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As populations worldwide are living longer, the impact of neurodegenerative diseases on health resource utilization is expected to increase. Providing care to older adults with neurodegenerative diseases is challenging, and requires adequate supports across multiple health sectors including community, acute care and nursing home settings to allow individuals to maximize their quality of life. The Ontario Neurodegenerative Disease Research Initiative (ONDRI) is a collaborative research program that aims to improve diagnosis, treatment and management of neurodegenerative diseases including Alzheimer’s disease and related dementias, Parkinson’s disease, Amyotrophic Lateral Sclerosis (ALS), and Vascular Cognitive Impairment. Using population-based linked health administrative and clinical databases--covering over 14 million individuals residing in the province of Ontario, Canada-- the ONDRI health services research platform will address knowledge gaps regarding the health service utilization and outcomes of older adults with neurodegenerative diseases and impacts on family and care partners. Access to over two decades of historical health administrative data on a large population of older individuals uniquely positions our collaborative to examine trajectories of health system use as well as rare neurodegenerative diseases which have been previously understudied. The health services research platform is embedded within a larger ONDRI network of biomedical researchers, provincial decision-makers and health system stakeholders. Our research findings will inform health system planning and interventions to support older adults to live independently in the community. This session will explore how health administrative databases may be used to address knowledge gaps regarding health service utilization and outcomes in older persons with neurodegenerative diseases.

Research suggests that older adults with neurodegenerative diseases are at increased risk of developing a subsequent neurodegenerative or comorbid psychiatric disorder or both. Depression and other psychiatric conditions, though prevalent, are often under-diagnosed and under-treated among those with neurodegenerative conditions potentially leading to more rapid disease progression, poorer health outcomes and increased health care use. Few population-based studies have comprehensively examined the risk and temporal ordering of common neurodegenerative and psychiatric conditions, including whether these associations differ by age or sex. Initial findings regarding the incidence of ordered pairs of neurological conditions (including dementia, Parkinson’s disease and stroke) and psychiatric disorders (including mood and anxiety disorders, and schizophrenia) will be summarized. This population-based retrospective cohort study will provide essential data to allow policymakers, planners and providers to better anticipate the prognosis and care needs of older adults with comorbid neurodegenerative and psychiatric conditions.

Objectives For persons with dementia, the appropriate duration of cholinesterase inhibitor (ChEI) use remains unclear. We examined patterns of ChEI use during nursing home (NH) transition and the factors associated with discontinuation following admission. Design Population-based retrospective cohort study using linked health administrative and Resident Assessment Instrument Minimum Dataset, version 2.0 databases. Setting and participants A total of 47,851 older adults (mean age = 84.8 years, standard deviation = 6.8) with dementia newly admitted to a NH in Ontario, Canada between 2011 and 2015. Measurements ChEI use at admission and during the following year was identified from prescription claims. Resident sociodemographic and health characteristics at admission, including a 72-item frailty index, were derived from the Resident Assessment Instrument Minimum Dataset 2.0. Additional resident and prescriber characteristics were derived from administrative data. Discontinuation was defined as a 30+-day gap in ChEI supply. Multivariable subdistribution hazard models were used to estimate the independent effect of resident frailty and other factors on ChEI discontinuation. Results Approximately one-third (17,560) of residents with dementia were on a ChEI at admission. Among this group, 17.7% (3110) discontinued use over follow-up. Incidence of discontinuation was significantly higher among residents with syncope [subdistribution hazard ratio, sHR = 2.21, 95% confidence interval, CI (1.52, 3.22)], more severe behavioral symptoms [sHR = 1.79, 95% CI (1.57, 2.05)], cognitive impairment [sHR = 1.26, 95% CI (1.07, 1.48)], higher frailty, [sHR = 1.19, 95% CI (1.04, 1.36)], and a primary prescriber active in the NH [sHR = 1.28, 95% CI (1.14, 1.45)]. A significantly lower incidence was observed for older and unmarried residents and those with a longer duration of use. Conclusions/Implications Less than one-fifth of residents on a ChEI at admission discontinued use during the following year. Although some of the predictors of discontinuation align with past research and current clinical recommendations, others were unexpected and point to novel drivers of ChEI use. Future investigations should explore the varied reasons underlying these associations and resident outcomes associated with ChEI discontinuation.

Objective With aging and obesity trends, the incidence and prevalence of osteoarthritis (OA) is expected to rise in Canada, increasing the demand for health resources. Resource planning to meet this increasing need requires estimates of the anticipated number of OA patients. Using administrative data from Alberta, we estimated OA incidence and prevalence rates and examined their sensitivity to alternative case definitions. Methods We identified cases in a linked data set spanning 1993 to 2010 (population registry, Discharge Abstract Database, physician claims, Ambulatory Care Classification System, and prescription drug data) using diagnostic codes and drug identification numbers. In the base case, incident cases were captured for patients with an OA diagnostic code for at least 2 physician visits within 2 years or any hospital admission. Seven alternative case definitions were applied and compared. Results Age- and sex-standardized incidence and prevalence rates were estimated to be 8.6 and 80.3 cases per 1,000 population, respectively, in the base case. Physician claims data alone captured 88% of OA cases. Prevalence rate estimates required 15 years of longitudinal data to plateau. Compared to the base case, estimates are sensitive to alternative case definitions. Conclusion Administrative databases are a key source for estimating the burden and epidemiologic trends of chronic diseases such as OA in Canada. Despite their limitations, these data provide valuable information for estimating disease burden and planning health services. Estimates of OA are mostly defined through physician claims data and require a long period of longitudinal data.

