Abstract Background Little has been quantified, at a population‐level, about the magnitude of heath service disruption to persons living with dementia in community settings during the COVID‐19 pandemic. Sustained access to health care services is particularly important for persons with dementia and other neurodegenerative diseases as they are vulnerable to decline. Method Health administrative data from Ontario, Canada were used to examine patterns of health service use among all persons with Alzheimer disease and related dementias (dementia) who were alive and living in the community. This cohort was compared to persons with Parkinson’s disease (PD) as well as all older adults (age 65+ years) without neurodegenerative diseases. Rates of all‐cause hospital admissions, emergency department visits, primary care and specialist physician visits and home care visits were analyzed for all individuals alive and eligible for provincial health insurance at the start of each weekly period from March 1, 2020 to September 20, 2020 (pandemic period) and from March 3, 2019 to September 22, 2019 (pre‐pandemic period). Rates of health service use during specific weeks in the pandemic period (i.e., lowest week, last available week) were compared to corresponding weeks in the pre‐pandemic period within each cohort using percent changes. Results On March 1, 2020, 128,696 persons with dementia, 30,099 with PD and 2,460,358 older adults were eligible for provincial health services. Across cohorts and services, dramatic declines in use of health services were observed at the lowest week: hospitalization (‐38.7% dementia, ‐72.3% PD, ‐44.2% older adults); emergency department (‐54.9% dementia, ‐57.7% PD, ‐53.6% older adults); home care (‐14.8% dementia, ‐19.4% PD, ‐7.4% older adults). Health services varied in how quickly they rebounded to pre‐pandemic levels within cohorts; notably, by the end of the study period, emergency department visits had increased to a level higher than corresponding 2019 weekly rates (24.2% dementia, 15.2% PD, 7.4% older adults). Conclusions The first wave of the COVID‐19 pandemic meaningfully and immediately disrupted use of health care services for persons living with dementia and PD and may have resulted in long‐term consequences that should be monitored.
Abstract Prescribing for community-dwelling older adults living with dementia is complex. Multiple medications may be used to manage symptoms associated with dementia and/or co-existing chronic conditions, and can lead to problematic polypharmacy. Our objective was to use network analysis, a data science method, to provide a comprehensive description of co-prescribed medications in persons with dementia and describe whether these patterns change over time. We created a population-based cohort of community-dwelling older adults (aged 67+ years) in Ontario, Canada, newly diagnosed with dementia (between April 2014 and January 2019), from health administrative data, and developed medication networks at one year prior to, at, and for up to five years following dementia diagnosis. Among 136,292 individuals newly diagnosed with dementia, the mean age was 82.2 years and 59% were female. The most common medication subclasses dispensed at diagnosis were primarily cardiovascular medications: statins (45.6%), proton pump inhibitors (27.3%), beta-blockers (27.0%), calcium blockers (25.1%), and ACE inhibitors (24.6%). Similar proportions of medication subclasses were found at five years after diagnosis, except cholinesterase inhibitors (34.0% at five years were dispensed cholinesterase inhibitors compared to 16.9% at diagnosis). The most frequent co-prescribed medication pairs at diagnosis included statins and beta-blockers (16.0%), proton pump inhibitors (16.0%), and ace inhibitors (15.4%), respectively. Co-prescription was similar at five years, but also included higher frequency of co-prescribing with cholinesterase inhibitors (e.g., 19.4% were prescribed cholinesterase inhibitors and statins). Network diagrams demonstrate the complexity of prescribing in this population and highlight concurrent prescribing which may require careful monitoring or deprescribing.
