Background SYNchronizing Exercises, Remedies in GaIt and Cognition @Home (SYNERGIC@Home/SYNERGIE~Chez soi) is a home-based, double-blind, randomized controlled trial. Sixty community dwelling older adults (aged 60–90 years), living in New Brunswick, Canada, who were at risk of dementia participated remotely using secure videoconferencing. Participants underwent 16 weeks (three sessions/week) of cognitive and physical interventions. This research aimed to determine the frequency, severity, and relationship of adverse events (AEs) that occurred during the physical and cognitive intervention phase of the SYNERGIC@Home study. This study addressed a critical question: Whether AEs occurring during a remote exercise and cognitive intervention for older adults at risk of dementia can be managed safely and effectively to optimize participation. Methods All AEs were recorded, including type, severity, and their relatedness to the intervention. Intervention modifications due to AEs were also recorded. Results Participant’s mean age was 69.5 years (SD=6.47), 76.7% were female, and 58.4% were living in suburban or urban communities. A total of 88 AEs affected 42 (70.0%) participants. Most AEs (71.6%) were unrelated to the intervention, and 69.3% were classified as mild, with musculoskeletal issues being the most common AE (39.8%). One unrelated serious AE was recorded. Modifications to the physical intervention were made for 31 participants, and two discontinued due to unrelated medical issues. Conclusions When delivered remotely, physical and cognitive interventions resulted in no serious related AEs and the few related, mostly mild AEs, were safely managed through modifications to the physical interventions.
Psychosocial interventions targeting cognition improve objective cognitive test performance, strategy use, emotional well-being, and quality of life in individuals with mild cognitive impairment and early dementia. These interventions have been labeled as cognitive training, cognitive remediation, cognitive rehabilitation, cognitive stimulation, and overlap with cognitive (psycho)therapy. The inconsistent labeling of the interventions has resulted in ambiguity of what a cognitive intervention entails and limits the translation of interventions into clinical practice. To address this, we propose a new frame-work, “PICC-M”, that classifies cognitive interventions based on five active ingredients or the mechanisms resulting in clinically significant change. These ingredients are psychotherapeutic support (P), individualized patient goals (I), cognitive exercises (C), compensatory strategies (C), and metacognitive strategies (M). We examine three intervention programs to illustrate how this framework clarifies each intervention’s active ingredients and their relation to cognitive, psychological, and functional outcomes. The PICC-M framework lays the foundation for dismantling studies to isolate and test the effectiveness of specific active ingredients and ultimately support clinical delivery of evidence-based interventions for older individuals with neurocognitive deficits.
Social isolation and loneliness are associated with many adverse health outcomes. The COVID-19 pandemic increased its prevalence and disproportionately affected older adults. Since telephone befriending was a potentially feasible and safe intervention during the pandemic, the McMaster Phone-a-Friend Program (PFP) was developed using this strategy to try to reduce social isolation and loneliness among older adults. Thus, this study aimed to evaluate the effectiveness and long-term feasibility of PFP. Community-dwelling older adults in Ontario, Canada were matched to trained university student volunteers, who provided social engagement and pandemic-related education through weekly telephone calls. Two main referral sources were used: 1) older adults identified by their primary care provider as at risk for social isolation; and 2) older adults referred for multi-modal frailty rehabilitation, where telephone befriending was a desired component intervention. Older adults completing ≥4 calls were contacted to participate in a telephone survey to provide program feedback. Of the 220 active participants in August 2021, 60 participated in our survey. At the time of survey completion, the mean number of calls completed was 8.3. The mean age of participants was 75.6 years and 71.7% (n=43) identified as female. Furthermore, 58.3% (n=35) of the participants agreed or strongly agreed that they felt less lonely after participating in the program and 68.3% (n=41) stated they would participate in the program after the pandemic resolves. The intergenerational PFP telephone befriending program is a safe and effective method of reducing or possibly preventing social isolation and loneliness among at-risk community-dwelling older adults.
