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Technology and health care for the elderly medical research studies
We facilitate evidence-based research, knowledge sharing and clinical practices that improve healthcare outcomes for older Canadians living with frailty, their families and caregivers.

Knowledge in action

Recently published papers

Keller HH, Lengyel C, Carrier N, Slaughter SE. Prevalence of inadequate micronutrient intakes of Canadian long-term care residents. British Journal of Nutrition, 1-10. doi:10.1017/S0007114518000107. Published online: 15 February 2018.

Abstract: This study determines the prevalence of inadequate micronutrient intakes consumed by long-term care (LTC) residents. This cross-sectional study was completed in thirty-two LTC homes in four Canadian provinces. Weighed and estimated food and beverage intake were collected over 3 non-consecutive days from 632 randomly selected residents. More than 50 % of participants in both sexes consumed inadequate amounts of folate, vitamins B6, Ca, Mg and Zn (males only), with >90 % consuming amounts below the EAR/AI for vitamin D, E, K, Mg (males only) and K. Vitamin D supplements resolved inadequate intakes for 50–70 % of participants. High proportions of LTC residents have intakes for nine of twenty nutrients examined below the EAR or AI. Strategies to improve intake specific to these nutrients are needed.

Matteo Cesari Islene Araujo de Carvalho Jotheeswaran Amuthavalli Thiyagarajan Cyrus Cooper Finbarr C Martin Jean-Yves Reginster Bruno Vellas John R Beard. Evidence for The Domains Supporting The Construct of Intrinsic Capacity.The Journals of Gerontology: Series A, early acceptance published February 2, 2018,

Abstract: Healthy ageing can be defined as “the process of developing and maintaining the functional ability that enables wellbeing in older age”. Functional ability (i.e., the health-related attributes that enable people to be and to do what they have reason to value) is determined by intrinsic capacity (i.e., the composite of all the physical and mental capacities of an individual), the environment (i.e., all the factors in the extrinsic world that form the context of an individual’s life), and the interactions between the two. This innovative model recently proposed by the World Health Organization has the potential to substantially modify the way in which clinical practice is currently conducted, shifting from disease-centered towards function-centered paradigms. By overcoming the multiple limitations affecting the construct of disease, this novel framework may allow the worldwide dissemination of a more proactive and function-based approach towards achieving optimal health status. In order to facilitate the translation of the current theoretical model into practice, it is important to identify the inner nature of its constituting constructs. In this paper, we consider intrinsic capacity. Using the International Classification of Functioning, Disability and Health (ICF) framework as background and taking into account available evidence, five domains (i.e., locomotion, vitality, cognition, psychological, sensory) are identified as pivotal for capturing the individual’s intrinsic capacity (and therefore also reserves) and, through this, pave the way for its objective measurement.

Watt J, Tricco AC, Talbot-Hamon C, Pham B, Rios P, Grudniewicz A, Wong C, Sinclair D, Straus SE. Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis. J GEN INTERN MED (2018).

Abstract: Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016, and 5692 titles and abstracts were screened. Forty-one studies (9384 patients) reported delirium-related prognostic factors. Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified protective and potentially modifiable prognostic factors, including smoking, frailty, and psychotropic medication use, which should be further studied to develop interventions aimed at mitigating potential harm.

Gajic-Feljanoski O, Papaioannou A, Kennedy C, Ioannidis G, Berger C, Wong AKO, Rockwood K, Kirkland S, Raina P, Thabane L, Adachi JD for the CaMos Research Group. Osteoporotic fractures and obesity affect frailty progression: a longitudinal analysis of the Canadian multicentre osteoporosis study. BMC GeriatricsBMC series – open, inclusive and trusted201818:4.

Abstract: Despite knowing better how to screen older adults, understanding how frailty progression might be modified is unclear. This study explored effects of modifiable and non-modifiable factors on changes in frailty in community-dwelling adults aged 50+ years who participated in the Canadian Multicentre Osteoporosis Study (CaMos). Rates of change in frailty over 10 years were examined using the 30-item CaMos Frailty Index (CFI). Older women and men with new vertebral fractures, hip fractures or obesity represent high-risk groups that should be considered for frailty interventions.

Wilson K, Kortes-Miller K, Stinchcombe A. Staying Out of the Closet: LGBT Older Adults’ Hopes and Fears in Considering End-of-Life. Canadian Journal on Aging (2018, 37:1), March 2018 , pp. 22-31.

Abstract: Canada is experiencing population aging, and given the heterogeneity of older adults, there is increasing diversity in late life. The purpose of this study was to help fill the research gaps on LGBT aging and end-of-life. Through focus groups, we sought to better understand the lived experience of older LGBT individuals and to examine their concerns associated with end-of-life. Our analysis highlights the idea that identifying as LGBT matters when it comes to aging and end-of-life care. In particular, gender identity and sexual orientation matter when it comes to social connections, in the expectations individuals have for their own care, and in the unique fear related to staying out of the closet and maintaining identity throughout aging and end-of-life. This study underscores the need to consider gender identity and sexual orientation at end-of-life. In particular, recognition of intersectionality and social locations is crucial to facilitating positive aging experiences and end-of-life care.

Liu B, Moore JE, Almaawiy U, Chan WH, Khan S, Ewusie J, Hamid JS, Straus SE on behalf of the MOVE ON Collaboration. Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): a multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation. Age and Ageing, Volume 47, Issue 1, 1 January 2018, Pages 112–119,

Abstract: Older patients admitted to hospitals are at risk for hospital-acquired morbidity related to immobility. The aim of this study was to implement and evaluate an evidence-based intervention targeting staff to promote early mobilisation in older patients admitted to general medical inpatient units. The early mobilisation implementation intervention for staff was multi-component and tailored to local context at 14 academic hospitals in Ontario, Canada. The primary outcome was patient mobilisation. Secondary outcomes included length of stay (LOS), discharge destination, falls and functional status. In total, 12,490 patients (mean age 80.0 years [standard deviation 8.36]) were included in the overall analysis. This is a large-scale study evaluating an implementation strategy for early mobilisation in older, general medical inpatients. The positive outcome of this simple intervention on an important functional goal of getting more patients out of bed is a striking success for improving care for hospitalised older patients.

Namasivayam-McDonald AM, Slaughter S, Morrison J, Steele CM, Carrier N, Lengyel C, Keller HH. Inadequate fluid intake in long term care residents: prevalence and determinants. Geriatric Nursing (in press).

Abstract: Dehydration is estimated to be present in half of long term care residents, as many do not consume the recommended levels of fluid intake. This study aimed to describe fluid intake in long term care residents and identify the factors associated with fluid intake. Data were collected from 622 long term care residents, with a mean age of 86.8 ± 7.8 over three non-consecutive days. The study provides new insight into the potential reasons for low fluid intake that can lead to dehydration, a form on malnutrition in the institutionalized elderly. Based on the current sample, residents in long term care are not consuming the daily recommended amount of fluids. Moreover, the majority of residents are not even consuming 1500 mL of fluids per day. This study shows that the factors that are contributing the most to poor fluid intake are: older age, being female, presence of mealtime difficulties and requiring physical assistance at meals. The latter two factors should be the focus of future research interventions.

Shears M, McGolrick D, Waters B, Jakab M, Boyd JG, Muscedere J. Frailty measurement and outcomes in interventional studies: protocol for a systematic review of randomised control trials. BMJ Open 2017;7:e018872. doi: 10.1136/bmjopen-2017-018872

Abstract: Frailty is associated with reduced functional capacity, decreased resistance to stressors and is predictive of a range of adverse health outcomes, including dependency, hospitalisation and mortality. Early identification of frailty may prevent, reduce and postpone adverse health outcomes. However, there is a need for additional evidence to guide decision-making for the care of frail patients since frail persons are frequently excluded from studies, the differential impact of frailty is often not examined in clinical trials and few large-scale clinical trials examining frail cohorts have been conducted. Randomised control trials (RCTs) published to date have used a diverse range of definitions of frailty, as well as a variety of outcome measures. The objective of this systematic review was to comprehensively characterise the frail populations enrolled and the end points reported in frailty RCTs. This systematic review comprehensively identified RCTs including frail patients to identify how frailty is measured and which outcomes are reported. The results may inform clinicians caring for persons with frailty, facilitate conduct of future RCTs and inform future efforts to develop common data elements and core outcomes for frailty studies. 

Blouin M, Sirois M-J, Aubertin-Leheudre M, Griffith L, Nadeau L, Daoust R, Lee J, Émond M. In the Emergency Department, Are Serum Biomarkers useful to Screen Independent Frail Seniors Exposed to Future Functional Decline or Mobility Impairments after a Minor Injury? J Gerontol Geriatr Res 2017, Vol 6(6): 457. DOI: 10.4172/2167-7182.1000457.

