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Background: While assisted living (AL) and nursing home (NHs) residents in share vulnerabilities, AL provides fewer staffing resources and services. Research has largely neglected AL, especially during the COVID‐19 pandemic. Our study compared trends of practice‐sensitive, risk‐adjusted quality indicators between AL and NHs, and changes in these trends after the start of the pandemic. Methods: This repeated cross‐sectional study used population‐based resident data in Alberta, Canada. Using Resident Assessment Instrument data (01/2017–12/2021), we created quarterly cohorts, using each resident's latest assessment in each quarter. We applied validated inclusion/exclusion criteria and risk‐adjustments to create nine quality indicators and their 95% confidence intervals (CIs): potentially inappropriate antipsychotic use, pain, depressive symptoms, total dependency in late‐loss activities of daily living, physical restraint use, pressure ulcers, delirium, weight loss, urinary tract infections. Run charts compared quality indicators between AL and NHs over time and segmented regressions assessed whether these trends changed after the start of the pandemic. Results: Quarterly samples included 2015–2710 AL residents and 12,881–13,807 NH residents. Antipsychotic use (21%–26%), pain (20%–24%), and depressive symptoms (17%–25%) were most common in AL. In NHs, they were physical dependency (33%–36%), depressive symptoms (26%–32%), and antipsychotic use (17%–22%). Antipsychotic use and pain were consistently higher in AL. Depressive symptoms, physical dependency, physical restraint use, delirium, weight loss were consistently lower in AL. The most notable segmented regression findings were an increase in antipsychotic use during the pandemic in both settings (AL: change in slope = 0.6% [95% CI: 0.1%–1.0%], p = 0.0140; NHs: change in slope = 0.4% [95% CI: 0.3%–0.5%], p < 0.0001), and an increase in physical dependency in AL only (change in slope = 0.5% [95% CI: 0.1%–0.8%], p = 0.0222). Conclusions: QIs differed significantly between AL and NHs before and during the pandemic. Any changes implemented to address deficiencies in either setting need to account for these differences and require monitoring to assess their impact. [ABSTRACT FROM AUTHOR]

Family or friend caregivers' concerns about assisted living (AL) residents' mental health are reflective of poor resident and caregiver mental health. COVID-19-related visiting restrictions increased caregiver concerns, but research on these issues in AL is limited. Using web-based surveys with 673 caregivers of AL residents in Western Canada, we assessed the prevalence and correlates of moderate to severe caregiver concerns about residents' depressed mood, loneliness, and anxiety in the 3 months before and after the start of the COVID-19 pandemic. Caregiver concerns doubled after the start of the pandemic (resident depressed mood: 23%–50%, loneliness: 29%–62%, anxiety: 24%–47%). Generalized linear mixed models identified various modifiable risk factors for caregiver concerns (e.g., caregivers' perception that residents lacked access to counseling services or not feeling well informed about and involved in resident care). These modifiable factors can be targeted in efforts to prevent or mitigate caregiver concerns and resident mental health issues. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic affected access to health care services in Canada; however, limited research examines the influence of the social determinants of health on unmet health care needs during the first year of the pandemic. The objectives of this study were to describe unmet health care needs during the first year of the pandemic and to investigate the association of unmet needs with the social determinants of health. Methods: We conducted a prospective cohort study of 23 972 adults participating in the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Study (April–December 2020) to identify the social determinants of health associated with unmet health care needs during the pandemic. Using logistic regression, we assessed the association between several social determinants of health on the following 3 outcomes (separately): experiencing any challenges in accessing health care services, not going to a hospital or seeing a doctor when needed, and experiencing barriers to accessing testing for SARS-CoV-2 infection. Results: From September to December 2020, 25% of participants experienced challenges accessing health care services, 8% did not go to a hospital or see a doctor when needed and 4% faced barriers accessing testing for SARS-CoV-2 infection. The prevalence of all 3 unmet need outcomes was lower among older age groups. Differences were observed by sex, region, education, income and racial background. Immigrants (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.09–1.27) or people with chronic conditions (OR 1.35, 95% CI 1.27–1.43) had higher odds of experiencing challenges accessing health care services and had higher odds of not going to a hospital or seeing a doctor (immigrants OR 1.26, 95% CI 1.11–1.43; chronic conditions OR 1.45, 95% CI 1.31–1.61). Prepandemic unmet health care needs were strongly associated with all 3 outcomes. Interpretation: Substantial unmet health care needs were reported by Canadian adults during the first year of the pandemic. The results of this study have important implications for health equity. [ABSTRACT FROM AUTHOR]

Objectives Studies on informal caregiving during the coronavirus disease 2019 (COVID-19) pandemic have mainly focused on subgroups of caregivers using cross-sectional or convenience samples, limiting the generalizability of findings. Conversely, this longitudinal study examines the effects of the pandemic and caregiving factors on depressive symptoms and anxiety over 9 months among informal caregivers in Canada. Methods This study uses data from the Baseline (2011–2015), Follow-up 1 (2015–2018), and COVID-19 Study Baseline survey (April to May 2020) and Exit surveys (September to December 2020) of the Canadian Longitudinal Study on Aging (CLSA). A total of 14,118 CLSA participants who were caregivers at Follow-up 1 and participated in the COVID-19 studies were selected. Linear mixed models were used to examine the effect of sex of caregiver, changes in caregiving (increase in caregiving hours and inability to care), and location of care (same household, another household, and health care institution) on depressive symptoms and anxiety from COVID-19 studies Baseline to Exit surveys (about 6–7 months apart). Results Informal caregivers reported more frequent depressive symptoms from the COVID-19 Baseline to Exit surveys, but not anxiety. Female caregivers reported greater depressive symptoms and anxiety, and male caregivers exhibited a greater increase in depressive symptoms and anxiety over time. More caregiving hours and inability to provide care were significantly positively associated with depressive symptoms and anxiety. Also, in-home caregivers reported more depressive symptoms and anxiety than those who cared for someone in health care institution, and more anxiety than those who cared for some in another household. Discussion The findings shed light on the change in mental health among informal caregivers during the outset of the pandemic. The demonstrated associations between studied variables and mental health among informal caregivers provide empirical evidence for intervention programs aiming to support caregivers, particularly those who are female, and providing intensive care at home. [ABSTRACT FROM AUTHOR]

Background: The indirect consequences of the COVID-19 pandemic in older adults, such as stress, are unknown. We sought to describe the stressors and perceived consequences of the COVID-19 pandemic on older adults in Canada and to evaluate differences by socioeconomic factors. Methods: We conducted a cross-sectional study using data from the Canadian Longitudinal Study on Aging COVID-19 Exit Questionnaire (September-December 2020). A 12-item checklist was used to assess stressors (e.g., income loss, separation from family) experienced during the pandemic, and a single question was used to measure perceived consequences. We used a generalized linear model with a binomial distribution and log link to estimate prevalence ratios and 95% confidence intervals (CIs) for the association between socioeconomic factors, stressors and perceived consequences. Results: Among the 23 972 older adults (aged 50-96 yr) included in this study, 17 977 (75.5%) reported at least 1 stressor during the pandemic, with 5796 (24.4%) experiencing 3 or more stressors. The consequences of the pandemic were perceived as negative by 23 020 (63.1%) participants. Females were more likely to report most stressors than males, such as separation from family (adjusted prevalence ratio 1.31, 95% CI 1.28-1.35). The perceived consequences of the pandemic varied by region; residents of Quebec were less likely to perceive the consequences of the pandemic as negative (adjusted prevalence ratio 0.87, 95% CI 0.84-0.91) than those of the Atlantic provinces. Interpretation: These findings suggest that older adults across Canada experienced stressors and perceived the pandemic consequences as negative, though stressors and perceptions of consequences varied by socioeconomic factors and geography, highlighting inequalities. Future research will be needed to estimate the impact of stress during the pandemic on future health outcomes. [ABSTRACT FROM AUTHOR]

Identifying persons who are least willing to receive a coronavirus disease 2019 (COVID-19) vaccine is critical for increasing uptake via targeted outreach. We conducted a survey of 23,819 Canadian Longitudinal Study on Aging participants from September 29 to December 29, 2020, to assess factors associated with COVID-19 vaccination willingness and reasons for willingness or lack thereof. Among adults aged 50–96 years, 84.1% (95% confidence interval (CI): 83.7, 84.6) were very or somewhat willing to receive a COVID-19 vaccine; 15.9% (95% CI: 15.4, 16.3) were uncertain or very or somewhat unwilling. Based on logistic regression, those who were younger, female, had lower education and income, were non-White, and lived in a rural area were less willing to receive a COVID-19 vaccine. After controlling for these factors, recent receipt of influenza vaccine (adjusted odds ratio = 14.3, 95% CI: 12.5, 16.2) or planning to receive influenza vaccine (adjusted odds ratio = 10.5, 95% CI: 9.5, 11.6), as compared with no receipt or planning, was most strongly associated with COVID-19 vaccination willingness. Willingness was also associated with believing one had never been infected with severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) and experiencing negative pandemic consequences. Safety concerns were most common among those unwilling. Our comprehensive assessment of COVID-19 vaccination willingness among older adults in Canada, a prioritized group for vaccination due to their risk of severe COVID-19 outcomes, provides a road map for conducting outreach to increase uptake, which is urgently needed. [ABSTRACT FROM AUTHOR]

