Paula A. Rochon

Objective: To identify and prioritise potentially inappropriate prescribing cascades based on population prevalence, incidence, and temporal association between the initial and subsequent drug. Design: Population level retrospective cohort study. Setting: Health administrative data from a source population of community dwelling older adults in Ontario, Canada. Participants: 2 297 942 community dwelling older adults alive on 1 January 2022. Main outcome measures: 65 potentially inappropriate prescribing cascades were identified through a 2025 international expert Delphi consensus. For each prescribing cascade, the analytic cohort comprised incident users of the initial and subsequent drug combination during the accrual period. The population prevalence of the drug starting the prescribing cascade and the incidence of the initial and subsequent drug combination were measured, and the strength of the temporal association between the initial and subsequent drug was evaluated using adjusted sequence ratios derived from prescription sequence symmetry analyses. Prioritised cascades were those with a population drug prevalence of the initial drug ≥5%, prescribing cascade incidence of ≥1%, and adjusted sequence ratio >1, with the lower limit of the 95% confidence interval (CI) above the corresponding threshold for each measure. Results were stratified by sex. Results: The cohort comprised 2 297 942 people (54.3% female) aged ≥66 years. Twenty four prescribing cascades (37%) met all three prioritisation criteria. From the prioritised list, cardiovascular drugs were the most prevalent drugs starting the prescribing cascade (drug class range 19.0-65.9%). The highest incidence cascades were iron supplement to laxative (11.9%, 95% CI 11.7% to 12.1%), hydroxymethylglutaryl coenzyme A reductase inhibitor to pain reliever (10.9%, 10.7% to 11%), and cholinesterase inhibitor to sleep agent (10.3%, 9.9% to 10.7%). Temporal association, reported as adjusted sequence ratios, was highest for corticosteroid to antipsychotic (2.55, 95% CI 2.47 to 2.64), laxative to antidiarrheal (2.53, 2.43 to 2.65), and cholinesterase inhibitor to antiemetic drug treatment (2.24, 1.90 to 2.65). The adjusted sequence ratios were consistent when stratified by sex except for the selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor to overactive bladder drug cascade, which was stronger for male older adults (1.21, 1.10 to 1.33) than for female older adults (1.02, 0.96 to 1.09). Conclusions: This prioritised list of 24 potentially inappropriate prescribing cascades could inform prescribing and deprescribing initiatives and policy development to improve drug safety in older adults at individual patient and population levels.

Amédé Gogovor and colleagues explain how scaling studies differ from implementation studies and present 33 recommendations for how to report scaling studies with maximum accuracy and usefulness.

Background: Advances in antiretroviral therapy have transformed HIV into a chronic condition, leading to a growing population of adults aged 50 years and older living with HIV in Canada and globally. These individuals experience higher rates of multimorbidity, frailty, cognitive changes, and polypharmacy than their HIV-negative peers, and many rely on caregivers for emotional and practical support. Caregiving often occurs within chosen families of partners, friends, and community members, yet these caregivers remain largely unrecognized in policies that prioritize bio-legal family structures. Existing person- and family-centered care (PFCC) models in HIV focus mainly on pediatric and adolescent populations, leaving a critical gap in guidance for older adults and their diverse caregivers. Objective: This study aims to co-design Canada’s first equity-informed person- and family-centered care model tailored to older adults living with HIV and their biological, bio-legal, and chosen family caregivers. The objectives are to (1) examine experiences of accessing and providing caregiving support, including gendered and intersectional differences; (2) identify key components of a PFCC model to improve access and care experiences; and (3) develop a context-sensitive implementation strategy to support uptake across care settings. Methods: This multiphase study uses an equity-informed Experience-Based Co-Design methodology guided by the UK Design Council’s Double Diamond framework. An advisory committee of knowledge users, clinicians, and older adults living with HIV will provide ongoing input. Phase 1 involves approximately 45 semistructured interviews with older adults living with HIV, caregivers, and health care professionals, analyzed using reflexive thematic analysis. Phase 2 includes 2 co-design workshops with about 45 participants to collaboratively develop model components. Phase 3 includes 3 to 4 focus groups (approximately 30 participants) guided by the Consolidated Framework for Implementation Research to refine an implementation strategy. Equity will be operationalized using the Culturally-Competent Research Criteria for Methodological Areas and monitored using PROGRESS-Plus (place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status, social capital, plus additional factors) indicators to support intersectional analysis. Results: The study was funded on July 17, 2025. Data collection for phase 1 is scheduled to begin in January 2027, with subsequent co-design workshops (phase 2) planned for fall 2027 and evaluation activities (phase 3) anticipated in winter-spring 2028. Completion of data analysis is expected by mid-2028, with dissemination of findings anticipated later in 2028. Conclusions: This study will generate a rigorously developed, equity-informed PFCC model grounded in lived experience. Findings will inform policy, program planning, and service delivery to better support older adults living with HIV and their diverse caregivers while offering a replicable framework for co-designing inclusive care models in other chronic or stigmatized conditions.

