Dawn M. Guthrie

Risk factors for restriction in activity associated with fear of falling among seniors within the community.

Background: Despite the significance of falling, fear of falling may represent a greater pervasive concern to the health of seniors. Activity restriction, resulting from fear of falling, which may or may not develop after a fall, may lead to balance deterioration, functional decline, anxiety or reductions in social/leisure/physical activity opportunities, and, consequently, compromised quality of life and health. Methods: The purpose of this research was to determine the risk factors for activity restriction resulting from fear of falling among community-based seniors using an early version of the interRAI Community Health Assessment (interRAI CHA). All participants (n = 560) were enrolled in 1 of 5 different fall intervention programs in Ontario funded through the Falls Prevention Initiative sponsored by Health Canada and Veterans Affairs Canada. All participants (or a predetermined number of seniors if the subject pool was extensive) were assessed both before and after intervention. Subjects were assessed using the interRAI CHA. Results: Thirty-five percent of seniors reported restricting their activity as a result of fear of falling. Risk factors predictive of activity restriction included previous history of falling, compromised instrumental activities of daily living, compromised cognitive performance, presence of pain, female sex, and impaired gait. Conclusions: Fear of falling is a prevalent issue among seniors, which has the potential to alter their quality of life and morbidity, and as such, including fear of falling in public health programs, health policies, and screening efforts seems imperative. The present findings add to the present research on risk factors for activity restriction because of fear of falling. These findings do not advocate for restriction of activity to prevent falls because restriction is not a good solution to fall prevention. Using a standardized and comprehensive tool such as the interRAI CHA would assist researchers in making comparisons between different research groups as well as assessing fear of falling from a multidisciplinary perspective.

The Health and Well-Being of Older Adults with Dual Sensory Impairment (DSI) in Four Countries

Objectives Dual sensory impairment (DSI) is a combination of vision and hearing impairments that represents a unique disability affecting all aspects of a person’s life. The rates of DSI are expected to increase due to population aging, yet little is known about DSI among older adults (65+). The prevalence of DSI and client characteristics were examined among two groups, namely, older adults receiving home care services or those residing in a long-term care (LTC) facility in four countries (Canada, US, Finland, Belgium). Methods Existing data, using an interRAI assessment, were analyzed to compare older adults with DSI to all others across demographic characteristics, functional and psychosocial outcomes. Results In home care, the prevalence of DSI across the four countries ranged from 13.4% to 24.6%; in LTC facilities, it ranged from 9.7% to 33.9%. Clients with DSI were more likely to be 85+, have moderate/severe cognitive impairment, impairments in activities of daily living, and have communication difficulties. Among residents of LTC facilities, individuals with DSI were more likely to be 85+ and more likely have a diagnosis of Alzheimer’s disease. Having DSI increased the likelihood of depression in both care settings, but after adjusting for other factors, it remained significant only in the home care sample. Conclusions While the prevalence of DSI cross nationally is similar to that of other illnesses such as diabetes, depression, and Alzheimer’s disease, we have a limited understanding of its affects among older adults. Raising awareness of this unique disability is imperative to insure that individuals receive the necessary rehabilitation and supportive services to improve their level of independence and quality of life.

Prevalence and risk factors of depressive symptoms in a Canadian palliative home care population: a cross-sectional study

BackgroundDepression in palliative care patients is important because of its intrinsic burden and association with elevated physical symptoms, reduced immunity and increased mortality risk. Identifying risk factors associated with depression can enable clinicians to more readily diagnose it, which is important since depression is treatable. The purpose of this cross-sectional study was to determine the prevalence of depressive symptoms and risk factors associated with them in a large sample of palliative home care patients.MethodsThe data come from interRAI Palliative Care assessments completed between 2006 and 2012. The sample (n = 5144) consists of adults residing in Ontario (Canada), receiving home care services, classified as palliative, and not experiencing significant cognitive impairment. Logistic regression identified the risk factors associated with depressive symptoms. The dependent variable was the Depression Rating Scale (DRS) and the independent variables were functional indicators from the interRAI assessment and other variables identified in the literature. We examined the results of the complete case and multiple imputation analyses, and found them to be similar.ResultsThe prevalence of depressive symptoms was 9.8%. The risk factors associated with depressive symptoms were (pooled estimates, multiple imputation): low life satisfaction (OR = 3.01 [CI = 2.37-3.82]), severe and moderate sleep disorders (2.56 [2.05-3.19] and 1.56 [1.18-2.06]), health instability (2.12 [1.42-3.18]), caregiver distress 2.01 [1.62-2.51]), daily pain (1.73 [1.35-2.22]), cognitive impairment (1.45 [1.13-1.87]), being female (1.37 [1.11-1.68]), and gastrointestinal symptoms (1.27 [1.03-1.55]). Life satisfaction mediated the effect of prognostic awareness on depressive symptoms.ConclusionsThe prevalence of depressive symptoms in our study was close to the median of 10-20% reported in the palliative care literature, suggesting they are present but by no means inevitable in palliative patients. Most of the factors associated with depressive symptoms in our study are amenable to clinical intervention and often targeted in palliative care programs. Designing interventions to address them can be challenging, however, requiring careful attention to patient preferences, the spectrum of comorbid conditions they face, and their social supports. Life satisfaction was one of the strongest factors associated with depressive symptoms in our study, and is likely to be among the most challenging to address.

