Long-Term Care Resident Health and Quality of Care During the COVID-19 Pandemic: A Synthesis Analysis of Canadian Institute for Health Information Data Tables.

Objective: Long-term care (LTC) homes ("nursing homes") were challenged during the first year of the COVID-19 pandemic in Canada. The objective of this study was to measure the impact of the COVID-19 pandemic on resident admission and discharge rates, resident health attributes, treatments, and quality of care. Design: Synthesis analysis of "Quick Stats" standardized data table reports published yearly by the Canadian Institute for Health Information. These reports are a pan-Canadian scorecard of LTC services rendered, resident health characteristics, and quality indicator performance. Setting and participants: LTC home residents in Alberta, British Columbia, Manitoba, and Ontario, Canada that were assessed with the interRAI Minimum Data Set 2.0 comprehensive health assessment in fiscal years 2018/2019, 2019/2020 (pre-pandemic period), and 2020/2021 (pandemic period). Methods: Risk ratio statistics were calculated to compare admission and discharge rates, validated interRAI clinical summary scale scores, medication, therapy and treatment provision, and seventeen risk-adjusted quality indicator rates from the pandemic period relative to prior fiscal years. Results: Risk of dying in the LTC home was greater in all provinces (risk ratio [RR] range 1.06-1.18) during the pandemic. Quality of care worsened substantially on 6 of 17 quality indicators in British Columbia and Ontario, and 2 quality indicators in Manitoba and Alberta. The only quality indicator where performance worsened during the pandemic in all provinces was the percentage of residents that received antipsychotic medications without a diagnosis of psychosis (RR range 1.01-1.09). Conclusions and implications: The COVID-19 pandemic has unveiled numerous areas to strengthen LTC and ensure that resident's physical, social, and psychological needs are addressed during public health emergencies. Except an increase in potentially inappropriate antipsychotic use, this provincial-level analysis indicates that most aspects of resident care were maintained during the first year of the COVID-19 pandemic.

The current and potential uses of Electronic Medical Record (EMR) data for primary health care performance measurement in the Canadian context: a qualitative analysis.

BACKGROUND: Electronic Medical Records (EMRs) are a rich data source to measure and improve quality of care. As Canadian primary health care (PHC) EMRs mature, there is increasing potential use of EMR data for performance measurement. This study identifies and describes current uses of EMR data for performance measurement and considerations to further its potential in the Canadian context. METHODS: We applied a qualitative case study design and descriptive assessment in three phases, consulting multiple data sources including scientific and grey literature, system leaders (n = 41), and clinician/researchers (n = 20). Phases included a multimethod approach to identify initiatives using EMR data for performance measurement across Canadian jurisdictions; in-depth review of current initiatives identified from a healthcare performance intelligence lens; and triangulation and thematic analysis across data sources to explore considerations for advancing performance measurement uses of EMR data in the Canadian context. RESULTS: Six initiatives of EMR data use for performance measurement were identified: one multi-jurisdictional; five jurisdiction-specific in the provinces of British Columbia, Manitoba and Ontario. EMR data uses were predominately for micro-level PHC physician and team performance improvement, with some use for meso-level organization/network-wide improvement. Indicator sets varied in number, though shared emphasis on chronic disease management and prevention/screening and to a lesser extent medication management. Key considerations for governing, resourcing and implementing EMR data for performance measurement were identified. CONCLUSIONS: The extent of EMR data use for performance measurement varies across Canada. To further its potential, pan-Canadian data and privacy standards, performance intelligence competencies and renewed core PHC indicators should be prioritized. Experiences across countries, coupled with increasing momentum for performance measurement using real-world data, should be leveraged to avoid unnecessarily slow progress in Canada and abroad.

How Children and Youth with Medical Complexity Use Hospital and Emergency Department Care across Canada.

Children and youth with medical complexity are a diverse group with uncommon diagnoses, a spectrum of needs and varying access to supports. Although this population represents a small proportion of all children, their unique needs lead to substantial use of healthcare services. With its first pan-Canadian report on children and youth with medical complexity, the Canadian Institute for Health Information examined how this population uses healthcare services. Key findings include the wide variation in the rate of medical complexity among children and youth across Canada. Children and youth with medical complexity were found to require a high proportion of hospital and emergency department care; however, their readmission rates were found to be lower than that of the general pediatric population.

Can markers of biological age predict dependency in old age?

