Showing papers in "Canadian Geriatrics Journal in 2014"
TL;DR: Older adults have distinct patterns of ED use that may be used to target future interventions involving alternative care for older adults, and length of stay increased with age group, as did the proportion of visits involving diagnostic testing and consultation.
Abstract: Background Emergency Departments (EDs) are playing an increasingly important role in the care of older adults. Characterizing ED usage will facilitate the planning for care delivery more suited to the complex health needs of this population. Methods In this retrospective cross-sectional study, administrative and clinical data were extracted from four study sites. Visits for patients aged 65 years or older were characterized using standard descriptive statistics. Results We analyzed 34,454 ED visits by older adults, accounting for 21.8% of the total ED visits for our study time period. Overall, 74.2% of patient visits were triaged as urgent or emergent. Almost half (49.8%) of visits involved diagnostic imaging, 62.1% involved lab work, and 30.8% involved consultation with hospital services. The most common ED diagnoses were symptom- or injury-related (25.0%, 17.1%. respectively). Length of stay increased with age group (Mann-Whitney U;p < .0001), as did the proportion of visits involving diagnostic testing and consultation (χ2; p < .0001). Approximately 20% of older adults in our study population were admitted to hospital following their ED visit. Conclusions Older adults have distinct patterns of ED use. ED resource use intensity increases with age. These patterns may be used to target future interventions involving alternative care for older adults.
123 citations
TL;DR: Though the studies examined conclude that there is an association between UTI and delirium, all of them had significant methodological flaws that likely led to biased results and it is difficult to ascertain the degree to which urinary tract infections cause Delirium.
Abstract: Background In geriatrics, delirium is widely viewed as a consequence of and, therefore, a reason to initiate workup for urinary tract infection (UTI). There is a possibility that this association is overestimated. To determine the evidence behind this clinical practice, we undertook a systematic review of the literature linking delirium with UTI. Methods A MEDLINE search was conducted from 1966 through 2012 using the MESH terms “urinary tract infection” and “delirium”, limited to humans, age 65 and older. The search identified 111 studies. Of these, five met our inclusion criteria of being primary studies that addressed the association of UTI and delirium. The studies were four cross-sectional observational studies and one case series. No randomized control trials were identified. All studies were published between 1988 and 2011. Four collected data retrospectively and one prospectively, with study sizes ranging from 14 to 1,285. The methodological strength of the studies was evaluated using six standards adapted from a previous systematic review. Results Only two of the five studies adequately matched or statistically adjusted for differences in comparison groups. None of the studies evaluated subjects with equal intensity for the presence of delirium and UTI, nor did they have objective criteria for either diagnosis. In subjects with delirium, UTI rates ranged from 25.9% to 32% compared to 13% in those without delirium. In subjects with UTI, delirium rates ranged from 30% to 35%, compared to 7.7% to 8% in those without UTI. Conclusions Few studies have examined the association between UTI and delirium. Though the studies examined conclude that there is an association between UTI and delirium, all of them had significant methodological flaws that likely led to biased results. Therefore, it is difficult to ascertain the degree to which urinary tract infections cause delirium. More research is needed to better define the role of UTI in delirium etiology.
63 citations
TL;DR: The majority of patients with dementia in hospital have a diagnosis of dementia and have been waiting in hospital for over one year for a long-term care bed in the community, suggesting home maker services alone may not be adequate for some community-dwelling older adults.
Abstract: Background Patients in acute care hospitals no longer in need of acute care are called Alternate Level of Care (ALC) patients. This is growing and common all across Canada. A better understanding of this patient population would help to address this problem. Methods A chart review was conducted in two hospitals in New Brunswick. All patients designated as ALC on July 1, 2009 had their charts reviewed. Results Thirty-three per cent of the hospital beds were occupied with ALC patients; 63% had a diagnosis of dementia. The mean length of stay was 379.6 days. Eighty-six per cent were awaiting a long-term care bed in the community. Most patients experienced functional decline during their hospitalization. One year prior to admission, 61% had not been admitted to hospital and 59.2% had had at least one visit to the emergency room. Conclusions The majority of the ALC patients in hospital have a diagnosis of dementia and have been waiting in hospital for over one year for a long-term care bed in the community. Many participants were recipients of maximum home care in the community, suggesting home maker services alone may not be adequate for some community-dwelling older adults. Early diagnosis of dementia, coupled with appropriate care in the community, may help to curtail the number of patients with dementia who end up in hospital as ALC patients.
37 citations
TL;DR: Perceived roles and attitudes towards the provision of dementia care from the perspectives of family physicians and specialists are explored, with physicians’ and other multi-disciplinary members’ perceived roles and responsibilities in dementia care explored.
Abstract: Background The assessment and ongoing management of dementia falls largely on family physicians. This pilot study explored perceived roles and attitudes towards the provision of dementia care from the perspectives of family physicians and specialists. Methods Semi-structured, one-to-one interviews were conducted with six family physicians and six specialists (three geriatric psychiatrists, two geriatricians, and one neurologist) from University of Toronto-affiliated hospitals. Transcripts were subjected to thematic content analysis. Results Physicians’ clinical experience averaged 16 years. Both physician groups acknowledged that family physicians are more confident in diagnosing/treating uncomplicated dementia than a decade ago. They agreed on care management issues that warranted specialist involvement. Driving competency was contentious, and specialists willingly played the “bad cop” to resolve disputes and preserve long-standing therapeutic relationships. While patient/caregiver education and support were deemed essential, most physicians commented that community resources were fragmented and difficult to access. Improving collaboration and communication between physician groups, and clarifying the roles of other multi-disciplinary team members in dementia care were also discussed. Conclusions Future research could further explore physicians’ and other multi-disciplinary members’ perceived roles and responsibilities in dementia care, given that different health-care system-wide dementia care strategies and initiatives are being developed and implemented across Ontario.
