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1.
Drugs Aging ; 2021 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-33880747

RESUMO

BACKGROUND: Atrial fibrillation (AF) is relatively common among nursing home residents, and decisions regarding anticoagulant therapy in this setting may be complicated by resident frailty and other factors. OBJECTIVES: The aim of this study was to examine trends and correlates of oral anticoagulant use among newly admitted nursing home residents with AF following the approval of direct-acting oral anticoagulants (DOACs). METHODS: We conducted a retrospective cohort study of all adults aged > 65 years with AF who were newly admitted to nursing homes in Ontario, Canada, between 2011 and 2018 (N = 36,466). Health administrative databases were linked with comprehensive clinical assessment data captured shortly after admission, to ascertain resident characteristics. Trends in prevalence of anticoagulant use (any, warfarin, DOAC) at admission were captured with prescription claims and examined by frailty and chronic kidney disease (CKD). Log-binomial regression models estimated crude percentage changes in use over time and modified Poisson regression models assessed factors associated with anticoagulant use and type. RESULTS: The prevalence of anticoagulant use at admission increased from 41.1% in 2011/2012 to 58.0% in 2017/2018 (percentage increase = 41.1%, p < 0.001). Warfarin use declined (- 67.7%, p < 0.001), while DOAC use increased. Anticoagulant use was less likely among residents with a prior hospitalization for hemorrhagic stroke (adjusted risk ratio [aRR] 0.65, 95% confidence interval [CI] 0.60-0.70) or gastrointestinal bleed (aRR 0.80, 95% CI 0.78-0.83), liver disease (aRR 0.78, 95% CI 0.69-0.89), severe cognitive impairment (aRR 0.89, 95% CI 0.85-0.94), and non-steroidal anti-inflammatory drug (aRR 0.76, 95% CI 0.71-0.81) or antiplatelet (aRR 0.25, 95% CI 0.23-0.27) use, but more likely for those with a prior hospitalization for ischemic stroke or thromboembolism (aRR 1.30, 95% CI 1.27-1.33). CKD was associated with a reduced likelihood of DOAC versus warfarin use in both the early (aRR 0.62, 95% CI 0.54-0.71) and later years (aRR 0.79, 95% CI 0.76-0.83) of our study period. Frail residents were significantly less likely to receive an anticoagulant at admission, although this association was modest (aRR 0.95, 95% CI 0.92-0.98). Frailty was not associated with anticoagulant type. CONCLUSIONS: While the proportion of residents with AF receiving oral anticoagulants at admission increased following the approval of DOACs, over 40% remained untreated. Among those treated, use of a DOAC increased, while warfarin use declined. The impact of these recent treatment patterns on the balance between benefit and harm among residents warrant further investigation.

2.
PLoS One ; 16(4): e0250567, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33901232

RESUMO

BACKGROUND: Multimorbidity is increasing among older adults, but the impact of these recent trends on the extent and complexity of polypharmacy and possible variation by sex remains unknown. We examined sex differences in multimorbidity, polypharmacy (5+ medications) and hyper-polypharmacy (10+ medications) in 2003 vs 2016, and the interactive associations between age, multimorbidity level, and time on polypharmacy measures. METHODS AND FINDINGS: We employed a repeated cross-sectional study design with linked health administrative databases for all persons aged ≥66 years eligible for health insurance in Ontario, Canada at the two index dates. Descriptive analyses and multivariable logistic regression models were conducted; models included interaction terms between age, multimorbidity level, and time period to estimate polypharmacy and hyper-polypharmacy probabilities, risk differences and risk ratios for 2016 vs 2003. Multimorbidity, polypharmacy and hyper-polypharmacy increased significantly over the 13 years. At both index dates prevalence estimates for all three were higher in women, but a greater absolute increase in polypharmacy over time was observed in men (6.6% [from 55.7% to 62.3%] vs 0.9% [64.2%-65.1%] for women) though absolute increases in multimorbidity were similar for men and women (6.9% [72.5%-79.4%] vs 6.2% [75.9%-82.1%], respectively). Model findings showed that polypharmacy decreased over time among women aged < 90 years (especially for younger ages and those with fewer conditions), whereas it increased among men at all ages and multimorbidity levels (with larger absolute increases typically at older ages and among those with 4 or fewer conditions). CONCLUSIONS: There are sex and age differences in the impact of increasing chronic disease burden on changes in measures of multiple medication use among older adults. Though the drivers and health consequences of these trends warrant further investigation, the findings support the heterogeneity and complexity in the evolving association between multimorbidity and polypharmacy measures in older populations.

