BACKGROUND:Long-term care (LTC) residents are frequently transferred to emergency departments (ED), which may increase the risk of impairment. OBJECTIVE:To examine associations between all-cause ED transfers and development of new permanent severe physical and cognitive impairments, and death. SETTING AND PARTICIPANT:Adults ≥65 with incident admission to LTC homes in Ontario, Canada between 2013 and 2018. METHODS:We conducted a retrospective cohort study. We examined rates of (i) severe physical impairment, (ii) severe cognitive impairment and (iii) all-cause mortality after transfer to ED. We used marginal structural models to estimate the combined effect of acute illness and ED transfer. We used an instrumental variable (IV) analysis to isolate the effect of transfer, adjusting for acute illness. RESULTS:Of 120,238 residents, 78,546 (65.3%) residents had at least one transfer to the hospital. The mean (SD) age was 84.6 (7.9) years, 67.2% were female. The incidence rate ratios were 3.0 (95% CI, 2.9-3.1) for new physical impairment, 2.2 (95% CI, 2.1-2.3) for cognitive impairment and 5.8 (95% CI, 5.7-5.9) for mortality, comparing transferred to never-transferred residents. In IV analysis, transfers were not associated with permanent physical or cognitive impairment (hazard ratio [HR] (95% CI) [HR1.20] (0.92-1.55); [HR0.86] (0.69-1.06), but were associated with decreased mortality [HR0.57] (CI 0.50-0.63). CONCLUSION:In unadjusted analyses, residents transferred to ED had a higher incidence of permanent physical impairment, cognitive impairment and mortality. After adjusting for acute illness, transfer decisions were not associated with changes in the risk of severe impairment and were associated with reduced mortality.

Introduction Long-term care (LTC) residents require extensive assistance with daily activities due to physical and cognitive impairments. Medical treatment for LTC residents, when not aligned with residents’ wishes, can cause discomfort without providing substantial benefits. Predictive models can equip providers with tools to guide treatment recommendations that support person-centred medical decision-making. This study protocol describes the derivation and validation of time-to-event predictive models for (1) permanent loss of independence in physical function, (2) permanent severe cognitive impairment and (3) time alive with complete dependence for those with disability starting from the date of onset.Methods and analysis We will use population-based administrative health data from the Institute for Clinical Evaluative Sciences of all LTC residents in Ontario, Canada, to construct the derivation and internal validation cohorts. The external validation cohort will use data from LTC residents in Alberta, Canada. Predictors were identified based on existing literature, patient advisors and expert opinions (clinical and analytical). We identified 50 variables to predict the loss of independence in physical function, 58 variables to predict the loss of independence in cognitive function and 36 variables to predict the time spent in a state of dependence. We will use time-to-event models to predict the time to loss of independence and time spent in the state of disability. Full and reduced models (using a step-down procedure) will be developed for each outcome. Predictive performance will be assessed in both derivation and validation cohorts using overall measures of predictive accuracy, discrimination and calibration. We will create risk groups to present model risk estimates to users as median time-to-event. Risk groups will be externally validated within the Alberta LTC cohort.Ethics and dissemination Ethics approval was obtained through the Bruyère Research Institute Ethics Committee. Study findings will be submitted for publication and disseminated at conferences. The predictive algorithm will be available to the general public.

