Jennifer E. Peterson, MSc, BEd1, Samantha A. Fowler, MA1,2, Karla J. Faig, PT, MAHSR1, Linda M. Yetman, RN, PhD1, Patrick J. G. Feltmate, MD, FRCPC3,4
1Research Services, Horizon Health Network, Saint John, NB
2Maritime SPOR SUPPORT Unit, Halifax, NS
3Faculty of Medicine, Dalhousie University, Halifax, NS
4Department of Geriatric Medicine, Horizon Health Network, Fredericton, NBDOI: https://doi.org/10.5770/cgj.28.823
ABSTRACT
Background
Acute care hospital stays often lead to increased frailty and functional decline in older adults. Interventions such as specialized education for nurses can improve health outcomes and decrease lengths of stay for these patients. This study aimed to identify the facilitators and barriers to providing care to older adults in acute care, and the efficacy of specialized education for front-line staff.
Methods
A specialized education program for front-line staff, Frailty Focused Enhancements to Seniors’ Hospital Care (FrESH), was developed and delivered across five family medicine units in New Brunswick (NB). A mixed methods approach was used to assess the knowledge, attitudes, and experiences of staff caring for hospitalized older adults, and evaluate the impact of providing specialized education. Patient-level data on delirium, mobility, and medications pre- and post-specialized education intervention were collected and analyzed.
Results
Sixty-three front-line staff participated. Analysis of questionnaires demonstrated that staff had positive attitudes and beliefs about caring for older adults; however, knowledge of geriatric care principles was limited and remained unchanged. There was no significant change in patient-level measures post-intervention. Environmental constraints hindered staff from implementing best practices, leading to practical challenges to care delivery. While respondents expressed satisfaction with the education, their capacity to deliver the type of care presented in the education sessions was not achievable.
Conclusion
Staff identified the need for specialized education; however, there was no impact on care after participation. Results will inform changes to the specialized education programs targeting care for hospitalized older adults in acute care.
Key words: specialized education, front-line staff education, frailty, Geriatric 5Ms, older adults, acute care, mixed methods
Frailty is a state of health in which a person’s overall well-being and ability to function independently are reduced, and vulnerability to deterioration is increased.(1) Some people become frail as they age; however, frailty is not normal. Frailty affects one’s ability to function in daily life and places individuals at higher rates of adverse health outcomes.(2) Being in the hospital can increase frailty, causing further deterioration.(3,4) Those who are already frail are at greater risk of requiring an extended hospital stay.(5,6)
Research suggests that targeted interventions may improve older adults’ health outcomes and quality of life. Promising interventions include mobilization and deprescribing non-therapeutic medications.(7,8) Research exploring interventions targeting frailty, including adoption of frailty assessment tools, completion of comprehensive geriatric assessments, and walking or other exercise programs for hospitalized older adults, holds potential benefits.(2,6,9,10) Applying the Geriatric 5Ms Framework(11) (Mind, Mobility, Medications, Multi-complexity, and Matters Most; see Figure 1) to examine the impact of best evidence on older adults’ health outcomes and frailty prevention offers a unique research approach.
|
| ||
|
FIGURE 1 5Ms of geriatric care (adapted from Molnar and Frank(11)) | ||
This mixed-methods study delivered a specialized education program, Frailty Focused Enhancements to Seniors’ Hospital Care (FrESH), for front-line staff, and evaluated the impact on staff knowledge of frailty prevention, the Geriatric 5Ms, and patient outcomes.
A mixed-method quasi-experimental design was used. The project occurred at five Horizon Health Network (Horizon) acute-care family medicine units in different cities/towns in New Brunswick, Canada. Patient participants underwent chart reviews and observational audits for mobility. Shift handover audits and questionnaires were used to gather data from front-line staff. Data collection was divided into three six-week phases: pre-education, education, and post-education.
In-patient participants were identified by clinical staff and consented by a research team member. To fulfill inclusion criteria, participants needed to be 60 years of age and older, capable of providing informed consent, able to read and understand English or French and medically stable. Proxy consents were not possible due COVID-19 visitor restrictions. Once enrolled, data were collected through chart review. Information collected included age, biological sex, pre-existing chronic conditions, number and type of prescribed medications, mobility status, and any documented episodes of delirium. Focus notes were examined for any nursing interventions completed when a patient had delirium.
