Factors associated with transition to a nursing home in older adults living in naturally occurring retirement communities.

BACKGROUND: Naturally occurring retirement communities (NORCs) are geographic areas (generally high-rise buildings or neighborhoods) that have a high concentration of individuals 65 years and older. Supportive service programs in NORCs can address resident needs and delay nursing home (NH) admission but understanding what factors are associated with NORC residents requiring NH admission is needed to tailor such programs. Our aim was to examine individual- and neighborhood-level factors associated with NH wait-list status in NORC residents in Ontario. METHODS: We conducted a population-based, cross-sectional study of Ontario adults 65 years of age or older living in a NORC building as of January 1, 2020, by linking a provincial registry of NORC high-rise buildings with health administrative data. Older adults were classified as being on the NH wait-list if they had an open application for a NH on the index date. We conducted a multilevel logistic regression analysis using generalized estimating equations to determine individual- and neighborhood-level factors associated with NH wait-list status, including sociodemographic, clinical, healthcare use, and building factors. We explored the role of sex and age through stratification by sex (male, female) and age (65-80 and 80+ years). RESULTS: Among 220,864 NORC residents, 4710 individuals (2.1%) were on the NH wait-list. Female sex, older age, immigrant status, dementia diagnosis, receiving homecare, multimorbidity, and polypharmacy (five or more unique drug names) were associated with an increased odds of wait-list status. Several neighborhood-level variables were associated with a significantly increased likelihood of wait-list status, including low income, high dependency, high ethnic diversity, and living in a building with supports. CONCLUSION: NORC supportive service programs can be tailored to account for the factors associated with NH wait-list status, allowing NORC residents who are living in the community to age in their desired place and achieve optimal health outcomes.

Sex-based trajectories of health system use in lonely and not lonely older people: A population-based cohort study.

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.

Association of a calcium channel blocker and diuretic prescribing cascade with adverse events: A population-based cohort study.

BACKGROUND: Prescribing cascades occur when a drug adverse event is misinterpreted as a new medical condition and a second, potentially unnecessary drug, is prescribed to treat the adverse event. The population-level consequences of prescribing cascades remain unknown. METHODS: This population-based cohort study used linked health administrative databases in Ontario, Canada. The study included community-dwelling adults, 66 years of age or older with hypertension and no history of heart failure (HF) or diuretic use in the prior year, newly dispensed a calcium channel blocker (CCB). Individuals subsequently dispensed a diuretic within 90 days of incident CCB dispensing were classified as the prescribing cascade group, and compared to those not dispensed a diuretic, classified as the non-prescribing cascade group. Those with and without a prescribing cascade were matched one-to-one on the propensity score and sex. The primary outcome was a serious adverse event (SAE), which was the composite of emergency room visits and hospitalizations in the 90-day follow-up period. We estimated hazard ratios (HRs) with 95% confidence intervals (CI) for SAE using an Andersen-Gill recurrent events regression model. RESULTS: Among 39,347 older adults with hypertension and no history of HF who were newly dispensed a CCB, 1881 (4.8%) had a new diuretic dispensed within 90 days after CCB initiation. Compared to the non-prescribing cascade group, those in the prescribing cascade group had higher rates of SAEs (HR: 1.21, 95% CI: 1.02-1.43). CONCLUSIONS: The CCB-diuretic prescribing cascade was associated with an increased rate of SAEs, suggesting harm beyond prescribing a second drug therapy. Our study raises awareness of the downstream impact of the CCB-diuretic prescribing cascade at a population level and provides an opportunity for clinicians who identify this prescribing cascade to review their patients' medications to determine if they can be optimized.

Maternal varicella antibodies in children aged less than one year: Assessment of antibody decay.

