular dementia and mild NCD. CONCLUSION: Our review quantifies the risk associated with 14 potentially modifiable risk factors for mild and major NCDs, including several factors infrequently included in dementia action plans. Prevention strategies should consider approaches that reduce the incidence and severity of these risk factors through health promotion, identification, and early management.

Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study.

OBJECTIVE: We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS: We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios. RESULTS: There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults. CONCLUSIONS AND IMPLICATIONS: The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study.

OBJECTIVE: We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS: Counts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019. RESULTS: There was a 34% relative increase in the resident population size of assisted living facilities (56,9752019 vs 42,6002013). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019. CONCLUSIONS AND IMPLICATIONS: Residents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.

Defining the Assisted Living Sector in Canada: An Environmental Scan.

OBJECTIVES: In this study, we (1) identify the terms used to describe the assisted living sector and the legislation governing operation in all Canadian provinces and territories; (2) identify the cost estimates associated with residency in these homes; and (3) quantify the growth of the sector. DESIGN: Environmental scan. SETTING AND PARTICIPANTS: Internet searches of Canadian provincial and territorial government websites and professional associations were conducted in 2021 to retrieve publicly accessible sources related to the assisted living sector. METHODS: We synthesized data that identified the terms used to describe the sector in all provinces and territories, the legislation governing operation, financing, median fees per month for care, and growth of the sector from 2012 to 2020. Counts and proportions were calculated for some extracted variables. All data were narratively synthesized. RESULTS: The terms used to describe the assisted living sector varied across Canada. The terms "assisted living," "retirement homes," and "supportive living" were prevalent. Ontario was the only province to regulate the sector through an independent, not-for-profit organization. Ontario, British Columbia, and Alberta had some of the highest median fees for room, board, and care per month (range: $1873 to $6726). The licensed assisted living sector in Ontario doubled in size (768 in 2020 vs 383 in 2012), and there was a threefold increase in the number of corporate-owned chain assisted living facilities (465 in 2020 vs 142 in 2012). CONCLUSIONS AND IMPLICATIONS: The rapid growth of the assisted living sector that is primarily financed through out-of-pocket payments may indicate a rise in a two-tier system of housing and health care for older adults. Policymakers need better mechanisms, such as standardized reporting systems and assessments, to understand the needs of older adults who reside in assisted living facilities and inform the need for sector regulation and oversight.

Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study.

BACKGROUND: Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults. METHODS: We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits. RESULTS: We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14). INTERPRETATION: Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.

Community-informed, integrated, and coordinated care through a community-level model: A narrative synthesis on community hubs.

We identify the core services included in a community hub model of care to improve the understanding of this model for health leaders, decision-makers in community-based organizations, and primary healthcare clinicians. We searched Medline, PubMed, CINAHL, Scopus, Web of Science, and Google from 2000 to 2020 to synthesize original research on community hubs. Eighteen sources were assessed for quality and narratively synthesized (n = 18). Our analysis found 4 streams related to the service delivery in a community hub model of care: (1) Chronic disease management; (2) mental health and addictions; (3) family and reproductive health; and (4) seniors. The specific services within these streams were dependent upon the needs of the community, as a community hub model of care responds and adapts to evolving needs. Our findings inform the work of health leaders tasked with implementing system-level transformations towards community-informed models of care.

Association Between Dementia Care Programs in Assisted Living Facilities and Transitions to Nursing Homes in Ontario, Canada: A Population-Based Cohort Study.

OBJECTIVE: We investigate whether older adults who were newly diagnosed with dementia (severity unspecified) and resided in an assisted living facility that offered a dementia care program had a lower rate of transition to a nursing home, compared to those who resided in an assisted living facility without such a program. DESIGN: Population-based retrospective cohort study. SETTING AND PARTICIPANTS: Linked, person-level health system administrative data on older adults who were newly diagnosed with dementia and resided in an assisted living facility in Ontario, Canada, from 2014 to 2019 (n = 977). METHODS: Access to a dementia care program in an assisted living facility (n = 57) was examined. Multivariable Cox proportional hazards regression with robust standard errors clustered on the assisted living facility was used to model the time to transition to a nursing home from the new dementia diagnosis. RESULTS: There were 11.8 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility with a dementia care program, compared with 20.5 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility without a dementia care program. After adjustment for relevant characteristics at baseline, older adults who resided in an assisted living facility with a dementia care program had a 40% lower rate of transition to a nursing home (hazard ratio 0.60, 95% confidence interval 0.44, 0.81), compared with those in an assisted living facility without such a program at any point during the follow-up period. CONCLUSIONS AND IMPLICATIONS: The rate of transition to a nursing home was significantly lower among older adults who resided in an assisted living facility that offered a dementia care program. These findings support the expansion of dementia care programs in assisted living facilities.

