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Background: Data on Canadian pharmacists’ knowledge and perceptions about frailty in older adults and its assessment in pharmacy practice are scarce. Methods: A cross-sectional survey of 349 Canadian pharmacists was conducted to evaluate pharmacists’ knowledge, perceptions and practices regarding frailty. Descriptive analyses summarized responses by practice setting, and a multivariable logistic regression model examined associations between respondent characteristics and the likelihood of assessing frailty. Results: Most respondents were female (70%), aged ≤34 years (47%), Canadian graduates (83%), from Ontario/Quebec (51%) and from urban centres (58%). Although a significant proportion agreed it is important for pharmacists to know (80%) and assess (56%) patient frailty status, only 36% reported assessing frailty in practice. Respondents exclusively practising in a community pharmacy were significantly less likely to agree that it is important for a pharmacist to know or assess frailty status and to report assessing it. Factors associated with a greater likelihood of assessment included positive beliefs about the importance of knowing a patient’s frailty status and having a greater proportion of older patients with cognitive or functional impairment in practice. Discussion: Findings suggest that pharmacists generally agree with the importance of understanding frailty as it relates to the appropriate use of medications, but most do not assess it. Further research is needed to identify the barriers to assessing frailty, while guidance is needed on which of the available screening tools can best be integrated into a clinical pharmacy practice. Conclusion: There is an opportunity to improve pharmaceutical care for older adults by providing pharmacists the means and resources to assess frailty in practice.

Background The COVID-19 pandemic has caused significant disruption to research activities across Canada. The Training and Capacity Building (T&CB) Program of the Canadian Consortium on Neurodegeneration in Aging (CCNA) conducted a survey be-tween May 11th, 2020 and May 19th, 2020 to identify the chal-lenges faced by CCNA trainees because of the pandemic and how to best support trainees in response to those challenges. Methods Graduate students and postdoctoral researchers working under the supervision of CCNA investigators (n=113) were invited to complete a web-based survey of 13 questions. Trainees were asked questions about the impact of COVID-19 on their research activities, degree progression, funding status, and suggestions for support from the T&CB Program during the COVID-19 pandemic. Results A total of 41 trainees responded to the survey (response rate: 36.3%); 83% of respondents reported that they experienced changes to their research activities as a result of COVID-19, and 50% anticipated that their degree completion would be delayed. Respondents requested information from the T&CB Program on funding for non-COVID-19 projects, alternative datasets, and short educational workshops. Conclusion The majority of CCNA trainees surveyed experienced sig-nificant changes to their research activities as a result of the COVID-19 pandemic. The T&CB Program responded by switching to online programming and facilitating remote research. Further engagement with trainees is needed to ensure continued progress of research in age-related neurodegenera-tive disease in Canada post-pandemic.

Background and ObjectivesThe multiple sclerosis (MS) population's survival from breast cancer and colorectal cancer is compromised. Cancer screening and timely diagnoses affect cancer survival and have not been studied in the MS cancer population. We investigated whether the diagnostic route, cancer stage, or diagnostic interval differed in patients with cancer with and without MS.MethodsWe conducted a matched population-based cross-sectional study of breast cancers (2007–2015) and colorectal cancers (2009–2012) in patients with MS from Ontario, Canada, using administrative data. Exclusion criteria included second or concurrent primary cancers, no health care coverage, and, for the patients without MS, those with any demyelinating disease. We based 1:4 matching of MS to non-MS on birth year, sex (colorectal only), postal code, and cancer diagnosis year (breast only). Cancer outcomes were diagnostic route (screen-detected vs symptomatic), stage (stage I vs all others), and diagnostic interval (time from first presentation to diagnosis). Multivariable regression analyses controlled for age, sex (colorectal only), diagnosis year, income quintile, urban/rural residence, and comorbidity.ResultsWe included 351 patients with MS and breast cancer, 1,404 matched patients with breast cancer without MS, 54 patients with MS and colorectal cancer, and 216 matched patients with colorectal cancer without MS. MS was associated with fewer screen-detected cancers in breast (odds ratio [OR] 0.68 [95% CI 0.52, 0.88]) and possibly colorectal (0.52 [0.21, 1.28]) cancer. MS was not associated with differences in breast cancer stage at diagnosis (stage I cancer, OR 0.81 [0.64, 1.04]). MS was associated with greater odds of stage I colorectal cancer (OR 2.11 [1.03, 4.30]). The median length of the diagnostic interval did not vary between people with and without MS in either the breast or colorectal cancer cohorts. Controlling for disability status attenuated some findings.DiscussionBreast cancers were less likely to be detected through screening and colorectal cancer more likely to be detected at early stage in people with MS than without MS. MS-related disability may prevent people from getting mammograms and colonoscopies. Understanding the pathways to earlier detection in both cancers is critical to developing and planning interventions to ameliorate outcomes for people with MS and cancer.

