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Healthy Aging Interventions, Programs, and Initiatives: An Environmental Scan

July 2020

Summary

  • Canadians are generally living longer in good health than previous generations. However, there is still a high risk of frailty among community-dwelling older adults. With the older adult population steadily rising in Canada, it is important that effective interventions, programs, and initiatives are developed to support the healthy aging of older adults in the community.
  • Most of the interventions identified from the literature review showing benefit in healthy community-dwelling older adults focused on improving mobility and balance and/or preventing falls. Several other interventions were beneficial for improving physical and cognitive function, nutrition, and quality of life, and decreasing social isolation. Vaccinations were also found to be effective for preventing influenza, herpes zoster, and pneumonia infections in older adults.
  • Healthy aging in the community is being promoted across Canada through programs and initiatives delivered at the national, provincial, regional, and community level. Areas of focus include falls prevention, increasing physical activity, deprescribing, improving nutrition, decreasing social isolation, and improving access to services that allow older adults to age in place (e.g., help with yard work, housekeeping, and home repairs).
  • Innovative approaches are being used across Canada to ensure that healthy aging interventions in the community are practical and sustainable given limited health care resources. Some programs and initiatives are using collaborative partnerships between diverse sectors such as government, not-for-profit, and community organizations. Others are focused on engaging older adults in the leadership, outreach, training, and delivery of healthy aging programs and initiatives.
  • Some Canadian programs have been evaluated and have yielded positive results in terms of healthy aging outcomes. International evidence-based healthy aging resources are also available, some of which have been implemented in Canada.

Context

The population of older adults in Canada has been steadily increasing. As of July 1, 2019, there were an estimated 6.6 million Canadians older than 65 years (accounting for 17.5%  of the total population).1 It is projected that by 2036, older adults will represent 23% to 25% of the total population (up to 10.9 million).2 Although people living in Canada are generally living longer in good health than previous generations, there is still a high risk of frailty among community-dwelling older adults.3 Currently, an estimated 1.5 million older Canadians are considered medically frail.4 While there is no consensus regarding the definition of frailty, it is generally seen as a state of vulnerability that becomes more prevalent with age, accompanied by various indicators including unintentional weight loss, weakness, exhaustion, slow gait, and lack of physical activity.5-7 Frailty increases the risk of numerous negative health outcomes in older people including falls-related injuries, incident disability, hospitalization, long-term care or nursing home placement, dementia, and death.8 Frailty is also linked to a higher expenditure of health care resources. The operating costs to care for Canadians older than 65 living in long-term care facilities is approximately $31 billion dollars annually.4 The direct health care costs associated with falls in older adults is estimated to be $2 billion annually.9

Due to the significant clinical and economic burden of frailty, developing effective interventions and programs to support the healthy aginga  of older adults in the community has become an increasingly critical issue for community leaders and decision-makers across the country. Research has shown that frailty and the severity of chronic diseases, cognitive decline, and disability later in life can be prevented, minimized, or delayed using interventions that involve lifestyle changes and the maintenance of intellectual and social activities.11 The purpose of this Environmental Scan was to gather information on interventions, programs, and initiatives to promote healthy aging and prevent frailty in healthy community-dwelling older adults. 

Objectives

The key objectives of this Environmental Scan were to:

  • identify interventions from the literature that have demonstrated benefit in promoting and maintaining physical, mental, or social well-being in healthy older people who are living in the community
  • identify and describe specific programs, interventions, and initiatives that are being used in Canada and internationally to promote health aging and prevent frailty.

Methods

The findings of this Environmental Scan are based on a review of the literature, responses received from a survey, and an internet search. A description of these three components follows. Table 1 outlines the criteria for information gathering and selection.

Table 1: Components for Information Screening and Inclusion

Components Inclusion Exclusion
Population

People considered “healthy” older adults (i.e., approximately 60* years of age and older) who are living independently in the community

*A cut-off age of 60 was used for the survey in keeping with the current threshold used by the United Nations to define older adults.12 However, a more conservative cut-off of 50 years was used when screening findings from the literature and internet searches in order to capture some relevant interventions, programs, and initiatives for healthy aging that are available to younger individuals.

