Sex Differences in Antipsychotic and Benzodiazepine Prescribing Patterns: A Cohort Study of Newly Admitted Nursing Home Residents with Dementia in Ontario, Canada

BACKGROUND

In nursing homes, residents with dementia frequently receive potentially inappropriate medications that are associated with an increased risk of adverse events. Despite known sex differences in clinical presentation and sociodemographic characteristics among persons with dementia, few studies have examined sex differences in patterns and predictors of potentially inappropriate medication use.

OBJECTIVES

The objectives of this study were to examine sex differences in the patterns of antipsychotic and benzodiazepine use in the 180 days following admission to a nursing home, estimate clinical and sociodemographic predictors of antipsychotic and benzodiazepine use in male and female residents, and explore the effects of modification by sex on the predictors of using these drug therapies.

METHODS

We conducted a retrospective cohort study of 35,169 adults aged 66 years and older with dementia who were newly admitted to nursing homes in Ontario, Canada between 2011 and 2014. Health administrative databases were linked to detailed clinical assessment data collected using the Resident Assessment Instrument (RAI-MDS 2.0). Cox proportional hazards models were adjusted for clinical and sociodemographic covariates to estimate the rate of antipsychotic and benzodiazepine initiation and discontinuation in the 180 days following nursing home admission in the total sample and stratified by sex. Sex-covariate interaction terms were used to assess whether sex modified the association between covariates and the rate of drug therapy initiation or discontinuation following nursing home entry.

RESULTS

Across 638 nursing homes, our analytical sample included 22,847 females and 12,322 males. At admission, male residents were more likely to be prevalent antipsychotic users than female residents (33.8% vs 28.3%; p < 0.001), and female residents were more likely to be prevalent benzodiazepine users than male residents (17.2% vs 15.3%, p < 0.001). In adjusted models, female residents were less likely to initiate an antipsychotic after admission (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.73-0.86); however, no sex difference was observed in the rate of benzodiazepine initiation (HR 1.04, 95% CI 0.96-1.12). Female residents were less likely than males to discontinue antipsychotics (HR 0.89, 95% CI 0.81-0.98) and benzodiazepines (HR 0.82, 95% CI 0.75-0.89). Sex modified the association between some covariates and the rate of changes in drug use (e.g., widowed males exhibited an increased rate of antipsychotic discontinuation (p-interaction = 0.03) compared with married males), but these associations were not statistically significant among females. Sex did not modify the effect of frailty on the rates of initiation and discontinuation.

CONCLUSIONS

Males and females with dementia differed in their exposure to antipsychotics and benzodiazepines at nursing home admission and their patterns of use following admission. A greater understanding of factors driving sex differences in potentially inappropriate medication use may help tailor interventions to reduce exposure in this vulnerable population.

Health Forums and Twitter for Dementia Research: Opportunities and Considerations

BACKGROUND/OBJECTIVES

Social media platforms are promising sources for large quantities of participant-driven research data and circumvent some common challenges when conducting dementia research. This study provides a summary of key considerations and recommendations about using these platforms as research tools for dementia.

DESIGN

Mixed methods.

SETTING

Alzheimer's Society's online Dementia Talking Point forum from inception to April 17, 2018, and Twitter in February and March 2018.

PARTICIPANTS

All users of Dementia Talking Point who posted in subforums labeled "I have dementia" and "I care for a person with dementia," and Twitter users whose posts contained the keywords "dementia," "Alzheimer," or "Alzheimer's."

MEASUREMENTS

We quantified the average daily number of dementia-related posts on each platform and number of words per post. Guided by a codebook, we conducted thematic content analysis of 5% of the 15,513 posts collected from Dementia Talking Point, and 10% of the 25,948 comprehensible posts from Twitter containing "dementia," "Alzheimer," or "Alzheimer's." We also summarized research-relevant characteristics inherent to platforms and posts.

RESULTS

On average, Dementia Talking Point provided less than two new daily dementia-related posts with 213.5 to 241.5 words, compared with 7,883 new daily Twitter posts with 14.5 words. Persons with dementia (PWDs) commonly shared dementia-related concerns (75.7%), experiences (68.6%), and requests for, as well as offers of, information and support (44.3% and 38.6%, respectively). Caregivers commonly shared caregiving experience (67.0%) and requests for information and support (52.5%). Most common dementia-related Twitter posts were derogatory use of the term dementia (14.5%), advocacy, fundraising, and awareness (11.6%), and research dissemination (8.0%). Recommendations about these platforms' unique technical and ethical considerations are outlined.

CONCLUSIONS

Understanding the priorities of PWDs and their caregivers remains important to understand how clinicians can best support them. This study will help clinicians and researcher to better leverage online health forums and Twitter for such dementia-related information.