Recent research has shown that markers of biological age, such as leukocyte telomere length (LTL), epigenetic clocks and the frailty index (FI) are predictive of mortality and age-related diseases. However, whether these markers associate with the need for care in old age, thereby having utility in reflecting dependency, is unclear. This study was undertaken to analyze whether LTL, two epigenetic clocks-the DNA methylation age (DNAmAge) and DNAm PhenoAge-and the FI are associated with the need for regular care in up to 604 individuals (aged 48-94 years) participating in the Swedish Adoption/Twin Study of Aging. Need for regular care was defined as receiving formal or informal help in daily routines at least once per week. Logistic regression adjusted for age, sex and education was used in the analysis. The predictive accuracies, assessed as the area under the curve (AUC) for the significant biological age measures were further compared to the accuracies of the limitations in activities of daily living (ADL) and instrumental ADL (IADL). Neither LTL nor the epigenetic clocks were associated with the need for care, whereas the FI was; odds ratio for 10% increase in FI 3.54 (95% confidence interval 2.32-5.41). The FI also demonstrated higher predictive accuracy than the ADL score (FI AUC 0.80 vs. ADL score AUC 0.62; p < 0.001 for equality of the AUCs), whereas the difference between FI AUC (0.80) and IADL score AUC (0.75) was not significant (p = 0.238). The FI might thus be a useful marker for the need for care.

Antipsychotic Drug Interactions and Mortality Among Nursing Home Residents With Cognitive Impairment.

OBJECTIVE: Among elderly individuals with dementia, the use of antipsychotics has been associated with serious adverse events including ischemic stroke and death. Multiple medications can interact with antipsychotics and increase the risk of such adverse events. The purpose of this retrospective, longitudinal cohort study was to estimate the prevalence of potential antipsychotic drug interactions and their effect on increasing the risk of death among cognitively impaired elderly individuals treated with antipsychotics. METHODS: We conducted a retrospective longitudinal cohort study in 59 nursing homes of 7 European Union countries and Israel. The study was conducted during the years 2009 to 2011. Participants were cognitively impaired individuals aged 65 years or older residing in the participating nursing homes and being treated with antipsychotics (N = 604). Risk of death associated with potential antipsychotic drug interactions was the main outcome. The inter-Resident Assessment Instrument for Long Term Care Facilities (interRAI LTCF) was used to assess participants. Follow-up time was 12 months. RESULTS: The prevalence of potential antipsychotic drug interactions was 46.0%. Antipsychotic drug interactions were associated with higher mortality (incidence rate of 0.26 per person-year in the antipsychotic drug-interaction group versus 0.17 per person year in the no antipsychotic drug-interaction group). After adjusting for potential confounders, risk of death was higher in the group of residents with potential antipsychotic drug interactions relative to those unexposed to such interactions (hazard ratio = 1.71; 95% CI, 1.15-2.54). CONCLUSIONS: Part of the observed excess risk of death associated with the use of antipsychotic medications in elderly individuals with cognitive impairment may be attributable to antipsychotic drug interactions. Antipsychotics should be used with extreme caution especially among those individuals receiving concomitant cardiovascular or psychotropic medications.

Genetic Influences on Functional Capacities in Aging.

PURPOSE: Older populations are characterized by great heterogeneity in functional capacities and understanding the factors underlying these differences has been a major area of research for some decades. Genetic differences arguably play an important role in the heterogeneity observed for many outcomes among older individuals. However, the role of genes in the variation and trajectories of functional capacities in older age is poorly understood. This review was conducted to explore the evidence for genetic influences on physical functional capacities in aging. DESIGN AND METHODS: This rapid review was conducted using the following criteria: journal articles retrieved from the PubMed, Embase, AgeLine, Scopus, and Web of Science electronic databases including the key words: genetics, genotype, polymorphism, physical or functional performance, functional capacity, activities of daily living, older, and elderly. In total, 118 articles were included for initial review. RESULTS: The heritability of objective measures of physical function ranges from 30% to 60% in studies of older twins. There is a paucity of evidence about genetic influences on functional capacities, but some candidate genes related to functional capacity have been identified. IMPLICATIONS: No strong candidate genes exist for functional capacities. Current methodologies are beginning to generate new evidence about genetic influences on overall physical function at older ages, but the variety of measures of functional capacity makes evidence difficult to compare.

Physical Restraint and Antipsychotic Medication Use Among Nursing Home Residents With Dementia.