OBJECTIVES: To investigate maternal antibody levels to varicella in infants <12 months of age in Ontario, Canada. STUDY DESIGN: In this study, we included specimens from infants <12 months of age, born at ≥37 weeks gestational age, who had sera collected at The Hospital for Sick Children (Toronto, Canada) between 2014-2016. We tested sera using a glycoprotein-based enzyme-linked immunosorbent assay (gpELISA). We measured varicella susceptibility (antibody concentration <150mIU/mL) and mean varicella antibody concentration, and assessed the probability of susceptibility and concentration between one and 11 months of age using multivariable logistic regression and Poisson regression. RESULTS: We found that 32% of 196 included specimens represented infants susceptible to varicella at one month of age, increasing to nearly 80% at three months of age. At six months of age, all infants were susceptible to varicella and the predicted mean varicella antibody concentration declined to 62 mIU/mL (95% confidence interval 40, 84), well below the threshold of protection. CONCLUSIONS: We found that varicella maternal antibody levels wane rapidly in infants, leaving most infants susceptible by four months of age. Our findings have implications for the timing of first dose of varicella-containing vaccine, infection control measures, and infant post-exposure prophylaxis recommendations.

Exploring physician gender bias in the initiation of prescribing cascades for older men and women: a qualitative clinical vignette study protocol.

INTRODUCTION: A prescribing cascade occurs when a drug is prescribed to manage the often unrecognised side effect of another drug; these cascades are of particular concern for older adults who are at heightened risk for drug-related harm. It is unknown whether, and to what extent, gender bias influences physician decision-making in the context of prescribing cascades. The aim of this transnational study is to explore the potential impact of physician implicit gender biases on prescribing decisions that may lead to the initiation of prescribing cascades in older men and women in two countries, namely: Canada and Italy. METHODS AND ANALYSIS: Male and female primary care physicians at each site will be randomised 1:1 to a case vignette that features either a male or female older patient who presents with concerns consistent with the side effect of a medication they are taking. During individual interviews, while masked to the true purpose of the study, participants will read the vignette and use the think-aloud method to describe their ongoing thought processes as they consider the patient's concerns and determine a course of action. Interviews will be recorded, transcribed verbatim and thematic analysis will be conducted to highlight differences in decisions in the interviews/transcripts, using a common analytical framework across the sites. ETHICS AND DISSEMINATION: This study has received ethics approval at each study site. Verbal informed consent will be received from participants prior to data collection and all data will be deidentified and stored on password-protected servers. Results of this study will be disseminated through peer-reviewed journal articles and presented at relevant national and international conferences.

Factors associated with loneliness in immigrant and Canadian-born older adults in Ontario, Canada: a population-based study.

BACKGROUND: While loneliness is common in older adults, some immigrant groups are at higher risk. To inform tailored interventions, we identified factors associated with loneliness among immigrant and Canadian-born older adults living in Ontario, Canada. METHODS: We conducted a cross-sectional analysis of 2008/09 data from the Canadian Community Health Survey (Healthy Aging Cycle) and linked health administrative data for respondents 65 years and older residing in Ontario, Canada. Loneliness was measured using the Three-Item Loneliness Scale, with individuals categorized as 'lonely' if they had an overall score of 4 or greater. For immigrant and Canadian-born older adults, we developed separate multivariable logistic regression models to assess individual, relationship and community-level factors associated with loneliness. RESULTS: In a sample of 968 immigrant and 1703 Canadian-born older adults, we found a high prevalence of loneliness (30.8% and 34.0%, respectively). Shared correlates of loneliness included low positive social interaction and wanting to participate more in social, recreational or group activities. In older immigrants, unique correlates included: widowhood, poor health (i.e., physical, mental and social well-being), less time in Canada, and lower neighborhood-level ethnic diversity and income. Among Canadian-born older adults, unique correlates were: female sex, poor mental health, weak sense of community belonging and living alone. Older immigrant females, compared to older immigrant males, had greater prevalence (39.1% vs. 21.9%) of loneliness. CONCLUSIONS: Although both groups had shared correlates of loneliness, community-level factors were more strongly associated with loneliness in immigrants. These findings enhance our understanding of loneliness and can inform policy and practice tailored to immigrants.

Sex-based differences in the association between loneliness and polypharmacy among older adults in Ontario, Canada.

