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Objective: To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services., Design: Nested case-control study., Setting and Participants: Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December 31, 2019. New residents of assisted living were matched on age, sex, and initiation date of home care (± 7 days) to community-dwelling home care recipients in a 1:4 ratio., Methods: Clinical and functional status, health service use, sociodemographic variables, and community-level characteristics were examined; conditional logistic regression was used to model associations with a transition to an assisted living facility., Results: There were 2427 new residents of assisted living who were matched to 9708 home care recipients [mean (SD) age 85.5 (6.02) years, 72% female]. Most of the new residents were concentrated in urban communities and communities with higher income quintiles. New residents had an increased rate of physician-diagnosed dementia [adjusted hazard ratio (aHR), 1.28; 95% CI, 1.14-1.43], mood disorders (aHR, 1.17; 95% CI, 1.05-1.29), and cardiac arrhythmias (aHR, 1.19; 95% CI, 1.07-1.32). They also had higher rates of mild cognitive impairment (aHR, 1.43; 95% CI, 1.24-1.66), 2 or more falls (aHR, 1.29; 95% CI, 1.11-1.51), participation in activities of long-standing interest in the past 7 days (aHR, 1.29; 95% CI, 1.11-1.50), and a lower rate of a spouse or partner unpaid caregiver vs a child (aHR, 0.66; 95% CI, 0.56-0.79)., Conclusions and Implications: New residents of assisted living were mostly women, were cognitively impaired, had clinical comorbidities that could increase their risk of injuries, and had caregivers who were their children. These findings stress the importance of upscaling memory and dementia care in assisted living to address the needs of this population., Competing Interests: Disclosures The authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

Background: It is unclear whether antibiotics impact delirium outcomes in older adults with pyuria or bacteriuria in the absence of systemic signs of infection or genitourinary symptoms., Methods: We registered our systematic review protocol with PROSPERO (CRD42023418091). We searched the Medline and Embase databases from inception until April 2023 for studies investigating the impact of antimicrobial treatment on the duration and severity of delirium in older adults (≥60 years) with pyuria (white blood cells detected on urinalysis or dipstick) or bacteriuria (bacteria growing on urine culture) and without systemic signs of infection (temperature > 37.9C [>100.2F] or 1.5C [2.4F] increase above baseline temperature, and/or hemodynamic instability) or genitourinary symptoms (acute dysuria or new/worsening urinary symptoms). Two reviewers independently screened search results, abstracted data, and appraised the risk of bias. Full-text randomized controlled trials (RCTs) and observational study designs were included without restriction on study language, duration, or year of publication., Results: We screened 984 citations and included 4 studies comprising 652 older adults (mean age was 84.6 years and 63.5% were women). The four studies were published between 1996 and 2022, and included one RCT, two prospective observational cohort studies, and one retrospective chart review. None of the four studies demonstrated a significant effect of antibiotics on delirium outcomes, with two studies reported a worsening of outcomes among adults who received antibiotics. The three observational studies included had a moderate or serious overall risk of bias, while the one RCT had a high overall risk of bias., Conclusions: Our systematic review found no evidence that treatment with antibiotics is associated with improved delirium outcomes in older adults with pyuria or bacteriuria and without systemic signs of infection or genitourinary symptoms. Overall, the evidence was limited, largely observational, and had substantial risk of bias., (© 2024 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