People with a history of frailty, cognitive impairment (including dementia and Alzheimer disease), or other chronic medical conditions

Intervention

Health-related interventions or programs provided at home or in the community aimed at promoting, improving, or maintaining physical, cognitive, and mental health and preventing frailty including:

  • promoting physical activity, exercise, and falls prevention
  • ensuring a healthy diet and nutritional support, and addressing malnutrition (excluding supplement-only interventions such as vitamins and herbs)
  • preventing social isolation, loneliness, and depression
  • promoting uptake of vaccinations
  • deprescribing inappropriate medications

The following programs, interventions, or initiatives were excluded:

  • those aimed at younger adults and children
  • those focused on reversing frailty (reablement), improving cognitive impairment, or slowing the progression of dementia
  • clinical interventions offered by health care professionals in primary, secondary, or tertiary health care settings (including screening for frailty or other health conditions) with the exception of deprescribing and immunization
  • non-health/health technology interventions, or interventions that are not part of a program (including community/environmental design, pet ownership, self-management resources)
  • social assistance programs
  • guidance documents or initiatives, including frameworks, strategies, recommendations, and guidelines
Settings
  • Home
  • Community
  • Health care settings
  • Assisted living/long-term care facilities
  • Nursing homes
Outcomes
  • Reduction in hospitalization
  • Falls reduction
  • Reduction in admission to assisted living, long-term care, or nursing home facilities
  • Delayed cognitive decline
  • Increased social engagement
  • Reduced social isolation, loneliness, and depression
  • Increased levels of mobility, fitness, and physical activity
  • Improved diet and nutrition
  • Reversal of frailty (reablement)
  • Improvement of cognitive impairment/dementia
  • Improved chronic disease management
  • Cost-effectiveness

Research Questions

The literature review, survey, and internet search components of this Environmental Scan aimed to address the following questions:

  1. What interventions have been shown to have evidence of benefit for promoting healthy aging or preventing frailty in healthy older adults living in the community?
  2. What healthy aging programs, interventions, or initiatives are being offered in centres across Canada?
    1. Which of these have been evaluated and shown to be effective?
  3. What evidence-based programs are offered internationally to support healthy aging?

A limited literature search was conducted by an information specialist on key resources, including PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, the University of York Centre for Reviews and Dissemination databases, and the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search strategy was comprised of both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and other keywords. The main search concepts were aging, frailty prevention, healthy aging, alternative therapies, social isolation prevention, and community-dwelling individuals. Search filters were applied to limit retrieval to health technology assessments, systematic reviews, meta-analyses, or network meta-analyses. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2014, and November 10, 2019. Regular alerts updated the search and citations retrieved until June 2, 2020, were incorporated into the report.

Survey

The survey comprised eight questions and used the SurveyMonkey platform. The questions were reviewed by external stakeholders and piloted within SurveyMonkey by independent CADTH researchers who were not involved with the project. The questions consisted of a combination of dichotomous (i.e., yes or no) and open-ended questions (see Appendix 1). The questions were designed to capture the following:

  • interventions that are currently being used in Canada to promote healthy aging or prevent frailty
  • whether any of these interventions had been formally evaluated
  • ongoing research or new initiatives to promote healthy aging in Canada.

The survey opened on December 12, 2019, and responses were received until February 13, 2020. Two email reminders were sent to non-responders. The survey attempted to capture information from across Canada, but not necessarily from every jurisdiction. The survey was distributed via email to key agencies, select stakeholders, and clinical experts involved in older adults’ health and health promotion. Respondents were identified through CADTH’s liaison officers, publications, and agencies identified while scoping and reviewing the literature, and from other survey respondents (some of whom forwarded the survey to other colleagues). All respondents gave explicit permission to use the information they provided in this report.