PURPOSE: To explore antipsychotic (AP) medications and physical restraint use and their effects on physical function and cognition in older nursing home residents. METHODS: This retrospective cohort studied involved 532 residents with dementia from 57 nursing homes participating in the Services and Health for Elderly in Long-Term Care study. Poisson log regression models explored the effect of physical restraint and/or AP medication use on cognitive or functional decline at 6 months. RESULTS: Physical restraint use was associated with a higher risk of both functional and cognitive decline compared with AP medication use alone. These risks were highest among residents receiving both AP medications and physical restraints, suggesting additive effects. DISCUSSION: Physical restraint use, and even more strongly, concurrent physical restraint and AP medication use, is related to function and cognitive decline in nursing home residents with dementia. Antipsychotic use is cautioned, but these results suggest physical restraint use is potentially more risky.

Chronic diseases and geriatric syndromes: The different weight of comorbidity.

BACKGROUND: Comorbidity is a relevant health determinant in older adults. Co-occurrence of several diseases and other age-associated conditions generates new clinical phenotypes (geriatric syndromes [GS] as falls, delirium etc.). We investigated the association of chronic diseases, alone or in combination, and GS in older adults receiving home care services in 11 European countries and one Canadian province. METHODS: Participants were cross-sectionally evaluated with the multidimensional assessment instrument RAI HC. We assessed 14 different diagnoses and 8 GS (pain, urinary incontinence, falls, disability, dizziness, weight loss, pressure ulcers and delirium). Adjusted mean number of GS per participant was calculated for groups of participants with each disease when occurring alone or with comorbidity. RESULTS: The mean age of the 6903 participants was 82.2±7.4 years and 4750 (69%) were women. Participants presented with an average of 2.6 diseases and 2.0 GS: pain (48%), urinary incontinence (47%) and falls (33%) were the most prevalent. Parkinson's disease, cerebrovascular disease and peripheral artery disease were associated with the highest number of GS (2.5, 2.3 and 2.2, respectively). Conversely, hypertension, diabetes, dementia, cancer and thyroid dysfunction were associated with the lowest number of GS (2.0 on average). For 9/14 examined diseases (hypertension, diabetes, dementia, COPD, heart failure, ischemic heart disease, atrial fibrillation, cancer and thyroid dysfunction) the number of GS increased with the degree of comorbidity. CONCLUSIONS: Comorbidity and GS are prevalent in older adults receiving home care. Different diseases have a variable impact on occurrence of GS. Comorbidity is not always associated with an increased number of GS.

Quality of care in European home care programs using the second generation interRAI Home Care Quality Indicators (HCQIs).

BACKGROUND: Evaluating the quality of care provided to older individuals is a key step to ensure that needs are being met and to target interventions to improve care. To this aim, interRAI's second-generation home care quality indicators (HCQIs) were developed in 2013. This study assesses the quality of home care services in six European countries using these HCQIs as well as the two derived summary scales. METHODS: Data for this study were derived from the Aged in Home Care (AdHOC) study - a cohort study that examined different models of community care in European countries. The current study selected a sub-sample of the AdHOC cohort from six countries whose follow-up data were complete (Czech Republic, Denmark, Finland, Germany, Italy and the Netherlands). Data were collected from the interRAI Home Care instrument (RAI-HC) between 2000 and 2002. The 23 HCQIs of interest were determined according to previously established methodology, including risk adjustment. Two summary measures, the Clinical Balance Scale and Independence Quality Scale were also determined using established methodology. RESULTS: A total of 1,354 individuals from the AdHOC study were included in these analyses. Of the 23 HCQIs that were measured, the highest proportion of individuals experienced declines in Instrumental Activities of Daily Living (IADLs) (48.4 %). Of the clinical quality indicators, mood decline was the most prevalent (30.0 %), while no flu vaccination and being alone and distressed were the most prevalent procedural and social quality indicators, respectively (33.4 and 12.8 %). Scores on the two summary scales varied by country, but were concentrated around the median mark. CONCLUSIONS: The interRAI HCQIs can be used to determine the quality of home care services in Europe and identify areas for improvement. Our results suggest functional declines may prove the most beneficial targets for interventions.

Comparing the characteristics of people living with and without HIV in long-term care and home care in Ontario, Canada.