Background Guidelines for fall prevention in older adults recommend mobility screening for fall risk assessment; however, there is no consensus on which test to use and at what cutoff. This study aimed to determine the accuracy and optimal cut-off values of commonly used mobility tests for predicting falls in the Canadian Longitudinal Study on Aging (CLSA). Methods Mobility tests at baseline included the Timed Up and Go (TUG), Single Leg Stance (SLS), chair-rise and gait speed. Inclusion criteria were: age ≥ 65 years and meeting first-level fall screening criteria (i.e. history of a fall or mobility problem) at baseline. Accuracy of fall prediction at 18-months for each test was measured by the area under the receiver operating curve (AUC). Results Of 1,121 participants that met inclusion criteria (mean age 75.2 ± 5.9 years; 66.6% women), 218 (19.4%) reported ≥one fall at 18 months. None of the tests achieved acceptable accuracy for identifying individuals with ≥one fall at follow-up. Among women 65–74 and 75–85 years, the TUG identified recurrent fallers (≥two falls) with optimal cut-off scores of 14.1 and 12.9 s (both AUCs 0.70), respectively. Among men 65–74 years, only the SLS showed acceptable accuracy (AUC 0.85) for identifying recurrent fallers with an optimal cutoff of 3.6 s. Conclusions Our findings indicate that commonly used mobility tests do not have sufficient discriminability to identify fallers in a population-based sample of community-dwelling older adults. The TUG and SLS can identify recurrent fallers; however, their accuracy and cut-off values vary by age and sex. [ABSTRACT FROM AUTHOR]

BACKGROUND: Recent studies have demonstrated that even in the absence of lung impairment as determined by spirometry, smoking and respiratory symptoms are associated with poor overall health and well-being. However, this relationship is not well defined; and it remains unclear the degree to which symptoms are related to poor health, independent of smoking. This is of particular importance to older adults, as they are more likely to exhibit respiratory symptoms and are, therefore, at risk of not receiving appropriate treatment if they have never smoked and have normal spirometry. METHODS: We performed a cross-sectional analysis of data from the Canadian Longitudinal Study on Aging to delineate the associations of respiratory symptoms and smoking on the health of participants age 45-86 who exhibited normal spirometry. Participant health was estimated using a frailty index, a multidimensional measure of vulnerability to adverse outcomes that has been validated in numerous health settings. RESULTS: Of the 21,293 participants included in our analysis, 87% exhibited a normal FEV1, FVC, and FEV1/FVC; of those, 45% reported at least one respiratory symptom, and 50% were former or current smokers. Both respiratory symptoms and smoking were independently associated with frailty (median interquartile range [IQR] = 0.11 [0.07-0.15]), the most substantial associations observed for those having at least one respiratory symptom (adjusted β 0.023, 95% CI 0.022-0.025) and current smokers with > 10 pack-year exposure (adjusted β 0.014, 95% CI [0.010-0.019). Not only was the association between symptoms and frailty evident in never smokers, a significant proportion of the total effect of smoking on frailty was observed to be mediated by symptoms. CONCLUSIONS: Our data show that respiratory symptoms, regardless of smoking history, were a significant correlate of frailty in older adults with normal spirometry. Hence, they should not be simply regarded as a benign by-product of aging. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to determine the relative and absolute reliabilities of 5 key performance-based measures of physical function in the Canadian Longitudinal Study on Aging (CLSA).Methods: An age-stratified subsample of 147 participants from the CLSA who were undergoing their 3-year data collection visit participated in 2 repeat visits (within 1 week). Participants underwent tests of grip strength, 4-m gait speed, Timed Up and Go (TUG), chair rise, and single-leg stance (left, right, mean, maximum). Intraclass correlation coefficients (ICCs), standard error of measurement, and minimal detectable change (MDC) values were calculated.Results: The relative reliability for grip strength was excellent (ICC = 0.95); the TUG and single-leg stance tests had good reliability (ICC = 0.80 or 0.78-0.82, respectively); gait speed and the chair-rise test had moderate reliability (ICC = 0.64 for both) for participants overall. For participants between 50 and 64 years, TUG and gait speed had poor reliabilities (ICC = 0.38 or 0.33, respectively). For participants aged 75 years and older, the single-leg stance had poor reliability (ICC = 0.30-0.39). The MDC90 was about 6 kg for grip strength, 2.3 seconds for TUG, 0.2 m/second for gait speed, 5.2 seconds for chair rise, and ranged from 22.8 to 26.2 seconds for the single-leg stance.Conclusions: Among community-dwelling Canadians older than 50 years, the reliabilities of the CLSA measures were moderate to excellent. The TUG and gait speed in the youngest age group, and the single-leg stance in the oldest age group, showed poor reliability. MDC values can be used to interpret changes over time. [ABSTRACT FROM AUTHOR]

Background: Longitudinal studies examining the impact of changes in COVID-19 pandemic-related stressors and experiences, and coping styles on the mental health trajectory of employed individuals during the lockdown are limited. The study examined the mental health trajectories of a sample of employed adults in Hamilton, Ontario during the initial lockdown and after the re-opening following the first wave in Canada. Further, this study also identified the pandemic-related stressors and coping strategies associated with changes in depressive symptoms in employed adults during the COVID-19 pandemic.Methods: The InHamilton COVID-19 longitudinal study involved 579 employees aged 22-88 years from a large public university in an urban area of Hamilton, Ontario at baseline (April 2020). Participants were followed monthly with 6 waves of data collected between April and November 2020. A growth mixture modeling approach was used to identify distinct groups of adults who followed a similar pattern of depressive symptoms over time and to describe the longitudinal change in the outcome within and among the identified sub-groups.Results: Our results showed two distinct trajectories of change with 66.2% of participants displaying low-consistent patterns of depressive symptoms, and 33.8% of participants displaying high-increasing depressive symptom patterns. COVID-19 pandemic-related experiences including health concerns, caregiving burden, and lack of access to resources were associated with worsening of the depressive symptom trajectories. Frequent use of dysfunctional coping strategies and less frequent use of emotion-focused coping strategies were associated with the high and increasing depressive symptom pattern.Conclusions: The negative mental health impacts of the COVID-19 pandemic are specific to subgroups within the population and stressors may persist and worsen over time. Providing access to evidence-informed approaches that foster adaptive coping, alleviate the depressive symptoms, and promote the mental health of working adults is critical. [ABSTRACT FROM AUTHOR]

Background/Objectives: The study objective was to understand characteristics and health outcomes of multimorbidity, distinguishing between multimorbidity onset in earlier and later phases of life among community‐dwelling older adults in Canada. DESIGN: A cross‐sectional analysis was conducted using baseline data from the Canadian Longitudinal Study on Aging (CLSA). Setting and Participants: This analysis included 11,161 older adults who were between the ages of 65 and 85 years at baseline and who were living in community‐based settings. Measurements: Multimorbidity was defined using two cutpoints: two or more chronic conditions (MM2+) and three or more chronic conditions (MM3+). After calculating the age of diagnosis for eligible participants, "early multimorbidity" was defined as multiple chronic conditions diagnosed before 45 years of age, while "late multimorbidity" was defined as multiple chronic conditions diagnosed at or after 45 years of age. The five health outcomes explored were physical disability, social limitation, frailty level, perceived general health status, and perceived mental health status. Results: Overall, the prevalence of MM2+ was 75.3% (95% CI: 74.3, 76.1) and the prevalence of MM3+ was 47.0% (95% CI: 46.0, 48.0). The majority of participants (both females and males) living with multimorbidity were categorized with late multimorbidity. Participants with early multimorbidity or both early and late multimorbidity had increased odds of physical disability, social limitation, increased frailty level, and negative perceived general and mental health. These patterns were detected for both MM2+ and MM3+. Conclusion: This study examined the impact of the timing of multimorbidity onset on five health outcomes. Our findings highlight the importance of clinical and public health interventions to prevent and manage the causes and consequences of multimorbidity, with particular focus on age of onset. Future longitudinal research should be done to further articulate the relationships between multimorbidity and these health outcomes over time. [ABSTRACT FROM AUTHOR]