34 citations
TL;DR: Compliance to therapy for elderly HNSCC patients was not significantly associated with advanced stage, poor general condition, intent of treatment or presence of co-morbidity, and nearly two-thirds of elderly head and neck carcinoma patients were compliant to cancer-directed therapy.
Abstract: Background Treatment compliance of elderly patients to intensive multimodality cancer therapy can be challenging and has not been adequately addressed in developing countries. The present study evaluated compliance of elderly head and neck carcinomas patients to cancer-directed therapy. Methods Forty-seven elderly HNSCC patients were evaluated in the present study. Patients were assessed as per stage and site of disease, general condition, performance status, and any pre-existing co-morbidities. Compliance was defined as patients who were able to complete cancer therapy as intended at primary clinic. Non-compliance to therapy was stratified as early, mid- and late-course non-compliance. Statistical analysis was done using STATA 9.1 software, chi-square/Fischer’s exact test to see strength of association between two categorical variables that could possibly affect compliance in elderly patients. Results Sixty-eight per cent of elderly patients were subjected to radical treatment, majority (42/47) presented in loco-regionally advanced stage (III-IV), most common site of malignancy was oropharynx (21/47). Sixty-two per cent of elderly HNSCC patients were compliance to cancer therapy. Median overall treatment time for patients subjected to radical radiation therapy was 52 (range 47–99) days, and for radical surgery and adjuvant radiotherapy was 109 (95–190) days. Compliance to therapy for elderly HNSCC patients was not significantly associated with advanced stage, poor general condition, intent of treatment or presence of co-morbidity. As regards to non-compliance, majority (14/18) of elderly patients showed mid-course treatment non-compliance. Conclusions Nearly two-thirds of elderly head and neck carcinoma patients were compliant to cancer-directed therapy.
30 citations
TL;DR: People move from the community chiefly due to dementia, and often with a precipitant, compared with a move to assisted living, moving to nursing homes generally indicates greater dependence, and typically worse dementia severity.
Abstract: Background In Canada, the rise of private-pay assisted living facilities is changing the long-term care landscape. Even so, few clinical implications of having these facilities in the spectrum of care have been studied. Our objective was to compare events and symptoms that might predispose and precipitate a move of older adults to assisted living or to a nursing home. Methods Cross-sectional, descriptive Nova Scotia survey of residents and family members on admission. Health-care use and dementia diagnosis were recorded from the admission record. Dementia was staged using the Global Deterioration Scale and the Dependence Scale. The SymptomGuide, a standardized dementia symptom inventory, was used to assay which symptoms were most influential in the decision to seek long term care. Caregiver stress was elicited by a self-report questionnaire. Results Of 353 people admitted during the enrolment period, 174 (49%) took part in the survey. Most (97; 55.7%) were involved in a move from the community to a nursing home, 54 (31.0%) from the community to assisted living, and 23 (13.2%) from assisted living to a nursing home. In each setting, dementia was the commonest predisposing factor (seen in >90%) with a precipitating event seen in 120 (69%) people. The precipitating events included a medical illness ( n = 97; 55%) or caregiver illness, death or move (33; 19%). Dependence was associated with place of care, with more severely impaired people more commonly represented in people who moved to nursing homes. Conclusions People move from the community chiefly due to dementia, and often with a precipitant. Compared with a move to assisted living, moving to nursing homes generally indicates greater dependence, and typically worse dementia severity. Even so, assisted-living facilities are not just for the “worried well”, but are used by people with dementia, caregiver stress, and recent hospitalization.
25 citations
TL;DR: The core competencies described were developed for Postgraduate Year (PGY)-I/II Family Medicine residents and PGY-III Enhanced Skills COE, with a focus on the development of geriatric expertise for those patients that would most benefit.
Abstract: Background There is a growing mandate for Family Medicine residency programs to directly assess residents’ clinical competence in Care of the Elderly (COE). The objectives of this paper are to describe the development and implementation of incremental core competencies for Postgraduate Year (PGY)-I Integrated Geriatrics Family Medicine, PGY-II Geriatrics Rotation Family Medicine, and PGY-III Enhanced Skills COE for COE Diploma residents at a Canadian University. Methods Iterative expert panel process for the development of the core competencies, with a pre-defined process for implementation of the core competencies. Results Eighty-five core competencies were selected overall by the Working Group, with 57 core competencies selected for the PGY-I/II Family Medicine residents and an additional 28 selected for the PGY-III COE residents. The core competencies follow the CanMEDS Family Medicine roles. Both sets of core competencies are based on consensus. Conclusions Due to demographic changes, it is essential that Family Physicians have the required skills and knowledge to care for the frail elderly. The core competencies described were developed for PGY-I/II Family Medicine residents and PGY-III Enhanced Skills COE, with a focus on the development of geriatric expertise for those patients that would most benefit.
19 citations
TL;DR: Eating location was influenced by compliance with the perceived rules of the unit, physical and emotional well-being, and quarantine orders, and some participants preferred eating at their bedsides, feeling the quality of social interaction was poor in the dining room.