Population aging and successful drug therapy in human immunodeficiency virus (HIV) management mean that more people are living longer with HIV. As these individuals age, they become more at risk of developing other chronic health conditions which will have many implications for disease management and choice of care setting. As people living with HIV turn to home care and long-term care (LTC) settings for care, understanding the particular needs of this population is becoming increasingly important. This study sought to describe the sociodemographic, clinical, and social attributes of people living with HIV in the home care and institutional environments. This work involved secondary analysis of data collected from both the international Resident Assessment Instruments (interRAI) home care and minimum data set instruments in the Canadian province of Ontario. Descriptive analysis was used to describe key attributes of people living with and without HIV in LTC, complex continuing care, and home care settings. A comparison of differences between people living with HIV across the three environments was also done using Chi-square analysis. People living with HIV were often younger, male and unmarried than other populations in the care settings studied. Together with specific health needs associated with issues like mental health and social isolation, people living with HIV represent a population with complex and distinctive health needs. Finding ways to better understand the needs of this vulnerable population will help to develop strategies to provide better formal and informal care and improve the quality of life of this group. interRAI standardized assessment instruments may be important tools for meeting this challenge.

Use of antipsychotic drugs among residents with dementia in European long-term care facilities: results from the SHELTER study.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are common reasons for use of antipsychotic drugs among older individuals with dementia. These drugs are not approved for such use and both the Food and Drug Administration and European Medicines Agency have issued warnings to limit such use. OBJECTIVES: This study aimed to describe patterns of antipsychotic drug use in a sample of nursing home residents with dementia in 7 European countries and Israel. DESIGN: This cross-sectional, retrospective cohort study used data from the SHELTER study that collected comprehensive resident data using the interRAI Long-Term Care Facility instrument. METHODS: Fifty-seven long-term care facilities participated from 8 countries, and the sample included 4156 long-term care residents from these settings. Individuals with dementia, both Alzheimer and non-Alzheimer types, were identified. Potential correlates of any antipsychotic and atypical versus conventional antipsychotic drug use among residents with dementia were identified using generalized estimation equation modeling. RESULTS: A total of 2091 individuals with dementia were identified. Antipsychotic drug use among these individuals varied by country, with overall prevalence of use being 32.8% (n = 662). Among antipsychotic users, 7 in 10 were receiving atypical agents. Generalized estimation equation analysis revealed that the strongest correlate of any antipsychotic drug use was severe behavioral symptoms, which increased the likelihood by 2.84. Correlates of atypical versus conventional antipsychotic drug use included psychiatric services, more than 10 medications, moderate behavioral symptoms, and female gender. CONCLUSION: Despite recommendations to avoid the use of antipsychotic drugs in patients with dementia, a large proportion of residents in European long-term care facilities continue to receive such agents. Future work should not only establish the appropriateness of such use through outcomes studies, but explore withdrawal strategies as well as alternative treatment modalities.

Prevalence and correlates of cardiovascular medication use among nursing home residents with ischemic heart disease: results from the SHELTER study.

OBJECTIVES: Despite being the highest group of users of many medications, older individuals remain underrepresented in clinical trials. This leaves a gap in evidence to guide management of many conditions, such as ischemic heart disease (IHD), in this population. This study aimed to describe factors associated with IHD medication use among nursing home residents in 7 European countries and Israel to depict challenges facing disease management in this population. DESIGN: This study was a retrospective cohort analysis. SETTING AND PARTICIPANTS: The sample included 4156 nursing home residents in the SHELTER study. MEASUREMENT: All residents were assessed using the interRAI Long-Term Care Facility (LTCF) instrument. Use of angiotensin-converting enzyme inhibitor (ACEi) and/or angiotensin receptor blocker (ARB), beta-blocker (BB), antiaggregants (including acetylsalicylic acid [ASA]) and statins was analyzed. Based on the use of these medications, residents were classified into groups by medication use (as nonusers, 1-2 medications, or 3-4 medications). Generalized Estimation Equation modeling was used to explore predictors of medication use from items on the LTCF instrument as well as facility questionnaire. RESULTS: Of the 1050 residents with IHD, medication use was 77.7% overall, but only 16.9% were receiving 3 to 4 medications. Use of antiaggregants was highest at 51.7% and variations in medication use were observed by country (highest in France and lowest in Italy). Functional disability was the strongest predictor of medication use, reducing the likelihood of any or optimal management. Severe cognitive impairment also reduced the likelihood of optimal management, and comorbidity generally increased the likelihood of medication use. Polypharmacy reduced the likelihood of use of 3 to 4 medications for IHD. CONCLUSION: Optimal management of IHD in nursing home residents was low and varied by country. Individual characteristics seemed to predict IHD medication use, suggesting prescribing bias and an effect of population differences from clinical trial cohorts.