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

Background: The relative contributions of long-term care (LTC) resident frailty and home-level characteristics on COVID-19 mortality has not been well studied. We examined the association between resident frailty and home-level characteristics with 30-day COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination in LTC., Methods: We conducted a population-based retrospective cohort study of LTC residents with confirmed SARS-CoV-2 infection in Ontario, Canada. We used multi-level multivariable logistic regression to examine associations between 30-day COVID-19 mortality, the Hubbard Frailty Index (FI), and resident and home-level characteristics. We compared explanatory models before and after vaccine availability., Results: There were 11,179 and 3,655 COVID-19 cases in the pre- and post-vaccine period, respectively. The 30-day COVID-19 mortality was 25.9 and 20.0% during the same periods. The median odds ratios for 30-day COVID-19 mortality between LTC homes were 1.50 (95% credible interval [CrI]: 1.41-1.65) and 1.62 (95% CrI: 1.46-1.96), respectively. In the pre-vaccine period, 30-day COVID-19 mortality was higher for males and those of greater age. For every 0.1 increase in the Hubbard FI, the odds of death were 1.49 (95% CI: 1.42-1.56) times higher. The association between frailty and mortality remained consistent in the post-vaccine period, but sex and age were partly attenuated. Despite the substantial home-level variation, no home-level characteristic examined was significantly associated with 30-day COVID-19 mortality during either period., Interpretation: Frailty is consistently associated with COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination. Home-level characteristics previously attributed to COVID-19 outcomes do not explain significant home-to-home variation in COVID-19 mortality., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Competing Interests: Intérêts concurrents: Christina Reppas-Rindlisbacher déclare bénéficier de l’appui du Programme de bourses d’études supérieures du Canada Vanier des Instituts de recherche en santé du Canada et du Programme de formation des cliniciens-chercheurs Eliot Phillipson de l’Université de Toronto. Lesley Wiesenfeld déclare avoir reçu du soutien institutionnel en tant que chef du service de psychiatrie du Système de santé Sinaï et des honoraires pour son intervention à un congrès national de psychothérapie gériatrique. Elle préside le comité de santé mentale et d’incapacité de l’Ordre des médecins et chirurgiens de l’Ontario. Aucun autre intérêt concurrent n’a été déclaré. Déclaration d’intérêts: Nathan Stall est rédacteur associé pour le CMAJ, mais n’a pas participé au processus ayant mené au choix de cet article.

Competing Interests: Competing interests: Christina Reppas-Rindlisbacher reports support from the Canadian Institutes of Health Research Vanier Scholarship Program and the Eliot Phillipson Clinician-Scientist Training Program at the University of Toronto. Lesley Wiesenfeld reports institutional support as the chief of psychiatry at Sinai Health and an honorarium for speaking at a geriatric psychotherapy national conference. She is chair of the Mental Health and Incapacity panel for the College of Physicians and Surgeons of Ontario. No other competing interests were declared.

Background: Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits., Methods: This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%)., Results: A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians ( n = 330) performed 58.6% of all home visits ( n = 227 321 out of 387 139). Compared with low-volume home visit physicians ( n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home., Interpretation: A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care., Competing Interests: Competing interests: None declared., (© 2023 CMA Impact Inc. or its licensors.)

