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      Canadian Geriatrics in the Time of COVID‐19

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          Abstract

          To the Editor: While older persons are at higher risk for severe disease with coronavirus disease 2019 (COVID‐19) infections, 1 individuals the same age vary widely in their resilience. A count of years lived is less predictive of outcomes than the personʼs overall state of health. This entails looking at the balance between health‐promoting assets and deficits, such as the type, severity, and number of morbidities, frailty, and disability. As of April 20, 2020, there have been 37,382 COVID‐19 cases in Canada, with 1,728 deaths. 2 Persons 60 years of age and older accounted for approximately two‐thirds of both hospitalizations and critical care admissions and 94% of deaths. 2 Geriatrics in Canada differs in significant ways from US practice. This letter summarizes the response of Canadian internists‐geriatricians to the COVID‐19 pandemic. In normal times, they function as consultants, typically working within academic healthcare centers. They do not provide primary medical care or play a major role in long‐term care (LTC) facilities. During the pandemic, Canadian internists‐geriatricians have combatted ageism3, 4 and spoken on the need to clarify and document goals of care before the onset of a potentially life‐threatening infection when decisions may have to be made quickly about hospitalization, admission to a critical care unit, intubation, and ventilatory support. A number have contributed to the development of COVID‐19 policies, where they emphasized the need for an individualized approach when deciding on allocation of limited healthcare resources. A unique consideration they brought to these deliberations was the assessment of frailty and its severity. On what seems a daily basis, Canadians hear about large numbers of LTC, assisted living and retirement home residents dying from COVID‐19. Some of these reports can only be described as horrific.5, 6 The congregation of highly vulnerable individuals makes these facilities dangerous sites in the best of circumstances, but limitations in the number (and training) of staff, access to personal protective equipment, and the physical environment coupled with lax institutional policies about visiting and staff working at multiple sites (often to earn a living wage) at the onset of the pandemic left them inadequately protected. 7 To support physicians and staff working in these facilities, geriatric groups across the country created advice lines and virtual consultation services, but clearly more must be done. In early March, the Canadian Geriatrics Society (CGS) provided guidance to older persons on minimizing their risk of contracting COVID‐19 that included physical (or social) distancing. 8 While this slows the spread of the disease, many older persons require assistance with daily activities, depend on regular contact with family members, or were isolated before distancing began, and have less familiarity with or ability to use personal communication technologies. How to mitigate the adverse effects of physical distancing has proved challenging. Canadian internists‐geriatricians are involved in the acute management of COVID‐19 infections. Specific areas that attracted attention within the field include risk assessment, determining goals of care, atypical presentations, iatrogenic complications, dealing with neurological manifestations, such as delirium, and discharge planning, particularly in complicated cases. Due to attendant deconditioning, stress often aggravated by restrictive visiting policies, sleep deprivation, malnutrition, and cognitive dysfunction with hospital stays, older persons are susceptible to postdischarge complications. A backlog of post‐acute needs is building that will have to be eventually addressed. Non–COVID‐19 clinical work is now done primarily as video or voice calls. There has been a good deal of internal discussion about how to effectively assess suspected cognitive impairment with these modalities. Both clinical research and teaching activities have been compromised by COVID‐19. What carries on has moved to an online environment. At an organizational level, the CGS established a national COVID‐19 group that meets on a weekly video call to share information, resources, and promising strategies. An unanswered question is what impact the COVID‐19 pandemic will have on the future practice of geriatrics in Canada. Some changes are givens. These include being stronger advocates for older persons, being more active in promoting advance care planning, and having greater involvement in the development of health policy. There will also be greater use of communication technologies. After that, things become debatable. Our ability to occupy a larger clinical role is limited by numbers. The most recent national count of internists‐geriatricians was 304, less than 0.4% of all Canadian physicians. Strategic thinking and hard choices will be required. 9 Should we seek a greater role in acute care or “at the sharp end,” as proponents describe it? What about addressing obvious needs in both facility‐ and community‐based continuing care? If we take on additional activities, what will be dropped?

