Canadian Geriatrics Journal最新文献

Background: There are few studies describing health services use and longer-term survival in older adults with major injuries. Our objectives were to characterize the outcomes of older adults experiencing a major injury, and to assess for associations between injury and rates of home-care services use (HCS), long-term care (LTC) placement, and survival.

Methods: We conducted a retrospective case-control study including adults 65 years or older admitted for a major injury (trauma survivors) or were uninjured (controls) between 2009 and 2023 in Ontario, Canada. Trauma survivors were matched 1:1 to controls based on age, sex, and number of comorbidities. Primary outcomes were rates of HCS use and LTC admissions for up to five years following discharge. Secondary outcomes were types of HCS use and survival. Multivariate regression was used to compare rates of HCS and LTC use. Cox proportional hazards models were used to assess time to LTC admission or death.

Results: The study cohort consisted of 31,508 individuals. Older adult trauma survivors experienced a twofold increased rate of home-care service use (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 2.1-2.4), a 30% increased rate of LTC admissions (OR: 1.3, 95% CI: 1.0-1.6), and a 40% increased rate of death (hazard ratio: 1.4, 95% CI: 1.4-1.5).

Conclusions: Compared to controls, older adults surviving trauma use HCS at significantly higher rates, require LTC placement more frequently, and experience a decreased rate of survival.

Background: This scoping review examines how biological sex has been considered in studies investigating the association between grip strength and cardiovascular outcomes and risk factors.

Methods: We used the Askey and O'Malley framework, reported as per the PRISMA extension for scoping reviews. A search was conducted in four electronic bibliographic databases to identify relevant peer-reviewed studies published after 2001.

Results: Of the 39 included studies, 82.0% (n = 32) used biological sex as a confounder variable in the association of interest. Two studies used interaction terms between biological sex and grip strength and found no statistically significant interactions. Five studies used sex-stratified analyses alone. Three of these studies found that the cardiovascular risk due to low grip strength is higher in males than in females. Two other studies used both interaction terms between biological sex and grip strength and sex-stratification analyses and found no statistically significant differences. Sociocultural gender was not considered in any of the identified studies.

Conclusion: We found that biological sex was often considered as a confounder variable in the association between grip strength and cardiovascular outcomes, as well as cardiovascular risk factors. On the other hand, two studies reported the presence of effect modification by sex rather than confounding, that these associations were stronger in males versus females. Five other studies did not identify evidence of interaction nor effect modification. Future research is needed to clarify the nature of these associations and understand any potential biological mechanisms.

Background: An early palliative approach to care may best suit the care needs of older persons with frailty living in long-term care (LTC). The study objective was to evaluate the barriers and facilitators to care for frailty in the LTC setting.

Methods: Semi-structured interviews were completed with physicians, nurse practitioners, registered nurses, allied health-care providers, care partners, and residents with care experience in LTC. Framework analysis methods that leveraged behaviour change theories were used to analyze the interview data and produce practice-oriented findings.

Results: Twenty-eight interviews were completed. Seven themes were identified: resident characteristics related to frailty; frailty detection and diagnosis; frailty treatment and care planning; frailty and prognosis conversations; palliative and end-of-life care; communication amongst LTC collaborators; and the LTC environment. All codes were labelled as barriers or facilitators and assigned to a primary domain within the Theoretical Domains Framework.

Conclusions: The lack of clinical recognition of frailty in the LTC setting was a key barrier to clinical pathway implementation. There is a need for frailty to be linked to prognosis and care decisions, for frailty to be directly addressed through individualized treatments, and for an early palliative approach to care to be accessible to residents. Identifying barriers to care for frailty is a critical step toward clinical care pathway implementation which may improve care and outcomes for residents of LTC.

Background: Steps per day can provide a lot of information about the activity of the average person whose main source of activity is derived from walking. This study looks at the distribution of step-count data to identify different subgroups of people which could be used to indicate walking reserve.