4.
Can Geriatr J ; 23(4): 297-328, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33282050

RESUMO

Background: Studies of mild cognitive impairment (MCI) employ rigorous eligibility criteria, resulting in sampling that may not be representative of the broader clinical population. Objective: To compare the characteristics of MCI patients in a Calgary memory clinic to those of MCI participants in published Canadian studies. Methods: Clinic participants included 555 MCI patients from the PROspective Registry of Persons with Memory SyMPToms (PROMPT) registry in Calgary. Research participants included 4,981 individuals with MCI pooled from a systematic literature review of 112 original, English-language peer-reviewed Canadian studies. Both samples were compared on baseline sociodemographic variables, medical and psychiatric comorbidities, and cognitive performance for MCI due to Alzheimer's disease and Parkinson's disease. Results: Overall, clinic patients tended to be younger, more often male, and more educated than research participants. Psychiatric disorders, traumatic brain injury, and sensory impairment were commonplace in PROMPT (up to 83% affected) but > 80% studies in the systematic review excluded these conditions. PROMPT patients also performed worse on global cognition measures than did research participants. Conclusion: Stringent eligibility criteria in Canadian research studies excluded a considerable subset of MCI patients with comorbid medical or psychiatric conditions. This exclusion may contribute to differences in cognitive performance and outcomes compared to real-world clinical samples.

6.
Drugs Aging ; 37(11): 817-827, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32978758

RESUMO

BACKGROUND: In nursing homes, residents with dementia frequently receive potentially inappropriate medications that are associated with an increased risk of adverse events. Despite known sex differences in clinical presentation and sociodemographic characteristics among persons with dementia, few studies have examined sex differences in patterns and predictors of potentially inappropriate medication use. OBJECTIVES: The objectives of this study were to examine sex differences in the patterns of antipsychotic and benzodiazepine use in the 180 days following admission to a nursing home, estimate clinical and sociodemographic predictors of antipsychotic and benzodiazepine use in male and female residents, and explore the effects of modification by sex on the predictors of using these drug therapies. METHODS: We conducted a retrospective cohort study of 35,169 adults aged 66 years and older with dementia who were newly admitted to nursing homes in Ontario, Canada between 2011 and 2014. Health administrative databases were linked to detailed clinical assessment data collected using the Resident Assessment Instrument (RAI-MDS 2.0). Cox proportional hazards models were adjusted for clinical and sociodemographic covariates to estimate the rate of antipsychotic and benzodiazepine initiation and discontinuation in the 180 days following nursing home admission in the total sample and stratified by sex. Sex-covariate interaction terms were used to assess whether sex modified the association between covariates and the rate of drug therapy initiation or discontinuation following nursing home entry. RESULTS: Across 638 nursing homes, our analytical sample included 22,847 females and 12,322 males. At admission, male residents were more likely to be prevalent antipsychotic users than female residents (33.8% vs 28.3%; p < 0.001), and female residents were more likely to be prevalent benzodiazepine users than male residents (17.2% vs 15.3%, p < 0.001). In adjusted models, female residents were less likely to initiate an antipsychotic after admission (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.73-0.86); however, no sex difference was observed in the rate of benzodiazepine initiation (HR 1.04, 95% CI 0.96-1.12). Female residents were less likely than males to discontinue antipsychotics (HR 0.89, 95% CI 0.81-0.98) and benzodiazepines (HR 0.82, 95% CI 0.75-0.89). Sex modified the association between some covariates and the rate of changes in drug use (e.g., widowed males exhibited an increased rate of antipsychotic discontinuation (p-interaction = 0.03) compared with married males), but these associations were not statistically significant among females. Sex did not modify the effect of frailty on the rates of initiation and discontinuation. CONCLUSIONS: Males and females with dementia differed in their exposure to antipsychotics and benzodiazepines at nursing home admission and their patterns of use following admission. A greater understanding of factors driving sex differences in potentially inappropriate medication use may help tailor interventions to reduce exposure in this vulnerable population.