Abstract: Background Eating together is promoted among hospitalized seniors to improve their nutrition. This study aimed to understand geriatric patients’ perceptions regarding meals in a common dining area versus at the bedside. Methods An exploratory qualitative study was conducted. Openended questions were asked of eight patients recruited from a geriatric rehabilitation unit where patients had a choice of meal location. Results Eating location was influenced by compliance with the perceived rules of the unit, physical and emotional well-being, and quarantine orders. Certain participants preferred eating in the common dining room where they had more assistance from hospital staff, a more attractive physical environment, and the opportunity to socialize. However, other participants preferred eating at their bedsides, feeling the quality of social interaction was poor in the dining room. Conclusions Participants’ experiences of, and preferences for, communal dining differed. If the benefits of communal dining are to be maximized, different experiences of this practice must be considered.
14 citations
TL;DR: The fact that the LTCFs were satisfied with the eye care services offered to their residents, although it was neither provided on a regular basis nor to all residents, suggests that eye care professionals should take a proactive educational role for improving services to older institutionalized adults.
Abstract: Background The objective was to evaluate the eye care services offered to older residents living in long-term care facilities (LTCFs). Methods A questionnaire targeting residents aged ≥65 years was sent to all LTCFs in Quebec. Questions related to the institution’s characteristics, demographic data related to residents, oculovisual health of residents and barriers to eye care, eye care services offered within and outside the institution, and degree of satisfaction regarding the eye care services offered to residents. Results 196/428 (45.8%) LTCFs completed the questionnaire. Participating LTCFs had an average of 97.0 ± 5.1 residents with a mean age of 82.8 ± 3.0 yrs and 69% women. Eye care services were mostly offered outside the institution, on a “per request” basis. The main barriers to eye care were the perception that residents could not cooperate and the lack of eye care professionals. Most LTCFs were satisfied with the eye care services offered to residents. Conclusions The fact that the LTCFs were satisfied with the eye care services offered to their residents, although it was neither provided on a regular basis nor to all residents, suggests that eye care professionals should take a proactive educational role for improving services to older institutionalized adults.
14 citations
TL;DR: The proposed shift for the acute care hospital to other models of care requires a fundamental shift to care that addresses the full range of an individual’s needs, rather than being based around single diseases.
Abstract: A report from the United Kingdom on making health and care systems fit for an ageing population proposes a range of interventions to make care better for older adults, especially those who are frail. Here, we discuss the proposed shift for the acute care hospital to other models of care. The key for these models of care requires a fundamental shift to care that addresses the full range of an individual’s needs, rather than being based around single diseases. How this might apply in the Canadian context is considered. We emphasize strategies to keep people out of hospital but still receive needed care, make acute hospital care less hazardous, and improve the interface between acute and long-term care.
13 citations
TL;DR: An on-going dialogue about this complex issue is required and the need for a modifiable, fair, rational, and widely accessible multi-step approach to the assessment of older drivers is required.
Abstract: Background The rapidly increasing number of older drivers is accentuating the challenges in concurrently identifying older drivers posing an unacceptable risk if they continue to drive, while not discriminating against those capable of safely driving. Attendees of an invitational meeting about the assessment of older drivers were asked to participate in a modified Delphi process designed to develop consensus statements on the assessment of older drivers. Methods Forty-one non-student symposium attendees were invited to participate in two rounds of a survey, in which they were asked to indicate their level of agreement (or disagreement) on a five-point Likert scale to a series of statements about the assessment of older drivers. Consensus was defined as 80% + of respondents either agreeing or disagreeing with a statement. Results More than one-half (n = 23) completed the first round of the survey and 12 participated in the second. There was consensus on the need for a modifiable, fair, rational, and widely accessible multi-step approach to the assessment of older drivers. This would require the engagement and support of physicians and other health-care practitioners in identifying and reporting medically at-risk drivers of any age. At a societal level, alternatives to driving a personal motor vehicle should be developed. Conclusions An on-going dialogue about this complex issue is required. Decisions should be based on explicitly stated principles and informed by the best available evidence.
TL;DR: Although the Web-based resource and awareness campaign were not associated with improvement in physician comfort in assessing driving risk in dementia, after completion of the campaign, fewer PCPs reported avoiding the topic of driving, and family resistance and lack of resources were less often reported as barriers.
Abstract: Background Canadian physicians are responsible for assessing medical fitness to drive; however, national data indicate that physicians lack confidence in performing such assessments and face numerous barriers to addressing driving in patients with dementia. We report on the impact of a provincial Web-based resource (www.notifbutwhen.ca) regarding driving cessation in dementia aimed towards primary care physicians (PCPs). Methods A pre/post cross-sectional survey (n = 134 baseline and n = 113 follow-up) of English-speaking, Nova Scotian PCPs. Descriptive statistics, chi-square, Pearson correlation, and multivariable logistic regression (controlling for sex, years of practice, and practice type) are reported. Results Most PCPs consider discussions regarding driving cessation to be routine part of dementia care; however, report multiple barriers to such discussions. Although the Web-based resource and awareness campaign were not associated with improvement in physician comfort in assessing driving risk in dementia, after completion of the campaign, fewer PCPs reported avoiding the topic of driving. Additionally, family resistance and lack of resources were less often reported as barriers. Conclusions Despite a lack of confidence, Nova Scotian PCPs routinely discuss driving cessation, and perform driving assessments for individuals with dementia. The Web-based resource and awareness campaign have shown moderate effectiveness in addressing specific barriers to assessment (e.g., caregiver resistance, lack of resources). Future efforts will address additional barriers, such as lack of comfort in decision-making.