Sarcopenia is an age-related skeletal muscle disorder characterized by decreased muscle mass, strength, and physical function, which increases the risk of adverse outcomes in older adults. Recently, ultrasound has emerged as a practical tool for estimating muscle thickness as a proxy for muscle quantity. However, standardized protocols, reference data, and diagnostic cut-off values for ultrasound-based muscle assessment remain lacking. This study pooled participants from three cohorts in which quadriceps muscle thickness was assessed in B-mode with a linear probe using point-of-care ultrasound (POCUS). Of 391 participants, 389 were included in the final analysis. Age was categorized into five-year groups (65-69, 70-74, 75-79, 80-85, and over 85 years old). Means and standard deviations (SD) of quadriceps thickness were calculated by sex and age group. Mean age was 77 ± 7 years. Quadriceps muscle thickness followed a normal distribution with a standard deviation of 0.5 cm. Mean thickness declined with advancing age. Our pooled analysis found a mean quadriceps muscle thickness of 2.0 cm. The decline with advancing age was modest, with the lowest value observed in participants aged 85 years and older (1.8 ± 0.4). On average, muscle thickness decreased by approximately 0.1 cm per decade after age 65. These findings provide age- and sex-specific reference values for quadriceps muscle thickness measured by POCUS, and support its potential utility as a feasible tool for muscle assessment in older adults.
Emotion-focused model of care delivery creates a supportive environment for persons with dementia. There is a lack of certainty regarding one such emotion-focused model's effectiveness (Butterfly) in an acute care environment, primarily because prior research has been confined to long-term care (LTC) facilities. Studies have demonstrated reduced neuropsychiatric symptoms (NPS) when person-centred dementia care models are deployed for persons living with dementia (PLWD). A multi-site cross-sectional design assessed NPS in PLWD using the NPI-Q scale in hospitalized patients on a Emotion-focused unit for 7-21 days. We identified 177 PLWD (88 from an acute care for elderly unit, 89 from general medicine units). The two cohorts had 40 female and 48 male patients in the ACE unit and 35 female and 54 male patients in the general medicine unit. The average age between the two groups was 83 and 84 yrs, respectively. NPI-Q symptom severity was lower on the ACE unit in comparison to the general medicine unit. Mean improvement for motor behaviours and sleep were significant. Caregiver distress scores were significantly lower for delusions, agitation, anxiety, irritability, motor behaviour and sleep. Emotion-focused care made a statistically significant change in NPS severity and caregiver distress when compared to care provided in general medicine units.
Background The Frailty Index (FI) is a measure of frailty with recent guidance on its calculation. Objectives were: 1) To determine the prevalence of frailty and its component domains at different ages in older men; and 2) To determine if the FI, and/or its component scores predict death or long-term care (LTC) admission. Design: A cohort study. Setting: Most of the participants lived in Canada. Subjects: 3,983 men who qualified for air crew training during the Second World War. We included 1,711 men (mean age 76) free of dementia, living in the community, who had data to construct a FI in 1996. Methods Medical conditions have been measured from 1948. Functional status, health status, and social well-being have been measured by survey since 1996. We constructed a FI from these data and calculated the prevalence of frailty from the age of 75+. We considered three domains of frailty: medical, functional, and psychosocial. We calculated the mortality risk and the risk of LTC care admission using proportional hazards models. Results Frailty, dementia, and LTC use are all strongly related to age. The FI is associated with mortality and LTC admission at all ages. This effect was a spectrum of risk. The effect of functional domains was seen at all ages, while the effect of medical conditions on these outcomes declined with advancing age. Psychosocial domains were less strongly correlated with these outcomes. Conclusions The FI is associated with adverse outcomes, and should be considered in clinical and policy decisions.
Background Reported estimates of frailty prevalence vary considerably. At least partially attributable to differences in the conceptualization of frailty used, a better understanding of the interre-lationships among frailty domains could clarify contributors to the noted heterogeneity. Methods A global frailty index (FI) created from baseline data on 30,097 Canadian Longitudinal Study on Aging comprehensive cohort participants was used to define physical, psychological, cognitive, and social domain-specific FIs. These were divided into quintiles with the highest 20% (Q5) representing the frailest participants. Logistic regression was used to estimate the associations between age group and biological sex with domain-specific FIs in unadjusted and adjusted (income, smoking status, nutritional risk, physical activity, social participation, interaction between sex and age group) models. The association between Q5 membership among the frailty domains was estimated using polychoric correlation coefficients. Results The prevalence of physical and cognitive frailty increased with age, but psychological frailty decreased, especially in males. Social frailty showed gradual increases with age in females that were only evident in the oldest age group (75–85) among men. The age-groups*sex interaction p value was p<.001 for social. Polychoric correlations were highest between the psychological/physical and psychological/social domains, and decreased with increasing age for all combinations. Conclusion We found that domain-specific frailty prevalences differed by age group and sex with low associations among frailty domains, particularly at older ages. Understanding the evolution of these findings could be instrumental in developing tailored interventions to prevent frailty or modify its trajectory.
