Matthias Hoben

BACKGROUND Potentially inappropriate antipsychotic use (APU), physical restraint use (PRU), and polypharmacy are common and potentially harmful care practices in long-term care (LTC) homes. Evidence on the social variables associated with these practices is predominantly US-based or pre-COVID-19, with limited contemporary Canadian research. We examined whether resident- and home-level social characteristics, including area-based deprivation, were associated with these practices across four Canadian provinces. OBJECTIVE To identify resident social characteristics and LTC home contextual factors associated with potentially inappropriate APU, PRU, and polypharmacy among LTC home residents in the Canadian provinces of Alberta, British Columbia, Manitoba, and Ontario. METHODS We used cross-sectional data from the Counting What Counts study, including 2,779 residents with cognitive impairment across 62 LTC homes in the four provinces. Homes were stratified by health region, bed size, and ownership model, with a random 10% drawn per stratum. Outcomes were derived from Resident Assessment Instrument – Minimum Data set 2.0 (RAI-MDS 2.0) records. Resident social characteristics were collected via staff proxy surveys. Area deprivation was measured using the Canadian Index of Multiple Deprivation linked by dissemination area. We estimated multivariable multilevel logistic regression models with random home-level intercepts for each outcome. Group-mean centring separated within-home from between-home effects of resident social characteristics. Sensitivity analyses tested alternative outcome definitions. RESULTS Potentially inappropriate APU prevalence was 18.9% (526/2,779), daily PRU was 3.5% (98/2,779), polypharmacy (≥9 medications) was 54.2% (1,507/2,779). In adjusted models, older age was associated with lower odds of APU (odd ratio [OR] 0.81, 95% confidence interval [CI] 0.73–0.89) and polypharmacy (OR 0.91, 95% CI 0.82–1.01). Residents without family or friend visitors had lower odds of polypharmacy (OR 0.67, 95% CI 0.49–0.93). In group-mean centred models, a higher proportion of residents who were not White in a home was associated with higher odds of PRU (OR 124.9, 95% CI 1.52–10,245.29), and a higher proportion speaking English as an additional language was associated with higher odds of APU (OR 16.2, 95% CI 3.3–79.1). Area-based economic dependency was associated with higher odds of APU (OR 1.19, 95% CI 1.02–1.38), and situational vulnerability with higher odds of PRU (OR 1.79, 95% CI 1.19–2.70). CONCLUSIONS Beyond clinical characteristics, social and structural factors, including area-level deprivation and language composition, were associated with potentially inappropriate care practices. These findings support structural interventions addressing staffing and resource allocation, alongside culturally safe, language-concordant care and caregiver support.

Several tools measure the Health-related quality of life (HRQOL) of people with chronic illnesses but evidence on their cross-cultural adaptation is limited. This study performed the cross-cultural adaptation of the Minnesota Living with Heart Failure Questionnaire (MLHFQ) for use with Urdu speakers in Pakistan, while documenting the adaptation process in detail. This methodological study employed a structured cross-cultural adaptation and linguistic validation design. We incorporated a Delphi Pannel to the MAPI Research Trusts’ 5-step linguistic validation process. Two forward translators independently adapted and reconciled the Indian Urdu version of the MLHFQ for use in Pakistan. Using a modified Delphi approach comprising three Heart Failure patients and one cardiologist reviewed the translation for linguistic accuracy, cultural relevance, and comprehensiveness, identified problems and provided feedback that informed the Pakistani Urdu version 1.0. Two independent back translators translated version 1.0 back to English. The Principal Investigator and back translators reconciled back-translations and proposed changes that were approved by forward translators. Translations, reconciliation reports, and Delphi panel feedback were analyzed using inductive qualitative content analysis, resulting in four themes describing the methodological challenges and adaptation strategies encountered during cross-cultural adaptation: (1) direct transferring of compatible words from the Indian Urdu version to Pakistani Urdu version of the MLHFQ, (2) using indirect substitutes for words lacking direct Urdu equivalents, (3) balancing the tone of written and spoken Urdu, and (4) incorporating contextual nuances within each element of the tool. This study successfully adapted the MLHFQ for Urdu-speaking patients with Heart Failure in Pakistan while systematically documenting the linguistic, cultural, and contextual challenges encountered throughout the adaptation process. The findings offer valuable methodological insights for researchers adapting HRQOL tools and provide quality evidence regarding the use of the MLHFQ for use with Urdu speakers in Pakistan.