Abstract: Frailty is a geriatric syndrome conferring a high risk of declining functional capacities. Some serum biomarkers are associated with frailty, but no study has specifically investigated the possible association between frailty and serum biomarkers in independent community-dwelling seniors who consulted the emergency department (ED) following a minor injury. The objectives of this study were to: 1) To explore baseline associations between six serum biomarkers and the frailty status of independent community-dwelling seniors who were seen in the ED for minor injuries, 2) to determine if ED serum biomarker assay combined with frailty status improves the prediction of 3-month functional decline or mobility impairments in this population, beyond frailty status alone. The study includee 190 participants (age ≥ 65 years, independent in daily activities and discharged home). Conclusions: ED biomarker assays are not useful in predicting 3-month functional decline or mobility impairments beyond what is predicted by frailty status alone in independent community-dwelling seniors who consulted for minor injuries.

McIsaac DI, Jen T, Mookerji N, Patel A, Lalu MM. Interventions to improve the outcomes of frail people having surgery: A systematic review. PLoS ONE 12(12): e0190071. Dec. 29.

Abstract: Frailty is an important prognostic factor for adverse outcomes and increased resource use in the growing population of older surgical patients. We identified and appraised studies that tested interventions in populations of frail surgical patients to improve perioperative outcomes. We systematically searched Cochrane, CINAHL, EMBASE and Medline to identify studies that tested interventions in populations of frail patients having surgery and identified 2,593 titles. Despite a growing literature that demonstrates strong independent associations between frailty and adverse outcomes, few interventions have been tested to improve the outcomes of frail surgical patients, and most available studies are at substantial risk of bias. Multicenter, low risk of bias, studies of perioperative exercise are needed, while substantial efforts are required to develop and test other interventions to improve the outcomes of frail people having surgery.

van Solm AIT, Hirdes JP, Eckel LA, Heckman GA, Bigelow, PL. Using standard clinical assessments for home care to identify vulnerable populations before, during, and after disasters. Journal of Emergency Management, Vol 5(6) 2017.

Abstract: Several studies have shown the increased vulnerability of and disproportionate mortality rate among frail community-dwelling older adults as a result of emergencies and disasters. This article discusses the applicability of the Vulnerable Persons at Risk (VPR) and VPR Plus decision support algorithms designed based on the Resident Assessment Instrument- Home Care (RAI-HC) to identify the most vulnerable community-dwelling (older) adults. A sample was taken from the Ontario RAI-HC database by selecting unique home care clients with assessments closest to December 31, 2014 (N = 275,797). The VPR and VPR Plus algorithms, were highly predictive of mortality, long-term care admission and hospitalization in ordinary circumstances. This provides a good indication of the strength of the algorithms in identifying vulnerable persons at times of emergencies. Access to real-time person-level information of persons with functional care needs is a vital enabler for emergency responders in prioritizing and allocating resources during a disaster, and has great utility for emergency planning and recovery efforts. The development of valid and reliable algorithms supports the rapid identification and response to vulnerable community-dwelling persons for all phases of emergency management.

Rios S, Perlman CM, Costa A, Heckman G, Hirdes JP, Mitchell L. Antipsychotics and dementia in Canada: a retrospective cross-sectional study of four health sectors. BMC Geriatr. 2017 Oct 23;17(1):244. doi: 10.1186/s12877-017-0636-8.

Abstract:Antipsychotic medications are not recommended for the management of symptoms of dementia, particularly among persons with no behavioral or psychological symptoms. The study examined patterns of antipsychotic medication use among persons with dementia across health sectors in Canada, with a focus on factors related to use among those without behavioral or psychotic symptoms. The research base was adults aged 65 or older with dementia in home care (HC), complex continuing care (CCC), long-term care (LTC), and among alternate level care patients in acute hospitals (ALC) and used clinical data from January 1, 2009 to December 31, 2014. Potentially inappropriate use of antipsychotic medications was found to be prevalent among older adults with dementia across health sectors. The variations in prevalence observed from community to facility based care suggests that system issues may exist in appropriately managing persons with dementia.

Tabue-Teguo M, Dartigues JF, Simo N, Kuate-Tegue C, Vellas B, Cesari M.  Physical status and frailty index in nursing home residents: Results from the INCUR study. Archives of Gerontology and Geriatrics, Volume 74, January–February 2018, Pages 72–76.

Abstract: The Short Physical Performance Battery (SPPB) is a widely used instrument for measuring physical performance, consisting of 3 sub-tests: a hierarchical test of balance, a gait speed test, and a chair stand test. Although equally considered in the computation of the SPPB score, each of the components may present a specific and different weight in clinical practice. The aim of this study was to estimate the relationship between SPPB and its component of an age-related deficit accumulation index (the so-called Frailty Index [FI] proposed by Rockwood). Of the 3 components of the SPPB, both balance and chair tests seem particularly relevant indicator of frailty among very old and complex elders living in nursing homes.

Hatheway OL, Mitnitski A, Rockwood K. Frailty affects the initial treatment response and time to recovery of mobility in acutely ill older adults admitted to hospital. Age Ageing. 2017 Nov 1;46(6):920-925. doi: 10.1093/ageing/afw257.

Abstract: The objective of this study was to investigate how frailty and mobility impairment affect recovery of balance and mobility in acutely ill older patients. It was a secondary analysis of a cohort study, including 409 older adults from general and geriatric medicine hospital inpatient units. The authors concluded that frailer patients are at a greater risk of incomplete or lengthier recovery from impaired mobility and balance. Tracking mobility and balance might help providers, patients and families understand the course of acute illness in older adults.

Dani M, Owen LH, Jackson TA, Rockwood K, Sampson EL, Davis D. Delirium, frailty and mortality: interactions in a prospective study of hospitalized older people. J Gerontol A Biol Sci Med Sci. 2017 Nov 1. doi: 10.1093/gerona/glx214. [Epub ahead of print].

Abstract: It is unknown if the association between delirium and mortality is consistent for individuals across the whole range of health states. A bimodal relationship has been proposed, where delirium is particularly adverse for those with underlying frailty, but may have a smaller effect (perhaps even protective) if it is an early indicator of acute illness in fitter people. This study investigated the impact of delirium on mortality in a cohort simultaneously evaluated for frailty. While delirium and frailty contribute to mortality, the overall impact of delirium on admission appears to be greater at lower levels of frailty. In contrast to the hypothesis that there is a bimodal distribution for mortality, delirium appears to be particularly adverse when precipitated in fitter individuals.

Brousseau AA, Dent E, Hubbard R, Melady D, Émond M, Mercier É, Costa AP, for the Multinational Emergency Department Study. Identification of older adults with frailty in the Emergency Department using a frailty index: results from a multinational study. Age and Ageing (20 November 2017).

Abstract: Frailty is a central concept in geriatric medicine, yet its utility in the Emergency Department (ED) is not well understood nor well utilised. Our objectives were to develop an ED frailty index (FI-ED), using the Rockwood cumulative deficits model and to evaluate its association with adverse outcomes. This was a large multinational prospective cohort study using data from the interRAI Multinational Emergency Department Study. The FI-ED was developed from the Canadian cohort and validated in the multinational cohort. All patients aged ≥75 years presenting to an ED were included. The FI-ED was created using 24 variables included in the interRAI ED-Contact Assessment tool. Tthere were 2,153 participants in the Canadian cohort and 1,750 in the multinational cohort. The FI-ED conformed to characteristics previously reported. A FI, developed and validated from a brief geriatric assessment tool could be used to identify ED patients at higher risk of adverse events.

Chhetri J, Chan P, Vellas B, Cesari M. Motoric Cognitive Risk Syndrome: Predictor of Dementia and Age-Related Negative Outcomes. Front. Med., 25 October 2017 |

Abstract: Cognitive disorders represent a leading cause of disability in the aging population, of which dementia has the highest global burden. Early signs of dementia such as slow gait and memory complaints are known to present well before the overt manifestation of the disease. Motoric cognitive risk (MCR) syndrome characterized by the simultaneous presence of gait disturbances and memory complaints in older subjects has been proposed to study the close interactions between the physical and cognitive domains as well as a possible approach to identify individuals at increased risk of dementia. In addition, studies have shown MCR as a predictor of other negative outcomes in older adults, including disability, falls and death. However, the concept of MCR is still in its early stage and approach to the syndrome is still not well established. This review aims to put together the various aspects of MCR syndrome including its pathophysiology, diagnosis, epidemiology, and relationship with other geriatric conditions.

Shepperd S, Cradduck-Bamford A, Butler C, Ellis G, Godfrey M, Gray A, Hemsley A, Khanna P, Langhorne P, McCaffrey P, Mirza L, Pushpangadan M, Ramsay S, Schiff R, Stott D, Young J, Yu LM. A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission. Trials. 2017 Oct 23;18(1):491. doi: 10.1186/s13063-017-2214-y.

Abstract: There is concern that existing models of acute hospital care will become unworkable as the health service admits an increasing number of frail older people with complex health needs, and that there is inadequate evidence to guide the planning of acute hospital level services. This study aims to evaluate whether geriatrician-led admission avoidance to hospital at home is an effective alternative to hospital admission. This is a multi-site randomised open trial in the UK of geriatrician-led admission avoidance hospital at home, compared with admission to hospital. This trial is the first large multi-site randomised trial of geriatrician-led admission avoidance hospital at home, and will provide evidence on alternative models of healthcare for older people who require hospital admission.

