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Objectives New models for the workforce are required in long-term care (LTC) homes, as was made evident during the Coronavirus Disease 2019 (COVID-19) pandemic. Nurse Practitioner (NP)-led models of care represent an effective solution. This study explored NPs’ roles in supporting LTC homes as changes in directives, policies, and recommendations related to COVID-19 were introduced. Design Qualitative exploratory study. Context Thirteen NPs working in LTC homes in Ontario, Canada. Methods Semi-structured interviews were conducted in March/April 2021. A five-step inductive thematic analysis was applied. Findings Analysis generated four themes: leading the COVID-19 vaccine rollout; promoting staff wellbeing related to COVID-19 fatigue; addressing complexities of new admissions; and negotiating evolving collaborative relationships. Conclusions Nurse practitioners were instrumental in supporting LTC homes through COVID-19 regulatory changes producing unintended consequences. The NPs’ leadership in transforming care is equally essential in LTC homes as in other established healthcare settings, such as primary and acute care.

BackgroundIn the early stage of dementia, persons living with dementia (PLwD) can identify their values and wishes for future care with a high degree of accuracy and reliability. However, there is a paucity of research to guide best practices on how best to incorporate advance care planning (ACP) in older adults diagnosed with mild dementia and therefore only a minority of these individuals participate in any ACP discussions. We developed an intervention called Voice Your Values (VYV) that healthcare professionals can implement to identify and document the values of PLwD and their trusted individuals such as friends or family.PurposeThis single-group pre-test and post-test design aimed to determine the feasibility, acceptability, and preliminary efficacy of the VYV intervention.MethodsA convenience sample of 21 dyads of PLwD and their trusted individuals were recruited from five outpatient geriatric clinics. The tailored VYV intervention was delivered to the dyads over two sessions using videoconferencing.ResultsIn terms of feasibility, the recruitment rate was lower (52%) than the expected 60%; the retention rate was high at 94%, and the intervention fidelity was high based on the audit of 20% of the sessions. In terms of preliminary efficacy, PLwD demonstrated improvement in ACP engagement (p = <0.01); trusted individuals showed improvements in decision-making confidence (p = 0.01) and psychological distress (p = 0.02); whereas a minimal change was noted in their dementia knowledge (p = 0.22).ConclusionMost of the feasibility parameters were met. A larger sample along with a control group, as well as a longitudinal study, are requisite to rigorously evaluate the efficacy of the promising VYV intervention. There is emerging evidence that people living with mild dementia can effectively participate in identifying and expressing their values and wishes for future care.

The COVID-19 pandemic rattled Canada's long-term care (LTC) sector by exacerbating the ingrained systemic and structural issues, resulting in tragic consequences for the residents, family members and LTC staff. At the core of LTC's challenges is chronic under-staffing, leading to lower quality of care for residents and higher degrees of moral distress among staff. A rejuvenation of the LTC sector to support its workforce is overdue. A group of diverse and renowned researchers from across Canada set out to implement innovative evidence-informed solutions in various LTC homes. Their findings call for immediate action from policy makers and LTC decision makers.

A palliative approach to care aims to meet the needs of patients and caregivers throughout a chronic disease trajectory and can be delivered by non-palliative specialists. There is an important gap in understanding the perspectives and experiences of primary care providers on an integrated palliative approach in dementia care and the impact of existing programs and models to this end. To address these, we undertook a scoping review. We searched five databases; and used descriptive numerical summary and narrative synthesizing approaches for data analysis. We found that: (1) difficulty with prognostication and a lack of interdisciplinary and intersectoral collaboration are obstacles to using a palliative approach in primary care; and (2) a palliative approach results in statistically and clinically significant impacts on community-dwelling individuals, specifically those with later stages of dementia. There is a need for high-quality research studies examining the integrated palliative approach models and initiation of these models sooner in the care trajectory for persons living with mild and moderate stages of dementia in the community.

Frailty is a syndrome involving increased vulnerability that usually develops from age-related decline in physiological reserves and function in multiple organ systems, resulting in an impaired ability to respond to acute changes in health conditions. It is imperative that healthcare providers who work with older adults in primary care and community settings understand how to assess frailty and can identify appropriate interventions. This article reports the results of a rapid review that examined how frailty is assessed in community-dwelling older adults and what interventions are used to address frailty in this population.