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          Estimates of the severity of coronavirus disease 2019: a model-based analysis

          Summary Background In the face of rapidly changing data, a range of case fatality ratio estimates for coronavirus disease 2019 (COVID-19) have been produced that differ substantially in magnitude. We aimed to provide robust estimates, accounting for censoring and ascertainment biases. Methods We collected individual-case data for patients who died from COVID-19 in Hubei, mainland China (reported by national and provincial health commissions to Feb 8, 2020), and for cases outside of mainland China (from government or ministry of health websites and media reports for 37 countries, as well as Hong Kong and Macau, until Feb 25, 2020). These individual-case data were used to estimate the time between onset of symptoms and outcome (death or discharge from hospital). We next obtained age-stratified estimates of the case fatality ratio by relating the aggregate distribution of cases to the observed cumulative deaths in China, assuming a constant attack rate by age and adjusting for demography and age-based and location-based under-ascertainment. We also estimated the case fatality ratio from individual line-list data on 1334 cases identified outside of mainland China. Using data on the prevalence of PCR-confirmed cases in international residents repatriated from China, we obtained age-stratified estimates of the infection fatality ratio. Furthermore, data on age-stratified severity in a subset of 3665 cases from China were used to estimate the proportion of infected individuals who are likely to require hospitalisation. Findings Using data on 24 deaths that occurred in mainland China and 165 recoveries outside of China, we estimated the mean duration from onset of symptoms to death to be 17·8 days (95% credible interval [CrI] 16·9–19·2) and to hospital discharge to be 24·7 days (22·9–28·1). In all laboratory confirmed and clinically diagnosed cases from mainland China (n=70 117), we estimated a crude case fatality ratio (adjusted for censoring) of 3·67% (95% CrI 3·56–3·80). However, after further adjusting for demography and under-ascertainment, we obtained a best estimate of the case fatality ratio in China of 1·38% (1·23–1·53), with substantially higher ratios in older age groups (0·32% [0·27–0·38] in those aged <60 years vs 6·4% [5·7–7·2] in those aged ≥60 years), up to 13·4% (11·2–15·9) in those aged 80 years or older. Estimates of case fatality ratio from international cases stratified by age were consistent with those from China (parametric estimate 1·4% [0·4–3·5] in those aged <60 years [n=360] and 4·5% [1·8–11·1] in those aged ≥60 years [n=151]). Our estimated overall infection fatality ratio for China was 0·66% (0·39–1·33), with an increasing profile with age. Similarly, estimates of the proportion of infected individuals likely to be hospitalised increased with age up to a maximum of 18·4% (11·0–7·6) in those aged 80 years or older. Interpretation These early estimates give an indication of the fatality ratio across the spectrum of COVID-19 disease and show a strong age gradient in risk of death. Funding UK Medical Research Council.
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            Canadian Geriatrics Society COVID-19 Recommendations for Older Adults. What Do Older Adults Need To Know?

            INTRODUCTION One of the goals of the Canadian Geriatrics Society (CGS) is to foster the health and well-being of older Canadians and older adults worldwide. Because there is currently no vaccine available to prevent COVID-19 and no specific antiviral medication to treat it, the best way to prevent illness is to avoid being exposed to the virus altogether. We have perused information on the outbreaks in China, Italy, and Spain and recommendations from governmental sites including the Public Health Agency of Canada, Public Health Ontario, and the U.S Centers for Disease Control and Prevention (CDC), to provide the following guidance to older adults in Canada. We realize that our patients and their caregivers likely have many questions about COVID-19. As our health system faces this new challenge, we know these are difficult times and it might be harder than normal to address all concerns. This article is intended for physicians assisting older patients with a resource to be shared with them. A shorter version with infographic is available in the CGS website (www.candiangeriatrics.ca) OUR 3 MAIN POINTS FOR COVID 19 1. Who is high risk for severe illness from COVID-19? Adults aged 60 and higher People suffering from heart disease, respiratory disease, and diabetes Being older and having existing conditions such as cardiovascular disease, lung disease, and diabetes, usually coexist; therefore, awareness is critical for older adults to take actions to reduce your risk of getting sick with COVID-19. 2. What should older adults do? a. Take any illness seriously Covid-19 may start like a common cold or mild flu; however, in older adults it may worsen quickly. Pay attention for potential COVID-19 symptoms including, fever, cough, and shortness of breath. If you have mild symptoms or have had contact with someone who has tested positive for the virus, call your doctor, health unit or pharmacist. They will tell you if you need to be tested and where to go. Go to the hospital immediately if you develop any of the symptoms below: Difficulty breathing or shortness of breath Persistent pain or pressure in the chest New confusion or inability to arouse Blue lips or face Vomiting b. Stay Informed Your local Health Unit has the most up-to-date and accurate information. Many Health Units have social media accounts, which will be the fastest and most reliable information for your specific area, including how to stay safe and what to do if you think