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Background: Emerging evidence shows loneliness is associated with polypharmacy and high‐risk medications in older adults. Despite notable sex‐based differences in the prevalence in each of loneliness and polypharmacy, the role of sex in the relationship between loneliness and polypharmacy is unclear. We explored the relationship between loneliness and polypharmacy in older female and male respondents and described sex‐related variations in prescribed medication subclasses. Methods: We performed a cross‐sectional analysis of representative data from the Canadian Community Health Survey—Healthy Aging cycle (2008/2009) linked to health administrative databases in Ontario respondents aged 66 years and older. Loneliness was measured using the Three‐Item Loneliness Scale, with respondents classified as not lonely, moderately lonely, or severely lonely. Polypharmacy was defined as five or more concurrently‐prescribed medications. Sex‐stratified multivariable logistic regression models with survey weights were used to assess the relationship between loneliness and polypharmacy. Among those with polypharmacy, we examined the distribution of prescribed medication subclasses and potentially inappropriate medications. Results: Of the 2348 individuals included in this study, 54.6% were female respondents. The prevalence of polypharmacy was highest in those with severe loneliness both in female (no loneliness, 32.4%; moderate loneliness, 36.5%; severe loneliness, 44.1%) and male respondents (32.5%, 32.2%, and 42.5%). Severe loneliness was significantly associated with greater adjusted odds of polypharmacy in female respondents (OR = 1.59; 95% CI: 1.01–2.50) but this association was attenuated after adjustment in male respondents (OR = 1.00; 95% CI: 0.56–1.80). Among those with polypharmacy, antidepressants were more commonly prescribed in female respondents with severe loneliness (38.7% [95% CI: 27.3–50.0]) compared to those who were moderately lonely (17.7% [95% CI: 9.3–26.2]). Conclusions: Severe loneliness was independently associated with polypharmacy in older female but not male respondents. Clinicians should consider loneliness as an important risk factor in medication reviews and deprescribing efforts to minimize medication‐related harms, particularly in older women. [ABSTRACT FROM AUTHOR]

Background: Common postpartum mental health (PMH) disorders such as depression and anxiety are preventable, but determining individual-level risk is difficult. Aims: To create and internally validate a clinical risk index for common PMH disorders. Method: Using population-based health administrative data in Ontario, Canada, comprising sociodemographic, clinical and health service variables easily collectible from hospital birth records, we developed and internally validated a predictive model for common PMH disorders and converted the final model into a risk index. We developed the model in 75% of the cohort (n = 152 362), validating it in the remaining 25% (n = 75 772). Results: The 1-year prevalence of common PMH disorders was 6.0%. Independently associated variables (forming the mnemonic PMH CAREPLAN) that made up the risk index were: (P) prenatal care provider; (M) mental health diagnosis history and medications during pregnancy; (H) psychiatric hospital admissions or emergency department visits; (C) conception type and complications; (A) apprehension of newborn by child services (newborn taken into care); (R) region of maternal origin; (E) extremes of gestational age at birth; (P) primary maternal language; (L) lactation intention; (A) maternal age; (N) number of prenatal visits. In the index (scored 0–39), 1-year common PMH disorder risk ranged from 1.5 to 40.5%. Discrimination (C-statistic) was 0.69 in development and validation samples; the 95% confidence interval of expected risk encompassed observed risk for all scores in development and validation samples, indicating adequate risk index calibration. Conclusions: Individual-level risk of developing a common postpartum mental health disorder can be estimated with data feasibly collectable from birth records. Next steps are external validation and evaluation of various cut-off scores for their utility in guiding postpartum individuals to interventions that reduce their risk of illness. [ABSTRACT FROM AUTHOR]

Background: While loneliness is common in older adults, some immigrant groups are at higher risk. To inform tailored interventions, we identified factors associated with loneliness among immigrant and Canadian-born older adults living in Ontario, Canada. Methods: We conducted a cross-sectional analysis of 2008/09 data from the Canadian Community Health Survey (Healthy Aging Cycle) and linked health administrative data for respondents 65 years and older residing in Ontario, Canada. Loneliness was measured using the Three-Item Loneliness Scale, with individuals categorized as 'lonely' if they had an overall score of 4 or greater. For immigrant and Canadian-born older adults, we developed separate multivariable logistic regression models to assess individual, relationship and community-level factors associated with loneliness. Results: In a sample of 968 immigrant and 1703 Canadian-born older adults, we found a high prevalence of loneliness (30.8% and 34.0%, respectively). Shared correlates of loneliness included low positive social interaction and wanting to participate more in social, recreational or group activities. In older immigrants, unique correlates included: widowhood, poor health (i.e., physical, mental and social well-being), less time in Canada, and lower neighborhood-level ethnic diversity and income. Among Canadian-born older adults, unique correlates were: female sex, poor mental health, weak sense of community belonging and living alone. Older immigrant females, compared to older immigrant males, had greater prevalence (39.1% vs. 21.9%) of loneliness. Conclusions: Although both groups had shared correlates of loneliness, community-level factors were more strongly associated with loneliness in immigrants. These findings enhance our understanding of loneliness and can inform policy and practice tailored to immigrants. [ABSTRACT FROM AUTHOR]

Background: Researchers often use survey data to study the effect of health and social variables on physician use, but how self-reported physician use compares to administrative data, the gold standard, in particular within the context of multimorbidity and functional limitations remains unclear. We examine whether multimorbidity and functional limitations are related to agreement between self-reported and administrative data for physician use.Methods: Cross-sectional data from 52,854 Ontario participants of the Canadian Community Health Survey linked to administrative data were used to assess agreement on physician use. The number of general practitioner (GP) and specialist visits in the previous year was assessed using both data sources; multimorbidity and functional limitation were from self-report.Results: Fewer participants self-reported GP visits (84.8%) compared to administrative data (89.1%), but more self-reported specialist visits (69.2% vs. 64.9%). Sensitivity was higher for GP visits (≥90% for all multimorbidity levels) compared to specialist visits (approximately 75% for 0 to 90% for 4+ chronic conditions). Specificity started higher for GP than specialist visits but decreased more swiftly with multimorbidity level; in both cases, specificity levels fell below 50%. Functional limitations, age and sex did not impact the patterns of sensitivity and specificity seen across level of multimorbidity.Conclusions: Countries around the world collect health surveys to inform health policy and planning, but the extent to which these are linked with administrative, or similar, data are limited. Our study illustrates the potential for misclassification of physician use in self-report data and the need for sensitivity analyses or other corrections. [ABSTRACT FROM AUTHOR]

Background: This study explores how socio-demographic and health factors shape the relationship between multimorbidity and one-year acute care service use (i.e., hospital, emergency department visits) in older adults in Ontario, Canada.Methods: We linked multiple cycles (2005-2006, 2007-2008, 2009-2010, 2011-2012) of the Canadian Community Health Survey (CCHS) to health administrative data to create a cohort of adults aged 65 and older. Administrative data were used to estimate one-year service use and to identify 12 chronic conditions used to measure multimorbidity. We examined the relationship between multimorbidity and service use stratified by a range of socio-demographic and health variables available from the CCHS. Logistic and Poisson regressions were used to explore the association between multimorbidity and service use and the role of socio-demographic factors in this relationship.Results: Of the 28,361 members of the study sample, 60% were between the ages of 65 and 74 years, 57% were female, 72% were non-immigrant, and over 75% lived in an urban area. Emergency department visits and hospitalizations consistently increased with the level of multimorbidity. This study did not find strong evidence of moderator or interaction effects across a range of socio-demographic factors. Stratified analyses revealed further patterns, with many being similar for both services - e.g., the odds ratios were higher at all levels of multimorbidity for men, older age groups, and those with lower household income. Rurality and immigrant status influenced emergency department use (higher in rural residents and non-immigrants) but not hospitalizations. Multimorbidity and the range of socio-demographic variables remained significant predictors of service use in the regressions.Conclusions: Strong evidence links multimorbidity with increased acute care service use. This study showed that a range of factors did not modify this relationship. Nevertheless, the factors were independently associated with acute care service use, pointing to modifiable risk factors that can be the focus of resource allocation and intervention design to reduce service use in those with multimorbidity. The study's results suggest that optimizing acute care service use in older adults requires attention to both multimorbidity and social determinants, with programs that are multifactorial and integrated across the health and social service sectors. [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]