Background Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs? Methods The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model. Results TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges. Conclusion TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Background and Objectives There is an urgency to respond to the longstanding deficiencies in health human resources in the long-term care (LTC) home sector, which have been laid bare by the coronavirus disease 2019 (COVID-19) pandemic. Nurse practitioners (NPs) represent an efficient solution to human resource challenges. During the current pandemic, many Medical Directors in LTC homes worked virtually to reduce the risk of transmission. In contrast, NPs were present for in-person care. This study aims to understand the NPs’ roles in optimizing resident care and supporting LTC staff during the pandemic. Research Design and Methods This exploratory qualitative study employed a phenomenological approach. A purposive sample of 14 NPs working in LTC homes in Ontario, Canada, was recruited. Data were generated using semistructured interviews and examined using thematic analysis. Results Four categories relating to the NPs’ practices and experiences during the pandemic were identified: (a) containing the spread of COVID-19, (b) stepping in where needed, (c) supporting staff and families, and (d) establishing links between fragmented systems of care by acting as a liaison. Discussion and Implications The findings suggest that innovative models of care that include NPs in LTC homes are required moving forward. NPs embraced a multitude of roles in LTC homes, but the need to mitigate the spread of COVID-19 was central to how they prioritized their days. The pandemic clearly accentuated that NPs have a unique scope of practice, which positions them well to act as leaders and build capacity in LTC homes.

Background and Objectives Despite emerging evidence that persons with cognitive impairment (CI) (including dementia and/or delirium) can be rehabilitated post-hip fracture surgery, there still remains a paucity of research on best practice rehabilitation strategies that help healthcare providers effectively rehabilitate persons with CI. Therefore, this qualitative study explores healthcare professionals’ (HCPs) perspectives who have been successfully providing rehabilitation for people with CI. Research Design and Methods Sixteen HCPs with a specialty in rehabilitating persons with CI from one inpatient rehabilitation facility with various professional backgrounds were purposively sampled using a maximum diversity sampling strategy. Three focus group discussions were conducted to explore their experiences of providing rehabilitation to persons with CI. A hybrid inductive–deductive approach was used to analyze the data. Findings HCPs acknowledged that older adults with CI deserved the opportunity for inpatient rehabilitation and that good outcomes were achievable; however, their knowledge, skills, and attitudes required reframing. The analysis identified three essential components to rehabilitation: (1) staff education and support, (2) tailored rehabilitation approaches, and (3) care partner involvement and support. Discussion and Implications Rehabilitation of persons with CI post-hip fracture surgery is achievable, and HCPs can learn to modify their practices to achieve positive patient outcomes. The attitudes of the healthcare team members had to be shifted to embrace the belief that persons with CI can be rehabilitated. However, it takes a steep learning curve, creativity, ingenuity, and tailored approaches to rehabilitate persons with CI successfully. This involves knowing the individual, maintaining routines, and learning the best ways to engage and motivate the person. As well, care partners’ knowledge and understanding of the individual improved the chances of a successful rehabilitation stay and discharge. Essential to the success of rehabilitation of persons with CI includes a supportive management team to help create the processes to enable their staff to succeed.

ObjectivesDespite inpatient rehabilitation, many older adults post-hip fracture have difficulty returning to their prefracture levels of function and activity. This scoping review aims to identify interventions for community-dwelling older adults discharged from inpatient rehabilitation and examine the function and activity outcomes associated with these interventions.DesignThis scoping review followed Arksey and O’Malley’s five-stage framework.Data sourcesWe searched MEDLINE, CINAHL, PsycINFO, EMBASE and Ageline electronic databases for English-language articles published between January 1946 and January 2020.Eligibility criteriaWe included studies with health and social interventions involving community-dwelling older adults and their caregivers after hip fracture and inpatient rehabilitation. The interventions were selected if initiated within 60 days post-hip fracture surgery.Data extraction and synthesisTwo independent reviewers screened abstracts and full texts and extracted the data based on the inclusion criteria. A third reviewer adjudicated any disagreement and collated the extracted data.ResultsOf the 24 studies included in the review, most studies (79%) used exercise-based interventions, over half (63%) included activities of daily living training and/or home assessment and environment modification as intervention components, and three studies used social intervention components. Over half of the interventions (58%) were initiated in the inpatient setting and physiotherapists provided 83% of the interventions. Only seven studies (29%) involved tailored interventions based on the older adults’ unique needs and progress in exercise training. Six studies (25%) enrolled patients with cognitive impairment, and only one study examined caregiver-related outcomes. Exercise-based interventions led to improved function and activity outcomes. 29 different outcome measures were reported.ConclusionWhile exercise-based multicomponent interventions have evidence for improving outcomes in this population, there is a paucity of studies, including social interventions. Further, studies with standardised outcome measures are needed, particularly focusing on supporting caregivers and the recovery of older adults with cognitive impairment.