TL;DR: There was no association between the SIMARD MD scores and the geriatricians’ clinical decision regarding fitness to drive in persons with mild dementia or mild cognitive impairment.
Abstract: Background The assessment of fitness to drive in patients with cognitive impairment is complex. The SIMARD MD was developed to assist with assessing fitness to drive. This study compares the clinical decision made by a geriatrician regarding driving with the SIMARD MD score. Methods Patients with a diagnosis of mild dementia or mild cognitive impairment, who had a SIMARD MD test, were included in the sample. A retrospective chart review was completed to gather diagnosis, driving status, and cognitive and functional information. Results Sixty-three patients were identified and 57 met the inclusion criteria. The mean age was 77.1 years (SD 8.9). The most common diagnosis was Alzheimer’s disease in 22 (38.6%) patients. The mean MMSE score was 24.9 (SD 3.34) and the mean MoCA was 19.9 (SD 3.58). The mean SIMARD MD score was 37.2 (SD 19.54). Twenty-four patients had a SIMARD MD score ≤ 30, twenty-eight between 31–70, and five scored > 70. The SIMARD MD scores did not differ significantly compared to the clinical decision (ANOVA p value = 0.14). Conclusions There was no association between the SIMARD MD scores and the geriatricians’ clinical decision regarding fitness to drive in persons with mild dementia or mild cognitive impairment.
TL;DR: The GCSD did not alter pre-clerkship students’ attitudes towards geriatrics, and this study adds to geriatric medical education research and warrants further investigation in a larger, multi-centred trial.
Abstract: Background The aging population requires an improvement in physicians’ attitudes, knowledge, and skills, regardless of their specialty. This study aimed to identify attitude changes of University of Toronto pre-clerkship medical students towards geriatrics after participation in a Geriatric Clinical Skills Day (GCSD). Methods This was a before and after study. The GCSD consisted of one large and four small interactive, inter-professional geriatric medicine workshops facilitated by various health professionals. A questionnaire, including the validated UCLA Geriatrics Attitudes Scale, was administered to participating pre-clerkship medical students before and after the GCSD. A one-sample t-test and signed rank parametric test were used to determine attitude changes. Results 42.1% indicated an interest in Geriatric Medicine, 26.3% in Geriatric Psychiatry, and 63.2% in working with elderly patients. Both pre- and post-mean scores were greater than 3 (neutral), indicating a positive attitude before and after the intervention ( p .11). Conclusions The GCSD did not alter pre-clerkship students’ attitudes towards geriatrics. This study adds to geriatric medical education research and warrants further investigation in a larger, multi centred trial.
TL;DR: Older current and former illegal drug users in a major inner city Canadian centre have different demographic, health-care, and drug utilization profiles.
Abstract: Background This study aimed to determine the baseline demographics, health status, and drug use profiles of current and former substance- using older adults in Vancouver’s Downtown Eastside. Methods Data were derived from two U.S. National Institutes of Health-funded cohort studies of current and former illegal drug users in Vancouver’s Downtown Eastside. We used logistic regression of cross-sectional data obtained between June and November 2008 to calculate odds ratios and identify factors that were more commonly associated with cohort members being older adults (greater than or equal to age 50). Results 214 subjects (25%) were greater than or equal to age 50 upon study enrollment. Females (Adjusted Odds Ratio [AOR]: 0.50; 95% CI: 0.34–0.75) and individuals who reported Aboriginal ancestry (AOR: 0.49; 95% CI: 0.33–0.72) were less likely to be in the older cohort. Individuals with higher income (AOR: 2.07; 95% CI: 1.16–3.68 per $1,000), and those with a regular place to stay were more likely to be in older cohort (AOR: 3.39; 95% CI: 1.90–6.06). Older participants accessed family physicians more frequently (OR: 1.47; 95% CI: 1.01 – 2.16) and were more likely to be actively taking (OR: 3.34; 95% CI 1.71–6.55) or have taken (OR 3.21; 95% CI 1.58–6.53) HIV antiretroviral therapy. There were no differences between groups in regard to injection drug use status or daily alcohol intake. Conclusions Older current and former illegal drug users in a major inner city Canadian centre have different demographic, health-care,and drug utilization profiles. Further studies in this population are warranted.
TL;DR: The authors found that the general medicine rotation provides opportunities to acquire geriatric competencies, but the rare uptake of opportunities suggests that, in curriculum-by-random-opportunity, presence of an opportunity does not justify the assumption that learning objectives will be met.
Abstract: Background While major clerkship blocks may have objectives related to specialized areas such as geriatrics, gay and lesbian bisexual transgender health, and palliative care, there is concern that teaching activities may not attend sufficiently to these objectives. Rather, these objectives are assumed to be met “by random opportunity”.(1) This study explored the case of geriatric learning opportunities on internal medicine clinical teaching units, to better understand the affordances and limitations of curriculum by random opportunity. Methods Using audio-recordings of morning case review discussions of 13 patients > 65 years old and the Canadian geriatric core competencies for medical students, we conducted a content analysis of each case for potential geriatric and non-geriatric learning opportunities. These learning opportunities were compared with attendings’ case review teaching discussions. The 13 cases contained 40 geriatric-related and 110 non-geriatric-related issues. While many of the geriatric issues (e.g., delirium, falls) were directly relevant to the presenting illness, attendings’ teaching discussions focused almost exclusively on non-geriatric medical issues, such as management of diabetes and anemia, many of which were less directly relevant to the reason for presenting to hospital. Results The authors found that the general medicine rotation provides opportunities to acquire geriatric competencies. However, the rare uptake of opportunities in this study suggests that, in curriculum-by-random-opportunity, presence of an opportunity does not justify the assumption that learning objectives will be met. Conclusions More studies are required to investigate whether these findings are transferrable to other vulnerable populations about which undergraduate students are expected to learn through curriculum by random opportunity.