Observational audits of patients’ mobilization were conducted three times per day, two days per week, and were rated by the Independent Mobility Validation Examination (I-MOVE) scale.(12,13)
Shift handovers were observed three times per week to determine whether patients’ mobility was reported.
Frailty was assessed using the Clinical Frailty Scale(14) completed at enrollment, by the Research Assistant (RA) in collaboration with the patients’ care team.
It was not possible to determine whether enrolled patients received care from staff participants enrolled in FrESH.
Staff participants included regular and casual staff working on participating study units. Front-line staff, consisting of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Personal Care Attendants (PCAs), were recruited to participate through emails and posted flyers. Participants provided informed consent and completed pre-implementation questionnaires (demographics, GerINCQ, and knowledge assessment). During the education phase, participants attended a four-hour specialized education session on the Geriatric 5Ms, frailty identification, risk factors and prevention, and the needs of hospitalized older adults. Materials focused on: the differentiation between dementia, depression, and delirium; the assessment and management of delirium; and the importance of mobility and implications of polypharmacy. A post-implementation knowledge assessment was completed.
The Clinical Frailty Scale(14) was administered by the RA in consultation with a member of the patients’ care team (charge nurse, physiotherapist) on enrollment. This is a 9-point scale ranging from 1 (very fit) to 9 (terminally ill).
Observational audits of patient mobility were conducted using the I-MOVE scale.(12,13) This 12-point scale ranges from 1 (patient needs assistance to turn in bed) to 12 (patient walks independently in hallway). Patients’ mobility status was summarized as to how they mobilized (I-MOVE > 5) during their first and last week hospitalized.
Chart reviews were conducted to monitor for newly prescribed medications. Of interest were potentially inappropriate medications (PIMs) for which the risk may outweigh the potential benefit for older adults. These medications included: anticholinergics (e.g., Dimenhydrinate, Diphenhydramine), sedatives (e.g., Benzodiazepines, “Z-drugs” e.g., Zopiclone) and antipsychotics (e.g., Haloperidol, Risperidone).
A demographics questionnaire was developed with seven questions: age, gender, hospital, department, role, and years of experience.
The Geriatric In-Hospital Nursing Questionnaire (GerINCQ)(15) was administered pre-intervention to measure the care older adults receive in hospitals, and nurses’ attitudes and perceptions about caring for older adults. The scale consists of five subscales: interventions performed, aging-sensitive care delivery, professional responsibility, attitudes towards caring for older adults, and perceptions about caring for older adults, measured with 67 items on a 5-point scale. Two open-ended questions were added to gather participants’ perspectives on caring for older adults in acute-care settings, and to ask what would help provide quality care to these patients.
A study-specific questionnaire was created concurrently with the content of the educational sessions. Administered pre- and post-intervention, these questions evaluated participants’ knowledge about the principles of geriatric care, including the Geriatric 5Ms.
Descriptive statistics were used to summarize demographic characteristics and survey responses, and chi-square tests of independence were used to compare patient outcome measures across phases. Open-ended survey questions were analyzed for themes related to participants’ experience providing care and what would help provide quality care. Five research team members conducted an iterative-inductive thematic analysis,(16) and themes were generated through consensus.
Sixty-three acute care staff provided informed consent to participate in the study (Table 1). The mean age was 36.9 years (SD = 10.8), and the majority were female (86.8%). Participants had an average of almost ten years of nursing experience, including nearly five in their respective units. The sample included RNs, LPNs and PCAs with most being employed full-time.
TABLE 1 Front-line staff demographic characteristics
Ninety-nine acute care in-patients consented to participate in the study (Table 2). The mean age was 76.2 (SD=9.0), and there were slightly more females (54.5%) than males. The most reported chronic conditions were high blood pressure (49.5%), heart disease (39.4%), chronic lung disease (35.4%), and diabetes (33.3%). Most participants (41.1%) were Fit to Mildly Frail (CFS 1–5), with 25.3% having a CFS score of 6 indicative of Moderate Frailty and 8.4% were Severely Frail (CFS 7–9).
TABLE 2 Patient participant data
Horizon Health Network’s Research Ethics Board reviewed and approved the research with approval number 2021–3042.