Morris JN, Declercq A, Hirdes JP, Finne-Soveri H, Fries BE, James ML, Geffen L, Kehayan V, Saks K, Szcerbinska K, Topinkova E. Hearing the Voice of the Resident in Long-Term Care Facilities-An Internationally Based Approach to Assessing Quality of Life. J Am Med Dir Assoc. 2017 Oct 10. pii: S1525-8610(17)30464-4. doi: 10.1016/j.jamda.2017.08.010. [Epub ahead of print]

Abstract: interRAI launched this study to introduce a set of standardized self-report measures through which residents of long-term care facilities (LTCFs) could describe their quality of life and services. This article reports on the international development effort, describing measures relative to privacy, food, security, comfort, autonomy, respect, staff responsiveness, relationships with staff, friendships, and activities. The study first evaluated these items individually and then combined them in summary scales. Second, it examined how the summary scales related to whether the residents did or did not say that the LTCFs in which they lived felt like home. Resident self-report data came from 16,017 individuals who resided in 355 LTCFs. The interRAI Self-Report Quality of Life Survey for LTCFs was used to assess residents' quality of life and services. This study establishes a set of standardized, self-report items and scales with which to assess the quality of life and services for residents in LTCFs. The study also demonstrates that these scales are significantly related to resident perception of the home-like quality of the facilities.

Canadian Frailty Network. Trainee Abstracts from the 2017 Annual Conference. Canadian Geriatrics Journal, Vol 20, No 3 (2017). DOI:

One of the components of the Canadian Frailty Network (CFN) Interdisciplinary Training Program allows trainees or HQPs (Highly Qualified Personnel) to gain experience in disseminating their work through publication and meetings. All trainees must submit an abstract and present a poster at the CFN Annual Conference. The 4th Annual Conference was held in Toronto, on April 23-24, 2017, and the compilation of abstracts was published in the September issue of Canadian Geriatrics Journal.

Urquhart R, Giguère AMC, Lawson B, Kendell C. Rules to Identify Persons with Frailty in Administrative Health Databases. Published online: 04 October 2017.

Abstract: This study sought to develop frailty “identification rules” using population-based health administrative data that can be readily applied across jurisdictions for living and deceased persons. Three frailty identification rules were developed based on accepted definitions of frailty, markers of service utilization, and expert consultation, and were limited to variables within two common population-based administrative health databases: hospital discharge abstracts and physician claims data. These rules were used to identify persons with frailty from both decedent and living populations across five Canadian provinces. Participants included persons who had died and were aged 66 years or older at the time of death (British Columbia, Alberta, Ontario, Quebec, and Nova Scotia) and living persons 65 years or older (British Columbia, Alberta, Ontario, and Quebec). Descriptive statistics were computed for persons identified using each rule. The proportion of persons identified as frail ranged from 58.2-78.1 per cent (decedents) and 5.1-14.7 per cent (living persons).

Hubbard RE, Peel NM, Samanta M, Gray LC, Mitnitski A, Rockwood K. Frailty status at admission to hospital predicts multiple adverse outcome. Age and Ageing, Volume 46, Issue 5, 1 September 2017, Pages 801–806,

Abstract: Frailty is proposed as a summative measure of health status and marker of individual vulnerability. This study aimed to investigate the discriminative capacity of a frailty index (FI) derived from interRAI Comprehensive Geriatric Assessment for Acute Care (AC) in relation to multiple adverse inpatient outcomes. In this prospective cohort study, an FI was derived for 1,418 patients ≥70 years across 11 hospitals in Australia. The interRAI-AC was administered at admission and discharge by trained nurses, who also screened patients daily for geriatric syndromes. The interRAI-AC can be used to derive a single score that predicts multiple adverse outcomes in older inpatients. A score of ≤0.40 can well discriminate patients who are unlikely to die or experience a geriatric syndrome. Whether the FI-AC can result in management decisions that improve outcomes requires further study.

Theou O, Park GH, Garm A, Song X, Clarke B, Rockwood K. Reversing Frailty Levels in Primary Care Using the CARES Model. Can Geriatr J. 2017 Sep 28;20(3):105-111. doi: 10.5770/cgj.20.274.

Abstract: The purpose of this study was to evaluate the effectiveness of the Community Actions and Resources Empowering Seniors (CARES) model in measuring and mitigating frailty among community-dwelling older adults. The CARES model is based on a goal-oriented multidisciplinary primary care plan which combines a comprehensive geriatric assessment (CGA) with health coaching. A total of 51 older adults (82 ± 7 years; 33 females) participated in the pilot phase of this initiative. Frailty was measured using the Clinical Frailty Scale (CFS) and the Frailty Index (FI-CGA) at baseline and at six-month follow-up. Pilot data showed that it is feasible to assess frailty in primary care and that the CARES intervention might have a positive effect on frailty, a promising finding that requires further investigations. General practitioners who participate in the CARES model can now access their patients' FI-CGA scores at point of service through their electronic medical records.

Andrew MK, Purcell CA, Marshall EG, Varatharasan N, Clarke B, Bowles SK. Polypharmacy and use of potentially inappropriate medications in long-term care facilities: does coordinated primary care make a difference? Int J Pharm Pract. 2017 Sep 27. doi: 10.1111/ijpp.12397. [Epub ahead of print]

Abstract: Polypharmacy is both common and harmful for frail residents of long-term care facilities (LTCF). This study aimed to examine rates of polypharmacy and potentially inappropriate medications (PIMs) before and after the implementation of a new model of coordinated primary care in LTCF, 'Care by Design (CBD)'. This was an observational before/after study in 10 LTCFs in Halifax, NS, Canada. Chart reviews were conducted for 529 LTCF residents for whom medication use was available. Both regularly scheduled and PRN medications were included but topical, inhaled and other non-systemic agents were excluded. Polypharmacy was defined as the concomitant use of more than 10 medications. PIMs were identified using Beers Criteria. Polypharmacy was the norm of this sample of LTCF residents. Implementation of coordinated care through the CBD model was associated with a small decrease in polypharmacy but not overall use of PIMs. Further targeted efforts are required to substantially reduce both polypharmacy and PIMs in clinical practice.

Nayfeh A, Marcoux I, Jatai J. Advance Care Planning for Mechanical Ventilation. OMEGA - Journal of Death and Dying. First published date: September 25, 2017.

Abstract: Advance care planning (ACP) is a method used for patients to express in advance their preferences for life-sustaining treatments at the end of life. With growing ethnocultural diversity in Canada, health-care providers are managing an increasing number of diverse beliefs and values that are commonly associated with preferences for intensive mechanical ventilation (MV) treatment at the end of life. This study aimed to identify and describe the approaches used by health-care providers to set advance care plans for MV with seriously ill patients from diverse ethnocultural backgrounds. Semistructured interviews were conducted with health-care providers from acute-care settings. Using a value-based approach in ACP was deemed an effective method of practice for managing and interpreting diverse beliefs and values that impact decisions for MV. However, personnel, organizational, and systemic barriers that exist continue to hinder the provision of ACP across cultures.

Ayah Nayfeh was a CFN Interdisciplinary Fellow funded in our CFN's inaugural cohort while an MSc student. This paper represents her MSc research findings.

McIsaac DI, Huang A, Wong CA, Wijeysundera DN, Bryson GL, van Walraven C. Effect of Preoperative Geriatric Evaluation on Outcomes After Elective Surgery: A Population-Based Study. J Am Geriatr Soc (2017). doi:10.1111/jgs.15100

Abstract: Older people are the fastest growing cohort of individuals undergoing surgery. Advanced age is associated with morbidity, mortality, and resource use after surgery. Given the projected increase in the number of older adults requiring surgery, interventions to improve their outcomes are needed. Geriatricians have in-depth training to address geriatric-specific risk factors, and perioperative geriatric care is associated with lower rates of complications and length of stay (LOS) in single-center randomized and nonrandomized studies. The effect of preoperative geriatric care (including comprehensive geriatric evaluations and geriatric consultations) on outcomes and resource use has not been described. The objectives of this study were to describe use of preoperative outpatient geriatric care and the association between preoperative geriatric care and postoperative survival, complications, need for supported discharge, readmissions, and healthcare costs. The study included adults aged 65 and older having major, elective, noncardiac surgery from 2002 to 2014 (N = 266,499). The study looked at geriatric consultations and comprehensive assessments performed in the 4 months prior to surgery. Measurements included ninety-day survival, in-hospital complications, length of stay, 30-day readmissions, need for supported discharge, and 90-day costs of care. In individuals aged 65 and older undergoing major, elective, noncardiac surgery, preoperative geriatric evaluation was associated with longer 90-day survival, but it is used infrequently. Given these results, and those of previous small studies, the influence of a geriatric evaluation on postoperative outcomes should be determined in a multicenter randomized trial.