TL;DR: This is a very personal response to the commentary in this month’s Canadian Geriatrics Journal by Andrew and Rockwood on the recent paper “Making Health and Care Systems Fit for an Ageing Population”, and I hope it has some relevance to Canada and might stimulate some constructive conversations.
Abstract: In response to the commentary(1) in this month’s Canadian Geriatrics Journal by Andrew and Rockwood on the recent paper I co-wrote with King’s Fund colleagues—“Making Health and Care Systems Fit for an Ageing Population”(2)—I wanted to pen a very personal response, not least because of my visits to health systems in Ontario and Alberta and conversations with many Canadian colleagues that are fresh in my mind The paper was certainly the most important and influential thing I have written, and was an attempt to weave all the elements of good practice in health care for older people into one overarching narrative Whilst its biggest target audience is UK health services, I hope it has some relevance to Canada and might stimulate some constructive conversations
TL;DR: Cognitive and motor performance, measured from late middle age, were associated with national income levels of both country of residence and country of birth, similar to previously observed differences in frailty index scores.
Abstract: Background Life course influences, including country of residence and country of birth, are associated with frailty index scores. We investigated these associations using performance-based health measures. Methods Among 33,745 participants age 50+ (mean age 64.8 ± 10.1; 55% women) in the Survey of Health, Ageing, and Retirement in Europe, grip strength, delayed word recall, and semantic verbal fluency were assessed. Participants were grouped by country of residence (Northern/Western Europe or Southern/Eastern Europe), and by country of birth (native-born, immigrants born in low- and middle-income countries [LMICs], or immigrants born in high-income countries [HICs]). Results Participants in Southern/Eastern Europe had lower mean test scores than those in Northern/Western Europe, and their scores did not differ by country of birth group. In Northern/Western Europe, compared with native-born participants, LMIC-born immigrants demonstrated lower mean grip strength (32.8 ± 7.6 kg vs. 35.7 ± 7.7 kg), delayed recall (2.9 ± 1.9 vs. 3.6 ± 1.9), and verbal fluency scores (16.0 ± 6.9 vs. 20.3 ± 7.0). HIC-born immigrants had mean scores higher than LMIC-born immigrants, but lower than native-born participants (all p<.001). Conclusions Cognitive and motor performance, measured from late middle age, were associated with national income levels of both country of residence and country of birth. This was similar to previously observed differences in frailty index scores.
TL;DR: The increases in costs observed during the year prior to institutionalization, characterized by a flurry of health service utilization, provide evidence of distinct cost patterns over the transition period.
Abstract: Objectives The objective of this study was to characterize patterns of formal health service utilization costs during older adults’ transition from community to institutional care. Methods Participants were 127 adults (age ≥ 65) from the British Columbia sample (N = 2 ,057) of the Canadian Study of Health and Aging who transitioned from community to institutional care between 1991 and 2001. Health service utilization costs were measured using Cost-Per-Day-At-Risk at five time points: > 12 months, 6–12 months, and ≤ 6 months preinstitutionalization, and ≤ 6 months and 6–12 months postinstitutionalization. Cost-Per-Day-At-Risk was measured for Continuing Care, Medical Services Plan, and PharmaCare costs by calculating total health service use over time, divided by the number of days the participant was alive. Results Significant differences in Cost-Per-Day-At-Risk were observed for Continuing Care, Medical Services Plan, and PharmaCare costs over time. All health service utilization costs increased significantly during the 6–12 months and ≤ 6 months prior to institutionalization. Postinstitutionalization Continuing Care costs continued to increase at ≤ 6 months before decreasing at 6–12 months, while decreases occurred for Medical Services Plan and PharmaCare costs relative to preinstitutionalization costs. Conclusions The increases in costs observed during the year prior to institutionalization, characterized by a flurry of health service utilization, provide evidence of distinct cost patterns over the transition period.
TL;DR: Five biggest concerns or hesitations about the DSM-5 changes as they pertain to the practice of geriatric psychiatry: A new diagnosis called “somatic symptom disorder” is meant to replace a variety of DSM-IV somatoform disorders, and this will likely be important for a small subgroup of older adults.
Abstract: Up until last year, the term “Geriatric Psychiatrist” was open to any psychiatrist in Canada who practiced with older adults. The new Royal College subspecialty is an important step in accrediting, training, and acknowledging the specialized work involved in geriatric psychiatry. No transition, however, can be entirely smooth. There is a dire need for expanded training positions and funding for these positions. Some senior members of our profession remain uncertain whether it is worth it to pursue this certification, which includes the need for an examination. It is possible that the subspecialty designation will be a requirement in certain jurisdictions, and there may be fee-code implications in the future, although uncertainty remains. The CAGP has offered a national review course and online study group for the last two years, and we have now tailored this for geriatricians, general psychiatrists, and other non-psychiatry stakeholders.
