Geriatric Medicine Leadership of Health Care Transformation: To Be or Not To Be?

Geriatric Medicine is well-suited to inform and lead healthcare system redesign to address the needs of seniors with complex conditions. We posit that geriatricians must urgently consider how to “brand” Geriatric Medicine in a manner that garners active support from those outside the specialty, including how to adapt practice patterns to better meet the needs of patients and of the health-care system

Identifying Feasible Physical Activity Programs for Long-Term Care Homes in the Ontario Context

Background Structured exercise programs for frail institutionalized seniors have shown improvement in physical, functional, and psychological health of this population. However, the ‘feasibility’ of implementation of such programs in real settings is seldom discussed. The purpose of this systematic review was to gauge feasibility of exercise and falls prevention programs from the perspective of long-term care homes in Ontario, given the recent changes in funding for publically funded physiotherapy services. Method Six electronic databases were searched by two independent researchers for randomized controlled trials that targeted longterm care residents and included exercise as an independent component of the intervention. Results A total of 39 studies were included in this review. A majority of these interventions were led by physiotherapist(s), carried out three times per week for 30–45 minutes per session. However, a few group-based interventions that were led by long-term care staff, volunteers, or trained non-exercise specialists were identified that also required minimal equipment. Conclusion This systematic review has identified ‘feasible’ physical activity and falls prevention programs that required minimal investment in staff and equipment, and demonstrated positive outcomes. Implementation of such programs represents cost-effective means of providing long-term care residents with meaningful gains in physical, psychological, and social health

Addressing Health Care Needs For Frail Seniors In Canada: The Role of InterRAI Instruments

Fiscal pressure on the Canadian health care system results from rising numbers of frail seniors with multiple concurrent medical co-morbidities and geriatric syndromes. Improving outcomes in such seniors is contingent on a comprehensive geriatric assessment (CGA) to identify strengths and deficits and to facilitate the development of a comprehensive care plan. InterRAI instruments are standardized, reliable, and validated suites of tools to conduct CGAs; they offer several benefits, including helping clinicians identify important health issues among patients, develop appropriate care plans, and monitor patient progess. These instruments also provide several benefits beyond the bedside, including quality indicators to assess care quality, and case-mix classification algorithms to facilitate funding of health services. Finally, interRAI instruments, which are implemented in several health care settings across Canada and abroad, provide a standardized and common language that is compatible with electronic medical records and will facilitate greater integration of the health care system

Meeting the Challenge of Managing Seniors With Multiple Complex Conditions: The Central Role of Primary Care

With the aging population, primary care physicians will be increasingly challenged to manage more seniors with complex chronic conditions. The North American population aged 65 years and above is projected to increase from 14% in 2009 to 24% by 2036, and, by 2050, the average life span worldwide is expected to extend another 10 years. Three quarters of seniors have one or more chronic conditions; in one Canadian study, nearly half of patients had five or more types of chronic disease. It is well established that chronic diseases contribute to disability, diminished quality of life, as well as increased health costs. Yet currently, Canadian seniors with chronic disease receive suboptimal quality of care. Most primary care physicians do not appear able to properly manage chronic illness although most of the visits for chronic conditions are provided in primary care. Continued poor management of chronic conditions is expected to have a profound impact on health system utilization and quality of life for these persons and their families. This article reviews evidence that can help to inform the development of future programs aimed at improving care for seniors with chronic illnesses

Care transitions for older patients with musculoskeletal disorders: continuity from the providers’ perspective

<p><strong>Introduction</strong>: Care transitions are a common and frequently adverse aspect of health care, resulting in a high-risk period for both care quality and patient safety. Patients who have complex care needs and undergo treatment in multiple care settings, such as older patients with musculoskeletal disorders, may be at higher risk for poor care transitions.</p><p><strong>Methods: </strong>Key informant interviews were used to gather in-depth information on transitional care issues, particularly those which impact informational continuity, from the perspective of a range of health professionals (η=17) in care settings relevant to the care continuum of older patients with hip fractures.</p><p><strong>Results:</strong> Three transitional care themes were identified; medical complexity impacts care trajectories, larger circles of care can be both beneficial and challenging, and a variety of channels and modes are required for meaningful information exchange. Many issues cut across each care setting, and address challenges to informational continuity among and between health care providers, patients, and caregivers.</p><p><strong>Conclusions:</strong> Medical complexity enlarges the circle of care which challenges care continuity. There may be fundamental elements which, regardless of care setting, strengthen transitional care quality. Standardized transitional care processes might help to offset informational discontinuity across care settings as a result of this population's larger circles of care.</p

Examining the Hospital Elder Life Program in a rehabilitation setting: a pilot feasibility study