Reliability of standardized assessment for adults who are deafblind

This study assessed the reliability of the interRAI Community Health Assessment (interRAI CHA) and Deafblind Supplement (DbS). The interRAI CHA and DbS represents a multidimensional, standardized assessment instrument for use with adults (18 and older) who are deafblind. The interrater reliability of the instrument was tested through the completion of dual assessments with 44 individuals who were deafblind in the province of Ontario, Canada. Overall, nearly 50% of items had a kappa value of at least 0.60, indicating fair to substantial agreement for these items. Several items related to psychosocial well-being, mood, and sense of involvement had kappa scores of less than 0.40. However, among these items with low kappa values, most (78%) showed at least 70% agreement between the two assessors. The internal consistency of several health subscales, embedded within the assessment, was also very good and ranged from 0.63 to 0.93. The interRAI CHA and DbS represents a reliable instrument for assessing adults with deafblindness to better understand their needs, abilities, and preferences.

Patient Characteristics Associated With Prognostic Awareness: A Study of a Canadian Palliative Care Population Using the InterRAI Palliative Care Instrument

CONTEXT Awareness of their medical prognosis enables terminally ill patients to make decisions on treatments and end-of-life care/planning, and to reach acceptance. Yet, many patients receiving palliative care (PC) are unaware of their prognosis, even when death is imminent and has been discussed with health care providers. A better understanding of patient characteristics associated with prognostic awareness (PA) is needed to develop interventions aimed at improving it. OBJECTIVES To identify patient characteristics associated with PA in a PC population. METHODS The sample comprised 2090 palliative home care patients in Ontario, Canada, assessed using the interRAI Palliative Care Assessment. Independent variables included sociodemographic, cognitive/physical functioning, mood, psychological well-being, and social support. Using cross-sectional data, an adjusted logistic regression model was developed to identify key patient characteristics associated with PA. A multifaceted definition of PA was assumed and represented dichotomously in the model. Multiple imputation was used to address missing data, generating results similar to the complete case analysis. RESULTS The PA was higher in patients with: a shorter prognosis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.93-4.33), increased hours of informal care (OR 1.71, 95% CI 1.15-2.52), less cognitive impairment (OR 1.61, 95% CI 1.14-2.28), and in patients at peace with life (OR 1.79, 95% CI 1.27-2.53). Site differences were observed but do not reflect differences in age, gender, prognosis, or diagnosis. CONCLUSION Some patient characteristics are amenable to clinical intervention to raise PA, such as being at peace, cognitive impairment, and depression. Prognostic communications vary in timing and quality and may underlie our site differences, but further research is required to confirm this.

A Comparison Between End-of-Life Home Care Clients With Cancer and Heart Failure in Ontario

Individuals with heart failure experience complex symptoms and have a poor prognosis, comparable to those with cancer. However, people with heart failure are less likely to be recognized as needing palliative care. We compared seriously ill home care clients with cancer versus those with heart failure to explore differences between them using existing data from the Resident Assessment Instrument for Home Care (RAI-HC). The sample included 1,475 older adults (65+) in Ontario who had a prognosis of less than 6 months or severe health instability. Clients with heart failure were significantly older (p < .0001) and experienced significantly higher rates of impairment in activities of daily living (p = .005), cognitive impairment (p < .0001), and severe health instability (p < .0001), but were significantly less likely to have a prognosis of less than 6 months (p < .0001). Home care clients with heart failure have needs similar to those with cancer yet are typically not identified as having a terminal prognosis.