Aims: The objective of the study was to quantify the association between SGLT2 inhibitors and genital mycotic infection and between SGLT2 inhibitors and urinary tract infection (UTI) within 30 days of drug initiation among older women and men. Materials and methods: This was a retrospective cohort study using linked administrative databases of women and men with diabetes, aged 66 years or older, in Ontario, Canada. We compared the incidence of genital mycotic infection or UTI within 30 days between new users of an SGLT2 inhibitor and of a dipeptidyl‐peptidase‐4 (DPP4) inhibitor. Results: We identified 21 444 incident users of SGLT2 inhibitor and 22 463 incident users of DPP4 inhibitor. Among SGLT2 inhibitor users, there were 8848 (41%) women and the mean age at index was 71.8 ± 5 (SD) years. After adjusting for propensity score, age, sex and recent UTI, there was a 2.47‐fold increased risk of genital mycotic infection with incident use of SGLT2 inhibitors (adjusted hazard ratio (HR), 2.47; 95% confidence interval (CI), 2.08‐2.92; P < 0.001) within 30 days compared to incident use of DPP4 inhibitors. For UTI, the adjusted HR was 0.89 (95% CI, 0.78‐1.00; P = 0.05). Conclusions: Incident use of SGLT2 inhibitors among older women and men is associated with increased risk of genital mycotic infections within 30 days; there is no associated increased risk of UTI. These findings from a real‐world setting provide evidence of the potential harms of SGLT2 inhibitors. [ABSTRACT FROM AUTHOR]

Background: Cholinesterase inhibitors (ChEIs) are one of only two drug therapies available to manage cognitive decline in dementia. Given sex-specific differences in medication access and effects, it is important to understand how ChEIs are used by women and men. Objective: The objective of this study was to provide contemporary sex-stratified evidence on patterns of ChEI use by community-dwelling older adults with dementia to inform opportunities to optimize drug prescribing. Methods: We conducted a population-based cross-sectional study examining ChEI use in older adults with dementia in Ontario, Canada. We identified all community-dwelling individuals aged 66 years and older with a pre-existing diagnosis of dementia as of 1 April, 2016. We examined the prevalence of ChEI use among women and men separately, and explored the association between ChEI use and age, sex, income status, geographic location of residence, use of palliative care services, comorbidity, and polypharmacy. Concurrent use of drugs known to impair cognition (including antipsychotics, benzodiazepines, and medications with strong anticholinergic properties) was separately assessed among women and men using multivariable analyses and prevalence risk ratios. Results: Of 74,799 women and 52,231 men living with dementia in the community, nearly 30% currently were using a ChEI (29.3% women, 28.6% men). Close to 70% of users were receiving the target therapeutic dose. Compared to men, women were less often taking the target therapeutic dose (67.8% women vs. 71.6% men, p < 0.001). Over 20% of users also were using drugs known to impair cognition, while being treated for cognitive decline using ChEIs. Compared to men, women were more often concurrently using drugs known to impair cognition (23.9% women vs. 21.8% men, p < 0.001). Conclusions: This is one of the first studies of ChEI use to account for important sex differences. The results remind clinicians and researchers that patterns of ChEI therapy use differ by sex, as women were less likely to receive target therapeutic doses and more vulnerable to potentially problematic polypharmacy than men. [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 examine dose‐related prescribing and short‐term serious events associated with initiation of cholinesterase inhibitor (ChEI) therapy. Design: Retrospective, population‐based cohort study. Setting: Ontario, Canada. Participants: Women (n=47,829) and men (n=32,503) aged 66 and older who initiated a ChEI between April 1, 2010, and June 30, 2016. Measurements: All‐cause serious events (emergency department (ED) visits, inpatient hospitalizations, death) within 30 days of ChEI initiation. Multivariable Cox proportional hazards models were used to estimate adjusted rates of serious events. Results: Overall, 4.8% of older adults were dispensed a lower‐than‐recommended ChEI starting dose, 87.9% a recommended dose, and 7.3% a higher‐than‐recommended starting dose. Eight thousand six hundred seventy‐one (10.8%) individuals experienced a serious event within 30 days of initiating therapy, primarily ED visits (8,540, 10.6%). Relative to those initiated on a recommended starting dose, those initiated on a higher dose had a significantly increased rate of serious events (women adjusted hazard ratio (aHR) 1.50, 95% confidence interval (CI) =1.38–1.63; men aHR 1.31, 95% CI=1.19–1.45). Similar patterns were found for ED visits and inpatient hospitalizations but not death. The relative effect of higher‐than‐recommended starting dose dispensed vs. recommended starting dose dispensed was greater in women than it was in men: the number needed to harm was 22 (95% confidence interval (CI)=18–29) for women and 36 (95% CI= 26–61) for men. Conclusion: Serious events immediately after initiation of ChEIs were associated with starting ChEI dose. This association was stronger in women. [ABSTRACT FROM AUTHOR]

Purpose: Psychiatric readmission is a common negative outcome. Predictors of readmission may differ by sex. This study aimed to derive and internally validate sex-specific models to predict 30-day psychiatric readmission.Methods: We used population-level health administrative data to identify predictors of 30-day psychiatric readmission among women (n = 33,353) and men (n = 32,436) discharged from all psychiatric units in Ontario, Canada (2008-2011). Predictor variables included sociodemographics, health service utilization, and clinical characteristics. Using derivation data sets, multivariable logistic regression models were fit to determine optimal predictive models for each sex separately. Results were presented as adjusted odds ratios (aORs) and 95% confidence intervals (CI). The multivariable models were then applied in the internal validation data sets.Results: The 30-day readmission rates were 9.3% (women) and 9.1% (men). Many predictors were consistent between women and men. For women only, personality disorder (aOR 1.21, 95% CI 1.03-1.42) and positive symptom score (aOR 1.41, 95% CI 1.09-1.82 for score of 1 vs. 0; aOR 1.44, 95% CI 1.26-1.64 for ≥ 2 vs. 0) increased odds of readmission. For men only, self-care problems at admission (aOR 1.20, 95% CI 1.06-1.36) and discharge (aOR 1.44, 95% CI 1.26-1.64 for score of 1 vs. 0; aOR 1.79, 95% CI 1.17-2.74 for 2 vs. 0), and mild anxiety rating (score of 1 vs. 0: aOR 1.30, 95% CI 1.02-1.64, derivation model only) increased odds of readmission. Models had moderate discriminative ability in derivation and internal validation samples for both sexes (c-statistics 0.64-0.65).Conclusions: Certain key predictors of psychiatric readmission differ by sex. This knowledge may help to reduce psychiatric hospital readmission rates by focusing interventions. [ABSTRACT FROM AUTHOR]

Objective: Many patients with bipolar disorder are reaching old age, but whether they are receiving evidence-based psychotropic treatment remains unclear. Our objective was to describe current psychotropic prescribing patterns in a large Canadian late-life bipolar sample.Methods: Population-based cross-sectional study of 1443 bipolar disorder patients aged ≥ 66, discharged from a psychiatric hospitalization in Ontario, Canada from 1 April 2006 to 31 March 2012. We described psychotropic medication prescribing within 30 days post-discharge.Results: Prescription of ≥2 psychotropic medications was highly prevalent (81.5%). The most common medications were atypical antipsychotics (75.3%), benzodiazepines/zopiclone (42.3%), and antidepressants (38.5%), with less frequent use of valproate (35.4%) and lithium (23.4%). Only 1.4% of patients were on lithium monotherapy, while 4.4% and 15.7% of patients were on antidepressant or atypical antipsychotic monotherapy; 8.9% of all patients were using ≥2 atypical antipsychotics.Conclusions: In clinical practice, older adults hospitalized with bipolar disorder are often prescribed multiple psychotropic medications upon discharge. In many instances, practices did not reflect bipolar treatment guidelines and may be putting patients at risk for poor physical health and psychiatric outcomes. One such example is the very infrequent use of lithium monotherapy. Future research should examine whether health system-wide protocolized late-life bipolar treatment may optimize prescribing to improve effectiveness and safety. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To determine the prevalence of and resident characteristics associated with the prescription of medications of questionable benefit ( MQBs) near the end of life in older adults with advanced dementia in nursing homes. Design Population-based, cross-sectional study using Resident Assessment Instrument Minimum Data Set 2.0 linked to health administrative data. Setting Ontario, Canada. Participants All 9,298 nursing home residents with advanced dementia who died between June 1, 2010, and March 31, 2013; were aged 66 and older at time of death; and received at least one MQB in their last year of life. Measurements Prevalence of eight classes of MQBs (e.g., lipid-lowering agents, antidementia drugs) used in the last 120 days and last week of life. Results Of older nursing home residents with advanced dementia who received at least one MQB in the last year of life, 8,027 (86.3%) received them in the last 120 days and 4,180 (45.0%) in the last week of life. The most commonly prescribed MQB were antidementia (63.6%) and lipid-lowering agents (47.8%). Severe cognitive impairment (adjusted odds ratio ( aOR) = 1.19, 95% confidence interval ( CI) = 1.07-1.33, P = .002) and fewer signs and symptoms of health instability ( aOR = 1.58, 95% CI = 1.44-1.74, P < .001) were associated with MQB use into the last week of life. Seeing a neurologist or psychiatrist was associated with less likelihood of MQB use in the last week of life. Conclusion Many nursing home residents with advanced dementia are dispensed MQBs in the last week of life. Given that MQBs may cause more harm than benefit in this vulnerable population, it is important for physicians to actively reassess the role of all medications toward the end of life. [ABSTRACT FROM AUTHOR]