Objectives: To compare mental illness prevalence, and agreement between mental illness measures, in home care (HC) and long‐term care (LTC) using administrative definitions and Resident Assessment Instrument (RAI)‐diagnoses. Methods: Applying a common protocol to linked administrative‐RAI datasets in Alberta, Manitoba, and Ontario, Canada, we selected adults receiving HC or LTC between 2012 and 2023. Cross‐sectionally, we compared administrative definitions with RAI‐diagnoses (depression, anxiety, bipolar disorder and schizophrenia) using kappa, sensitivity, specificity, positive and negative predictive value. We examined discordance‐associated factors using multivariable logistic regression. Results: Depression was the most prevalent mental illness (administrative data, HC: 29%–34% of 493,895 people; LTC: 21%–51% of 357,117 people). Prevalence estimates were consistently lower using RAI‐diagnoses than administrative definitions. Agreement between data sources was moderate for depression ( k = 0.33–0.57) and anxiety disorders ( k = 0.35–0.63). Younger age, dementia, and more physician visits were associated with higher likelihood of discordance between data sources; male sex had a lower likelihood. Conclusion: While mental illness prevalence is high in HC and LTC populations, RAI‐based estimates are lower than administrative data estimates. Discordance between data sources differs by individual characteristics. Concurrent comparison of RAI‐diagnoses and administrative data to a gold standard clinical interview would clarify the optimal surveillance strategy.

Adult day programs (ADPs) are essential for dementia care. Ethnoculturally diverse older adults often benefit less due to culturally misaligned care and systemic inequities. Cultural safety addresses disparities by challenging provider biases and structural barriers, but it is underexplored in ADPs. This critical review examined how culturally safe ADP care for persons living with dementia is conceptualized, experienced, and implemented. We selected 20 studies from references included in a broader realist review by our team. Cultural safety and intersectionality guided study appraisal, data extraction, and thematic synthesis. Five themes emerged: first, definitions of culturally safe care in ADPs; second, experiences of ethnoculturally diverse older adults and their caregivers, including belonging alongside challenges (exclusion, language barriers, environmental incongruence); third, contexts and mechanisms shaping culturally safe care (organizational rigidity, provider-centered routines, workforce constraints); fourth, implementation of culturally safe care, (superficial adaptations vs relational change); fifth, gaps/future directions (absence of operational models, insufficient outcome evaluation, limited participant and caregiver voices). Culturally safe ADP care can advance equity for ethnoculturally diverse older adults living with dementia and their caregivers, yet current approaches remain largely symbolic. Achieving culturally safe care will require structural reforms, organizational accountability, participatory design, and policies that support flexibility, relational practice, and system-level responsiveness.

Adult day programs (ADPs) are one of the few community care services supporting both, persons living with dementia and their caregivers. However, despite being eligible, persons living with dementia may not attend an ADP, reduce attendance, or stop attendance. Such use patterns may reduce potential ADP benefits for individuals living with dementia (e.g., delayed institutional care, cognitive and physical stimulation, meaningful social connections, improved mental health and quality of life) and their family or friend caregivers (respite, reduced caregiver burden, improved mental health and quality of life). We lack literature syntheses, critically discussing reasons of these potentially unfavorable ADP use patterns. Our objective was to conduct a critical literature review to address this knowledge gap. We searched (database inception to January 6, 2026) Ovid MEDLINE(R), APA PsycInfo, Social Work Abstracts, and CINAHL. Pairs of team members independently screened titles, abstracts, full texts, and reconciled discrepancies by consensus. We extracted data, coded, then synthesized data using reflexive thematic analysis. Of 2,314 screened references, 38 met inclusion criteria. Reasons of non-attendance, reduced, or stopped attendance included those related to (1) the person living with dementia (e.g., not being comfortable in a group setting) and their caregiver (e.g., not recognizing the potential benefits of ADP use), (2) family conditions and influence from extended family members (e.g., certain family members’ fear of stigmatization when others learn about the person’s dementia), (3) ADP contexts (e.g., ADPs not meeting the person’s or caregiver’s needs and expectations, and (4) community and system contexts (e.g., lack of transportation or insufficient number of ADP spaces in a region). ADP attendance is a fluid, relational process shaped by evolving needs, expectations, and constraints. ADP policy and practice must address structural barriers to ensure equitable access across diverse populations.

Background: Limited epidemiologic data exists for mental illnesses among at-risk home care (HC) and residential long-term care (LTC) recipients. Objective: To estimate the annual prevalence (April 1, 2012-March 31, 2023) of various mental illnesses among HC and LTC populations (versus matched comparators) with and without dementia in the Canadian provinces of Ontario, Alberta, and Manitoba. Methods: Parallel repeated cross-sectional studies were conducted in each province using linked health administrative data. HC and LTC recipients aged ≥18 years were matched to comparators on demographics, dementia and comorbidity. Prevalence estimates were derived using validated case definitions for any mental illness, mood/anxiety disorders, depression and anxiety (with/without drug claims), schizophrenia, bipolar disorder and suicide attempt. Prevalence ratios (95% CIs) were estimated with modified Poisson regression models. Results: Included were 682,466 HC clients and 233,499 LTC residents. Mental illnesses were common in HC and LTC settings across all three provinces. Prevalence estimates were typically higher among care recipients versus matched comparators and among persons with versus without dementia. Up to 70% of HC clients and 80% of LTC residents with dementia had any mental illness; in both settings, 40% had mood/anxiety disorders, 4% bipolar disorders, and between 2%-6% schizophrenia. Suicide attempts were rare (0.5–0.6%). Prevalence varied by province and was higher for case algorithms including drug claims. Conclusions: The high prevalence of mental illness and its common co-occurrence with dementia in HC and LTC recipients illustrates the complexity and challenges of care in these populations and raises concerns about potential unmet mental health needs.