The GER-INCQ was administered at baseline; the sub-scale reliability coefficients were low (α < 0.60). Therefore, reporting sub-scale scores is not appropriate; only individual items are reported. Only noteworthy findings are reported here relating to three of the Geriatric 5M topics: Mind, Mobility and Medications.
Under the topic of Mind, participants reported that nursing interventions for delirium were performed an adequate amount (31.2%) or less frequently (53.1%). Responses related to their level of perceived responsibility for behavioural problems among people with dementia, feelings of anxiety or dejection, and the development of delirium were highly variable among the staff. Most staff reported that they often (37.5%) or always (51.6%) keep a close eye on confused older adults.
For Mobility, most participants (53.1%) indicated that interventions to prevent falls were offered an adequate amount. However, only about a third (35.9%) felt active mobilization policies were used adequately, with many staff indicating these interventions were used less frequently than required (46.9%). When asked whether they felt responsible for fall incidents, the most common response was neutral (42.2%), but many participants (45.3%) also reported a greater amount of perceived responsibility. Regarding their responsibility for mobility retention, most staff reported a neutral (25.0%) amount of responsibility or more (50.0%).
For Medications, participants mainly indicated that medicinal interventions, including pain medication (57.8%), sleep medication (48.4%), and medicinal restrictive measures (45.3%), were used adequately.
Participants completed the study-specific geriatric knowledge questionnaire pre- and post-education (Table 3). Before the training, most participants answered six items correctly (≥ 60%). Seven items posed challenges for the staff, including questions about each of the 5Ms. Following the training, six of these questions were still answered largely incorrectly, although three improved somewhat. Questions that were answered correctly pre-training displayed little change post-training.
TABLE 3 Front-line staff pre- and post-intervention knowledge assessment
A series of chi-square tests of independence were used to examine differences in Mind (incidents of delirium), Mobility (mobilization and reports at shift handover), and Medications (PIM prescriptions) across the three study phases. Given the number of comparisons, a stringent alpha (p > .01) was used to evaluate the significance of the results and protect against type I error.
With outcomes related to the Mind, chart abstraction revealed that only five participants had noted instances of delirium while in hospital, precluding further comparisons due to the small sample size. No nursing interventions pertaining to reported delirium were documented.
For Mobility across the three study phases, patient mobilization ranged from 46.2–71.4% during their first week hospitalized, and 61.9–72.7% during their last week in hospital. The proportion of patients mobilized during their first week (χ2 (2, N = 99) = 4.34, p = .114) and last week (χ2 (2, N = 86) = 0.76, p = .684) hospitalized did not differ significantly across the three phases.
Reports of patient mobility during shift handover were also examined. Mobility was discussed consistently during patients’ first (78.1–96.9%) and last week (81.2–88.5%) hospitalized throughout the duration of the study. The proportion of patients whose mobility was mentioned during their first (χ2 (2, N = 90) = 5.26, p = .072) and last week (χ2 (2, N = 95) = 0.577, p = .749) in the hospital did not vary across the study phases.
With Medication reviews, the rate of new PIM prescriptions across the study phases ranged from 5.9–34.6% during the first week of hospitalization and 6.1–20.0% during the last week of hospitalization. Further analyses revealed there were no statistically significant differences among the phases during either first week hospitalized (χ2 (2, N = 97) = 8.49, p = .014) or last week hospitalized (χ2 (2, N = 95) = 3.31, p = .191).
Thirty-nine participants responded to the open-ended questions. Four themes (Figure 2) derived from the survey questions are outlined below: too many patients—not enough time, more training needed, activities, and mobility and exercise. Exemplar quotations are included in Table 4.
|
| ||
|
FIGURE 2 Qualitative themes derived from front-line staff open-ended questions | ||
TABLE 4 Qualitative themes derived from front-line staff open-ended questions
In questions related to their perception of care for older adults, most participants expressed the care required for these patients as “demanding”, primarily because “… not enough time to care for them [patients] as we should”. This lack of time was attributed to staffing shortages. They noted that patients were dependent for mobilization and most activities of daily living (ADLs). Additionally, they found the care delivery physically and emotionally draining because of the challenges in managing patient behaviours such as “confusion, aggression, and paranoia”.
Challenges with monitoring wandering patients were expressed. Comments about witnessing the loneliness in patients who rang the bell for company evidenced the emotional drain on participants.