Objectives: To examine how the COVID-19 pandemic affected the demographic and clinical characteristics, in-hospital care, and outcomes of long-term care residents admitted to general medicine wards for non-COVID-19 reasons., Methods: We conducted a retrospective cohort study of long-term care residents admitted to general medicine wards, for reasons other than COVID-19, in four hospitals in Toronto, Ontario between January 1, 2018 and December 31, 2020. We used an autoregressive linear model to estimate the change in monthly admission volumes during the pandemic period (March-December 2020) compared to the previous two years, adjusting for any secular trend. We summarized and compared differences in the demographics, comorbidities, interventions, diagnoses, imaging, psychoactive medications, and outcomes of residents before and during the pandemic., Results: Our study included 2,654 long-term care residents who were hospitalized for non-COVID-19 reasons between January 2018 and December 2020. The crude rate of hospitalizations was 79.3 per month between March-December of 2018-2019 and 56.5 per month between March-December of 2020. The was an adjusted absolute difference of 27.0 (95% CI: 10.0, 43.9) fewer hospital admissions during the pandemic period, corresponding to a relative drop of 34%. Residents admitted during the pandemic period had similar demographics and clinical characteristics but were more likely to be admitted for delirium (pandemic: 7% pre-pandemic: 5%, p = 0.01) and were less likely to be admitted for pneumonia (pandemic: 3% pre-pandemic: 6%, p = 0.004). Residents admitted during the pandemic were more likely to be prescribed antipsychotics (pandemic: 37%, pre-pandemic: 29%, p <0.001) and more likely to die in-hospital (pandemic:14% pre-pandemic: 10%, p = 0.04)., Conclusions and Implications: Better integration between long-term care and hospitals systems, including programs to deliver urgent medical care services within long-term care homes, is needed to ensure that long-term care residents maintain equitable access to acute care during current and future public health emergencies., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Jones et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: It is unknown how much of current physician home visit volume is driven by low-complexity or low-continuity visits. Our objectives were to measure physician home visit volumes and costs in Ontario from 2005/06 to 2018/19, and to compare patient characteristics and postvisit use of health care services across home visit types., Methods: This was a retrospective cross-sectional study using health administrative data. We examined annual physician home visit volumes and costs from 2005/06 to 2018/19 in Ontario, and characteristics and postvisit use of health care services of residents who received at least 1 home visit from any physician in 2014/15 to 2018/19. We categorized home visits as palliative, provided to a patient who also received home care services or "other," and compared characteristics and outcomes between groups., Results: A total of 4 418 334 physician home visits were performed between 2005/06 and 2018/19. More than half (2 256 667 [51.1%]) were classified as "other" and accounted for 39.1% ($22 million) of total annual physician billing costs. From 2014/15 to 2018/19, of the 413 057 home visit patients, 240 933 (58.3%) were adults aged 65 or more, and 323 283 (78.3%) lived in large urban areas. Compared to the palliative care and home care groups, the "other" group was younger, had fewer comorbidities, and had lower rates of emergency department visits and hospital admissions in the 30 days after the visit., Interpretation: About half of physician home visits in 2014/15 to 2018/19 were to patients who were receiving neither palliative care nor home care, a group that was younger and healthier, and had low use of health care services after the visit. There is an opportunity to refine policy tools to target patients most likely to benefit from physician home visits., Competing Interests: Competing interests: Nathan Stall is an associate editor of CMAJ. He was not involved in the editorial decision-making process for this article. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Background: Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults., Methods: We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits., Results: We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14)., Interpretation: Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes., Competing Interests: Competing interests: Andrew Costa holds the Schlegel Chair in Clinical Epidemiology in Aging at McMaster University, which was established by a gift by the Schlegel family (who own and operate Schlegel Villages; a chain of long-term care and retirement homes). Andrew Costa and Susan Bronskill have received honoraria from the Canadian Institutes for Health Research Best Brains Exchange on Retirement Homes. Derek Manis was a member of the Board of Directors of The Justice Emmett Hall Memorial Foundation (2018–2021). Paula Rochon holds the RTOERO Chair in Geriatric Medicine at the University of Toronto. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Background: Homebound status is associated with an increased risk of morbidity and mortality in older adults, yet little is known about homebound older adults in Canada. Our objectives were to describe time trends in the prevalence of homebound status among community-dwelling long-term home care recipients and the characteristics associated with homebound status., Methods: This was a retrospective cross-sectional and cohort study using linked health administrative data in Canada's most populous province, Ontario. We included adults aged 65 years and older who received at least one long-term home care assessment from 2006 to 2017 (N = 666,514). Homebound individuals were those who exited the home an average of 0-1 days/week over the previous 30 days; not homebound comparators exited the home 2-7 days per week. We compared baseline characteristics between groups and estimated the association between these characteristics and homebound status at baseline and over time., Results: From 2006 to 2017, the annual proportion of long-term home care recipients who were homebound increased from 48% to 65%. At first assessment, 50% of the cohort (331,836 of 666,514) were homebound. Among those with a 4-12 month repeat assessment, homebound status persisted over time for 80%, and developed anew in 24%. Dependency on others for locomotion, use of an assistive device, poor access to dwelling, older age, and female sex were most strongly associated with homebound status at baseline, as well as its development and persistence over time., Conclusions: We found that half of Ontario older adult long-stay home care clients were homebound at the time of their first assessment, and that the prevalence of homebound status among home care recipients rose steadily from 2006 to 2017. This informs further research and policy development to ensure the adequacy of supports for older homebound persons., (© 2021 The American Geriatrics Society.)

Competing Interests: Competing interests: Nathan Stall is the 2022 Ontario Liberal Party candidate for Toronto — St. Paul’s. Kieran Quinn serves as a volunteer member of the clinical advisory council for the Ontario Palliative Care Network. No other competing interests were declared.