Another change for geriatric psychiatry, which has been perceived by the media as huge, was the introduction in May 2013 of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).(1) I believe it is worthwhile to reflect on some of these changes further, as any change to diagnostic classification has important potential implications for clinical practice and our patients. The publication of the DSM-III in 1980 introduced standardized criteria for the diagnosis of mental disorders. This improved the reliability of psychiatric diagnoses over earlier classifications, which were guided by clinical impression in a more idiosyncratic fashion. While many biomarkers associated with a variety of mental disorders have been identified since the introduction of DSM-III, there are still no clinical laboratory tests or alternative “gold standards” for diagnosing mental disorder.(2)
Overall, the DSM-5 categorical diagnostic scheme is largely unchanged from DSM-IV, with more similarities than differences compared with the recent previous editions from DSM-III onward. Nonetheless, DSM-5 has eliminated the multi-axial scheme in which personality disorders, medical illness, psychosocial stressors, and a global functioning score were each listed on different “axes” from primary psychiatric disorders. Substance dependence and abuse have been simplified into a single substance use disorder. It was recognized that patients with delusional disorder do not necessarily have “non-bizarre” delusions, and that patients with anxiety disorders may not necessarily see their worries as “excessive or unreasonable”. A few new disorders, like hoarding disorder and gambling disorder, have been introduced formally into the nomenclature, and this will likely be important for a small subgroup of older adults. There are other, more minor changes, which I will not summarize here, but these are my five biggest concerns or hesitations about the DSM-5 changes as they pertain to the practice of geriatric psychiatry:
A new diagnosis called “somatic symptom disorder” is meant to replace a variety of DSM-IV somatoform disorders. To meet criteria for this disorder, a patient must have one or more physical symptoms that are distressing or result in significant disruption of daily life. Additionally, they must have excessive thoughts, feelings, and behaviour about the symptoms or associated health concerns, generally for six months or more. The changes were made because of the rarely used category of the DSM-IV somatoform disorders, and to move away from a prior emphasis on difficult-to-characterize “medically unexplained symptoms”(3). Some clinicians, particularly those working in primary or tertiary care medical settings, would be hard-pressed to find patients with physical symptoms that they are not overly concerned about. Although there is reasonable reliability, and although rates are reasonably low when specific questions are applied to ascertain the psychological aspects of the symptoms (less than 10% prevalence in a recent medically ill cohort),(3) it remains to be seen whether in clinical practice, this category over-identifies those with physical symptoms as having a mental disorder.
Dementia has been re-named “major neurocognitive disorder”, which introduces a supposedly more culturally sensitive term, but will likely confuse many. The body of the text of DSM-5 indicates that the term “dementia” may still be used, but I am uncertain as to who will read the entire body of the text of a book that is almost 1000 pages long. My patients and their family members have enough trouble understanding the differences between dementia and Alzheimer’s disease. What will “neuro-cognitive disorder” mean to them?
A new diagnosis which was not listed in the main body of DSM-IV, called “mild neurocognitive disorder”, has been introduced. Essentially this is fairly similar to the concept of mild cognitive impairment (or MCI) which is very familiar to most geriatricians and geriatric psychiatrists. The text of the DSM-5 indicates that performance 1 to 2 standard deviations below the mean in one cognitive domain (as established by several possible neurocognitive tests), in addition to subjective cognitive concerns or concerns of the informant or clinician about the patient’s cognition, would qualify for this diagnosis. Research has shown that even subtle changes to the exact MCI definition has a dramatic impact on prevalence.(4) In clinical settings, neuropsychological testing is not widely available. Although the DSM-5 indicates that “another quantified clinical assessment” can substitute when neuropsycho-logical testing is not feasible, the details and cut-offs are not specified. It is clear that dementia is underdiagnosed, but pathologizing normative cognitive changes, which are present in the 16% of older persons that by definition score 1 standard deviation below the population mean, is unlikely to be helpful. Patients with other versions of MCI diagnoses so far have not been seen to respond to conventional pharmacotherapy for dementia the way patients with mild-to-moderate Alzheimer’s disease do.(5,6)
The DSM-IV prevented the diagnosis a major depressive episode (MDE) within two months of the death of one spouse or a loved one unless serious functional impairment or unless specific complicated symptoms (e.g., psychomotor slowing, worthlessness, psychosis, and suicidal thoughts) were present. The authors of the DSM-5 have suggested that an MDE could be diagnosed at any time after a loss as long as criteria are met, essentially removing the “bereavement exclusion”. Wakefield et al.(7) are among the authors who have demonstrated differences between bereavement complicated by major depression and bereavement uncomplicated by major depression. The authors demonstrated that there were three-fold more false positives (or lack of external validators) when the bereavement exclusion was changed from one year (in the DSM-III-R) to two months with the DSM-IV, and when one or more complicating symptoms (instead of two or more in the DSM-IIIR) could yield a major depression diagnosis; the false-positive rate rose from 6.2% to 28.4%.(7) It is possible that without the time exclusion, DSM-5 will be associated with more false positives, but this has not yet been studied. On the other hand, another recent large-scale study showed that the presence or absence of the bereavement exclusion did not predict antidepressant treatment response,(8) so the relevance to treatment remains questionable. Furthermore, both of the bereavement studies that I have mentioned focused on younger adults, so it is unclear whether the situation is the same in the elderly.
The reliability of established experts in the field trials of DSM-5 was suboptimal, particularly for major depression, but also for minor neurocognitive disorder.(9) I would suspect that the inter-rater agreement of clinicians, who do not always use the criteria verbatim, would be even less. Although this was probably also a problem with prior editions of the DSM, there have been no direct comparisons.