To comprehensively examine the cardiovascular health of Canadians, we developed the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) health index. We analyzed trends in health behaviours and factors to monitor the cardiovascular health of the Canadian population.We used data from the Canadian Community Health Survey (2003-2011 [excluding 2005]; response rates 70%-81%) to examine trends in the prevalence of 6 cardiovascular health factors and behaviours (smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes and hypertension) among Canadian adults aged 20 or older. We defined ideal criteria for each of the 6 health metrics. The number of ideal metrics was summed to create the CANHEART health index; values range from 0 (worst) to 6 (best or ideal). A separate CANHEART index was developed for youth age 12-19 years; this index included 4 health factors and behaviours (smoking, physical activity, fruit and vegetable consumption and overweight/obesity). We determined the prevalence of ideal cardiovascular health and the mean CANHEART health index score, stratified by age, sex and province.During the study period, physical activity and fruit and vegetable consumption increased and smoking decreased among Canadian adults. The prevalence of overweight/obesity, hypertension and diabetes increased. In 2009-2010, 9.4% of Canadian adults were in ideal cardiovascular health, 53.3% were in intermediate health (4-5 healthy factors or behaviours), and 37.3% were in poor cardiovascular health (0-3 healthy factors or behaviours). Twice as many women as men were in ideal cardiovascular health (12.8% vs. 6.1%). Among youth, the prevalence of smoking decreased and the prevalence of overweight/obesity increased. In 2009-2010, 16.6% of Canadian youth were in ideal cardiovascular health, 33.7% were in intermediate health (3 healthy factors or behaviours), and 49.7% were in poor cardiovascular health (0-2 healthy factors or behaviours).Fewer than 1 in 10 Canadian adults and 1 in 5 Canadian youth were in ideal cardiovascular health from 2003 to 2011. Intensive health promotion activities are needed to meet the Heart and Stroke Foundation of Canada's goal of improving the cardiovascular health of Canadians by 10% by 2020 as measured by the CANHEART health index.
Abstract Introduction Comprehensive, population-based investigations of the extent and temporality of associations between common neurological and psychiatric disorders are scarce. Methods This retrospective cohort study used linked health administrative data for Ontarians aged 40–85 years on 1 April 2002, to estimate the adjusted rate of incident dementia, Parkinson’s disease (PD), stroke or mood/anxiety disorder (over 14 years) according to the presence and time since diagnosis of a prior disorder. Sex differences in the cumulative incidence of a later disorder were also examined. Results The cohort included 5,283,546 Ontarians (mean age 56.2 ± 12.1 years, 52% female). The rate of dementia was significantly higher for those with prior PD (adjusted hazard ratio [adjHR] 4.05, 95% confidence interval [CI] 3.99–4.11); stroke (adjHR 2.49, CI 2.47–2.52) and psychiatric disorder (adjHR 1.79, CI 1.78–1.80). The rate of PD was significantly higher for those with prior dementia (adjHR 2.23, CI 2.17–2.30) and psychiatric disorder (adjHR 1.77, CI 1.74–1.81). The rate of stroke was significantly higher among those with prior dementia (adjHR 1.56, CI 1.53–1.58). Prior dementia (adjHR 2.36, CI 2.33–2.39), PD (adjHR 1.80, CI 1.75–1.85) and stroke (adjHR 1.47, CI 1.45–1.49) were associated with a higher rate of an incident psychiatric disorder. Generally, associations were strongest in the 6 months following a prior diagnosis and demonstrated a J-shape relationship over time. Significant sex differences were evident in the absolute risks for several disorders. Conclusions The observed nature of bidirectional associations between these neurological and psychiatric disorders indicates opportunities for earlier diagnosis and interventions to improve patient care.
Abstract Objectives Patients with chronic diseases are often forced to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge. Methods We performed a MEDLINE search of English‐language articles published between 1990 and March 2015. We created a data‐charting form a priori of the search. Papers were organized into themes, with new themes created when none of the existing themes matched the paper. Papers with multiple themes were assigned preferentially to the theme that was consistent with their primary objectives. We created a descriptive numerical summary of the included studies. Results Of 1,138 titles, there were 252 potentially relevant abstracts, and among those 122 met criteria for full paper review. An additional 11 papers were acquired from reference review. From the 133 papers, 85 were included in the study. The papers were categorized into seven themes. These included Follow‐up compliance and its predictors (38 studies), Telephone calls to discharged ED patients (15 studies), ED navigators (14 studies), The current system (nine studies), Ways to alert primary care providers ( PCP s) of the ED visit (seven studies), and Patient views and PCP information requirements (one each). In the Follow‐up compliance and predictors theme, the two most frequently identified significant predictors for increasing the frequency of follow‐up care were the provision of a follow‐up appointment time prior to ED departure and the presence of health insurance. Follow‐up telephone calls to patients resulted in better follow‐up rates, but increased ED return visits in some studies. In the current system patients themselves are the conduit, and the barriers to follow‐up care can be high. E‐mail and/or electronic medical record alerts to the PCP are relatively new, and no studies limited the alerts to patients who had a defined need for follow‐up care. Conclusions A plethora of work has been published on the transition of care from ED to primary care. To decrease hospitalizations among the upcoming wave of patients with chronic diseases, it appears that the two most efficient areas to target are a primary care follow‐up appointment system and health insurance. Further research is needed in particular to identify the patients who actually need follow‐up care and to develop information technology solutions that can be effectively implemented within the current emergency healthcare system.