Many studies have shown that estimates of biological age (BA) can predict health-related outcomes in older adults. Often, researchers employ multiple measures belonging to a variety of biological/physiological systems, and assess the validity of BA estimates by how well they approximate chronological age (CA). However, it is not clear whether this is the best approach for judging a BA estimate, or whether certain groups of measures are more informative to this end. Using data from the Canadian Longitudinal Study on Aging, we composed panels of biological measures based on the physiological systems/domains they belong to (blood, organ function, physical/cognitive performance), and also composed a panel of measures that optimized the association of BA with CA. We then compared BA estimates for each according to their association with CA and health-related outcomes, including frailty, multimorbidity, chronic condition domains, disability, and health care utilization. Although BA estimated using all 40 measures (r = 0.74) or our age-optimized panel (r = 0.77) most closely approximated CA, the strength of associations to health-related outcomes was comparable or weaker than that of our panel composed only of physical performance measures (CA r = 0.59). All BA estimates were significantly associated to the outcomes considered, with exception to the neurological and musculoskeletal disease domains, and only varied slightly by sex. In summary, while the approximation of CA is important to consider when estimating BA, the strength of associations to prospective outcomes may be of greater importance. Hence, the context in which BA is estimated should be influenced by an investigator's specific research goals. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity, the co-existence of 2+ (or 3+) chronic diseases in an individual, is an increasingly common global phenomenon leading to reduced quality of life and functional status, and higher healthcare service use and mortality. There is an urgent need to develop and test new models of care that incorporate the components of multimorbidity interventions recommended by international organizations, including care coordination, interdisciplinary teams, and care plans developed with patients that are tailored to their needs and preferences. Purpose: To determine the effectiveness of a 6-month, community-based, multimorbidity intervention compared to usual home care services for community-dwelling older adults (age 65+ years) with multimorbidity (3+ chronic conditions) that were newly referred to and receiving home care services. Methods: A pragmatic, parallel, two-arm randomized controlled trial evaluated the intervention, which included in-home visits by an interdisciplinary team, personal support worker visits, and monthly case conferences. The study took place in two sites in central Ontario, Canada. Eligible and consenting participants were randomly allocated to the intervention and control group using a 1:1 ratio. The participants, statistician/analyst, and research assistants collecting assessment data were blinded. The primary outcome was the Physical Component Summary (PCS) score of the 12-Item Short-Form health survey (SF-12). Secondary outcomes included the SF-12 Mental Component Summary (MCS) score, Center for Epidemiological Studies of Depression (CESD-10), Generalized Anxiety Disorder (GAD-7), Self-Efficacy for Managing Chronic Disease, and service use and costs. Analysis of covariance (ANCOVA) tested group differences using multiple imputation to address missing data, and non-parametric methods explored service use and cost differences. Results: 59 older adults were randomized into the intervention (n = 30) and control (n = 29) groups. At baseline, groups were similar for the primary outcome and number of chronic conditions (mean of 8.6), but the intervention group had lower mental health status. The intervention was cost neutral and no significant group differences were observed for the primary outcome of PCS from SF-12 (mean difference: −4.94; 95% CI: −12.53 to 2.66; p = 0.20) or secondary outcomes. Conclusion: We evaluated a 6-month, self-management intervention for older adults with multimorbidity. While the intervention was cost neutral in comparison to usual care, it was not found to improve the PCS from SF-12 or secondary health outcomes. Recruitment and retention challenges were significant obstacles limiting our ability to assess intervention effectiveness. Yet, the intervention was grounded in internationally-endorsed recommendations and implemented in a practice setting (home care) viewed as a key upstream resource fostering independence in older adults. These features collectively support the identification of ways to recruit/retain older adults and test alternative implementation strategies for interventions that are based on sound principles of multimorbidity management. [ABSTRACT FROM AUTHOR]

Objectives: To compare the prevalence of poor self‐reported oral health (SROH) and dental service‐use in a representative sample of Canadian residents, and to identify associations between SROH and psychosocial determinants of health at baseline of the Canadian Longitudinal Study on Aging. Methods: Data from baseline interviews from 2010 to 2015 involving 93% of 51 388 adults (n = 47 761) were weighted to compare the prevalence of oral health characteristics adjusted for age, sex, socioeconomics, general health and residence. SROH was assessed as 'excellent', 'very good', 'good', 'fair' or 'poor', and dichotomized as 'fair/poor' and 'good/very good/excellent'. Multivariable logistic regression was used to assess the association of fair/poor oral health with psychosocial determinants of health. Results: Most participants reported 'good/very good/excellent' oral health (92.5%), natural teeth (92.0%) and dental service‐use in the previous year (79.6%), yet over 10% had discomfort when eating. Reports of 'fair/poor' oral health were significantly more frequent among participants who had dental concerns, had low socioeconomic status, smoked tobacco or reported poor general health. Dental service‐use and tooth loss differed by province. The odds of poor/fair SROH were high (odds ratio ≥1.5) among participants who avoided foods, did not use dental services frequently, had low incomes, smoked tobacco, were depressed, felt unhealthy or had multiple chronic conditions, but by neither sex or age. There were no interprovincial differences. Conclusions: Most Canadian residents feel in good oral health and use dental services. Oral health inequality is evident between different socioeconomic groups and between healthy and unhealthy people. SROH is strongly associated with socioeconomic and general health status but not with place of residence. However, there were substantial differences in reports of tooth loss and dental service‐use across provinces. [ABSTRACT FROM AUTHOR]

Objective: To examine agreement between administrative and self-reported data on the number of and constituent chronic conditions (CCs) used to measure multimorbidity. Study Design and Setting: Cross-sectional self-reported survey data from four Canadian Community Health Survey waves were linked to administrative data for residents of Ontario, Canada. Agreement for each of 12 CCs was assessed using kappa (κ) statistics. For the overall number of CCs, perfect agreement was defined as agreement on both the number and constituent CCs. Jackknife methods were used to assess the impact of individual CCs on perfect agreement. Results: The level of chance-adjusted agreement between self-report and administrative data for individual CCs varied widely, from κ = 5.5% (inflammatory bowel disease) to κ = 77.5% (diabetes), and there was no clear pattern on whether using administrative data or self-reported data led to higher prevalence estimates. Only 26.9% of participants had perfect agreement on the number and constituent CCs; 10.6% agreed on the number but not constituent CCs. The impact of each CC on perfect agreement depended on both the level of agreement and the prevalence of the individual CC. Conclusion: Our results show that measuring agreement on multimorbidity is more complex than for individual CCs and that even small levels of individual condition disagreement can have a large impact on the agreement on the number of CCs. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To explore how different frameworks and categories of chronic conditions impact multimorbidity (defined as two or more chronic conditions) prevalence estimates and associations with patient‐important functional outcomes. DESIGN: Baseline data from a population‐based cohort study. SETTING: National sample of Canadians. PARTICIPANTS: A total of 51 338 community‐living adults, aged 45 to 85 years. MAIN OUTCOME MEASURES: Chronic conditions from three commonly recognized frameworks were categorized as: (1) diseases, (2) risk factors, or (3) symptoms. Estimates of multimorbidity prevalence were compared among frameworks by age and sex. Separate weighted logistic regression models were used to explore the impact of the different frameworks and categories of chronic conditions on odds ratios (ORs) for multimorbidity for four patient‐important functional outcomes: disability, social participation restriction, and self‐rated physical and mental health. RESULTS: One framework included diseases and risk factors, and two frameworks included diseases, risk factors, and symptoms. The prevalence of multimorbidity differed among the frameworks, ranging from 33.5% to 60.6% having two or more chronic conditions. Including risk factors in frameworks increased prevalence estimates, while including symptoms increased prevalence estimates and associations with most patient‐important outcomes. The two frameworks that included symptoms had the largest ORs for associations with disability, social participation restriction, and self‐rated physical health but not self‐rated mental health. Similar results were found when we compared ORs for patient‐important outcome for multimorbidity based on three subframeworks: one including diseases only, one including diseases and risk factors, and one including diseases, risk factors, and symptoms. CONCLUSIONS: Including risk factors appeared to increase only the prevalence of multimorbidity without significantly altering relationships to outcomes. The inclusion of symptoms increased prevalence and associations with patient‐important outcomes. These findings underscore the importance of considering not only the number, but also the category, of conditions included in multimorbidity frameworks, as simply counting the number of diagnoses may reduce sensitivity to outcomes that are important to individuals. J Am Geriatr Soc 67:1632–1640, 2019 [ABSTRACT FROM AUTHOR]

Background: Most studies that examine comorbidity and its impact on health service utilization focus on a single index-condition and are published in disease-specific journals, which limit opportunities to identify patterns across conditions/disciplines. These comparisons are further complicated by the impact of using different study designs, multimorbidity definitions and data sources. The aim of this paper is to share insights on multimorbidity and associated health services use and costs by reflecting on the common patterns across 3 parallel studies in distinct disease cohorts (diabetes, dementia, and stroke) that used the same study design and were conducted in the same health jurisdiction over the same time period.Methods: We present findings that lend to broader Insights regarding multimorbidity based on the relationship between comorbidity and health service use and costs seen across three distinct disease cohorts. These cohorts were originally created using multiple linked administrative databases to identify community-dwelling residents of Ontario, Canada with one of diabetes, dementia, or stroke in 2008 and each was followed for health service use and associated costs.Results: We identified 376,434 indviduals wtih diabetes, 95,399 wtih dementia, and 29,671 with stroke. Four broad insights were identified from considering the similarity in comorbidity, utilization and cost patterns across the three cohorts: 1) the most prevalent comorbidity types were hypertension and arthritis, which accounted for over 75% of comorbidity in each cohort; 2) overall utilization increased consistently with the number of comorbidities, with the vast majority of services attributed to comorbidity rather than the index conditions; 3) the biggest driver of costs for those with lower levels of comorbidity was community-based care, e.g., home care, GP visits, but at higher levels of comorbidity the driver was acute care services; 4) service-specific comorbidity and age patterns were consistent across the three cohorts.Conclusions: Despite the differences in population demographics and prevalence of the three index conditions, there are common patterns with respect to comorbidity, utilization, and costs. These common patterns may illustrate underlying needs of people with multimorbidity that are often obscured in literature that is still single disease-focused. [ABSTRACT FROM AUTHOR]