you may be infected. Click here for links to health units by province: check CBC and local news 3. What can you do to reduce your risk of becoming infected? Take everyday precautions to maintain a physical distance between yourself and others, at least 2 meters (6 feet) if possible. See our 10 Recommendations. Avoid crowds as much as possible. When you go out in public, keep away from others who are sick and limit close contact with others, wash your hands thoroughly and often. Wash your hands thoroughly and often. Avoid touching your face, especially the “T Zone” formed by your eyes, nose, and mouth. Avoid any non-essential travel. Stock up on supplies that you know you will need in case you need to stay home for at least 2 weeks. During a COVID-19 outbreak in your community, stay home as much as possible to further reduce your risk of being exposed, and stay informed. OUR 10 RECOMMENDATIONS 1. Take everyday preventive actions: Wash your hands often and thoroughly with soap and water for at least 20 seconds, especially after having been in a public space and after blowing your nose, coughing, or sneezing. If soap and water are not available, use a hand sanitizer that contains at least 60% alcohol. Click here for the recommended method for hand washing. Avoid touching high-touch surfaces in public places – these include elevator buttons, door handles, handrails, handshaking with people, etc. Use a tissue or your sleeve to cover your hand or finger if you must touch something. Wash your hands after touching surfaces in public places. Avoid touching your face, especially your mouth, eyes, and nose. Clean and disinfect your home to remove germs: practice routine cleaning of frequently touched surfaces (for example: tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks & cell phones). 2. Avoid crowds, especially in poorly ventilated spaces. Your risk of exposure to respiratory viruses like COVID-19 may increase in crowded, closed-in settings with little air circulation if there are people in the crowd who are sick. Take extra measures to put distance between yourself and other people to further reduce your risk of being exposed to this new virus. Stay home as much as possible. Consider ways of getting food brought to your house through family, social, or commercial networks 3. Avoid all non-essential travel (including plane trips and tourism and especially avoid embarking on any cruise ships), and non-essential in-person visits to your health provider (e.g., family physician checkups). 4. Have medical supplies handy Contact your health-care provider to ask about obtaining extra necessary medications for 30 days to have on hand in case there is an outbreak of COVID-19 in your community and you need to stay home for a prolonged period of time. Some physicians have access to virtual appointments; ask if this is an option. Call your pharmacist before you run out and need more of any medication. Ask if they deliver. If you cannot get extra medications, consider using mail-order for medications. Be sure to have over-the-counter medicines and medical supplies (tissues, etc.) to treat fever and other symptoms. Most people will be able to recover from COVID-19 at home. Have enough household items and groceries and non-perishable food on hand so that you will be prepared to stay at home or to minimize trip to stores. 5. If a COVID-19 outbreak happens in your community It could last for a long time. (An outbreak is when a large number of people suddenly get sick). Depending on how severe the outbreak is, public health officials may recommend community actions to reduce people’s risk of being exposed to COVID-19. These actions can slow the spread and reduce the impact of the disease. 6. Have a plan in place in case you get sick Consult with your health-care provider for more information about monitoring your health for symptoms, especially if they are suggestive of COVID-19. Stay in touch with others by phone or email. You may need to ask for help from friends, family, neighbors, community health workers, etc., if you become sick. Determine who can care for you if your caregiver gets sick. Watch for symptoms and emergency warning signs Pay attention for potential COVID-19 symptoms including, fever, cough, and shortness of breath. If you feel like you are developing symptoms, call your doctor. If you develop emergency warning signs for COVID-19 get medical attention immediately. In older adults, emergency warning signs include the following: – Difficulty breathing or shortness of breath – Persistent pain or pressure in the chest – New confusion or inability to arouse – Bluish lips or face 7. If you get sick If you get sick, do the following: Stay home and call your doctor and let them know about your symptoms. Tell them that you have or may have COVID-19. This will help them take care of you and keep other people from getting infected or exposed. If you are not sick enough to be hospitalized, you can recover at home, and thus, staying home is the best option. We provide below some guidelines for how to take care of yourself at home. Know when to get emergency help (emergency warning symptoms in Recommendation 6). Get medical attention immediately if you have any of the emergency warning signs listed above. 