Effect of Access to After-Hours Primary Care on the Association Between Home Nursing Visits and Same-Day Emergency Department Use

PURPOSE

Previous work has demonstrated that home care patients have an increased risk of visiting the emergency department after a home nursing visit on the same day. We investigated whether this association is modified by greater access to after-hours primary care.

METHODS

We conducted a population-based case-crossover study of home care patients in Ontario, Canada in 2014-2016. Emergency department visits after 5:00 pm were selected as case periods and matched, within the same patient, to control periods within the previous week. The association between home nursing visits and same-day emergency department visits was estimated with conditional logistic regression. Access to after-hours primary care, measured on the patient and practice level, was tested for effect modification using an interaction term approach. Analysis was performed separately for all emergency department visits and a less urgent subset not admitted to hospital.

RESULTS

A total of 11,840 patients contributed cases to the analysis. Patients with a history of after-hours primary care use had a smaller increased risk of a same-day after-hours emergency department visit (OR = 1.18; 95% CI, 1.06-1.30) compared with patients with no after-hours care (OR = 1.31; 95% CI, 1.25-1.39). The modifying effect was stronger among emergency department visits not admitted to hospital (OR = 1.11; 95% CI, 0.97-1.28 vs OR = 1.41; 95% CI, 1.31-1.51).

CONCLUSION

Greater access to after-hours primary care reduced the risk of less-urgent emergency department use associated with home nursing visits. These findings suggest increasing access to after-hours primary care could prevent some less-urgent emergency department visits.

Trajectories of health system use and survival for community-dwelling persons with dementia: a cohort study

OBJECTIVES

To determine the long-term trajectories of health system use by persons with dementia as they remain in the community over time.

DESIGN

Population-based cohort study using health administrative data.

SETTING

Ontario, Canada from 1 April 2007 to 31 March 2014.

PARTICIPANTS

62 622 community-dwelling adults aged 65+ years with prevalent dementia on 1 April 2007 matched 1:1 to persons without dementia based on age, sex and comorbidity.

MAIN OUTCOME MEASURES

Rates of health service use, long-term care placement and mortality over time.

RESULTS

After 7 years, 49.0% of persons with dementia had spent time in long-term care (6.8% without) and 64.5% had died (30.0% without). Persons with dementia were more likely than those without to use home care (rate ratio (RR) 3.02, 95% CI 2.93 to 3.11) and experience hospitalisations with a discharge delay (RR 2.36, 95% CI 2.30 to 2.42). As they remained in the community, persons with dementia used home care at a growing rate (10.7%, 95% CI 10.0 to 11.3 increase per year vs 6.7%, 95% CI 4.3 to 9.0 per year among those without), but rates of acute care hospitalisation remained constant (0.6%, 95% CI -0.6 to 1.9 increase per year).

CONCLUSIONS

While persons with dementia used more health services than those without dementia over time, the rate of change in use differed by service type. These results, particularly enumerating the increased intensity of home care service use, add value to capacity planning initiatives where limited budgets require balancing services.

Physician Home Visit Patterns and Hospital Use Among Older Adults with Functional Impairments

BACKGROUND

Home-based primary care has been associated with reductions in hospital use among homebound older adults, but population-based studies on the general home visit patterns of primary care physicians are lacking.

OBJECTIVE

We examined the association between the provision of home visits by primary care physicians and subsequent use of hospital-based care among their older adult patients with extensive functional impairments.

DESIGN

Population-based retrospective cohort study.

SETTING

The setting was Ontario, Canada, from October 2014 to September 2016.

PARTICIPANTS

Older adults (aged ≥65 years) with extensive functional impairments receiving publicly funded home care.

MEASUREMENTS

We measured the provision of home visits by a patient's most responsible primary care physician during the year before a comprehensive home care assessment. Physician home visit patterns were measured as the proportion of the total outpatient visits in a year that were home visits, categorized with quartiles. Multivariable, multilevel negative binomial regression models examined the associations between physician-level home visit provision and patient emergency department visits and hospital admissions over the 6 months following the home care assessment.

RESULTS

There were 49,613 patients in the cohort who were linked to 8,096 unique primary care physicians. A total of 69.1% of physicians provided at least one home visit in a year, with the median proportion of home visits to total visits ranging from 0.057% to 3.19% across quartiles. Patients whose physicians were in the highest home visit provision quartile had lower rates of emergency department visits (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI] = 0.90-0.96) and hospital admissions (IRR = 0.89; 95% CI = 0.85-0.93) compared with patients whose physician did not do home visits.

CONCLUSION

Home care patients with extensive functional impairments whose physicians provided higher levels of home visits had fewer emergency department visits and hospital admissions. Expanding home visits by primary care physicians could reduce hospital use by older adults living with functional impairments in the community.

Associations between continuity of primary and specialty physician care and use of hospital-based care among community-dwelling older adults with complex care needs

Objective

While research suggests that higher continuity of primary and specialty physician care can improve patient outcomes, their effects have rarely been examined and compared concurrently. We investigated associations between continuity of primary and specialty physician care and emergency department visits and hospital admissions among community-dwelling older adults with complex care needs.