Objectives: To compare the effect of a 6‐month community‐based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self‐efficacy, self‐management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM) and 2 or more comorbidities. Design: Multisite, single‐blind, parallel, pragmatic, randomized controlled trial. Setting: Four communities in Ontario, Canada. Participants: Community‐dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159). Intervention: Client‐driven, customized self‐management program with up to 3 in‐home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation. Measurements: Quality‐of‐life measures included the Physical Component Summary (PCS, primary outcome) and Mental Component Summary (MCS, secondary outcome) scores of the Medical Outcomes Study 12‐item Short‐Form Health Survey (SF‐12). Other secondary outcome measures were the Generalized Anxiety Disorder Scale, Center for Epidemiologic Studies Depression Scale (CES‐D‐10), Summary of Diabetes Self‐Care Activities (SDSCA), Self‐Efficacy for Managing Chronic Disease, and healthcare costs. Results: Morbidity burden was high (average of eight comorbidities). Intention‐to‐treat analyses using analysis of covariance showed a group difference favoring the intervention for the MCS (mean difference = 2.68, 95% confidence interval (CI) = 0.28–5.09, P = .03), SDSCA (mean difference = 3.79, 95% CI = 1.02–6.56, P = .01), and CES‐D‐10 (mean difference = −1.45, 95% CI = −0.13 to −2.76, P = .03). No group differences were seen in PCS score, anxiety, self‐efficacy, or total healthcare costs. Conclusion: Participation in a 6‐month community‐based intervention improved quality of life and self‐management and reduced depressive symptoms in older adults with T2DM and comorbidity without increasing total healthcare costs. [ABSTRACT FROM AUTHOR]

Background: there is no standardised test for assessing mobility in the Emergency Department (ED). Objective: we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma. Methods: this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated. Results: TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores 10-19 seconds, 20-29 seconds and ≥30 seconds, respectively: (i) frailty RR (95% CI): 1.8 (1.3-2.4), 3.0 (2.2-4.2) and 3.7 (2.6-5.1); (ii) functional decline RR (95% CI): 2.7 (1.1-6.4), 5.5 (2.1-14.3) and 8.9 (3.0-25.8); (iii) falls RR (95% CI): 0.9 (0.5-1.5), 1.3 (0.6-2.5) and 1.1 (0.4-3.5). Conclusion: in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline. [ABSTRACT FROM AUTHOR]

Aims: This study describes the comorbid conditions in Canadian, community-dwelling older adults with diabetes and the association between the number of comorbidities and health service use and costs.Methods: This retrospective cohort study used multiple linked administrative data to determine 5-year health service utilization in a population-based cohort of community-living individuals aged 66 and over with a diabetes diagnosis as of April 1, 2008 (baseline). Utilization included physician visits, emergency department visits, hospitalizations, and home care services.Results: There were 376,421 cohort members at baseline, almost all (95%) of which had at least one comorbidity and half (46%) had 3 or more. The most common comorbidities were hypertension (83%) and arthritis (61%). Service use and associated costs consistently increased as the number of comorbidities increased across all services and follow-up years. Conditions generally regarded as nondiabetes-related were the main driver of service use. Over time, use of most services declined for people with the highest level of comorbidity (3+). Hospitalizations and emergency department visits represented the largest share of costs for those with the highest level of comorbidity (3+), whereas physician visits were the main costs for those with fewer comorbidities.Conclusions: Comorbidities in community-living older adults with diabetes are common and associated with a high level of health service use and costs. Accordingly, it is important to use a multiple chronic conditions (not single-disease) framework to develop coordinated, comprehensive and patient-centred programs for older adults with diabetes so that all their needs are incorporated into care planning. [ABSTRACT FROM AUTHOR]

Standardization procedures are commonly used to combine phenotype data that were measured using different instruments, but there is little information on how the choice of standardization method influences pooled estimates and heterogeneity. Heterogeneity is of key importance in meta-analyses of observational studies because it affects the statistical models used and the decision of whether or not it is appropriate to calculate a pooled estimate of effect. Using 2-stage individual participant data analyses, we compared 2 common methods of standardization, T-scores and category-centered scores, to create combinable memory scores using cross- sectional data from 3 Canadian population-based studies (the Canadian Study on Health and Aging (1991-1992), the Canadian Community Health Survey on Healthy Aging (2008-2009), and the Quebec Longitudinal Study on Nutrition and Aging (2004-2005)). A simulation was then conducted to assess the influence of varying the following items across population-based studies: 1) effect size, 2) distribution of confounders, and 3) the relationship between confounders and the outcome. We found that pooled estimates based on the unadjusted category-centered scores tended to be larger than those based on the T-scores, although the differences were negligible when adjusted scores were used, and that most individual participant data meta-analyses identified significant heterogeneity. The results of the simulation suggested that in terms of heterogeneity, the method of standardization played a smaller role than did different effect sizes across populations and differential confounding of the outcome measure across studies. Although there was general consistency between the 2 types of standardization methods, the simulations identified a number of sources of heterogeneity, some of which are not the usual sources considered by researchers. [ABSTRACT FROM AUTHOR]

Background: Minor fractures (e.g. wrist, ankle) are risk factors for lower physical health-related quality of life (HRQoL) in seniors. Recent studies found that measures of frailty were associated with decreased physical and mental HRQoL in older people. As most people with minor fractures go to emergency departments (EDs) for treatment, measuring their frailty status in EDs may help stratify their level of HRQoL post-injury and provide them with appropriate health care and services after discharge. This study thus examines the HRQoL of seniors visiting EDs for minor fractures at 3 and 6 months after discharge, according to their frailty status.Methods: This prospective sub-study was conducted within the larger Canadian Emergency Team Initiative (CETI) cohort. Independent seniors (≥65 years) were recruited in 7 Canadian EDs after treatment for various minor fractures. Frailty status in the ED phase was assessed by the Canadian Study of Health and Aging--Clinical Frailty Scale (CSHA-CFS). The SF-12 questionnaire was completed at 3 and 6 months after ED discharge to ascertain HRQoL. Demographic and clinical data were collected. Linear mixed models were used to test for differences between frailty levels and HRQoL outcomes, controlling for confounding variables and repeated measures over time.Results: The sample comprised 334 participants with minor fractures. Prevalence of frailty was as follows: 56.6 % very fit-well; 32.3 % well with treated comorbidities-apparently vulnerable; and 11.1 % mildly-moderately frail. After adjusting for confounding variables, the frailest group showed significantly lower mean HRQoL scores than the fittest group on the physical scale at 3 months (49.3 ± 3.7 vs 60.9 ± 2.0) and 6 months (48.7 ± 3.8 vs 61.1 ± 1.8), as well as on the mental scale at 3 months (59.5 ± 4.4 vs 69.6 ± 1.9). Analyses exploring differences in proportion of patients with HRQoL < 50/100 between the three groups produced similar results.Conclusions: Older adults with minor fractures who were frail had lower physical and mental HRQoL scores at 3 and 6 months after ED discharge than their fittest counterparts. Measuring the frailty status of older adults who suffered a minor fracture in ED might help clinical decision-making at the time of discharge by providing them with appropriate health care and services to improve their HRQoL in the following months. [ABSTRACT FROM AUTHOR]

Objective: the objectives of this study were: (i) to estimate the rate of discrepancy between participant single-item self-reports of good memory and poor performance on a list-learning task and (ii) to identify the factors including age, gender and health status that influence these discrepant classifications. Study design and settings: in total, 14,172 individuals, aged 45-85, were selected from the 2008-09 Canadian Community Health Survey on Healthy Aging. We examined the individual characteristics of participants with and without discrepancies between memory self-reports and performance with a generalised linear model, adjusting for potential covariates. Results: the mean age of respondents was 62.9 years with 56.7% being female, 53.8% having post-secondary graduation and 83% being born in Canada. Higher discrepant classification rates we observed for younger people (6.77 versus 3.65 for lowest and highest group), female (5.90 versus 3.68) and with higher education (6.17 versus 3.52). Discrepant classification rates adjusted with all covariates were higher for those without chronic diseases (5.37 [95% Confidence Interval (CI): 4.16, 6.90] versus 4.05 95% CI: 3.38, 4.86; P= 0.0127), those who did not drink alcohol (5.87 95% CI: 4.69, 7.32 versus 3.70 95% CI: 3.00, 4.55; P< 0.0001), lonely participants (5.45 95% CI: 4.20, 7.04 versus 3.99 95% CI: 3.36, 4.77; P= 0.0081) and bilingual participants (5.67 95% CI: 4.18, 7.64 versus 3.83 95% CI: 3.27, 4.50; P = 0.0102). Conclusion: the findings of this study suggest that the self-reported memory and memory performance differ in a substantial proportion of the population. Therefore, relying on a self-reported memory status may not accurately capture those experiencing memory difficulties. [ABSTRACT FROM AUTHOR]

Falls among community-dwelling seniors constitute a major public health concern because of the potential morbidity and mortality associated with the fall. This study examined the informal care networks accessed by Canadian seniors who had visited the Emergency Department as a result of a fall, and considered the implications of the processes of asking for and receiving help on the senior's identity. Four themes were identified. The first was valuing independence. The remaining three themes concerned threats to the participants' identities linked to the need to ask for or receive help from family and friends. They were: becoming indebted, feeling devalued and becoming a burden to others. Seniors were noted to excuse family members from the expectation of helping because of work and family commitments, and illness. Participants described a mutually beneficial relationship with friends wherein both parties valued their independence and provided assistance to the other when needed. Their comments suggested that assistance was viewed as a good to be traded among peers. Our findings indicate that seniors value their independence and may not seek help even when it appears to be available, if asking threatens valued identities. Health and social care practitioners and policy makers responsible for planning and delivery of services should take this into account in order to ensure the best possible care for injured community-dwelling seniors. [ABSTRACT FROM PUBLISHER]