Background: The extent to which the degree of baseline frailty, as measured using standardized multidimensional health assessments before hospital admission, predicts survival among older adults after admission to an ICU remains unclear., Research Question: Is baseline frailty an independent predictor of survival among older adults receiving care in an ICU?, Study Design and Methods: Retrospective cohort study of community-dwelling older adults (age, ≥ 65 years) receiving public home services who were admitted to any ICU in Ontario, Canada, between April 1, 2009, and March 31, 2015. All individuals underwent an interRAI Resident Assessment Instrument-Home Care (RAI-HC) assessment completed within 180 days of ICU admission. These assessments were linked to hospital discharge abstract records. Patients were categorized using frailty measures each calculated from the RAI-HC: a classification tree version of the Clinical Frailty Scale; the Frailty Index-Acute Care; and the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale. One-year survival models were used to compare their performance. Patients were stratified based on the receipt of mechanical ventilation in the ICU., Results: Of 24,499 individuals admitted to an ICU within 180 days of a RAI-HC assessment, 26.4% (n = 6,467) received mechanical ventilation. Overall, 43.0% (95% CI, 42.4%-43.6%) survived 365 days after ICU admission. In general, among the overall cohort and both mechanical ventilation subgroups, mortality hazards increased with the severity of baseline frailty. Models predicting survival 30, 90, and 365 days after admission to an ICU that adjusted for one of the frailty measures were more discriminant than reference models that adjusted only for age, sex, major clinical category, and area income quintile., Interpretation: Severity of baseline frailty is independently associated with survival after ICU admission and should be considered when determining goals of care and treatment plans for people with critical illness., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background/objectives: Gabapentinoids are commonly prescribed to relieve pain. The development of edema, an established adverse effect of gabapentinoids, may lead to a potentially harmful prescribing cascade whereby individuals are subsequently prescribed diuretics and exposed to diuretic-induced adverse events. The frequency of this prescribing cascade is unknown. Our objective was to measure the association between new dispensing of a gabapentinoid and the subsequent dispensing of a diuretic in older adults with new low back pain., Design: Population-based cohort study., Setting: Ontario, Canada., Participants: A total of 260,344 community-dwelling adults aged 66 years or older, newly diagnosed with low back pain between April 1, 2011, and March 31, 2019., Measurements: Exposure status was assigned using dispensed medications in the 1 week after low back pain diagnosis. Older adults newly dispensed a gabapentinoid (N = 7867) were compared with older adults who were not newly dispensed a gabapentinoid (N = 252,477). Hazard ratios (HRs) with 95% confidence intervals (CIs) for dispensing of a diuretic within 90 days of follow-up among older adults prescribed gabapentin relative to those who were not., Results: Older adults newly dispensed a gabapentinoid had a higher risk of being subsequently dispensed a diuretic within 90 days compared with older adults who were not prescribed a gabapentinoid (2.0% vs. 1.3%). After covariate adjustment, new gabapentinoid users had a higher rate of being dispensed a diuretic compared with those not prescribed a gabapentinoid (HR: 1.44, 95% CI: 1.23, 1.70). The rate of diuretic prescription among new gabapentinoid users increased with increasing gabapentinoid dosages., Conclusions: We have demonstrated the presence of a potentially inappropriate and harmful prescribing cascade. Given the widespread use of gabapentinoids, the population-based scale of this problem may be substantial. Increased awareness of this prescribing cascade is required to reduce the unnecessary use of diuretics and the exposure of patients to additional adverse drug events., (© 2021 The American Geriatrics Society.)

