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BACKGROUND: We developed clinical practice guidelines to provide health care providers with evidence-based recommendations for decisions related to the effective management of frailty and pre-frailty using nutrition and physical activity interventions. METHODS: We based the recommendations on two systematic reviews with meta-analyses. Nutrition, physical activity, and combined nutrition and physical activity interventions for adults ≥65y were considered if study populations were identified as frail using a frailty tool or assessment. Risk of bias and certainty of evidence were evaluated. We included physical outcomes, mobility, frailty, cognitive function, activities of daily living, falls, quality of life, diet quality, energy/fatigue levels, health services use, and caregiver outcomes. RESULTS: Overall, mobility improvements were moderate with nutritional strategies that optimize dietary intake, various types of physical activity interventions, and interventions that combine nutrition and physical activity. Physical outcomes, such as body mass and muscle strength, improved moderately with nutritional strategies and interventions that combined nutrition with physical activity. Frailty status improved with multi-component physical activity interventions. Strong recommendations include optimizing dietary intake, performing physical activity, and adopting interventions that combine nutrition and physical activity. We strongly recommend various types of physical activity including muscle strengthening activities, mobilization or rehabilitation exercises, and multi-component physical activity interventions. INTERPRETATION: Tailored nutrition and physical activity interventions based on individual goals and health status are associated with improved clinical and physical outcomes. While the recommendations facilitate shared decision-making, we identified sparse application of validated frailty assessments and lack of standardized research outcomes as critical gaps in knowledge.

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Objectives: Family caregivers (defined broadly as family and friends) of persons with dementia are challenged to cope with myriad stressors and changes that occur along the dementia trajectory. The purpose of this study was to explore the transitions experienced by caregivers of persons with dementia after their relative relocated to a 24-hour care home.Method: Qualitative thematic and conversational analysis were used: themes were co-created and modes of speech and syntactical patterns analysed to expose discourses related to caregiving after placement in 24-hour care homes.Results: Four main themes were co-constructed from the data analysis: living with loss, relinquishing, redefining the caregiving role, and rediscovering and recreating a new self.Discussion: Caregiving continues after placement of family members with dementia in 24-hour care homes. Caregivers are at-risk group and require ongoing support throughout the caregiving journey. Study participants reported that navigation skills such as relationship building, communication, and advocacy were particularly salient to the post-placement period, when navigating the complex health care environment was a significant obstacle. Ultimately, findings from these focus groups will be used to inform an online intervention to support caregivers of a family member with dementia residing in a 24-hour care home.

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BACKGROUND: Advance care planning (ACP) encompasses both verbal and written communications expressing preferences for future health and personal care and helps prepare people for healthcare decision-making in times of medical crisis. Healthcare systems are increasingly promoting ACP as a way to inform medical decision-making, but it is not clear how public engagement in ACP activities is changing over time. METHODS: Raw data from 3 independently conducted public polls on ACP engagement, in the same Canadian province, were analysed to assess whether participation in ACP activities changed over 6 years. RESULTS: Statistically significant increases were observed between 2007 and 2013 in: recognising the definition of ACP (54.8% to 80.3%, OR 3.37 (95% CI 2.68 to 4.24)), discussions about healthcare preferences with family (48.4% to 59.8%, OR 1.41 (95% CI 1.17 to 1.69)) and with healthcare providers (9.1% to 17.4%, OR 1.98 (95% CI 1.51 to 2.59)), written ACP plans (21% to 34.6%, OR 1.77 (95% CI 1.45 to 2.17)) and legal documentation (23.4% to 42.7%, OR 2.13 (95% CI 1.75 to 2.59)). These remained significant after adjusting for age, education and self-rated health status. CONCLUSIONS: ACP engagement increased over time, although the overall frequency remains low in certain elements such as discussing ACP with healthcare providers. We discuss factors that may be responsible for the increase and provide suggestions for healthcare systems or other public bodies seeking to stimulate engagement in ACP.

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BACKGROUND: Advance care planning (acp) is an important process in health care today. How to prospectively identify potential local barriers and facilitators to uptake of acp across a complex, multi-sector, publicly funded health care system and how to develop specific mitigating strategies have not been well characterized. METHODS: We surveyed a convenience sample of clinical and administrative health care opinion leaders across the province of Alberta to characterize system-specific barriers and facilitators to uptake of acp. The survey was based on published literature about the barriers to and facilitators of acp and on the Michie Theoretical Domains Framework. RESULTS: Of 88 surveys, 51 (58%) were returned. The survey identified system-specific barriers that could challenge uptake of acp. The factors were categorized into four main domains. Three examples of individual system-specific barriers were "insufficient public engagement and misunderstanding," "conflict among different provincial health service initiatives," and "lack of infrastructure." Local system-specific barriers and facilitators were subsequently explored through a semi-structured informal discussion group involving key informants. The group identified approaches to mitigate specific barriers. CONCLUSIONS: Uptake of acp is a priority for many health care systems, but bringing about change in multi-sector health care systems is complex. Identifying system-specific barriers and facilitators to the uptake of innovation are important elements of successful knowledge translation. We developed and successfully used a simple and inexpensive process to identify local system-specific barriers and enablers to uptake of acp, and to identify specific mitigating strategies.