Background: minor traumatic injuries among independent older people have received little attention to date, but increasingly the impact of such injuries is being recognised. Objectives: we assessed the frequency and predictors of acute health care use, defined as return to the emergency department (ED) or hospitalisation. Study design: national multicentre prospective observational study. Setting: eight Canadian teaching EDs between April 2009 and April 2013. Participants: a total of 1,568 patients aged 65-100 years, independent in basic activities of daily living, discharged from ED following a minor traumatic injury. Methods: trained assessors measured baseline data including demographics, functional status, cognition, comorbidities, frailty and injury severity. We then conducted follow-up telephone interviews at 6 months to assess subsequent acute health care use. We used log-binomial regression analyses to identify predictors of acute health care use, and reported relative risks and 95% CIs. Results: participants' mean age was 77.0, 66.4% female, and their injuries included contusions (43.5%), lacerations (25.1%) and fractures (25.4%). The cumulative rate of acute health care use by 6 months post-injury was 21.5% (95% CI: 19.0-24.3%). The strongest predictors of acute health care use within 6 months were cognitive impairment, RR =1.6 (95% IC: 1.2-2.1) and the mechanism of injury including pedestrian struck or recreational injuries, RR =1.6 (95% CI 1.2-2.2). Conclusions: among independent community living older persons with a minor injury, cognitive impairment and mechanism of injury were independent risk factors for acute healthcare use. Future studies should look at whether tailored discharge planning can reduce the need for acute health care use. [ABSTRACT FROM AUTHOR]

Objectives: to investigate the population impact on functional disability of chronic conditions individually and in combination.Methods: data from 9,008 community-dwelling individuals aged 65 and older from the Canadian Study of Health and Aging (CSHA) were used to estimate the population attributable risk (PAR) for chronic conditions after adjusting for confounding variables. Functional disability was measured using activity of daily living (ADL) and instrumental activity of daily living (IADL).Results: five chronic conditions (foot problems, arthritis, cognitive impairment, heart problems and vision) made the largest contribution to ADL- and IADL-related functional disabilities. There was variation in magnitude and ranking of population attributable risk (PAR) by age, sex and definition of disability. All chronic conditions taken simultaneously accounted for about 66% of the ADL-related disability and almost 50% of the IADL-related disability.Conclusions: in community-dwelling older adults, foot problems, arthritis, cognitive impairment, heart problems and vision were the major determinants of disability. Attempts to reduce disability burden in older Canadians should target these chronic conditions; however, preventive interventions will be most efficient if they recognize the differences in the drivers of PAR by sex, age group and type of functional disability being targeted. [ABSTRACT FROM AUTHOR]

Objective. To understand the national utilization pattern of heat and moisture exchangers (HME) and heated humidifiers (HH) in mechanically ventilated ICU patients. Design. Cross-sectional survey. Population. ICU directors in French and Canadian university-affiliated hospitals. Response rate was 89%. Measurements. We asked respondents whether they primarily used HME or HH. We recorded whether HME were used in all patients and for how long, how often they were changed, for whom, and why they were not used. Results. HME were used more often in France HH in Canada. HME were more likely to be used for all patients in France than in Canada (63% vs. 13% and for any duration of ventilation (93% vs. 35%). Short-term use of HME was more common in Canada than in France (59% vs. 7%). HME were primarily changed every day in both countries. The patients for whom HME were not used and reasons for nonutilization were similar in France and Canada. The variable of country was the strongest predictor of HME utilization for every patient (France vs. Canada, odds ratio 11) and utilization for periods of 5 days or less (Canada vs. France, odds ratio 22). Conclusions. HME were reportedly used more in often in France than in Canada for the entire duration of mechanical ventilation. This survey highlights perceptions and practices related to the determinants and consequences of airway humidification and suggests differences in the cost of mechanical ventilation between countries [ABSTRACT FROM AUTHOR]

Objective: To identify the frequency of psychological and emotional abuse, gender discrimination, verbal sexual harassment, physical sexual harassment, physical assault, and homophobia experienced by general internists.Design: Cross-sectional survey.Setting: Canadian general internal medicine practices.Results: The overall response rate was 70.6% (984/1,393); the 501 respondents who classified themselves as general internists were studied. Three-fourths of the internists experienced psychological and emotional abuse at the hands of patients, and 38% of the women and 26% of the men experienced physical assault by patients. The majority of the female internists experienced gender discrimination by patients (67%) and by physician peers (56%). Forty-five percent of the women experienced verbal sexual harassment by patients, and 22% experienced physical sexual harassment by patients. The male internists experienced verbal sexual harassment from nurses slightly more often than the female internists did (19% vs 13%, p > 0.05). Verbal sexual harassment by male colleagues was reported by 35% of the female internists, and physical sexual harassment was reported by 11%. Approximately 40% of general internists reported homophobic remarks by both health care team members and patients.Conclusions: Abuse, discrimination, and homophobia are prevalent in the internal medicine workplace. A direct, progressive, multidisciplinary approach is necessary to label and address these problems. [ABSTRACT FROM AUTHOR]

• Prior influenza vaccination is a strong predictor of subsequent influenza vaccine uptake. • Individual concern about COVID-19 increases the likelihood of influenza vaccine uptake. • COVID-19 vaccine willingness is higher among those previously vaccinated against influenza. • Vaccination campaigns should conduct outreach to individuals with no recent history of vaccination. Understanding how influenza vaccine uptake changed during the 2020/2021 influenza season compared to previous pre-pandemic seasons is a key priority, as is identifying the relationship between prior influenza vaccination and COVID-19 vaccine willingness. We analyzed data from a large, nationally representative cohort of Canadian residents aged 50 and older to assess influenza vaccination status three times between 2015 and 2020. We investigated: 1) changes in self-reported influenza vaccine uptake, 2) predictors of influenza vaccine uptake in 2020/2021, and 3) the association between influenza vaccination history and self-reported COVID-19 vaccine willingness using logistic regression models. Among 23,385 participants analyzed for aims 1–2, influenza vaccination increased over time: 14,114 (60.4%) in 2015–2018, 15,692 (67.1%) in 2019/2020, and 19,186 (82.0%; combining those already vaccinated and those planning to get a vaccine) in 2020/2021. After controlling for socio-demographics, history of influenza vaccination was most strongly associated with influenza vaccination in 2020/2021 (adjusted odds ratio [aOR] 147.9 [95% CI: 120.9–180.9]); this association remained after accounting for multiple health and pandemic-related factors (aOR 140.3 [95% CI: 114.5–171.8]). To a lesser degree, those more concerned about COVID-19 were also more likely to report influenza vaccination in fall 2020, whereas those reporting a very negative impact of the pandemic were less likely to get vaccinated. Among 23,819 participants with information on COVID-19 vaccine willingness during the last quarter of 2020 (aim 3), prior influenza vaccination was most strongly associated with willingness to get a COVID-19 vaccine (aOR 15.1 [95% CI: 13.5–16.8] for those who had received influenza vaccine at all previous timepoints versus none). Our analysis highlights the importance of previous vaccination in driving vaccination uptake and willingness. Efforts to increase vaccination coverage for influenza and COVID-19 should target individuals who do not routinely engage with immunization services regardless of demographic factors. [ABSTRACT FROM AUTHOR]

To explore if older adults with osteosarcopenia are at a greater risk of falls, fractures, frailty, and worsening life satisfaction and activities of daily living (ADL) compared to those with normal bone mineral density (BMD) and without sarcopenia. The baseline and 3-year follow-up of a longitudinal study. Community-dwelling people aged 65 years or older in Canada. Caucasian participants 65 years or older that completed the Canadian Longitudinal Study on Aging (CLSA) 2015 baseline interview, physical measurements and 3-year follow-up were included. Osteopenia/osteoporosis was defined as BMD T score below −1 SD according to the World Health Organization, and sarcopenia was defined as low grip strength and/or low gait speed according to the Sarcopenia Definition Outcomes Consortium. Osteosarcopenia was defined as the coexistence of osteopenia/osteoporosis and sarcopenia. Self-reported incident falls and fractures in the last 12 months before the 3-year follow-up were measured. Frailty was assessed through the Rockwood Frailty Index (FI); life satisfaction through the Satisfaction With Life Scale (SWLS); and ADL through the Older American Resources and Services modules. Multivariable logistic and linear regression, including subgroup analyses by sex, were conducted. The sample of 8888 participants (49.1% females) had a mean age (SD) of 72.7 (5.6) years. At baseline, neither osteopenia/osteoporosis nor sarcopenia (reference group) was present in 30.1%, sarcopenia only in 18.4%, osteopenia/osteoporosis only in 29.2%, and osteosarcopenia in 22.3%. Osteosarcopenia was significantly associated with incident falls and fractures in males [adjusted odds ratio (aOR), 1.90, 95% CI 1.15, 3.14, and aOR 2.60, 95% CI 1.14, 5.91, respectively] compared to males without osteopenia/osteoporosis or sarcopenia. Participants with osteosarcopenia had worsening ADL of 0.110 (estimated β coefficient 0.110, 95% CI 0.029, 0.192) and a decrease in their SWLS by 0.660 (estimated β coefficient −0.660, 95% CI −1.133, −0.187), compared to those without. Osteosarcopenia was not associated with frailty for both males and females. Osteosarcopenia was associated with self-reported incident falls and fractures in males and worse life satisfaction and ADL for all participants. Assessing and identifying osteosarcopenia is essential for preventing falls and fractures. Furthermore, it improves life satisfaction and ADL. [ABSTRACT FROM AUTHOR]