Background:COVID-19 exposed long-standing systemic challenges experienced by congregate settings and created a crisis for long-term care homes (LTCHs) and retirement homes (RHs). This study explored the pandemic-related challenges LTCHs and RHs faced and the strategies they used to mitigate them. Method:Ninety-one key informant interviews were held with LTCH and RH leadership across 47 homes (33 LTCHs, 14 RHs) in Ontario, Canada from February 2021 to July 2022. Data were analyzed following the framework method. Results:Findings confirmed evidence of three main challenges. First, leaders were challenged to implement infection prevention and control (IPAC) protocols and measures. Second, leaders required supports to facilitate COVID-19 vaccine access and to promote vaccine acceptance. Finally, LTCH/RH staff experienced well-being and mental health challenges in the face of COVID-19 pressures. Despite widespread attention and efforts to support these congregate settings, challenges persisted over one year into the pandemic. Conclusions:Our findings reveal a plethora of strategies implemented by homes, with ranging reports of perceived success.
Background Canada is a bilingual country; however, outside of Quebec, healthcare services are predominantly offered in English. With the increasing older adult population and stretched healthcare resources, Francophone older adults may face significant challenges in accessing care due to their linguistic minority status. This study explores the experiences of caregivers of Francophone older adults in the Greater Toronto Area (GTA). Methods Using a convenience sampling strategy, caregivers of patients who had undergone geriatric assessment at the Centre Francophone du Grand Toronto (CFGT) were recruited. Participants underwent 45-minute, semi-structured interviews and completed demographic questionnaires. Three independent reviewers conducted qualitative content analysis of the interview transcripts, using the socioecological model of health and NVivo12. Results Nine participants were primarily female (n=5), with age ranges of 40–49 (n=2), 50–59 (n=3), and 60+ (n=4). They originated from North America (n=5), Africa (n=3), and the Middle East (n=1); about half preferred English over French. Thematic analysis identified three key themes: 1) Barriers Accessing Health Care in the French Language; 2) The Need for Interpreter Support; 3) Importance of Comprehensive Francophone Community Services. Conclusions Despite the presence of organizations (e.g., CFGT), this study reveals a significant gap in French-language services for older adults in the GTA, leading to increased challenges for their caregivers. Due to linguistic barriers, caregivers must act as interpreters to mitigate the risks associated with miscommunication and potentially worse health outcomes. Addressing these issues requires increasing bilingual healthcare providers, enhancing funding for Francophone community services, and improving support systems (e.g., interpreters).
Background:Falls in older adults are a worldwide health issue, and lead to high morbidity, mortality, and health-care costs. Paramedics play a unique and important role in post-fall management. The objectives of this study were to measure the frequency with which paramedics made referrals to fall-prevention programs, understand the factors influencing these decisions, and compare outcomes between those who received a referral with those who did not. Methods:This mixed-methods study evaluated a paramedic fall-referral program in Nova Scotia for older adults with non-transport dispositions after a 911 response. Patient demographics and outcomes were analyzd using a matched cohort approach, while paramedic beliefs regarding the program were explored using The Theory of Planned Behavior. Results:From 2014 to 2019, a total of 289 referrals were made, and a matched cohort analysis (1:2) found no significant difference in the mean number of fall-related 911 calls in the following 12 months between those who were referred (m=0.31, SD=0.94) and those who were not (m=0.30, SD=1.28). Paramedics acknowledged the importance of fall prevention, but felt a lack of education, loop closure-feedback to the referring paramedic, and patient reluctance to consider the program, were all significant barriers to referral. Discussion:This study assessed Nova Scotia's paramedic fall-prevention referral program, revealing low referral frequency despite high numbers of fall-related 911 calls, and no significant reduction in relapse 911 calls. Barriers to referral included patient reluctance, poor systematization, and lack of education and feedback. Conclusion:The study highlights opportunities for improving referral systems, as paramedics play a bigger role in the prevention of age-related health issues such as falls.