Background: For community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships.Methods and Findings: A retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine-Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC. Multimorbidity was highly prevalent, with 35% (n = 10,568) of the cohort having five or more chronic conditions. In multivariable analyses, risk of hospitalization and risk of ED visit increased monotonically with level of multimorbidity: sub-hazards were 88% greater (sub-hazard ratio [sHR] = 1.88, 95% CI: 1.72-2.05, p < 0.001) and 63% greater (sHR = 1.63; 95% CI: 1.51-1.77, p < 0.001), respectively, among those with five or more conditions, relative to those with dementia alone or with dementia and one other condition. Low (versus high) COC was associated with an increased risk of both hospitalization and ED visit in age- and sex-adjusted analyses only (sHR = 1.11, 95% CI: 1.07-1.16, p < 0.001, for hospitalization; sHR = 1.07, 95% CI: 1.03-1.11, p = 0.001, for ED visit) but did not modify associations between multimorbidity and outcomes (Wald test for interaction, p = 0.566 for hospitalization and p = 0.637 for ED visit). The main limitations of this study include use of fixed (versus time-varying) covariates and focus on all-cause rather than cause-specific hospitalizations and ED visits, which could potentially inform interventions.Conclusions: Older adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients' risk of health outcomes. [ABSTRACT FROM AUTHOR]

Background: Many community-based self-management programs have been developed for older adults with type-2 diabetes mellitus (T2DM), bolstered by evidence from randomized controlled trials (RCTs) that T2DM can be prevented and managed through lifestyle modifications. However, the evidence for their effectiveness is contradictory and weakened by reliance on single-group designs and/or small samples. Additionally, older adults with multiple chronic conditions (MCC) are often excluded because of recruiting and retention challenges. This paper presents a protocol for a two-armed, multisite, pragmatic, mixed-methods RCT examining the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP), a new 6-month interprofessional, nurse-led program to promote self-management in older adults (aged 65 years or older) with T2DM and MCC and support their caregivers (including family and friends).Methods/design: The study will enroll 160 participants in two Canadian provinces, Ontario and Alberta. Participants will be randomly assigned to the control (usual care) or program study arm. The program will be delivered by registered nurses (RNs) and registered dietitians (RDs) from participating diabetes education centers (Ontario) or primary care networks (Alberta) and program coordinators from partnering community-based organizations. The 6-month program includes three in-home visits, monthly group sessions, monthly team meetings for providers, and nurse-led care coordination. The primary outcome is the change in physical functioning as measured by the Physical Component Summary (PCS-12) score from the short form-12v2 health survey (SF-12). Secondary client outcomes include changes in mental functioning, depressive symptoms, anxiety, and self-efficacy. Caregiver outcomes include health-related quality of life and depressive symptoms. The study includes a comparison of health care service costs for the intervention and control groups, and a subgroup analysis to determine which clients benefit the most from the program. Descriptive and qualitative data will be collected to examine implementation of the program and effects on interprofessional/team collaboration.Discussion: This study will provide evidence of the effectiveness of a community-based self-management program for a complex target population. By studying both implementation and effectiveness, we hope to improve the uptake of the program within the existing community-based structures, and reduce the research-to-practice gap.Trial Registration: ClinicalTrials.gov, Identifier: NCT02158741 . Registered on 3 June 2014. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to identify differences between men and women hospitalized for psychiatric conditions.Methods: Men and women with an inpatient psychiatric hospitalization in Ontario, Canada, between 2008 and 2013 (N=95,055) were compared on sociodemographic characteristics, health history, and clinical profiles and on 30-day and 90-day postdischarge readmission, emergency department (ED) visits, self-harm, and death.Results: Compared with men, women were older and more likely to be educated, to live with a partner, and to report trauma history. Mood disorders were more common among women; psychotic and substance use disorders were more common among men. Postdischarge, there was no difference in either readmission or ED revisits. Compared with men, women had greater risk of self-harm at 30 days (adjusted odds ratio [AOR]=1.17, 95% confidence interval [CI]=1.04-1.32) and at 90 days (AOR=1.28, CI=1.17-1.39). Death was rare (<1%), with women at lower risk at both 30 days (AOR=.49, CI=.38-.63) and 90 days (AOR=.53, CI=.45-.63).Conclusions: These data can inform inpatient psychiatric service delivery for both men and women. [ABSTRACT FROM AUTHOR]

Background: Patients with dementia have increased healthcare utilization and often have comorbid chronic conditions. It is not clear if the increase in utilization is driven by dementia, the comorbidities or both. The objective of this study was to describe the number and types of comorbid conditions in a population-based cohort of older adults with dementia and how the level of comorbidity impacts dementia-related and non-dementia-related health service utilization. Methods: This study is a retrospective cohort study using multiple linked administrative databases to examine health service utilization and costs of 100,630 community-living older adults living with pre-existing dementia in Ontario, Canada. Comorbid conditions and health service utilization were measured using administrative data (physician visits, emergency department visits, hospitalizations, and homecare contacts). Results: Nearly all, 96.3%, had at least one comorbid condition, while 18.4% had five or more comorbid conditions. The most common comorbid conditions were hypertension (77.8%), and arthritis (66.2%). All types of utilization increased consistently with the number of comorbid conditions. The average number of dementia-related services tended to be similar across all levels of comorbidity while the average number of non-dementia related visits tended to increase with the level of comorbidity. Conclusions: Comorbidities in community-living older adults with dementia are common and account for a substantial proportion of health service use and costs in this population. Our results suggest that comprehensive programs that take a holistic view to identify the needs of patients in the context of other comorbidities are required for persons with dementia living in the community. [ABSTRACT FROM AUTHOR]

Purpose: To examine the relative impact of 16 common chronic conditions and increasing morbidity on health-related quality of life (HRQL) in a population-based sample of home care clients in Ontario, Canada.Methods: Participants were adult clients assessed with the Resident Assessment Instrument for Home Care (RAI-HC) between January and June 2009 and diagnosed with one (or more) of 16 common chronic conditions. HRQL was evaluated using the Minimum Data Set-Health Status Index (MDS-HSI), a preference-based measure derived from items captured in the RAI-HC. Multivariable linear regression models assessed the relative impact of each condition, and increasing number of diagnoses, on MDS-HSI scores.Results: Mean (SD) MDS-HSI score in the study population (n = 106,159) was 0.524 (0.213). Multivariable analysis revealed a statistically significant (p < 0.05) and clinically important (difference ≥ 0.03) decrease in MDS-HSI scores associated with stroke (-0.056), osteoarthritis (-0.036), rheumatoid arthritis (-0.033) and congestive heart failure (CHF, -0.030). Differences by age and sex were observed; most notably, the negative impact associated with dementia was greater among men (-0.043) than among women (-0.019). Further, HRQL decreased incrementally with additional diagnoses. In all models, chronic conditions and number of diagnoses accounted for a relatively small proportion of the variance observed in MDS-HSI.Conclusion: Clinically important negative effects on HRQL were observed for clients with a previous diagnosis of stroke, osteo- and rheumatoid arthritis, or CHF, as well as with increasing levels of multimorbidity. Findings provide baseline preference-based HRQL scores for home care clients with different diagnoses and may be useful for identifying, targeting and evaluating care strategies toward populations with significant HRQL impairments. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity poses a significant clinical challenge and has been linked to greater health services use, including hospitalization; however, we have little knowledge about the influence of contextual factors on outcomes in this population.Objectives: To describe the extent to which the association between multimorbidity and hospitalization is modified by age, gender, primary care practice model, or continuity of care (COC) among adults with at least one chronic condition.Methods: A retrospective cohort study with linked population-based administrative data.Setting: Ontario, Canada.Cohort: All individuals 18 and older with at least one of 16 priority chronic conditions as of April 1, 2009 (baseline).Main Outcome Measures: Any hospitalization, 3 or more hospitalizations, non-medical discharge delay, and 30-day readmission within the 1 year following baseline.Results: Of 5,958,514 individuals, 484,872 (8.1 %) experienced 646,347 hospitalizations. There was a monotonic increase in the likelihood of hospitalization and related outcomes with increasing multimorbidity which was modified by age, gender, and COC but not primary care practice model. The effect of increasing multimorbidity was greater in younger adults than older adults and in those with lower COC than with higher COC. The effect of increasing multimorbidity on hospitalization was greater in men than women but reversed for the other outcomes.Conclusions: The effect of multimorbidity on hospitalization is influenced by age and gender, important considerations in the development of person-centred care models. Greater continuity of physician care lessened the effect of multimorbidity on hospitalization, further demonstrating the need for care continuity across providers for people with chronic conditions. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effects of postoperative rehabilitation on the outcomes of older adults with dementia who experienced hip fracture. Design Retrospective cohort study. Setting Ontario, Canada. Participants Community-dwelling adults with dementia who underwent hip fracture surgery between 2003 and 2011. Participants were categorized as no rehabilitation, complex continuing care ( CCC), home-care based rehabilitation ( HCR), and inpatient rehabilitation ( IPR). Measurements Time to long-term care ( LTC) placement, mortality, and risk of repeat hip fracture and falls. Results Of 11,200 individuals with dementia who experienced a hip fracture during the study period, 4,494 (40.1%) received no rehabilitation, 2,474 (22.1%) were admitted to CCC, 1,157 (10.3%) received HCR, and 3,075 (27.4%) received IPR. HCR and IPR were associated with less risk of LTC admission after discharge from hospital than no rehabilitation. All three forms of rehabilitation were associated with lower risk of mortality than no rehabilitation, with the greatest effect observed with IPR. HCR was associated with a higher risk of falls than no rehabilitation ( P = .03); there were no other significant between-group differences in risk of falls or repeat fractures ( P > .05). Conclusion Postfracture rehabilitation for older adults with dementia is associated with lower risk of LTC placement and mortality. Improving access to rehabilitation services for this vulnerable population may improve postfracture outcomes. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity, the co-occurrence of two or more chronic conditions, is common among older adults and is known to be associated with high costs and gaps in quality of care. Population-based estimates of multimorbidity are not readily available, which makes future planning a challenge. We aimed to estimate the population-based prevalence and trends of multimorbidity in Ontario, Canada and to examine patterns in the co-occurrence of chronic conditions. Methods: This retrospective cohort study includes all Ontarians (aged 0 to 105 years) with at least one of 16 common chronic conditions. Descriptive statistics were used to examine and compare the prevalence of multimorbidity by age and number of conditions in 2003 and 2009. The co-occurrence of chronic conditions among individuals with multimorbidity was also explored. Results: The prevalence of multimorbidity among Ontarians rose from 17.4% in 2003 to 24.3% in 2009, a 40% increase. This increase over time was evident across all age groups. Within individual chronic conditions, multimorbidity rates ranged from 44% to 99%. Remarkably, there were no dominant patterns of co-occurring conditions. Conclusion: The high prevalence of multimorbidity and numerous combinations of conditions suggests that single, disease-oriented management programs may be less effective or efficient tools for high quality care compared to person-centered approaches. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between anesthetic technique and postoperative complications in older adults with dementia undergoing hip fracture surgery. Design Population-based, retrospective cohort study. Setting Ontario, Canada. Participants All older adults with dementia who underwent surgery for hip fracture repair in Ontario, Canada, between April 1, 2003 and March 31, 2011. Measurements The baseline characteristics of individuals who received general anesthesia ( GA) and regional anesthesia ( RA) were compared. Individuals who received GA were matched to similar individuals who received RA using propensity scores to control for confounding, and their outcomes compared, including 30-day mortality, intensive care unit ( ICU) admissions, specific postoperative medical complications, and hospital length of stay ( LOS). Results In the 6,135 matched pairs, there was no statistically significant difference in postoperative 30-day mortality ( GA, 11.3%; RA, 10.8%, P = .44). There were no statistically significant differences in the rates of specific postoperative medical complications or LOS in the two anesthetic groups, but GA was associated with higher rates of ICU admissions (6.1% vs 4.2%, P < .001). Conclusion For older adults with dementia undergoing hip fracture surgery, GA and RA are associated with similar rates of most perioperative adverse events. Further studies are required to determine the optimal methods of providing anesthesia and perioperative care for older adults with dementia undergoing surgical procedures. [ABSTRACT FROM AUTHOR]