McCleary L, Boscart V, Donahue P, Harvey K. Educator Readiness to Improve Gerontological Curricula in Health and Social Service Education. Published online: 15 September 2017

Abstract: This study investigated the state of gerontology content in health and social service education programs in Ontario, and readiness indicators for change among administrators and faculty. We conducted a survey of teaching faculty (n = 100) and deans or directors (n = 56) of 89 education programs, which revealed mixed evidence on readiness for change. Most respondents thought their programs were adequate but needed enhancement. However, they were unaware of published gerontological competencies with which to evaluate their curricula. Beliefs about capacity for change varied, with half the participants indicating that their programs had sufficient faculty expertise in gerontology and geriatrics. Factors influencing readiness for change include lack of gerontological expertise; need for institutional and management support; need for additional teaching resources; and recognizing the need for change. There is an opportunity, by committing resources and time, to capitalize on the faculty and administrators who thought their programs should improve.

Yarnall AJ, Sayer AA, Clegg A, Rockwood K, Parker S, Hindle JV. New horizons in multimorbidity in older adults. Age Ageing. 2017 Sep 4:1-7. doi: 10.1093/ageing/afx150. [Epub ahead of print]

Abstract:The concept of multimorbidity has attracted growing interest over recent years, and more latterly with the publication of specific guidelines on multimorbidity by the National Institute for Health and Care Excellence (NICE). Increasingly it is recognised that this is of particular relevance to practitioners caring for older adults, where multimorbidity may be more complex due to the overlap of physical and mental health disorders, frailty and polypharmacy. The overlap of frailty and multimorbidity in particular is likely to be due to the widespread health deficit accumulation, leading in some cases to functional impairment. The NICE guidelines identify 'target groups' who may benefit from a tailored approach to care that takes their multimorbidity into account, and make a number of research recommendations. Management includes a proactive individualised assessment and care plan, which improves quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care.

Vetrano D, Calderón-Larrañaga A, Marengoni A, Onder G, Bauer J, Cesari M, Ferrucci L, Fratiglioni L. An international perspective on chronic multimorbidity: approaching the elephant in the room. The Journals of Gerontology: Series A, glx178, Published Sept 16 2017.

Abstract: Multimorbidity is a common and burdensome condition that may affect quality of life, increase medical needs and make people live more years of life with disability. Negative outcomes related to multimorbidity occur beyond what we would expect from the summed effect of single conditions, as chronic diseases interact with each other, mutually enhancing their negative effects, and eventually leading to new clinical phenotypes. Moreover, multimorbidity mirrors an accelerated global susceptibility and a loss of resilience, which are both hallmarks of aging. Due to the complexity of its assessment and definition, and the lack of clear evidence steering its management, multimorbidity represents one of the main current challenges for clinicians, researchers and policymakers. The authors of this paper recently reflected on these issues during two twin international symposia at the 2016 European Union Geriatric Medicine Society (EUGMS) meeting in Lisbon, Portugal, and the 2016 Gerontological Society of America (GSA) meeting in New Orleans, USA. The present work summarizes the most relevant aspects related to multimorbidity, with the ultimate goal to identify knowledge gaps and suggest future directions to approach this condition.

Stelfox HT, Leigh JP, Dodek PM, Turgeon AF, Forster AJ, Lamontagne F, Fowler RA, SooA, Bagshaw SM. A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward. Intensive Care Med. 2017 Aug 29. doi: 10.1007/s00134-017-4910-1. [Epub ahead of print]

Abstract: The purpose of this study was toprovide a 360-degree description of ICU-to-ward transfers. It was a prospective cohort study of 451 adults transferred from a medical-surgical ICU to a hospital ward in 10 Canadian hospitals July 2014-January 2016. Transfer processes documented in the medical record. Patient (or delegate) and provider (ICU/ward physician/nurse) perspectives solicited by survey 24-72 h after transfer. Medical records (100%) and survey responses (ICU physicians-80%, ICU nurses-80%, ward physicians-46%, ward nurses-64%, patients-74%) were available for most transfers. Recommendations for improvement included having a documented care plan travel with the patient (all stakeholders), standardized face-to-face handover (physicians), avoiding transfers at shift change (nurses) and informing patients about pending transfers in advance (patients).ICU-to-ward transfers are characterized by failures of patient flow and communication; experienced differently by patients, ICU/ward physicians and nurses, with distinct suggestions for improvement.

Click here to learn more about this CFN-funded research (CORE 2013-12).

Sussman T, Kaasalainen S, Mintzberg S, Sinclair S, Young L, Ploeg J, Bourgeois-Buérin V, Thompson G, Venturato L, Earl M, Strachan P, You JJ, Bonifas R, McKee M. Broadening End-of-Life Comfort to Improve Palliative Care Practices in Long Term Care. Can J Aging. 2017 Sep;36(3):306-317. doi: 10.1017/S0714980817000253. Epub 2017 Jul 27. 

Abstract: This study aimed to (1) explore how palliative care in long-term care (LTC) addresses the tensions associated with caring for the living and dying within one care community, and (2) to inform how palliative care practices may be improved to better address the needs of all residents living and dying in LTC as well as those of the families and support staff. This article reports findings from 19 focus groups and 117 participants. Study findings reveal that LTC home staff, resident, and family perspectives of end-of-life comfort applied to those who were actively dying and to their families. Our findings further suggest that eliciting residents' perceptions of end-of-life comfort, sharing information about a fellow resident's death more personally, and ensuring that residents, families, and staff can constructively participate in providing comfort care to dying residents could extend the purview of end-of-life comfort and support expanded integration of palliative principles within LTC.

Maclagan LC, Maxwell CJ, Gandhi S, Guan J, Bell CM, Hogan DB, Daneman N, Gill SS, Morris AM, Jeffs L, Campitelli MA, Seitz DP, Bronskill SE. Frailty and Potentially Inappropriate Medicate use at Nursing Home Transition. J Am Geriatr Soc. 2017 Jul 28. doi: 10.1111/jgs.15016. [Epub ahead of print].

Abstract: This study was designed to estimate the prevalence of potentially inappropriate medication (PIM) use among older adults with cognitive impairment or dementia prior to and following admission to nursing homes and in relation to frailty. It was a retrospective cohort study using health administrative databases. Participants were 41,351 individuals with cognitive impairment or dementia, aged 66+ years newly admitted to Ontario nursing homes between 2011 and 2014. Many residents with cognitive impairment or dementia enter nursing homes on PIMs. PIMs are more likely to be started in frail individuals following admission. Interventions to support deprescribing of PIMs should be implemented targeting frail individuals during the transition to nursing home.

Click here to learn more about this CFN-funded research (SIG2014-M1).

Robinson SM, Reginster JY, Rizzoli R, Shaw SC, Kanis JA, Bautmans I, Bischoff-Ferrari H, Bruyère O, Cesari M, Dawson-Hughes B, Fielding RA, Kaufman JM, Landi F. Does nutrition play a role in the prevention and management of sarcopenia? Clinical Nutrition: pre-publication online version.

Abstract: There is a growing body of evidence that links nutrition to muscle mass, strength and function in older adults, suggesting that it has an important role to play both in the prevention and management of sarcopenia. This review summarises the discussions of a working group [ESCEO working group meeting 8th September 2016] that met to review current evidence and to consider its implications for preventive and treatment strategies. The review points to the importance of ‘healthier’ dietary patterns that are adequate in quality in older age, to ensure sufficient intakes of protein, vitamin D, antioxidant nutrients and long-chain polyunsaturated fatty acids. In particular, there is substantial evidence to support the roles of dietary protein and physical activity as key anabolic stimuli for muscle protein synthesis. However, much of the evidence is observational and from high-income countries. Further high-quality trials, particularly from more diverse populations, are needed to enable an understanding of dose and duration effects of individual nutrients on function, to elucidate mechanistic links, and to define optimal profiles and patterns of nutrient intake for older adults.

Theou O, Blodgett JM, Godin J, Rockwood K. Association between sedentary time and mortality across levels of frailty. CMAJ: August 21, 2017 vol. 189 no. 33 doi: 10.1503/cmaj.161034.

Abstract: Sedentary behaviours are associated with adverse health outcomes in middle-aged and older adults, even among those who exercise. This study examined whether the degree of frailty affects the association between sedentary behaviours and higher risk of mortality. In this prospective cohort study, the study used data from 3141 community-dwelling adults 50 years of age or older from the 2003/04 and 2005/06 cohorts of the US National Health and Nutrition Examination Survey. The study found that the effect of sedentary behaviours on mortality varied by level of frailty. Adults with the highest frailty level experienced the greatest adverse impact. Low frailty levels (frailty index score ≤ 0.1) seemed to eliminate the increased risk of mortality associated with prolonged sitting, even among people who did not meet recommended physical activity guidelines.