Frailty is a state of vulnerability to stressors which has long been a focus of Geriatric Medicine, and is gaining acceptance in other fields. The notion of frailty considers individuals, but many similarities exist between individuals and health care systems (HCS). We have drawn parallels between frail individuals and frail health care systems. We have adapted a commonly used measure of frailty-the "Frailty Phenotype", to measure HCS which are vulnerable to acute and chronic stresses. Finally, we note the "double jeopardy" of frail older adults within frail HCS. Ensuring that HCS remain robust and unlikely to fail should be a priority for health-care policy makers.
Background Our study strived to 1) describe the characteristics of older adults incurring delayed discharge days in Alberta from Apr 01, 2019 to March 31, 2022; 2) examine the prevalence and length of delayed discharge days during the COVID-19 pandemic. Method We conducted a cross-sectional descriptive study using provincial health administrative data. We included adults ≥65 discharged from hospital from Apr 01, 2019–Mar 31, 2022 in Alberta and whose hospital stay included at least one delayed discharge day. The demographic characteristics of participants were reported in proportions or mean/median. Study period was divided into pandemic waves (pre-pandemic: Apr 1, 2019-Jan 31, 2020; Wave 1: Feb 1, 2020-Aug 31, 2020; Wave 2: Sept 1, 2020-Feb 14, 2021; Wave 3 and beyond: Feb 15, 2021-Mar 31, 2022). Prevalence of delayed discharge in each wave and their median length of stay (IQR) were reported. Results From Apr 01, 2019 to Mar 31, 2022, there were 367,912 hospitalizations among older adults living in Alberta. 3.73% (n=13,717) contained at least one delayed discharge day. The percentage of delayed discharge prior to COVID-19 and during each wave stayed consistent. Wave 3 had the shortest median length of stay (29, IQR 15-51). Wave 2 (45.2%) and Wave 3 (45.3%) had higher proportion of patients requiring maximal assistance on the Activities of Daily Living (ADLs). From pre-COVID to Wave 3, there were increases in the proportions of patients discharged to long term care (36.4% in pre-COVID to 40.8% by Wave 3). Conclusions Frequency of delayed discharge hospitalizations was consistent across the pandemic waves. Wave 3 had shorter length of delayed discharge hospitalization. The proportion of patients who were discharged to LTC increased over the course of the pandemic.
Background:Prolonged cycle times for new geriatric medicine assessments at the Centre for Healthy Aging have reduced the capacity to see patients. Using a time series design, the aim of the project was to decrease the average cycle time for new patients during one geriatrician's clinic from 114 to 90 minutes by May 1, 2024. Methods:Lean methodology was used for diagnostics by creating a value stream map of the workflow. This informed change ideas to improve efficiency by implementing a shared note within the electronic health record for information sharing and an assessment guide for targeted cognitive testing. The primary outcome measure was total cycle time. Balancing measures were patient clinic experience scores and counseling time. Process measures included caregiver interview time, pre-clinic intake completion rate, assessment guide use rate, and nursing assessment time. Results:Total cycle time decreased 19% from 114 minutes (19 patients) to 93 minutes (33 patients). Pre-clinic intake assessment completion rate increased from 60 to 80% and caregiver interview time decreased from 45 to 33 minutes. There was 100% uptake of the assessment guide, and nursing assessment time decreased from 43 to 31 minutes. Counseling time remained stable, and the average clinic experience scores did not decline from the baseline. Conclusions:This is the first study examining potential methods to improve efficiency of the comprehensive geriatric assessment by using value stream mapping. Spread of change ideas across the centre will be examined next with the goal of increasing capacity using available resources.