Methods

We conducted a retrospective cohort study of home care patients in Ontario, Canada, from October 2014 to September 2016. We measured continuity of primary and specialty physician care over the two years prior to a home care assessment and categorized them into low, medium, and high groups using terciles of the distribution. We used Cox regression models to concurrently test the associations between continuity of primary and specialty care and risk of an emergency department visit and hospital admission within six months of assessment, controlling for potential confounders. We examined interactions between continuity of care and count of chronic conditions, count of physician specialties seen, functional impairment, and cognitive impairment.

Results

Of 178,686 participants, 49% had an emergency department visit during follow-up and 27% had a hospital admission. High vs. low continuity of primary care was associated with a reduced risk of an emergency department visit (HR = 0.90 (0.89–0.92)) as was continuity of specialty care (HR = 0.93 (0.91–0.95)). High vs. low continuity of primary care was associated also with a reduced risk of a hospital admission (HR = 0.94 (0.92–0.96)) as was continuity of specialty care (HR = 0.92 (0.90–0.94)). The effect of continuity of specialty care was moderately stronger among patients who saw four or more physician specialties.

Conclusion

Higher continuity of primary physician and specialty physician care had independent, protective effects of similar magnitude against emergency department use and hospital admissions. Improving continuity of specialty care should be a priority alongside improving continuity of primary care in complex, older adult populations with significant specialist use.

Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension

IMPORTANCE

Calcium channel blockers (CCBs) are commonly prescribed agents for hypertension that can cause peripheral edema. A prescribing cascade occurs when the edema is misinterpreted as a new medical condition and a diuretic is subsequently prescribed to treat the edema. The extent to which this prescribing cascade occurs at a population level is not well understood.

OBJECTIVE

To measure the association between being newly dispensed a CCB and subsequent dispensing of a loop diuretic in older adults with hypertension.

DESIGN, SETTING, AND PARTICIPANTS

A population-based cohort study was performed using linked health administrative databases of community-dwelling adults 66 years or older with hypertension and new prescription drug claims from September 30, 2011, to September 30, 2016, in Ontario, Canada. The dates of analysis were September 1, 2018, to May 30, 2019.

EXPOSURES

Individuals who were newly dispensed a CCB were compared with the following 2 groups: (1) individuals who were newly dispensed an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker and (2) individuals who were newly dispensed an unrelated medication.

MAIN OUTCOMES AND MEASURES

Hazard ratios (HRs) with 95% CIs were estimated for individuals who were dispensed a loop diuretic within 90 days of follow-up using Cox proportional hazards regression models.

RESULTS

The cohort included 41 086 older adults (≥66 years) with hypertension who were newly dispensed a CCB, 66 494 individuals who were newly dispensed another antihypertensive medication, and 231 439 individuals who were newly dispensed an unrelated medication. At index (ie, the dispensing date), the mean (SD) age was 74.5 (6.9) years, and 191 685 (56.5%) were women. Individuals who were newly dispensed a CCB had a higher cumulative incidence at 90 days of being dispensed a loop diuretic than individuals in both control groups (1.4% vs 0.7% and 0.5%, P < .001). After adjustment, individuals who were newly dispensed a CCB had increased relative rates of being dispensed a loop diuretic compared with individuals who were newly dispensed an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (HR, 1.68; 95% CI, 1.38-2.05 in the first 30 days after index [days 1-30]; 2.26; 95% CI, 1.76-2.92 in the subsequent 30 days [days 31-60]; and 2.40; 95% CI, 1.84-3.13 in the third month of follow-up [days 61-90]) and individuals who were newly dispensed unrelated medications (HR, 2.51; 95% CI, 2.13-2.96 for 1-30 days after index; 2.99; 95% CI, 2.43-3.69 for 31-60 days after index; and 3.89; 95% CI, 3.11-4.87 for 61-90 days after index). This association persisted, although slightly attenuated, from 90 days to up to 1 year of follow-up and when restricted to a subgroup of individuals who were newly dispensed amlodipine.

CONCLUSIONS AND RELEVANCE

Many older adults with hypertension who are newly dispensed a CCB subsequently receive a loop diuretic. Given how widely CCBs are prescribed, interventions are needed to raise clinicians' awareness of this common prescribing cascade to reduce the prescribing of potentially unnecessary medications that may cause harm.

Increasing Complexity of New Nursing Home Residents in Ontario, Canada: A Serial Cross-Sectional Study

OBJECTIVES

The main objective of the study was to investigate annual changes in the sociodemographic characteristics, morbidity, and functional status of new nursing home residents in Ontario, Canada, between 2000 and 2015. A secondary objective was to develop and assess the quality of an algorithm for ascertaining admissions into publicly funded nursing homes in Ontario using a combination of health administrative data sources that indirectly identifies the residential status of new nursing home residents.