8. Things you can do to support yourself and to minimize stress during the COVID 19 outbreak. Stress symptoms can include Fear and worry about your own health and the health of your loved ones Changes in sleep or eating patterns Difficulty sleeping or concentrating Worsening of chronic health problems Increased use of alcohol, tobacco, or other drugs Older adults with preexisting mental health conditions should continue with their treatment and be aware of new or worsening symptoms. Take breaks from watching, reading, or listening to news stories, including social media. Hearing about the pandemic repeatedly can be upsetting. Take care of your body. Take deep breaths, stretch, or meditate. Try to eat healthy, well-balanced meals, exercise regularly, get plenty of sleep, and avoid alcohol and drugs. Make time to unwind. Try to do some other activities you enjoy. Connect with others. Talk with people you trust about your concerns and how you are feeling. If you live alone, schedule daily telephone calls with your friend/family members/caregiver 9. What others can do to support older adults Family and caregiver support. Below are some guidelines for those supporting older adults: Know what medications your loved one is taking and see if you can help them have extra medication available on hand. Monitor food and other medical supplies needed (oxygen, incontinence, dialysis, wound care) and create a back-up plan. Stock up on non-perishable food to have on hand in your home in order to minimize trips to stores. If you care for a loved one living in a care facility, monitor the situation, ask about the health of the other residents frequently, and know the outbreak protocol of that facility if there is an outbreak. 10. Where can I find out more information on COVID-19? CGS is following Health Canada’s recommendations for COVID-19 and monitoring their ongoing information, as updates become available. To learn more, please view the following resources: Health Canada: COVID-19 World Health Organization: COVID-19 World Health Organization COVID-19 F.A.Q.
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              The Choices Facing Geriatrics

              “Ah, but a man’s reach should exceed his grasp/Or what’s a heaven for?” -Andrea Del Sarto, Robert Browning (1812–1889) These words of Browning suggest that to achieve anything worthwhile, a person should attempt even those things that may turn out to be impossible. Canadian geriatricians have tried to abide by this dictate, but it has not always worked out as well as hoped. We have spread ourselves thinly in our efforts to both improve the lives of older persons and fulfill our academic responsibilities. As a relatively new discipline, we have striven to respond to requests from colleagues in other fields, academic leaders, health-care managers, and administrators. Our efforts at multi-tasking have likely made us less, not more effective.(1) History tells us that “to do two things at once is to do neither.”(2) With our small and currently static number, we have no recourse other than to focus our finite time and energy on what is truly important and where we can, in collaboration with colleagues from medical fields and health professions, be most effective. But what should that be? Many both within and outside our field argue that we should first attend to the care of hospitalized older persons for four primary reasons. Firstly, older Canadians disproportionally use this expensive and limited resource. In 2003–2003, the approximately 13% of the Canadian population 65 years and older accounted for one-third of all acute care hospitalizations and almost half of total hospital bed-days.(3) There is every reason to believe that these proportions will increase in the coming years. Seniors admitted to hospital are more likely to have multiple morbidities, impaired cognition, and higher levels of disability (including mobility) than younger adults.(4–7) They present unique challenges (multiple morbidity and, in its shadow, polypharmacy, cognitive impairment, and disability) that play into our particular areas of competency. Secondly, a hospital admission is a dangerous time for seniors. An acute care stay can have long-lasting deleterious effects on the functional abilities of older patients.(8,9) There is a growing body of literature attesting to the ability of geriatric programs to mitigate this danger.(10,11) Thirdly, hospitals are still the site where the lion’s share of clinical teaching in internal medicine takes place. It is where we can share our expertise with students and residents, as well as excite them about geriatrics. All this speaks to the need for us to be there. The final force pulling us into acute care is not directly related to either the care of older patients or our academic mission. Departments of Internal Medicine and hospitals need physicians to care for unattached patients whose problems do not qualify them for care by other hospital services. This leads to the ticklish question of finances. Especially in jurisdictions without an alternative payment system, sessional fees, or preferential billing codes, rotations on a busy hospital service can generate enough income to allow geriatricians to support the less remunerative aspects of their work. There is also, we would argue, a need for us to have a presence as medical directors and consultants in long-term care institutions and supportive housing settings where medical care can be suboptimal. Poor adherence to treatment guidelines,(12) limited recognition of treatable conditions such as depression,(13) and inappropriate pharmacotherapy(14) are some of the problems prevalent in these facilities. While geriatricians as medical directors and consultants can help address these issues, to deal effectively with them would require organizational changes, better funding, and improvements in the quantity, mix, and training of staff. These settings are being increasingly used to provide sub-acute and palliative care. We feel these services would benefit from the active involvement of consultants in geriatrics and linkages with specialized geriatric services. And then there is the community, where the majority of frail and/or disabled older persons reside. Increasing emphasis on community-based care is surely the future of our health-care system. There is growing evidence that complex community-based interventions can help older patients live safely and independently for longer,(15) while the utility of targeted home visits and ambulatory consultations is confirmed by experience in this country and others.