An internet search of various government, health care, academic, research, and community-based organizations was conducted to identify additional Canadian healthy aging resources as well as to capture relevant international evidence-based resources to promote healthy aging.

Synthesis Approach

One author screened the results of the database and grey literature searches for articles that met the inclusion criteria (see Table 1). Systematic reviews, meta-analyses, or network meta-analyses describing interventions to promote healthy aging in community-dwelling older adults were selected as well as literature describing programs or initiatives for healthy aging. The reference lists of relevant papers were also scanned to identify further relevant information. When several relevant reports for a particular outcome were identified (such as falls prevention), the most recent report and/or report using studies with higher methodological rigour were selected.

Programs and initiatives identified from survey responses and the internet search that met the inclusion criteria were also included in the report. Findings are summarized narratively and grouped by objective.

Findings

Objective #1: Identify interventions from the literature that have demonstrated benefit in promoting and maintaining physical, mental, or social well-being in older people who are living in the community.

The literature search identified a total of 689 articles. Of these, 141 were selected for full-text screening. A total of 30 systematic reviews were selected for inclusion in the Environmental Scan. Of these, 23 systematic reviews of interventions showing benefit for healthy aging outcomes in healthy community-dwelling older adults are summarized in the main report. The details of these reports are presented in Appendix 3, Table 3. Most of the identified interventions focused on improving mobility and balance and/or preventing falls. Several other interventions showing benefits in other outcomes (including improving physical and cognitive function, nutrition, social isolation, and quality of life) were also identified. Vaccinations were also found to be an effective intervention for preventing influenza, herpes zoster, and pneumonia in older adults.

Seven additional systematic reviews describing interventions that showed limited or no benefit for healthy aging outcomes are summarized in Appendix 3, Table 4. These included community screening for visual impairment; protein supplementation; computerized cognitive training; exergaming to improve cognition (physical activity in an interactive and cognitively demanding digital, augmented, or virtual game-like environment); various interventions to reduce social isolation (including physical activity, social interactions, and use of information and communications technology); and web-based interventions targeting cardiovascular risk factors.

Vaccinations

Vaccinations have been shown to be effective for preventing morbidity and mortality associated with certain infectious diseases.13 While the majority of routine vaccinations are administered in childhood and adolescence, some are also recommended in older adults due to the weakening of the immune system, the presence of medical comorbidities, and an increased risk of serious health complications and death.14 These include the influenza, herpes zoster, and pneumococcal vaccines. 13

Influenza Vaccine

Seasonal influenza epidemics are responsible for significant disease burden each year. Severe illness from influenza causes an estimated 12,200 hospitalizations and 3,500 deaths annually in Canada.15 Older adults are at increased risk of severe outcomes.15-17 In Canada, the standard-dose trivalent inactivated influenza vaccine is provided by publicly funded immunization programs.17 There is evidence that the standard-dose vaccination is less effective in adults over the age of 65 compared with younger adults.18,19 A new high-dose trivalent formulation (Fluzone High-Dose) has been developed to increase immune response and protection from influenza illness and was approved by Health Canada in September 2015. Findings from two systematic reviews show that in people 65 years of age and older, high-dose trivalent inactivated influenza vaccine improved protection against influenza-like illness compared with the standard-dose influenza vaccine.16,20 One systematic review also showed that the high-dose vaccine was more effective for preventing hospital admissions due to influenza illness, pneumonia, and cardiorespiratory events, as well as all-cause hospital admissions.16 However, the results did not show that the high-dose vaccine was more effective compared to the standard-dose vaccine for preventing post-influenza mortality or all-cause mortality.16 The National Advisory Committee on Immunization (NACI) recommends that adults over the age of 65 receive the high-dose influenza vaccine, given evidence of better protection compared to the standard-dose formulation.21 As of 2020, Ontario is the only jurisdiction that provides the high-dose vaccine to all people aged 65 years and older free of charge as part of the publicly funded influenza vaccine program.22 An estimated 70% of Canadians 65 years of age or older received the influenza vaccine during the 2018–2019 season.13 This is below the national goal of 80% vaccination coverage in adults aged 65 years and older23 and it’s not clear what proportion received the high-dose vaccine.