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

OBJECTIVE Severe hypoglycemia is associated with an increased risk of dementia. We examined if the association is consistently present in mid- and late-life hypoglycemia. RESEARCH DESIGN AND METHODS Using health care data from Population Data BC, we created a base cohort of patients age ≥40 years with incident type 2 diabetes. Exposure was the first occurrence of severe hypoglycemia (hospitalization or physician visit). We assessed exposure versus no exposure in mid- (age 45–64 years) and late-life (age 65–84 years) cohorts. Index date was the later of the 45th birthday (midlife cohort), 65th birthday (late-life cohort), or diabetes diagnosis. Those with hypoglycemia or dementia before the index date were excluded. Patients were followed from index date until dementia diagnosis, death, emigration, or 31 December 2018. Exposure was modeled as time dependent. We adjusted for confounding using propensity score weighting. Dementia risk was estimated using cause-specific hazards models with death as a competing risk. RESULTS Of 221,683 patients in the midlife cohort, 1,793 experienced their first severe hypoglycemic event. Over a median of 9.14 years, 3,117 dementia outcomes occurred (32 among exposed). Of 223,940 patients in the late-life cohort, 2,466 experienced their first severe hypoglycemic event. Over a median of 6.7 years, 15,997 dementia outcomes occurred (158 among exposed). The rate of dementia was higher for those with (vs. without) hypoglycemia in both the mid- (hazard ratio 2.85; 95% CI 1.72–4.72) and late-life (2.38; 1.83–3.11) cohorts. CONCLUSIONS Both mid- and late-life hypoglycemia were associated with approximately double the risk of dementia, indicating the need for prevention throughout the life course of those with diabetes.

Background and ObjectivesWe tested the hypothesis that overall and cancer-specific survival after a colorectal cancer diagnosis is lower in persons with multiple sclerosis (MS) than in those without MS using a retrospective matched cohort design.MethodsUsing population-based administrative data in Manitoba and Ontario, we identified persons with MS from a validated case definition and linked these cohorts to cancer registries to identify those with colorectal cancer. We selected persons with colorectal cancer and without MS, matching 4:1 on birth year, sex, cancer diagnosis year, and region. We used Cox proportional hazards regression to compare all-cause survival between cohorts, adjusting for age at cancer diagnosis, cancer diagnosis year, income, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a cause-specific hazards model. We pooled findings across provinces using random-effects meta-analysis. Complementary analyses using a subcohort from Ontario, adjusted for cancer stage and disability status, as measured from the use of home care or long-term care services.ResultsWe included 338 MS cases and 1,352 controls with colorectal cancer. The mean (SD) age at cancer diagnosis was 64.7 (11.1) years. After adjustment, MS was associated with an increased hazard for all-cause death that was highest 6 months after diagnosis (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.19–1.76) and then declined over time (HR [95% CI] at 1 year 1.34 [1.09–1.63], 2 years 1.24 [0.99–1.56], 5 years 1.10 [0.80–1.50]). MS was associated with increased cancer-specific death at 6 months after diagnosis only (HR 1.29, 95% CI 1.04–1.61). After adjustment for cancer stage, MS was associated with an increased hazard of death due to any cause (1.60, 95% CI 1.16–2.21) and with cancer-specific death (HR 1.47, 95% CI 1.02–2.12). The association of MS and all-cause death was partially attenuated after adjustment for disability status (HR 1.37, 95% CI 0.97–1.92), as was the association with cancer-specific death (HR 1.34, 95% CI 0.91–1.97).DiscussionOverall and cancer-specific survival was lower in persons with than without MS in the early period after colorectal cancer diagnosis. Further study is warranted to determine what factors underlie these worse outcomes.

Background Previous studies have shown hypoglycaemia to be associated with an increased risk of dementia; however, there are several design challenges to consider. The objective of this study is to assess the association between hypoglycaemia and dementia while addressing these challenges using a lag period, exposure density sampling (EDS) and inverse probability of treatment weighting (IPTW). Methods This was a population-based cohort using data (1996–2018) from British Columbia, Canada. From a cohort of incident type 2 diabetes patients aged 40–70 years, we created a dynamic sub-cohort of hypoglycaemia-exposed (≥1 episode requiring hospitalization or a physician visit) and unexposed individuals using EDS, in which four unexposed individuals per one exposed were randomly selected into risk sets based on diabetes duration and age. Follow-up was until dementia diagnosis, death, emigration or 31 December 2018. Those diagnosed with dementia within 2 years of follow-up were censored. We adjusted for confounding using IPTW and estimated the hazard ratio (HR, 95% CI) of dementia using weighted conditional cause-specific hazards risk models with death as a competing risk. Results Among 13 970 patients with incident type 2 diabetes, 2794 experienced hypoglycaemia. There were 329 dementia events over a median (interquartile range: IQR) follow-up of 5.03 (5.7) years. IPTW resulted in well-balanced groups with weighted incidence rates (95% CI) of 4.59 (3.52, 5.98)/1000 person-years among exposed and 3.33 (2.58, 3.88)/1000 person-years among unexposed participants. The risk of dementia was higher among those with hypoglycaemia (HR, 1.83; 95% CI 1.31, 2.57). Conclusions After addressing several methodological challenges, we showed that hypoglycaemia contributes to an increased risk of all-cause dementia among patients with type 2 diabetes.