8.
PLoS One ; 15(7): e0234876, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32645017

RESUMO

BACKGROUND: Access to neurology specialty care can influence outcomes in individuals with multiple sclerosis (MS), but may vary based on patient sociodemographic characteristics, including immigration status. OBJECTIVE: To compare health services utilization in the year of MS diagnosis, one year before diagnosis and two years after diagnosis in immigrants versus long-term residents in Ontario, Canada. METHODS: We identified incident cases of MS among adults aged 20-65 years by applying a validated algorithm to health administrative data in Ontario, Canada, a region with universal health insurance and comprehensive coverage. We separately assessed hospitalizations, emergency department (ED) visits, outpatient neurology visits, other outpatient specialty visits, and primary care visits. We compared rates of health service use in immigrants versus long-term residents using negative binomial regression models with generalized estimating equations adjusted for age, sex, socioeconomic status, urban/rural residence, MS diagnosis calendar year, and comorbidity burden. RESULTS: From 2003 to 2014, there were 13,028 incident MS cases in Ontario, of whom 1,070 (8.2%) were immigrants. As compared to long-term residents, rates of hospitalization were similar (Adjusted rate ratio (ARR) 0.86; 95% CI: 0.73-1.01) in immigrants the year before MS diagnosis, but outpatient neurology visits (ARR 0.93; 95% CI: 0.87-0.99) were slightly less frequent. However, immigrants had higher rates of hospitalization during the diagnosis year (ARR 1.20, 95% CI: 1.04-1.39), and had greater use of outpatient neurology (ARR 1.17, 95% CI: 1.12-1.23) but fewer ED visits (ARR 0.86; 95% CI: 0.78-0.96). In the first post-diagnosis year, immigrants continued to have greater numbers of outpatient neurology visits (ARR 1.16; 95% CI: 1.10-1.23), but had fewer hospitalizations (ARR 0.79; 95% CI: 0.67-0.94). CONCLUSIONS: Overall, our findings were reassuring concerning health services access for immigrants with MS in Ontario, a publicly funded health care system. However, immigrants were more likely to be hospitalized despite greater use of outpatient neurology care in the year of MS diagnosis. Reasons for this may include more severe disease presentation or lack of social support among immigrants and warrant further investigation.


Assuntos
Emigrantes e Imigrantes/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adulto , Assistência Ambulatorial/tendências , Canadá/etnologia , Estudos de Coortes , Serviço Hospitalar de Emergência/tendências , Feminino , Hospitalização/tendências , Humanos , Masculino , Transtornos Mentais/terapia , Serviços de Saúde Mental/tendências , Pessoa de Meia-Idade , Esclerose Múltipla/psicologia , Ontário/etnologia , Atenção Primária à Saúde/tendências , Estudos Retrospectivos , Classe Social
9.
BMJ Open ; 10(7): e037485, 2020 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-32709654

RESUMO

OBJECTIVES: To determine the long-term trajectories of health system use by persons with dementia as they remain in the community over time. DESIGN: Population-based cohort study using health administrative data. SETTING: Ontario, Canada from 1 April 2007 to 31 March 2014. PARTICIPANTS: 62 622 community-dwelling adults aged 65+ years with prevalent dementia on 1 April 2007 matched 1:1 to persons without dementia based on age, sex and comorbidity. MAIN OUTCOME MEASURES: Rates of health service use, long-term care placement and mortality over time. RESULTS: After 7 years, 49.0% of persons with dementia had spent time in long-term care (6.8% without) and 64.5% had died (30.0% without). Persons with dementia were more likely than those without to use home care (rate ratio (RR) 3.02, 95% CI 2.93 to 3.11) and experience hospitalisations with a discharge delay (RR 2.36, 95% CI 2.30 to 2.42). As they remained in the community, persons with dementia used home care at a growing rate (10.7%, 95% CI 10.0 to 11.3 increase per year vs 6.7%, 95% CI 4.3 to 9.0 per year among those without), but rates of acute care hospitalisation remained constant (0.6%, 95% CI -0.6 to 1.9 increase per year). CONCLUSIONS: While persons with dementia used more health services than those without dementia over time, the rate of change in use differed by service type. These results, particularly enumerating the increased intensity of home care service use, add value to capacity planning initiatives where limited budgets require balancing services.