Herpes Zoster Vaccine

Herpes zoster, also known as shingles, is a manifestation of the reactivation of the varicella-zoster virus, which as a primary infection causes varicella (chickenpox).24 Complications from shingles include prolonged and often debilitating neuropathic pain (postherpetic neuralgia) that can significantly compromise quality of life.25 In Canada, approximately one in three people develop herpes zoster in their lifetime.25 The incidence and severity of herpes zoster and its complications increases sharply after the age of 50 years.25 Vaccination reduces the risk of varicella-zoster virus reactivation and the development of herpes zoster.26 Two herpes zoster vaccines are currently available for use in Canada — a live attenuated vaccine (Zostavax II) and an adjuvant recombinant subunit herpes zoster vaccine (recombinant zoster vaccine, Shingrix). Results from a systematic review indicate that using the recombinant zoster vaccine may prevent more cases of herpes zoster in adults aged 50 and older compared with the live attenuated vaccine.27 Based on the available evidence, NACI recommends that the recombinant zoster Falkenhorst vaccine should be offered to adults over the age of 50 who do not have any contraindications.26 As of 2020, Ontario is the only jurisdiction that provides the herpes zoster vaccine free of charge to people aged 65 to 70 years as part of the publicly funded vaccine program.28 Approximately 28% of Canadians 50 years of age or older have received the herpes zoster vaccine.13

Pneumococcal Vaccine

Pneumonia is a lung infection that may result in various symptoms including difficulty breathing, coughing, fever, fatigue, chest pain, and confusion.29 The bacterium Streptococcus pneumoniae, also referred to as pneumococcus, is a common cause of pneumonia.30 The most severe form of pneumococcal disease is invasive pneumococcal disease (IPD), which occurs when the bacteria infects normally sterile sites, such as the bloodstream (bacteremia) or central nervous system (meningitis).31 Adults over the age of 65 are at higher risk for IPD and case fatality in this population can exceed 20%.31 Pneumonia can also be the result of an influenza infection.29 In 2018, pneumonia arising from an influenza infection was the seventh leading cause of death in Canada in individuals aged 70 to 79, and the fourth leading cause of death in individuals over the age of 85.32 There are currently two vaccines available in Canada for the prevention of pneumococcal pneumonia — pneumococcal 23-valent polysaccharide vaccine (Pneu-P-23, Pneumovax 23), containing 23 pneumococcal serotypes, and pneumococcal 13-valent conjugate vaccine (Pneu-C-13, Prevnar 13), containing 13 pneumococcal serotypes.33 Results from a systematic review showed that Pneu-P-23 is effective against IPD and pneumococcal pneumonia in adults over the age of 60.34 Based on the available evidence, and in view of its broader serotype coverage compared to Pneu-C-13, NACI recommends adults of the age of 65 receive one dose of the Pneu-P-23 vaccine.33 As of 2020, the Pneu-P-23 vaccine is publicly funded in all the provinces and territories for all adults over the age of 65.28 However, it is estimated that 58% of adults over the age of 65 have received the pneumococcal vaccine.13 This is below the national goal of 80% vaccination (one dose) coverage of a pneumococcal vaccine in adults 65 years of age and older.23

Nutrition

Malnutrition, defined as a deficiency or imbalance in nutrient intake, has a relevant prevalence in community-living older adults, resulting in worsening of health conditions, frailty, and disability, and greater likelihood for hospitalization and mortality.35 Factors that contribute to malnutrition in older adults include loss of appetite due to an impaired sense of smell and taste, socioeconomic factors, and functional decline. A large population-based survey conducted in 2008 by Statistics Canada estimated that up to 34% of Canadians aged 65 years or older were at nutritional risk.36

Nutritional Intake

Meal delivery and congregate meal programs have been described as facilitating access to nutritional meals while encouraging individuals to engage in social interaction. To avoid malnutrition and address some of the barriers of obtaining an adequate food supply, home-delivered meals services provide meals in the home or in congregate settings for older adults living in the community who require nutritional support. Results from one systematic review suggest a beneficial effect of home-delivered meals on dietary intake of energy, protein and/or certain micronutrients (including calcium, vitamin A, B-complex vitamins, vitamin D, zinc, and magnesium) in older adults.37 Results for congregate meal services were limited, but these did not appear to improve nutritional intake.