The Role of Medications in Predicting Activity Restriction Due to a Fear of Falling

Objectives: To examine the role of medication use and other factors in predicting activity restriction due to a fear of falling (AR/FF). Methods: Older adults were assessed twice with the interRAI Community Health Assessment and the Berg Balance Scale (BBS). The main outcome was limiting going outdoors due to an AR/FF. Medications were recorded by trained assessors. Results: Participants (n = 441) had a mean age of 80.3 (SD = 7.1) years, most were aged 65+ (96.8%) and 29.3% reported activity restriction. Taking nervous system active or cardiovascular medications was associated with AR/FF. In a multivariate model, the main predictors were having 3+ comorbid health conditions, lower (i.e., worse) scores on the BBS, having difficulty with climbing stairs, and having a visual impairment. Discussion: Modifiable risk factors, related to functional impairments, such as difficulties with balance and vision, appear to be more important predictors than medications.

Self-Rated Health, Cognition, and Dual Sensory Impairment Are Important Predictors of Depression Among Home Care Clients in Ontario

Depression can be a disabling and debilitating condition among older adults (aged 65+). This study examined risk factors for symptoms of depression in a large sample of older home care clients (n = 218,850) in Ontario, Canada, using existing data collected with the Resident Assessment Instrument for Home Care (RAI-HC). The RAI-HC has been mandated across the province since 2002. The most important predictors of depression were lower self-rated health (odds ratio [OR] = 3.4), cognitive impairment (OR = 2.9), dual sensory impairment (OR = 1.2), and a primary language other than English or French (OR = 1.5). This suggests that not only physical health but also sensory impairments and communication difficulties increase the risk for depression among home care recipients.

Older Adults With a Combination of Vision and Hearing Impairment Experience Higher Rates of Cognitive Impairment, Functional Dependence, and Worse Outcomes Across a Set of Quality Indicators:

Objectives: Hearing and vision impairment were examined across several health-related outcomes and across a set of quality indicators (QIs) in home care clients with both vision and hearing loss (or dual sensory impairment [DSI]). Method: Data collected using the Resident Assessment Instrument for Home Care (RAI-HC) were analyzed in a sample of older home care clients. The QIs represent the proportion of clients experiencing negative outcomes (e.g., falls, social isolation). Results: The average age of clients was 82.8 years (SD = 7.9), 20.5% had DSI and 8.5% had a diagnosis of Alzheimer’s disease (AD). Clients with DSI were more likely to have a diagnosis of dementia (not AD), have functional impairments, report loneliness, and have higher rates across 20 of the 22 QIs, including communication difficulty and cognitive decline. Clients with highly impaired hearing, and any visual impairment, had the highest QI rates. Discussion: Individuals with DSI experience higher rates of adverse events across many health-related outcomes and QIs. Understanding the unique contribution of hearing and vision in this group can promote optimal quality of care.

Combined impairments in vision, hearing and cognition are associated with greater levels of functional and communication difficulties than cognitive impairment alone: Analysis of interRAI data for home care and long-term care recipients in Ontario

Objectives The objective of the current study was to understand the added effects of having a sensory impairment (vision and/or hearing impairment) in combination with cognitive impairment with respect to health-related outcomes among older adults (65+ years old) receiving home care or residing in a long-term care (LTC) facility in Ontario, Canada. Methods Cross-sectional analyses were conducted using existing data collected with one of two interRAI assessments, one for home care (n = 291,824) and one for LTC (n = 110,578). Items in the assessments were used to identify clients with single sensory impairments (e.g., vision only [VI], hearing only [HI]), dual sensory impairment (DSI; i.e., vision and hearing) and those with cognitive impairment (CI). We defined seven mutually exclusive groups based on the presence of single or combined impairments. Results The rate of people having all three impairments (i.e., CI+DSI) was 21.3% in home care and 29.2% in LTC. Across the seven groups, individuals with all three impairments were the most likely to report loneliness, to have a reduction in social engagement, and to experience reduced independence in their activities of daily living (ADLs) and instrumental ADLs (IADLs). Communication challenges were highly prevalent in this group, at 38.0% in home care and 49.2% in LTC. In both care settings, communication difficulties were more common in the CI+DSI group versus the CI-alone group. Conclusions The presence of combined sensory and cognitive impairments is high among older adults in these two care settings and having all three impairments is associated with higher rates of negative outcomes than the rates for those having CI alone. There is a rising imperative for all health care professionals to recognize the potential presence of hearing, vision and cognitive impairments in those for whom they provide care, to ensure that basic screening occurs and to use those results to inform care plans.