COVID-19 pandemic has resulted in a significant increase in deaths in long-term care homes (LTCH). People with dementia living in LTCHs represent one of the most frail and marginal­ized populations in Canada. The surge of COVID-19 cases in LTCHs and rationing of health-care resources during the pandemic have amplified the pre-existing need for improve­ments in palliative and end-of-life care in LTCHs. This pos­ition statement, created by a task force commissioned by the Alzheimer Society of Canada, provides recommendations for a multipronged coordinated approach to improving palliative and end-of-life care of people with dementia living in LTCHs during the COVID-19 pandemic and beyond.

Advance care planning (ACP) can improve outcomes for persons living with dementia (PLwD). Clinicians see the lack of acceptability of these conversations as a barrier to ACP in individuals with mild dementia. COVID-19 pandemic has magnified the need for ACP discussions in older adults, particularly for those living with dementia. In light of the pandemic, much of the healthcare is provided virtually, but little evidence exists on how to best implement ACP virtually. We designed Voice Your Values (VYV), a tailored ACP intervention for persons living with mild dementia and their trusted individuals such as friends or family. Purpose Determine the acceptability of the VYV intervention, in terms of its content and the potential utility of videoconferencing to deliver it. Methods For this pilot study, we recruited 21 dyads of older adults with mild dementia and their trusted individuals from five geriatric clinics in Ontario, Canada. The tailored VYV intervention was delivered to dyads over two sessions over videoconferencing. Acceptability was assessed using scores on a modified Treatment Evaluation Inventory. The interventionist diary and Researcher Virtual Experience Questionnaire were used to examine facilitators and barriers, whereas Participant Virtual Experience Questionnaire was used to understand their experience. Qualitative data was analyzed using inductive content analysis. Results 100% of the participants rated VYV as acceptable. Participants and researcher rated video and sound quality highly. PLwD who lived with their trusted individuals were more likely to find the intervention acceptable (t = 3.559, p = 0.001, β = 0.323). Five interrelated themes were established that describe the acceptability of the virtually delivered VYV intervention. All PLwD were able to articulate their values and wishes related to being in a terminal and vegetative states and had them documented. Conclusion The virtual VYV intervention was an acceptable approach to ACP in older adults with mild dementia and their trusted individuals.

Remote approaches for dementia research are required in the era of COVID-19, but moving a research program from in person to remote involves additional considerations. We recommend using outcome measures that have psychometric properties for remote delivery, and we recommend against adapting in-person scales for remote delivery without evidence for psychometric equivalency. We suggest remote research designs that maximize benefit for participants, which could have implications for control groups. Researchers should plan for flexibility in their methods for remote research and must not assume all participants will be able to videoconference; telephone-only research is possible. We recommend performing an assessment of information communication technology infrastructure and prior exposure to this technology with each participant before making a final choice on remote methods for research. In general, researchers should adapt their methods for remote research to each participant rather than requesting participants to adapt to the researchers. Screening for sensory loss should be conducted, and the impact of this on the use of technology for remote research should be considered. In this viewpoint, we detail how individualized training is required prior to engaging in remote research, how training plans interact with cognitive impairments and, finally, the steps involved in facilitating technology-based remote data collection.

UNSTRUCTURED Remote approaches for dementia research are required in the era of COVID-19, but moving a research program from in person to remote involves additional considerations. We recommend using outcome measures that have psychometric properties for remote delivery, and we recommend against adapting in-person scales for remote delivery without evidence for psychometric equivalency. We suggest remote research designs that maximize benefit for participants, which could have implications for control groups. Researchers should plan for flexibility in their methods for remote research and must not assume all participants will be able to videoconference; telephone-only research is possible. We recommend performing an assessment of information communication technology infrastructure and prior exposure to this technology with each participant before making a final choice on remote methods for research. In general, researchers should adapt their methods for remote research to each participant rather than requesting participants to adapt to the researchers. Screening for sensory loss should be conducted, and the impact of this on the use of technology for remote research should be considered. In this viewpoint, we detail how individualized training is required prior to engaging in remote research, how training plans interact with cognitive impairments and, finally, the steps involved in facilitating technology-based remote data collection.