In response to the question related to what would help provide quality care, most participants requested training for the care of persons with dementia and how to cope with patient behaviours.
Some participants stated that, as their unit is not a geriatric unit, more training was needed in the general care of older adults. In contrast, several participants noted that more training was unnecessary, and that addressing staff shortages is required.
Respondents indicated that their patients lacked emotional and mental stimulation, with only some patients having visitors. The lack of recreational activities left a gap in mental stimulation and limited opportunities for patient interaction. Some participants stated that they did not have time to sit and have meaningful conversations with patients, which led to feelings of disconnection.
While respondents highlighted the importance of more mobility for their patients, their ability to implement this was not achieved primarily due to insufficient staff. Mobility was perceived as one of the “extra things”, rather than a standard of practice.
While caring for older adults in acute care requires a specific skill set and competencies, offering specialized education to front-line staff does not always improve patient outcomes. This study’s three central patient-focused areas were Mind, Mobility, and Medication from the Geriatric 5Ms model.
Delirium is a common and potentially serious condition in hospitalized older adults, which may lead to falls, extended hospitalizations, and functional decline. Data collection related to delirium was low, with only five documented instances among participants. Standardized assessment tools, such as the Confusion Assessment Method,(17) were available to staff. While quantitative data analysis suggests that participants perceived nursing interventions for delirium were performed at an adequate amount, no interventions were documented. Furthermore, the level of perceived responsibility for the development of delirium was highly variable, with staff reporting that they were mostly unaware of available delirium assessment tools and clinical order sets. Low reported numbers of delirium may also have been impacted by the recruitment process and the need for consent without proxy.
Literature suggests that nursing assessment is essential to detect delirium, but nurses often fail to do so.(18,19) Reasons for this have been linked to faulty clinical reasoning, including a lack of knowledge about cognitive disorders and assessment methods.(20,21) A study by El Hussein and Hirst(22) proposed that nurses do not have the flexibility to assess for delirium effectively due to a task-driven care delivery system and an overwhelming workload. Our study findings are congruent with this and other studies(23,24) that highlight how nursing staff constantly juggle and prioritize care between patients, which might impact their ability to detect delirium.
Quantitative results suggest that participants perceived nursing staff offered fall prevention interventions to an adequate extent, while many indicated that active mobilization interventions were used less frequently. Qualitative findings support these results, as staff indicated they understood the importance of encouraging patient mobilization; however, there was “…no time to mobilize”. Instead, the perspective was that patients deteriorated “…due to immobility”. In the qualitative findings, participants repeatedly reported that older adults were not getting the care they needed because of staff shortages.
Decreased mobility during hospitalization may result in a patient’s inability to reach pre-admission performance with ADLs. A study by O’Brien and colleagues(10) showed that older and frailer patients were generally less likely to recover to pre-admission ADL levels.
Quantitative results indicated that participants reported greater perceived responsibility for fall prevention and that keeping the patients in bed was a way to keep them safe. In the grounded theory of “Exerting Capacity”, Leger and Phillips(24) suggest that nurses strategically balance the demands of keeping their patients safe.
The negative effects of PIMs in older adults are well-cited in the literature.(25–30) In our study, quantitative results showed that the perceived use of medications for pain, sleep, and sedatives/antipsychotics was adequate. Only newly prescribed PIMs were included in the data collection and not which PIMs were administered.
The positive feedback on the education sessions and the expressed desire for training are also at odds with this study’s quantitative findings, as there was no change in patient-related outcomes. The quantitative data indicate that staff did not retain and apply the newly acquired knowledge. Qualitative findings suggest that staff are saturated with day-to-day changes to workload, competing priorities from organization initiatives, and mixed patient acuity. Education strategies to support professional development—including mentorship and coaching opportunities, case-based learning, and interdisciplinary team learning—may better facilitate the implementation of evidence-based practice education.(31)
An unanticipated result of the education intervention was that staff recognized that optimal care could not be provided, leaving them questioning the quality of care being offered.