DESIGN

Population-based serial cross-sectional study with an accompanying quality assessment study of algorithms.

SETTING

Publicly funded nursing care homes in Ontario, Canada.

PARTICIPANTS

The reference standard for the assessment of algorithm performance was 21 544 newly admitted nursing home residents identified from the Resident Assessment Instrument-Minimum Data Set in 2012. The selected algorithm was then used to identify serial cross-sectional cohorts of newly admitted residents between 2000 and 2015 that ranged in size between 14 651 and 23 630 residents.

MEASUREMENTS

Sociodemographic characteristics, morbidity, and functional status of new residents were determined upon admission to examine patterns in the cohorts' profiles.

RESULTS

The proportion of residents aged 85 years and older increased from 45.1% to 53.8% over 16 years. The proportions of individuals with seven or more chronic conditions (from 14.1% to 22.1%) and with nine or more prescription medications (from 44.9% to 64.2%) have also increased in parallel over time. Hypertension, osteoarthritis, and dementia were the most prevalent conditions captured, with the proportion of incoming residents with dementia increasing from 42.3% to 54.1% between 2000 and 2015. Newly admitted residents were more likely to have extensive physical and cognitive impairments upon admission.

CONCLUSION

Admission trends show that new residents were older and had greater multimorbidity and limitations in physical functioning over time. J Am Geriatr Soc 68:1293-1300, 2020.

Effectiveness of confidential reports to physicians on their prescribing of antipsychotic medications in nursing homes

Background

Antipsychotic medication use in nursing homes is associated with potential for harms. In Ontario, Canada, an agency of the provincial government offers nursing home physicians quarterly audit and feedback on their antipsychotic prescribing. We compared the characteristics of physicians who did and did not engage with the intervention, and assessed early changes in prescribing.

Methods

This population-level, retrospective cohort study used linked administrative databases to track prescribing practices in nursing homes pre-intervention (baseline), immediately post-initiative (3 months), and at follow-up (6 months). Exposure variables identified whether a physician signed up to participate (or not) or viewed the feedback following sign up (or not). Differences in the proportion of days that residents received antipsychotic medications at 6 months compared to baseline by exposure(s) were assessed using a linear mixed effects regression analysis to adjust for a range of resident, physician, and nursing home factors. Benzodiazepine and statin prescribing were assessed as a balance and tracer measures, respectively.

Results

Of 944 eligible physicians, 210 (22.3%) signed up to recieve the feedback report and 132 (13.9%) viewed their feedback. Physicians who signed up for feedback were more likely to have graduated from a Canadian medical school, work in urban nursing homes, and care for a larger number of residents. The clinical and functional characteristics of residents were similar across physician exposure groups. At 6 months, antipsychotic prescribing had decreased in all exposure groups. Those who viewed their feedback report had a signicantly greater reduction in antipsychotic prescribing than those who did not sign up (0.94% patient-days exposed; 95% CI 0.35 to 1.54%, p = 0.002). Trends in prescribing patterns across exposure groups for benzodiazepines and statins were not statistically significant.

Interpretation

Almost a quarter of eligible physicians engaged early in a voluntary audit and feedback intervention related to antipsychotic prescribing in nursing homes. Those who viewed their feedback achieved a small but statistically significant change in prescribing, equivalent to approximately 14,000 fewer days that nursing home residents received antipsychotic medications over 6 months. This study adds to the literature regarding the role of audit and feedback interventions to improve quality of care.

Understanding transitional care programmes for older adults who experience delayed discharge: a scoping review protocol

INTRODUCTION

Many hospitalised older adults experience delayed discharges due to increased postacute health and social support needs. Transitional care programmes (TCPs) provide short-term care to these patients to prepare them for transfer to nursing homes or back to the community with supports. There are knowledge gaps related to the development, implementation and evaluation of TCPs. The aims of this scoping review (ScR) are to identify the characteristics of older patients served by TCPs; criteria for transfer, components and services provided by TCPs; and outcomes used to evaluate TCPs.

METHODS AND ANALYSIS

The study involves six-step ScR and is informed by a collaborative/participatory approach whereby stakeholders engage in the development of the research questions, identification of literature, data abstraction and synthesis; and participation in consultation workshop. The search for scientific literature will be done in the Medline, PsychINFO, Emcare and CINAHL databases; as well, policies and reports that examined models of transitional care and the outcomes used to evaluate them will be reviewed. Records will be selected if they involve community dwelling older adults aged 65 years or older, or indigenous persons 45 years or older; and presented in English, French, Dutch and German languages. Records will be screened, reviewed and abstracted by two independent reviewers. Extracted data will be analysed using descriptive statistics and a narrative analysis, and organised according to Donabedian's model of structure (characteristics of older adults experiencing delayed discharge and served by TCPs), process (TCP components and services) and outcome.