Objectives. We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings. Methods. We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates. Results. Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%-20%) in LTC and 28% (27%-29%) in the community. Results for hospital admissions were comparable. Conclusions. We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies. [ABSTRACT FROM AUTHOR]

Objectives To better understand how centenarians use the healthcare system as an important step toward improving their service delivery. Design Population-based retrospective cohort study using linked health administrative data. Setting Ontario-Canada's largest province. Participants All individuals living in Ontario aged 65 and older on April 1 of each year between 1995 and 2010 were identified and divided into three age groups (65-84, 85-99, ≥100). A detailed description was obtained on 1,842 centenarians who were alive on April 1, 2010. Measurements Sociodemographic characteristics and use of health services. Results The number of centenarians increased from 1,069 in 1995 to 1,842 in 2010 (72.3%); 6.7% were aged 105 and older. Over the same period, the number of individuals aged 85 to 99 grew from 119,955 to 227,703 (89.8%). Women represented 85.3% of all centenarians and 89.4% of those aged 105 and older. Almost half of centenarians lived in the community (20.0% independently, 25.3% with publicly funded home care). Preventive drug therapies (bisphosphonates and statins) were frequently dispensed. In the preceding year, 18.2% were hospitalized and 26.6% were seen in an emergency department. More than 95% saw a primary care provider, and 5.3% saw a geriatrician. Conclusion The number of centenarians in Ontario increased by more than 70% over the last 15 years, with even greater growth among older people who could soon become centenarians. Almost half of centenarians live in the community, most are women, and almost all receive care from a primary care physician. [ABSTRACT FROM AUTHOR]

Objectives To understand how drug therapy differently affects older women and men. Design Population-based, retrospective cohort study. Setting Ontario, Canada. Participants Twenty-one thousand five hundred twenty-six older adults (13,760 women, 7,766 men) with dementia newly started on oral atypical antipsychotic therapy between April 1, 2007, and March 1, 2010. Measurements Numbers and rates of serious events. Serious events were defined as a hospital admission or death within 30 days of treatment initiation. Unadjusted and adjusted odds ratios of women and men were compared in the full cohort and in strata based on setting of care, age, Charlson Comorbidity Index ( CCI), and antipsychotic dose. Results Of 21,526 older adults with a median age of 84, 1,889 (8.8%) had a serious event (1,044 women, 7.6%; 845 men, 10.9%). Of these, 363 women (2.6%) and 355 men (4.6%) died. Men were more likely than women to be hospitalized or die during the 30-day follow-up period (adjusted odds ratio = 1.47, 95% confidence interval = 1.33-1.62) and consistently more likely to experience a serious event in each stratum. A gradient of risk according to drug dose was found for the development of a serious event in women and men. Conclusion The risk of developing a serious event shortly after the initiation of antipsychotic therapy was high in women and men with dementia but was consistently higher in older men. This pattern remained the same in strata based on setting of care, age, CCI, and antipsychotic dose. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Long term care (LTC) residents commonly experience transitions between health care settings that can have important health consequences. The objective of this study was to quantify the effect of recent transitions on the risk of emergency department (ED) transfer among chronic LTC residents. Two types of transitions were considered: admission into LTC and discharge from hospital. Design: Retrospective cohort study using linked administrative data from Ontario, Canada. Participants: All chronic LTC residents in Ontario older than 66 years on the date of the 2005 provincial LTC facility census. Measurements: Using facility census date as baseline, admission to LTC was defined as the number of days between LTC admission and baseline. Residents were categorized as one of: newly admitted (≤30 days), shorter-stay (31–90 days), or longer-stay (≥91 days). Within each group, residents were further subdivided based on having had a recent discharge from hospital. The first ED visit for each resident during the 6-month follow-up was counted, as were death and other competing risks. The cumulative incidence of ED transfer for each group was estimated and logistic regression was used to test whether differences between groups persisted after controlling for resident characteristics. Results: Of the 64,589 residents, 3.0% were newly admitted, 4.9% were shorter-stay, and 92.1% were longer-stay. The 6-month cumulative incidences of ED transfers were 35.0% for newly admitted, 30.7% for shorter-stay, and 22.0% for longer-stay. The odds of an ED transfer were higher for newly admitted and shorter-stay residents relative to longer-stay residents, even after adjustment for resident characteristics (adjusted odds ratio, 95% confidence interval 1.9, 1.7–2.1; and 1.5, 1.4–1.7, respectively). Regardless of time since LTC admission, residents with a recent discharge from hospital had a cumulative incidence of nearly 40% and an increase in the odds of ED transfer of at least 50% compared with those who had not been in hospital. Conclusions: Health care transitions, especially those from hospital, are associated with an increase in ED transfers among older chronic LTC residents. These findings highlight the need for a stronger focus on transitional care, especially posthospital care, for LTC residents. [Copyright &y& Elsevier]

The article discusses research on the risk of acute urinary retention (AUR) in older people with chronic obstructive pulmonary disease (COPD) using inhaled anticholinergic drug therapy (IACs). The study was conducted using population-based linked databases from Ontario involving 565,073 individuals with COPD aged 66 years old or older. The use of short- and long-acting IACs was found to be associated with higher risk of AUR in men with COPD.