Background: Understanding the needs and values of older people is vital to build responsive policies, services and research agendas in this time of demographic transition. Older peoples' expectations and priorities for ageing, as well as their beliefs regarding challenges facing ageing societies, are multi-faceted and require regular updates as populations' age., Objective: To develop an understanding of self-perceptions of ageing and societal ageing among Canadian retirees of the education sector to define a meaningful health research agenda., Methods: We conducted four qualitative focus groups among 27 members of a Canadian retired educators' organisation. Data were analysed using an inductive thematic approach., Results: We identified four overarching themes: (1) vulnerability to health challenges despite a healthier generation, (2) maintaining health and social connection for optimal ageing, (3) strengthening person-centred healthcare for ageing societies and (4) mobilising a critical mass to enact change. Participants' preconceptions of ageing differed from their personal experiences. They prioritised maintaining health and social connections and felt that current healthcare practices disempowered them to manage and optimise their health. Although the sheer size of their demographic instilled optimism of their potential to garner positive change, participants felt they lacked mechanisms to contribute to developing solutions to address this transition., Conclusion: Our findings suggest a need for health research that improves perceptions of ageing and supports health system transformations to deliver person-centred care. Opportunities exist to harness their activism to engage older people as partners in shaping solution-oriented research that can support planning for an ageing society., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Competing Interests: Intérêts concurrents: Andrew Costa déclare avoir reçu du soutien pendant la conduite de l’étude de la part de l’Institut de recherche Juravinski. Le Dr Costa déclare aussi avoir reçu des subventions de l’Agence de la santé publique du Canada et des Instituts de recherche en santé du Canada (IRSC), en plus de rémunérations et d’honoraires des IRSC et de la Société de médecine de soins post-aigus et de longue durée de la Floride, indépendamment des travaux soumis. Le Dr Costa a été membre du Groupe de travail sur les établissements de soins de proximité du collectif Ontario Science Table, du Groupe pour le consensus en matière de modélisation relative à la COVID-19 du collectif Ontario Science Table, et du ministère de la Santé de l’Ontario et du gouvernement de l’Ontario, il occupe la chaire de recherche Schlegel sur l’épidémiologie clinique et le vieillissement. George Heckman déclare avoir reçu des honoraires de Merck pour participer à un comité consultatif. Michael Himmer déclare avoir reçu du soutien pour assister à une réunion. Adriane Castellino, Chloe Ma et Paul Pham déclarent être des employés de l’ORMR (Office de réglementation des maisons de retraite de l’Ontario), un régulateur indépendant, autofinancé, à but non lucratif mandaté par le gouvernement de l’Ontario; les membres du conseil d’administration (CA) de l’ORMR incluent du personnel-cadre des résidences Chartwell, de Diversicare Canada et d’Amica Senior Lifestyles, qui représentent l’industrie des RPA auprès du CA. Derek Manis déclare avoir reçu une bourse Mitacs Accélération pendant la conduite de cette étude et une participation en tant qu’étudiant au conseil d’administration de la Fondation Juge-Emmett-Hall. Samir Sinha déclare avoir reçu des honoraires de consultation du ministère de la Santé et des Soins de longue durée de l’Ontario et une rémunération ou des honoraires à titre de conférencier et de présentateur et lors d’activités de formation de l’Association des soins de longue durée de l’Alberta, de l’Association des fournisseurs de soins de santé de la Colombie-Britannique, de l’Association canadienne des soins de longue durée, du programme Échanges Meilleurs Cerveaux des Instituts de recherche en santé du Canada sur la Réglementation des maisons de retraite en Ontario, de l’Association des soins de longue durée du Manitoba, de l’Association des foyers de soins du Nouveau-Brunswick, de l’Association des soins de longue durée de l’Ontario et de l’Association des collectivités de retraités de l’Ontario. Aucun autre intérêt concurrent déclaré.

Competing Interests: Intérêts concurrents: Kevin Brown, Nathan Stall et Peter Jüni sont affiliés à l’Ontario COVID-19 Science Advisory Table. Peter Jüni est membre non rémunéré d’un groupe qui dirige plusieurs essais cliniques subventionnés par Appili Therapeutics, AstraZeneca, Biotronik, Biosensors, Eli Lilly, St. Jude Medical et The Medicines Company, et a participé à des comités consultatifs ou agi à titre de consultant pour Amgen, Ava et Fresenius, indépendamment des travaux soumis. Aucun autre intérêt concurrent n’a été déclaré. Déclaration d’intérêts: Nathan Stall est corédacteur pour le JAMC et n’a pas participé au processus ayant mené au choix de cet article.