(16,17) We need to improve support provided to primary medical and community care by offering consultation services within primary care group practices, home assessments when indicated, and timely access to traditional facility-based ambulatory care. Geriatric clinics and day hospitals (which were invented by geriatricians) assess and manage memory disorders, chronic pain, falls, incontinence, multi-morbidity, chronic pain, and other disabling conditions.(18) But we also have our academic mission. Across the country, small divisions of geriatric medicine in collaboration with Care of the Elderly physicians and geriatric psychiatrists introduce Canada’s future doctors to the care of older patients, albeit not to the depth we would wish. We teach residents in family medicine, psychiatry, neurology, and internal medicine, along with other health-care workers, while enthusiastically participating in continuing professional education and development, as well as public education. For a small specialty, our research and publication output is more than respectable, and is growing annually. Canada ranks third of all countries in the number of articles published in gerontology and/or geriatric journals.(19) We have internationally recognized leaders in areas such as Alzheimer’s disease and other dementias, frailty, health services, and population research. And then there is our time-consuming, important, and often solicited involvement with policy and program development, health service evaluation, medical administration, and advocacy for seniors. But we cannot do equal and adequate service to these competing demands with our limited numbers. What are the solutions? It is time for bold thinking and action. We have to define those areas that are unique to us or where we perform demonstrably better than others and that are vital to our mission—where we can be the most effective given our relatively small numbers. We must ditch those areas not meeting these criteria. To use human resource jargon, because of our limited numbers we must opt for a restricted scope of practice that addresses our “core business”. Whatever is not will have to be performed by others. We do not believe that we should focus all our efforts in one location (such as acute hospitals). To improve the health of seniors and the effectiveness as well as efficiency of the health-care system, it is necessary to look upstream and downstream of hospitals. We have to develop a balanced portfolio. Specifically, we feel that we should: Maintain a Presence in Acute and Long-term Care: In acute care we need to demonstrate how to optimally manage older patients with complex needs through geriatric consultation teams in emergency departments and, on the wards, through geriatric evaluation and management (GAU/GEM) units, acute care of the elderly (ACE) units, and or Hospital Elder Life (HELP) Program,(20) as well as on sub-acute units in long-term care where our clinical role would be consultative. We will need to negotiate these roles with our hospital-based colleagues to ensure we are used in an effective and efficient manner. Certainly, we will need to limit the number of beds for which we have primary responsibility, and recognize that the vast majority of older persons will be cared for by others. For these patients, we will offer an active consultation service that can co-manage referred patients. Expand our Presence in Primary Care: We need to foster effective partnerships with primary care professionals who will be increasingly challenged by caring for our aging population. It is essential for us to provide relevant, effective, and timely support to primary care physicians, as well as to other community-based professionals, through a balanced combination of facility-based specialty clinics and community-based consultations. There is growing evidence that a period of frailty or vulnerability precedes the onset of disability in many older individuals. We must work with primary care to help identify older people at risk and then intervene to reduce the subsequent likelihood of disability. And, we must appreciate the importance of chronic disease management. While huge strides have been made for conditions such as diabetes, heart failure, dementia disorders, and chronic renal disease, there is room for improvement in the management of multi-morbidity where the competing demands of disability, cognitive impairment, and dealing with several chronic medical conditions have to be juggled. We should embrace this area and work with our colleagues in primary care and other fields to develop chronic disease management strategies for older individuals with multiple, interacting, and summating diseases. Education: We must teach as the demographic imperative demands that nearly all present and future health-care workers will have to be proficient in the care of the ever-increasing number of older patients. But which learners should we particularly target? We feel it is most important to influence medical students, internal medicine and family medicine residents, as well as trainees in other medical specialties and sub-specialties, from whose ranks will spring those caring for older persons and future specialists in geriatrics. Research: We have an obligation to continue to contribute to the discovery of new knowledge, and its translation and then implementation into practice settings. Our unique perspective allows us to appreciate significant clinical issues for older patients that cut across system-based specialties. We must maintain our reputation for high-quality research while doing better in knowledge transfer. Advocacy: We must advocate more strongly for the rights of older people. Our hospitals and community