Purpose: To describe the proportion of long-term care (LTC) residents excluded from quality measurement because of standard length of stay inclusion criteria and the extent to which this varies across facilities. Design and Methods: A 2005 province-wide census of LTC residents’ charts was linked to additional databases from Ontario, Canada. The proportion of residents who were newly admitted (≤90 days) and who exited the facility within 90 days were identified and interfacility variation in each was described. Results: Of the 68,930 residents in 574 facilities, 5363 (7.8%) were admitted in the prior 90 days and 7833 (11.4%) were discharged in the subsequent 90 days. Overall, 55,734 (80.4%) residents were neither admitted nor discharged within 90 days and were defined as “stable”; however, this ranged from 67.2% to 95.1% across facilities. Implications: Stable residents are the focus of most quality measurement in LTC but transitioning residents are an important part of the caseload for these facilities. In Ontario, transitioning residents accounted for 20% of the population but there was substantial variation in this proportion across facilities. This raises concerns about the comprehensiveness and comparability of publicly reported quality indicators for a population with frequent transitions in Ontario and elsewhere. [Copyright &y& Elsevier]

To determine which nursing home (NH) resident-level admission characteristics are associated with potentially preventable emergency department (PPED) transfers. We conducted a population-level retrospective cohort study on NH resident data collected using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and linked to the National Ambulatory Care Reporting System for ED transfers. We used all NH resident admission assessments from January 1, 2017, to December 31, 2018, in Ontario. The cohort included the admission assessment of 56,433 NH residents. PPED transfers were defined based on the International Classification of Disease, Version 10 (Canadian) We used logistic regression with 10-fold cross-validation and computed average marginal effects to identify the association between resident characteristics at NH admission and PPED transfers within 92 days after admission. Overall, 6.2% of residents had at least 1 PPED transfer within 92 days of NH admission. After adjustment, variables that had a prevalence of 10% or more that were associated with a 1% or more absolute increase in the risk of a PPED transfer included polypharmacy [of cohort (OC) 84.4%, risk difference (RD) 2.0%], congestive heart failure (OC 29.0%, RD 3.0%), and renal failure (OC 11.6%, RD 1.2%). Female sex (OC 63.2%, RD -1.3%), a do not hospitalize directive (OC 24.4%, RD -2.6%), change in mood (OC 66.9%, RD -1.2%), and Alzheimer's or dementia (OC 62.1%, RD -1.2%) were more than 10% prevalent and associated with a 1% or more absolute decrease in the risk of a PPED. Though many routinely collected resident characteristics were associated with a PPED transfer, the absence of sufficiently discriminating characteristics suggests that emergency department visits by NH residents are multifactorial and difficult to predict. Future studies should assess the clinical utility of risk factor identification to prevent transfers. [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]

To examine the association between the COVID-19 pandemic and opioid use among nursing home residents followed up to March 2021, and possible variation by dementia and frailty status. Population-based cohort study with an interrupted time series analysis. Linked health administrative databases for residents of all nursing homes (n = 630) in Ontario, Canada were examined. Residents were divided into consecutive weekly cohorts (first observation week was March 5 to 11, 2017 and last was March 21 to March 27, 2021). The weekly proportion of residents dispensed an opioid was examined overall and by strata defined by the presence of dementia and frailty. Autoregressive Integrated Moving Average models with step and ramp intervention functions tested for immediate level and slope changes in weekly opioid use after the onset of the pandemic (March 1, 2020) and were fit on prepandemic data for projected trends. The average weekly cohort ranged from 76,834 residents (prepandemic) to 69,359 (pandemic period), with a consistent distribution by sex (69% female) and age (54% age 85 + years). There was a statistically significant increased slope change in the weekly proportion of residents dispensed opioids (parameter estimate (β) = 0.035; standard error (SE) = 0.005, P <.001). Although significant for all 4 strata, the increased slope change was more pronounced among nonfrail residents (β = 0.038; SE = 0.008, P <.001) and those without dementia (β = 0.044; SE = 0.008, P <.001). The absolute difference in observed vs predicted opioid use in the last week of the pandemic period ranged from 1.25% (frail residents) to 2.28% (residents without dementia). Among Ontario nursing home residents, there was a statistically significant increase in opioid dispensations following the onset of the pandemic that persisted up to 1 year later. Investigations of the reasons for increased use, potential for long-term use and associated health consequences for residents are warranted. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the association between dementia and postoperative outcomes of older adults with hip fractures. Design: Population-based, retrospective cohort study. Setting: Province of Ontario, Canada. Participants: All individuals with hip fractures who underwent hip fracture surgery in Ontario, Canada between April 1, 2003 and March 31, 2010 were identified. Physician-diagnosed dementia, prior to hip fracture, was identified using a diagnostic algorithm in the administrative databases. Measurements: The preoperative characteristics of older adults with and without dementia were compared separately for individuals admitted to hospital from community or long-term care (LTC). Multivariable regression was used to compare postoperative health service utilization, time with LTC admission, and mortality for individuals with and without dementia. Results: A total of 45,602 older adults had hip fractures and individuals with dementia accounted for 23.9% and 83.5% of all hip fractures from the community and LTC settings, respectively. Compared with those without dementia, individuals with dementia were less likely to be admitted to rehabilitation facilities. Among community-dwelling older adults, dementia was associated with an increased risk of LTC admission [hazard ratio (HR) = 2.49, 95% confidence interval (CI): 2.38–2.61, P < .0001]. Dementia was also associated with a higher mortality for older adults from community (HR = 1.47, 95% CI: 1.41–1.52, P < .0001) and LTC (HR = 1.10; 95% CI: 1.02–1.18, P = .005) settings. Conclusions: Dementia is common among older adults with hip fractures and associated with poor prognosis following hip fracture surgery. Specialized services targeting the growing number of older adults with dementia may help to prevent hip fractures and optimize postoperative care for this vulnerable population. [Copyright &y& Elsevier]

Purpose There is substantial evidence that women with schizophrenia in many parts of the world have fewer children than their peers. Our objective was to analyze recent trends in general and age-specific fertility rates among women with schizophrenia in Ontario, Canada. Methods We conducted a repeated cross-sectional population-based study from 1996 to 2009 using population-based linked administrative databases for the entire province of Ontario. Women aged 15–49 years were classified into schizophrenia and non-schizophrenia groups in each successive 12-month period. Annual general and age-specific fertility rates were derived. Results The general fertility rate (GFR) among women with schizophrenia was 1.16 times higher in 2007–2009 than in 1996–1998 (95% confidence interval [CI] 1.04–1.31). The annual GFR ratio of women with vs. without schizophrenia was 0.41 (95% CI 0.36–0.47) in 2009, which was slightly higher than the same ratio in 1996 of 0.30 (95% CI 0.25–0.35). Annual age-specific fertility rates (ASFR) increased over time among women with schizophrenia aged 20–24, 25–29, 35–39 and 40–44 years, but the increase was not always statistically significant. Among women aged 20–24 years, the ASFR ratio in women with vs. without schizophrenia was not significant by the end of the study period (0.93, 95% CI 0.70–1.22). Conclusions The general fertility rate among women with schizophrenia appears to have increased modestly over the past 13 years. Clinical care and health policy should consider new strategies that focus on the mental health of women with schizophrenia as new mothers, while optimizing healthy pregnancies and child rearing. [ABSTRACT FROM AUTHOR]