10.
J Appl Gerontol ; : 733464820920102, 2020 May 26.
Artigo em Inglês | MEDLINE | ID: mdl-32456510

RESUMO

Objective: The main objective was to develop a decision-support tool to assess the risk of caregiver burden, the Caregiver Risk Evaluation (CaRE) algorithm. Methods: Home care clients were assessed using the Resident Assessment Instrument for Home Care (RAI-HC). Their caregiver completed the 12-item Zarit Burden Interview (ZBI), the main dependent measure, which was linked to the RAI-HC. Results: In the sample (n = 344), 48% were aged 85+ years and 61.6% were female. The algorithm can be collapsed into four categories (low, moderate, high, and very high risk). Relative to the low-risk group, clients in the very high-risk group had an odds ratio of 5.16 (95% confidence interval: [2.05, 12.9]) for long-term care admission, after adjusting for client age, sex, and regional health authority. Discussion: The CaRE algorithm represents a new tool to be used by home care clinicians as they proactively plan for the needs of clients and their caregivers.

11.
Can J Psychiatry ; 65(11): 790-801, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32274934

RESUMO

OBJECTIVES: Cholinesterase inhibitors (ChEIs) and memantine are approved for Alzheimer disease in Canada. Regional drug reimbursement policies are associated with cross-provincial variation in ChEI use, but it is unclear how these policies influence predictors of use. Using standardized data from two provinces with differing policies, we compared resident-level characteristics associated with dementia pharmacotherapy at long-term care (LTC) admission. METHODS: Using linked clinical and administrative databases, we examined characteristics associated with dementia pharmacotherapy use among residents with dementia and/or significant cognitive impairment admitted to LTC facilities in Saskatchewan (more restrictive reimbursement policies; n = 10,599) and Ontario (less restrictive; n = 93,331) between April 1, 2009, and March 31, 2015. Multivariable logistic regression models were utilized to assess resident demographic, functional, and clinical characteristics associated with dementia pharmacotherapy. RESULTS: On admission, 8.1% of Saskatchewan residents were receiving dementia pharmacotherapy compared to 33.2% in Ontario. In both provinces, residents with severe cognitive impairment, aggressive behaviors, and recent antipsychotic use were more likely to receive dementia pharmacotherapy; while those who were unmarried, admitted in later years, had a greater degree of frailty, and recent hospitalizations were less likely. The direction of the association for older age, rural residency, medication number, and anticholinergic therapy differed between provinces. CONCLUSIONS: While more restrictive criteria for dementia pharmacotherapy coverage in Saskatchewan resulted in fewer residents entering LTC on dementia pharmacotherapy, there were relatively few differences in the factors associated with use across provinces. Longitudinal studies are needed to assess how differences in prevalence and characteristics associated with use impact patient outcomes.