To examine the prevalence of coping behaviors during the first 2 waves of the COVID-19 pandemic among caregivers of assisted living residents and variation in these behaviors by caregiver gender and mental health. Cross-sectional and longitudinal survey. Family/friend caregivers of assisted living residents in Alberta and British Columbia. A web-based survey, conducted twice (October 28, 2020 to March 31, 2021 and July 12, 2021 to September 7, 2021) on the same cohort obtained data on caregiver sociodemographic characteristics, anxiety and depressive symptoms, and coping behaviors [seeking counselling, starting a psychotropic drug (sedative, anxiolytic, antidepressant), starting or increasing alcohol, tobacco and/or cannabis consumption] during pandemic waves 1 and 2. Descriptive analyses and multivariable (modified) Poisson regression models identified caregiver correlates of each coping behavior. Among the 673 caregivers surveyed at baseline, most were women (77%), White (90%) and age ≥55 years (81%). Alcohol (16.5%) and psychotropic drug (13.3%) use were the most prevalent coping behaviors reported during the initial wave, followed by smoking and/or cannabis use (8.0%), and counseling (7.4%). Among the longitudinal sample (n = 386), only alcohol use showed a significantly lower prevalence during the second wave (11.7% vs 15.1%, P =.02). During both waves, coping behaviors did not vary significantly by gender, however, psychotropic drug and substance use were significantly more prevalent among caregivers with baseline anxiety and depressive symptoms, including in models adjusted for confounders [eg, anxiety: adjusted risk ratio = 3.87 (95% CI 2.50-6.00] for psychotropic use, 1.87 (1.28-2.73) for alcohol use, 2.21 (1.26-3.88) for smoking/cannabis use). Assisted living caregivers experiencing anxiety or depressive symptoms during the pandemic were more likely to engage in drug and substance use, potentially maladaptive responses. Public health and assisted living home initiatives that identify caregiver mental health needs and provide targeted support during crises are required to mitigate declines in their health. [ABSTRACT FROM AUTHOR]

Measures of obesity, including body mass index (BMI) and waist circumference (WC), do not fully capture the complexity of obesity-related health risks. This study identified distinct classes of obesity-related characteristics and evaluated their associations with BMI, WC, and percent body fat (%BF) using cross-sectional data from 30,096 participants aged 45-85 in the Canadian Longitudinal Study on Aging (2011-2015). Sixteen obesity-related variables, including behavioural, metabolic, physical health, and mental health/social factors, were included in a latent class analysis to identify distinct classes of participants. Adjusted odds ratios (OR) were estimated from logistic regression for associations between each class and obesity defined by BMI, WC and %BF. Six latent classes were identified: "low-risk" (39.8%), "cardiovascular risk" (19.4%), "metabolic risk" (16.9%), "sleep and mental health risk" (12.1%), "multiple and complex risk" (6.7%), and "cardiometabolic risk" (5.1%). Compared to "low-risk", all classes had increased odds of BMI-, WC- and %BF-defined obesity. For example, the "complex and multiple risk" class was associated with obesity by BMI (OR: 10.70, 95% confidence interval (CI): 9.51, 12.04), WC (OR: 9.21, 95% CI: 8,15, 10,41) and %BF (OR: 7.54, 95% CI: 6.21, 9.16). Distinct classes of obesity-related characteristics were identified and were strongly associated with obesity defined by multiple measures. [ABSTRACT FROM AUTHOR]

The objective of this study was to explore how behavioural risk factors (smoking, physical activity, and nutrition) cluster together and assess how clusters of behavioural risk factors are associated with functional disability by age and sex at the individual and population level. We used currently available baseline cross-sectional data from the Canadian Longitudinal Study on Aging (CLSA). The CLSA is a national, population-based longitudinal study established to understand and examine health of an aging population. This study included 51,338 Canadian men and women aged 45 to 85 years residing in the community in 10 Canadian provinces. Behavioural risk factors included smoking, physical activity, and nutrition. The main outcome used in the study was functional disability, which was assessed using a questionnaire adapted from the Older Americans Resources and Services Multidimensional Assessment Questionnaire. In this analyses of unique combinations of the risk factors of smoking, physical activity, and nutritional risk, the magnitude of the association of the behavioural risk factors with functional disability was dependent on which risk factors were included and differed by age and sex strata. Of the risk factors, physical activity accounted for between 70% to 90% of the total population level risk in individuals with all three risk factors, suggesting it is a key driver of the population burden of disability. Together, these results show that considering unique clusters of risk factors, as well as age and sex, is essential for tailoring public health strategies to reduce the burden of disability among aging populations. [ABSTRACT FROM AUTHOR]

Objectives: To examine the impact of two key choices when conducting a network analysis (clustering methods and measure of association) on the number and type of multimorbidity clusters., Study Design and Setting: Using cross-sectional self-reported data on 24 diseases from 30,097 community-living adults aged 45-85 from the Canadian Longitudinal Study on Aging, we conducted network analyses using 5 clustering methods and 11 association measures commonly used in multimorbidity studies. We compared the similarity among clusters using the adjusted Rand index (ARI); an ARI of 0 is equivalent to the diseases being randomly assigned to clusters, and 1 indicates perfect agreement. We compared the network analysis results to disease clusters independently identified by two clinicians., Results: Results differed greatly across combinations of association measures and cluster algorithms. The number of clusters identified ranged from 1 to 24, with a low similarity of conditions within clusters. Compared to clinician-derived clusters, ARIs ranged from -0.02 to 0.24, indicating little similarity., Conclusion: These analyses demonstrate the need for a systematic evaluation of the performance of network analysis methods on binary clustered data like diseases. Moreover, in individual older adults, diseases may not cluster predictably, highlighting the need for a personalized approach to their care., Competing Interests: Declaration of competing interest The authors declare no financial conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Determine whether levels of anxiety and depression, cognitive ability, and self-quarantining during and prior to the pandemic predict decreases in perceived functional ability., Design and Setting: Longitudinal data collected from the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Questionnaire Study (2020) and core CLSA study (Follow-Up 1; 2014-2018)., Participants: 17 541 CLSA participants., Measurements: Self-quarantining behaviours from questionnaires administered at Baseline (April 2020), Monthly, and Exit (December 2020) time points of the CLSA COVID-19 Questionnaire Study, levels of anxiety and depression at Baseline, perceived change in functional ability at Exit, and performance on neuropsychological tests (Rey Auditory Verbal Learning Task, Mental Alternation Task, Animal Fluency Test) and functional ability (Older Americans Resources and Services [OARS] Multidimensional Assessment Questionnaire) from the core CLSA study., Results: Greater cognitive ability pre-pandemic ( B = -.003, P < .01), higher levels of anxiety ( B = -.024, P < .01) and depressive symptoms ( B = -.110, P < .01) at Baseline, and higher frequency of engaging in self-quarantining throughout the COVID-19 survey period ( B = -.098, P < .01) were associated with perceived loss in functional ability at Exit. Self-quarantining behaviour was associated with perceived loss in functional ability only at average and high levels of depressive symptoms ( B = -.013, P < .01)., Conclusions: Older adults with higher cognitive and lower functional ability prior to the pandemic were at greater risk of decreased perceived functional ability during the first year of the pandemic, as were those who experienced greater levels of anxiety and depressive symptoms during the pandemic. Strategies/interventions to preserve functional ability in older adults with cognitive independence prior to future pandemics are warranted., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Urban greenness has been shown to confer many health benefits including reduced risks of chronic disease, depression, anxiety, and, in a limited number of studies, loneliness. In this first Canadian study on this topic, we investigated associations between residential surrounding greenness and loneliness and social isolation among older adults., Methods: This cross-sectional analysis of the Canadian Longitudinal Study on Aging included 26,811 urban participants between 45 and 86 years of age. The Normalized Difference Vegetation Index (NDVI), a measure of greenness, was assigned to participants' residential addresses using a buffer distance of 500 m. We evaluated associations between the NDVI and (i) self-reported loneliness using the Center for Epidemiological Studies Depression Scale, (ii) whether participants reported "feeling lonely living in the local area", and (iii) social isolation. Logistic regression models were used to characterize associations between greenness and loneliness/social isolation while adjusting for individual socio-economic and health behaviours., Results: Overall, 10.8% of participants perceived being lonely, while 6.5% reported "feeling lonely in their local area". Furthermore, 16.2% of participants were characterized as being socially isolated. In adjusted models, we observed no statistically significant difference (odds ratio (OR) = 0.99; 95% confidence interval (CI) 0.93-1.04) in self-reported loneliness in relation to an interquartile range (IQR) increase of NDVI (0.06). However, for the same change in greenness, there was a 15% (OR = 0.85; 95% CI 0.72-0.99) reduced risk for participants who strongly agreed with "feeling lonely living in the local area". For social isolation, for an IQR increase in the NDVI, we observed a 7% (OR = 0.93; 95% CI 0.88-0.97) reduction in prevalence., Conclusion: Our findings suggest that urban greenness plays a role in reducing loneliness and social isolation among Canadian urbanites., (© 2023. The Author(s).)