BACKGROUND: Emerging evidence shows loneliness is associated with polypharmacy and high-risk medications in older adults. Despite notable sex-based differences in the prevalence in each of loneliness and polypharmacy, the role of sex in the relationship between loneliness and polypharmacy is unclear. We explored the relationship between loneliness and polypharmacy in older female and male respondents and described sex-related variations in prescribed medication subclasses. METHODS: We performed a cross-sectional analysis of representative data from the Canadian Community Health Survey-Healthy Aging cycle (2008/2009) linked to health administrative databases in Ontario respondents aged 66 years and older. Loneliness was measured using the Three-Item Loneliness Scale, with respondents classified as not lonely, moderately lonely, or severely lonely. Polypharmacy was defined as five or more concurrently-prescribed medications. Sex-stratified multivariable logistic regression models with survey weights were used to assess the relationship between loneliness and polypharmacy. Among those with polypharmacy, we examined the distribution of prescribed medication subclasses and potentially inappropriate medications. RESULTS: Of the 2348 individuals included in this study, 54.6% were female respondents. The prevalence of polypharmacy was highest in those with severe loneliness both in female (no loneliness, 32.4%; moderate loneliness, 36.5%; severe loneliness, 44.1%) and male respondents (32.5%, 32.2%, and 42.5%). Severe loneliness was significantly associated with greater adjusted odds of polypharmacy in female respondents (OR = 1.59; 95% CI: 1.01-2.50) but this association was attenuated after adjustment in male respondents (OR = 1.00; 95% CI: 0.56-1.80). Among those with polypharmacy, antidepressants were more commonly prescribed in female respondents with severe loneliness (38.7% [95% CI: 27.3-50.0]) compared to those who were moderately lonely (17.7% [95% CI: 9.3-26.2]). CONCLUSIONS: Severe loneliness was independently associated with polypharmacy in older female but not male respondents. Clinicians should consider loneliness as an important risk factor in medication reviews and deprescribing efforts to minimize medication-related harms, particularly in older women.

Retrospective cross-sectional study examining the association between loneliness and unmet healthcare needs among middle-aged and older adults using the Canadian Longitudinal Study of Aging (CLSA).

OBJECTIVES: Our primary objective was to estimate the association between loneliness and unmet healthcare needs and if the association changes when adjusted for demographic and health factors. Our secondary objective was to examine the associations by gender (men, women, gender diverse). DESIGN, SETTING, PARTICIPANTS: Retrospective cross-sectional data from 44 423 community-dwelling Canadian Longitudinal Study on Aging participants aged 45 years and older were used. PRIMARY OUTCOME MEASURE: Unmet healthcare needs are measured by asking respondents to indicate (yes, no) if there was a time when they needed healthcare in the last 12 months but did not receive it. RESULTS: In our sample of 44 423 respondents, 8.5% (n=3755) reported having an unmet healthcare need in the previous 12 months. Lonely respondents had a higher percentage of unmet healthcare needs (14.4%, n=1474) compared with those who were not lonely (6.7%, n=2281). Gender diverse had the highest percentage reporting being lonely and having an unmet healthcare need (27.3%, n=3), followed by women (15.4%, n=887) and men (13.1%, n=583). In our logistic regression, lonely respondents had higher odds of having an unmet healthcare need in the previous 12 months than did not lonely (adjusted odd ratios (aOR) 1.80, 95% CI 1.64 to 1.97), adjusted for other covariates. In the gender-stratified analysis, loneliness was associated with a slightly greater likelihood of unmet healthcare needs in men (aOR 1.90, 95% CI 1.64 to 2.19) than in women (aOR 1.73, 95% CI 1.53 to 1.95). In the gender diverse, loneliness was also associated with increased likelihood of having an unmet healthcare need (aOR 1.38, 95% CI 0.23 to 8.29). CONCLUSIONS: Loneliness was related to unmet healthcare needs in the previous 12 months, which may suggest that those without robust social connections experience challenges accessing health services. Gender-related differences in loneliness and unmet needs must be further examined in larger samples.

ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People.