OBJECTIVE To describe differences in home care use in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with dementia compared with those without dementia. DESIGN Retrospective cohort study of individually linked health administrative data. SETTING Community-dwelling older adults after discharge from inpatient rehabilitation facilities in Ontario, Canada. PARTICIPANTS A total of 17,263 older adults (N=17,263), of whom 2489 had dementia (14.4%), who were treated for hip fracture in acute care and then admitted to inpatient rehabilitation facilities between January 1, 2011 and March 31, 2017. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The proportion receiving home care services and number of visits (physiotherapy, occupational therapy, nursing, personal/homemaking) in the 30 days after discharge were compared by dementia status with multivariate models, stratified by sex. RESULTS Compared with those without dementia, adults with dementia were older, had lower functional scores, and were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P

There is an absence of high-quality workforce data that could be used globally for comparative research on workforce planning in the residential long-term care (LTC) sector. We know that older adults residing in the LTC settings have multimorbidities resulting in complex care needs, yet the workforce is insufficiently able to meet their needs. A further reduction in LTC workforce was noted during the COVID-19 pandemic which increased the risk of adverse outcomes for residents. Survey results focused on the workforce in LTC homes collected from several countries during the current pandemic, highlighted that several members of the workforce were either absent or worked virtually (e.g., physicians, social workers). A better understanding of who is/or should be in the house to meet the needs of residents during or after future pandemics requires a workforce data system that routinely collects this information to ensure best quality outcomes for residents and their carers.

Older adults diagnosed with mild dementia can identify their wishes, values and goals of care with a high degree of accuracy and reliability. However, there is a paucity of research to guide best practices on how to incorporate Advance Care Planning (ACP) in the care of older adults living with mild dementia. Thus, only a minority of them participate in any ACP discussions. We developed an intervention called Voice Your Values (VYV) that healthcare professionals can implement to identify and document values of older adults. This single group pretest and posttest design aimed to determine the feasibility, acceptability and preliminary efficacy of the intervention. A convenience sample of 20 dyads of older adults and their trusted individuals were recruited from 4 geriatric clinics. Tailored VYV intervention was delivered to dyads on a one-on-one basis over two sessions using videoconferencing. Feasibility was determined through recruitment and retention rates, and intervention fidelity. Acceptability was assessed using modified Treatment Evaluation Inventory. Primary outcome was the Surrogate Decision-Making Confidence Scale. Secondary outcomes included an ACP engagement survey to assess older adults’ engagement in ACP; Dementia Knowledge Assessment Tool for trusted individuals; and the Kessler Psychological Distress Scale for all participants. The recruitment rate was 45%, retention rate was 100% and 92% participants rated VYV as highly acceptable. Trusted individuals showed statistically significant improvement in decision-making confidence (p=.02) and psychological distress (p=.02); but no improvement in dementia knowledge (p=.47). Older adults demonstrated statistically significant improvement in ACP engagement (p=

Many hospitalized older adults experience delayed discharge. Transitional care programs (TCPs) provide short-term care to these patients to prepare them for transfer to nursing homes or back to the community. There are knowledge gaps related to the processes and outcomes of TCPs. We conducted a scoping review following Arksey & O’Malley’s framework to identify the: 1) characteristics of older patients served by TCPs, 2) services provided within TCPs, and 3) outcomes used to evaluate TCPs. We searched bibliographic databases and grey literature. We included papers and reports involving community-dwelling older adults aged ≥ 65 years and examined the processes and/or outcomes of TCPs. The search retrieved 4828 references; 38 studies and 2 reports met the inclusion criteria. Most studies were conducted in Europe (n=19) and America (n=13). Patients admitted to TCPs were 59-86 years old, had 2-10 chronic conditions, 26-74% lived alone, the majority were functionally dependent and had mild cognitive impairment. Most TCPs were staffed by nurses, physiotherapists, occupational therapists, social workers and physicians, and support staff. The TCPs provided 5 major types of services: assessment, care planning, treatment, evaluation/care monitoring and discharge planning. The outcomes most frequently assessed were discharge destination, mortality, hospital readmission, length of stay, cost and functional status. TCPs that reported significant improvement in older adults’ functions (which was the main goal of the TCPs) included multiple services delivered by multidisciplinary teams. There is a wide variation in the operationalization of TCPs within and between countries.