High patient turnover and low staff participation in the educational intervention meant that patients were not necessarily cared for by staff who received the specialized education, thus obscuring potential effects on patient outcomes. A larger proportion of staff attending the sessions may have led to detectable impacts to patient level outcomes. Furthermore, low patient recruitment across phases prevented more nuanced inferential analysis of these effects, while low reliability of the GER-INCQ precluded sub-scale score computation and, as such, a high-level understanding of staff’s attitudes and perceptions. Data collection for PIMS occurred for those newly prescribed; collection related to administration may have provided better data of the usage of PIMs.
The data collection and education intervention for this research were conducted amidst the pandemic (2021–2022) when COVID-19 restrictions were in place. Research implementation was fraught with challenges, such as pausing data collection due to unit closures, or rescheduling education delivery due to staffing shortages.
This study aimed to examine the impact of offering specialized geriatric education to nursing staff who care for hospitalized older adults. While no significant findings were recorded pre- and post-implementation of education, there were several lessons learned.
Despite study implementation at the height of the pandemic, the research team was welcomed in the study units even through challenging conditions. Ongoing interest and curiosity by front-line staff was encouraging, and high levels of staff engagement may be seen as a facilitator which may be leveraged to support similar future research activities.
Staff desire to learn and do what is best for their patients, but system issues present barriers to application of new knowledge. Certain types of training/education may negatively impact front-line staff.
None to declare.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare we have none.
The authors gratefully acknowledge financial support from the Government of Canada through the Public Health Agency of Canada.
1. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med. 2011 Feb 1;27(1):17–26.
Crossref
2. Theou O, Squires E, Mallery K, Lee JS, Fay S, Goldstein J, et al. What do we know about frailty in the acute care setting? A scoping review. BMC Geriatr. 2018 Jun 11;18(1):139.
Crossref PubMed PMC
3. Liu B, Almaawiy U, Moore JE, Chan WH, Straus SE, MOVE ON Team. Evaluation of a multisite educational intervention to improve mobilization of older patients in hospital: protocol for mobilization of vulnerable elders in Ontario (MOVE ON). Implement Sci. 2013 Jul 3;8(1):76.
Crossref PubMed PMC
4. Liu B, Moore JE, Almaawiy U, Chan WH, Khan S, Ewusie J, et al. Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): a multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation. Age Ageing. 2018 Jan 1;47(1):112–19.
Crossref PMC
5. Hogan DB, Maxwell CJ, Afilalo J, Arora RC, Bagshaw SM, Basran J, et al. A scoping review of frailty and acute care in middle-aged and older individuals with recommendations for future research. Can Geriatr J. 2017 Mar 31;20(1):22–37.
Crossref PubMed PMC
6. Ley L, Khaw D, Duke M, Botti M. The dose of physical activity to minimise functional decline in older general medical patients receiving 24-hr acute care: a systematic scoping review. J Clin Nurs. 2019 Sep;28(17–18):3049–64.
Crossref PubMed
7. Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009 May 11; 169(9):894–900.
Crossref PubMed
8. Moore JE, Liu B, Khan S, Harris C, Ewusie JE, Hamid JS, et al. Can the effects of the mobilization of vulnerable elders in Ontario (MOVE ON) implementation be replicated in new settings: an interrupted time series design. BMC Geriatr. 2019 Apr 5;19(1):99.
Crossref PubMed PMC
9. Wong RY, Banerjee, J, Lim, WS, Chan,T. Developing cost-effective novel acute care services for older people in the hospital of the future: Global perspectives for the new decade. CGS J CME. 2019;9(1):1–10.
10. O’Brien MW, Mallery K, Rockwood K, Theou O. Impact of hospitalization on patients ability to perform basic activities of daily living. Can Geriatr J. 2023 Dec 1;26(4):524.
Crossref PMC
11. Molnar F, Frank CC. Optimizing geriatric care with the GERIATRIC 5Ms. Can Fam Physician. 2019 Jan 1;65(1):39.
PubMed PMC
12. Manning DM, Keller AS, Frank DL. Home alone: sssessing mobility independence before discharge. J Hosp Med. 2009 Apr; 4(4):252–54.
Crossref PubMed
13. Hoyer EH, Young DL, Klein LM, Kreif J, Shumock K, Hiser S, et al. Toward a common language for measuring patient mobility in the hospital: reliability and construct validity of interprofessional mobility measures. Phys Ther. 2018 Feb 1;98(2):133–42.