Background: There is a role for brief assessment instruments in detection and management of major depression in MS. However, candidate scales have rarely been validated against a validated diagnostic interview. In this study, we evaluated the performance of several candidate scales: Patient Health Questionnaire (PHQ)-9, PHQ-2, Center for Epidemiologic Studies Depression rating scale (CES-D), and Hospital Anxiety and Depression Scale (HADS-D) in relation to the Structured Clinical Interview for DSM-IV (SCID). Methods: The sample was an unselected series of 152 patients attending a multiple sclerosis (MS) clinic. Participants completed the scales during a clinic visit or returned them by mail. The SCID was administered by telephone within two weeks. The diagnosis of major depressive episode, according to the SCID, was used as a reference standard. Receiver-operator curves (ROC) were fitted and indices of measurement accuracy were calculated. Results: All of the scales performed well, each having an area under the ROC > 90%. For example, the PHQ-9 had 95% sensitivity and 88.3% specificity when scored with a cut-point of 11. This cut-point achieved a 56% positive predictive value for major depression. Conclusions: While all of the scales performed well in terms of their sensitivity and specificity, the availability of the PHQ-9 in the public domain and its brevity may enhance the feasibility of its use.

This paper provides a comprehensive review of studies examining adherence and (or) persistence with dementia pharmacotherapy during the past decade, including a summary of the key patient-, drug-, system-, and provider-level factors associated with these measures. Estimates of adherence and 1-year persistence to these drugs have ranged from 34% to 94% and 35% to 60%, respectively. Though many studies reported nonsignificant associations, there are data suggesting that patient age, sex, ethnoracial background, socioeconomic status, and region-specific reimbursement criteria, as well as the extent and quality of interactions among patients, caregivers, and providers, may influence persistence with pharmacotherapy. As many studies relied on administrative data, limited information was available regarding the relevance of patient's cognitive and functional status or the importance of caregiver involvement or assistive devices to adherence or persistence.

Background/Objectives To estimate the prevalence of potentially inappropriate medication (PIM) use among older adults with cognitive impairment or dementia prior to and following admission to nursing homes and in relation to frailty. Design Retrospective cohort study using health administrative databases. Setting Ontario, Canada. Participants 41,351 individuals with cognitive impairment or dementia, aged 66+ years newly admitted to nursing home between 2011 and 2014. Measurements PIMs were defined with 2015 Beers Criteria and included antipsychotics, H2-receptor antagonists, benzodiazepines, and drugs with strong anticholinergic properties. Medication information was obtained at nursing home admission and in the subsequent 180 days. Multivariable Cox proportional-hazards models were used to assess the impact of frailty status (determined by a 72-item frailty index) on the hazard of starting and discontinuing PIMs. Results At admission, 44% of residents with cognitive impairment or dementia were on a PIM and prevalence varied by frailty (38.7% non-frail, 42.8% pre-frail, and 48.1% frail, P < .001). Following admission, many residents discontinued PIMs (23.5% for antipsychotics, 49.3% benzodiazepines, 32.2% anticholinergics, and 30.9% H2-receptor antagonists). However, PIMs were also introduced with 10.9% newly started on antipsychotics, benzodiazepines (10.1%), anticholinergics (6.6%), and H2-receptor antagonists (1.2%). After adjustment for other characteristics, frail residents had a similar risk of PIM discontinuation as non-frail residents except for anticholinergics (HR = 1.21, 95% CI 1.06–1.39) but were more likely to be newly prescribed benzodiazepines (HR = 1.32, 95% CI 1.20–1.44), antipsychotics (HR = 1.36, 1.23–1.49), and anticholinergics (HR = 1.34, 95% CI 1.20–1.50). Conclusion Many residents with cognitive impairment or dementia enter nursing homes on PIMs. PIMs are more likely to be started in frail individuals following admission. Interventions to support deprescribing of PIMs should be implemented targeting frail individuals during the transition to nursing home.

Assisted living (AL) has emerged as a popular residential care option for older adults in Canada. Similar to the U.S. experience, its introduction has raised concerns about regulatory oversight, eligibility criteria, staffing levels and quality of care. The Alberta Continuing Care Epidemiological Studies (ACCES) is the first prospective cohort study in Canada to examine AL residents’ health and social needs and healthcare outcomes. ACCES included 1,089 older (65+) residents from 59 AL residences and 1,000 residents from 54 nursing homes (NHs) across Alberta. In both settings, dementia was the most common diagnosis (58% AL, 71% NH). Despite being less impaired, AL residents exhibited an annual incidence of hospitalization 3-times higher than NH residents (38.9% vs. 13.7%). They also showed an annual incidence of NH placement of 18.3%. Key drivers of both outcomes included AL resident characteristics (health and social vulnerability) and residence factors (size, staffing levels and oversight).

This presentation will summarize evidence arising from a multi-year population-based study of over 6 Million people in Ontario, Canada who have one of 17 common chronic conditions, and particularly the more than 2.5 Million individuals with multiple chronic conditions. Aside from the expected increases in health care utilization, adverse outcomes and health care costs associated with an increasing number of conditions, the results highlight several novel insights. For example: there are very few patterns of clustering of multiple chronic conditions; the increasing effect of additional conditions on health care use is attenuated for those aged 65 or over; the gradient in mortality associated with socio-economic status is not apparent after controlling for the number of chronic conditions that a person has. Results also indicate modifiable factors: having greater than median continuity of care was equivalent to having one less chronic condition in terms of hospitalization outcomes.