Background: The epidemiology of SARS-CoV-2 infection in retirement homes (also known as assisted living facilities) is largely unknown. We examined the association between home-and community-level characteristics and the risk of outbreaks of SARS-CoV-2 infection in retirement homes since the beginning of the first wave of the COVID-19 pandemic., Methods: We conducted a population-based, retrospective cohort study of licensed retirement homes in Ontario, Canada, from Mar. 1 to Dec. 18, 2020. Our primary outcome was an outbreak of SARS-CoV-2 infection (≥ 1 resident or staff case confirmed by validated nucleic acid amplification assay). We used time-dependent proportional hazards methods to model the associations between retirement home- and community-level characteristics and outbreaks of SARS-CoV-2 infection., Results: Our cohort included all 770 licensed retirement homes in Ontario, which housed 56 491 residents. There were 273 (35.5%) retirement homes with 1 or more outbreaks of SARS-CoV-2 infection, involving 1944 (3.5%) residents and 1101 staff (3.0%). Cases of SARS-CoV-2 infection were distributed unevenly across retirement homes, with 2487 (81.7%) resident and staff cases occurring in 77 (10%) homes. The adjusted hazard of an outbreak of SARS-CoV-2 infection in a retirement home was positively associated with homes that had a large resident capacity, were co-located with a long-term care facility, were part of larger chains, offered many services onsite, saw increases in regional incidence of SARS-CoV-2 infection, and were located in a region with a higher community-level ethnic concentration., Interpretation: Readily identifiable characteristics of retirement homes are independently associated with outbreaks of SARS-CoV-2 infection and can support risk identification and priority for vaccination., Competing Interests: Competing interests: Andrew Costa reports receiving support during the conduct of the study from the Juravinski Research Institute. Dr. Costa also reports receiving grants from the Public Health Agency of Canada and the Canadian Institutes of Health Research and payments or honoraria from CIHR and Florida Society for Post-Acute & Long-Term Care Medicine, outside the submitted work. Dr. Costa reports being a member of Ontario COVID-19 Congregate Care Setting Science Advisory Table Working Group, Ontario COVID-19 Science Advisory Table, Ontario Ministry of Health and the Government of Ontario, and is the Schlegel Chair in Clinical Epidemiology and Aging. George Heckman reports receiving fees from Merck for participation in an advisory board. Michael Himmer reports receiving support for attending a meeting. Adriane Castellino, Chloe Ma and Paul Pham report being employees of the Retirement Homes Regulatory Authority (RHRA), an independent, self-funded, not-for-profit regulator mandated by the Ontario government; members of RHRA’s Board of Directors include executives of Chartwell Retirement Residences, Diversicare Canada and Amica Senior Lifestyles, which represent the retirement home industry on the Board.. Derek Manis reports receiving Mitacs Accelerate Fellowship, during the conduct of this study, and student membership of the Board of Directors of the Justice Emmett Hall Memorial Foundation. Samir Sinha reports receiving consulting fees from Ontario Ministry of Health and Long-Term Care, and payment or honoraria for lectures, presentations or educational events from the Alberta Continuing Care Association, BC Care Providers Association, Canadian Association for Long-Term Care, Canadian Institutes of Health Research Best Brains Exchange Program on the Regulation of the Ontario Retirement Homes Sector, Long-Term Care Association of Manitoba, New Brunswick Association of Nursing Homes, Ontario Long-Term Care Association and the Ontario Retirement Communities Association. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

Polypharmacy is very common in older adults and increases the risk of inappropriate and unsafe prescribing for older adults. Older adults, particularly women (who make up the majority of this age group), are at the greatest risk for drug-related harm. Therefore, optimising drug prescribing for older people is very important. Identifying potentially inappropriate medications and opportunities for judicious deprescribing processes are intrinsically linked, complementary, and essential for optimising medication safety. This Review focuses on optimising prescribing for older adults by reducing doses or stopping drugs that are potentially harmful or that are no longer needed. We explore how sex (biological) and gender (sociocultural) factors are important considerations in safe drug prescribing. We conclude by providing a practical approach to optimising medication safety that clinicians can routinely apply to the care of their older patients, highlighting how sex and gender considerations inform medication decision making., Competing Interests: Declaration of interests PAR, NMS, GO, SAS, and MP declare no competing interests. DO has a patent (11757950.8-1952) issued from the European Patent Office on Aug 30, 2011, called A Prescription Decision Support System (based on STOPP/START criteria). JHG reports personal fees from United Healthcare, outside of the submitted work. AC reports personal fees from Bristol Myers Squibb for participating in an advisory board on direct anticoagulants and personal fees from MSD for a lecture on aging, outside of the submitted work., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Nonpharmaceutical interventions remain the primary means of controlling severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) until vaccination coverage is sufficient to achieve herd immunity. We used anonymized smartphone mobility measures to quantify the mobility level needed to control SARS-CoV-2 (i.e., mobility threshold), and the difference relative to the observed mobility level (i.e., mobility gap)., Methods: We conducted a time-series study of the weekly incidence of SARS-CoV-2 in Canada from Mar. 15, 2020, to Mar. 6, 2021. The outcome was weekly growth rate, defined as the ratio of cases in a given week versus the previous week. We evaluated the effects of average time spent outside the home in the previous 3 weeks using a log-normal regression model, accounting for province, week and mean temperature. We calculated the SARS-CoV-2 mobility threshold and gap., Results: Across the 51-week study period, a total of 888 751 people were infected with SARS-CoV-2. Each 10% increase in the mobility gap was associated with a 25% increase in the SARS-CoV-2 weekly case growth rate (ratio 1.25, 95% confidence interval 1.20-1.29). Compared to the prepandemic baseline mobility of 100%, the mobility threshold was highest in the summer (69%; interquartile range [IQR] 67%-70%), and dropped to 54% in winter 2021 (IQR 52%-55%); a mobility gap was present in Canada from July 2020 until the last week of December 2020., Interpretation: Mobility strongly and consistently predicts weekly case growth, and low levels of mobility are needed to control SARS-CoV-2 through spring 2021. Mobility measures from anonymized smartphone data can be used to guide provincial and regional loosening and tightening of physical distancing measures., Competing Interests: Competing interests: Kevin Brown, Nathan Stall and Peter Jüni are affiliated with the Ontario COVID-19 Science Advisory Table. Peter Jüni serves as an upaid member of the steering group of trials funded by Appili Therapeutics, AstraZeneca, Biotronik, Biosensors, Eli Lilly, St. Jude Medical and The Medicines Company, and has participated in advisory boards or consulted with Amgen, Ava and Fresenius, outside the submitted work. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