Providing critical care for people living with dementia (PLWD) during the COVID-19 pandemic outbreak was raised as a global concern. A task force commissioned by the Alzheimer Society of Canada published 7 principles to consider when planning access to scarce resources to ensure that respect for the dignity of PLWD is preserved.
Objective:
To measure the impact of the first two waves of the pandemic on intensive care unit (ICU) use among PLWD. Study Design: Retrospective historically controlled cohort study using population-level administrative health data.
Setting:
Alberta, Ontario, Quebec. Population: PLWD aged 65+. Methods: We identified two closed cohorts of PLWD on March 3, 2019 (pre-pandemic) and March 1, 2020 (pandemic) and stratified them by community and nursing home settings
Outcome measures:
Rates of intensive care unit admissions.
Analysis:
We used a 2-step meta-analytical approach. Step 1: Compared rates of ICU admissions in three 2020 periods (1st wave; interim period; 2nd wave) to the corresponding 2019 periods. Step 2: Conducted random effect meta-analyses on the provincial incident rate ratios (IRR) and 95% CIs.
Results:
Community cohorts included 160,288 (pre-pandemic) and 166,392 (pandemic) individuals. Nursing home cohorts included 91,646 (pre-pandemic) and 90,727 (pandemic) individuals. The rates of ICU admissions in the community were 25% (IRR=0.75 [0.69–0.82]) lower in the interim period and 24% lower in the second wave (IRR=0.76 [0.74–0.78]). Pre-pandemic rates of ICU admissions from nursing homes were higher than expected, showing differences between provinces (from 0.01 to 0.06 per 100-person week). In nursing homes, rates of ICU admissions were lower throughout the pandemic year: 29% (IRR=0.71 [0.69–0.73]) less in the first wave, 32% (IRR=0.68 [0.57–0.82]) less in the interim period, and 24% (IRR=0.76, [0.63–0.93]) less in the second wave.
Conclusions:
There is a need for a single hospital/ICU triage protocol, particularly for very frail older adults such as PLWD. Pre-pandemic high use of ICU from nursing homes is unexpected given that PLWD have advanced stage of dementia. This speaks to the need for better practices for advance care planning and for a global consensus on the level of frailty making the use of ICU futile. In the community, lower ICU admissions during the pandemic periods are surprising given that PLWD had more severe COVID infections. Future studies should explore provincial practices and policies.
COVID-19 has had devastating effects on the health and well-being of older adult residents and health care professionals in nursing homes. Uncertainty about the associated consequences of these adverse effects on the use of medications common to this care setting remains.
Immigrants from ethnic minority groups represent an increasing proportion of the population in many high-income countries but little is known about the causes and amount of variation between various immigrant groups in the incidence of major cardiovascular events.We conducted the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) Immigrant study, a big data initiative, linking information from Citizenship and Immigration Canada's Permanent Resident database to nine population-based health databases. A cohort of 824 662 first-generation immigrants aged 30 to 74 as of January 2002 from eight major ethnic groups and 201 countries of birth who immigrated to Ontario, Canada between 1985 and 2000 were compared to a reference group of 5.2 million long-term residents. The overall 10-year age-standardized incidence of major cardiovascular events was 30% lower among immigrants compared with long-term residents. East Asian immigrants (predominantly ethnic Chinese) had the lowest incidence overall (2.4 in males, 1.1 in females per 1000 person-years) but this increased with greater duration of stay in Canada. South Asian immigrants, including those born in Guyana had the highest event rates (8.9 in males, 3.6 in females per 1000 person-years), along with immigrants born in Iraq and Afghanistan. Adjustment for traditional risk factors reduced but did not eliminate differences in cardiovascular risk between various ethnic groups and long-term residents.Striking differences in the incidence of cardiovascular events exist among immigrants to Canada from different ethnic backgrounds. Traditional risk factors explain part but not all of these differences.
