There are at present two inconsistencies with respect to the sharing of personal health information (PHI) among health care professionals caring for a patient whom the information concerns. First, there is an inconsistency between what is in theory the ethics and law governing the confidentiality and privacy of this information—it may only be disclosed with informed consent—and what is the actual practice of health care professionals—they share it without such consent. Second, there is an inconsistency between what ethics and law demand in theory and what all parties want: They all approve of the current practice. Ethics and law can be brought into line with what is needed to act in the patient's best interests and with what people want, without opening up any serious potential for abuse of privacy and confidentiality, by establishing a safeguarded, provision-of-care exception that allows co-caring health care professionals to share patients' PHI. The requirements for a system establishing such safeguards are proposed. The basic governing presumption is respect for the person and for rights to autonomy, self-determination, privacy, and confidentiality. Therefore, disclosure may only be made with the informed consent of the competent person to whom the information pertains, unless a defence of necessity applies. Where there is doubt about someone's competence, there should likewise be doubt about disclosure without that person's informed consent. Where the person is incompetent, such a disclosure can be made to the patient's substitute decision makers, most often the family, if that is necessary for the care of the patient and in the patient's best interests. To the extent possible, consistent with the best interests of the patient, the wishes of incompetent people should be respected.

Developments in information technology and the ongoing restructuring of health services to increase provision in community settings militate in favour of a streamlining of communications and the exchange of information about patients among health and social care providers. Yet the principles of confidentiality and privacy appear to inhibit this process. In order to explore the practical, ethical, and legal imperatives attendant upon personal health information exchange, we conducted a series of interviews with professional care providers, persons with early-stage dementia, and their family caregivers. The findings indicate some degree of discordance. Professionals reported valuing disclosure both to colleagues and family caregivers on the basis of its being in the patients' best interests. Patients also valued inter-professional exchange, but sought strong control over disclosure to family members. Family caregivers valued being kept informed of the patient's condition, even without the latter's consent. Implications for research and policy are discussed.

This study compared the changes in some bio-psychosocial variables (functional independence, nutritional risk, pain, balance and walking, grip strength, general well-being, psychiatric profile, perception of social support, leisure satisfaction, and caregivers' feeling of burden) in four categories of clients during their program at a geriatric day hospital (GDH). The study also evaluated whether or not improvements, if any, were maintained 3 months after discharge. One-hundred-and-fifty-one people, categorized by primary reason for admission, were assessed at the GDH with reliable and valid tools, at admission and at discharge. Three months after discharge, they were reassessed with the same tools. Overall, two categories of clients, stroke / neurological diseases and musculoskeletal disorders / amputations, improved the most. For the gait disorders and falls group, only the functional independence score improved, but not at a clinically significant level. Finally, clients in the cognitive function disorders / psychopathologies group improved the most on their well-being scores and caregivers' burden decreased the most. All gains were maintained up to 3 months after discharge, except for leisure satisfaction. With the exception of clients who attended the GDH because of gait disorders and falls, the improvements and maintenance achieved in each category occurred in the domains where improvement had been hoped for, because of the particular disabilities in question and because of the nature of the GDH services offered.

The aim of this study was to examine the effectiveness of a new, integrated service delivery (ISD) network of health and social services for frail elderly living in a semi-urban community. A quasi-experimental study was conducted from 1997 to 2000, with measures taken before implementation (T0) and every 12 months after implementation for a 3-year period (T1, T2, T3); 482 people aged 75 years or older from 2 communities, 272 in the experimental and 210 in the control group, were followed. Analyses were conducted using parametric and non-parametric statistics, a generalized linear model, and Cox regression for survival analysis. A declining trend in institutionalization was observed and the desire to be institutionalized was lower in the study group. When absence of deterioration on follow-up was analysed in terms of the level of autonomy, the ISD network produced positive effects on the frailer clientele at T1, effects that tended to be maintained at T2. In regard to caregivers' burden, the ISD network seemed to have been effective, with caregivers' burden being less at T1 and T2. The ISD network did not have a marked effect on the utilization of services. The ISD network did, in fact, produce some effects that should be seen as important for the elderly population.

The objective of this study was to describe the incidence, type, risk factors, and sequelae of fractures experienced by community-dwelling elderly Canadians. Data are from the Canadian Study of Health and Aging (CSHA), a longitudinal cohort study, collected in three waves: baseline (1991), wave 2 (1996), and wave 3 (2001). In CSHA-2 (1996), fractures were reported by 3.7 per cent of men and 7.5 per cent of women; in CSHA-3 (2001), by 2.9 per cent of men and 7.3 per cent of women. The distribution of fracture types was similar for men and women. Risk factors for women were increased age, history of fracture, and regular alcohol use; for men, stroke, arthritis, and lack of independent bathing. Walkers or wheelchairs were needed by over 30 per cent of those with any lower body fracture. One third of subjects with any fracture and over 50 per cent with femur fractures reported moderate or severe pain. It is concluded that elderly Canadians are at high risk for fractures, and older women are at most risk. Pain and mobility problems were common sequelae. The need for primary and secondary prevention of these age-related events is paramount.

We describe the age-specific outcomes for patients hospitalized with newly diagnosed congestive heart failure using administrative hospital abstracts from Alberta, Canada, from April 1, 1994, to March 31, 2000. Seniors (aged 65 years and older) constituted about 85 per cent of the 16,162 patients. Both co-morbidity and severity of illness tended to increase with age. The use of special care unit admissions, coronary artery diagnostic services (cardiac catheterization), and revascularization procedures (percutanenous transluminal coronary angioplasty/stenting, coronary artery bypass surgery) peaked in the 50-to 64-year age group and decreased with increasing age. Specialist/sub-specialist care, prescriptions of beta blockers and angiotensin-converting enzyme inhibitors / angiotensin receptor blockers decreased with age in seniors. Adjusted in-hospital, 1-year mortality and crude, age-specific 5-year mortality were significantly greater in those 75 years and older. Outcomes and process of care in patients with newly diagnosed congestive heart failure were not uniformly distributed with age. The elderly had greater mortality but received less therapy.

The purpose of this study was to identify barriers to the management of pain in long-term care institutions. Formal caregivers practising in four long-term care institutions in Hamilton, Ontario participated in eight focus groups. Participants included 6 physicians, 19 registered nurses, 8 registered practical nurses, 13 health care aides and 8 occupational therapists or physiotherapists. Three types of barriers were found: caregiver-related, patient-related and systems-related. Four themes for facilitating pain management were identified: (a) caregivers knowing the patient, (b) family support, (c) caregivers demonstrating understanding and compassion, and (d) teamwork by caregivers. Formal caregivers practising in long-term care institutions encounter a multitude of barriers that hinder the adequate assessment and treatment of pain, such as caregiver beliefs and knowledge and cognitive impairment in patients. Innovative strategies and strong political will are needed to overcome them.

Private, unregulated residential care facilities have become an increasingly important component of the continuum of housing and care for frail older adults in Canada. To date, this growing segment of the older population has received very little research attention. This study involved an in-depth examination of the functional/health profile, patterns of service use, and medical/care needs of a representative sample of 178 older adults in residential care facilities in the City of Ottawa. The results indicate great diversity in resident and facility profiles in this setting and confirm earlier impressions that special care units in the residential care sector have become increasingly close to being unlicensed pseudo-nursing homes. Despite the heavy burden of care, the evidence suggests that the care needs of the majority of residents are adequately met in the residential care environment. The results can inform future research, case finding, educational, and policy planning initiatives in this setting.