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

Objectives: To assess changes in the mobility of staff between nursing homes in Ontario, Canada, before and after enactment of public policy restricting staff from working at multiple homes., Design: Pre-post observational study., Setting and Participants: 623 nursing homes in Ontario, Canada, between March 2020 and June 2020., Methods: We used GPS location data from mobile devices to approximate connectivity between all 623 nursing homes in Ontario during the 7 weeks before (March 1-April 21) and after (April 22-June 13) the policy restricting staff movement was implemented. We constructed a network diagram visualizing connectivity between nursing homes in Ontario and calculated the number of homes that had a connection with another nursing home and the average number of connections per home in each period. We calculated the relative difference in these mobility metrics between the 2 time periods and compared within-home changes using McNemar test and the Wilcoxon rank-sum test., Results: In the period preceding restrictions, 266 (42.7%) nursing homes had a connection with at least 1 other home, compared with 79 (12.7%) homes during the period after restrictions, a drop of 70.3% (P < .001). Including all homes, the average number of connections in the before period was 3.90 compared to 0.77 in the after period, a drop of 80.3% (P < .001). In both periods, mobility between nursing homes was higher in homes located in larger communities, those with higher bed counts, and those part of a large chain., Conclusions and Implications: Mobility between nursing homes in Ontario fell sharply after an emergency order by the Ontario government limiting long-term care staff to a single home, though some mobility persisted. Reducing this residual mobility should be a focus of efforts to reduce risk within the long-term care sector during the COVID-19 pandemic., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed., Objective: To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic., Design, Setting, and Participants: This population-based retrospective cohort study included more than 78 000 residents across more than 600 nursing homes in Ontario, Canada, and was conducted from March 29 to May 20, 2020., Exposures: The nursing home crowding index equaled the mean number of residents per bedroom and bathroom., Main Outcomes and Measures: The cumulative incidence of COVID-19 cases confirmed by a validated nucleic acid amplification assay and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) was a negative tracer., Results: Of 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78 607 residents (women, 54 160 [68.9%]; age ≥85 years, 42 919 [54.6%]). A total of 5218 residents (6.6%) developed COVID-19 infection, and 1452 (1.8%) died of COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes; 4496 infections (86%) occurred in 63 homes (10%). The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 homes (50%) had a high crowding index (≥2). Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (P < .001), while COVID-19 mortality was 2.7% vs 1.3%, respectively (P < .001). The likelihood of COVID-19 introduction did not differ (high = 31.3% vs low = 30.2%; P = .79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with an increased incidence of infection (relative risk [RR] = 1.73, 95% CI, 1.10-2.72) and mortality (RR, 1.69; 95% CI, 0.99-2.87). A propensity score analysis yielded similar conclusions for infection (RR, 2.09; 95% CI, 1.30-3.38) and mortality (RR, 1.83; 95% CI, 1.09-3.08). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 998 COVID-19 cases (19.1%) and 263 deaths (18.1%)., Conclusions and Relevance: In this cohort of Canadian nursing homes, crowding was common and crowded homes were more likely to experience larger and deadlier COVID-19 outbreaks.