BACKGROUND AND OBJECTIVE: Prescribing cascades occur when a drug is prescribed to manage side effects of another drug, typically when a side effect is misinterpreted as a new condition. A consensus list of clinically important prescribing cascades that adversely affect older persons' health (i.e., where risks of the prescribing cascade usually exceed benefits) was developed to help identify, prevent, and manage prescribing cascades. METHODS: Three rounds of a modified Delphi process were conducted with a multidisciplinary panel of 38 clinicians from six countries with expertise in geriatric pharmacotherapy. The clinical importance of 139 prescribing cascades was assessed in Round 1. Cascades highly rated by ≥ 70% of panelists were included in subsequent rounds. Factors influencing ratings in Rounds 1 and 3 were categorized. After three Delphi rounds, highly rated prescribing cascades were reviewed by the study team to determine the final list of clinically important cascades consistent with potentially inappropriate prescribing. RESULTS: After three rounds, 13 prescribing cascades were highly rated by panelists. Following a study team review, the final tool includes nine clinically important prescribing cascades consistent with potentially inappropriate prescribing. Panelists reported that their ratings were influenced by many factors (e.g., how commonly they encountered the medications involved and the cascade itself, the severity of side effects, availability of alternatives). The relative importance of these factors in determining clinical importance varied by panelist. CONCLUSIONS: A nine-item consensus-based list of clinically important prescribing cascades, representing potentially inappropriate prescribing, was developed. Panelists' decisions about what constituted a clinically important prescribing cascade were multi-factorial. This tool not only raises awareness about these cascades but will also help clinicians recognize these and other important prescribing cascades. This list contributes to the prevention and management of polypharmacy and medication-related harm in older people.

Detection of pyrethroid resistance mutations and intron variants in the voltage-gated sodium channel of Aedes (Stegomyia) aegypti and Aedes (Stegomyia) albopictus mosquitoes from Lao People's Democratic Republic.

In Lao People's Democratic Republic, Aedes aegypti (Linnaeus 1762) and Aedes albopictus (Skuse 1894) mosquitoes (Diptera: Culicidae) are vectors of arboviral diseases such as dengue. As the treatment for these diseases is limited, control of the vectors with the use of pyrethroid insecticides is still essential. However, mutations in the voltage-gated sodium channel (vgsc) gene giving rise to pyrethroid resistance are threatening vector control programs. Here, we analysed both Ae. aegypti and Ae. albopictus mosquitoes, which were collected in different districts of Laos (Kaysone Phomvihane, Vangvieng, Saysettha and Xaythany), for vgsc mutations commonly found throughout Asia (S989P, V1016G and F1534C). Sequences of the vgsc gene showed that the F1534C mutation was prevalent in both Aedes species. S989P and V1016G mutations were detected in Ae. aegypti from each site and were always found together. In addition, the mutation T1520I was seen in Ae. albopictus mosquitoes from Saysettha district as well as in all Ae. aegypti samples. Thus, mutations in the vgsc gene of Ae. aegypti are prevalent in the four districts studied indicating growing insecticide resistance throughout Laos. Constant monitoring programmes and alternative strategies for controlling Aedes should be utilized in order to prolong the effectiveness of pyrethroids thereby maximizing vector control.

The Factors Associated With Nonuse of Social Media or Video Communications to Connect With Friends and Family During the COVID-19 Pandemic in Older Adults: Web-Based Survey Study.