It is easy for me to be an armchair critic of this process, and I can certainly say that I personally have no better solutions. Many parts of Canada do not and cannot approach the Mental Health Commission of Canada’s benchmarks for staffing in geriatric psychiatry(10) and an increase in false positives with the lower thresholds in DSM-5 could worsen this situation. On the flip-side, mental disorders in late life are woefully under-diagnosed, and if DSM had instead taken a more restrictive approach, that would have been perpetuated.
Hopefully we will see more studies about the reliability and external validity of the criteria published in the next several years which may provide reassurance and, ideally, there will be direct comparisons between new proposals with the current and recent editions. It will also be interesting to see whether, in practice, the newly introduced dimensional measures in the DSM-5, which are freely available online,(11) turn out to be reliable, valid, helpful, practical, and sensitive to change, particularly in the older population.
TL;DR: This year’s ASM included a workshop on how to disclose a diagnosis of dementia using a person-centred, comprehensive, and progressive approach, and there was also a workshop devoted to reviewing the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia guidelines.
Abstract: The Annual Scientific Meeting of the Canadian Academy of Geriatric Psychiatry was held in Ottawa, Ontario on September 25th 2013 Given greater weight this year due to the inaugural Royal College Geriatric Psychiatry subspecialty certification exam being written across the country the following day, the meeting proved to be not only a venue for dissemination of current knowledge in Geriatric Psychiatry, but also for networking and meeting with colleagues Preceded by the 2nd Annual CAGP Review Course, the theme of the ASM, “Emerging Concepts in Geriatric Psychiatry”, was all the more relevant in the context of the exam and the changes in Geriatric Psychiatry certification in Canada
The keynote presentation this year was given by Dr Benoit Mulsant on the topic of the changes relevant to Geriatric Psychiatry that were introduced with the publication of the 5th edition of the Diagnostic and Statistical Manual of Psychiatric Disorders by the American Psychiatric Association Dr Mark Rapoport has written an editorial discussing Dr Mulsant’s presentation with his own reflections, as well The plenary session was a panel entitled “Advances in Therapeutic Brain Stimulation”, presented by Dr Daniel Blumberger and Dr Paul Lesperance Dr Blumberger started by categorizing brain stimulation into non-convulsive, convulsive, and surgical intervention categories As an example of non-convulsive treatment, he discussed the advent of Transcranial Direct Current Stimulation, in which low-voltage current is delivered to the prefrontal cortex (PFC) over 20–40 minutes(1) He described the mechanism of anode stimulation leading to increased neuronal activity (depolarization), leading to enhanced cortical excitability, leading to the choice of the prefrontal cortex for stimulation He then discussed electroconvulsive therapy (ECT), and described the importance of ultra-brief pulse width stimuli of 03–037 ms and the evidence indicating that it is more effective than bilateral standard pulse width ECT with fewer cognitive side effects(2) He also described the use of nortryptiline and lithium for post-ECT maintenance treatment, and highlighted the need for more research in this area Dr Blumberger also described Magnetic Seizure Therapy(3) as a new advance in brain stimulation He described it as a high-power Transcranial Magnetic Stimulation (rTMS) device for seizure induction, ideally with less cognitive impairment and faster recovery, compared to ECT, due to more focal electrical fields, narrower pulse widths, and lower anaesthesia requirements Dr Lesperance further elaborated on rTMS, looking at the evidence for this treatment modality, and leading a discussion on whether the data is clinically meaningful(4) He indicated that the parameters of stimulation are still in development and that predictors of response are not yet available Dr Lesperance concluded with an update on Vagus Nerve Stimulation, indicating that it is approved for treatment-resistant depression, with sustained remission with no switch to mania and improved cognition compared to ECT(5) While he described the mechanisms working via deactivation of the orbitofrontal cortex, he acknowledged that there is little data in the geriatric population thus far
In addition to the keynote and plenary session, this year’s annual meeting included a number of additional highlights These included a workshop on how to disclose a diagnosis of dementia using a person-centred, comprehensive, and progressive approach Participants were asked to work through disclosure of a diagnosis of dementia using a three-tiered process involving pre-disclosure, disclosure, and post-disclosure There was also time allocated for reflection Keeping with the theme of dementia, there was also a workshop devoted to reviewing the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia guidelines(6) with respect to imaging and dementia Participants had an opportunity to interact directly with members of the expert panel who came up with the guidelines, and increase their knowledge of neuroimaging as it pertains to dementia In addition, there was a workshop entitled “Too Old for Therapy”, in which the principles of Cognitive Behavioural Therapy were adapted for use in older adults
Further, Dr Mulsant, in conjunction with Drs Daniel Blumberger, Zahinoor Ismail, Kiran Rabheru, and Mark Rapoport, led a workshop on developing an algorithmic approach to pharmacotherapy of late-life depression (LLD) Participants described their approaches to treatment of LLD at various stages of treatment and tried to integrate this into a stepped-care approach to treatment(7)