Background: There is growing interest in understanding the care needs of lonely people but studies are limited and examine healthcare settings separately. We estimated and compared healthcare trajectories in lonely and not lonely older female and male respondents to a national health survey., Methods: We conducted a retrospective cohort study of community-dwelling, Ontario respondents (65+ years) to the 2008/2009 Canadian Community Health Survey-Healthy Aging. Respondents were classified at baseline as not lonely, moderately lonely, or severely lonely using the Three-Item Loneliness Scale and then linked with health administrative data to assess healthcare transitions over a 12 -year observation period. Annual risks of moving from the community to inpatient, long-stay home care, long-term care settings-and death-were estimated across loneliness levels using sex-stratified multistate models., Results: Of 2684 respondents (58.8% female sex; mean age 77 years [standard deviation: 8]), 635 (23.7%) experienced moderate loneliness and 420 (15.6%) severe loneliness. Fewer lonely respondents remained in the community with no transitions (not lonely, 20.3%; moderately lonely, 17.5%; and severely lonely, 12.6%). Annual transition risks from the community to home care and long-term care were higher in female respondents and increased with loneliness severity for both sexes (e.g., 2-year home care risk: 6.1% [95% CI 5.5-6.6], 8.4% [95% CI 7.4-9.5] and 9.4% [95% CI 8.2-10.9] in female respondents, and 3.5% [95% CI 3.1-3.9], 5.0% [95% CI 4.0-6.0], and 5.4% [95% CI 4.0-6.8] in male respondents; 5-year long-term care risk: 9.2% [95% CI 8.0-10.8], 11.1% [95% CI 9.3-13.6] and 12.2% [95% CI 9.9-15.3] [female], and 5.3% [95% CI 4.2-6.7], 9.1% [95% CI 6.8-12.5], and 10.9% [95% CI 7.9-16.3] [male])., Conclusions: Lonely older female and male respondents were more likely to need home care and long-term care, with severely lonely female respondents having the highest probability of moving to these settings., (© 2024 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: Chronic non-cancer pain is common among older residents of long-term care (LTC) homes and often poorly recognized and treated. With heightened concerns regarding opioid prescribing in recent years, it is important to examine the current prevalence of opioid use and its association with resident characteristics to help identify those potentially at risk of medication harms as well as suboptimal pain management., Objectives: The aims were to estimate the prevalence and correlates of opioid use among non-palliative LTC residents and explore variation in opioid prevalence and correlates across strata defined by pain frequency and intensity., Methods: We conducted a population-based cross-sectional study of all older (aged > 65 years) LTC residents (excluding those with cancer or receiving palliative care) in Ontario, Canada during 2018-2019. Health administrative databases were linked with standardized clinical assessment data to ascertain residents' health and pain characteristics and their opioid and other medication use. Modified Poisson regression models estimated unadjusted and adjusted associations between residents' characteristics and opioid use, overall and across strata capturing pain frequency and intensity., Results: Among 75,020 eligible residents (mean age 85.1 years; 70% female), the prevalence of opioid use was 18.5% and pain was 29.4%. Opioid use ranged from 12.2% for residents with no current pain to 55.7% for those with severe pain. In adjusted models, residents newly admitted to LTC (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI] 0.57-0.62) and with moderate to severe cognitive impairment (aRR = 0.69, 95% CI 0.66-0.72) or dementia (aRR = 0.76, 95% CI 0.74-0.79) were significantly less likely to receive an opioid, whereas residents with select conditions (e.g., arthritis, aRR = 1.37, 95% CI 1.32-1.41) and concurrently using gabapentinoids (aRR = 1.80, 95% CI 1.74-1.86), benzodiazepines (aRR = 1.33, 95% CI 1.28-1.38), or antidepressants (aRR = 1.31, 95% CI 1.27-1.35) were significantly more likely to receive an opioid. The associations observed for residents newly admitted, with dementia, and concurrently using gabapentinoids, benzodiazepines, or antidepressants were largely consistent across all pain strata., Conclusions: Our findings describe resident sub-groups at potentially higher risk of adverse health outcomes in relation to both opioid use and non-use. LTC clinical and policy changes informed by research are required to ensure the appropriate recognition and management of non-cancer pain in this setting., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Importance: COVID-19 has had devastating effects on the health and well-being of older adult residents and health care professionals in nursing homes. Uncertainty about the associated consequences of these adverse effects on the use of medications common to this care setting remains., Objective: To examine the association between the COVID-19 pandemic and prescription medication changes among nursing home residents., Design, Setting, and Participants: This population-based cohort study with an interrupted time-series analysis used linked health administrative data bases for residents of all nursing homes (N = 630) in Ontario, Canada. During the observation period, residents were divided into consecutive weekly cohorts. The first observation week was March 5 to 11, 2017; the last observation week was September 20 to 26, 2020., Exposures: Onset of the COVID-19 pandemic on March 1, 2020., Main Outcomes and Measures: Weekly proportion of residents dispensed antipsychotics, benzodiazepines, antidepressants, anticonvulsants, opioids, antibiotics, angiotensin receptor blockers (ARBs), and angiotensin-converting enzyme (ACE) inhibitors. Autoregressive integrated moving average models with step and ramp intervention functions tested for level and slope changes in weekly medication use after the onset of the pandemic and were fit on prepandemic data for projected trends., Results: Across study years, the annual cohort size ranged from 75 850 to 76 549 residents (mean [SD] age, 83.4 [10.8] years; mean proportion of women, 68.9%). A significant increased slope change in the weekly proportion of residents who were dispensed antipsychotics (parameter estimate [β] = 0.051; standard error [SE] = 0.010; P < .001), benzodiazepines (β = 0.026; SE = 0.003; P < .001), antidepressants (β = 0.046; SE = 0.013; P < .001), trazodone hydrochloride (β = 0.033; SE = 0.010; P < .001), anticonvulsants (β = 0.014; SE = 0.006; P = .03), and opioids (β = 0.038; SE = 0.007; P < .001) was observed. The absolute difference in observed vs estimated use in the last week of the pandemic period ranged from 0.48% (for anticonvulsants) to 1.52% (for antipsychotics). No significant level or slope changes were found for antibiotics, ARBs, or ACE inhibitors., Conclusions and Relevance: In this population-based cohort study, statistically significant increases in the use of antipsychotics, benzodiazepines, antidepressants, anticonvulsants, and opioids followed the onset of the COVID-19 pandemic, although absolute differences were small. There were no significant changes for antibiotics, ARBs, or ACE inhibitors. Studies are needed to monitor whether changes in pharmacotherapy persist, regress, or accelerate during the course of the pandemic and how these changes affect resident-level outcomes.

Objective: Physical distancing and stay-at-home measures implemented to slow transmission of novel coronavirus disease (COVID-19) may intensify feelings of loneliness in older adults, especially those living alone. Our aim was to characterise the extent of loneliness during the first wave in a sample of older adults living in the community and assess characteristics associated with loneliness., Design: Online cross-sectional survey between 6 May and 19 May 2020., Setting: Ontario, Canada., Participants: Convenience sample of members of a national retired educators' organisation., Primary Outcome Measures: Self-reported loneliness, including differences between women and men., Results: 4879 respondents (71.0% women; 67.4% 65-79 years) reported that in the preceding week, 43.1% felt lonely at least some of the time, including 8.3% who felt lonely always or often. Women had increased odds of loneliness compared with men, whether living alone (adjusted OR (aOR) 1.52, 95% CI 1.13 to 2.04) or with others (2.44, 95% CI 2.04 to 2.92). Increasing age group decreased the odds of loneliness (aOR 0.69 (95% CI 0.59 to 0.81) 65-79 years and 0.50 (95% CI 0.39 to 0.65) 80+ years compared with <65 years). Living alone was associated with loneliness, with a greater association in men (aOR 4.26, 95% CI 3.15 to 5.76) than women (aOR 2.65, 95% CI 2.26 to 3.11). Other factors associated with loneliness included: fair or poor health (aOR 1.93, 95% CI 1.54 to 2.41), being a caregiver (aOR 1.18, 95% CI 1.02 to 1.37), receiving care (aOR 1.47, 95% CI 1.19 to 1.81), high concern for the pandemic (aOR 1.55, 95% CI 1.31 to 1.84), not experiencing positive effects of pandemic distancing measures (aOR 1.94, 95% CI 1.62 to 2.32) and changes to daily routine (aOR 2.81, 95% CI 1.96 to 4.03)., Conclusions: While many older adults reported feeling lonely during COVID-19, several characteristics-such as being female and living alone-increased the odds of loneliness. These characteristics may help identify priorities for targeting interventions to reduce loneliness., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Sedative and hypnotic medications are associated with harm, and guidelines suggest limiting their use. Only limited evidence has described how older adults are managed following an initial sleep disorder diagnosis. We aimed to describe clinical management patterns of sleep disorders in older women and men at the time of initial diagnosis., Design: Population-based retrospective cohort study using linked administrative databases., Setting: Ontario, Canada., Participants: Community-dwelling adults aged 66 and older, diagnosed with a new sleep disorder by a primary care provider (n = 30 729; 56% women and 44% men). We compared women and men for each outcome., Measurements: The primary outcome was prescription of a medication used for sleep within 30 days of a new sleep disorder diagnosis. Additional analysis included medical investigations such as sleep studies and visits to specialists who manage obstructive sleep disorders within 90 days of diagnosis., Results: Among the 30 729 older adults with a new sleep disorder diagnosis, 5512 (17.9% total; 18.8% of women and 16.9% of men) were prescribed a medication used for sleep. Compared with men, women were somewhat more likely to be prescribed at least one sedative medication (adjusted odds ratio = 1.09; 95% confidence interval = 1.03-1.16). A total of 2573 (8.4%) older adults underwent a sleep study, and 3743 (12.2%) were evaluated by a specialist; both occurred more commonly in men., Conclusion: In our cohort, almost 1 in 5 older adults with a new sleep disorder diagnosis were prescribed a medication used for sleep; of these, a higher proportion were women. Comparatively few older adults were further evaluated; of these, a higher proportion were men. Our study highlights the high rates at which medications are prescribed to older adults with a new sleep disorder diagnosis and identifies potential sex differences in the management of such diagnoses. J Am Geriatr Soc 1-8, 2019. J Am Geriatr Soc 67:2094-2101, 2019., (© 2019 The American Geriatrics Society.)