ObjectiveEfforts to enable persons with dementia to remain at home longer, and to reduce use of costly acute care resources, are at the forefront of policy agendas internationally. Foundational to planning appropriate health system supports is the ongoing, comparable and accurate estimation of the prevalence and incidence of dementia across regions, as well as associated patterns of health services use and cost. Our objective was to explore emerging approaches to using population data in dementia research and demonstrate the policy contribution of the resulting new knowledge. ApproachUsing population-based health administrative data and an algorithm that was validated using electronic medical records, we developed a series of repeated, cross-sectional cohort studies to examine trends in dementia prevalence, incidence and publicly-funded health service use and costs between 2004/05 and 2013/14 among adults aged 65 years and older in Ontario, Canada. Trends in yearly rates of health service use were assessed using regression models for serially correlated data and compared to a 1:1 matched control group based on age, sex, geographic region and comorbidity level. ResultsOver time, age- and sex-adjusted prevalence of dementia increased by 18.2% (from 63.0 to 74.5 per 1,000 persons; p-value < 0.001) and age- and sex-adjusted incidence decreased slightly (from 18.2 to 17.0 per 1,000 persons; p-value = 0.05). Community-dwelling persons with dementia were more likely than matched controls to be placed in long-term care (11.8% vs. 1.5% in 2013; p

ObjectiveThere is limited evidence from randomized trials and observational studies to guide clinical practice regarding the use of statins in long-term care (LTC); the effectiveness of statins among those with limited life expectancy is not clear and there is concern that the risk of drug-related adverse events might outweigh any benefit. We examined the impact of initiating statin therapy on mortality for patients newly admitted to LTC. ApproachPopulation-based health administrative data from Ontario, Canada were used to conduct a retrospective cohort study of newly admitted LTC residents, aged 66+ years and no statin use in the previous year, between January 1 2011 and December 31 2014. This cohort was linked to Resident Assessment Instrument (interRAI) data to capture clinical and functional characteristics (including frailty, activities of daily living, and cognitive function). The primary exposure was statin use within 30 days following LTC entry; residents who died or did not receive an interRAI assessment within 30 days were excluded. A propensity score for receiving statins was computed using resident demographic, clinical and functional characteristics. We matched exposed to unexposed patients on the basis of age (±1 year), sex, prior myocardial infarction(MI)/stroke hospitalization, frailty and propensity score (±0.2 standard deviations). Patients were followed in an intention-to-treat manner from the end of the exposure window until the earliest of death or March 31 2015. Cox regression was used to compare mortality between the study groups. ResultsWe identified 39,560 newly admitted LTC residents aged 66+ years with no statin use in the previous year, of which 1,953 (4.9%) were prescribed a statin within 30 days of LTC entry. Propensity score matching resulted in 1,710 pairs of exposed and unexposed patients. In the matched cohort, those receiving statins had a lower rate of mortality compared with those not receiving statins (Hazard Ratio 0.77; 95% Confidence Interval [CI] 0.70-0.85). In pre-specified subgroup analyses, the association between statin use and reduced mortality persisted among those with and without a prior MI/stroke hospitalization and among those categorized as frail and not frail. ConclusionOur data suggest initiating statins may be beneficial in reducing mortality risk among LTC residents, despite the complexity and advanced age of the patients. By linking rich resident-level health and functional assessment data with health administrative data we were able to characterize the association between demographic and clinical characteristics (including frailty) and exposure to statins more fully than with administrative data alone.

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., In a retrospective analysis of routinely collected data, Luke Mondor and colleagues examine the associations between multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada., Author summary Why was this study done? The co-occurrence of multiple chronic conditions in an individual (multimorbidity) has been linked to poor outcomes including increased hospital use, longer length of stays, and worse cognitive and physical functioning. Particularly for community-residing older adults with dementia, multimorbidity can result in challenges to both self-care and provided care. Individuals with multimorbidity often receive care from multiple physicians across different care settings each year. This lack of physician continuity may lead to poorer quality of care and outcomes. Important gaps exist in our understanding of the interplay between multimorbidity, health system use, and continuity of physician care specifically for individuals with dementia. Our historical cohort study was designed to estimate the risk of acute care hospitalization and emergency department (ED) visit by level of multimorbidity (i.e., chronic disease burden) among persons with dementia in the community. We were especially interested in whether the risk of these health outcomes was lower for those with better continuity of physician care. What did the researchers do and find? We performed a retrospective cohort study of 30,112 home care clients with dementia in Ontario, Canada, using routinely collected health and clinical information linked at the individual level. We defined the level of multimorbidity (i.e., chronic disease burden in addition to dementia diagnosis) based on a count of the presence of 16 common chronic conditions, and compared time, in days, from a health assessment to initial hospitalization (for any cause) and ED visit (not resulting in an inpatient stay) in persons with different multimorbidity levels. We accounted for other possible outcomes including death or placement in a long-term care facility. We found that multimorbidity was highly prevalent in this population—89% of the cohort had been diagnosed with two or more conditions in addition to dementia. In multivariable analyses, we found that the risk of hospitalization and ED visit increased with each higher level of multimorbidity. These associations were comparable in clients with dementia who had high and low degrees of physician continuity. In other words, continuity of physician care did not modify the association between level of multimorbidity and the outcomes. What do these findings mean? Multimorbidity is the norm rather than the exception among older adults with dementia in the home care sector. This increased chronic disease burden is associated with a greater likelihood for costly hospital admissions and emergency visits. With increases in life expectancy, improvements to disease detection, and a shift to community-based care, use of home care services and the prevalence of multimorbidity among older persons with dementia will likely rise. Data from this study may be useful in identifying at-risk individuals and prioritizing the deployment of limited healthcare resources.