Objectives To explore the current perceived relationship between older adults with varying levels of frailty and healthcare needs and community pharmacists. Methods This qualitative study conducted a thematic analysis of focus groups with older adults and older adult caregivers and community pharmacist participants. Participants were recruited following a maximum variation sampling technique. Verbatim transcripts were inductively coded using NVivo to develop key findings. Key findings Four major themes emerged: (i) Pharmacy Landscape, (ii) Prescription and Non-Prescription Drug Safety, (iii) Patient–Pharmacist Relationship and (iv) Recommendations for Pharmacy Practice. Themes demonstrate three key findings: (1) older adults approach drug information with a key focus on safety and cost of both prescription and non-prescription drugs, (2) there is a demonstrated opportunity, recognized by older adults and practitioners, for community pharmacists to expand their role in the care of older adults, (3) community pharmacists are able, interested and/or have already incorporated frailty assessments into their practice to better support their care of the older adult population with varying levels of frailty. Conclusions The results demonstrate a reason for the community pharmacist role to shift. The unique knowledge and skills of community pharmacists, coupled with their accessibility and strong patient–clinician relationship, have the potential to better support older adults with varying levels of frailty.

ObjectiveTo test the hypotheses that overall survival and cancer-specific survival after breast cancer diagnosis would be lower in persons with multiple sclerosis (MS) as compared to persons without MS using a retrospective matched cohort design.MethodsWe applied a validated case definition to population-based administrative data in Manitoba and Ontario, Canada, to identify women with MS. We linked the MS cohorts to cancer registries to identify women with breast cancer. Then we selected 4 breast cancer controls without MS matched on birth year, cancer diagnosis year, and region. We compared all-cause survival between cohorts using Cox proportional hazards regression adjusting for age at cancer diagnosis, cancer diagnosis period, income quintile, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a multivariable cause-specific hazards model. We pooled findings between provinces using meta-analysis.ResultsWe included 779 patients with MS and 3,116 controls with breast cancer. Most patients with stage data (1,976/2,822 [70.0%]) were diagnosed with stage I or II breast cancer and the mean (SD) age at diagnosis was 57.8 (10.7) years. After adjustment for covariates, MS was associated with a 28% increased hazard for all-cause mortality (hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.08–1.53), but was not associated with altered cancer-specific survival (HR 0.98; 95% CI 0.65–1.46).ConclusionWomen with MS have lower all-cause survival after breast cancer diagnosis than women without MS. Future studies should confirm these findings in other populations and identify MS-specific factors associated with worse prognosis.

Atrial fibrillation (AF) is relatively common among nursing home residents, and decisions regarding anticoagulant therapy in this setting may be complicated by resident frailty and other factors. The aim of this study was to examine trends and correlates of oral anticoagulant use among newly admitted nursing home residents with AF following the approval of direct-acting oral anticoagulants (DOACs). We conducted a retrospective cohort study of all adults aged > 65 years with AF who were newly admitted to nursing homes in Ontario, Canada, between 2011 and 2018 (N = 36,466). Health administrative databases were linked with comprehensive clinical assessment data captured shortly after admission, to ascertain resident characteristics. Trends in prevalence of anticoagulant use (any, warfarin, DOAC) at admission were captured with prescription claims and examined by frailty and chronic kidney disease (CKD). Log-binomial regression models estimated crude percentage changes in use over time and modified Poisson regression models assessed factors associated with anticoagulant use and type. The prevalence of anticoagulant use at admission increased from 41.1% in 2011/2012 to 58.0% in 2017/2018 (percentage increase = 41.1%, p

Objective This study aimed to provide population-level data regarding trends in multimorbidity over 13 years. Methods We linked provincial health administrative data in Ontario, Canada, to create 3 cross-sectional panels of residents of any age in 2003, 2009, and 2016 to describe: (i) 13-year trends in multimorbidity prevalence and constellations among residents and across age, sex, and income; and (ii) chronic condition clusters. Multimorbidity was defined as having at least any 2 of 18 selected conditions, and further grouped into levels of 2, 3, 4, or 5 or more conditions. Age-sex standardized multimorbidity prevalence was estimated using the 2009 population as the standard. Clustering was defined using the observed combinations of conditions within levels of multimorbidity. Results Standardized prevalence of multimorbidity increased over time (26.5%, 28.8%, and 30.0% across sequential panels), across sex, age, and area-based income. Females, older adults and those living in lower income areas exhibited higher rates in all years. However, multimorbidity increased relatively more among males, younger adults, and those with 4 or 5 or more conditions. We observed numerous and increasing diversity in disease clusters, namely at higher levels of multimorbidity. Conclusion Our study provides relevant and needed population-based information on the growing burden of multimorbidity, and related socio-demographic risk factors. Multimorbidity is markedly increasing among younger age cohorts. Also, there is an increasing complexity and lack of common clustering patterns at higher multimorbidity levels. Supplementary Information The online version contains supplementary material available at 10.17269/s41997-021-00474-y.

