Knowledge in action
Recently published papers
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.
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 Gap. Can 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 reviews. J 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.
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.
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:http://dx.doi.org/10.5770/cgj.19.233
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
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. http://dx.doi.org/10.14283/jfa.2016.108.
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 G. Diabetes 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:
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: http://dx.doi.org/10.1016/j.ejim.2016.03.005
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. http://dx.doi.org/10.1016/j.cjca.2015.06.011
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.