Crossref
14. Rockwood K, Theou O. Using the clinical frailty scale in allocating scarce health care resources. Can Geriatr J. 2020 Aug 24; 23(3):254–59.
Crossref
15. Persoon A, Bakker FC, van der Wal-Huisman H, Olde Rikkert MG. Development and validation of the geriatric in-hospital nursing care questionnaire. J Am Geriatr Soc. 2015;63(2):327–34.
Crossref PubMed
16. Clarke V, Braun V. Teaching thematic analysis: overcoming challenges and developing strategies for effective learning. The Psychologist. 2013 Feb 1;26:120–23.
17. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990 Dec 15;113(12):941–48.
Crossref PubMed
18. Rice KL, Bennett MJ, Clesi T, Linville L. Mixed-methods approach to understanding nurses’ clinical reasoning in recognizing delirium in hospitalized older adults. J Contin Educ Nurs. 2014 Mar;45(3):136–48.
Crossref PubMed
19. Ryan DJ, O’Regan NA, Caoimh RÓ, Clare J, O’Connor M, Leonard M, et al. Delirium in an adult acute hospital population: predictors, prevalence and detection. BMJ Open. 2013 Jan 1; 3(1):e001772.
Crossref PubMed PMC
20. Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LM. Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med. 2001 Nov 12; 161(20):2467–73.
Crossref PubMed
21. Rice KL, Bennett M, Gomez M, Theall KP, Knight M, Foreman MD. Nurses’ recognition of delirium in the hospitalized older adult. Clin Nurs Special. 2011 Nov 1;25(6):299–311.
Crossref
22. El Hussein M, Hirst S. Institutionalizing clinical reasoning: a grounded theory of the clinical reasoning processes RNs use to recognize delirium. J Gerontol Nurs. 2015 Oct 1;41:38–44.
Crossref PubMed
23. Ebright PR, Patterson ES, Chalko BA, Render ML. Understanding the complexity of registered nurse work in acute care settings. J Nurs Admin. 2003 Dec 1;33(12):630–38.
Crossref
24. Leger JM, Phillips CA. Exerting capacity: bedside RNs talk about patient safety. West J Nurs Res. 2017 May;39(5):660–73.
Crossref
25. Koyama A, Steinman M, Ensrud K, Hillier TA, Yaffe K. Long-term cognitive and functional effects of potentially inappropriate medications in older women. J Gerontol Series A. 2014 Apr 1; 69(4):423–29.
Crossref
26. Hyttinen V, Jyrkkä J, Valtonen H. A systematic review of the impact of potentially inappropriate medication on health care utilization and costs among older adults. Med Care. 2016 Oct 1; 54(10):950–64.
Crossref PubMed
27. Nilsson A, Rasmussen B, Edvardsson D. Falling behind: a substantive theory of care for older people with cognitive impairment in acute settings. J Clin Nurs. 2013;Mar 4; 22(11–12):1682–91.
Crossref PubMed
28. Fabbietti P, Ruggiero C, Sganga F, Fusco S, Mammarella F, Barbini N, et al. Effects of hyperpolypharmacy and potentially inappropriate medications (PIMs) on functional decline in older patients discharged from acute care hospitals. Arch Gerontol Geriatr. 2018 Jul 1;77:158–62.
Crossref PubMed
29. Malakouti SK, Javan-Noughabi J, Yousefzadeh N, Rezapour A, Mortazavi SS, Jahangiri R, et al. A systematic review of potentially inappropriate medications use and related costs among the elderly. Value Health Reg Issues. 2021 Sep 1; 25:172–79.
Crossref PubMed
30. Tian F, Chen Z, Zeng Y, Feng Q, Chen X. Prevalence of use of potentially inappropriate medications among older adults worldwide: a systematic review and meta-analysis. JAMA Netw Open. 2023 Aug 2;6(8):e2326910.
Crossref PubMed PMC
31. Mlambo M, Silén C, McGrath C. Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature. BMC Nurs. 2021 Apr 14;20(1):62.
Crossref PubMed PMC
Correspondence to: Patrick Feltmate, MD, FRCPC, Healthy Aging, Department of Geriatric Medicine, Horizon Health Network, 180 Woodbridge Street, Fredericton, NB E3B 4R3, E-mail: Dr.Patrick.Feltmate@horizonnb.ca
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 28, No. 2, JUNE 2025