BACKGROUND: Digital technologies have enabled social connection during prolonged periods of physical distancing and travel restrictions throughout the COVID-19 pandemic. These solutions may exclude older adults, who are at higher risk for social isolation, loneliness, and severe outcomes if infected with SARS-CoV-2. OBJECTIVE: This study investigated factors associated with nonuse of social media or video communications to connect with friends and family among older adults during the pandemic's first wave. METHODS: A web-based, cross-sectional survey was administered to members of a national retired educators' organization based in Ontario, Canada, between May 6 and 19, 2020. Respondents (N=4879) were asked about their use of social networking websites or apps to communicate with friends and family, their internet connection and smartphone access, loneliness, and sociodemographic characteristics. Factors associated with nonuse were evaluated using multivariable logistic regression. A thematic analysis was performed on open-ended survey responses that described experiences with technology and virtual connection. RESULTS: Overall, 15.4% (751/4868) of respondents did not use social networking websites or apps. After adjustment, male gender (odds ratio [OR] 1.60, 95% CI 1.33-1.92), advanced age (OR 1.88, 95% CI 1.38-2.55), living alone (OR 1.68, 95% CI 1.39-2.02), poorer health (OR 1.33, 95% CI 1.04-1.71), and lower social support (OR 1.44, 95% CI 1.20-1.71) increased the odds of nonuse. The reliability of internet connection and access to a smartphone also predicted nonuse. Many respondents viewed these technologies as beneficial, especially for maintaining pre-COVID-19 social contacts and routines, despite preferences for in-person connection. CONCLUSIONS: Several factors including advanced age, living alone, and low social support increased the odds of nonuse of social media in older adults to communicate with friends and family during COVID-19's first wave. Our findings identified socially vulnerable subgroups who may benefit from intervention (eg, improved access, digital literacy, and telephone outreach) to improve social connection.

Gender Differences in Mental Health Symptoms Among Canadian Older Adults During the COVID-19 Pandemic: a Cross-Sectional Survey.

Background: Older women's mental health may be disproportionally affected by the COVID-19 pandemic due to differences in gender roles and living circumstances associating with aging. Methods: We administered an online cross-sectional nationwide survey between May 1st and June 30th, 2020 to a convenience sample of older adults aged ≥55 years. Our outcomes were symptoms of depression, anxiety, and loneliness measured by three standardized scales: the eight-item Center for Epidemiological Studies Depression Scale, the five-item Beck Anxiety Inventory, and the Three-Item Loneliness Scale. Multivariable logistic regression was used to compare the odds of depression, anxiety and loneliness between men and women, adjusting for relevant confounders. Results: There were 1,541 respondents (67.8% women, mean age 69.3 ± 7.8). 23.3% reported symptoms of depression (29.4% women, 17.0% men), 23.2% reported symptoms of anxiety (26.0% women, 19.0% men), and 28.0% were lonely (31.5% women, 20.9% men). After adjustment for confounders, the odds of reporting depressive symptoms were 2.07 times higher in women compared to men (OR 2.07 [95%CI 1.50-2.87] p < .0001). The odds of reporting anxiety and loneliness were also higher. Conclusions: Older women had twice the odds of reporting depressive symptoms compared to men, an important mental health need that should be considered as the COVID-19 pandemic unfolds.

Examining the association between loneliness and emergency department visits using Canadian Longitudinal Study of Aging (CLSA) data: a retrospective cross-sectional study.

BACKGROUND: Loneliness is a public health concern and its influence on morbidity and mortality are well documented. The association between loneliness and emergency department visits is less clear. Further, while sex and gender-related factors are known to be associated with loneliness and health services use, little research looks at the relationship by gender. Our study aimed to estimate the association between loneliness and emergency department use in the previous 12 months. We aimed to determine if this association differed based on gender identity and gender-related characteristics. METHODS: We used a retrospective cohort study design to analyze population-based survey data from the Canadian Longitudinal Study on Aging (CLSA). We analysed data from the baseline and follow-up 1 survey respondents (2015-2018) from both the tracking (telephone interviews) and comprehensive (in-home data collection) cohorts (n=44816). Loneliness was assessed using a dichotomous measure (lonely/not lonely) from a validated scale. Emergency department visits were dichotomous (yes/no) by self-reported emergency department use in the 12 months prior to the survey date. Multivariable logistic regression analyses using analytic weights examined the association between loneliness and emergency department visit, controlling for other demographic, social, and health related factors. RESULTS: We identified 44,413 respondents to the baseline and follow-up 1 survey. The prevalence of loneliness in our sample was 23.1% (n=10263). Of those who had been to the emergency department in the previous year, 27.2% (n=2793) were lonely. Lonely respondents had higher odds of an emergency department visit (aOR: 1.13, 95% CI: 1.05-1.21), adjusted for various demographic and health factors. Loneliness was associated with emergency department visits more so in women (aOR: 1.15, 95% CI: 1.05-1.25) than in men (aOR: 1.10, 95% CI: 0.99-1.22). CONCLUSIONS: In our study, loneliness was associated with emergency department visits in the previous 12 months. When our analysis was disaggregated by gender, we found differences in the odds of emergency department visit for men, women, and gender-diverse respondents. The odds of ED visit were higher in women than men. These findings highlight the general importance of identifying loneliness in both primary care and hospital. Care providers in ED need resources to refer patients who present in this setting with health issues complicated by social conditions such as loneliness.