The Value of Admission Clinical Data for Diagnosing Heart Failure in Long-term Care.

BACKGROUND: Heart failure (HF) is common in long-term care (LTC). Diagnostic uncertainty is important barrier to optimal HF management, stemming from inadequate health information transfer upon LTC admission. We determine the utility of admission clinical information to confirm a HF diagnosis in new LTC residents. METHODS: This was a prospective cohort study. From February 2004 to November 2006, information about new residents from 41 LTC homes in Ontario, Canada, was collected from residents and caregivers, and all available health records. A prior HF diagnosis was confirmed by consensus review of available data by two independent experts. Multivariate modelling was utilized to determine the utility of the admission clinical assessment in confirming a prior HF diagnosis. RESULTS: A total of 449 residents were included for analysis, aged 84.3±6.5 years, and 21.6% had a prior HF diagnosis. The most useful clinical item for diagnosing HF was a "history of HF". The final model included "history of HF' (OR [odds ratio] 13.66, 95% CI 6.61-28.24), "fluid on the lungs" (OR 2.01, 95% CI 1.04-3.89), "orthopnea" (OR 1.76, 95% CI 0.93-3.33), "taking ß-blocker" (OR 2.09, 95% CI 1.10-3.94), "taking loop diuretics" (OR 2.11, 95% CI 1.12-3.98), and "history of coronary artery disease" (OR 2.83, 95% CI 1.42-5.64). CONCLUSION: Elements of the clinical assessment for new LTC residents can help confirm a prior HF diagnosis. An admission history of HF is highly predictive.

Diagnostic data for neurological conditions in interRAI assessments in home care, nursing home and mental health care settings: a validity study.

BACKGROUND: The interRAI suite of assessment instruments can provide valuable information to support person-specific care planning across the continuum of care. Comprehensive clinical information is collected with these instruments, including disease diagnoses. In Canada, interRAI data holdings represent some of the largest repositories of clinical information in the country for persons with neurological conditions. This study examined the accuracy of the diagnostic information captured by interRAI instruments designed for use in the home care, long-term care and mental health care settings as compared with national administrative databases. METHODS: The interRAI assessments were matched with an inpatient hospital record and emergency department (ED) visit record in the preceding 90 days. Diagnoses captured on the interRAI instruments were compared to those recorded in either administrative record for each individual. Diagnostic validity was examined through sensitivity, specificity and positive predictive value analysis for the following conditions: multiple sclerosis, epilepsy, Alzheimer's disease and other dementias, Parkinson's disease, traumatic brain injury, stroke, diabetes mellitus, heart failure and reactive airway disease. RESULTS: In the three large study samples (home care: n = 128,448; long-term care: n = 26,644; mental health: n = 13,812), interRAI diagnoses demonstrated high specificity when compared to administrative records, for both neurological conditions (range 0.80-1.00) and comparative chronic diseases (range 0.83-1.00). Sensitivity and positive predictive values (PPV) were more varied by specific diagnosis, with sensitivities and PPV for neurological conditions ranging from 0.23 to 0.94 and 0.14 to 0.77, respectively. The interRAI assessments routinely captured more cases of the diagnoses of interest than the administrative records. CONCLUSIONS: The interRAI assessment collected accurate information about disease diagnoses when compared to administrative records within three months. Such information is likely relevant to day-to-day care in these three environments and can be used to inform care planning and resource allocation decisions.

Heart failure--related mortality and hospitalization in the year following admission to a long-term care facility: the geriatric outcomes and longitudinal decline in heart failure (GOLD-HF) study.