POINTS CLES Au Canada, la maladie a coronavirus 2019 (COVID-19) s’est revelee beaucoup plus mortelle chez les residents des foyers de soins de longue duree que dans le reste de la population[1][1]. Toutefois, la COVID-19 a eu un effet variable selon les provinces et les territoires. A

ObjectiveTo determine whether cancer risk differs in people with and without multiple sclerosis (MS), we compared incidence rates and cancer-specific mortality rates in MS and matched cohorts using population-based data sources.MethodsWe conducted a retrospective matched cohort study using population-based administrative data from Manitoba and Ontario, Canada. We applied a validated case definition to identify MS cases, then selected 5 controls without MS matched on birth year, sex, and region. We linked these cohorts to cancer registries, and estimated incidence of breast, colorectal, and 13 other cancers. For breast and colorectal cancers, we constructed Cox models adjusting for age at the index date, area-level socioeconomic status, region, birth cohort year, and comorbidity. We pooled findings across provinces using meta-analysis.ResultsWe included 53,983 MS cases and 269,915 controls. Multivariable analyses showed no difference in breast cancer risk (pooled hazard ratio [HR] 0.92 [95% confidence interval (CI) 0.78–1.09]) or colorectal cancer risk (pooled HR 0.83 [95% CI 0.64–1.07]) between the cohorts. Mortality rates for breast and colorectal did not differ between cohorts. Bladder cancer incidence and mortality rates were higher among the MS cohort. Although the incidence of prostate, uterine, and CNS cancers differed between the MS and matched cohorts, mortality rates did not.ConclusionThe incidence of breast and colorectal cancers does not differ between persons with and without MS; however, the incidence of bladder cancer is increased. Reported differences in the incidence of some cancers in the MS population may reflect ascertainment differences rather than true differences.

KEY POINTS People living in long-term care (LTC) homes in Canada have been far more likely to die of coronavirus disease 2019 (COVID-19) than the rest of the population.[1][1] However, the effect of COVID-19 on residents in LTC has varied across provinces and territories. For example, as of Sept. 10

Background/objectives To examine the association between hospitalization for a fall-related injury and the co-prescription of a cholinesterase inhibitor (ChEI) among persons with dementia receiving a beta-blocker, and whether this potential drug-drug interaction is modified by frailty. Design Nested case-control study using population-based administrative databases. Setting All nursing homes in Ontario, Canada. Participants Persons with dementia aged 66 and older who received at least one beta-blocker between April 2013 and March 2018 following nursing home admission (n = 19,060). Measurements Cases were persons with dementia with a hospitalization (emergency department visit or acute care admission) for a fall-related injury with concurrent beta-blocker use. Each case (n = 3,038) was matched 1:1 to a control by age (±1 year), sex, cohort entry year, frailty, and history of fall-related injuries. The association between fall-related injury and exposure to a ChEI in the 90 days prior was examined using multivariable conditional logistic regression. Secondary exposures included ChEI type, daily dose, incident versus prevalent use, and use in the prior 30 days. Subgroup analyses considered frailty, age group, sex, and history of hospitalization for fall-related injuries. Results Exposure to a ChEI in the prior 90 days occurred among 947 (31.2%) cases and 940 (30.9%) controls. In multivariable models, no association was found between hospitalization for a fall-related injury and prior exposure to a ChEI in persons with dementia dispensed beta-blockers (adjusted odds ratio = .96, 95% confidence interval = .85-1.08). Findings were consistent across secondary exposures and subgroup analyses. Conclusion Among nursing home residents with dementia receiving beta-blockers, co-prescription of a ChEI was not associated with an increased risk of hospitalization for a fall-related injury. However, we did not assess for its association with falls not leading to hospitalization. This finding could inform clinical guidelines and shared decision making between persons with dementia, caregivers, and clinicians concerning ChEI initiation and/or discontinuation.

In this narrative review, we focus on aspects of the complicated relationship between frailty and medications that we feel would be of particular interest to researchers and health care practitioners. Frailty and polypharmacy (≥5 medications) are inter-related with evidence of a bidirectional potentially casual relationship. Medication review and withdrawal of potentially inappropriate medications is frequently advised for the management of frailty. Changes in the pharmacokinetics and pharmacodynamics of drugs with frailty are felt to parallel those seen with aging though possibly more pronounced. While both frailty and polypharmacy are associated with adverse outcomes, recent research suggests that relative measures of associated risk may be blunted among older adults with frailty compared to non-frail older adults. Research on drug therapy in later life should include a consideration of frailty and how changes in frailty status may affect the balance between benefit and risk with pharmacotherapy.

ObjectiveWe compared the prevalence of physical and mental conditions and rate of health care utilization in mothers of children with multiple sclerosis (MS) (MS-mothers) with that of mothers of children without MS (non-MS-mothers).MethodsUsing population-based administrative data from Ontario, Canada, we identified MS-mothers and non-MS-mothers, matched on maternal age at childbirth, region, and the child's age and sex at the time of MS diagnosis. We compared the prevalence of any physical condition or any mood or anxiety disorder between the cohorts, in the child's MS diagnosis year, and 5 years before and after diagnosis. We compared rates of physician visits before diagnosis, during the diagnosis year, and after the child's diagnosis using multivariable regression models with generalized estimating equations adjusting for maternal age, socioeconomic status, region of residence, and index year.ResultsWe identified 156 MS-mothers and 624 non-MS-mothers. MS-mothers had a higher prevalence of any physical condition and of any mood or anxiety disorder than non-MS-mothers, before, during, and after their child's diagnosis. On multivariable analysis, MS-mothers did not have higher rates of primary care visits (rate ratio [RR] 1.04; 95% confidence interval [CI] 0.90–1.20), but exhibited increased odds of having any psychiatry visits (odds ratio 1.60; 95% CI 1.10–2.31); the rate of visits did not differ when they did occur (RR 0.66; 95% CI 0.33–1.30).ConclusionMothers of children with MS use more mental health services before and after their child's MS diagnosis than mothers of children without MS. Pediatric health care providers should consider the mental well-being of mothers and their children with MS.