12.
BMJ Open ; 10(4): e037301, 2020 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-32265252

RESUMO

INTRODUCTION: Maintenance of cognitive function into old age is important for ageing populations. Researchers seek to identify modifiable risk and protective factors for cognitive function. One such modifiable factor is functional social support, that is, one's perception of whether their social network can provide resources such as material help, companionship, information and emotional contact, if needed. While the literature generally reports positive associations between functional social support and cognitive function, results vary according to study methods such as the tool used to measure functional social support or the specific cognitive domain under investigation. Our review will summarise the association between functional social support and cognitive function in middle-aged and older-aged adults who reside in any setting (eg, community dwelling, long-term care facilities). We will also identify sources of discrepant findings between studies. METHODS AND ANALYSIS: This protocol was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guideline. PubMed, PsycINFO, Sociological Abstracts, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Scopus will be searched from inception to the present using a search strategy developed with a medical librarian's help. We will supplement the database searches with a grey literature search. English-language or French-language studies with a comparison group will be subject to inclusion, regardless of the measures used to assess functional social support or cognitive function. We will assess risk of bias with the Cochrane Risk of Bias Tool-Version 2 or the Newcastle-Ottawa Scale, narratively synthesise the extracted data and conduct a meta-analysis of studies with similar characteristics (eg, sample age and sex, cognitive function outcomes). Two independent raters will screen articles and assess risk of bias. ETHICS AND DISSEMINATION: This review is timely given the push toward early diagnosis and treatment of dementia/major neurocognitive disorder and other types of cognitive impairment. This protocol does not require a formal ethics review. We will publish our findings in a peer-reviewed journal.

13.
Arch Gerontol Geriatr ; 86: 103962, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31704625

RESUMO

OBJECTIVES: This study examines the association between a modifiable psychosocial factor, social support availability (SSA), and the memory domain of cognitive function in persons aged 45-85 years. METHODS: We used baseline data from the Canadian Longitudinal Study on Aging (CLSA) (n = 21,241) to conduct multiple linear regression analyses of the association between SSA (overall and four subscales) and memory. The CLSA assessed immediate and delayed recall memory using the Rey Auditory Verbal Learning Test (RAVLT). RESULTS: Higher levels of each type of SSA were positively associated with better performance on both immediate and delayed recall memory. The largest associations (ß coefficients [95% confidence intervals]) for z-score differences on the RAVLT were observed for overall SSA (immediate: 0.07 [0.04-0.10]; delayed recall: 0.06 [0.02-0.09]) and the emotional/informational subscale (immediate: 0.06 [0.03-0.09]; delayed recall: 0.05 [0.02-0.08]). CONCLUSION: SSA is modifiable and positively associated with memory. Public health initiatives to provide support resources such as material aid, emotional support, or companionship may entail positive benefits for memory. Promotion of SSA is also important for policies encouraging early diagnosis and intervention in dementia.


Assuntos
Memória , Apoio Social , Idoso , Idoso de 80 Anos ou mais , Envelhecimento , Estudos Transversais , Feminino , Humanos , Estudos Longitudinais , Masculino , Rememoração Mental , Pessoa de Meia-Idade
14.
J Am Geriatr Soc ; 68(11): 2516-2524, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33460072

RESUMO

BACKGROUND/OBJECTIVES: To examine the association between hospitalization for a fall-related injury and the co-prescription of a cholinesterase inhibitor (ChEI) among persons with dementia receiving a beta-blocker, and whether this potential drug-drug interaction is modified by frailty. DESIGN: Nested case-control study using population-based administrative databases. SETTING: All nursing homes in Ontario, Canada. PARTICIPANTS: Persons with dementia aged 66 and older who received at least one beta-blocker between April 2013 and March 2018 following nursing home admission (n = 19,060). MEASUREMENTS: Cases were persons with dementia with a hospitalization (emergency department visit or acute care admission) for a fall-related injury with concurrent beta-blocker use. Each case (n = 3,038) was matched 1:1 to a control by age (±1 year), sex, cohort entry year, frailty, and history of fall-related injuries. The association between fall-related injury and exposure to a ChEI in the 90 days prior was examined using multivariable conditional logistic regression. Secondary exposures included ChEI type, daily dose, incident versus prevalent use, and use in the prior 30 days. Subgroup analyses considered frailty, age group, sex, and history of hospitalization for fall-related injuries. RESULTS: Exposure to a ChEI in the prior 90 days occurred among 947 (31.2%) cases and 940 (30.9%) controls. In multivariable models, no association was found between hospitalization for a fall-related injury and prior exposure to a ChEI in persons with dementia dispensed beta-blockers (adjusted odds ratio = .96, 95% confidence interval = .85-1.08). Findings were consistent across secondary exposures and subgroup analyses. CONCLUSION: Among nursing home residents with dementia receiving beta-blockers, co-prescription of a ChEI was not associated with an increased risk of hospitalization for a fall-related injury. However, we did not assess for its association with falls not leading to hospitalization. This finding could inform clinical guidelines and shared decision making between persons with dementia, caregivers, and clinicians concerning ChEI initiation and/or discontinuation.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Antagonistas Adrenérgicos beta/uso terapêutico , Inibidores da Colinesterase/uso terapêutico , Hospitalização/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Estudos de Coortes , Bases de Dados Factuais , Demência/epidemiologia , Interações Medicamentosas , Feminino , Fragilidade/epidemiologia , Instituição de Longa Permanência para Idosos/estatística & dados numéricos , Humanos , Masculino , Casas de Saúde/estatística & dados numéricos , Ontário
15.
J Gen Intern Med ; 34(12): 2763-2771, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31576508