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BACKGROUND: Frail older inpatients are at risk of unintended adverse events while in hospital, particularly falls, functional decline, delirium and incontinence. OBJECTIVE: The aim of this pragmatic trial was to pilot and evaluate a multi-component knowledge translation intervention that incorporated a nurse-initiated computerized clinical decision support tool to reduce harms in the care of older medical inpatients. METHODS: A stepped wedge trial design was conducted on six medical units at two hospitals in Calgary, Alberta, Canada. The primary quantitative outcome was the rate of order set use. Secondary outcomes included the number of falls, the average number of days in hospital, and the total number of consults ordered for each of orthopedics, geriatrics, psychiatry and physiotherapy. Qualitative analysis included interviews with nurses to explore barriers and facilitators around the implementation of the electronic decision support tool. RESULTS: The estimated mean rate of order set use over a 2 week period was 3.1 (95% CI 1.9-5.3) sets higher after the intervention than before. The estimated odds of a fall happening on a unit over a 2-week period was 9.3 (p = 0.065) times higher before than after the intervention. There was no significant effect of the intervention on length of hospital stay (p = 0.67) or consults to related clinical services (all p <0.2). Interviews with front-line nurses and nurse managers/educators revealed that the order set is not being regularly ordered because its content is perceived as part of good nursing care and due to the high workload on these busy medical units. CONCLUSIONS: Although not statistically significant, a reduction in the number of falls as a result of the intervention was noted. Frontline users' engagement is crucial for the successful implementation of any decision support tool. New strategies of implementation will be evaluated before broad dissemination of this knowledge translation intervention.

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AIMS: Few studies have documented the effectiveness of continence promotion programs targeting older incontinent women. We sought to evaluate the impact of an interactive continence workshop on changing participants' attitudes, knowledge and skills in relation to self-managing or seeking care for incontinence. METHODS: A quasi-experimental prospective cohort study with repeated measures was carried out on a population of 90 incontinent women aged 55-87 participating in a continence promotion workshop. Inclusion criteria were a weekly average of one or more episodes of involuntary urine loss during the preceding 3 months and having never sought help for this problem. Incontinence-related knowledge, attitudes, skills and intentions for seeking care were assessed immediately prior and subsequent to the workshop. Three- and 6-month telephone follow-ups were conducted to determine rates of healthcare seeking and reasons for not seeking care. RESULTS: Improvements in incontinence-related knowledge and attitudes occurred in up to 94% participants. Forty-three percent of the study participants initiated and were satisfied with self-treatment, and an additional 42% consulted a health care professional. CONCLUSION: Interactive continence workshops promote self-management and consultation seeking among older women with incontinence. Further testing of different strategies for promoting continence awareness needs to occur in larger studies with more sensitive instruments, a control group, and better specification of the goals, process and outcomes of the health promotion activity being tested.

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BACKGROUND AND PURPOSE: Previous studies have documented sex differences in the management and outcome of patients with cardiovascular disease. However, little data exist on whether similar sex differences exist in stroke patients. We conducted a study to determine whether sex differences exist in patients with acute stroke admitted to Ontario hospitals. METHODS: Using linked administrative databases, we performed a population-based cohort study. The databases contained information on all 44 832 patients discharged from acute-care hospitals in Ontario between April 1993 and March 1996 with a most responsible diagnosis of acute stroke. The main outcomes measured consisted of sex differences in comorbidities, the use of rehabilitative services, the use of antiplatelet therapy and anticoagulants (in elderly stroke survivors aged > or =65 years only), discharge destination, and mortality. RESULTS: Male stroke patients were more likely than female stroke patients to have a history of ischemic heart disease (18.1% versus 15.3%, respectively; P<0.001) and diabetes mellitus (20.1% versus 18. 7%, respectively; P<0.001), whereas female patients were more likely than male patients to have hypertension (33.8% versus 30.0%, respectively; P<0.001) and atrial fibrillation (12.9% versus 10.2%, respectively; P<0.001). There were no sex differences in the usage of in-hospital rehabilitative services. The overall 90-day postdischarge use of aspirin and ticlopidine was similar in stroke survivors aged 65 to 84 years. However, among stroke survivors aged > or =85 years, men were more likely than women to receive aspirin (36. 0% versus 30.7%, respectively; P<0.001) and ticlopidine (9.2% versus 6.8%, respectively; P=0.007). Use of warfarin was similar for the two sexes. Men were more likely than women to be discharged home (50. 6% versus 40.9%, respectively; P<0.001) and less likely to be discharged to chronic care facilities (16.8% versus 25.2%, respectively; P<0.001). The risk of death 1 year after stroke was somewhat lower in women than men (adjusted odds ratio 0.939, 95% CI 0.899 to 0.980; P=0.004). The mortality differences were greatest among elderly stroke patients. CONCLUSIONS: Elderly men are more likely than elderly women to receive aspirin and ticlopidine and equally like to receive warfarin after a stroke. Despite these differences, elderly women have a better 1-year survival after a stroke.

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