Fougère B, Boulanger E,  Nourhashémi F, Guyonnet S, Cesari M. Chronic Inflammation: Accelerator of Biological Aging. The Journals of Gerontology: Series A, Volume 72, Issue 9, 1 September 2017, Pages 1218–1225,

Abstract: Biological aging is characterized by a chronic low-grade inflammation level. This chronic phenomenon has been named “inflamm-aging” and is a highly significant risk factor for morbidity and mortality in the older persons. The most common theories of inflamm-aging include redox stress, mitochondrial dysfunction, glycation, deregulation of the immune system, hormonal changes, epigenetic modifications, and dysfunction telomere attrition. Inflamm-aging plays a role in the initiation and progression of age-related diseases such as type II diabetes, Alzheimer’s disease, cardiovascular disease, frailty, sarcopenia, osteoporosis, and cancer. This review will cover the identification of pathways that control age-related inflammation across multiple systems and its potential causal role in contributing to adverse health outcomes.

Sawatzky R, Porterfield Pat, Roberts D, Lee J, Liang L, Reimer-Kirkham S, Pesut B, Schalkwyk T, Stajduhar K, Tayler C, Baumbusch J, Thorne S. Embedding a Palliative Approach in Nursing Care Delivery: An Integrated Knowledge Synthesis. Advances in Nursing Science: July/September 2017 - Volume 40 - Issue 3 - p 263–279. doi: 10.1097/ANS.0000000000000163.

Abstract: A palliative approach involves adapting and integrating principles and values from palliative care into the care of persons who have life-limiting conditions throughout their illness trajectories. The aim of this research was to determine what approaches to nursing care delivery support the integration of a palliative approach in hospital, residential, and home care settings. The findings substantiate the importance of embedding the values and tenets of a palliative approach into nursing care delivery, the roles that nurses have in working with interdisciplinary teams to integrate a palliative approach, and the need for practice supports to facilitate that embedding and integration.

Cummings GG, Hewko SJ, Wang M, Wong CA, Laschinger HKS, Estabrooks CA. Impact of Managers' Coaching Conversations on Staff Knowledge Use and Performance in Long-Term Care Settings. Worldviews Evid Based Nurs. 2017 Jul 29. doi: 10.1111/wvn.12233. [Epub ahead of print]

Abstract: Extended lifespans and complex resident care needs have amplified resource demands on nursing homes. Nurse managers play an important role in staff job satisfaction, research use, and resident outcomes. Coaching skills, developed through leadership skill-building, have been shown to be of value in nursing. This study aimed to test a theoretical model of nursing home staff perceptions of their work context, their managers' use of coaching conversations, and their use of instrumental, conceptual and persuasive research. Using a two-group crossover design, 33 managers employed in seven Canadian nursing homes were invited to attend a 2-day coaching development workshop. Survey data were collected from managers and staff at three time points; we analyzed staff data collected after managers had completed the workshop. Resonant leadership (a relational approach to influencing change) had the strongest significant relationship with manager support, which in turn influenced frequency of coaching conversations. Coaching conversations had a positive, non-significant relationship with staff persuasive use of research, which in turn significantly increased instrumental research use. Importantly, coaching conversations were significantly, negatively related to job satisfaction. Findings add to growing research exploring the role of context and leadership in influencing job satisfaction and use of research by healthcare practitioners. One-on-one coaching conversations may be difficult for staff not used to participating in such conversations. Resonant leadership, as expected, has a significant impact on manager support and job satisfaction among nursing home staff.

Andrew MK, Shinde V, Lingyun Ye S., Hatchette T, Haguinet F, Dos Santos G, McElhaney JE, Ambrose A, Boivin G, Bowie W,Chit A, El Sherif M, Green K, Halperin S, Ibarguchi B, Johnstone J, Katz K, Langley J, Leblanc J, Loeb M, MacKinnon-Cameron D, McCarthy A, McGeer A, Powis J, Richardson D, Semret M, Stiver G, Trottier S, Valiquette L, Webster D, McNeil S for the Serious Outcomes Surveillance Network of the Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) and the Toronto Invasive Bacterial Diseases Network (TIBDN).The Importance of Frailty in the Assessment of Influenza Vaccine Effectiveness Against Influenza-Related Hospitalization in Elderly People. The Journal of Infectious Diseases, jix282, (published 26 July 2017).

Abstract: Influenza is an important cause of morbidity and mortality among older adults. Even so, effectiveness of influenza vaccine for older adults has been reported to be lower than for younger adults, and the impact of frailty on vaccine effectiveness (VE) and outcomes is uncertain. We aimed to study VE against influenza hospitalization in older adults, focusing on the impact of frailty. This study reported VE of trivalent influenza vaccine (TIV) in people ≥65 years of age hospitalized during the 2011–2012 influenza season using a multicenter, prospective, test-negative case-control design. A validated frailty index (FI) was used to measure frailty. (Clinical Trials Registration: NCT01517191.) Despite commonly held views that VE is poor in older adults, we found that TIV provided good protection against influenza hospitalization in older adults who were not frail, though VE diminished as frailty increased.

Liu b, Moore JE, Almaawiy U, Chan WH, Khan S, Ewusie J, Hamid JS, Straus SE, MOVE ON Collaboration. Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): a multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation. Age Ageing. 2017 Jul 15:1-7. doi: 10.1093/ageing/afx128. [Epub ahead of print]

Abstract: Older patients admitted to hospitals are at risk for hospital-acquired morbidity related to immobility. The aim of this study was to implement and evaluate an evidence-based intervention targeting staff to promote early mobilisation in older patients admitted to general medical inpatient units. The early mobilization implementation intervention for staff was multi-component and tailored to local context at 14 academic hospitals in Ontario. The primary outcome was patient mobilization. Secondary outcomes included length of stay (LOS), discharge destination, falls and functional status. This was a large-scale study evaluating an implementation strategy for early mobilisation in older, general medical inpatients. The positive outcome of this simple intervention on an important functional goal of getting more patients out of bed is a striking success for improving care for hospitalised older patients.

Slaughter SE, Bampton E, Erin DF, Ickert C, Wagg AS, Allyson Jones C, Schalm C, Estabrooks, CA. Knowledge translation interventions to sustain direct care provider behaviour change in long-term care: A process evaluation. J Eval Clin Pract. 2017 Jul 10. doi: 10.1111/jep.12784. [Epub ahead of print].

Abstract: Process evaluation can be used to understand the factors influencing the impact of knowledge translation (KT) interventions. The aim of this mixed methods process evaluation was to evaluate the processes and perceived outcomes of eight KT interventions that were used with healthcare aides (HCAs) to introduce a mobility innovation into their daily care practices. The study examined the perceived effectiveness of various KT interventions in sustaining daily performance of the sit-to-stand mobility innovation by HCAs with residents in long-term care. Results: Both HCAs and their leaders perceived reminders, followed by discussion groups, to be the most effective KT interventions to sustain practice change. Healthcare aide champions were deemed least effective by both leaders and HCAs. Leaders identified both the focus group discussion and audit and feedback posters in the study as the most difficult to implement. Participants valued interventions that were strategically visible, helped to clarify misconceptions about the new care innovation, supported teamwork, and made visible the resident benefits of the care innovation. Logistical issues, such as staff scheduling and workload, influenced the perceived feasibility of the various KT interventions. Conclusions: Understanding how care staff in long-term care settings perceive KT interventions can inform the choice of future use of these interventions to move research evidence into practice.

Eamer G, Gibson J, Gillis C, Hsu A, Krawczyk M, MacDonald E, Whitlock R, Khadaroo R. Surgical frailty assessment: a missed opportunity. BMC Anesthesiology, 2017 (17:99).

Muscedere, J. Moving towards standardized data and outcomes for frailty studies. Journal of Frailty & Aging vol. 6, supp 1, 9-10 (July 2017).

Click here to learn more about this CFN-funded research (SIG2014-M1).

Abstract:  Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians’ historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment, use of prolonged treatment durations and selection of fluoroquinolones. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice. Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities.

Hubbard, R.E., Peel, N,M., Samanta, M., Gray, L.C., Mitnitski, A., Rockwood, K. Age Ageing. 2017 May 22:1-6. Frailty status at admission to hospital predicts multiple adverse outcomes. doi: 10.1093/ageing/afx081. [Epub ahead of print]

Abstract: Frailty is proposed as a summative measure of health status and marker of individual vulnerability. We aimed to investigate the discriminative capacity of a frailty index (FI) derived from interRAI Comprehensive Geriatric Assessment for Acute Care (AC) in relation to multiple adverse inpatient this prospective cohort study, an FI was derived for 1,418 patients ≥70 years across 11 hospitals in Australia. The interRAI-AC was administered at admission and discharge by trained nurses, who also screened patients daily for geriatric syndromes. The interRAI-AC can be used to derive a single score that predicts multiple adverse outcomes in older inpatients. A score of ≤0.40 can well discriminate patients who are unlikely to die or experience a geriatric syndrome. Whether the FI-AC can result in management decisions that improve outcomes requires further study.