Background Competency-based medical education (CBME) aims to enhance the quality of medical training by providing timely, actionable feedback through entrustable professional activities (EPAs). However, variability in feedback quality remains a concern across residency programs. Methods We conducted a retrospective analysis of EPA feedback forms from a geriatric medicine program, comparing two distinct time periods: 2019–2020 and 2021–2022. This program averages eight residents per year with 30 full-time faculty members. The quality of feedback was assessed based on timeliness, task orientation, actionability, and polarity. Results 404 EPAs were initiated and completed in 2019–2020, with 69% (n=278) being timely, 89% (n=360) task oriented, 50% (n=203) very actionable, and 62% (n=250) corrective in polarity. 851 EPAs were initiated in 2021–2022 and 76% (n=645) were completed, with 64% (n=410) being timely, 78% (n=501) task oriented, 40% (n=259) very actionable, and 47% (n=305) corrective in polarity. Timely feedback was more likely to be task-oriented (χ2(1)=11.87, p<.001), actionable (χ2(2)=24.40, p<.001), and corrective (χ2(3)=22.80, p<.001) in the second timeframe. Compared to the second timeframe, EPAs completed in the first timeframe were more likely to be task oriented (χ2(1)=22.08, p<.001), actionable (χ2(2)=25.54, p<.001), and corrective in polarity (χ2(3)=25.89, p<.001). Conclusions Our study revealed lower quality feedback over time since implementing CBME at a geriatric medicine subspecialty training program. The root causes of the reduction in quality were not explored but are theorized to be multifactorial. Further investigation into the reasons for the reduction in feedback quality will help direct interventions to better sustain the quality of CBME implementation.
Background:Fluoroquinolone (FQ) antibiotics are associated with QT-interval prolongation and Torsades de Pointes (TdP). Female sex, older age, and other QT-interval prolonging medications further increase risk for TdP. Our aim was to describe QT-interval prolonging drug interactions when FQs were dispensed to women who resided in long-term care (LTC) for uncomplicated urinary tract infections (UTIs). Methods:This retrospective cohort study used administrative health data from the Nova Scotia Seniors' Pharmacare program from January 2005 through March 2020. The cohort included women residing in LTC dispensed a FQ antibiotic within five days of a diagnostic code for an uncomplicated UTI in physician billing data. Additional drug dispensations were collected 30 and 90 days after the FQ to identify drug interactions that resulted in potentially increased QT-interval prolongation risk. Drug interactions were described. A Mann-Kendall trend test assessed the change in the frequency of FQ-drug interactions over the study period. Results:Annual dispensation of FQs ranged from 12-28% of antibiotic dispensations for presumed uncomplicated UTI. The proportion of FQ dispensations associated with a QT-interval prolonging drug interaction increased over time (p=.00007). Within 30 days of the FQ dispensation, the most common drug interactions identified were: furosemide (n=702, 20.3% of FQ-drug interactions), citalopram (n=566, 16.4% of FQ-drug interactions), and trazodone (n=461, 13.3% of FQ-drug interactions). Conclusions:An increasing proportion of women dispensed a FQ for uncomplicated UTI experienced a potential QT-interval prolonging drug interaction over the study period. When prescribing FQs to older women, addressing potentially modifiable risk factors for TdP, and monitoring closely, is warranted.
Background Ultrasonography can be used to evaluate the echo intensity (EI) and strain ratio (SR) to identify muscle quality and stiff-ness, respectively. EI and SR are affected by aging, frailty, and joint angle positions. We investigated the effects of aging and frailty on muscle EI and SR at different joint angle positions, and identified a useful measurement method to reflect muscle changes related to contractures in frail older adults. Methods This study had a cross-sectional design. Twenty-two healthy young adults (young group), 22 non-frail older adults (non-frail group), and 22 frail older adults (frail group) participated in this study. The range of motion (ROM) of hip abduction, EI, and SR of the adductor longus in the zero- and full-abduction positions were measured. To investigate the effects of aging and frailty, the Kruskal–Wallis test, followed by the post-hoc Steel–Dwass test, was used. In addition, to confirm whether EI and SR in each position were useful for assessing contracture, Spearman’s correlation test was used. Results ROM and SR in full-abduction were significantly lower in the frail group than in the other groups and lower in the non-frail group than in the young group. The SR in full- abduction (ρ = 0.73, p < .001) and in zero-abduction (ρ = 0.41, p < .001) showed strong and moderate correlation with the ROM, respectively. Conclusions SR in full-abduction is affected by both frailty and aging and is useful for evaluating muscle stiffness related to contracture in frail older adults.