Methods: A time series design of a secondary data analysis was conducted to track the variability of daily step count for 44 seniors post-fracture. The mean age was 75.8 years (SD: 9.75). The full percentile distribution was used in a cluster analysis and group-based trajectory analysis was used for the longitudinal data. Ordinal regression was used to identify factors associated with cluster membership.

Results: Four clusters best represented the distribution of reserve in this sample, hypothesized to be defined as the difference between the median and 90^th percentile of the step-count distribution. Cluster 1, with the lowest reserve would also be classified as sedentary based on median step count (1,555 step count; 1,314 reserve). Cluster 2 represented people with limited activity with low reserve (4,081 step count; 2,439 reserve). Cluster 3 represented active people with high reserve (7,197 step count; 4,370 reserve). Cluster 4, was very active with very high reserve (9,202 step count, 6,964 reserve).The factors associated with cluster membership were gait speed, sit-to-stand, and depression.

Conclusions: The median and 90^th percentile over a longer period indicates the potential "reserve" for participating in activities that demand additional walking.

We evaluated the validity of using the CanMEDS Resident as Teacher Multisource Feedback (RaTMSF) assessment tool to gather learner feedback from structured resident-led teaching within the University of Toronto's postgraduate geriatric medicine residency program. The RaTMSF consists of 10 rated items and narrative comments. Completed RaTMSF evaluations from resident teachers were analyzed by descriptive statistics for internal consistency and inter-rater reliability, and narrative comments were reviewed for thematic content. Resident teachers were surveyed on the acceptability of the tool to develop teaching competencies. A total of 132 evaluations were collected prospectively from 11 residents from April 2021 to April 2022, and retrospectively from seven graduates from 2016 to 2019. The overall performance rating, 4.75 (SD 0.47), was very positive for all resident teachers. The RaTMSF demonstrated high internal consistency with Cronbach's alpha of 0.97, 95% CI 0.89-0.99 between all 10 items, and good inter-rater reliability with Fleiss kappa of 0.73 (95% CI 0.13-0.80). The most common themes of narrative comments also captured in the rated items were organization to teach (n=53) and openness to questions (n=36). Written comments regarding delivery style (n=52) and audience interactivity (n=44) were not captured on the rated items. While most resident teachers surveyed found the RaTMSF acceptable to use, we suggest opportunities to improve the RaTMSF by restructuring focus onto written feedback and revising rated items to better reflect themes found in narrative comments. The RaTMSF can be a valuable feedback tool to help residents gather high-quality feedback on their teaching skills.

Background: Primary care is essential in dementia management, offering diagnosis, treatment, and support for people living with dementia (PLWD) and their caregivers. Telemedicine became a key advancement during the COVID-19 pandemic, offering crucial access to care. This study explores the pros and cons of telemedicine for dementia care during the pandemic to guide future improvements.

Methods: Data collection involved semi-structured interviews with caregivers recruited from a Montreal memory clinic and secondary analysis of two other studies related to dementia and telemedicine, focusing on the educational needs of patients and the impact of the pandemic on health-care services. Data analysis employed the framework method, combining inductive and deductive approaches to code the data and develop categories aligned with Chang's framework, providing insights into caregivers' experiences and the challenges and benefits of telemedicine.

Results: The study involved interviews with four caregivers of people with dementia, complemented by secondary analysis from two Canadian studies. Through framework analysis, four themes were developed: relationship and communication; the advantages and selective suitability of telemedicine (TM) in dementia care; preferences for in-person consultations; and the need to improve awareness and technical confidence in TM.

Conclusion: This study highlights the potential of telemedicine (TM) as an effective modality for dementia care, particularly during situations like the COVID-19 pandemic, but emphasizes that it cannot fully replace in-person consultations due to the enduring preference for face-to-face interactions.