ETHICS AND DISSEMINATION

This ScR does not require ethics approval. Dissemination activities include integrated knowledge translation (KT) (consultation with stakeholders throughout the study) and end-of-grant KT strategies (presentations at national and international conferences; and publication in peer-reviewed interdisciplinary journal).

DIVERT-Collaboration Action Research and Evaluation (CARE) Trial Protocol: a multiprovincial pragmatic cluster randomised trial of cardiorespiratory management in home care

INTRODUCTION

Home care clients are increasingly medically complex, have limited access to effective chronic disease management and have very high emergency department (ED) visitation rates. There is a need for more appropriate and targeted supportive chronic disease management for home care clients. We aim to evaluate the effectiveness and preliminary cost effectiveness of a targeted, person-centred cardiorespiratory management model.

METHODS AND ANALYSIS

The Detection of Indicators and Vulnerabilities of Emergency Room Trips (DIVERT) - Collaboration Action Research and Evaluation (CARE) trial is a pragmatic, cluster-randomised, multicentre superiority trial of a flexible multicomponent cardiorespiratory management model based on the best practice guidelines. The trial will be conducted in partnership with three regional, public-sector, home care providers across Canada. The primary outcome of the trial is the difference in time to first unplanned ED visit (hazard rate) within 6 months. Additional secondary outcomes are to identify changes in patient activation, changes in cardiorespiratory symptom frequencies and cost effectiveness over 6 months. We will also investigate the difference in the number of unplanned ED visits, number of inpatient hospitalisations and changes in health-related quality of life. Multilevel proportional hazard and generalised linear models will be used to test the primary and secondary hypotheses. Sample size simulations indicate that enrolling 1100 home care clients across 36 clusters (home care caseloads) will yield a power of 81% given an HR of 0.75.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Hamilton Integrated Research Ethics Board as well as each participating site's ethics board. Results will be submitted for publication in peer-reviewed journals and for presentation at relevant conferences. Home care service partners will also be informed of the study's results. The results will be used to inform future support strategies for older adults receiving home care services.

TRIAL REGISTRATION NUMBER

NCT03012256.

Sex Differences in the Prevalent Use of Oral Formulations of Cholinesterase Inhibitors in Older Adults with Dementia

BACKGROUND

Cholinesterase inhibitors (ChEIs) are one of only two drug therapies available to manage cognitive decline in dementia. Given sex-specific differences in medication access and effects, it is important to understand how ChEIs are used by women and men.

OBJECTIVE

The objective of this study was to provide contemporary sex-stratified evidence on patterns of ChEI use by community-dwelling older adults with dementia to inform opportunities to optimize drug prescribing.

METHODS

We conducted a population-based cross-sectional study examining ChEI use in older adults with dementia in Ontario, Canada. We identified all community-dwelling individuals aged 66 years and older with a pre-existing diagnosis of dementia as of 1 April, 2016. We examined the prevalence of ChEI use among women and men separately, and explored the association between ChEI use and age, sex, income status, geographic location of residence, use of palliative care services, comorbidity, and polypharmacy. Concurrent use of drugs known to impair cognition (including antipsychotics, benzodiazepines, and medications with strong anticholinergic properties) was separately assessed among women and men using multivariable analyses and prevalence risk ratios.

RESULTS

Of 74,799 women and 52,231 men living with dementia in the community, nearly 30% currently were using a ChEI (29.3% women, 28.6% men). Close to 70% of users were receiving the target therapeutic dose. Compared to men, women were less often taking the target therapeutic dose (67.8% women vs. 71.6% men, p < 0.001). Over 20% of users also were using drugs known to impair cognition, while being treated for cognitive decline using ChEIs. Compared to men, women were more often concurrently using drugs known to impair cognition (23.9% women vs. 21.8% men, p < 0.001).

CONCLUSIONS

This is one of the first studies of ChEI use to account for important sex differences. The results remind clinicians and researchers that patterns of ChEI therapy use differ by sex, as women were less likely to receive target therapeutic doses and more vulnerable to potentially problematic polypharmacy than men.

Association between Physician Intensity of Antibiotic Prescribing and the Prescription of Benzodiazepines, Opioids and Proton-Pump Inhibitors to Nursing Home Residents: a Population-Based Observational Study

BACKGROUND

Prescribing patterns for episodic medications, such as antibiotics, might make useful surrogate measures of a physician's overall prescribing practice because use is common, and variation exists across prescribers. However, the extent to which a physician's current antibiotic prescribing practices are associated with the rate of prescription of other potentially harmful medications remains unknown.

OBJECTIVE

To examine the association between a physician's rate of antibiotic prescribing and their prescribing rate of benzodiazepines, opioids and proton-pump inhibitors in older adults.

DESIGN

Population-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients.