Raslan, I.A., McDonald, E.G., Lee, T.C. Missed Opportunities for Deprescription: A Teachable Moment. JAMA Intern Med. Published online May 5, 2017. doi: 10.1001/jamainternmed.2017.1435.

Howard M, Chalifoux M, Tanuseputro P. Does Primary Care Model Effect Healthcare at the End of Life? A Population-Based Retrospective Cohort Study. Jounal of Palliative Medicine. April 2017, 20(4): 344-351.

Abstract: This study addressed the concept that comprehensive primary care may enhance patient experience at end of life. The objective was to examine whether belonging to different models of primary care is associated with end-of-life healthcare use and outcomes. It was a retrospective population cohort study, using health administrative databases to describe health services and costs in the last six months of life across three primary care models: enrolled to a physician remunerated mainly by capitation, with incentives for comprehensive care and access in some to allied health practitioners (Capitation); remunerated mainly from fee-for-service (FFS) with smaller incentives for comprehensive care (Enhanced FFS); and not enrolled, seeing physicians remunerated solely through FFS (Traditional FFS). It measured health service utilization, costs, and place of death in people who died from April 1, 2010 to March 31, 2013 in Ontario. Conclusion: Decedents in comprehensive primary care models received more care in the community and spent less time in institutions.

Matlow, J. N., Bronskill, S. E., Gruneir, A., Bell, C. M., Stall, N. M., Herrmann, N., Seitz, D. P., Gill, S. S., Austin, P. C., Fischer, H. D., Fung, K., Wu, W. and Rochon, P. A. (2017), Use of Medications of Questionable Benefit at the End of Life in Nursing Home Residents with Advanced Dementia. J Am Geriatr Soc. doi:10.1111/jgs.14844.

Abstract: The objectives of this study were to determine the prevalence of and resident characteristics associated with the prescription of medications of questionable benefit (MQBs) near the end of life in older adults with advanced dementia in nursing homes. It was a population-based, cross-sectional study using Resident Assessment Instrument (RAI) Minimum Data Set 2.0 linked to health administrative data. Participants were all 9,298 nursing home residents with advanced dementia who died between June 1, 2010, and March 31, 2013; who were aged 66 and older at time of death; and who received at least one MQB in their last year of life. The prevalence of eight classes of MQBs (e.g., lipid-lowering agents, antidementia drugs) used in the last 120 days and last week of life was measured. Conclusion: Many nursing home residents with advanced dementia are dispensed MQBs in the last week of life. Given that MQBs may cause more harm than benefit in this vulnerable population, it is important for physicians to actively reassess the role of all medications toward the end of life.

Laur CV, McNicholl T, Valaitis R, Keller H. Malnutrition or frailty? Overlap and evidence gaps in the diagnosis and treatment of frailty and malnutrition. Applied Physiology, Nutrition, and Metabolism, 2017, 42(5): 449-458, 10.1139/apnm-2016-0652.

Abstract: There is increasing awareness of the detrimental health impact of frailty on older adults and of the high prevalence of malnutrition in this segment of the population. Experts in these 2 arenas need to be cognizant of the overlap in constructs, diagnosis, and treatment of frailty and malnutrition. There is a lack of consensus regarding the definition of malnutrition and how it should be assessed. While there is consensus on the definition of frailty, there is no agreement on how it should be measured. Separate assessment tools exist for both malnutrition and frailty; however, there is intersection between concepts and measures. This narrative review highlights some of the intersections within these screening/assessment tools, including weight loss/decreased body mass, functional capacity, and weakness (handgrip strength). The potential for identification of a minimal set of objective measures to identify, or at least consider risk for both conditions, is proposed. Frailty and malnutrition have also been shown to result in similar negative health outcomes and consequently common treatment strategies have been studied, including oral nutritional supplements. While many of the outcomes of treatment relate to both concepts of frailty and malnutrition, research questions are typically focused on the frailty concept, leading to possible gaps or missed opportunities in understanding the effect of complementary interventions on malnutrition. A better understanding of how these conditions overlap may improve treatment strategies for frail, malnourished, older adults.

Holroyd-Leduc JM, McMillan J, Jette N, Brémault-Phillips SC, Duggleby W, Hanson HM, Parmar J. Stakeholder Meeting: Integrated Knowledge Translation Approach to Address the Caregiver Support GapCan J Aging. 2017 Mar;36(1):108-119. doi: 10.1017/S0714980816000660. Epub 2017 Jan 5.

Abstract: Family caregivers are an integral and increasingly overburdened part of the health care system. There is a gap between what research evidence shows is beneficial to caregivers and what is actually provided. Using an integrated knowledge translation approach, a stakeholder meeting was held among researchers, family caregivers, caregiver associations, clinicians, health care administrators, and policy makers. The objectives of the meeting were to review current research evidence and conduct multi-stakeholder dialogue on the potential gaps, facilitators, and barriers to the provision of caregiver supports. A two-day meeting was attended by 123 individuals. Three target populations of family caregivers were identified for discussion: caregivers of seniors with dementia, caregivers in end-of-life care, and caregivers of frail seniors with complex health needs. The results of this meeting can and are being used to inform the development of implementation research endeavours and policies targeted at providing evidence-informed caregiver supports.

Cesari M, Landi F, Calvani R et al. Rationale for a preliminary operational definition of physical frailty and sarcopenia in the SPRINTT trial. Aging Clin Exp Res (2017) 29: 81. doi:10.1007/s40520-016-0716-1 

Abstract: In the present article, the rationale that guided the operationalization of the theoretical concept of physical frailty and sarcopenia (PF&S), the condition of interest for the “Sarcopenia and Physical Frailty in Older People: Multicomponent Treatment Strategies” (SPRINTT) trial, is presented. In particular, the decisions lead to the choice of the adopted instruments, and the reasons for setting the relevant thresholds are explained. In SPRINTT, the concept of physical frailty is translated with a Short Physical Performance Battery score of ≥3 and ≤9. Concurrently, sarcopenia is defined according to the recent definitions of low muscle mass proposed by the Foundation for the National Institutes of Health—Sarcopenia Project. Given the preventive purpose of SPRINTT, older persons with mobility disability (operationalized as incapacity to complete a 400-m walk test within 15 min; primary outcome of the trial) at the baseline are not included within the diagnostic spectrum of PF&S. 

Cesari M, Pérez-Zepeda MU, Marzetti E. Frailty and Multimorbidity: Different Ways of Thinking about Geriatrics. Impact of home care versus alternative locations of care on elder health outcomes: an overview of systematic reviewsJ Am Med Dir Assoc. 2017 Mar 6. pii: S1525-8610(17)30034-8. doi: 10.1016/j.jamda.2016.12.086. [Epub ahead of print] 

Abstract: The terms multimorbidity and frailty are increasingly used in the medical literature to measure the risk profile of an older individual in order to support clinical decisions and design ad hoc interventions. The construct of multimorbidity was initially developed and used in nongeriatric settings. It generates a monodimensional nosological risk profile, grounding its roots in the somewhat inadequate framework of disease. On the other hand, frailty is a geriatric concept that implies a more exhaustive and comprehensive assessment of the individual and his/her environment, facilitating the implementation of multidimensional and tailored interventions. This article aims to promote among geriatricians the use of terms that may better enhance their background and provide more value to their unrivaled expertise in caring for biologically aged persons.

Boland L, Légaré F, Becerra Perez MM, Menear M, Garvelink MM, McIsaac DI, Guérard GP, Emond J, Brière N, Stacey D. Impact of home care versus alternative locations of care on elder health outcomes: an overview of systematic reviews. BMC Geriatrics, 2017(17:20) DOI: 10.1186/s12877-016-0395-y

Click here to learn more about this CFN-funded research (CORE2013-56).

Abstract: Many elders struggle with the decision to remain at home or to move to an alternative location of care. A person’s location of care can influence health and wellbeing. Healthcare organizations and policy makers are increasingly challenged to better support elders’ dwelling and health care needs. A summary of the evidence that examines home care compared to other care locations can inform decision making. We surveyed and summarized the evidence evaluating the impact of home care versus alternative locations of care on elder health outcomes.

Puts MTE, Toubasi S, Andrew MK, Ashe MC, Ploeg J, Atkinson E, Ayala AP, Roy A, Monforte MR, Bergman H, McGilton K.  Interventions to prevent or reduce the level of frailty in community-dwelling older adults: a scoping review of the literature and international policies. Age Ageing (2017) 46(3): 383-392. DOI:

Abstract: Frailty impacts older adults’ ability to recover from an acute illness, injuries and other stresses. Currently, a systematic synthesis of available interventions to prevent or reduce frailty does not exist. This study was a scoping review of interventions and international policies designed to prevent or reduce the level of frailty in community-dwelling older adults, using the framework of Arksey and O'Malley. Fourteen studies were included: 12 randomised controlled trials and 2 cohort studies (mean number of participants 260 (range 51–610)), with most research conducted in USA and Japan. The study quality was moderate to good. The interventions included physical activity; physical activity combined with nutrition; physical activity plus nutrition plus memory training; home modifications; prehabilitation (physical therapy plus exercise plus home modifications) and comprehensive geriatric assessment (CGA). The review showed that the interventions that significantly reduced the number of frailty markers present or the prevalence of frailty included the physical activity interventions (all types and combinations), and prehabilitation. Nine of the 14 studies reported that the intervention reduced the level of frailty. The results need to be interpreted with caution, as only 14 studies using 6 different definitions of frailty were retained. Future research could combine interventions targeting more frailty markers including cognitive or psychosocial well-being.