Introduction: Little is known about how mortality in multiple sclerosis (MS) may differ based on sociodemographic factors, such as immigrant status. We compared mortality in immigrants versus long-term residents with MS in Ontario, Canada. Methods: In this retrospective cohort study, we applied a validated algorithm to linked, population-based immigration and health administrative data to identify incident MS cases in Ontario between 1994 and 2014. We identified date of death, if it occurred. We used a Cox model adjusting for age, sex, income, and comorbidity, to compare survival in immigrants versus long-term residents. Results: There were 23,603 incident MS cases of whom 1,410 (6.0%) were immigrants. After adjusting for covariates, risk of death was higher in immigrants in the first year after diagnosis (hazard ratio [HR] 1.66; 95% CI 1.05–2.63, p = 0.031). However, in years 1–5 (HR 0.63; 95% CI 0.40–0.98, p = 0.041) and 5–10 (HR 0.42; 95% CI 0.24–0.75, p = 0.003) after diagnosis, risk of death was lower in immigrants. Older age at onset and comorbidity were associated with higher mortality; female sex and higher socioeconomic status were associated with lower mortality. Conclusions: In this large population with universal access to health care, immigrants with MS had higher mortality compared to long-term residents in the first year after onset and lower mortality thereafter. Lower mortality in immigrants to Canada is well described and thought to be due to the healthy immigrant effect. Higher mortality in the first year after MS onset warrants further investigation as some early deaths may be preventable.

This study investigated the association between subtypes of social support availability (SSA) and memory in persons aged 45 to 85 years (n = 24,719). We examined two memory outcomes using a modified Rey Auditory Verbal Learning Test (RAVLT)-immediate recall (RAVLT I) and delayed recall (RAVLT II)-and five subtypes of SSA: affectionate, emotional/informational, positive interactions, tangible, overall. We found statistically significant and adjusted positive associations between all SSA subtypes and memory, except for positive interactions and delayed recall memory. For RAVLT I, the regression coefficients (

Estimates of polypharmacy have primarily been derived from prescription claims, and less is known about the use of non-prescription medications (alone or in combination with prescription medications) across the frailty spectrum or by sex. Our objectives were to estimate the prevalence of polypharmacy (total, prescription, non-prescription, and concurrent prescription and non-prescription) overall, and by frailty, sex and broad age group.Canadian Health Measures Survey, Cycle 5, 2016 to 2017.Among Canadians aged 40 to 79 years, all prescription and non-prescription medications used in the month prior to the survey were documented. Polypharmacy was defined as using five or more medications total (prescription and non-prescription), prescription only and non-prescription only. Concurrent prescription and non-prescription use was defined as two or more and three or more of each. Frailty was defined using a 31-item frailty index (FI) and categorized as non-frail (FI ≤ 0.1) and pre-frail or frail (FI0.1). Survey-weighted descriptive statistics were calculated overall and age standardized.We analyzed 2,039 respondents, representing 16,638,026 Canadians (mean age of 56.9 years; 51% women). Overall, 52.4% (95% confidence interval [CI] = 47.3 to 57.4) were defined as pre-frail or frail. Age-standardized estimates of total polypharmacy, prescription polypharmacy and concurrent prescription and non-prescription medication use were significantly higher among pre-frail or frail versus non-frail adults (e.g., total polypharmacy: 64.1% versus 31.8%, respectively). Polypharmacy with non-prescription medications was common overall (20.5% [95% CI = 16.1 to 25.8]) and greater among women, but did not differ significantly by frailty.Polypharmacy and concurrent prescription and non-prescription medication use were common among Canadian adults, especially those who were pre-frail or frail. Our findings highlight the importance of considering non-prescribed medications when measuring the exposure to medications and the potential risk for adverse outcomes.

Background: Migration studies may provide insights into environmental determinants of multiple sclerosis (MS) and whether a critical window for exposure exists. We aimed to determine risk factors for MS in immigrants and compare MS risk in immigrants versus long-term residents in Ontario, Canada. Methods: We applied a validated algorithm to linked, population-based immigration and health claims data to identify incident MS cases in immigrants and long term-residents between 1994 and 2016. We conducted two multivariable Cox proportional hazards regression analyses including one limited to the immigrant cohort assessing potential risk factors for developing MS; and one comparing MS risk between immigrants and matched long-term residents (1:3 match). Results: We identified 2,304,302 immigrants for the immigrant-only analysis, of whom 1,526 (0.066%) developed MS. Younger age at migration, female sex, greater co-morbidity burden, lower neighbourhood income, and time since landing were associated with increased MS risk. Risk was greatest in those