PARTICIPANTS

1926 physicians who provided care among 128,979 physician-patient pairs in 2015.

MAIN MEASURES

Likelihood of prescribing a benzodiazepine, opioid or proton-pump inhibitor between low-, average- and high-intensity antibiotic prescribers, adjusted for patient characteristics.

KEY RESULTS

Compared with average-intensity antibiotic prescribers, high-intensity prescribers had an increased likelihood of prescribing a benzodiazepine (odds ratio 1.21 [95% CI, 1.11-1.32]), an opioid (odds ratio 1.28 [95% CI, 1.17-1.39]) or a proton-pump inhibitor (odds ratio 1.38 [95% CI, 1.27-1.51]]. High-intensity antibiotic prescribers were more likely to be high prescribers of all three medications (odds ratio 6.24 [95% CI, 2.90-13.39]) and also more likely to initiate all three medications, compared with average-intensity prescribers.

CONCLUSIONS

The intensity of a physician's episodic antibiotic prescribing was significantly associated with the likelihood of new and continued prescribing of opioids, benzodiazepines and proton-pump inhibitors in nursing homes. Patterns of episodic prescribing may be a useful mechanism to target physician-level interventions to optimize general prescribing behaviors, instead of prescribing behaviors for single medications.

COMORBIDITY IN NEURODEGENERATIVE DISEASES AND MENTAL HEALTH CONDITIONS: IMPLICATIONS FOR HEALTH SYSTEM BURDEN

Research suggests that older adults with neurodegenerative diseases are at increased risk of developing a subsequent neurodegenerative or comorbid psychiatric disorder or both. Depression and other psychiatric conditions, though prevalent, are often under-diagnosed and under-treated among those with neurodegenerative conditions potentially leading to more rapid disease progression, poorer health outcomes and increased health care use. Few population-based studies have comprehensively examined the risk and temporal ordering of common neurodegenerative and psychiatric conditions, including whether these associations differ by age or sex. Initial findings regarding the incidence of ordered pairs of neurological conditions (including dementia, Parkinson’s disease and stroke) and psychiatric disorders (including mood and anxiety disorders, and schizophrenia) will be summarized. This population-based retrospective cohort study will provide essential data to allow policymakers, planners and providers to better anticipate the prognosis and care needs of older adults with comorbid neurodegenerative and psychiatric conditions.

WHAT’S OLD IS NEW: USING ARTIFICIAL INTELLIGENCE TO ACCELERATE DISCOVERY OF NEW TREATMENTS

Given the high cost of drug development and low success rates, repurposing drugs already proven safe provides a promising avenue for identifying effective therapies with additional indications. The IBM Watson artificial intelligence system was used to search 1.3 million Medline abstracts to prioritize medications that may be potentially disease-modifying in Parkinson’s disease. We assessed patterns of use of the top 50 Watson-ranked drugs among 14,866 adults with Parkinson’s disease aged 70 and older who were matched to persons without Parkinson’s disease on age, sex, and comorbidity. Sociodemographic characteristics, chronic conditions, and use of other medications were compared using standardized differences. Patterns of potentially disease-modifying drug use were examined prior to and following ascertainment of Parkinson’s disease. Preliminary findings from multivariable conditional logistic regression models on the association between previous exposure to potentially disease-modifying drugs and Parkinson’s disease diagnosis will be presented.

ONDRI: A PROVINCIAL INITIATIVE TO UNDERSTAND THE HEALTH SYSTEM IMPACT OF AGING AND NEURODEGENERATIVE DISEASES

As populations worldwide are living longer, the impact of neurodegenerative diseases on health resource utilization is expected to increase. Providing care to older adults with neurodegenerative diseases is challenging, and requires adequate supports across multiple health sectors including community, acute care and nursing home settings to allow individuals to maximize their quality of life. The Ontario Neurodegenerative Disease Research Initiative (ONDRI) is a collaborative research program that aims to improve diagnosis, treatment and management of neurodegenerative diseases including Alzheimer’s disease and related dementias, Parkinson’s disease, Amyotrophic Lateral Sclerosis (ALS), and Vascular Cognitive Impairment. Using population-based linked health administrative and clinical databases--covering over 14 million individuals residing in the province of Ontario, Canada-- the ONDRI health services research platform will address knowledge gaps regarding the health service utilization and outcomes of older adults with neurodegenerative diseases and impacts on family and care partners. Access to over two decades of historical health administrative data on a large population of older individuals uniquely positions our collaborative to examine trajectories of health system use as well as rare neurodegenerative diseases which have been previously understudied. The health services research platform is embedded within a larger ONDRI network of biomedical researchers, provincial decision-makers and health system stakeholders. Our research findings will inform health system planning and interventions to support older adults to live independently in the community. This session will explore how health administrative databases may be used to address knowledge gaps regarding health service utilization and outcomes in older persons with neurodegenerative diseases.