The global population is aging, and with this demographic shift, the incidence and prevalence of dementia are expected to increase. According to the World Health Organization, an estimated 50 million people are living with dementia worldwide, and this number is expected to triple to 150 million by 2050. Dementia initially affects the brain, eventually affecting the entire body culminating in death, commonly from the complications and comorbidities. People with dementia often experience eating difficulties in addition to a severe decline in cognitive, verbal, and functional abilities secondary to gradual neurodegenerative process, leading to weight loss, malnutrition, and dehydration. When eating difficulties and weight loss occur, health care providers and families often feel obligated to decide to either continue the oral feeding or opt for feeding tube placement. Primary care clinicians, both nurse practitioners and physicians, are presented with challenges when facilitating the decision regarding the feeding options in patients with advanced dementia. This narrative review aims at evaluating the impact of enteral nutrition versus oral feeding by comparing the rates of survival and adverse events in older adults with advanced dementia. It also highlights the best approaches to optimizing nutrition for this frail population.

IntroductionMany hospitalised older adults experience delayed discharges due to increased postacute health and social support needs. Transitional care programmes (TCPs) provide short-term care to these patients to prepare them for transfer to nursing homes or back to the community with supports. There are knowledge gaps related to the development, implementation and evaluation of TCPs. The aims of this scoping review (ScR) are to identify the characteristics of older patients served by TCPs; criteria for transfer, components and services provided by TCPs; and outcomes used to evaluate TCPs.Methods and analysisThe study involves six-step ScR and is informed by a collaborative/participatory approach whereby stakeholders engage in the development of the research questions, identification of literature, data abstraction and synthesis; and participation in consultation workshop. The search for scientific literature will be done in the Medline, PsychINFO, Emcare and CINAHL databases; as well, policies and reports that examined models of transitional care and the outcomes used to evaluate them will be reviewed. Records will be selected if they involve community dwelling older adults aged 65 years or older, or indigenous persons 45 years or older; and presented in English, French, Dutch and German languages. Records will be screened, reviewed and abstracted by two independent reviewers. Extracted data will be analysed using descriptive statistics and a narrative analysis, and organised according to Donabedian’s model of structure (characteristics of older adults experiencing delayed discharge and served by TCPs), process (TCP components and services) and outcome.Ethics and disseminationThis ScR does not require ethics approval. Dissemination activities include integrated knowledge translation (KT) (consultation with stakeholders throughout the study) and end-of-grant KT strategies (presentations at national and international conferences; and publication in peer-reviewed interdisciplinary journal).

Background: Older adults who sustain hip fractures encounter physical and functional decline after discharge from inpatient rehabilitation. Currently, a synthesis of literature is lacking on health and social supports that may impact outcomes in the community-dwelling older adults, post-discharge from rehabilitation. Methodology: We conducted a systematic review to a) evaluate how health and social supports influence outcomes for older adults and their caregivers following inpatient rehabilitation post-hip fracture surgery, and b) identify the factors that affect their impact on outcomes. We searched Medline, CINAHL, Embase, Emcare, Psychinfo, and Ageline for publications between 2000 and 2018. We followed Cochrane Handbook methods to screen titles and abstracts, appraise quality, collect data and synthesize results. Results: A total of 3364 articles were retrieved, and 34 studies were included for final synthesis, including 24 randomized control trials and 10 observational studies. Most studies excluded persons with moderate or severe cognitive impairment. Interventions can be broadly categorized as either comprehensive care delivered by interdisciplinary teams focusing on exercise, nutrition and fracture prevention; or exercise sessions delivered by health professionals, trained instructors or volunteers. Interventions involving interdisciplinary teams demonstrated moderate improvement of mobility and functional ability in the first 3 months. However, the longitudinal effects of interventions were not realized for all. Conclusion: This review provides evidence of the effectiveness of health and social supports provided to older adults post-hip fracture. We are uncertain of the applicability to people with cognitive decline due to exclusion from most studies. Implications for practice and research will be discussed.