Long-term care (LTC) residents have been disproportionately impacted by the COVID-19 pandemic, both from the virus itself and the restrictions in effect for infection prevention and control. Many barriers exist in LTC to prevent the effective isolation of suspect or confirmed COVID-19 cases. Furthermore, these measures have a severe impact on the well-being of LTC residents. Our aim was to develop a guide for long-term care to address the ethical challenges associated with isolating dementia patients during the pandemic. The Dementia Isolation Toolkit (DIT) was developed by members of the research team in partnership with LTC stakeholders to address: 1) the practical challenges of isolating or quarantining people with dementia in a compassionate, safe, and effective manner; and 2) the need for ethical guidance to support decision-making regarding isolation and infection control in LTC, to prevent indecision and moral distress. To develop the DIT the team reviewed and synthesized the literature on pandemic ethics in a plain-language document, which was then reviewed by our partners and stakeholders. The final ethical guidance tool includes a discussion of the ethics around infection control measures in a pandemic, an ethical decision-making tool, and a person-centred isolation care planning tool. The ethical guidance tool has been downloaded more than 6500 times since it was published (bit.ly/dementiatoolkit), and has been disseminated internationally. The worksheets are being used during outbreaks to support care and decision-making, as well as proactively, to prepare for outbreaks by developing isolation care plans. There is a need for support for ethical decision-making in the context of a pandemic, particularly in settings such as LTC. Future studies will evaluate the implementation of the tool and its impact in addressing moral distress in health care providers in long-term care.

The first wave of the COVID-19 pandemic necessitated extensive infection control measures in long-term care (LTC) and had a significant impact on staffing and services. Anecdotal reports indicate that this negatively affected LTC residents' quality of care and wellbeing, but there is scarce evidence on the effects of COVID-19 on quality of dementia care in LTC.From December 2020 to March 2021, we conducted a cross-sectional online survey among staff who worked in LTC homes in Ontario, Canada. Survey questions examined staffs' perceptions of the impact of COVID-19 on dementia quality of care during the initial wave of the COVID-19 pandemic (beginning 1 March 2020).There were a total of 227 survey respondents; more than half reported both worsened overall quality of care (51.3%) and worsening of a majority of specific quality of care measures (55.5%). Measures of cognitive functioning, mobility and behavioural symptoms were most frequently described as worsened. Medical and allied/support staff had the highest odds of reporting overall worsened quality of care, while specialized behavioural care staff and those with more experience in LTC were less likely to. LTC home factors including rural location and smaller size, staffing challenges, higher number of outbreaks and less COVID-19 preparedness were associated with increased odds of perceived worsening of quality of dementia care outcomes.These findings suggest that COVID-19 pandemic restrictions and related effects such as inadequate staffing may have contributed to poor quality of care and outcomes for those with dementia in LTC.

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.

Background The coronavirus disease 2019 (COVID-19) pandemic has potentially impacted outpatient antibiotic prescribing. Investigating this impact may identify stewardship opportunities in the ongoing COVID-19 period and beyond. Methods We conducted an interrupted time series analysis on outpatient antibiotic prescriptions and antibiotic prescriptions/patient visits in Ontario, Canada, between January 2017 and December 2020 to evaluate the impact of the COVID-19 pandemic on population-level antibiotic prescribing by prescriber specialty, patient demographics, and conditions. Results In the evaluated COVID-19 period (March–December 2020), there was a 31.2% (95% CI, 27.0% to 35.1%) relative reduction in total antibiotic prescriptions. Total outpatient antibiotic prescriptions decreased during the COVID-19 period by 37.1% (95% CI, 32.5% to 41.3%) among family physicians, 30.7% (95% CI, 25.8% to 35.2%) among subspecialist physicians, 12.1% (95% CI, 4.4% to 19.2%) among dentists, and 25.7% (95% CI, 21.4% to 29.8%) among other prescribers. Antibiotics indicated for respiratory infections decreased by 43.7% (95% CI, 38.4% to 48.6%). Total patient visits and visits for respiratory infections decreased by 10.7% (95% CI, 5.4% to 15.6%) and 49.9% (95% CI, 43.1% to 55.9%). Total antibiotic prescriptions/1000 visits decreased by 27.5% (95% CI, 21.5% to 33.0%), while antibiotics indicated for respiratory infections/1000 visits with respiratory infections only decreased by 6.8% (95% CI, 2.7% to 10.8%). Conclusions The reduction in outpatient antibiotic prescribing during the COVID-19 pandemic was driven by less antibiotic prescribing for respiratory indications and largely explained by decreased visits for respiratory infections.

Introduction/aims Amyotrophic lateral sclerosis (ALS) symptoms mimic those of other conditions and often require multiple physician and healthcare contacts for investigation and accurate diagnosis. We examined the type and frequency of healthcare service utilization prior to ALS diagnosis and tracheostomy-free survival by sex and rurality among individuals treated with riluzole in Ontario, Canada. Methods This population-based cohort study used administrative databases to identify patients aged 18+ years diagnosed with ALS and started on riluzole between April 2002-March 2018. Using Poisson regression, rate ratios of healthcare utilization and atypical diagnostic tests and unnecessary therapeutic interventions five years prior to ALS diagnosis were compared by sex and rurality. Tracheostomy-free survival after diagnosis was compared between groups using Kaplan-Meier estimators and proportional hazards models. Results 1071 patients with ALS were identified with a mean age of 70 years; 563 (52.6%) were men and 134 (12.5%) were rural residents. The number of physician visits increased in the 18 months prior to ALS diagnosis. We observed modest sex differences in healthcare utilization. Rural patients had lower neurologist visit rates (RR 0.78, 95%CI 0.70-0.87) and were significantly more likely to receive an atypical diagnostic test or unnecessary therapeutic intervention (RR 1.80, 95%CI 1.04-3.10). Tracheostomy-free survival did not differ by sex (log-rank p-value = 0.78) or rurality (p-value = 0.84). Discussion Given disparities observed in healthcare of rural ALS patients, policy strategies are needed to ensure all patients have timely access to care along the pathway from symptom onset to ALS diagnosis, to enable access to new therapeutics and clinical trials. This article is protected by copyright. All rights reserved.