Frailty, Functional Disability, and Cognitive Function

The Mediterranean diet is characterized by a high intake of plant-based foods (including fruits, vegetables, beans, nuts, and whole grains) and fish (a source of polyunsaturated fat); a moderate intake of alcohol, dairy products, and olive oil; and a low intake of meat.38 The recommended foods are rich with monounsaturated fats, fibre, and omega-3 fatty acids. Results from two systematic reviews found that community-dwelling older adults with greater adherence to a Mediterranean diet were less likely to develop frailty.39,40 Results from one systematic review also suggests that a greater adherence to a Mediterranean diet decreases the risk of developing functional disability.40 The effect of adherence to a Mediterranean diet on cognitive function was assessed in one systematic review.41 Results showed that adherence to a Mediterranean diet was associated with better cognitive performance and less cognitive decline over time.

Physical Activity

There is consistent evidence that physical activity is positively associated with healthy aging outcomes, regardless of definition and measurement.42,43 The key benefits of exercise in older adults include improved strength, flexibility, mobility, and fitness, which can improve daily function, help to maintain independence, and reduce the risk of falls and fall-related injuries.44-47 Group exercise programs have an added benefit of providing social engagement. Based on objectively measured data, only 15% of Canadians aged 65 to 79 years of age achieve the amount of exercise recommended by the Canadian Physical Activity Guidelines (at least 150 minutes of weekly moderate to vigorous physical activity in sessions of 10 minutes or more).48 Furthermore, adults aged 65 to 79 are sedentary for an estimated average of 10.1 hours per day (excluding sleep time).48 Several barriers to achieving the recommended amount of physical activity among older adults, particularly in rural communities, may include adverse weather and long winters, limited indoor recreational facilities, and the requirement to travel to larger centres with the necessary infrastructure and programs.

Falls and Fear of Falling

An estimated 20% to 30% of Canadians older than 65 years fall each year.9 Falls account for 85% of injury-related hospitalizations among older adults and 95% of all hip fractures.9 Older adults who have fallen commonly experience negative health outcomes such as chronic pain, fear of falling, loss of independence, greater isolation, confusion, reduced mobility, and depression.49 Over a third of older adults are admitted to long-term care faculties following a fall-related hospitalization.9 In Canada, the number of deaths due to falls increased by 65% from 2003 to 2008.9

Exercises that target balance, gait, and muscle strength have been studied to prevent falls in older adults. Results from a Cochrane systematic review found that exercise programs reduce the rate of falls and the number of people experiencing one or more falls.49 Exercise programs were effective regardless of whether they were delivered individually or in groups, by health professionals or trained non-health professionals, to younger or older participants (based on a 75 years of age threshold), or to those identified as high- or low-risk for falls.

The effects of exercise on risk for fracture and hospitalization are uncertain, mainly reflecting the considerable under-reporting of these outcomes in the included studies. Different forms of exercise had different impacts on falls. Results showed that exercises that mainly consisted of balance and functional training for an average of 25 weeks were significantly more effective for reducing falls when compared with an inactive control group.50 Programs involving multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) for an average of 26 weeks and tai chi for an average of 20 weeks may also reduce falls in community-dwelling older adults.50 The effects of other types of exercise on falls, such as resistance training (alone), dance, or walking were less certain. Flexibility and endurance training have not been evaluated for falls prevention.

