Predicting heart failure mortality in frail seniors: comparing the NYHA functional classification with the Resident Assessment Instrument (RAI) 2.0.

BACKGROUND: Though the NYHA functional classification is recommended in clinical settings, concerns have been raised about its reliability particularly among older patients. The RAI 2.0 is a comprehensive assessment system specifically developed for frail seniors. We hypothesized that a prognostic model for heart failure (HF) developed from the RAI 2.0 would be superior to the NYHA classification. The purpose of this study was to determine whether a HF-specific prognostic model based on the RAI 2.0 is superior to the NYHA functional classification in predicting mortality in frail older HF patients. METHODS: Secondary analysis of data from a prospective cohort study of a HF education program for care providers in long-term care and retirement homes. Univariate analyses identified RAI 2.0 variables predicting death at 6 months. These and the NYHA classification were used to develop logistic models. RESULTS: Two RAI 2.0 models were derived. The first includes six items: "weight gain of 5% or more of total body weight over 30 days", "leaving 25% or more food uneaten", "unable to lie flat", "unstable cognitive, ADL, moods, or behavioural patterns", "change in cognitive function" and "needing help to walk in room"; the C statistic was 0.866. The second includes the CHESS health instability scale and the item "requiring help walking in room"; the C statistic was 0.838. The C statistic for the NYHA scale was 0.686. CONCLUSIONS: These results suggest that data from the RAI 2.0, an instrument for comprehensive assessment of frail seniors, can better predict mortality than the NYHA classification.

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.

Prevalence and predictors of antibiotic use in community-based elderly in Ontario, Canada.

Little is known about antibiotic use in the elderly receiving home care. We found that 6,873 (5.4%) of 126,339 home care patients in Ontario received antibiotic treatment; 26% of the antibiotics administered were fluoroquinolones. Antibiotic treatment was most frequent in patients less than 65 years of age and among those with a poorer health status.

Reliability of standardized assessment for adults who are deafblind.

This study assessed the reliability of the interRAI Community Health Assessment (interRAI CHA) and Deafblind Supplement (DbS). The interRAI CHA and DbS represents a multidimensional, standardized assessment instrument for use with adults (18 and older) who are deafblind. The interrater reliability of the instrument was tested through the completion of dual assessments with 44 individuals who were deafblind in the province of Ontario, Canada. Overall, nearly 50% of items had a kappa value of at least 0.60, indicating fair to substantial agreement for these items. Several items related to psychosocial well-being, mood, and sense of involvement had kappa scores of less than 0.40. However, among these items with low kappa values, most (78%) showed at least 70% agreement between the two assessors. The internal consistency of several health subscales, embedded within the assessment, was also very good and ranged from 0.63 to 0.93. The interRAI CHA and DbS represents a reliable instrument for assessing adults with deafblindness to better understand their needs, abilities, and preferences.