BACKGROUND/OBJECTIVES To examine the association between hospitalization for a fall‐related injury and the co‐prescription of a cholinesterase inhibitor (ChEI) among persons with dementia receiving a beta‐blocker, and whether this potential drug‐drug interaction is modified by frailty. DESIGN Nested case‐control study using population‐based administrative databases. SETTING All nursing homes in Ontario, Canada. PARTICIPANTS Persons with dementia aged 66 and older who received at least one beta‐blocker between April 2013 and March 2018 following nursing home admission (n = 19,060). MEASUREMENTS Cases were persons with dementia with a hospitalization (emergency department visit or acute care admission) for a fall‐related injury with concurrent beta‐blocker use. Each case (n = 3,038) was matched 1:1 to a control by age (±1 year), sex, cohort entry year, frailty, and history of fall‐related injuries. The association between fall‐related injury and exposure to a ChEI in the 90 days prior was examined using multivariable conditional logistic regression. Secondary exposures included ChEI type, daily dose, incident versus prevalent use, and use in the prior 30 days. Subgroup analyses considered frailty, age group, sex, and history of hospitalization for fall‐related injuries. RESULTS Exposure to a ChEI in the prior 90 days occurred among 947 (31.2%) cases and 940 (30.9%) controls. In multivariable models, no association was found between hospitalization for a fall‐related injury and prior exposure to a ChEI in persons with dementia dispensed beta‐blockers (adjusted odds ratio = .96, 95% confidence interval = .85–1.08). Findings were consistent across secondary exposures and subgroup analyses. CONCLUSION Among nursing home residents with dementia receiving beta‐blockers, co‐prescription of a ChEI was not associated with an increased risk of hospitalization for a fall‐related injury. However, we did not assess for its association with falls not leading to hospitalization. This finding could inform clinical guidelines and shared decision making between persons with dementia, caregivers, and clinicians concerning ChEI initiation and/or discontinuation.
Aim We assessed population differentiation and gene flow across the range of the blue-footed booby (Sula nebouxii) (1) to test the generality of the hypothesis that tropical seabirds exhibit higher levels of population genetic differentiation than their northern temperate counterparts, and (2) to determine if specialization to cold-water upwelling systems increases dispersal, and thus gene flow, in blue-footed boobies compared with other tropical sulids. Location Work was carried out on islands in the eastern tropical Pacific Ocean from Mexico to northern Peru. Methods We collected samples from 173 juvenile blue-footed boobies from nine colonies spanning their breeding distribution and used molecular markers (540 base pairs of the mitochondrial control region and seven microsatellite loci) to estimate population genetic differentiation and gene flow. Our analyses included classic population genetic estimation of pairwise population differentiation, population growth, isolation by distance, associations between haplotypes and geographic locations, and analysis of molecular variance, as well as Bayesian analyses of gene flow and population differentiation. We compared our results with those for other tropical seabirds that are not specialized to cold-water upwellings, including brown (Sula leucogaster), red-footed (S. sula) and masked (S. dactylatra) boobies. Results Blue-footed boobies exhibited weak global population differentiation at both mitochondrial and nuclear loci compared with all other tropical sulids. We found evidence of high levels of gene flow between colonies within Mexico and between colonies within the southern portion of the range, but reduced gene flow between these regions. We also found evidence for population growth, isolation by distance and weak phylogeographic structure. Main conclusions Tropical seabirds can exhibit weak genetic differentiation across large geographic distances, and blue-footed boobies exhibit the weakest population differentiation of any tropical sulid studied thus far. The weak population genetic structure that we detected in blue-footed boobies may be caused by increased dispersal, and subsequently increased gene flow, compared with other sulids. Increased dispersal by blue-footed boobies may be the result of the selective pressures associated with cold-water upwelling systems, to which blue-footed boobies appear specialized. Consideration of foraging environment may be particularly important in future studies of marine biogeography.