Introduction: The Emergency Department Avoidability Classification (EDAC) retrospectively classifies emergency department (ED) visits that could have been safely managed in subacute primary care settings, but has not been validated against a criterion standard. A validated EDAC could enable accurate and reliable quantification of avoidable ED visits. We compared agreement between the EDAC and ED physician judgements to specify avoidable ED visits., Materials and Methods: We conducted a cluster randomized, single-blinded agreement study in an academic hospital in Hamilton, Canada. ED visits between January 1, 2019, and December 31, 2019 were clustered based on EDAC classes and randomly sampled evenly. A total of 160 ED visit charts were randomly assigned to ten participating ED physicians at the academic hospital for evaluation. Physicians judged if the ED visit could have been managed appropriately in subacute primary care (an avoidable visit); each ED visit was evaluated by two physicians independently. We measured interrater agreement between physicians with a Cohen's kappa and 95% confidence intervals (CI). We evaluated the correlation between the EDAC and physician judgements using a Spearman rank correlation and ordinal logistic regression with odds ratios (ORs) and 95% CIs. We examined the EDAC's precision to identify avoidable ED visits using accuracy, sensitivity and specificity., Results: ED physicians agreed on 139 visits (86.9%) with a kappa of 0.69 (95% CI 0.59-0.79), indicating substantial agreement. Physicians judged 96.2% of ED visits classified as avoidable by the EDAC as suitable for management in subacute primary care. We found a high correlation between the EDAC and physician judgements (0.64), as well as a very strong association to classify avoidable ED visits (OR 80.0, 95% CI 17.1-374.9). The EDACs avoidable and potentially avoidable classes demonstrated strong accuracy to identify ED visits suitable for management in subacute care (82.8%, 95% CI 78.2-86.8)., Discussion: The EDAC demonstrated strong evidence of criterion validity to classify avoidable ED visits. This classification has important potential for accurately monitoring trends in avoidable ED utilization, measuring proportions of ED volume attributed to avoidable visits and informing interventions intended at reducing ED use by patients who do not require emergency or life-saving healthcare., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Strum et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

As the COVID-19 pandemic impacted mental health, this longitudinal study examined the effect of age-friendly communities (AFC) action plan on older adults' depressive symptoms. Using the CLSA, the CLSA COVID-19 Questionnaire study, survey of Canadian municipalities, and the census, the depressive symptoms trajectories were modeled with multilevel multinomial regressions. Most respondents (66.1%) had non-depressed trajectories, 28.1% experienced a moderate increase in depressive symptoms, and 5.8% had a depressed trajectory. AFC action plans did not have a protective effect on these trajectories. Being a female, greater loneliness, lower income, ≥2 chronic conditions, inferior social participation, weaker sense of belonging, COVID-19 infection, and pandemic stressors predicted a depressed trajectory. Neighborhood's deprivation had a weak protective effect on the declining trajectory. Although AFC action plans provided no benefits during the pandemic, volunteers facilitating resource access and social interactions could limit any increase in depressive symptoms., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The aim is to investigate whether social isolation and loneliness are associated with changes in grip strength, gait speed, BMD, and fractures., Methods: Canadian Longitudinal Study on Aging (CLSA) Comprehensive Cohort participants aged 65 years and older at baseline (2012-2015) who completed the three-year follow-up interview (2015-2018) were included in this analysis (n = 11,344). Social isolation and loneliness were measured using the CLSA social isolation index (CLSA-SII, range 0-10). We calculated absolute and percent change in grip strength (kg) and gait speed (m/s) and annualized absolute (g/cm2) and percent change in femoral neck and total hip BMD during the three-year follow-up. Self-reported incident fractures of all skeletal sites in the previous 12 months were measured at three-year follow-up. Multivariable analyses were conducted. Odd ratio (OR) and 95% confidence interval (CI) are reported., Results: The mean age (standard deviation [SD]) was 72.9 (5.6) years and 49.9% were female. The mean (SD) of CLSA-SII at baseline was 3.5 (1.4). Mean absolute and percentage change (SD) in grip strength (kg) and gait speed (m/s) were -1.33 (4.60), -3.02% (16.65), and -0.05 (0.17), -3.06% (19.28) during the three-year follow-up, respectively. Mean annualized absolute (g/cm2) and percentage change (SD) in femoral neck and total hip BMD were -0.004 (0.010), -0.47% (1.43) and -0.005 (0.009), -0.57% (1.09), respectively. 345 (3.1%) participants had incident fractures. As CLSA-SII increased (per one unit change), participants had 1.13 (adjusted OR 1.13, 95% CI 1.01-1.27) times greater odds for incident fractures. The interaction term between the CLSA-SII and centre for epidemiology studies depression 9 scale (CES-D 9) for self-reported incident fractures was shown (interaction OR 1.02, 95% CI 1.00-1.04)., Conclusions: Socially isolated and lonely older adults were more likely to have had incident fractures, but social isolation was not associated with the three-year changes in grip strength, gait speed, or BMD., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lee et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Prevalence of overall cognitive impairment based on each participant's performance across a neuropsychological battery is challenging; consequently, we define and validate a dichotomous cognitive impairment/no cognitive indicator (CII) using a neuropsychological battery administered in a population-based study. This CII approximates the clinical practice of interpretation across a neuropsychological battery and can be applied to any neuropsychological dataset., Methods: Using data from participants aged 45-85 in the Canadian Longitudinal Study on Aging receiving a telephone-administered neuropsychological battery (Tracking, N = 21,241) or a longer in-person battery (Comprehensive, N = 30,097), impairment was determined for each neuropsychological test based on comparison with normative data. We adjusted for the joint probability of abnormally low scores on multiple neuropsychological tests using baserates of low scores demonstrated in the normative samples and created a dichotomous CII (i.e., cognitive impairment vs no cognitive impairment). Convergent and discriminant validity of the CII were assessed with logistic regression analyses., Results: Using the CII, the prevalence of cognitive impairment was 4.3% in the Tracking and 5.0% in the Comprehensive cohorts. The CII demonstrated strong convergent and discriminant validity., Conclusions: The approach for the CII is a feasible method to identify participants who demonstrate cognitive impairment on a battery of tests. These methods can be applied in other epidemiological studies that use neuropsychological batteries., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Adverse childhood experiences (ACEs) are a risk factor for obesity; however, the causal mechanisms are not well understood. Objectives were to measure the impact of ACEs on adulthood obesity and to investigate whether the association was mediated by nutrition and stress., Methods: A longitudinal study was conducted using adults aged 46-90 years (n = 26 615) from the Canadian Longitudinal Study on Aging. Participants were asked to recall ACEs from <18 years of age. Body mass index (BMI), waist circumference and per cent body fat were measured (2015-18) and obesity was defined using standard cut points. Nutrition was measured using data from the Short Diet Questionnaire and stress was measured using allostatic load. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% CIs for each obesity measure. Causal mediation methods were used to determine whether nutrition and stress were mediators., Results: There were 66% of adults who had experienced one or more ACE. The odds of obesity defined by BMI and waist circumference increased in a dose-response manner with increasing number of ACEs (P trend <0.001). For instance, adults with four to eight ACEs, compared with none, had greater odds of obesity, defined by BMI (adjusted OR: 1.54; 95% CI: 1.28-1.75) and waist circumference (adjusted OR: 1.30; 95% CI: 1.15-1.47). There was no evidence of mediation by stress or nutrition., Conclusions: Adversity experienced in early life is strongly associated with obesity among Canadian adults. Further research is needed to identify other mechanisms for this association to inform obesity prevention strategies., (© The Author(s) 2023. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Background: Older adults have been disproportionately impacted by COVID-19 and related preventative measures undertaken during the pandemic. Given clear evidence of the relationship between loneliness and health outcomes, it is imperative to better understand if, and how, loneliness has changed for older adults during the COVID-19 pandemic, and whom it has impacted most., Method: We used "pre-pandemic" data collected between 2015-2018 (n = 44,817) and "during pandemic" data collected between Sept 29-Dec 29, 2020 (n = 24,114) from community-living older adults participating in the Canadian Longitudinal Study on Aging. Loneliness was measured using the 3-item UCLA Loneliness Scale. Weighted generalized estimating equations estimated the prevalence of loneliness pre-pandemic and during the pandemic. Lagged logistic regression models examined individual-level factors associated with loneliness during the pandemic., Results: We found the adjusted prevalence of loneliness increased to 50.5% (95% CI: 48.0%-53.1%) during the pandemic compared to 30.75% (95% CI: 28.72%-32.85%) pre-pandemic. Loneliness increased more for women (22.3% vs. 17.0%), those in urban areas (20.8% vs. 14.6%), and less for those 75 years and older (16.1% vs. 19.8% or more in all other age groups). Loneliness during the pandemic was strongly associated with pre-pandemic loneliness (aOR 4.87; 95% CI 4.49-5.28) and individual level sociodemographic factors [age < 55 vs. 75 + (aOR 1.41; CI 1.23-1.63), women (aOR 1.34; CI 1.25-1.43), and no post-secondary education vs. post-secondary education (aOR 0.73; CI 0.61-0.86)], living conditions [living alone (aOR 1.39; CI 1.27-1.52) and urban living (aOR 1.18; CI 1.07-1.30)], health status [depression (aOR 2.08; CI 1.88-2.30) and having two, or ≥ three chronic conditions (aOR 1.16; CI 1.03-1.31 and aOR 1.34; CI 1.20-1.50)], health behaviours [regular drinker vs. non-drinker (aOR 1.15; CI 1.04-1.28)], and pandemic-related factors [essential worker (aOR 0.77; CI 0.69-0.87), and spending less time alone than usual on weekdays (aOR 1.32; CI 1.19-1.46) and weekends (aOR 1.27; CI 1.14-1.41) compared to spending the same amount of time alone]., Conclusions: As has been noted for various other outcomes, the pandemic did not impact all subgroups of the population in the same way with respect to loneliness. Our results suggest that public health measures aimed at reducing loneliness during a pandemic should incorporate multifactor interventions fostering positive health behaviours and consider targeting those at high risk for loneliness., (© 2023. The Author(s).)