Perspectives on ageing: a qualitative study of the expectations, priorities, needs and values of older people from two Canadian provinces.

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.

Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain.

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.

A multisite study of pertussis vaccine effectiveness by time since last vaccine dose from three Canadian provinces: A Canadian Immunization Research Network study.

BACKGROUND: Pertussis remains poorly controlled relative to other diseases targeted by childhood vaccination programs. We combined estimates from four population-based studies of pertussis vaccine effectiveness (VE) in three Canadian provinces using a meta-analytic approach to improve precision and explore regional variation in VE and durability of protection. METHODS: Studies were conducted in Alberta, Manitoba, and Ontario over periods ranging from 1996 to 2015. Adjusted log odds ratios (OR; VE = 100*[1-OR]) of the effect of vaccination on pertussis risk were estimated by time since last vaccination in each study and pooled using DerSimonian and Laird random-effects models. We used the I2 statistic to estimate between-study heterogeneity and assessed methodological and clinical heterogeneity through subgroup analyses of study design and age. RESULTS: Data on 3,270 pertussis cases and 23,863 controls were available. Pertussis VE declined from 86% (95% CI 79%-90%, I2 = 81.5%) at < 1 year since last vaccination to 51% (11%-74%, I2 = 80.9%) by ≥ 8 years. Effect estimates were the most heterogeneous in the least and most elapsed time periods since last vaccine dose. This was attributable mostly to variation between provinces in the distribution of age groups and number of vaccine doses received within time periods, as well as study design and small numbers in the most elapsed time period. INTERPRETATION: Consistent trends of decreasing pertussis VE with increasing time since last vaccination across three Canadian provinces indicate the need for immunization schedules and vaccine development to optimize protection for all individuals, especially for adolescents and young adults at greatest risk of infection.

Loneliness among older adults in the community during COVID-19: a cross-sectional survey in Canada.

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.

A Call for Caution in Use of Pertussis Vaccine Effectiveness Studies to Estimate Waning Immunity: A Canadian Immunization Research Network Study.

BACKGROUND: Vaccine effectiveness (VE) studies provide essential evidence on waning vaccine-derived immunity, a major threat to pertussis control. We evaluated how study design affects estimates by comparing 2 case-control studies conducted in Ontario, Canada. METHODS: We compared results from a test-negative design (TND) with a frequency-matched design (FMD) case-control study using pertussis cases from 2005-2015. In the first study, we identified test-negative controls from the public health laboratory that diagnosed cases and, in the second, randomly selected controls from patients attending the same physicians that reported cases, frequency matched on age and year. We compared characteristics of cases and controls using standardized differences. RESULTS: In both designs, VE estimates for the early years postimmunization were consistent with clinical trials (TND, 84%; FMD, 89% at 1-3 years postvaccination) but diverged as time since last vaccination increased (TND, 41%; FMD, 74% by 8 years postvaccination). Overall, we observed lower VE and faster waning in the TND than the FMD. In the TND but not FMD, controls differed from cases in important confounders, being younger, having more comorbidities, and higher healthcare use. Differences between the controls of each design were greater than differences between cases. TND controls were more likely to be unvaccinated or incompletely vaccinated than FMD controls (P < .001). CONCLUSIONS: The FMD adjusted better for healthcare-seeking behavior than the TND. Duration of protection from pertussis vaccines is unclear because estimates vary by study design. Caution should be exercised by experts, researchers, and decision makers when evaluating evidence on optimal timing of boosters.