Do assisted living facilities that offer a dementia care program differ from those that do not? A population-level cross-sectional study in Ontario, Canada.

BACKGROUND: Many residents of assisted living facilities live with dementia, but little is known about the characteristics of assisted living facilities that provide specialized care for older adults who live with dementia. In this study, we identify the characteristics of assisted living facilities that offer a dementia care program, compared to those that do not offer such a program. METHODS: We conducted a population-level cross-sectional study on all licensed assisted living facilities in Ontario, Canada in 2018 (n = 738). Facility-level characteristics (e.g., resident and suite capacities, etc.) and the provision of the other 12 provincially regulated care services (e.g., pharmacist and medical services, skin and wound care, etc.) attributed to assisted living facilities were examined. Multivariable Poisson regression with robust standard errors was used to model the characteristics of assisted living facilities associated with the provision of a dementia care program. RESULTS: There were 123 assisted living facilities that offered a dementia care program (16.7% versus 83.3% no dementia care). Nearly half of these facilities had a resident capacity exceeding 140 older adults (44.7% versus 21.6% no dementia care) and more than 115 suites (46.3% versus 20.8% no dementia care). All assisted living facilities that offered a dementia care program also offered nursing services, meals, assistance with bathing and hygiene, and administered medications. After adjustment for facility characteristics and other provincially regulated care services, the prevalence of a dementia care program was nearly three times greater in assisted living facilities that offered assistance with feeding (Prevalence Ratio [PR] 2.91, 95% Confidence Interval [CI] 1.98 to 4.29), and almost twice as great among assisted living facilities that offered medical services (PR 1.78, 95% CI 1.00 to 3.17), compared to those that did not. CONCLUSIONS: A dementia care program was more prevalent in assisted living facilities that housed many older adults, had many suites, and offered at least five of the other 12 regulated care services. Our findings deepen the understanding of specialized care for dementia in assisted living facilities.

Facteurs de risque d'éclosion de SRAS-CoV-2 dans les résidences pour aînés en Ontario, au Canada: étude de cohorte à l'échelle de la population.

CONTEXTE: L'épidémiologie de l'infection au SRAS-CoV-2 dans les résidences pour aînés (offrant une aide à la vie autonome), est pour une bonne part inconnue. Nous avons étudié le lien entre les caractéristiques des résidences et des communautés avoisinantes et le risque d'éclosion de SRAS-CoV-2 dans les résidences pour aînés depuis le début de la première vague de la pandémie de COVID-19. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective dans la population des résidences pour aînés certifiées en Ontario, au Canada, entre le 1er mars et le 18 décembre 2020. Notre paramètre principal était toute éclosion de SRAS-CoV-2 (≥ 1 cas confirmé parmi les résidents ou le personnel au moyen d'un test d'amplification des acides nucléiques). Nous avons utilisé la méthode des risques proportionnels avec prédicteurs chronologiques pour modéliser les liens entre les caractéristiques des résidences et des communautés avoisinantes et les éclosions de SRAS-CoV-2. RÉSULTATS: Notre cohorte a inclus l'ensemble des 770 résidences privées pour aînés (RPA) certifiées en Ontario qui hébergeaient 56 491 résidents. On a dénombré 273 (35,5 %) résidences pour aînés qui ont connu 1 éclosion de SRAS-CoV-2 ou plus; 1944 résidents (3,5 %) et 1101 employés (3,0 %) ont contracté l'infection. Ces cas étaient inégalement distribués entre les résidences. En effet, 2487 cas parmi les résidents et le personnel (81,7 %) sont survenus dans 77 résidences (10 %). Le rapport de risque ajusté d'une éclosion de SRAS-CoV-2 dans une résidence a été clairement associé aux établissements qui avaient une grande capacité d'accueil, qui comportaient des unités de soins de longue durée, qui appartenaient à de plus grandes bannières et offraient plusieurs services sur place, qui se trouvaient dans des régions marquées par une hausse de l'incidence régionale de SRAS-CoV-2 et où la concentration ethnique à l'échelle de la communauté était supérieure. INTERPRÉTATION: Certaines caractéristiques facilement identifiables des résidences pour aînés sont associées de manière indépendante aux éclosions de SRAS-CoV-2 et peuvent faciliter l'évaluation des risques et orienter la priorisation de la vaccination.