RESUMO

BACKGROUND: Prescribing patterns for episodic medications, such as antibiotics, might make useful surrogate measures of a physician's overall prescribing practice because use is common, and variation exists across prescribers. However, the extent to which a physician's current antibiotic prescribing practices are associated with the rate of prescription of other potentially harmful medications remains unknown. OBJECTIVE: To examine the association between a physician's rate of antibiotic prescribing and their prescribing rate of benzodiazepines, opioids and proton-pump inhibitors in older adults. DESIGN: Population-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients. PARTICIPANTS: 1926 physicians who provided care among 128,979 physician-patient pairs in 2015. MAIN MEASURES: Likelihood of prescribing a benzodiazepine, opioid or proton-pump inhibitor between low-, average- and high-intensity antibiotic prescribers, adjusted for patient characteristics. KEY RESULTS: Compared with average-intensity antibiotic prescribers, high-intensity prescribers had an increased likelihood of prescribing a benzodiazepine (odds ratio 1.21 [95% CI, 1.11-1.32]), an opioid (odds ratio 1.28 [95% CI, 1.17-1.39]) or a proton-pump inhibitor (odds ratio 1.38 [95% CI, 1.27-1.51]]. High-intensity antibiotic prescribers were more likely to be high prescribers of all three medications (odds ratio 6.24 [95% CI, 2.90-13.39]) and also more likely to initiate all three medications, compared with average-intensity prescribers. CONCLUSIONS: The intensity of a physician's episodic antibiotic prescribing was significantly associated with the likelihood of new and continued prescribing of opioids, benzodiazepines and proton-pump inhibitors in nursing homes. Patterns of episodic prescribing may be a useful mechanism to target physician-level interventions to optimize general prescribing behaviors, instead of prescribing behaviors for single medications.


Assuntos
Analgésicos Opioides/administração & dosagem , Antibacterianos/administração & dosagem , Benzodiazepinas/administração & dosagem , Prescrições de Medicamentos , Casas de Saúde/tendências , Padrões de Prática Médica/tendências , Inibidores da Bomba de Prótons/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Assistência de Longa Duração/estatística & dados numéricos , Assistência de Longa Duração/tendências , Masculino , Casas de Saúde/estatística & dados numéricos , Ontário/epidemiologia , Vigilância da População , Padrões de Prática Médica/estatística & dados numéricos
16.
CMAJ Open ; 7(3): E582-E589, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31551235

RESUMO

BACKGROUND: Opioids are an important pain therapy, but their use may be associated with adverse events in frail and cognitively impaired long-term care residents. The objective of this study was to investigate trends in opioid prescribing among Ontario long-term care residents over time, given the paucity of data for this setting. METHODS: We used linked clinical and health administrative databases to conduct a population-based, repeated cross-sectional study of opioid use among Ontario long-term care residents between Apr. 1, 2009, and Mar. 31, 2017. We identified prevalent opioid use by drug type, dosage and coprescription with benzodiazepines, and within certain vulnerable subgroups. We used log-binomial regression to quantify the percent change between 2009/10 and 2016/17. RESULTS: Among an average of 76 147 long-term care residents per year, the prevalence of opioid use increased from 15.8% in 2009/10 to 19.6% in 2016/17 (p < 0.001). Over the study period, the use of hydromorphone increased by 233.2%, whereas the use of all other opioid agents decreased. The use of high-dose opioids (> 90 mg of morphine equivalents) and the coprescription of opioids with benzodiazepines decreased significantly, by 17.7% (p < 0.001) and 23.8% (p < 0.001), respectively. Increases in opioid prevalence were more notable among frail residents (37.6% v. 18.8% among nonfrail residents, p < 0.001) and those with dementia (38.6% v. 21.6% among those without dementia, p < 0.001). INTERPRETATION: Within Ontario long-term care, trends suggest a shift toward increased use of hydromorphone but reduced prevalence of use of other opioid agents and potentially inappropriate opioid prescribing. Further investigation is needed on the impact of these trends on resident outcomes.