Fear of falling has been associated with reductions in physical and social activities, negative impacts on quality of life, and an increased risk of future falls.51,52 A Cochrane systematic review investigated the effects of exercise interventions on fear of falling in community-dwelling adults aged 65 years and older.53 Results showed that exercise interventions were associated with a small to moderate reduction in fear of falling in community-living older adults immediately post-intervention. There was a small but not statistically significant effect in the longer term (≥ six months post-intervention). The effect of exercise interventions did not vary by type, frequency, or duration of exercise (five weeks to 130 weeks), or by the falls risk of participants. Subgroup analyses suggested that the effect of exercise interventions may be greater when group exercises rather than individual exercises were used. No significant reduction in fear of falling was found beyond the end of the exercise intervention.

Sarcopenia, Lean Body Mass, Muscle Strength, and Physical Performance

Physical activity represents a key approach to preventing muscle weakness and improving physical function in older adults.54,55 Sarcopenia is an age-associated progressive decrease of skeletal muscle mass and strength.56 Sarcopenia is known to lead to frailty, cachexia (weight loss and muscle wasting), osteoporosis, metabolic syndrome, and death.57 A growing body of research has confirmed the association between physical activity and a lower prevalence of sarcopenia.57 Results from one systematic review indicate that physical activity in community-dwelling adults over the age of 60 reduces the odds of developing sarcopenia later in life.58 A systematic review and network meta-analysis assessed the comparative effects of resistance training, endurance training, and whole-body vibration exercise on lean body mass, muscle strength, and physical performance in older people over the age of 60.59 Results showed that resistance training for a minimum of six weeks was the most effective intervention, achieving substantial increases in muscle strength and moderate improvement in physical performance compared to usual care. Whole-body vibration exercise appeared to have a small beneficial effect on physical performance. None of the interventions (resistance training, endurance training, or whole-body vibration) had any significant effect on lean body mass.

Physical and Cognitive Function

Evidence suggests that physical function and cognitive function are linked, and being physically active may protect against the onset of dementia or slow its progression.60-62 A systematic review and meta-analysis examined the effects of exercise training on physical and cognitive function and the association between changes in both outcomes in older adults over the age of 60.63 Results showed that an exercise program with components of both aerobic training and resistance training was beneficial for both physical function (with the greatest benefits being toward improving functional capacity and body strength) and cognitive function in older adults. At the study level, there was a positive correlation between the size of the exercise-induced effect on physical function and on cognitive function (such that studies with large effects in physical function tended to show large effects on cognitive function).

Quality of Life

A higher quality of life may be associated with a lower risk of cardiovascular disease, chronic disease, and falling in older adults.64,65 Moreover, improving quality of life may positively affect sleep quality, which may help reduce psychological disorders such as depression and reduce the risk of cognitive decline.66,67 A meta-analysis quantified the overall effect of physical exercise training on quality of life in healthy older adults over the age of 65.68 Secondary outcomes included the effects of physical exercise on social, physical, and psychological components of quality of life. The analysis showed a positive, medium-sized effect of physical exercise training on quality of life in healthy older adults. Results also showed a medium-sized effect of physical exercise on the physical and psychological component of quality of life, but no effect on the social component of quality of life.

Musical Programs to Enhance Cognitive Function

Musical practice is one of the activities that is considered to contribute to cognitive reserve by involving multiple sensory and motor systems and requiring a higher-level cognitive process.69 One systematic review investigated the potential of musical practice as an enhancer of cognitive function in healthy aging. Results indicated that piano lessons of four to six months’ duration lead to improvements in cognitive functions in older adults, especially in high-level functions, such as reasoning.