Background/objectives: Social media platforms are promising sources for large quantities of participant-driven research data and circumvent some common challenges when conducting dementia research. This study provides a summary of key considerations and recommendations about using these platforms as research tools for dementia., Design: Mixed methods., Setting: Alzheimer's Society's online Dementia Talking Point forum from inception to April 17, 2018, and Twitter in February and March 2018., Participants: All users of Dementia Talking Point who posted in subforums labeled "I have dementia" and "I care for a person with dementia," and Twitter users whose posts contained the keywords "dementia," "Alzheimer," or "Alzheimer's.", Measurements: We quantified the average daily number of dementia-related posts on each platform and number of words per post. Guided by a codebook, we conducted thematic content analysis of 5% of the 15,513 posts collected from Dementia Talking Point, and 10% of the 25,948 comprehensible posts from Twitter containing "dementia," "Alzheimer," or "Alzheimer's." We also summarized research-relevant characteristics inherent to platforms and posts., Results: On average, Dementia Talking Point provided less than two new daily dementia-related posts with 213.5 to 241.5 words, compared with 7,883 new daily Twitter posts with 14.5 words. Persons with dementia (PWDs) commonly shared dementia-related concerns (75.7%), experiences (68.6%), and requests for, as well as offers of, information and support (44.3% and 38.6%, respectively). Caregivers commonly shared caregiving experience (67.0%) and requests for information and support (52.5%). Most common dementia-related Twitter posts were derogatory use of the term dementia (14.5%), advocacy, fundraising, and awareness (11.6%), and research dissemination (8.0%). Recommendations about these platforms' unique technical and ethical considerations are outlined., Conclusions: Understanding the priorities of PWDs and their caregivers remains important to understand how clinicians can best support them. This study will help clinicians and researcher to better leverage online health forums and Twitter for such dementia-related information., (© 2020 The American Geriatrics Society.)

Objectives: Nursing homes became epicenters of COVID-19 in the spring of 2020. Due to the substantial case fatality rates within congregate settings, federal agencies recommended restrictions to family visits. Six months into the COVID-19 pandemic, these largely remain in place. The objective of this study was to generate consensus guidance statements focusing on essential family caregivers and visitors., Design: A modified 2-step Delphi process was used to generate consensus statements., Setting and Participants: The Delphi panel consisted of 21 US and Canadian post-acute and long-term care experts in clinical medicine, administration, and patient care advocacy., Methods: State and federal reopening statements were collected in June 2020 and the panel voted on these using a 3-point Likert scale with consensus defined as ≥80% of panel members voting "Agree." The consensus statements then informed development of the visitor guidance statements., Results: The Delphi process yielded 77 consensus statements. Regarding visitor guidance, the panel made 5 strong recommendations: (1) maintain strong infection prevention and control precautions, (2) facilitate indoor and outdoor visits, (3) allow limited physical contact with appropriate precautions, (4) assess individual residents' care preferences and level of risk tolerance, and (5) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes psychosocial well-being of residents., Conclusions and Implications: The COVID-19 pandemic has seen substantial regulatory changes without strong consideration of the impact on residents. In the absence of timely and rigorous research, the involvement of clinicians and patient care advocates is important to help create the balance between individual resident preferences and the health of the collective. The results of this evidence-based Delphi process will help guide policy decisions as well as inform future research., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Intérêts concurrents: Andrew Costa indique qu’il est titulaire d’une chaire de recherche de l’Institut Schlegel de l’Université McMaster. Cette chaire est financée par la famille Schlegel (qui est propriétaire de Schlegel Villages [une chaîne de foyers de retraite et de soins de longue durée à but lucratif] ainsi que d’autres entreprises non apparentées). Aucun autre intérêt concurrent déclaré.

Competing Interests: Intérêts concurrents: Aucun déclaré.

Background: Retirement home residents represent a growing proportion of older Ontarians who cannot be identified within existing administrative databases., Objective: This article aims to develop an approach for determining, from an individual's postal code, their likelihood of residing in a retirement home., Methods: We identified 748 licensed retirement homes in Ontario as of June 1, 2018, from a public registry. We developed a two-step evaluation and verification process to determine the probability (certain, likely or unlikely) of identifying a retirement home, as opposed to other dwellings, within a postal code., Results: We identified 274 (36.7%) retirement homes within a postal code certain to indicate that a person was residing in a retirement home, 200 (26.7%) for which it was likely and 274 (36.7%) for which it was unlikely. Postal codes that were certain and likely identified retirement homes with a capacity for 59,920 residents (79.9% of total provincial retirement home capacity)., Conclusion: It is feasible to identify a substantive cohort of retirement home residents using postal code data in settings where street address is unavailable for linkage to administrative databases., (Copyright © 2020 Longwoods Publishing.)