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). https://doi.org/10.1186/s12871-017-0390-7
Muscedere, J. Moving towards standardized data and outcomes for frailty studies. Journal of Frailty & Aging vol. 6, supp 1, 9-10 (July 2017).
Daneman N, Campitelli MA, Giannakeas V, Morris AM, Bell CM, Maxwell CJ, Jeffs L, Austin PC, Bronskill SE. CMAJ June 26, 2017 vol. 189 no. 25. Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities. doi: 10.1503/cmaj.161437. Click here to view infographic.
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 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.
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. https://doi.org/10.1089/jpm.2016.0283
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 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.
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: https://doi.org/10.1093/ageing/afw247
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.
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: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: 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.