Micaela Jantzi

Pain among the oldest old in community and institutional settings

Abstract The relationship between pain and increasing age was investigated using data from two different care settings collected on a province‐wide basis in Ontario. Home care clients (HC) and complex continuing care patients (CCC) are assessed using the Resident Assessment Instrument – Home Care and Resident Assessment Instrument 2.0 instruments, respectively, as part of normal clinical practice. For this study, the sample was restricted to those aged 65 years and older and totaled 193,158 individuals. Centenarians (those 100 years of age or older) made up 0.41% (n = 788) of the sample. Pain was assessed according to a previously validated pain scale embedded in both assessments that uses items on frequency and intensity. Based on 5‐year age groups beginning at 65, the mean reported pain score was lower with each increment in age for men and women. Multiple logistic regression models were constructed and the odds ratios for pain in both HC and CCC groups decreased consistently in higher age groups after adjusting for disease diagnoses, cognition, functional status and health indicators. A model that included categories of analgesic medications coded based on the WHO pain ladder showed the relationship persisted after controlling for analgesia. In clinical settings, the oldest old appear to have lower levels of pain compared with the young old after adjusting for a variety of potential confounding variables.

Osteoporosis management among residents living in long-term care

SummaryFractures in long-term care (LTC) residents have substantial economic and human costs. Osteoporosis management in residents with fractures or osteoporosis is low, and certain subgroups are less likely to receive therapy, e.g., those with >5 comorbidities, dementia, and wheelchair use. Many LTC residents who are at risk of fracture are not receiving optimal osteoporosis management.IntroductionThe objective of this study was to describe the prevalence and predictors of osteoporosis management among LTC residents with osteoporosis or fractures.MethodsIn a retrospective study, LTC residents of 17 facilities in Ontario and Manitoba, Canada were investigated. The participants were 65+ years old with osteoporosis, history of hip fracture, or recent fracture. Comprehensive assessments were conducted by trained nurse assessors between June 2005 and June 2006 using a standardized instrument, known as the Resident Assessment Instrument 2.0.ResultsAmong residents (n = 525) with osteoporosis or fractures, 177 (34%) had had a recent fall. Bisphosphonate use was reported in 199 (38%) residents, calcitonin use in six (1%), and raloxifene use in six (1%). Calcium and vitamin D supplementation were reported in 140 (27%) residents. Fifty-four (10.3%) residents were on a bisphosphonate but were not taking vitamin D or multivitamin. Variables negatively associated with osteoporosis therapy [OR (95% CI)]: six or more comorbidities [0.46 (0.28–0.77), p = 0.028], wheelchair use [0.62 (0.40–0.95), p = 0.003], cognitive impairment [0.71 (0.55–0.92), p = 0.009], depression [0.54 (0.34–0.87), p = 0.01], swallowing difficulties [0.99 (0.988–0.999), p = 0.034] or Manitoba residence [0.47 (0.28–0.78), p = 0.004]. Prescription of 10+ medications was positively associated with therapy [3.34 (2.32–4.84), p < 0.001].ConclusionOsteoporosis management is not optimal among residents at risk of future fracture. Identifying at-risk subgroups of residents that are not receiving therapy may facilitate closing the osteoporosis care gap.

Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study

BackgroundHome care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario.MethodsA retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences.ResultsThe study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death.ConclusionsOur study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.

Individuals with neurological diseases are at increased risk of fractures within 180 days of admission to long-term care in Ontario

BACKGROUND Individuals residing in long-term care (LTC) are more likely to have a fragility fracture than community-dwelling seniors. The purpose of this study was to determine whether the presence of neurological diseases was associated with an increased risk of fracture within 180 days of admission to LTC. METHODS This retrospective cohort study used data collected in the LTC setting using the Resident Assessment Instrument (RAI) 2.0 during the period from 2006 to 2011 (N=42,089). Multivariable logistic regression analyses were conducted to determine the associations between the presence of neurological conditions and incident fractures, with and without adjustment for clinical variables. RESULTS The incident fracture rate for all LTC residents was 2.6% (N=1,094). Neurological condition group size ranged from n=21,015 for Alzheimers disease or related dementias (ADRD) to n=21 for muscular dystrophy (MD). The incidence of fracture among residents with specific neurological diseases was as follows: ADRD, 3.2% (n=672), MD, 4.8% (n=1), Parkinsons disease, 2.5% (n=57), stroke, 2.3% (n=166), epilepsy, 2.5% (n=38), Huntingtons disease, 1.4% (n=1), multiple sclerosis, 0.3% (n=1) and traumatic brain injury, 3.8% (n=11); among the comparison group with no neurological conditions, the fracture rate was 2.0% (n=366). The neurological diseases that were associated with a significantly greater odds of having an incident fracture in the first 180 days of LTC admission were as follows: ADRD (1.3; 95% CI: 1.1-1.5), epilepsy (1.5; 95% CI: 1.0-2.1) and traumatic brain injury (2.7; 95% CI: 1.4-5.0). CONCLUSION LTC residents with ADRD, epilepsy and traumatic brain injury are at a higher risk for sustaining an incident fracture in the first 180 days of admission and should be considered for fracture prevention strategies.