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

Introduction This study provides a comprehensive summary of the sociodemographic, psychosocial and health characteristics of a large population-based cohort of Ontario home care clients (aged 50 years and over) with dementia and examines the variation in these characteristics in those with co-existing neurological conditions. Methods Clients were assessed with the Resident Assessment Instrument-Home Care (RAI-HC) between January 2003 and December 2010. Descriptive analyses examined the distribution of these characteristics among clients with dementia relative to several comparison groups, as well as clients with other recorded neurological conditions. Results Approximately 22% of clients (n = 104 802) had a diagnosis of dementia (average age 83 years, 64% female) and about one in four within this group had a co-existing neurological condition (most commonly stroke or Parkinson disease). About 43% of those with dementia did not live with their primary caregiver. Relative to several comparison groups, clients with dementia showed considerably higher levels of cognitive and functional impairment, aggression, anxiety, wandering, hallucinations/delusions, caregiver distress and a greater risk for institutionalization. Conversely, they showed a lower prevalence of several chronic conditions and lower levels of recent health service use. Depressive symptoms were relatively common in the dementia and other neurological groups. Conclusion Clients with co-existing neurological conditions exhibited unique clinical profiles illustrating the need for tailored and flexible home care services and enhanced caregiver assistance programs.

Introduction Cette étude fournit une synthèse des caractéristiques sociodémographiques, psychosociales et sanitaires d'une vaste cohorte représentative des clients des soins à domicile en Ontario (âgés de 50 ans ou plus) atteints de démence et elle examine les variations de ces caractéristiques chez les clients atteints de maladies neurologiques concomitantes. Méthodologie Les clients ont été évalués à l'aide de l'Instrument d'évaluation des résidents – Soins à domicile (RAI-HC) entre janvier 2003 et décembre 2010. Les analyses descriptives fournissent la répartition de ces caractéristiques en comparant les clients atteints de démence et ceux de plusieurs autres groupes ainsi que ceux atteints d'autres maladies neurologiques documentées. Résultats Environ 22 % des clients (n = 104 802) avaient reçu un diagnostic de démence (âge moyen de 83 ans, 64 % de femmes) et un sur quatre parmi eux était atteint d'une maladie neurologique concomitante (AVC ou maladie de Parkinson la plupart du temps). Environ 43 % des clients atteints de démence n'habitaient pas avec leur principal aidant. Par rapport aux clients des groupes de comparaison, les clients atteints de démence présentaient des taux considérablement plus élevés de déficit cognitif et fonctionnel, d'agressivité, d'anxiété, d'errance et d'hallucinations ou de délire, avaient plus souvent un aidant en détresse et couraient un plus grand risque de placement en établissement. Par contre, ils étaient moins souvent atteints de diverses maladies chroniques et étaient moins nombreux à avoir eu recours à des services de santé récemment. Les symptômes de dépression étaient relativement fréquents chez les clients atteints de démence et chez ceux atteints d'une autre maladie neurologique. Conclusion Les clients atteints de maladies neurologiques concomitantes présentaient des profils cliniques bien particuliers illustrant la nécessité de personnaliser et d'assouplir les services de soins à domicile et d'améliorer les programmes de soutien pour les aidants.

Objectives The objective of our study is to evaluate the effectiveness of dementia case management compared with usual care on reducing long-term care placement, hospitalization, and emergency department visits for adult patients with dementia. We also sought to evaluate the effectiveness of this intervention on delaying time to long-term care placement and hospitalization. Methods We searched electronic databases supplemented by bibliographies and conference proceedings for randomized controlled trials testing the effectiveness of dementia case management in reducing resource utilization in a population of caregiver–care recipient dyads living in the community. We meta-analyzed the risk ratio (RR) and weighted mean differences of long-term care placement and the RR of hospital admissions. Pooled estimates were further stratified by study characteristics and measures of study quality. Results Seventeen studies were included in the meta-analysis. The overall pooled RR of long-term care placement was 0.94 (95% confidence interval [0.85, 1.03]; p = 0.227) for dementia case management compared with usual care. Stratification by follow-up duration indicated a statistically significant reduction in risk of long-term care placement when follow-up duration was less than 18 months (RR 0.61, 95% confidence interval [0.41, 0.91], p = 0.015). There was no effect of dementia case management compared with usual care for the other outcomes. Conclusion Dementia case management demonstrated a short-term positive effect on reducing the risk of long-term care placement among older people with dementia residing in the community. However, other sources of resource utilization and more extended effects of dementia case management on risk of long-term care placement warrant further investigation. Copyright © 2012 John Wiley & Sons, Ltd.

Objective: To estimate the prevalence of depression in persons with epilepsy (PWE) and the strength of association between these 2 conditions. Methods: The MEDLINE (1948–2012), EMBASE (1980–2012), and PsycINFO (1806–2012) databases, reference lists of retrieved articles, and conference abstracts were searched. Content experts were also consulted. Two independent reviewers screened abstracts and extracted data. For inclusion, studies were population-based, original research, and reported on epilepsy and depression. Estimates of depression prevalence among PWE and of the association between epilepsy and depression (estimated with reported odds ratios [ORs]) are provided. Results: Of 7,106 abstracts screened, 23 articles reported on 14 unique data sources. Nine studies reported on 29,891 PWE who had an overall prevalence of active (current or past-year) depression of 23.1% (95% confidence interval [CI] 20.6%–28.31%). Five of the 14 studies reported on 1,217,024 participants with an overall OR of active depression of 2.77 (95% CI 2.09–3.67) in PWE. For lifetime depression, 4 studies reported on 5,454 PWE, with an overall prevalence of 13.0% (95% CI 5.1–33.1), and 3 studies reported on 4,195 participants with an overall OR of 2.20 (95% CI 1.07–4.51) for PWE. Conclusions: Epilepsy was significantly associated with depression and depression was observed to be highly prevalent in PWE. These findings highlight the importance of proper identification and management of depression in PWE.