Background: Multiple sclerosis (MS) has been associated with certain comorbidities in general population studies, but it is unknown how comorbidity may affect immigrants with MS. Objective: To compare prevalence of comorbidities in immigrants and long-term residents at MS diagnosis, and in matched control populations without MS. Methods: We identified incident MS cases using a validated definition applied to health administrative data in Ontario, Canada, from 1994 to 2017, and categorized them as immigrants or long-term residents. Immigrants and long-term residents without MS (controls) were matched to MS cases 3:1 on sex, age, and geography. Results: There were 1534 immigrants and 23,731 long-term residents with MS matched with 4585 and 71,193 controls, respectively. Chronic obstructive pulmonary disease (COPD), diabetes, hypertension, ischemic heart disease, migraine, epilepsy, mood/anxiety disorders, schizophrenia, inflammatory bowel disease (IBD), and rheumatoid arthritis were significantly more prevalent among immigrants with MS compared to their controls. Prevalence of these conditions was generally similar comparing immigrants to long-term residents with MS, although COPD, epilepsy, IBD, and mood/anxiety disorders were less prevalent in immigrants. Conclusion: Immigrants have a high prevalence of multiple comorbidities at MS diagnosis despite the “healthy immigrant effect.” Clinicians should pay close attention to identification and management of comorbidity in immigrants with MS.

Introduction Comprehensive, population-based investigations of the extent and temporality of associations between common neurological and psychiatric disorders are scarce. Methods This retrospective cohort study used linked health administrative data for Ontarians aged 40–85 years on 1 April 2002, to estimate the adjusted rate of incident dementia, Parkinson’s disease (PD), stroke or mood/anxiety disorder (over 14 years) according to the presence and time since diagnosis of a prior disorder. Sex differences in the cumulative incidence of a later disorder were also examined. Results The cohort included 5,283,546 Ontarians (mean age 56.2 ± 12.1 years, 52% female). The rate of dementia was significantly higher for those with prior PD (adjusted hazard ratio [adjHR] 4.05, 95% confidence interval [CI] 3.99–4.11); stroke (adjHR 2.49, CI 2.47–2.52) and psychiatric disorder (adjHR 1.79, CI 1.78–1.80). The rate of PD was significantly higher for those with prior dementia (adjHR 2.23, CI 2.17–2.30) and psychiatric disorder (adjHR 1.77, CI 1.74–1.81). The rate of stroke was significantly higher among those with prior dementia (adjHR 1.56, CI 1.53–1.58). Prior dementia (adjHR 2.36, CI 2.33–2.39), PD (adjHR 1.80, CI 1.75–1.85) and stroke (adjHR 1.47, CI 1.45–1.49) were associated with a higher rate of an incident psychiatric disorder. Generally, associations were strongest in the 6 months following a prior diagnosis and demonstrated a J-shape relationship over time. Significant sex differences were evident in the absolute risks for several disorders. Conclusions The observed nature of bidirectional associations between these neurological and psychiatric disorders indicates opportunities for earlier diagnosis and interventions to improve patient care.

Objective In this study, we investigated the incremental 1-year direct costs of health care associated with frailty among home care recipients in Ontario with and without dementia. Methods We conducted a cohort study of 159,570 home care clients aged 50 years and older in Ontario, Canada in 2014/2015. At index home care assessment, we ascertained dementia status using a validated algorithm and frailty level (robust, prefrail, frail) based on the proportion of accumulated to potential health deficits. Clients were followed for 1-year during which we obtained direct overall and sector-specific publicly-funded health care costs (in 2015 Canadian dollars). We estimated the incremental effect of frailty level on costs using a 3-part survival- and covariate-adjusted estimator. All analyses were stratified by dementia status. Results Among those with dementia (n=42,828), frailty prevalence was 32.1% and the average 1-year cost was $30,472. The incremental cost of frailty (vs. robust) was $10,845 [95% confidence interval (CI): $10,112-$11,698]. Among those without dementia (n=116,742), frailty prevalence was 25.6% and the average 1-year cost was $28,969. Here, the incremental cost of frailty (vs. robust) was $12,360 (95% CI: $11,849-$12,981). Large differences in survival between frailty levels reduced incremental cost estimates, particularly for the dementia group (survival effect: -$2742; 95% CI: -$2914 to -$2554). Conclusions Frailty was associated with greater 1-year health care costs for persons with and without dementia. This difference was driven by a greater intensity of health care utilization among frail clients. Mortality differences across the frailty levels mitigated the association especially among those with dementia.