TRAJECTORIES OF HEALTH SYSTEM USE AND TRANSITIONS IN OLDER ADULTS WITH DEMENTIA

Health systems strive to enable persons with Alzheimer’s and related dementias to remain at home to maximize their quality of life. There is limited evidence describing long-term trajectories of health system use by persons with dementia as they remain in the community over time. A cohort of 62,622 community-dwelling older adults was followed for seven years and matched to persons without dementia (controls) based on age, sex and comorbidities. Overall, persons with dementia were more likely than controls to use health services, particularly home care and hospitalizations with discharge delay; and were more likely to be admitted to a nursing home. As they remained in the community over time, persons with dementia used home care at an increasingly intensive rate. Our approach to examine trajectories of health system use among persons with dementia is of particular value to capacity planning initiatives to anticipate future health service needs of this population.

UNDERSTANDING SEX DIFFERENCES IN OLDER PERSONS WITH NEURODEGENERATIVE DISEASES

Sex differences in the incidence, prevalence, and clinical presentation of neurodegenerative diseases have been previously documented, however, sex differences in how individuals with neurodegenerative diseases access the health system remain understudied. Clinical trials and observational studies often do not report data stratified by sex, which limits the understanding of sex-related differences in persons with neurodegenerative diseases. This session will highlight both opportunities and methodological challenges researchers face when undertaking sex and gender research in persons with neurodegenerative diseases using two case studies: 1) sex differences in health service utilization prior to a diagnosis of Amyotrophic Lateral Sclerosis (ALS); and 2) sex differences in care needs and survival among persons who are admitted to a nursing home after a stroke. The findings of these studies may support the development of guidelines and care plans to meet the needs of men and women with neurodegenerative disorders in varied care settings.

CHALLENGES IN IDENTIFYING PERSONS WITH NEURODEGENERATIVE DISEASES USING HEALTH ADMINISTRATIVE DATABASES

Health administrative databases can be used to quantify prevalence and incidence of neurodegenerative diseases and their impact on health service utilization outcomes at the population level. Algorithms based on diagnosis codes and health service patterns can be used to identify persons suspected to have a neurodegenerative disease. Previous studies have developed and validated algorithms to identify persons with Alzheimer’s and related dementias using primary care medical records as the reference standard, however, little previous work has focused on developing algorithms for rare neurodegenerative diseases including amyotrophic lateral sclerosis (ALS). This session will discuss challenges in developing algorithms to identify persons with neurodegenerative diseases accurately and opportunities to improve existing definitions using novel data sources including electronic medical record databases. Preliminary findings regarding the development of an ALS algorithm will be presented.

Sodium glucose cotransporter 2 inhibitors and risk of genital mycotic and urinary tract infection: A population-based study of older women and men with diabetes

AIMS

The objective of the study was to quantify the association between SGLT2 inhibitors and genital mycotic infection and between SGLT2 inhibitors and urinary tract infection (UTI) within 30 days of drug initiation among older women and men.

MATERIALS AND METHODS

This was a retrospective cohort study using linked administrative databases of women and men with diabetes, aged 66 years or older, in Ontario, Canada. We compared the incidence of genital mycotic infection or UTI within 30 days between new users of an SGLT2 inhibitor and of a dipeptidyl-peptidase-4 (DPP4) inhibitor.

RESULTS

We identified 21 444 incident users of SGLT2 inhibitor and 22 463 incident users of DPP4 inhibitor. Among SGLT2 inhibitor users, there were 8848 (41%) women and the mean age at index was 71.8 ± 5 (SD) years. After adjusting for propensity score, age, sex and recent UTI, there was a 2.47-fold increased risk of genital mycotic infection with incident use of SGLT2 inhibitors (adjusted hazard ratio (HR), 2.47; 95% confidence interval (CI), 2.08-2.92; P < 0.001) within 30 days compared to incident use of DPP4 inhibitors. For UTI, the adjusted HR was 0.89 (95% CI, 0.78-1.00; P = 0.05).

CONCLUSIONS

Incident use of SGLT2 inhibitors among older women and men is associated with increased risk of genital mycotic infections within 30 days; there is no associated increased risk of UTI. These findings from a real-world setting provide evidence of the potential harms of SGLT2 inhibitors.

Does Physician Retirement Affect Patients? A Systematic Review

OBJECTIVES

Older patients that have aged with their doctors will likely experience their physician retiring. It is unclear if this interruption in continuity of care leaves patients at risk for adverse events or whether a new physician improves care. We sought to identify and synthesize findings from all articles examining the association between physician retirement and patient outcomes.

DESIGN

Systematic review. We searched English-language articles cataloged in Medline, Embase, Cochrane, and PsycINFO, from database inception to May 4, 2018.

PARTICIPANTS

Any patient whose physician (generalist or specialist) retired.