Interventions to Reduce Social Isolation

Remaining socially engaged has been found to be a key factor in aging well.70 Having a network of family and friends allows older adults to participate in social life and achieve a sense of belonging and purpose.71,72 Socially isolated individuals lack contact with others, support, and a sense of belonging.73-75 They have an unmet need for meaningful social interactions, which is often identified as loneliness.75,76 Older adults who are socially isolated are more likely to experience a poor quality of life, morbidity, and mortality.77 Social isolation is also linked to the undervaluing of older adults in society and the loss of older adults’ valuable contributions to the volunteer sector, and to the paid economy.78-80 Statistics Canada estimates that 24% of Canadians 65 and older feel isolated from others and wish they could participate in more social activities.70

One systematic review investigated the impact on health and well-being of interventions that foster respect and social inclusion (defined as the opportunity for individuals to cultivate social relationships, have access to resources, and feel part of the community they live in) of community-dwelling adults over the age of 60.81 Interventions involved mentoring (engaging older people in social activities with others within a group setting), intergenerational programs (including mentoring, school, reading, and reminiscence initiatives and interventions based on service-learning pedagogy), multi-activity programs (including projects to encourage older people to participate in various activities organized in the city, regular gatherings at neighbours’ homes and interactions with others, social clubs and exercise programs, regular meetings to discuss health information topics, peer-led exercise, or cultural activities), dancing, music and singing, art and culture, and the use of information and communications technology (including computer training and internet usage). The interventions that were associated with an overall positive impact on health outcomes were music and singing, intergenerational interventions, art and culture, and multi-activity interventions. Benefits included improvements in depression, well-being, subjective health, quality of life, perceived stress and mental health, and physical health. Due to a paucity of evidence for mentoring, dancing, and the use of information and communications technologies, the effect of these interventions on healthy aging outcomes was not clear.

Cognitive Behavioural Therapy

Cognitive behavioural therapy (CBT) is a psychotherapeutic approach that functions on the assumption that an individual’s behaviour and emotions are influenced by their perceptions toward the event.82 CBT-based strategies aim to change the underlying beliefs that give rise to the maladaptive behaviour through the use of motivational techniques and goal-setting.83

Fear of Falling and Balance

A CBT-based approach could potentially alter maladaptive behaviours (such as refusing to leave the home) in older adults with a fear of falling and enhance positive behaviours such as physical activity participation, social participation, and self-care. One systematic review evaluated the effects of CBT for reducing fear of falling and enhancing balance in healthy community-dwelling adults over the age of 60.84 CBT was delivered in groups or privately, either in person or over the phone. The CBT sessions lasted between four weeks and 20 weeks and included goal-setting and promoting physical activity. Results indicated that CBT may slightly lower the risk of falling and improve balance. For risk of falling, the beneficial effects of the interventions began immediately after therapy ended and lasted for six months to 12 months, while for balance the beneficial effects of the intervention were observed within six months of the end of treatment. Results also indicated that individual CBT may produce stronger effects than CBT done in groups.

e-Health Interventions

e-Health is a term used to describe the use of information and communications technology (including the internet, web-based apps, tablets, and smartphones), health care and health promotion-focused web-driven applications (such as telemedicine and electronic health records), virtual interventions, exergaming (physical activity in an interactive and cognitively demanding digital, augmented, or virtual game-like environment) , and personal health monitoring systems (including wearables) to deliver treatment, information, and interventions designed to improve health.85 e-Health technologies have the potential to deliver low-cost health interventions on a large scale and could change how many community services are delivered and accessed. Although there is considerable breadth in terms of the types of e-health interventions that have been studied, there is limited high-quality evidence to establish the role of these technologies for improving physical or cognitive performance, or quality of life in older adults.86,87 Furthermore, systematic reviews of computerized cognitive training88 or exergaming89 to improve cognition, information and communications technology interventions for reducing social isolation,81,90 and web-based interventions targeting cardiovascular risk factors91 have not found evidence of consistent benefit in older adults. The section that follows describes e-health interventions that have shown to be beneficial for mobility, balance, and fear of falling in community-dwelling older adults.