Objectives To determine whether decreased communication ability among long-term care residents is associated with increased antibiotic exposure. Design Retrospective cohort study. Setting All long-term care homes in Ontario, Canada. Participants All adults aged 66 years or older residing in long-term care and undergoing a full assessment between January 1 and December 31, 2016 (N = 87,947). Measurements Data were obtained from linkable, population-wide administrative data sets. Residents were identified, and characteristics were abstracted from the Resident Assessment Instrument Minimum Dataset version 2.0. The primary predictors of interest were residents' ability to make themselves understood and ability to understand others. The primary outcome was antibiotic days of treatment per 1000 resident days in the 90 days following assessment (obtained from the Ontario Drug Benefits Database). Results Those who were sometimes/rarely/never able to make themselves understood received 50.7 antibiotic days per 1000 person-days of follow-up, compared to 62.1 received by those who were able to make themselves understood. Those who were sometimes/rarely/never able to understand others received 50.0 antibiotic days per 1000 person-days of follow-up, compared to 61.4 by those who were able to understand others. Multivariable Poisson regression, accounting for resident characteristics, confirmed that compared to those with highest levels of communication ability, those who could sometimes/rarely/never make themselves understood had significantly fewer days on antibiotics (rate ratio [RR] = 0.76; confidence interval [95% CI] = 0.73-0.79) as did those who could sometimes/rarely/never understand others (RR = 0.76; 95% CI = 0.74-0.79). Conclusion Poor resident communication ability is not a driver of antibiotic overuse in long-term care. In fact, lower ability to understand others and/or be understood by others is associated with less antibiotic exposure. Further work is needed to optimize antibiotic use in long-term care residents across the entire spectrum of communication skills.

BACKGROUND: Guidance from randomized clinical trials about the ongoing benefits of statin therapies in residents of long-term care facilities is lacking. We sought to examine the effect of statin dose on 1-year survival and admission to hospital for cardiovascular events in this setting. METHODS: We conducted a retrospective cohort study using population-based administrative data from Ontario, Canada. We identified 21 808 residents in long-term care facilities who were 76 years of age and older and were prevalent statin users on the date of a full clinical assessment between April 2013 and March 2014, and categorized residents as intensive- or moderate-dose users. Treatment groups were matched on age, sex, admission to hospital for atherosclerotic cardiovascular disease, resident frailty and propensity score. Differences in 1-year survival and admission to hospital for cardiovascular events were measured using Cox proportional and subdistribution hazard models, respectively. RESULTS: Using propensity-score matching, we included 4577 well-balanced pairs of residents who were taking intensive- and moderate-dose statins. After 1 year, there were 1210 (26.4%) deaths and 524 (11.5%) admissions to hospital for cardiovascular events among residents using moderate-dose statins compared with 1173 (25.6%) deaths and 522 (11.4%) admissions to hospital for cardiovascular events among those taking intensive-dose statins. We found no significant association between prevalent use of intensive-dose statins and 1-year survival (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.90 to 1.05) or 1-year admission to hospital for cardiovascular events (HR 0.99, 95% CI 0.88 to 1.12) compared with use of moderate-dose statins. INTERPRETATION: The rates of mortality and admission to hospital for cardiovascular events at 1 year were similar between residents in long-term care taking intensive-dose statins compared with those taking moderate-dose statins. This lack of benefit should be considered when prescribing statins to vulnerable residents of long-term care facilities who are at potentially increased risk of statin-related adverse events.

Antipsychotic reduction in nursing homes has been a focus of research and policy attention for several decades; however, there is evidence that these initiatives may have had unintended consequences, such as medication substitution and changes in diagnosis coding. Our objectives were to describe temporal changes in the use of antipsychotics, potential substitution medications, and diagnoses and symptoms used to establish the appropriateness of antipsychotic prescribing.Repeated cross-sectional study design.Individuals, 66 to 105 years of age, living in nursing homes in Ontario, Canada between April 1, 2010 and December 31, 2019.Linked health administrative and clinical data were used to estimate the quarterly prevalence of dispensed antipsychotics, antidepressants, anticonvulsants, and benzodiazepines, as well as diagnoses and symptoms (eg, schizophrenia and delusions) applied to establish the appropriateness of antipsychotic use. Generalized linear models with generalized estimating equations, binomial distribution, and identity link function estimated the absolute changes over time among the population overall, by dementia diagnosis, and by severity of aggressive behaviors and cognitive impairment.Among over 70,000 nursing home residents each quarter, we observed general declines in antipsychotic (-0.70% per year [95% confidence limit (CL) -0.74%, -0.66%]) and benzodiazepine use (-1.17% per year [95% CL -1.20%, -1.14%]), and increases in antidepressant (0.89% per year [95% CL 0.84%, 0.94%]) and anticonvulsant use (1.06% per year [95% CL 1.03%, 1.09%]). Although initially stable, the coding of delusions increased from 3.5% to 10.2% (1.18% per year [95% CL 1.12%, 1.24%]) between 2014 and 2019, whereas schizophrenia remained stable. Increases in antidepressant use and recorded delusions were more pronounced among residents with dementia and aggressive behaviors.Medication substitution and changes in diagnosis/symptom coding may be potential unintended consequences of initiatives to reduce inappropriate antipsychotic use. How this corresponds to resident-level prescribing and clinical outcomes warrants further investigation.