17.
PLoS One ; 14(6): e0218215, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31185042

RESUMO

We aimed to compare health care utilization of children with pediatric-onset multiple sclerosis to that of age, sex and geographically-matched children without multiple sclerosis. Using population-based administrative data from Ontario, Canada for the period 2003-2014, we applied a validated case definition to identify persons aged ≤18 years with multiple sclerosis. We identified up to 5 children without multiple sclerosis matched on sex, age, and region of residence. In each cohort, we determined annual rates of any hospitalization and physician services use. Using general linear models we compared utilization rates adjusting for age, sex, region, socioeconomic status and year. Subsequently, we limited the analysis to incident cases of multiple sclerosis and their matches, and compared rates of utilization in the year of multiple sclerosis diagnosis, and the three years thereafter. We identified 659 youth with multiple sclerosis (428 incident cases), and 3,294 matched controls. Two-thirds of both cohorts were female. After adjustment for sociodemographic factors and year, the multiple sclerosis cohort was more likely to be hospitalized than the matched cohort (odds ratio 15.2; 95%CI: 12.0, 19.1), and had higher rates of ambulatory physician visits (rate ratio 4.58; 95%CI: 4.26, 4.92). The odds of hospitalization (odds ratio 40.1; 95%CI: 27.1, 59.5) and physician visits (rate ratio 5.14; 95%CI: 4.63, 5.71) were markedly elevated in the year of MS diagnosis, declining thereafter but remaining elevated versus the matched cohort. Children with multiple sclerosis have substantially elevated rates of health care utilization as compared to matched children without multiple sclerosis, over calendar time and throughout the early disease course.


Assuntos
Hospitalização , Esclerose Múltipla/terapia , Aceitação pelo Paciente de Cuidados de Saúde , Adolescente , Adulto , Canadá/epidemiologia , Criança , Estudos de Coortes , Feminino , Humanos , Masculino , Esclerose Múltipla/epidemiologia
18.
BMJ Open ; 9(6): e029523, 2019 06 21.
Artigo em Inglês | MEDLINE | ID: mdl-31230032

RESUMO

OBJECTIVES: To examine the associations between dementia and 1-year health outcomes (urgent hospitalisation, long-term care (LTC) admission, mortality) among long-stay home care recipients and the extent to which these associations vary by clients' frailty level. DESIGN: A retrospective cohort study using linked clinical and health administrative databases. SETTING: Home care in Ontario, Canada. PARTICIPANTS: Long-stay (≥60 days) care clients (n=153 125) aged ≥50 years assessed between April 2014 and March 2015. MAIN OUTCOME MEASURES: Dementia was ascertained with a validated administrative data algorithm and frailty with a 66-item frailty index (FI) based on a previously validated FI derived from the clinical assessment. We examined associations between dementia, FI and their interactions, with 1-year outcomes using multivariable Fine-Gray competing risk (urgent hospitalisation and LTC admission) and Cox proportional hazards (mortality) models. RESULTS: Clients with dementia (vs without) were older (mean±SD, 83.3±7.9 vs 78.9±11.3 years, p<0.001) and more likely to be frail (30.3% vs 24.2%, p<0.001). In models adjusted for FI (as a continuous variable) and other confounders, clients with dementia showed a lower incidence of urgent hospitalisation (adjusted subdistribution HR (sHR)=0.84, 95% CI: 0.83 to 0.86) and mortality rate (adjusted HR=0.87, 95% CI: 0.84 to 0.89) but higher incidence of LTC admission (adjusted sHR=2.60, 95% CI: 2.53 to 2.67). The impact of dementia on LTC admission and mortality was significantly modified by clients' FI (p<0.001 interaction terms), showing a lower magnitude of association (ie, attenuated positive (for LTC admission) and negative (for mortality) association) with increasing frailty. CONCLUSIONS: The strength of associations between dementia and LTC admission and death (but not urgent hospitalisation) among home care recipients was significantly modified by their frailty status. Understanding the public health impact of dementia requires consideration of frailty levels among older populations, including those with and without dementia and varying degrees of multimorbidity.