services must be elder-friendly. And, we need to be more effective in raising the concerns of seniors at a policy level. Demographic aging is no secret, but somehow it always seems to slide below the threshold needed for political action. Can we ensure that there is an effective aging national strategy in place prior to large relative and absolute increases in older Canadians we can expect over the next twenty years? We are not seeking Renaissance workers able to personally grapple with all five suggested actions, but we feel that every division of geriatric medicine must be able to deal collectively with them. On the other side of this coin, we must declare what we can no longer do. We suggest that: Decisions about how to allocate our clinical time should be driven by where we can make the most difference and not by financial concerns. We have to retain, as well as recruit. Collectively we must fight against losing any of our small cadre of specialists to other clinical fields. Division Heads will need to be creative in ensuring comparable rewards and be willing to modify positions to make them attractive to potential, as well as current, members. Everyone stepping out (or students and residents “stepping away” from the field after initially expressing interest) of geriatrics should have an exit interview to discover what went wrong and how we could have prevented the defection. We should not be doing things which can be done equally as well, if not better, by others. This means more than working with fellow physicians. Those of us who have worked with nurse practitioners (NP), clinical nurse specialists, and other advanced practice nurses appreciate their ability to improve our efficiency and comprehensiveness. The same can be said for the other professionals with whom we work. We must acquire the resources to establish integrated and comprehensive teams of health-care professionals that can broaden and enhance our impact. Family physicians are admirably prepared to provide primary medical care for seniors with complex needs in both facilities and the community. Specialists in geriatrics should not be providing primary care but supporting the true specialists in this field. In many jurisdictions family physicians with additional geriatric training (e.g., Care for the Elderly) have worked side-by-side with geriatricians in the provision of consultative care to older persons. We have to ensure that these physicians have employment opportunities, equitable reimbursement, and job security. We must stop doing what doesn’t work or is inefficient—even if we like doing it. Where is the evidence that medical day hospitals are more effective than other forms of comprehensive care?(21) If there isn’t any, why do we persist in supporting them? While home or domiciliary visits are necessary for some of our patients, they are not needed by all. Domiciliary visits are rewarding and educational, but can be inappropriate and inefficient. Are we planning and performing these visits in an appropriate manner? Redefining ourselves in the manner described is all moot if we are unable to entice more trainees and practicing physicians into the field. It is not widely known that geriatric medicine is one of the most satisfying fields of practice, yet few trainees are currently choosing geriatrics, a phenomenon not unique to Canada. This trend needs to be reversed as the baby boomers travel through the last third of their life span. It is surely time for an urgent dialogue on these matters and how to deal with them not only within our divisions of geriatric medicine, but also with our hospital and university departments, faculties of medicine, and regional and provincial health authorities. We must establish priorities for the future of our specialty but, more importantly, for the future of quality care for older persons. And if we do not, Canada will become, to borrow a film title, No Country for Old Men (or Women).
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                Author and article information

                Contributors
                dhogan@ucalgary.ca
                Journal
                J Am Geriatr Soc
                J Am Geriatr Soc
                10.1111/(ISSN)1532-5415
                JGS
                Journal of the American Geriatrics Society
                John Wiley & Sons, Inc. (Hoboken, USA )
                0002-8614
                1532-5415
                11 May 2020
                : 10.1111/jgs.16518
                Affiliations
                [ 1 ] Division of Geriatric Medicine, Cumming School of Medicine University of Calgary Calgary Alberta Canada
                [ 2 ] Division of Geriatric Medicine Dalhousie University Halifax Nova Scotia Canada
                [ 3 ] Allan M. McGavin Chair in Geriatric Medicine University of British Columbia Vancouver British Columbia Canada
                [ 4 ] Division of Geriatric Medicine, Department of Medicine Schulich School of Medicine and Dentistry, Western University London Ontario Canada
                [ 5 ] Department of Medicine and Institute of Health Policy, Management and Evaluation University of Toronto Toronto Ontario Canada
                Article
                JGS16518
                10.1111/jgs.16518
                7267568
                32343365
                5bca7f94-e825-421d-9aa7-5bc1c28b5ce0
                © 2020 The American Geriatrics Society

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                : 22 April 2020
                : 22 April 2020
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                Categories
                Letter to the Editor
                Letters to the Editor
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                Geriatric medicine
                Geriatric medicine

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