Health care systems differ worldwide, allowing learning from each other and improving care for older adults with similar clinical profiles. In the early 1990s, Dr. Howard Bergman and Dr. Mark Clarfield from Canada and Dr. Joseph Ouslander from the United States described the approach to care for the same patient in their respective health care systems. Yet, challenges identified then, such as limited access to geriatric medicine care, as well as multimorbidity and system constraints, remain relevant to the care of older adults today. This article revisits the original exercise summarizing the joint symposium of the America, Canadian, and European geriatric medicine societies, held at the 2025 European Geriatric Medicine Society (EuGMS) Congress in Iceland. Using the case of an 82‐year‐old woman with multimorbidity, frailty, and social vulnerability, experts examined how three systems would manage key aspects of care for this patient: Delirium prevention (U.S.), falls and rehabilitation (Canada), and medication optimization (Europe). Each presentation situated clinical priorities within broader systemic realities, including workforce shortages, care fragmentation, and policy challenges. Emerging models, such as Age‐Friendly Health Systems and the Hospital Elder Life Program in the U.S., Acute Care for the Elderly units and Geriatric Rehabilitation Units in Canada and structured medication review initiatives in Europe, illustrate innovations and persistent gaps. By contrasting clinical strategies and organizational structures, this analysis identifies transferable best practices and policy levers to improve geriatric medicine care globally. Recommendations emphasize harmonizing geriatric expertise, embedding evidence‐based interventions, and fostering cross‐system learning to optimize outcomes for older adults.

Background and Objectives: Circumstances more common with aging may challenge the ability for older adults to maintain appropriate housing. The objective of this scoping review was to identify the risk factors and conditions associated with homelessness in older adults. Research Design and Methods: We searched OVID, CINAHL, Embase, PsycINFO, CENTRAL, and Social Work Abstracts from inception to February 2023. We included studies of older adults (defined as 50 years of age or older) or completed subgroup analyses accounting for older adults. We mapped the risk factors and conditions using an ecological framework (individual, relational, and structural/societal components). Results: Sixty-five studies were included. Individual factors included identifying membership in a racialized group and experiencing psychiatric illnesses or substance use disorders. Relational factors included being unmarried, relationship breakdown, and adverse childhood events. Structural factors included the lack of affordable housing or income supports and systemic discrimination. Those experiencing first-onset late-life homelessness were more likely to be female, had relative lifelong socioeconomic stability, but experienced sudden relational or economic changes. Those experiencing chronic homelessness were more likely to be male, often facing persistent structural vulnerabilities with comorbid substance use or psychiatric disorders. Important research gaps include measures of social support and age- and sex-disaggregated analyses. Discussion and Implications: Key individual, relational, and structural factors are associated with homelessness in older adults. Adverse experiences and structural factors, such as social losses and isolation, have important implications toward the risk of homelessness at different stages in life. Further research evaluating age-appropriate interventions is paramount.

Background: Understanding the prevalence and risk of dementia in homeless adults has important implications for ensuring appropriate resources are directed towards dementia prevention and healthy aging. We aimed to estimate the: (1) prevalence and (2) risk of dementia among homeless adults, and (3) risk of homelessness in adults experiencing dementia. Methods: A systematic search was completed in MEDLINE, PsycINFO, Embase, CINAHL, Cochrane Central, Social Works Abstracts, and the gray literature from inception to September 26, 2024. Studies investigating the prevalence of dementia among individuals experiencing homelessness aged 18 years or older were included. Title, abstract, and full text screening, extraction, and risk of bias assessments were completed in duplicate. Random effects meta‐analysis using generalized linear mixed models was used to estimate the prevalence of dementia. For the risk and incidence of dementia, we meta‐analyzed the risk and hazards of dementia comparing homeless to housed individuals. Results: A total of 1585 citations were retrieved, with 102 studies undergoing full‐text review. Thirty‐six studies were included in the final review (504,766 individuals experiencing homelessness, with the following weighted by sample size: mean age 63.08, female percentage 10.64). The prevalence of dementia was 6.81% (95% CI: 4.49, 10.19%, I ² = 99.7%). Among those who experienced homelessness compared to housed individuals, the risk ratio for dementia was 1.03 (95% CI: 0.52, 2.03, I ² = 99.7%), and the incidence (hazard ratio) for dementia was 1.54 (0.52, 4.50, I ² = 98.0%). One study showed that a younger age was associated with homelessness among adults with dementia. Conclusions: This systematic review and meta‐analysis suggests that homeless individuals have a dementia prevalence higher than population‐based studies of housed adults of a similar age, where the estimated prevalence is under 3%. Research on models of care aimed at reducing homelessness in those experiencing dementia is needed. Trial Registration: PROSPERO: CRD42024595047

Purpose: Prescribing cascades contribute to potentially inappropriate prescribing, especially among older adults. With the prescribing cascade framework maturation, it is important to distinguish potentially inappropriate from potentially appropriate prescribing cascades. The objective was to create a comprehensive consensus list of Potentially Inappropriate Prescribing Cascades (PIPCs). Methods: A prescribing cascade inventory was compiled using published lists. An international panel of 12 experts in geriatric medicine and pharmacology was selected. Panelists participated in a Delphi consensus process completing two questionnaire rounds and one discussion round. Results: A total of 107 proposed prescribing cascades were identified. After Questionnaire Round 1, 56 prescribing cascades achieved a rating of agree or strongly agree by ≥ 75% of the panelists and were included in the PIPC list. For 32 of the 107 proposed cascades, 50–74% of panelists provided a rating of agree or strongly agree, and were moved to Round 2. In Questionnaire Round 2, 9 of 32 proposed cascades achieved a rating of agree or strongly agree by ≥ 75% of panelists and were included in the final PIPC list. For 14 prescribing cascades, 50–74% of panelists provided a rating of agree or strongly agree, and were included in the Discussion Round. After discussion, no additional prescribing cascades were included. Conclusion: An explicit list of 65 PIPCs was created using a rigorous Delphi consensus process conducted by international experts on pharmacotherapy for older adults. The PIPC list provides a crucial tool for clinicians and researchers to detect potentially inappropriate prescribing patterns and to foster efforts to improve medication safety. Graphical