This is the protocol for a review and there is no abstract. The objectives are as follows:\ud \ud To identify the accuracy of depression rating scales as screening tools for detecting DpD and compare the diagnostic accuracy of different depression rating scales for detecting MDD among adults with Alzheimer's disease and related forms of dementia.\ud \ud To examine factors that may impact on the accuracy of depression rating scales that are used to diagnose depression. We will examine the reference standard used for verification of DpD, baseline prevalence of DpD in the study population, age of the underlying study population, gender of participants, type of dementia (any-cause dementia versus Alzheimer’s disease), study setting (community or primary care setting, long-term care, tertiary care setting), and study country as potential sources of heterogeneity. We will also evaluate the effects of using different cut-points of individual depression rating scales on the diagnostic accuracy of the scales.

RÉSUMÉIl y a eu peu d’études qui se concentrent sur les chutes chez les clients qui reçoivent des soins à domicile (SD) avec des conditions neurologiques. Cette étude a identifié les facteurs qui accroissent le risque de chutes chez les clients SD sans histoire récente de telles chutes, et a exploré si les profils de risque variaient parmi les personnes atteintes de démence ou le parkinsonisme, par rapport à celles sans conditions neurologiques sélectionnés. Une étude de cohorte rétrospective a été utilisée, et l’analyse des données provenant de clients SD communautaires de l’Ontario a été menée sur un échantillon de clients ambulatoires atteints de démence, de parkinsonisme, ou d’aucune des conditions neurologiques sélectionnées. Les données ont été obtenues à partir de l’instrument d’évaluation des résidents en soins à domicile (IERSD-SD). Dans l’analyse multivariée, le résultat utilisé était de savoir si les clients ont tombé au cours du suivi. Une démarche instable était un fort prédicteur des chutes dans les trois groupes. Le parkinsonisme co-morbide a prédit plus fortement les chutes dans le groupe de démence. Les clients qui ont montré la limite intacte à la déficience cognitive légère étaient plus susceptibles de se sont trouvés dans les groupes de parkinsonisme et de comparaison. Les chances de tomber étaient plus élevées pour les clients avec la limite intacte à la déficience cognitive légère qui également faisaient partie des groupes de la maladie de Parkinson et de comparaison.

BackgroundPopulation-based prevalence and incidence studies are essential for understanding the societal burden of dementia with Lewy bodies (DLB).MethodsThe MEDLINE and EMBASE databases were searched to identify publications addressing the incidence and/or prevalence of DLB. References of included articles and prior systematic reviews were searched for additional studies. Two reviewers screened all abstracts and full-text reviews, abstracted data and performed quality assessments.ResultsTwenty-two studies were included. Incidence rates ranged from 0.5 to 1.6 per 1000 person-years. DLB accounted for 3.2-7.1% of all dementia cases in the incidence studies. Point and period prevalence estimates ranged from 0.02 to 63.5 per 1000 persons. Increasing prevalence estimates were reported with increasing age. DLB accounted for from 0.3 to 24.4% of all cases of dementia in the prevalence studies.ConclusionsDLB becomes more common with increasing age and accounts for about 5% of all dementia cases in older populations.

Background Evaluating different approaches to identifying frail home care clients at heightened risk for adverse health outcomes is an important but understudied area. Our objectives were to determine the prevalence and correlates of frailty (as operationally defined by three measures) in a home care cohort, the agreement between these measures, and their predictive validity for several outcomes assessed over one year. Methods We conducted a retrospective cohort study with linked population-based administrative and clinical (Resident Assessment Instrument [RAI]) data for all long-stay home care clients (aged 66+) assessed between April 2010–2013 in Ontario, Canada (n = 234,552). We examined two versions of a frailty index (FI), a full and modified FI, and the CHESS scale, compared their baseline characteristics and their predictive accuracy (by calculating the area under the ROC curve [AUC]) for death, long-term care (LTC) admission, and hospitalization endpoints in models adjusted for age, sex and comorbidity. Results Frailty prevalence varied by measure (19.5, 24.4 and 44.1 %, for full FI, modified FI and CHESS, respectively) and was similar among female and male clients. All three measures were associated with a significantly increased risk of death, LTC admission and hospitalization endpoints in adjusted analyses but their addition to base models resulted in modest improvement for most AUC estimates. There were significant differences between measures in predictive accuracy, with the full FI demonstrating a higher AUC for LTC admission and CHESS a higher AUC for hospitalization - although none of the measures performed well for the hospitalization endpoints. Conclusions The different approaches to detecting vulnerability resulted in different estimates of frailty prevalence among home care clients in Ontario. Although all three measures were significant predictors of the health outcomes examined, the gains in predictive accuracy were often modest with the exception of the full FI in predicting LTC admission. Our findings provide some support for the clinical utility of a comprehensive FI measure and also illustrate that it is feasible to derive such a measure at the population level using routinely collected data. This may facilitate further research on frailty in this setting, including the development and evaluation of interventions for frailty. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0309-z) contains supplementary material, which is available to authorized users.