Objective: Lithium is an effective treatment for mood disorders, but lithium level and renal monitoring every 3 months is recommended in older patients treated with lithium to prevent serious adverse events. This study examined lithium monitoring practices in a large geriatric cohort., Methods: This population-based cohort study (N = 11,006) used linked health care administrative databases. Older lithium users (n = 5,503; mean age = 70.6 years) in Ontario, Canada, enrolled between April 1, 2002, and March 31, 2014, were propensity score matched 1:1 to valproate users (n = 5,503). The frequency with which serum lithium levels were monitored and renal and endocrine laboratory testing was done during a 1-year follow-up period was examined., Results: The baseline characteristics of the 2 groups were similar. At least 1 serum lithium concentration recorded within 90, 180, and 365 days of follow-up was present in 24.1%, 42.4%, and 66.8% of lithium users, respectively. Corresponding numbers for serum creatinine were 29.6%, 50.4%, and 75.4%, respectively. While serum creatinine monitoring (hazard ratio [HR] = 1.19; 95% CI, 1.12-1.27; P < .001), thyroid-stimulating hormone monitoring (HR = 1.47; 95% CI, 1.37-1.58; P < .001), and calcium testing (HR = 1.15; 95% CI, 1.02-1.29; P = .018) were statistically higher in lithium compared to valproate users, absolute differences between groups were not clinically meaningful., Conclusions: In a geriatric Canadian community sample, lithium monitoring was infrequent and inconsistent with international standards that call for screening of lithium levels and renal function every 3 months., (© Copyright 2018 Physicians Postgraduate Press, Inc.)

Importance: Subtle but important differences have been described in the way that male and female physicians care for their patients, with some evidence suggesting women are more likely to adhere to best practice recommendations., Objective: To determine if male and female physicians differ in their prescribing practices as measured by the initiation of lower-than-recommended dose cholinesterase inhibitor (ChEI) drug therapy for dementia management., Design, Setting, and Participants: All community-dwelling Ontario residents aged 66 years and older with dementia and newly dispensed an oral ChEI drug (donepezil, galantamine, or rivastigmine) between April 1, 2010 and June 30, 2016 were included., Main Outcome and Measures: The association between physician sex and the initiation of a lower than recommended-dose ChEI was examined using generalized linear mixed regression models, adjusting for patient and physician characteristics. Data were stratified by specialty. Secondary analyses explored the association between physician sex and cardiac screening as well as shorter duration of the initial prescription., Results: The analysis included 3,443 female and 5,811 male physicians and the majority (83%) were family physicians, Female physicians were more likely to initiate ChEI therapy at a lower-than-recommended dose (Adjusted odds ratio = 1.43,95% confidence interval = 1.17 to 1.74). Compared to their male counterparts, female physicians were also more likely to follow other conservative prescribing practices including cardiac screening (55.1% vs. 49.2%, P-value<0.001) around the time of ChEI initiation, and dispensing a shorter duration of initial prescription (41.8% vs 35.5% P-value<0.001)., Conclusions: There is a statistically significant and important difference in ChEI prescribing patterns between female and male physicians, suggesting that female physicians may be more careful and conservative in their approaches. This will inform future research to determine if patients receiving lower-than-recommended initial doses also have better outcomes., Competing Interests: There is a data sharing agreement between the Institute for Clinical Evaluative Sciences (ICES) (a not for profit corporation) and the commercial company, IMS Brogan Inc., which governs a piece of the ICES data used to generate the project dataset. No employment relationship should be inferred in connection with this statement. No author on this work is employed by IMS Brogan. Dr. Gurwitz serves as a member of the UnitedHealthcare Pharmacy & Therapeutics Committee. Dr. Seitz involves in a clinical trial sponsored by Hoffman La Roche. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

Background: Despite the fact that many older adults receive home or long-term care services, the effect of these care settings on hospital readmission is often overlooked. Efforts to reduce hospital readmissions, including capacity planning and targeting of interventions, require clear data on the frequency of and risk factors for readmission among different populations of older adults., Methods: We identified all adults older than 65 years discharged from an unplanned medical hospital stay in Ontario between April 2008 and December 2015. We defined 2 preadmission care settings (community, long-term care) and 3 discharge care settings (community, home care, long-term care) and used multinomial regression to estimate associations with 30-day readmission (and death as a competing risk)., Results: We identified 701 527 individuals (mean age 78.4 yr), of whom 414 302 (59.1%) started in and returned to the community. Overall, 88 305 in dividuals (12.6%) were re admitted within 30 days, but this proportion varied by care setting combination. Relative to individuals returning to the community, those discharged to the community with home care (adjusted odds ratio [OR] 1.43, 95% confidence interval [CI] 1.39-1.46) and those returning to long-term care (adjusted OR 1.35, 95% CI 1.27-1.43) had a greater risk of readmission, whereas those newly admitted to long-term care had a lower risk of readmission (adjusted OR 0.68, 95% CI 0.63-0.72)., Interpretation: In Ontario, about 40% of older people were discharged from hospital to either home care or long-term care. These discharge settings, as well as whether an individual was admitted to hospital from long-term care, have important implications for understanding 30-day readmission rates. System planning and efforts to reduce readmission among older adults should take into account care settings at both admission and discharge., Competing Interests: Competing interests: Chaim Bell is a medical consultant with the Policy and Innovations Branch of the Ontario Ministry of Health and Long-Term Care. No other competing interests were declared., (© 2018 Joule Inc. or its licensors.)

Background: Nursing home (NH) residents are frequent users of emergency departments (ED) and while prior research suggests that repeat visits are common, there is little data describing this phenomenon. Our objectives were to describe repeat ED visits over one year, identify risk factors for repeat use, and characterize "frequent" ED visitors., Methods: Using provincial administrative data from Ontario, Canada, we identified all NH residents 65 years or older who visited an ED at least once between January 1 and March 31, 2010 and then followed them for one year to capture all additional ED visits. Frequent ED visitors were defined as those who had 3 or more repeat ED visits. We used logistic regression to estimate risk factors for any repeat ED visit and for being a frequent visitor and Andersen-Gill regression to estimate risk factors for the rate of repeat ED visits., Results: In a cohort of 25,653 residents (mean age 84.5 (SD = 7.5) years, 68.2% female), 48.8% had at least one repeat ED visit. Residents who experienced a repeat ED visit were generally similar to others but they tended to be slightly younger, have a higher proportion male, and a higher proportion with minimal cognitive or physical impairment. Risk factors for a repeat ED visit included: being male (adjusted odds ratio 1.27, (95% confidence interval 1.19-1.36)), diagnoses such as diabetes (AOR 1.28 (1.19-1.37)) and congestive heart failure (1.26 (1.16-1.37)), while severe cognitive impairment (AOR 0.92 (0.84-0.99)) and 5 or more chronic conditions (AOR 0.82 (0.71-0.95)) appeared protective. Eleven percent of residents were identified as frequent ED visitors, and they were more often younger then 75 years, male, and less likely to have Alzheimer's disease or other dementias than non-frequent visitors., Conclusions: Repeat ED visits were common among NH residents but a relatively small group accounted for the largest number of visits. Although there were few clear defining characteristics, our findings suggest that medically complex residents and younger residents without cognitive impairments are at risk for such outcomes.

Purpose: To examine the association between new antipsychotic use and mortality over 6 months among community-based older adults with cognitive impairment, and variation in risk by frailty and sex., Methods: We conducted a retrospective cohort study of older (aged 66+) home care clients in Ontario, Canada, using linked administrative health and clinical databases. Included were clients with dementia and/or significant cognitive impairment assessed during April 2008 to March 2013. Frailty was defined using a validated 72-item index. Exposed were those newly dispensed an antipsychotic in the 6 months post cohort entry, with no such claims in the year prior to drug index date. Two-stage matching defined unexposed clients and their index date (matching on age, sex, frailty, assessment year, and propensity score). Outcome was time to death following index date. Cause-specific hazards models were used, and number needed to harm at 6 months was estimated from cumulative incidence function curves., Results: Among 4955 matched exposed-unexposed pairs, new antipsychotic users showed a significantly increased hazard of mortality at 1, 3, and 6 months relative to unexposed, with the highest risk observed in the first month (hazard ratio [HR] = 2.08 [95% CI, 1.79-2.43]). At 1 month, risk was significantly higher for robust (HR = 3.72 [95% CI, 2.45-5.66]) vs frail (HR = 1.74 [95% CI, 1.40-2.17], P = .002) clients. The number needed to harm was 22.7 and did not vary by frailty but was lower for men (14.9) than for women (35.0)., Conclusions: Risk of antipsychotic-associated mortality was highest in the first month following exposure, varied significantly by client frailty, and was greater among men than among women., (Copyright © 2018 John Wiley & Sons, Ltd.)