Concurrent paper sessions focused on a number of common themes, including use of technology, psychotropic medication, health systems issues, and some controversial topics There was a session devoted to using an artificial intelligence device in a hospital setting to detect falls in older adults with complex psychiatric issues and then link these events to other factors such as behaviour and medication Another session provided some practical advice on how to set up a geriatric telepsychiatry service to provide access to patients in remote or rural areas Dr Jonathan Crowson from McMaster University explained how he and his allied health team established the Geriatric Psychiatry Telemedicine Network to provide consultation to remote and rural areas in Waterloo and Wellington County Telemedicine has been used in geriatric psychiatry successfully, although there are some unique challenges(8) He elaborated on the potential benefits of such a network in terms of improving access to care, and also described some of the barriers, such as establishing a therapeutic alliance with a patient you can only see on camera A third session focused on adapting a telehealth service to address the needs of residents with behavioural and psychological symptoms of dementia (BPSD) living in remote institutions Dr Marie-Andree Bruneau from the University of Montreal discussed how she and her colleagues developed a Telepsychogeriatry (teleformation and teleconsultation) program to connect with two partner institutions in remote and rural Quebec Research in other sectors of North American, such as the United States, suggests that this may be both clinically useful and cost effective(9) The purpose of the program was to identify and provide recommendations around the management of patients with BPSD Factors associated with implementation success and failure were discussed, and the evidence base for teleconsultation in treating BPSD was reviewed Two sessions focused on psychotropic medication—one addressed concerns about QT prolongation and proposing a risk management tool, and the other examined common medical side effects to psychotropic medication among older adults with mood disorders In the area of health systems, there was a session focusing on referral patterns among the “oldest old” in the Thunder Bay area and the resource implications of this Another session looked at a knowledge translation intervention designed to increase the competence of primary care physicians treating patients with dementia There were two somewhat controversial sessions The first examined the role of the psychiatrist among terminally ill patients wishing to die in light of new legislation being proposed in Quebec Dr Simon Dufour-Turbis from McGill University reviewed the international experience of psychiatrists dealing with physician-assisted suicide/euthanasia Psychiatrists are frequently called upon to consult in such cases, although their role is not always clear(10) He also reviewed the potential challenges associated with the legalization of “medical aid in dying”, legislation currently being debated in the Quebec National Assembly The legislation calls for psychiatrists to be consulted when patient competency is in question Potential ethical and logistical challenges associated with such assessments were discussed The session included a review of international experts in this area The second session postulated that the concept of BPSD may be in decline, as it may lack specificity
Finally, the CAGP Fellowship Award was given to Dr Jennifer Brault, who presented her ongoing research into “Exogenous Melatonin for Insomnia in Older Adults—a Meta-analysis” She described the research methodology and her plans for future research The award for Outstanding Contributions in Geriatric Psychiatry was shared by Drs Melissa Andrew and Catherine Shea for their devoted and successful efforts over many years to get Geriatric Psychiatry officially recognized at the Royal College level
In summary, the CAGP ASM was successful in providing current and up-to-date education in Geriatric Psychiatry, with a focus on new approaches and treatments The 2014 ASM will be held in Toronto on September 9 and 10, in a joint venture with the Canadian Coalition for Seniors Mental Health
TL;DR: This issue of the Canadian Geriatrics Journal addresses a wide variety of issues, including medical education, the relationship between urinary tract infections and delirium, and an analysis of which patients are admitted to a facility versus assisted living.
Abstract: We are pleased to present the first issue of the Canadian Geriatrics Journal for 2014. This issue addresses a wide variety of issues, including medical education, the relationship between urinary tract infections and delirium, and an analysis of which patients are admitted to a facility versus assisted living.
The role of assisted living in providing functional support for older adults is a growing, but relatively unexamined area of research. Rockwood et al.(1) have provided a cross-sectional analysis of which factors and events predispose patients to be admitted to assisted living versus facility care. The underlying assumption of most physicians is that assisted living is just for the “worried well”, but the findings by Rockwood et al. show that assisted living is playing a role in discharge planning for much sicker and frailer patients.
Another area of concern is the growing population of older adults who are either current or former illicit drug users. Dr. Sztramko and his co-investigators(2) have examined the demographic characteristics and health utilization behaviours in older adults in Canada’s most impoverished community (Vancouver’s Downtown Eastside).
Rounding out our issue, Haque et al.(3) prospectively examined the ability of a Clinical Skills Day to change medical students attitudes about caring for older adults, and Balogun et al.(4) has performed a systematic review that formally examines the relationship between urinary tract infections and delirium. We are also delighted to include a summary of the recent Geriatric Psychiatry meeting,(5) as well as presenting the abstracts for the Geriatric Psychiatry scientific sessions.(6)
Thanks, again, for all of your support!
TL;DR: The authors' 2014 spring issue focuses on assessing driving fitness in older adults, and a prospective comparison of the SIMARD MD to overall clinical impression of driving fitness is done.
Abstract: In celebration of Canada’s recovery from the horrible 2014 winter that seemed never-ending, we are excited to present our 2014 spring issue that focuses on assessing driving fitness in older adults. Wernham et al. have done a prospective comparison of the SIMARD MD to overall clinical impression of driving fitness.(1) On the education side of things, Moorhouse and Hamilton have prospectively examined the effect of a campaign designed to address perceived barriers to assessing driving by primary care providers.(2) Hogan et al., after a modified Delphi procedure, present consensus statements on assessing driving fitness in older adults.(3)
We also are pleased to note the article by Charles et al. that presents core geriatric competencies for both family practice programs and specialized care of the elderly programs.(4) Naslund et al. have examined Canadian Study of Health and Aging data to demonstrate changes in health service utilization costs in the year prior to institutionalization.(5) Baptiste et al. have prepared a qualitative assessment of patient’s perceptions of dining locations in a rehabilitation ward.(6)