BACKGROUND: Heart failure (HF) is common in long-term care facilities (LTCs). This study compared mortality and hospitalization rates and examined predictors of these outcomes among new LTC residents with and without HF. METHODS AND RESULTS: This prospective cohort study followed 546 newly admitted residents from 42 LTCs for up to 1 year. Health information was collected from participant and caregiver interviews, physicians' records, diagnostic procedures, and hospitalization records. Multivariate logistic regression modeling determined predictors of hospitalization among residents, and Cox proportional hazards regression determined predictors for time to mortality. HF prevalence was 21.4%. The sample was predominantly (>70%) female, and individuals with HF were significantly older with higher prevalence of reduced left ventricular ejection fraction. Overall annual mortality and hospitalization rates were 24% and 27%, respectively. Among residents with HF, 42% died and 31% were hospitalized within 1 year. Among residents with HF, use of major tranquilizers was the strongest predictor of sooner mortality; use of anticoagulants and major tranquilizers also increased mortality risk, whereas higher baseline function was associated with longer time to mortality. History of peripheral vascular disease was the strongest predictor of hospitalizations among residents with HF, and use of antiplatelet agents and history of any smoking exposure increased this risk. CONCLUSIONS: Among LTC residents, HF is associated with high mortality and hospitalization rates. Many factors contribute to mortality and hospitalizations among residents with HF, and comprehensive HF management programs are needed to improve outcomes.

Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study.

BACKGROUND: Home care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario. METHODS: A retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences. RESULTS: The study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death. CONCLUSIONS: Our study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.

Caregiver status affects medication adherence among older home care clients with heart failure.

BACKGROUND AND AIMS: For older individuals living in the community with chronic diseases such as heart failure (HF), caregivers may play an important role in medication adherence. This role may be increasingly important as cognition declines. This study aimed to 1) examine the role of caregivers in medication adherence in a complex population of older home care clients with mild cognitive impairment (MCI) and 2) examine the effect of caregiver stress on medication non-adherence. METHODS: The interRAI Resident Assessment Instrument - Home Care (RAIHC) instrument collects comprehensive information about all individuals receiving long-term home care services in the Canadian province of Ontario. This analysis of secondary data utilized this database to examine the relationship between caregiver residence and stress on medication adherence among a subset of clients with MCI who were over age 75. RESULTS: The prevalence of HF among the sample was 15.5%, while MCI was present in 42.3% of the sample. Among individuals with MCI, having a caregiver at the same residence reduced medication non-adherence. Additionally, caregiver stress was significantly associated with higher rates of non-adherence. CONCLUSIONS: MCI can impair medication adherence. The presence of a caregiver at home significantly improves medication adherence in patients with HF and MCI. Supporting caregivers is an important strategy in allowing clinically complex older adults to remain safely at home.

Clinical, demographic and functional characteristics associated with pharmacotherapy for heart failure in older home care clients: a retrospective, population-level, cross-sectional study.

BACKGROUND: Use of combination pharmacotherapy, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin II type 1 receptor antagonists (angiotensin receptor blockers) and ß-adrenoceptor antagonists (ß-blockers) in the management of heart failure (HF) can reduce mortality, prevent functional decline and reduce health service use. However, these first-line therapies are underused in older populations. This article describes the use and predictors of use of first-line HF therapies in a population-based cohort of older home care clients in Ontario, Canada. OBJECTIVES: To examine the use and correlates of first-line pharmacotherapy in older home care clients with HF. METHODS: This was a retrospective, cross-sectional study of Resident Assessment Instrument - Home Care (RAI-HC) data in individuals aged ≥65 years receiving home care services in the province of Ontario, Canada. Data collected were from all 14 health regions in Ontario. Home care clients with HF were identified from among those aged ≥65 years whose first RAI-HC assessment occurred between January 2004 and December 2007 (n = 176 866). Potential correlates of pharmacotherapy for HF were identified from the RAI-HC and examined using multivariable logistic regression. RESULTS: HF prevalence was 12.4%. Among clients with HF, 28.6% received no first-line pharmacotherapy; this proportion declined by 6% over the 4 years studied. Only 28.0% were receiving recommended combination therapy. First-line pharmacotherapy use was dependent on hypertension and diabetes mellitus status. Use of pharmacotherapy was less likely among older clients and those with functional impairment, airway disease or behavioural symptoms. CONCLUSIONS: Approximately 29% of older home care clients with HF received no first-line HF pharmacotherapy, while another 28% received optimal first-line HF pharmacotherapy. In addition to the expected clinical correlates, the increased likelihood of non-use associated with clients' demographic and functional characteristics raises concerns about quality of care. A better understanding of how these factors affect prescribing practices, particularly for combination therapy, would help to optimize HF disease management. For clinicians, this work also serves as a potential reminder to follow guideline recommendations for HF management in older, vulnerable adults.