Risk factors for outbreaks of SARS-CoV-2 infection at retirement homes in Ontario, Canada: a population-level cohort study.

BACKGROUND: The epidemiology of SARS-CoV-2 infection in retirement homes (also known as assisted living facilities) is largely unknown. We examined the association between home-and community-level characteristics and the risk of outbreaks of SARS-CoV-2 infection in retirement homes since the beginning of the first wave of the COVID-19 pandemic. METHODS: We conducted a population-based, retrospective cohort study of licensed retirement homes in Ontario, Canada, from Mar. 1 to Dec. 18, 2020. Our primary outcome was an outbreak of SARS-CoV-2 infection (≥ 1 resident or staff case confirmed by validated nucleic acid amplification assay). We used time-dependent proportional hazards methods to model the associations between retirement home- and community-level characteristics and outbreaks of SARS-CoV-2 infection. RESULTS: Our cohort included all 770 licensed retirement homes in Ontario, which housed 56 491 residents. There were 273 (35.5%) retirement homes with 1 or more outbreaks of SARS-CoV-2 infection, involving 1944 (3.5%) residents and 1101 staff (3.0%). Cases of SARS-CoV-2 infection were distributed unevenly across retirement homes, with 2487 (81.7%) resident and staff cases occurring in 77 (10%) homes. The adjusted hazard of an outbreak of SARS-CoV-2 infection in a retirement home was positively associated with homes that had a large resident capacity, were co-located with a long-term care facility, were part of larger chains, offered many services onsite, saw increases in regional incidence of SARS-CoV-2 infection, and were located in a region with a higher community-level ethnic concentration. INTERPRETATION: Readily identifiable characteristics of retirement homes are independently associated with outbreaks of SARS-CoV-2 infection and can support risk identification and priority for vaccination.

Outcomes for Implemented Macroeconomic Policy Responses and Multilateral Collaboration Strategies for Economic Recovery After a Crisis: A Rapid Scoping Review.

To promote postpandemic recovery, many countries have adopted economic packages that include fiscal, monetary, and financial policy measures; however, the effects of these policies may not be known for several years or more. There is an opportunity for decision makers to learn from past policies that facilitated recovery from other disease outbreaks, crises, and natural disasters that have had a devastating effect on economies around the world. To support the development of the United Nations Research Roadmap for COVID-19 Recovery, this review examined and synthesized peer-reviewed studies and gray literature that focused on macroeconomic policy responses and multilateral coalition strategies from past pandemics and crises to provide a map of the existing evidence. We conducted a systematic search of academic and gray literature databases. After screening, we found 22 records that were eligible for this review. The evidence found demonstrates that macroeconomic and multilateral coalition strategies have various impacts on a diverse set of countries and populations. Although the studies were heterogeneous in nature, most did find positive results for macroeconomic intervention policies that addressed investments to strengthen health and social protection systems, specifically cash and unconventional/nonstandard monetary measures, in-kind transfers, social security financing, and measures geared toward certain population groups.

Associations with rates of falls among home care clients in Ontario, Canada: a population-based, cross-sectional study.

BACKGROUND: Accidental falls among older adults are a leading cause of injury-related hospitalizations. Reducing falls is an ongoing quality improvement priority for home care, given that many home care clients experience falls. In this study, we identify factors associated with the rate of falls among home care clients. METHODS: We conducted a population-based, cross-sectional study using secondary data from the Hamilton, Niagara, Haldimand, and Brant health region of Ontario, Canada from January 1 - March 31, 2018. We captured person-level characteristics with falls from the Resident Assessment Instrument - Home Care (RAI-HC). Negative binomial regression was used to model the rate of falls. RESULTS: Functional characteristics of home care clients had strong, statistically significant associations with the rate of falls. Declines in activities of daily living, assistive device use for locomotion indoors, polypharmacy, and health conditions, such as dizziness or lightheadedness, and parkinsonism, were associated with a higher rate of falls. Males who used assistive devices had a higher rate of falls compared to females; however, males with neurological and cardiovascular health conditions had a decrease in the rate of falls compared to females. Home care clients with parkinsonism who used a cane and took eight or more drugs had stronger associations with an increased rate of falls compared to those who do not have parkinsonism. CONCLUSIONS: Functional characteristics, polypharmacy, and health conditions are associated with increased rates of falls among home care clients. Home care clients who are at a greater risk of falls may require environmental adjustments in their home to reduce or eliminate the possibility of falling.