RÉSUMÉInstitutionalization of the Elderly in Canadaa proposé que les efforts de s’attaquer aux causes sous-jacentes de baisses liées à l’âge de santé pourraient éradiquer la necessité pour les maisons de soins infirmiers. Cependant, la prévalence des maladies chroniques a augmenté, et les conditions comme la démence signifie que les maisons de soins infirmiers sont susceptibles de rester des éléments importants du système de soins de santé canadien. Le manque d’information clinique à l’échelle individuelle a été un problème fondamental qui limite la capacité de comprendre comment les maisons de soins infirmiers peuvent changer pour mieux répondre aux besoins d’une population vieillissante L’introduction d’instruments d’évaluation interRAI pour la plupart des provinces et territoires canadiens et la création du Système d’information sur les soins représentent des étapes importantes dans notre capacité à comprendre les soins dispensés par les maisons de soins infirmiers au Canada. Le témoignage de huit provinces et territoires montre que les besoins des personnes dans les soins de longue durée sont très complexes, que les allocations de ressources ne correspondent pas toujours aux besoins, et que la qualité varie considérablement entre et au sein des provinces.

Background: Use of combination pharmacotherapy, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin II type 1 receptor antagonists (angiotensin receptor blockers) and β-adrenoceptor antagonists (β-blockers) in the management of heart failure (HF) can reduce mortality, prevent functional decline and reduce health service use. However, these first-line therapies are underused in older populations. This article describes the use and predictors of use of first-line HF therapies in a population-based cohort of older home care clients in Ontario, Canada. Objectives: To examine the use and correlates of first-line pharmacotherapy in older home care clients with HF. Methods: This was a retrospective, cross-sectional study of Resident Assessment Instrument — Home Care (RAI-HC) data in individuals aged ≥65 years receiving home care services in the province of Ontario, Canada. Data collected were from all 14 health regions in Ontario. Home care clients with HF were identified from among those aged ≥65 years whose first RAI-HC assessment occurred between January 2004 and December 2007 (n = 176 866). Potential correlates of pharmacotherapy for HF were identified from the RAI-HC and examined using multivariable logistic regression. Results: HF prevalence was 12.4%. Among clients with HF, 28.6% received no first-line pharmacotherapy; this proportion declined by 6% over the 4 years studied. Only 28.0% were receiving recommended combination therapy. First-line pharmacotherapy use was dependent on hypertension and diabetes mellitus status. Use of pharmacotherapy was less likely among older clients and those with functional impairment, airway disease or behavioural symptoms. Conclusions: Approximately 29% of older home care clients with HF received no first-line HF pharmacotherapy, while another 28% received optimal first-line HF pharmacotherapy. In addition to the expected clinical correlates, the increased likelihood of non-use associated with clients’ demographic and functional characteristics raises concerns about quality of care. A better understanding of how these factors affect prescribing practices, particularly for combination therapy, would help to optimize HF disease management. For clinicians, this work also serves as a potential reminder to follow guideline recommendations for HF management in older, vulnerable adults.

OBJECTIVES: To construct a brief frailty index for older patients with coronary artery disease (CAD) undergoing coronary angiography that includes physical, cognitive, and psychosocial criteria and accurately predicts future disability and decline in health-related quality of life (HRQL). DESIGN: Prospective cohort. SETTING: An urban tertiary care hospital in Alberta, Canada. PARTICIPANTS: Three hundred seventy-four patients aged 60 and older (73% male) undergoing cardiac catheterization for CAD between October 2003 and May 2007. MEASUREMENTS: Potential frailty criteria examined at baseline (before the procedure) included measures of balance, gait speed, cognition, self-reported health, body mass index (BMI), depressive symptoms, and living alone. The outcomes assessed over 1 year were dependency in activities of daily living (ADLs) and HRQL. RESULTS: The five best-fitting criteria from regression analyses for ADL decline were poor balance (risk ratio (RR)=2.4, 95% confidence interval (CI)=1.4–4.0), abnormal BMI (RR=1.8, 95% CI=1.1–3.0), impaired Trail-Making Test Part B performance (RR=2.3, 95% CI=1.3–4.2), depressive symptoms (RR=1.8, 95% CI=1.1–3.1), and living alone (RR=2.2, 95% CI=1.3–3.8). Using the five criteria as separate variables or as a summary frailty index yielded identical areas under the receiver operating characteristic curve (0.76, 95% CI=0.66–0.84). Patients with three or more criteria (vs none) were at statistically significant greater risk for increased disability (RR=10.4, 95% CI=4.4–24.2) and decreased HRQL (RR=4.2, 95% CI=2.3–7.4) after 1 year. CONCLUSION: This brief frailty index including physical, cognitive, and psychosocial criteria was predictive of increased disability and decreased HRQL at 1 year in older patients with CAD undergoing angiography. This index may have applications for clinicians and researchers but requires further validation.

This study examined physicians' attitudes toward advanced directives and practices for the end-of-life care at Chiang Mai University Hospital, Thailand. The data were collected from 55 physicians (24 instructors and 31 residents) using self-reported questionnaires. The majority of the participants affirmed the usefulness of the advance directive (AD) for cardiopulmonary resuscitation and respected the patients' wish for this directive, although advanced end-of-life care and resuscitation planning with the patients was limited. Mostly, the relatives were consulted regarding ADs. This study suggests that, in traditional Thai culture, physicians and families are more inclined to make decisions for the patient when they feel that it is in the patient's best interest. Further research is needed to investigate how and to what extent such attitudes can affect medical practice for end-of-life care in the context of the rapid development and consequent changes taking place in Thailand.