Objective: Bipolar disorder is associated with high rates of medical comorbidity, particularly in late life. Little is known about medical health service utilization and potential effects of bipolar pharmacotherapy. We hypothesized that lithium use would not be associated with higher rates of medical hospitalization., Methods: Population-based retrospective cohort study of 1388 bipolar disorder patients aged ≥66years discharged from a psychiatric hospitalization in Ontario, Canada, between 2006 and 2012. Patients were divided into lithium users, valproate users, and non-lithium/non-valproate users. The main outcome was acute non-psychiatric, medical/surgical hospitalization during 1-year follow-up., Results: The rate of medical hospitalizations was 0.22 per patient-year. Time-to-medical hospitalization did not differ among lithium, valproate, and non-lithium/non-valproate users after adjusting for age, sex, past medical hospitalization, and antipsychotic use. Lithium, valproate, and non-lithium/non-valproate users did not differ markedly in terms of reason for medical hospitalization, 1-year acute medical health utilization outcomes, and medical comorbidity rates., Conclusion: There were high rates of health service use for medical conditions among older adults with bipolar disorder, but this did not appear to be associated with lithium use, compared to valproate and other medication use (e.g., antipsychotics). A proactive collaborative care approach may prevent medical service utilization in severe late-life bipolar disorder., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To establish if proprietary status (ie, for-profit or not-for-profit) is associated with mortality and hospitalizations among publicly funded long-term care (nursing) homes., Methods: We conducted a retrospective cohort study of new admissions in 640 publicly funded long-term care facilities in Ontario, Canada (384 for-profit, 256 not-for-profit). A population-based cohort of 53,739 incident admissions into long-term care facilities between January 1, 2010, and March 1, 2012, was observed. We measured adjusted rates of hospital admissions and mortality, per 1000 person-years (PY) of follow-up, among for-profit and not-for-profit facilities at 3, 6, and 12 months postadmission. Rates were measured postadmission and until discharge or death, whichever came first., Results: One year after admission and before discharge, 11.7% of residents died and 25.7% had at least one hospitalization. After 12 months of follow-up, residents in for-profit facilities had a hospitalization rate of 462 per 1000 PY versus 358 per 1000 PY in not-for-profit facilities. During this period, the crude mortality rate in for-profit facilities was 208 per 1000 PY versus 185 per 1000 PY in not-for-profit facilities. At 3, 6, and 1 year after admission, for-profit facilities had an adjusted hazard ratio of 1.36 (95% confidence interval [CI] 1.28-1.43), 1.33 (95% CI 1.27-1.39), and 1.25 (95% CI 1.21-1.30) for hospitalizations and hazards of 1.20 (95% CI 1.11-1.29), 1.16 (95% CI 1.09-1.24), and 1.10 (95% CI 1.05-1.16) for mortality, respectively., Conclusions: Publicly funded for-profit facilities have significantly higher rates of both mortality and hospital admissions., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: Antibiotics are frequently and often inappropriately prescribed to patients in nursing homes. These antibiotics pose direct risks to recipients and indirect risks to others residing in the home., Objective: To examine whether living in a nursing home with high antibiotic use is associated with an increased risk of antibiotic-related adverse outcomes for individual residents., Design, Setting, and Participants: In this longitudinal open-cohort study performed from January 1, 2010, through December 31, 2011, we studied 110,656 older adults residing in 607 nursing homes in Ontario, Canada., Exposures: Nursing home-level antibiotic use was defined as use-days per 1000 resident-days, and facilities were classified as high, medium, and low use according to tertile of use. Multivariable logistic regression modeling was performed to assess the effect of nursing home-level antibiotic use on the individual risk of antibiotic-related adverse outcomes., Main Outcomes and Measures: Antibiotic-related harms included Clostridium difficile, diarrhea or gastroenteritis, antibiotic-resistant organisms (which can directly affect recipients and indirectly affect nonrecipients), allergic reactions, and general medication adverse events (which can affect only recipients)., Results: Antibiotics were provided on 2,783,000 of 50,953,000 resident-days in nursing homes (55 antibiotic-days per 1000 resident-days). Antibiotic use was highly variable across homes, ranging from 20.4 to 192.9 antibiotic-days per 1000 resident-days. Antibiotic-related adverse events were more common (13.3%) in residents of high-use homes than among residents of medium-use (12.4%) or low-use homes (11.4%) (P < .001); this trend persisted even among the residents who did not receive antibiotic treatments. The primary analysis indicated that residence in a high-use nursing home was associated with an increased risk of a resident experiencing an antibiotic-related adverse event (adjusted odds ratio, 1.24; 95% CI, 1.07-1.42; P = .003). A sensitivity analysis examining nursing home-level antibiotic use as a continuous variable confirmed an increased risk of resident-level antibiotic-related harms (adjusted odds ratio, 1.004 per additional day of nursing home antibiotic use; 95% CI, 1.001-1.006; P = .01)., Conclusions and Relevance: Antibiotic use is highly variable across nursing homes; residents of high-use homes are exposed to an increased risk of antibiotic-related harms even if they have not directly received these agents. Antibiotic stewardship is needed to improve the safety of all nursing home residents.

Purpose: Days supply (prescription duration) values are commonly used to estimate drug exposure and quantify adherence to therapy, yet accuracy is not routinely assessed, and potential inaccurate reporting has been previously identified. We examined the impact of cleaning days supply values on the measurement of adherence to oral bisphosphonates., Methods: We identified new users of oral bisphosphonates among Ontario seniors (April 2001-March 2011). Days supply values were examined by dose, and we identified misclassification by comparing observed values to dose-specific expected values. Days supply values not matching expected values were cleaned using dose-specific algorithms. One-year adherence to therapy was defined using measures of compliance (mean proportion of days covered [PDC], and categorized into high [PDC ≥ 80%], medium [50% < PDC < 80%], low [PDC ≤ 50%]) and persistence (30-day permissible gap). Estimates were compared using the observed and cleaned days supply values, stratified by site of patient residence (community or long-term care [LTC])., Results: We identified 337 729 (5% LTC) eligible new users. Among LTC patients, adherence estimates increased significantly following data cleaning: mean PDC (59 to 83%), proportion with high compliance (47 to 76%), and proportion persisting with therapy (62 to 78%). Modest increases were identified among community-dwelling patients following data cleaning (mean PDC, 71 to 74%; high compliance, 54 to 58%; and persistence, 56 to 61%)., Conclusions: Data cleaning to correct for exposure misclassification can influence estimates of adherence with oral bisphosphonate therapy, particularly in LTC. Results highlight the importance of developing data cleaning strategies to correct for exposure misclassification and improve transparency in pharmacoepidemiologic studies., (Copyright © 2014 John Wiley & Sons, Ltd.)

Objective: Lithium is an important treatment for mood disorders, but concern about its association with renal disease has contributed to its limited use, particularly in older adults. Because high-quality evidence examining renal disease in this population is lacking, this study aims to quantify the prevalence and identify clinical correlates of renal disease in geriatric lithium users., Methods: In a population-based cross-sectional study on 2,480 lithium users aged 70 or more years, the authors searched the provincial administrative health data from Ontario, Canada between April 1, 2005 and March 31, 2011. Prevalence of chronic kidney disease (CKD), acute kidney injury (AKI), and nephrogenic diabetes insipidus (NDI) was measured using International Classification of Diseases, Tenth Revision codes. Logistic regression analyses were used to identify independent correlates of renal disease., Results: The 6-year prevalence rates of CKD, AKI, and NDI were 13.9%, 1.3%, and 3.0%, respectively. Hypertension (odds ratio [OR]: 2.05; 95% confidence interval [CI]: 1.50-2.79), diabetes mellitus (OR: 1.86; 95% CI: 1.45-2.38), ischemic heart disease (OR: 1.65; 95% CI: 1.24-2.20), NDI (OR: 2.54; 95% CI: 1.47-4.40), AKI (OR: 11.7; 95% CI: 5.26-26.1), lithium use for more than 2 years (OR: 1.71; 95% CI: 1.05-2.81), loop diuretic use (OR: 1.74; 95% CI: 1.26-2.41), hydrochlorothiazide use (OR: 1.48; 95% CI: 1.07-2.05), and atypical antipsychotic use (OR: 1.49; 95% CI: 1.17-1.89) were all independently associated with CKD., Conclusion: Older lithium users have high rates of CKD. Lithium use duration was independently associated with CKD. Longitudinal studies including individuals without lithium exposure will be necessary to confirm whether lithium is indeed a risk factor for CKD in older adults., (Copyright © 2014 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Our purpose was to evaluate the association of new benzodiazepine use relative to non-use with adverse clinical respiratory outcomes among older adults with chronic obstructive pulmonary disease (COPD). This was a retrospective population-based cohort study of Ontario, Canada, residents between 2003 and 2010. A validated algorithm was applied to health administrative data to identify adults aged 66 years and older with COPD. Relative risks (RRs) of several clinically important respiratory outcomes were examined within 30 days of incident benzodiazepine use compared with non-use, applying propensity score matching. New benzodiazepine users were at significantly higher risk for outpatient respiratory exacerbations (RR 1.45, 95% CI 1.36-1.54) and emergency room visits for COPD or pneumonia (RR 1.92, 95% CI 1.69-2.18) compared to non-users. Risk of hospitalisation for COPD or pneumonia was also increased in benzodiazepine users, but was nonsignificant (RR 1.09, 95% CI 1.00-1.20). There were no significant differences in intensive care unit admissions between the two groups and all-cause mortality was slightly lower among new versus non-users. Benzodiazepines were associated with increased risk for several serious adverse respiratory outcomes among older adults with COPD. The findings suggest that decisions to use benzodiazepines in older patients with COPD need to consider potential adverse respiratory outcomes., (©ERS 2014.)