Background: Acute care hospital stays often lead to increased frailty and functional decline in older adults. Interventions such as specialized education for nurses can improve health outcomes and decrease lengths of stay for these patients. This study aimed to identify the facilitators and barriers to providing care to older adults in acute care, and the efficacy of specialized education for front-line staff.

Methods: A specialized education program for front-line staff, Frailty Focused Enhancements to Seniors' Hospital Care (FrESH), was developed and delivered across five family medicine units in New Brunswick (NB). A mixed methods approach was used to assess the knowledge, attitudes, and experiences of staff caring for hospitalized older adults, and evaluate the impact of providing specialized education. Patient-level data on delirium, mobility, and medications pre- and post-specialized education intervention were collected and analyzed.

Results: Sixty-three front-line staff participated. Analysis of questionnaires demonstrated that staff had positive attitudes and beliefs about caring for older adults; however, knowledge of geriatric care principles was limited and remained unchanged. There was no significant change in patient-level measures post-intervention. Environmental constraints hindered staff from implementing best practices, leading to practical challenges to care delivery. While respondents expressed satisfaction with the education, their capacity to deliver the type of care presented in the education sessions was not achievable.

Conclusion: Staff identified the need for specialized education; however, there was no impact on care after participation. Results will inform changes to the specialized education programs targeting care for hospitalized older adults in acute care.

Background: SARS-CoV-2 infection can lead to persistent post-acute neuropsychiatric symptoms. Older adults with multimorbidity may be at increased risk of post-acute symptoms after COVID-19. The goals of the present study were to assess the associations of SARS-CoV-2 infection with neuropsychiatric symptoms and psychotropic medication prescription among older adults living in long-term care facilities.

Methods: Nursing home residents (n=111) participated in this three-month longitudinal study. Nurse ratings of neuropsychiatric symptoms were conducted at baseline and at the three-month follow-up. SARS-CoV-2 infection status and psychotropic medication prescription were extracted from a medical chart review.

Results: About 73.9% of participants were infected with SARS-CoV-2 on average 480.49 (SD= 228) days before study enrollment. There were no significant changes in neuropsychiatric symptoms during the study follow-up period. Participants with a SARS-CoV-2 infection had more agitation compared to those who were never infected. However, this effect disappeared after adjusting for age, sex, history of psychiatric disorder, neurocognitive status, and multimorbidity. Participants with SARS-CoV-2 had a higher number of psychotropic medication prescription. This effect was driven by increased use of antidepressants and antipsychotic medications.

Conclusion: Both acute and short-term neuropsychiatric symptoms associated with COVID-19 may contribute to long-term psychoactive polypharmacy among older adults living in long-term facilities.

Background: Prescribing rates for subcutaneous medications may be an indicator of quality of end-of-life care in long-term care (LTC). It is not known if this system level measure is valid across jurisdictions. We compared prescribing rates of medications used for end-of-life symptom relief among LTC residents in Alberta and Ontario.

Methods: This retrospective cohort study of LTC residents compared those who died between January 1, 2017, and March 17, 2020 in Alberta, with a published cohort from Ontario. Prescribed end-of-life medications during a resident's last 14 days of life were extracted from administrative dispensation records. LTC homes were ranked into quintiles based on prescribing rates within each home, and the home characteristics were described. The proportion of residents who transferred out of LTC in the last 14 days of life was also determined, as another quality measure.

Results: We identified 10,038 decedents in 117 LTC homes. Among LTC decedents, 16.9% were prescribed ≥1 injectable end-of-life medication and 44.9% were prescribed at least one end-of-life medication by any route of administration, within the last 14 days of life. Across prescribing quintiles, there were no associations with transfer rates prior to death. Comparing Alberta to Ontario, there were markedly lower rates of injectable medicine prescribing (16.9% vs. 64.7%). Potential reasons and data limitations were explored.

Conclusions: Rates of injectable end-of life medication prescribing differed across Alberta LTC homes; however, current provincial data limitations impact the validity of using these rates as a comparative indicator of the quality of end-of-life care.