INTERVENTION

Physician retirement, defined as voluntary practice closure, death, or departure.

MEASUREMENTS

Articles were categorized as anecdotes, qualitative studies, or quantitative studies. Each patient outcome was indexed under one of 11 themes (eg, adverse event, difficulty accessing care) and classified as favorable, neutral, or unfavorable. Patient outcomes included but were not limited to clinical (eg, death), resource utilization (eg, hospitalization), treatment plan adherence (eg, access to medications), and patient satisfaction (eg, expressed frustration). Two reviewers independently assessed study quality.

RESULTS

Of 2099 articles screened, 17 met inclusion criteria: 12 anecdotes, 2 qualitative studies, and 3 quantitative studies. Most patient outcomes described were unfavorable. These included feelings of loss, difficulties with transition to a new provider, adverse clinical outcomes, and increased use of high-cost services. The quality of qualitative studies was high, but that of quantitative studies was poor or moderate.

CONCLUSION

Current evidence from qualitative studies suggests physician retirement affects patients unfavorably and that patients are vulnerable during this transition of care. High-quality quantitative research is lacking to identify whether this disproportionately affects older adults and whether physician retirement has significant consequences for the broader healthcare system. J Am Geriatr Soc 68:641-649, 2020.

Comparative risk of harm associated with trazodone or atypical antipsychotic use in older adults with dementia: a retrospective cohort study

BACKGROUND

Trazodone is increasingly prescribed for behavioural and psychological symptoms of dementia, but little is known about its risk of harm. Our objective was to describe the comparative risk of falls and fractures among older adults with dementia dispensed trazodone or atypical antipsychotics.

METHODS

The study cohort included adults with dementia (excluding patients with chronic psychotic illnesses) living in long-term care and aged 66 years and older. Data were obtained from routinely collected, linked health administrative databases in Ontario, Canada. We compared new users of trazodone with new users of atypical antipsychotics (quetiapine, olanzapine or risperidone) between Dec. 1, 2009, and Dec. 31, 2015. The primary outcome was a composite of fall or major osteoporotic fracture within 90 days of first prescription. Secondary outcomes were falls, major osteoporotic fractures, hip fractures and all-cause mortality.

RESULTS

We included 6588 older adults dispensed trazodone and 2875 dispensed an atypical antipsychotic, of whom 95.2% received a low dose of these medications. Compared with use of atypical antipsychotics, use of trazodone was associated with similar rates of falls or major osteoporotic fractures (weighted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.73 to 1.07), major osteoporotic fracture (weighted HR 1.03, 95% CI 0.73 to 1.47), falls (weighted HR 0.91, 95% CI 0.75 to 1.11) and hip fractures (weighted HR 0.92, 95% CI 0.59 to 1.43). Use of trazodone was associated with a lower rate of mortality (weighted HR 0.75, 95% CI 0.66 to 0.85).

INTERPRETATION

Trazodone is not a uniformly safer alternative to atypical antipsychotics, given the similar risk of falls and fractures among older adults with dementia.

One-year survival and admission to hospital for cardiovascular events among older residents of long-term care facilities who were prescribed intensive- and moderate-dose statins

BACKGROUND

Guidance from randomized clinical trials about the ongoing benefits of statin therapies in residents of long-term care facilities is lacking. We sought to examine the effect of statin dose on 1-year survival and admission to hospital for cardiovascular events in this setting.

METHODS

We conducted a retrospective cohort study using population-based administrative data from Ontario, Canada. We identified 21 808 residents in long-term care facilities who were 76 years of age and older and were prevalent statin users on the date of a full clinical assessment between April 2013 and March 2014, and categorized residents as intensive- or moderate-dose users. Treatment groups were matched on age, sex, admission to hospital for atherosclerotic cardiovascular disease, resident frailty and propensity score. Differences in 1-year survival and admission to hospital for cardiovascular events were measured using Cox proportional and subdistribution hazard models, respectively.

RESULTS

Using propensity-score matching, we included 4577 well-balanced pairs of residents who were taking intensive- and moderate-dose statins. After 1 year, there were 1210 (26.4%) deaths and 524 (11.5%) admissions to hospital for cardiovascular events among residents using moderate-dose statins compared with 1173 (25.6%) deaths and 522 (11.4%) admissions to hospital for cardiovascular events among those taking intensive-dose statins. We found no significant association between prevalent use of intensive-dose statins and 1-year survival (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.90 to 1.05) or 1-year admission to hospital for cardiovascular events (HR 0.99, 95% CI 0.88 to 1.12) compared with use of moderate-dose statins.

INTERPRETATION

The rates of mortality and admission to hospital for cardiovascular events at 1 year were similar between residents in long-term care taking intensive-dose statins compared with those taking moderate-dose statins. This lack of benefit should be considered when prescribing statins to vulnerable residents of long-term care facilities who are at potentially increased risk of statin-related adverse events.