Development and validation of the Fracture Risk Scale (FRS) that predicts fracture over a 1-year time period in institutionalised frail older people living in Canada: an electronic record-linked longitudinal cohort study

Objectives To develop and validate our Fracture Risk Scale (FRS) over a 1-year time period, using the long-term care (LTC) Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS 2.0). Design A retrospective cohort study. Setting LTC homes in Ontario, Canada. Participants Older adults who were admitted to LTC and received a RAI-MDS 2.0 admission assessment between 2006 and 2010. Results A total of 29 848 LTC residents were enrolled in the study. Of these 22 386 were included in the derivation dataset and 7462 individual were included in the validation dataset. Approximately 2/3 of the entire sample were women and 45% were 85 years of age or older. A total of 1553 (5.2%) fractures were reported over the 1-year time period. Of these, 959 (61.8%) were hip fractures. Following a hip fracture, 6.3% of individuals died in the emergency department or as an inpatient admission and did not return to their LTC home. Using decision tree analysis, our final outcome scale had eight risk levels of differentiation. The percentage of individuals with a hip fracture ranged from 0.6% (lowest risk level) to 12.6% (highest risk level). The area under the curve of the outcome scale was similar for the derivation (0.67) and validation (0.69) samples, and the scale exhibited a good level of consistency. Conclusions Our FRS predicts hip fracture over a 1-year time period and should be used as an aid to support clinical decisions in the care planning of LTC residents. Future research should focus on the transformation of our scale to a Clinical Assessment Protocol and to assess the FRS in other healthcare settings.

Prevalence and predictors of antibiotic use in community-based elderly in Ontario, Canada.

Little is known about antibiotic use in the elderly receiving home care. We found that 6,873 (5.4%) of 126,339 home care patients in Ontario received antibiotic treatment; 26% of the antibiotics administered were fluoroquinolones. Antibiotic treatment was most frequent in patients less than 65 years of age and among those with a poorer health status.

Measuring health related quality of life (HRQoL) in community and facility-based care settings with the interRAI assessment instruments: development of a crosswalk to HUI3

BackgroundHealth-related quality of life (HRQoL) measures are of interest because they can be used to describe health of populations and represent a broader health outcome for population health analyses than mortality rates or life expectancy. The most widely used measure of HRQoL for deriving estimates of health-adjusted life expectancy is the Health Utilities Index Mark 3 (HUI3). The HUI3 is available in most national surveys administered by Statistics Canada, and has been used as part of a microsimulation model to examine the impact of neurological conditions over the life course. Persons receiving home care and nursing home services are often not well-represented in these surveys; however, interRAI assessment instruments are now used as part of normal clinical practice in these settings for nine Canadian provinces/territories. Building on previous research that developed a HUI2 crosswalk for the interRAI assessments, the present study examined a new interRAI HRQoL index crosswalked to the HUI3.MethodsinterRAI and survey data were used to examine the distributional properties of global and domain-specific interRAI HRQoL and HUI3 index scores, respectively. Three populations were considered: well-elderly persons not receiving home care, home care clients and nursing home residents.ResultsThe mean HUI3 and interRAI HRQoL index global scores declined from independent healthy older persons to home care clients, followed by nursing home residents. For the home care and nursing home populations, the interRAI HRQoL global estimates tended to be lower than HUI3 global scores obtained from survey respondents. While there were some statistically significant age, sex and diagnostic group differences in global scores and within attributes, the most notable differences were between populations from different care settings.DiscussionThe present study provides strong evidence for the validity of the interRAI HRQoL based on comparisons of distributional properties with those obtained with survey data based on the HUI3. The results demonstrate the importance of admission criteria for home care and nursing home settings, where function plays a more important role than demographic or diagnostic criteria. The interRAI HRQoL has a distinct advantage because it is gathered as part of normal clinical practice in care settings where interRAI instruments are mandatory and are used to assess all eligible persons in those sectors. In particular, those with severe cognitive and functional impairments (who tend to be under-represented in survey data) will be evaluated using the interRAI tools. Future research should build on this work by providing direct, person-level comparisons of interRAI HRQoL index and HUI3 scores, as well as longitudinal analyses to examine responsiveness to change.

THE BURDEN AND CORRELATES OF PERSISTENT DEPRESSIVE SYMPTOMS AMONG OLDER HOME-CARE CLIENTS WITH DEMENTIA

Project Description: The National Center for Geriatrics and Gerontology (NCGG) has begun to provide educational support for family caregivers of persons with dementia. In this study, we aim to search for the family caregivers’ needs in order to provide efficient educational support programs. The subjects were 33 caregivers and 33 patients of Alzheimer-type dementia, who participated in the program of six lectures in one term (3 months: May-July 2013). The principal data collected was the relation of the caregiver to the patient, and the evaluations of lectures (changes in their acceptance of dementia, degree of willingness to utilize the knowledge in actual care as results of the lectures). Data was collected in descriptive questionnaires (once at the start of the term, and once at the end), and from patients’ electronic health records (NM, N-ADL, BPSD, ZBI). We conducted statistical analyses.Conditional changes of the patients (3 months) were; NM: 26.2613.2y’26.8613.1, N-ADL: 38.4612.7y’36.7613.2, BPSD: 24.2613.8y’27.5615.2, and the progression of dementia was observed. Also, ZBI was 34.8615.7y’39.3613.8. Furthermore, we divided the subjects into two groups by their ZBI increase and decrease, and compared their evaluations of lectures. In terms of acceptance of dementia, struggling with the reality was dominant in both groups. Also, in terms of their willingness to utilize the learned knowledge in care, the group with decreased ZBI showed positive responses to the wide-ranged, comprehensive knowledge such as explanations of the disorder, treatment methods, and care logics. On the other hand, the ZBI increase group showed positive responses to how to relate to a person with dementia, and care skills. Based on the results, we conducted hearings for those family caregivers who were struggling to cope with those in need of care, and concluded that there is a need to implement 2-class step-up method programs and proper classifications. The two classes should be: 1) a sit-in class providing mainly medical and nursing knowledge, and 2) a class providing case studies based on exercise style focused on nursing and care.