Background and Aims: Performance-based tests of mobility or physical function such as the Timed Up and Go (TUG), gait speed, chair-rise, and single-leg stance (SLS) are often administered using different protocols in aging populations, however, the reliability of their assessment protocols is not often considered. The purpose of this study was to examine the reliabilities of frequently used assessment protocols for the TUG, gait speed, chair-rise, and SLS in different age groups., Methods: We administered the following assessment protocols in an age-stratified (50-64, 65-74, 75+ years) sample of participants (N = 147) from the Canadian Longitudinal Study on Aging (CLSA): TUG fast pace and TUG normal pace: TUG-cognitive counting backwards by ones and counting back by threes, gait speed with 3-m and 4-m course, chair-rise with arms crossed and allowing the use of arms, and SLS using preferred leg or both legs-on two occasions within 1 week. We assessed the relative (intra-class correlation) and absolute reliability (standard error of measurement, SEM and minimal detectable change, MDC) for each protocol variation and provided recommendations based on relative reliability., Results: For participants aged 50-64 years, our results suggest better reliability for TUG fast-pace compared with normal-pace (ICC and 95% CI 0.70; 0.41-0.85 versus 0.38; 0.12-0.59). The reliability values for 3-m gait speed were potentially higher than for 4-m gait speed (ICC 0.75; 0.67-0.82 versus 0.64; 0.54-0.73) and values for chair-rise suggested better reliability allowing participants to use their arms than with arms crossed (ICC 0.79; 0.66-0.86 versus 0.64; 0.45-0.77) for participants overall. For participants aged 75+ years, ICCs for SLS with the preferred leg showed better reliability than for both legs (ICC = 0.62-0.79 versus 0.30-0.39)., Conclusions and Discussion: These reliability data and the recommendations can help guide the selection of the most appropriate performance-based test protocols for measuring mobility in middle-aged and older community-dwelling adults., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: decreased muscle strength and physical function often precede disability, nursing home admission, home care use and mortality in older adults. Normative values for commonly used physical performance-based tests are not widely available for older adults but are required for clinicians and researchers to easily identify individuals with low performance., Objective: to develop normative values for grip strength, gait speed, timed up and go, single-leg balance and five-repetition chair rise tests in a large population-based sample of Canadians aged 45-85 years., Methods: baseline data (2011-2015) from the Canadian Longitudinal Study on Ageing was used to estimate age- and sex-specific normative values for each of the physical tests. Participants were without disability or mobility limitation (no assistance with activities of daily living or use of mobility devices)., Results: of the 25,470 participants eligible for the analyses 48.6% (n = 12,369) were female with a mean age of 58.6 ± 9.5 years. Sex-specific 5th, 10th, 20th, 50th, 80th, 90th and 95th percentile values for each physical performance-based test were estimated. Cross-validation (n = 100 repetitions) with a 30% holdout sample was used to evaluate model fit., Conclusions: the normative values developed in this paper can be used in clinical and research settings to identify individuals with low performance relative to their peers of the same age and sex. Interventions targeting these at-risk individuals including physical activity can prevent or delay mobility disability and the resulting cascade of increasing care requirements, health care costs and mortality., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: Our primary objective was to estimate the association between loneliness and unmet healthcare needs and if the association changes when adjusted for demographic and health factors. Our secondary objective was to examine the associations by gender (men, women, gender diverse)., Design, Setting, Participants: Retrospective cross-sectional data from 44 423 community-dwelling Canadian Longitudinal Study on Aging participants aged 45 years and older were used., Primary Outcome Measure: Unmet healthcare needs are measured by asking respondents to indicate (yes, no) if there was a time when they needed healthcare in the last 12 months but did not receive it., Results: In our sample of 44 423 respondents, 8.5% (n=3755) reported having an unmet healthcare need in the previous 12 months. Lonely respondents had a higher percentage of unmet healthcare needs (14.4%, n=1474) compared with those who were not lonely (6.7%, n=2281). Gender diverse had the highest percentage reporting being lonely and having an unmet healthcare need (27.3%, n=3), followed by women (15.4%, n=887) and men (13.1%, n=583). In our logistic regression, lonely respondents had higher odds of having an unmet healthcare need in the previous 12 months than did not lonely (adjusted odd ratios (aOR) 1.80, 95% CI 1.64 to 1.97), adjusted for other covariates. In the gender-stratified analysis, loneliness was associated with a slightly greater likelihood of unmet healthcare needs in men (aOR 1.90, 95% CI 1.64 to 2.19) than in women (aOR 1.73, 95% CI 1.53 to 1.95). In the gender diverse, loneliness was also associated with increased likelihood of having an unmet healthcare need (aOR 1.38, 95% CI 0.23 to 8.29)., Conclusions: Loneliness was related to unmet healthcare needs in the previous 12 months, which may suggest that those without robust social connections experience challenges accessing health services. Gender-related differences in loneliness and unmet needs must be further examined in larger samples., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: People with obesity are at increased risk of chronic stress, and this may have been exacerbated during the COVID-19 pandemic. Adverse childhood experiences (ACE) are also associated with both obesity and stress, and may modify risk of stress among people with obesity. The objectives of this study were to evaluate the associations between obesity, ACEs, and stress during the pandemic, and to determine if the association between obesity and stress was modified by ACEs., Methods: A longitudinal study was conducted among adults aged 50-96 years (n = 23,972) from the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Study. Obesity and ACEs were collected pre-pandemic (2015-2018), and stress was measured at COVID-19 Exit Survey (Sept-Dec 2020). We used logistic, Poisson, and negative binomial regression to estimate relative risks (RRs) and 95% confidence intervals (CIs) for the associations between obesity, ACEs, and stress outcomes during the pandemic. Interaction by ACEs was evaluated on the additive and multiplicative scales., Results: People with obesity were more likely to experience an increase in overall stressors (class III obesity vs. healthy weight RR = 1.19; 95% CI: 1.12-1.27) as well as increased health related stressors (class III obesity vs. healthy weight RR: 1.25; 95% CI: 1.12-1.39) but did not perceive the consequences of the pandemic as negative. ACEs were also associated an increase in overall stressors (4-8 ACEs vs. none RR = 1.38; 95% CI: 1.33-1.44) and being more likely to perceive the pandemic as negative (4-8 ACEs vs. none RR = 1.32; 95% CI: 1.19-1.47). The association between obesity and stress was not modified by ACEs., Conclusions: Increased stress during the first year of the COVID-19 pandemic was observed among people with obesity or ACEs. The long-term outcomes of stress during the pandemic need to be determined., (© 2023. The Author(s).)

Background: Adverse childhood experiences (ACEs) are associated with multimorbidity in adulthood. This link may be mediated by psychosocial and biological factors, but evidence is lacking. The current study evaluates this mediation model., Method: We analyzed data from the Canadian Longitudinal Study of Aging ( N = 27 170 community participants). Participants were 45-85 years at recruitment, when allostatic load and social engagement data were collected, and 3 years older at follow-up, when ACEs and multimorbidity data were collected. Structural equation modeling was used to test for mediation in the overall sample, and in sex- and age-stratified subsamples, all analyses adjusted for concurrent lifestyle confounds., Results: In the overall sample, ACEs were associated with multimorbidity, directly, β = 0.12 (95% confidence interval 0.11-0.13) and indirectly. Regarding indirect associations, ACEs were related to social engagement, β = -0.14 (-0.16 to -0.12) and social engagement was related to multimorbidity, β = -0.10 (-0.12 to -0.08). ACEs were related to allostatic load, β = 0.04 (0.03-0.05) and allostatic load was related to multimorbidity, β = 0.16 (0.15-0.17). The model was significant for males and females and across age cohorts, with qualifications in the oldest stratum (age 75-85)., Conclusions: ACEs are related to multimorbidity, directly and via social engagement and allostatic load. This is the first study to show mediated pathways between early adversity and multimorbidity in adulthood. It provides a platform for understanding multimorbidity as a lifespan dynamic informing the co-occurrence of the varied disease processes represented in multimorbidity.

Introduction: Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion., Objectives: Our primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians' judgement as a criterion standard. Our tertiary objective is to examine how the ED physician's perception of a virtual ED care alternative correlates with the EDAC., Methods and Analysis: A randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC., Ethics and Dissemination: This study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)