The provision of preventive services and continuity of care are important aspects of long-term care (LTC). A proposed quality indicator of such care is the rate of hospitalizations due to ambulatory care sensitive conditions (ACSCs). As the ACSC approach to identifying potentially avoidable hospitalizations (PAH) was developed for younger community-dwelling adults in the United States, we sought to examine its applicability as a quality indicator for older institutionalized residents in Canada.ACSCs were identified in a linked hospital-based LTC and acute care administrative database at the Institute for Clinical Evaluative Sciences in Ontario, Canada. An expert panel was then convened to assess the applicability of existing ACSCs to an older institutionalized population in Canada and to develop consensus-based revisions appropriate to this setting. The revised definition of PAH was then applied to the same linked database.The proportion of hospitalizations categorized as a PAH using the original ACSCs was 47% (4177 of 8885). The panel suggested the inclusion of 2 new conditions (septicemia and falls/fractures) coupled with the deletion of 4 of the original ACSCs (immunization-preventable conditions; nutritional deficiency; severe ear, nose and throat infections; tuberculosis) that were rare hospital diagnoses in this population. Using the revised definition, 55% of hospitalizations (4874) were identified as potentially avoidable.Changes to the original list of ACSCs led to more hospitalizations being categorized as potentially avoidable. Significant variation between LTC facilities and over time in our PAH indicator may identify areas for improvement in preventive services and continuity of care for LTC residents.

Stress plays an important role in the etiology of mental and physical disorders. The effect of stress on health may be moderated by how people deal with stress. The objectives of this analysis were to (1) estimate the population proportions using various ways of dealing with stress in healthy people, in people with mental disorders and substance dependence and in individuals with general medical conditions only, and (2) identify factors associated with ways of dealing with stress. Data from the Canadian Community Health Survey, Mental Health and Well-being (CCHS-1.2) were used (n = 36,984). This was a national mental health survey which used a probability sample and incorporated a version of the Composite International Diagnostic Interview. Participants with mental disorders differed from healthy people in ways of dealing with stress. Among participants with mental disorders, women were more likely to report that they “talk to others” and “eat more/less” to deal with stress. Men were more likely to use “avoid people” and “drink alcohol” to deal with stress than women. Age differences within groups in ways of dealing with stress were found and having a history of mental disorders was also associated with reported ways of dealing with stress. Ways of dealing with stress differ by gender and age, but there is no over-arching pattern of maladaptive coping associated with mental disorders that applies across illness, age and gender categories. Healthy behaviors should be promoted as ways to relieve stress, leading to better self-care skills.

Objective To examine the prevalence and correlates of potentially inappropriate pharmacotherapy (including potential under-treatment) for depression in adult home care clients. Methods A cross-sectional study of clients receiving services from Community Care Access Centres in Ontario. Three thousand three hundred and twenty-one clients were assessed with the Resident Assessment Instrument for Home Care (RAI-HC). A score of 3 or greater on the Depression Rating Scale (DRS), a validated scale embedded within the RAI-HC, indicates the presence of symptoms of depression. Medications listed on the RAI-HC were used to categorize treatment into two groups: potentially appropriate and potentially inappropriate antidepressant drug therapy. Adjusted logistic regression models were used to explore relevant predictors of potentially inappropriate pharmacotherapy. Results 12.5% (n = 414) of clients had symptoms of depression and 17% received an appropriate antidepressant. Over half of clients (64.5%) received potentially inappropriate pharmacotherapy (including potential under-treatment). Age 75 years or older, higher levels of caregiver stress and the presence of greater comorbidity were associated with a higher risk of potentially inappropriate pharmacotherapy in multivariate analyses. Documentation of any psychiatric diagnosis on the RAI-HC and receiving more medications were significantly associated with a greater likelihood of appropriate drug treatment. Conclusion Most clients with significant depressive symptoms were not receiving appropriate pharmacotherapy. Having a documented diagnosis of a psychiatric condition on the RAI-HC predicted appropriate pharmacotherapy. By increasing recognition of psychiatric conditions, the use of standardized, comprehensive assessment instruments in home care may represent an opportunity to improve mental health care in these settings. Copyright © 2008 John Wiley & Sons, Ltd.

OBJECTIVES: To investigate whether exercise confounds the relationship between folate and cerebrovascular events, all-cause dementia, and Alzheimer's disease. DESIGN: Prospective cohort study. SETTING: Multiple centers in Canada. PARTICIPANTS: In the Canadian Study of Health and Aging, 466 people reported exercise levels, had folate measurements, and were not demented at baseline. After 5 years, 194 had adverse cerebrovascular events, and 65 had dementia (Alzheimer's disease in 47). MEASUREMENTS: Associations between folate and cerebrovascular outcomes were examined using logistic regression in the presence and absence of exercise and other confounders. RESULTS: Folate was associated with greater risk of Alzheimer's disease (odds ratio (OR)=2.12, 95% confidence interval (CI)=1.01–4.54) and cerebrovascular outcomes (OR=2.05, 95% CI=1.11–3.78) in adjusted analyses before the inclusion of exercise and neared significance with all-cause dementia (OR=1.80, 95% CI=0.94–3.45). After the inclusion of exercise, the association between folate and dementia and Alzheimer's disease was 29% and 25% lower, respectively, and neither association was any longer significant (Alzheimer's disease: OR=1.91, 95% CI=0.89–4.11; all-cause dementia: OR=1.62, 95% CI=0.84–3.15). Exercise was a significant confounder in the relationship between folate and Alzheimer's disease (P=.03) and dementia (P=.003) but not cerebrovascular outcomes (P=.64). Unlike folate, exercise was significantly associated with Alzheimer's disease (OR=0.43, 95% CI=0.19–0.98) and dementia (OR=0.35, 95% CI=0.17–0.72) in adjusted analyses. CONCLUSION: Exercise seems to account for much of the relationship between folate and incident dementia and Alzheimer's disease.