Background:Goals of Care Designations are important medical orders that are used to determine the appropriate level of medical intervention for individuals in the event of life limiting illness. Canada has an aging population and individuals are living with higher levels of chronic illness and comorbidity. As patient autonomy increases, it has become increasingly important to have accurate and up-to-date documentation of a patient's medical wishes for life sustaining care. Methods:This was a retrospective chart review of 400 randomly selected patients 65 years of age and over, seen at the University of Alberta Hospital outpatient clinic for Comprehensive Geriatric Assessment from July 1, 2022 to June 30, 2023. We extracted the frequency of Goals of Care Designation (GCD) documentation determined by historical data available within selected patient charts, the setting of each discussion, and the specialty of each provider completing Goals of Care documentation. Results:Only 49.3% (197/400) of patients had any documented GCD entered on their electronic medical record (EMR). Of the 356 completed GCD forms, 267 (75%) were completed in an inpatient setting; the majority of GCD forms were completed by a specialist in Internal Medicine (39.89%, n=142) or Family Medicine (37.64%, n=134). Conclusions:Our study revealed that less than half of patients had any GCD documentation in the provincial EMR. As accurate Goals of Care documentation is vital to patient care and autonomy, every opportunity should be taken by health-care professionals to complete this essential documentation.
Driving cessation is an expected eventuality in dementia care that has significant consequences for people with dementia (PWD) and care partners (CPs) alike. In collaboration with the Alzheimer Society of Saskatchewan, we explored CPs' experiences of the driving cessation process. Using an online survey including closed- and open-ended questions, we collected data from 44 CPs of current drivers and from 207 CPs of former drivers. Our quantitative and qualitative analyses identified three key findings. First, although CPs want and expect regulatory bodies and medical practitioners to be involved in the driving cessation process, their involvement is often less than anticipated. Second, driving cessation poses unique challenges to CPs in rural areas given the centrality of driving in smaller communities and limited transportation options to access services. Finally, CPs of former drivers found several positive benefits from the driving cessation process that were unanticipated. In conclusion, these three areas represent opportunities for education, support, and resources for PWD, CPs, and professionals through the driving cessation process.
Background:A novel Patient Navigator Program (PNP) was introduced at a Canadian hospital's Reactivation Care Centre (RCC) to support transitions by helping older adults navigate the complexities of delayed discharge stays by improving their transition from hospital to home. The PNP was comprised of a community agency patient navigator who was embedded into the RCC setting to support transitions in care, and who followed patients up to 90 days post-hospital discharge. The purpose of this study was to describe the PNP, which included detailing the needs of patients (i.e., socio-demographics, case-mix, delayed discharge), the scope of service provision (i.e., referral process, follow-up duration), and patient outcomes (i.e., post-discharge location). Methods:A cohort observational design was used to collect data on the PNP mainly via the patient navigator's clinical tracking sheet, and secondly via the hospital's administrative system. Data analysis included the use of frequencies and descriptive statistics. Results:Between November 2021 and October 2022, 100 patients were referred to the PNP, with 70 patients (39% male; 61% female; median age of 81 years) being admitted to the patient navigator's caseload. The patient navigator provided follow-up care for a median of 58 days, and supported 76% of the patients (n=53) to return to their next point of care (e.g., homes or to a supportive housing setting). Conclusion:The PNP led to a high proportion of patients being discharged back to the community. This study provides insights to providers and decision-makers interested in implementing PNP care models in a hospital in partnership with a community agency.
Background:Geriatricians' work provides holistic recommendations to improve the health of older adults, considering medical, social, psychological, and functional domains. Their implementation most often relies on primary care physicians. Extant evidence suggests benefit from systematized information transfer between hospital-based specialists and primary care physicians. Yet, direct communication between hospitals and primary care physicians is rare. We aimed to describe the information transfer practice of hospital-based geriatricians in Quebec, Canada. Methods:We sent a survey to all (146) geriatricians and Geriatric Medicine residents of Quebec on their current practice and opinions on information transfer and obtained 64 responses. We then performed 20-minute semi-structured interviews with 13 participants to further explore knowledge on information transfer, barriers and facilitators, risks and benefits, and recommendations to improve transmission. Results:While geriatricians believe that their recommendations should be transmitted to primary care physicians and that the absence of a systematic information transfer procedure has a negative impact on quality of care, only 1.6% report having such a procedure in place in their practice. They think that the absence of information transfer procedures disrupts the communications of key diagnoses and medication changes, and leads to duplicated interventions. Harnessing technology to facilitate information transfer is viewed as a solution. Conclusion:Information transfer between hospital-based geriatricians and primary care physicians in Quebec is rare. The absence of a systematic information transfer procedure is seen by geriatricians as a hindrance to the provision of safe, high-quality care to older adults.