Importance:Care decisions for long-term care (LTC) residents should be frailty-informed to maximize well-being and avoid burdensome treatments that do not align with patient wishes. Objective:To investigate the incidence and time spent living with severe impairment among LTC residents to help inform person-centered decision-making. Design, Setting, and Participants:This retrospective cohort study was conducted among a population-based cohort of incident admissions to LTC facilities between April 1, 2013, and March 31, 2018, determined using administrative health data in Ontario, Canada. Ontario residents aged 65 years or older who were admitted to LTC were included. Participants were followed up until death, discharge, or April 1, 2023. Data analysis was completed from October 17, 2023, to March 31, 2024. Main Outcomes and Measures:Outcomes were states of impairment that care partners identified as meaningful and some considered worse than death. The incidence of total care dependence, inability to make any decisions, inability to communicate, and incontinence of stool or urine was described. Survival after becoming impaired, characteristics of residents when they became impaired, and characteristics of those who survived for more than 1 year with each impairment were described. Residents at risk of a specific impairment (at-risk residents) were those who did not already have the impairment at admission. Results:A total of 120 238 residents admitted to LTC (mean [SD] age, 84.3 [7.7] years; 77 868 female [64.8%]) were included. By the end of follow-up, 22 018 of 109 830 at-risk residents (20.0%) had become permanently unable to make decisions, 9138 of 118 132 at-risk residents (7.7%) had become permanently unable to communicate, 15 711 of 116 848 at-risk residents (13.4%) had developed total care dependence, and 30 449 of 92 974 at-risk residents (32.8%) had developed incontinence of stool or urine. Median (IQR) survival time was shortest for residents who entered a state of total care dependence (45 [5-310] days) and longest for those with newly developed incontinence of stool or urine (356 [79-1031] days). Younger residents (eg, median [IQR] survival after developing total care dependence, 133 (17-735) days for ages <80 years vs 30 (4-217) days for ages ≥80 years) and those with dementia at admission (eg, median [IQR] survival after developing the inability to make decisions, 318 [40-1020] days with dementia vs 74 [4-474] days without dementia) had longer median survival after entering a state of severe impairment. Conclusions and Relevance:In this study, severe permanent impairment in function and cognition were common and often present near the end of life for LTC residents, but a minority of residents lived in these states for years. These results suggest that building shared understanding and open communication about the natural course of frailty trajectories for LTC residents may support resident-centered medical decision-making.

BACKGROUND:The trajectory of Mild Cognitive Impairment (MCI) to dementia within primary care is not well understood. OBJECTIVE:We investigated the 5-year trajectory of patients initially diagnosed with MCI, evaluated their risk of developing dementia considering age, sex, and Montreal Cognitive Assessment (MoCA) test scores and determined the annual conversion rate from MCI to dementia for patients assessed in a MINT (Multispecialty Interprofessional Team) memory clinic. METHODS:We conducted a longitudinal cohort study using a retrospective chart review of 751 patients assessed within a MINT memory clinic in Ontario, Canada. The conversion rate from MCI to dementia was estimated with the Kaplan-Meier method. Cox regression examined time to dementia diagnosis and the association between baseline MoCA scores and dementia risk. FINDINGS:The observed 5-year conversion rate from MCI to dementia was 28.0%, though with limited follow-up data. Accounting for missing data, the estimated 5-year conversion rate was 48.8% (39.5%, 59.2%) with an average annual rate of 9.8%. Each one-point increase in MoCA score at initial visit was associated with a 10% lower rate of conversion to dementia (aHR: 0.90, 95%CI: 0.85-0.96). DISCUSSION:Findings highlight the profile of patients assessed in MINT clinics, cognitive trajectory of those diagnosed with MCI, and the importance of primary care-based memory clinics in early detection and intervention.

Introduction Long-term care (LTC) residents are frequently transferred to acute care hospitals. Transfer decisions should align with residents’ wishes and goals. Decision to transfer to hospital, when not aligned with the resident’s wishes, can result in transfers that are harmful to residents, leaving residents in a state of disability that could be considered worse than death. We aim to examine whether transfer to an acute care hospital is associated with subsequent new onset of severe permanent physical and cognitive disability in LTC residents.Method and analysis We will conduct a retrospective cohort study of all LTC residents ≥65 admitted to LTC homes between 1 April 2013 and 31 March 2018 in Ontario, Canada. We will use health administrative data from the Continuing Care Reporting System (CCRS), National Ambulatory Care Reporting System (NACRS) and Registered Persons Databases (RPDB), which include data on emergency department visits, hospitalisations, demographic information and mortality. All participants will be followed until 31 March 2023. The exposure is any transfer from LTC to an emergency department or acute care hospital. The outcomes are (1) subsequent new permanent physical disability, (2) subsequent new permanent cognitive disability and (3) all-cause mortality. Due to the time-varying nature of the exposure and confounders, we will use an extended cause-specific Cox regression model to explore this relationship. We will fit marginal structural models (MSMs) to account for the known shortcomings of traditional regression modelling, such as collider bias. Lastly, we will use a preference-based instrumental variable approach to address unmeasured confounders.Ethics and dissemination Ethics approval was obtained through Bruyère Research Institute Ethics Committee (REB#M16-23-030). Study findings will be submitted for publication in a peer-reviewed journal. Findings will be disseminated in conferences and seminars.Trial registration Open Science Framework (https://doi.org/10.17605/OSF.IO/JCDEY).