Major depressive episodes (MDE) and anxiety disorders are associated with significantly lower health-related quality of life (HRQL). The present study explores the ability of the EQ-5D HRQL measure to differentiate among those with a clinical diagnosis of MDE and/or anxiety disorders.Data were collected as part of the Alberta Mental Health Survey (2003). MDE and anxiety were defined by DSM-IV using the Mini International Neuropsychiatric Interview (M.I.N.I). Descriptive and multivariate regression analyses were used to examine associations between EQ-5D scores and mental health diagnoses.The prevalence for diagnoses (and proportion within each group reporting problems on the Anxiety/Depression domain) were: MDE alone 2.6% (48.6%); anxiety disorders alone 11.2% (38.9%); MDE and anxiety 5.2% (81.1%); and neither 80.9% (8.2%), respectively. Adjusted mean EQ-Index and EQ-VAS scores were shown to be significantly lower among those with MDE and anxiety disorders (0.70, 64.2), followed by those with MDE alone (0.83, 70.8) and anxiety disorders alone (0.84, 76.7), when compared with subjects with none of these conditions.Reporting problems on the EQ-5D Anxiety/Depression domain was more common among subjects with MDE alone than anxiety disorders alone. Other domains of the EQ-5D did identify the burden of co-morbid mental health conditions, but not as well as the Anxiety/Depression domain.

The main objective of this study was to summarize the effects of various individual, caregiver, and system-related factors on the risk of long-term care (LTC) placement for persons with dementia.We searched electronic databases for longitudinal studies reporting on predictors of LTC placement for persons with dementia residing in the community or supportive care settings. We performed meta-analyses with hazard ratios (HRs) of various predictors using random effects models and stratified the HRs with several study variables. Data on predictors not included in the meta-analyses were summarized descriptively.Full-text reviews of 360 papers were performed with data from 37 papers used to calculate pooled HRs for LTC placement of select person with dementia (age, sex, race, marital status, type of dementia, living arrangement, and relationship to caregiver) and caregiver (age, sex, and depressive symptoms) characteristics. White race [HR = 1.67, 95% confidence intervals (CI): 1.41-1.99], greater dementia severity (HR = 1.05, 95% CI: 1.03-1.06), and older age (HR = 1.02, 95% CI: 1.01-1.03) increased the risk of LTC placement. Married persons with dementia (HR = 0.38, 95% CI: 0.16-0.86) and living with their caregiver (HR = 0.72, 95% CI: 0.56-0.92) had a lower risk. Behavioral and psychological symptoms of dementia, the degree of functional impairment, and caregiver burden had a consistent effect on the risk of LTC placement in our descriptive review.We quantified the predictive effect of several risk factors for LTC placement. These estimates could be used to more precisely categorize the risk of institutionalization and potentially link those at higher risk to appropriate services. Copyright © 2016 John WileySons, Ltd.

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. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1415-5) contains supplementary material, which is available to authorized users.

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. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1733-2) contains supplementary material, which is available to authorized users.

To compare gambling behaviors in a random sample of community residents with and without mental disorders identified by the Composite International Diagnostic Interview (CIDI). A large national community survey conducted by Statistics Canada included questions about problems arising from gambling activities as per the Canadian Problem Gambling Index (CPGI). We compared respondents within three gambling severity categories (non-problem, low severity and moderate/high severity gambling) across three diagnostic groupings (mood/anxiety disorders, substance dependence/harmful alcohol use, no selected psychiatric disorder). Of the 14,934 respondents age 18–64 years who engaged in at least one type of gambling activity in the previous 12 months, 5.8% fell in the low severity gambling category while 2.9% fell in the moderate/high severity category. Females accounted for 51.7% of the sample. The risk of moderate/high severity gambling was 1.7 times higher in persons with mood or anxiety disorder compared to persons with no selected disorder. For persons with substance dependence or harmful alcohol use, the risk of moderate/high severity gambling was 2.9 times higher. Persons with both mood/anxiety and substance/alcohol disorders were five times more likely to be moderate/high severity gamblers. The odds ratio for females was 0.6 and for those with less than post-secondary education it was 1.52. Differences in age and personal income were not significant. Individuals in the community suffering from mood/anxiety disorders and substance dependence/harmful alcohol, and especially those with both, experience a higher risk for gambling problems. The treatment of these comorbidities should be integrated into any problem gambling treatment program.

To examine the predictive validity of the transtheoretical model (TTM) stages of change for mammography participation in Canadian women.We examined the association between baseline TTM stage of mammography adoption and subsequent mammography participation in a representative sample of 3,125 Canadian women aged 40 and older from the longitudinal Canadian National Population Health Survey.The likelihood of having a mammogram at follow-up (1998/1999) increased with progressive stages of change at baseline (1996/1997) even after adjusting for potential confounders. Relative to women in maintenance, women in precontemplation, relapse, contemplation, relapse risk, and action were significantly less likely to report a recent mammogram during follow-up (adjusted RR of 0.41, 0.50, 0.63, 0.75, and 0.92, respectively; P(trend)0.01). This pattern held for women within and outside of the 50-69 target age range, and for urban and to a lesser degree rural-dwelling women.Our findings support the predictive validity of the TTM stages of mammography adoption construct and the inclusion of both relapse and relapse risk categories to improve the sensitivity of the predictive model. Interventions to promote the eventual maintenance of mammography screening should also benefit from further research that aims to understand the variables that promote progressive movement through the stages.