Aim: To describe the processes, consensus‐building activities, learning and challenges of prioritizing initial programme theories on appropriate nurse staffing models across a multinational research team of academics, trainees and knowledge users from four countries. Design: Realist review involving literature review, multinational stakeholder engagement and prioritization of programme theories. Realist reviews explore what works, for whom and in what contexts, enabling the development and testing of initial programme theories. Data Sources: Data sources included (1) a literature review to identify existing theories on optimal nurse staffing models, (2) input from methodological and health system decision makers experts to identify context‐mechanism‐outcome configurations and prioritize initial programme theories and (3) feedback from health decision‐makers and nursing staff through focus groups to augment and prioritize a final set of initial programme theories for subsequent testing. Outcomes: We summarize the key learnings we gained regarding: (1) effectively communicating the value and unique aspects of realist methodology to team members with varying levels of expertise; (2) achieving a compromise between rigour and relevance in the design of the review itself in working within ‘social laboratories’ and (3) the logistics of conducting a multinational realist investigation: navigating working remotely, differences in time zones and differences in context and language. Conclusion: Prioritizing initial programme theories on nurse staffing through a multinational realist review is both feasible and valuable. Clear communication, balancing rigour with relevance and managing logistical challenges are essential to producing context‐sensitive and evidence‐informed staffing models. Relevance to Clinical Practice: Developing evidence‐informed staffing models requires local context consideration and stakeholder collaboration. This study offers (a) practical insights for nurse leaders and managers on balancing rigour and relevance, (b) effective team communication and (c) navigating logistical challenges in multinational teams to prioritize programme theories for clinical translation to improve patient care and staff wellbeing. Reporting Methods: Consolidated criteria for reporting qualitative research (COREQ). Patient or Public Contribution: Health care decision makers, care managers, researchers and academicians were involved.

BACKGROUND Older people are the fastest-growing segment of the population in all developed countries, and in part due to this trend, nursing homes (NHs) are now reserved for people with extensive comorbid physical, cognitive, and social needs. While the challenges related to NH care are well known, strategies are needed to more effectively bridge the transactional gap between what we know from research and what we do in practice. OBJECTIVE This protocol paper describes how we designed, implemented, and evaluated an innovation called SHIFT (Supporting Healthcare Improvement through Facilitated Training) that helps front-line NH providers incorporate formal quality improvement techniques (e.g., Plan-Do-Study-Act, PDSA cycles) into their everyday care routines. Our goal was to understand how providers received this facilitated support and implemented their quality improvement ideas, assess their ability to use more structured care improvement processes, examine the facilitators and barriers to their success, and describe how SHIFT impacted resident quality of care and staff-related outcomes. METHODS SHIFT is a sequential mixed-methods clinical trial guided by key implementation science frameworks and lessons learned from the Translating Research in Elder Care (TREC) research program. It consists of a core module based on the Institute for Healthcare Improvement (IHI) Breakthrough Series framework (e.g., learning congresses interspersed with action periods, various forms of facilitation). From TREC learnings, we added to this core module (i) readiness-for-change activities to help identify suitable intervention environments and team members with requisite skills, and (ii) a leadership program that provides person-level coaching to boost internal facilitation. SHIFT and its components were examined using a suite of quantitative (e.g., team member surveys) and qualitative (e.g., focus groups, quality advisor field notes, research observations) data. Our primary goal was to assess implementation strategies and secondarily measure intervention effectiveness. RESULTS Ten NH sites involving 65 team members have participated in SHIFT. Recruitment occurred in February 2024, and the study concluded in July 2024. As of January 2026, all data have been analyzed, and four manuscripts are in preparation that discuss participant perspectives on (i) SHIFT team implementation and intervention effectiveness, (ii) the value of R4C and leadership activities and how they impacted innovation success, (iii) challenges teams encountered specific to SHIFT fidelity, and (iv) future innovation directions based on participant input (e.g., creating more targeted quality advisor training sessions, increasing the number of these sessions with fewer cross-team learning congress workshops). CONCLUSIONS SHIFT investigates strategies that help NH front-line care teams embed, with support, quality improvement methodology into their daily care routines. This innovation is positioned as the first in a series of iterative collaborations that aim to achieve this goal while balancing best evidence with the everyday complexities of NH care. CLINICALTRIAL ClinicalTrials.gov NCT06106087; https://clinicaltrials.gov/study/NCT06106087