Assuntos
Demência/complicações , Idoso Fragilizado/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Demência/mortalidade , Feminino , Idoso Fragilizado/psicologia , Serviços de Assistência Domiciliar/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Assistência de Longa Duração/estatística & dados numéricos , Masculino , Ontário/epidemiologia , Estudos Retrospectivos
19.
Med Care ; 57(7): 512-520, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31107398

RESUMO

OBJECTIVE: In this study, we investigated the incremental 1-year direct costs of health care associated with frailty among home care recipients in Ontario with and without dementia. METHODS: We conducted a cohort study of 159,570 home care clients aged 50 years and older in Ontario, Canada in 2014/2015. At index home care assessment, we ascertained dementia status using a validated algorithm and frailty level (robust, prefrail, frail) based on the proportion of accumulated to potential health deficits. Clients were followed for 1-year during which we obtained direct overall and sector-specific publicly-funded health care costs (in 2015 Canadian dollars). We estimated the incremental effect of frailty level on costs using a 3-part survival- and covariate-adjusted estimator. All analyses were stratified by dementia status. RESULTS: Among those with dementia (n=42,828), frailty prevalence was 32.1% and the average 1-year cost was $30,472. The incremental cost of frailty (vs. robust) was $10,845 [95% confidence interval (CI): $10,112-$11,698]. Among those without dementia (n=116,742), frailty prevalence was 25.6% and the average 1-year cost was $28,969. Here, the incremental cost of frailty (vs. robust) was $12,360 (95% CI: $11,849-$12,981). Large differences in survival between frailty levels reduced incremental cost estimates, particularly for the dementia group (survival effect: -$2742; 95% CI: -$2914 to -$2554). CONCLUSIONS: Frailty was associated with greater 1-year health care costs for persons with and without dementia. This difference was driven by a greater intensity of health care utilization among frail clients. Mortality differences across the frailty levels mitigated the association especially among those with dementia.


Assuntos
Demência/enfermagem , Idoso Fragilizado , Custos de Cuidados de Saúde/estatística & dados numéricos , Serviços de Assistência Domiciliar/economia , Idoso , Idoso de 80 Anos ou mais , Feminino , Avaliação Geriátrica , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Estudos Retrospectivos
20.
Eur J Public Health ; 29(6): 1084-1089, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30932148

RESUMO

BACKGROUND: Cognitive function is important for healthy aging. Social support availability (SSA) may modify cognitive function. We descriptively examined the association between SSA and cognitive function in a population-level sample of middle- and older-aged adults. METHODS: We analyzed the tracking dataset of the Canadian Longitudinal Study on Aging. Participants aged between 45 and 85 years answered questions about SSA and performed three cognitive tests (Rey Auditory Verbal Learning Test, Animal Fluency Test and Mental Alternation Test) via telephone. We divided global SSA and global cognitive function scores into tertiles and generated contingency tables for comparisons across strata defined by sex, age group, region of residence, urban vs. rural residence and education. RESULTS: The proportion of participants with low global cognitive function was often greater among persons who reported low global SSA. The proportion of persons with high cognitive function was greater in participants with high SSA. The findings were most pronounced for females, 45- to 54-year olds, all regions (especially Québec) except Atlantic Canada, urban dwellers and persons with less than high school education. CONCLUSIONS: Our results can help public health officials focus on providing social supports to subgroups of the population who would benefit the most from policy interventions.


Assuntos
Cognição , Apoio Social , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Saúde Pública
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