Moorhouse P, Theou O, Fay S, McMillan M, Moffat H, Rockwood K. Treatment in a Geriatric Day Hospital improve individualized outcome measures using Goal Attainment Scaling. BMC Geriatrics, 2017(17:9)

Abstract: Evidence regarding outcomes in the Geriatric Day Hospital (GDH) model of care has been largely inconclusive, possibly due to measurement issues. This prospective cohort study aimed to determine whether treatment in a GDH could improve individualized outcome measures using goal attainment scaling (GAS) and whether improvements are maintained 6-months post-discharge.The study demonstrated short- and long-term effectiveness of GDH in helping patients achieve individualized outcome measures using GAS.

Durepos P, Wickson-Griffiths A, Hazzan AA, Kaasalainen S, Vastis V, Battistella L, Papaioannou A. (2017) Assessing palliative care content in Dementia Care Guidelines: A Systematic Review. J Pain Symptom Manage. doi: 10.1016/j.jpainsymman.2016.10.368. Epub 2017 Jan 4. Review. PMID: 28063859.

Abstract: Families of persons with dementia continue to report unmet needs during end of life (EOL). Strategies to improve care and quality of life for persons with dementia include development of clinical practice guidelines (CPGs) and an integrative palliative approach. We aimed to assess palliative care content in dementia CPGs to identify the presence or limitations of recommendations and discussion pertaining to common issues or domains affected by illness as described by the Canadian Hospice Palliative Care Association "Square of Care."A systematic review of databases and gray literature was conducted for recent CPGs. Guidelines meeting inclusion criteria were evaluated using the Appraisal of Guidelines for Research and Evaluation II instrument. Eleven CPGs were selected from 3779 citations and analyzed using illness domains described by the "Canadian Hospice Palliative Care Association Model." Nine guidelines demonstrated the maximum level of content regarding physical, psychological, and social care. Conversely, spiritual care was either absent (three) or minimal (three) in CPGs. Six CPGs did not address loss or grief, and seven CPGs did not address or had minimal content regarding EOL care. The lack of content surrounding grief represents a gap for this population at high risk for complicated grief and chronic sorrow. Results of this review require attention by CPG developers and researchers to develop evidence-based recommendations surrounding spiritual care, EOL, and grief.

Ball I, Bagshaw S, Burns K, Cook D, Day A, Dodek P, Kutsogiannis J, Mehta S, Muscedere J, Stelfox H, Turgeon A, Wells G, Stiell I. Hospital Outcomes of Very Elderly Critically Ill Medical and Surgical Patients: A Multi-Centre Prospective Cohort Study. Canadian Journal of Anaesthesia 64(3) December 2016. DOI: 10.1007/s12630-016-0798-4.

Abstract: Very elderly (over 80 yr of age) critically ill patients admitted to medical-surgical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and dependent living conditions should they survive. The primary purpose of this study was to describe the outcomes and differences in outcomes between very elderly medical patients and their surgical counterparts admitted to Canadian ICUs, thereby informing decision-making for clinicians and substitute decision-makers. Methods: This was a prospective multicentre cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Outcome measures included ICU length of stay and mortality, hospital length of stay and mortality, and disposition following hospital discharge. There were 1,671 patients evaluated. Conclusions: In this large sample of critically ill medical and surgical patients, the admission SOFA score and hospital lengths of stay were not different between the two groups, but medical patients had longer ICU lengths of stay and higher ICU and hospital mortality than surgical patients.

Heckman G, Boscart VM, D’Elia T, Kelley ML, Kaasalainen S, McAiney CA, van der Horst M-L, McKelvie RS. Managing Heart Failure in Long-Term Care: Recommendations from an Interprofessional Stakeholder Consultation’, Canadian Journal on Aging / La Revue canadienne du vieillissement 2016;35(4), pp. 447–464. doi: 10.1017/S071498081600043X.

Abstract: Heart failure (HF) affects up to 20 per cent of residents in long-term care (LTC) and is associated with substantial morbidity, mortality, and health service utilization. Our study objective was to formulate recommendations on implementing HF care processes in LTC. A three-phase and iterative stakeholder consultation process, guided by expert panel input, was employed to develop recommendations on implementing care processes for HF in LTC. This article presents the results of the third phase, which consisted of a series of interdisciplinary workshops. We developed 17 recommendations. Key elements of these recommendations focus on improving interprofessional communication and improving HF-related knowledge among all LTC stakeholders. Engaging frontline staff, including personal support workers, was stated as an essential component of all recommendations. System-level recommendations include improving communication between LTC homes and acute care and other external health service providers, and developing facility-wide interventions to reduce dietary sodium intake and increase physical activity.

Heckman GA, Boscart VM, Franco BB, Hillier L, Crutchlow L, Lee L, Molnar F, Seitz D, Stolee P. Quality of Dementia Care in the Community: Identifying Key Quality Assurance Components. Canadian Geriatrics Jounal 2016 Dec;19(4). DOI:

Abstract: Primary care-based memory clinics (PCMCs) have been
established in several jurisdictions to improve the care for
persons with Alzheimer’s disease and related dementias.
We sought to identify key quality indicators (QIs), quality
improvement mechanisms, and potential barriers and facilitators
to the establishment of a quality assurance framework
for PCMCs.

Sawatzky R, Porterfield P, Roberts D, Lee J, Liang L, Reimer-Kirkham S, Pesut B, Schalkwyk T, Stajduhar K, Tayler C, Baumbusch J, Thorne S. Embedding a Palliative Approach in Nursing Care Delivery: An Integrated Knowledge Synthesis. Advances in Nursing Science (2016), online first. doi: 10.1097/ANS.0000000000000163

Abstract: A palliative approach involves adapting and integrating principles and values from palliative care into the care of persons who have life-limiting conditions throughout their illness trajectories. The aim of this research was to determine what approaches to nursing care delivery support the integration of a palliative approach in hospital, residential, and home care settings. The findings substantiate the importance of embedding the values and tenets of a palliative approach into nursing care delivery, the roles that nurses have in working with interdisciplinary teams to integrate a palliative approach, and the need for practice supports to facilitate that embedding and integration.

Giangregorio L, MacIntyre N, Laprade J, McArthur C, Cheung A, Jain R, and Papaioannou A. How to Implement Physical Activity Evidence for your Geriatric Patients with Falls or Fractures: A Case-Based Exercise in Knowledge Translation. Canadian Geriatrics Journal of CME CME Journal 2016 Nov;6(2)

Abstract: We present a case-based approach to applying exercise and physical activity recommendations for individuals at high risk of falls and fractures. The case has a history of falls, and two osteoporotic vertebral fractures. We summarize Too Fit to Fracture “clinical pearls” for geriatrics practice, including advice on assessment, exercise, safe physical activity, and pain management. Best evidence supports the recommendation that older adults should engage in a multicomponent exercise program, including resistance training and challenging balance exercises, in addition to aerobic physical activity. The Too Fit to Fracture recommendations support daily attention to posture, and exercises to improve back extensor strength.

Theou O, Chapman I, Wijeyaratne L, Piantadosi C, Lange K, Naganathan V, Hunter P, Cameron ID, Rockwood K, Visvanathan R. Can an intervention with testosterone and nutritional supplement improve the frailty level of under-nourished older people?. The Journal of Frailty and Aging (JFA) 2016;5(4):247-252.

Abstract: The objective of this study was to examine whether a testosterone and a high calorie nutritional supplement intervention can reduce frailty scores in undernourished older people using multiple frailty tools. Frailty was operationalized using three frailty indices (FI-lab, FI-self-report, FI-combined) and the frailty phenotype. A testosterone and a high calorie nutritional supplement intervention did not improve the frailty levels of under-nourished older people. Even so, when frailty was measured using a frailty index combining self-reported and lab data we found that participants who received the intervention were more likely to show persistent improvement in their frailty scores.

Légaré F, Brière N, Stacey D, Lacroix G, Desroches S, Dumont S, Fraser KD, Rivest L-P, Durand PJ, Turcotte S, Taljaard M, Bourassa H, Roy L, Painchaud Guérard G. Implementing shared decision-making in interprofessional home care teams (the IPSDM-SW study): protocol for a stepped wedge cluster randomised trial . BMJ Open 2016;6:e014023 doi:10.1136/bmjopen-2016-014023. Epub 2016 Nov 24.

Click here to learn more about the CFN-funded research this study is based on (CORE2013-56).