Background: The Hospital Elder Life Program (HELP) has been shown to effectively prevent delirium and functional decline in older patients in acute care, but has not been examined in a rehabilitation setting. This pilot study examined potential successes and implementation factors of the HELP in a post-acute rehabilitation hospital setting. Methods: A mixed methods (quantitative and qualitative) evaluation, incorporating a repeated measures design, was used. A total of 100 patients were enrolled; 58 on the pilot intervention unit and 42 on a usual care unit. Group comparisons were made using change scores (pre-post intervention) on outcome measures between pilot unit patients and usual care patients (separate analyses compared usual care patients with pilot unit patients who did or did not receive the HELP). Qualitative data were collected using focus group and individual interviews, and analyzed using emergent coding procedures. Results: Delirium prevalence reduced from 10.9 % (n = 6) to 2.5 % (n = 1) in the intervention group, while remaining the same in the usual care group (2.5 % at both measurement points). Those who received the HELP showed greater improvement on cognitive and functional outcomes, particularly short-term memory and recall, and a shorter average length of stay than patients who did not. Participant groups discussed perceived barriers, benefits, and recommendations for further implementation of the HELP in a rehabilitation setting. Conclusions: This study adds to the limited research on delirium and the effectiveness of the HELP in post-acute rehabilitation settings. The HELP was found to be feasible and have potential benefits for reduced delirium and improved outcomes among rehabilitation patients.Funded in part by an Emerging Team Grant (ETG 92249) from the Canadian Institutes of Health Researc

Use of the interRAI CHESS Scale to Predict Mortality among Persons with Neurological Conditions in Three Care Settings

Background: Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions. Methods: Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories. Results: CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings. Conclusions: CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.Public Health Agency of Canada, Project #6271-15-2010/3970773, Ontario Home Care Research and Knowledge Exchange Chair (to JPH) through the Ontario Ministry of Health and Long Term Car

X-ray absorption and rapid variability of the dwarf Seyfert nucleus of NGC4395

We report the detection of an absorbed central X-ray source and its strong, rapid variability in NGC4395, the least luminous Seyfert nucleus known. The X-ray source exhibits a number of flares with factors of 3-4 flux changes during a half day ASCA observation. Such X-ray variability is in constrast to the behaviour of other low luminosity active galaxies. It provides further support for an accreting black hole model rather than an extreme stellar process in accounting for the nuclear activity of NGC4395. The soft X-ray emission below 3 keV is strongly attenuated by absorption. The energy spectrum in this absorption band shows a dramatic change in response to the variation in continuum luminosity. A variable warm absorber appears to be an explanation for the spectral change. The absorption-corrected 2-10 keV luminosity is 4e39 erg/s for a source distance of 2.6 Mpc, and at 1 keV is one order of magnitude above previous ROSAT estimates. Our X-ray results infer the nuclear source of NGC4395 to be a scaled-down version of higher luminosity Seyfert nuclei, with an intermediate mass (10^4-10^5 Msun) black hole, unlike the nearby low luminosity active galaxies in which underfed massive black holes are suspected to reside.Comment: 12 pages, accepted for publication in MNRA

Engaging older adults in healthcare research and planning: a realist synthesis

Background The importance of engaging the community in healthcare research and planning has been widely recognized. Currently however, there is a limited focus on older adults, Canada’s fastest growing segment of the population and biggest users of the healthcare system. Objective This project aimed to develop an understanding of engagement of older adults and their caregivers in healthcare research and planning. Method A realist synthesis was conducted of the available knowledge on engagement in healthcare research and planning. The search methodology was informed by a framework for realist syntheses following five phases, including consultations with older adults. The synthesis included theoretical frameworks, and both peer-reviewed and grey literature. Results The search generated 15,683 articles, with 562 focusing on healthcare research and planning. The review lead to the development of a framework to engage older adults and their caregivers in healthcare research and planning. The 5 stages environment, plan, establish, build, and transition are accompanied with example context, mechanism, and outcomes to guide the use of this framework. Conclusion We have identified a framework that promotes meaningful engagement of older adults and their caregivers. We are continuing to collaborate with our community partners to further develop and evaluate engagement strategies that align with the presented framework.This work was supported by a Knowledge Synthesis Grant from the Technology Evaluation for the Elderly Network (TVN), grant # KS2013-08, which is funded by the Government of Canada’s Networks of Centres of Excellence (NCE) Program

Heart Failure in Older Persons: Considerations For The Primary Care Physician

Heart failure (HF) affects over 500,000 Canadians, with 50,000 new patients diagnosed each year. While mortality from cardiovascular diseases has progressively declined in Canada, the burden of HF is expected to continue rising as a result of population aging and improved survival of patients with other cardiovascular diseases. HF is the leading cause of hospitalization and death among those aged 65 years and over, with a mortality rate of up to 50% within 5 years of diagnosis. Elderly HF patients are complex: a recent Ontario study of home care recipients with HF found that these clients had more health instability, took more medications, and had more co-morbidities compared with other home care clients. Optimal management of HF in “complex seniors” requires that clinicians understand the interactions between HF and age-associated syndromes such as frailty, cognitive impairment, and functional decline. As the majority of Canadian patients with HF are treated by primary care providers (PCPs), this article is directed at PCPs caring for older adults with HF. It is meant as a brief overview and discusses how the Canadian Cardiovascular Society (CCS) Consensus Guidelines on HF can be applied in daily practice