Abstract: The frail elderly in Canada face a tough decision when they start to lose autonomy: whether to stay at home or move to another location. This study seeks to scale up and evaluate the implementation of shared decision-making (SDM) in interprofessional (IP) home care teams caring for elderly clients or their caregivers facing a decision about staying at home or moving elsewhere.

Theou O, Tan EC, Bell JS, Emery T, Robson L, Morley JE, Rockwood K, Visvanathan R. Frailty Levels in Residential Aged Care Facilities Measured Using the Frailty Index and FRAIL-NH Scale. J Am Geriatr Soc. 2016 Nov;64(11):e207-e212. doi: 10.1111/jgs.14490. Epub 2016 Oct 26.

Abstract: OBJECTIVES: To compare the FRAIL-NH scale with the Frailty Index in assessing frailty in six Australian residential aged care facilities in individuals aged 65 and older. Frailty was assessed using the 66-item Frailty Index and the FRAIL-NH scale. Other measures examined were dementia diagnosis, level of care, resident satisfaction with care, nurse-reported resident quality of life, neuropsychiatric symptoms, and professional caregiver burden. CONCLUSION:The FRAIL-NH scale is a simple and practical method to screen for frailty in residential aged care facilities.

Moorhouse P, Mallery L, McNally M, Ellen R and Moffatt H. Frailty: It’s Time to Give Family Caregivers a Real Seat at the Table. J Fam Med. 2016; 3(5): 1067.

Abstract: The functional impact of lifelong accumulation of health issues (known as frailty), creates several challenges to traditional approaches to care planning and decision-making. In particular, the role of the caregiver (often a family member) in supporting the frail adult's needs is often at odds with how clinicians and teams approach " patient-centered care ". As the prevalence of frailty continues to increase, we need to embrace new approaches that widen the circle of care to include the caregiver more prominently in the provision of information and a more nuanced approach to shared decision-making.

Osman O, Sherifali D, Stolee P, Heckman GDiabetes Management in Long-Term Care: An Exploratory Study of the Current Practices and Processes to Managing Frail Elderly Persons with Type 2 Diabetes. Canadian Journal of Diabetes 40 (2016): 17-30.

Abstract: There is limited evidence for the management of diabetes in frail elderly residents living in long-term care (LTC) settings. The purpose of this study was to explore the current practices of glycemic management in frail elderly persons with diabetes living in LTC settings. The findings of this study were triangulated with both a quantitative survey and qualitative interviews. The implications of these findings suggest a disparity between what physicians feel should be achieved for diabetes management and what is actually done for frail elderly adults in LTC settings. Further research needs to be completed to assess the distinct needs and considerations of this unique population and healthcare setting.

Daniel I. McIsaac, Monica Taljaard, Gregory L. Bryson, Paul E. Beaule, Sylvain Gagne, Gavin Hamilton, Emily Hladkowicz, Allen Huang, John Joanisse, Luke T. Lavallée, Hussein Moloo, Kednapa Thavorn, Carl van Walraven, Homer Yang and Alan J. Forster. Comparative assessment of two frailty instruments for risk-stratification in elderly surgical patients: study protocol for a prospective cohort study. BMC Anesthesiology. 2016:16:111.DOI: 10.1186/s12871-016-0276-0

Click here to learn more about this CFN-funded research (FRA2015B-06).

Abstract: Frailty is an aggregate expression of susceptibility to poor outcomes, owing to age-, and disease-related deficits that accumulate within multiple domains. Older patients who are frail before surgery are at an increased risk of morbidity and mortality, and use a disproportionately high amount of healthcare resources. While frailty is now a well-established risk factor for adverse postoperative outcomes, the perioperative literature lacks studies that: 1) compare the predictive accuracy of different frailty instruments; 2) consider the impact of frailty on patient-reported outcome measures; and 3) consider the acceptability and feasibility of using frailty instruments in clinical practice.

Tom Noseworthy, Lesley Soril and Fiona Clement. Bioethics, health technology reassessment, and management. Healthcare Management Forum. 2016: 29(6): 275.

Abstract: Health Technology Reassessment (HTR) is an emerging area of health services and policy research that supports optimal management of technologies throughout their lifecycle. As a structured, evidence-based assessment of the clinical, economic, social, and ethical impacts of existing technologies, HTR is a means of achieving optimal use, managed exit, and better value for money from technologies used in healthcare. This has been documented as raising ethical concerns among clinicians who are providing direct patient care, particularly when managed exit may be the goal. This article discusses the ethical considerations relevant to clinicians and HTR, using a principles’ approach to bioethical decision-making.

Canadian Frailty Network. Brief to the federal Finance Committee 2017 pre-budget consultations. Click here to read our submission -- Ensuring a more equitable healthcare system: addressing the needs of Canada’s frail elderly.

We believe that frailty should be incorporated into federal healthcare funding models, and that by implementing frailty assessment in the healthcare system and producing evidence-based interventions and practices, true socioeconomic benefit to Canadians will result including improved quality of life and more efficient healthcare resource utilization.

Kho ME, Molloy AJ, Clarke F, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Pellizzari JR, Tarride JE, Mourtzakis M, Karachi T, Cook DJ, Canadian Clinical Trials Group. CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry versus routine physiotherapy in mechanically ventilated patients. BMJ Open 2016;6:
e011659. doi:10.1136/bmjopen-2016-011659 

Click here to learn more about this CFN-funded research (CAT2014-06).

Abstract: Early exercise with in-bed cycling as part of an intensive care unit (ICU) rehabilitation programme has the potential to improve physical and functional outcomes following critical illness. The objective of this study is to determine the feasibility of enrolling adults in a multicentre pilot randomised clinical trial (RCT) of early in-bed cycling versus routine physiotherapy to inform a larger RCT.

Cesari M, Marzetti E, Thiem U, Pérez-Zepeda MU, Van Kan GA, Landi F, Petrovic M, Cherubini A, Bernabei R. The geriatric management of frailty as paradigm of “The end of the disease era”. European Journal of Internal Medicine. 2016 June;31;11-14.DOI:

Abstract: The sustainability of healthcare systems worldwide is threatened by the absolute and relative increase in the number of older persons. The traditional models of care (largely based on a disease-centered approach) are inadequate for a clinical world dominated by older individuals with multiple (chronic) comorbidities and mutually interacting syndromes. There is the need to shift the center of the medical intervention from the disease to the biological age of the individual. Thus, multiple medical specialties have started looking with some interest at concepts of geriatric medicine in order to better face the increased complexity (due to age-related conditions) of their average patient. In this scenario, special interest has been given to frailty, a condition characterized by the reduction of the individual's homeostatic reserves and increased vulnerability to stressors. Frailty may indeed represent the fulcrum to lever for reshaping the healthcare systems in order to make them more responsive to new clinical needs. However, the dissemination of the frailty concept across medical specialties requires a parallel and careful consideration around the currently undervalued role of geriatricians in our daily practice.

Henrich NJ, Dodek PM, Alden L, Keenan SP, Reynolds S, Rodney P. Causes of moral distress in the intensive care unit: A qualitative study. J Crit Care. 2016 Oct;35:57-62. doi: 10.1016/j.jcrc.2016.04.033. Epub 2016 May 12.

Abstract: The purpose of the study was to examine the causes of moral distress in diverse members of the intensive care unit (ICU) team in both community and tertiary ICUs. Focus groups and coding of transcripts into themes and subthemes in 2 tertiary care ICUs and 1 community ICU were used. The most commonly reported causes of moral distress were concerns about the care provided by other health care workers, the amount of care provided (especially too much care at end of life), poor communication, inconsistent care plans, and issues around end of life decision making.Causes of moral distress vary among ICU professional groups, but all are amenable to improvement.

Muscedere J, Andrew MK, Bagshaw SM, Estabrooks C, Hogan D, Holroyd-Leduc J, Howlett S, Lahey W, Maxwell C, McNally M, Moorhouse P, Rockwood K, Rolfson D, Sinha S, Tholl B. Screening for Frailty in Canada's Health Care System: A Time for Action. Canadian Journal on Aging. 2016 Sept; 35(3):281-297. doi: 10.1017/S0714980816000301. Epub 2016 May 23.

Click here to learn more about CFN's National Frailty Forum and further work regarding the implications of frailty assessment.

Abstract: As Canada’s population ages, frailty – with its increased risk of functional decline, deterioration in health status, and death – will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.

Heckman GA, Braceland B. Integrating Frailty Assessment Into Cardiovascular Decision Making. Canadian Journal of Cardiology. Volume 32, Issue 2, February 2016, Pages 139–141.

Abstract: Atrial fibrillation (AF) is the most common tachyarrhythmia, affecting > 1% of the population. Like most cardiovascular conditions, its prevalence increases with age, and the lifetime risk approaches 25%. The most feared complication of AF is stroke: AF accounts for approximately 20% of ischemic strokes, which are generally more severe and associated with greater disability and mortality. Furthermore, in the context of population aging, emerging data suggest that a strong association also exists between AF and the development of 2 important geriatric syndromes: dementia and frailty.