Mobility, Balance, and Fear of Falling

One systematic review assessed the clinical effectiveness of computerized cognitive-based interventions for improving simple (normal walking) and complex (walking while talking) gait in adults older than 60 without major cognitive, psychiatric, neurologic, and/or sensory impairments.92 Results showed that computerized cognitive training interventions can improve mobility-related outcomes, especially during complex walking conditions requiring higher-order executive functions. Intervention duration, training frequency, total number of sessions, and total minutes on the intervention were not significant predictors of improvement in complex walking speed. Cognitive-based approaches could provide a low-risk and accessible treatment opportunity serving as an alternative or supplemental strategy for those older adults who do not or cannot engage in physical exercise regimens as a result of physical, motivational, medical, or socioeconomic limitations.

One systematic review assessed the effectiveness of virtual reality games for falls prevention in community-dwelling older adults.93 Several studies investigating virtual reality games compared with no treatment and conventional exercise interventions demonstrated that the virtual reality games had significant and positive effects on balance and mobility. Moreover, studies showed benefits in favour of the virtual reality games for fear of falling, reaction time, and muscle strength of the lower limbs compared with traditional programs, such as balance and resistance exercises.

Multi-Component and Multifactorial Interventions

A broad range of sociodemographic, physical, biological, lifestyle, and psychological factors have shown to be associated with the development of frailty in community-dwelling adults.3,94 Hence, an approach integrating different types of interventions that targets two or more risk factors for frailty may be beneficial. Multi-component interventions include different components that are fixed (i.e., the same component interventions are provided to all participants). Multifactorial interventions are focused interventions that target multiple modifiable risk factors identified during a comprehensive risk assessment. As such, the applied interventions are individualized and, within any treatment cohort, not all people receive the same combination of interventions. The manner in which multifactorial interventions are delivered also varies.95

Cognitive Function

One meta-analysis evaluated the potential synergistic effects on objectively measured cognitive functions (e.g., memory, attention, executive control) when physical activity interventions are combined with cognitive activity interventions.96 Relative to the control group, multi-component interventions combining physical activity (including aerobic and/or strength training components) and cognitive activity (involving cognitive training exercises) showed significantly larger gains in cognition. Studies that compared combined physical activity and cognitive activity interventions to physical activity interventions alone showed small but significantly greater cognitive improvement in favour of combined interventions. No significant difference was found when combined physical activity and cognitive activity interventions were compared to interventions of cognitive activity alone. Furthermore, cognitive effects tended to be more pronounced for studies using simultaneous designs (interventions including physical activity and cognitive activity concurrently such as exergames, dance, tai chi, or martial arts) versus sequential designs (interventions with separate sessions of physical activity before or after separate sessions of cognitive activity).

Falls Prevention

A Cochrane systematic review assessed the effects of multi-component and multifactorial interventions to prevent falls in community-dwelling adults over the age of 60.97 Multi-component interventions included exercise in combination with education; home safety; nutrition; psychological interventions; home safety and nutrition; home safety and vision assessment; and nutrition and psychological interventions. Exercise was the most common pre-specified component of multifactorial interventions, followed by environment and assistive technologies (e.g., home hazard assessment and modifications, referral to occupational therapist), medication review, and psychological interventions (e.g., cognitive behavioural interventions, referral to mental health services). Compared to usual care or attention control (intervention not thought to reduce falls), results showed that both multi-component and multifactorial interventions may reduce the rate of falls. Multi-component interventions may also reduce the risk of sustaining one or more falls and the number of people who experience recurrent falls. There was not enough evidence to determine the effects of either intervention on other fall-related outcomes (such as fractures or hospital admissions). There was no evidence to indicate that either multi-component or multifactorial interventions were superior to exercise alone for preventing falls.

Another systematic review assessed the longer-term effects (greater than 12 months of follow-up) of multifactorial interventions compared with usual care (i.e., no change in usual activities) or usual care plus advice (in either written, audio, or visual format) for preventing falls in older people living in the community.95 The results showed that while multifactorial interventions may reduce the rate of falls and slightly reduce the risk of people sustaining one or more falls and recurrent falls, they may make little or no difference to other fall-related outcomes (such as fall-related fractures, falls requiring hospital admission or medical attention, and health-related quality of life). Results also showed that the effect of multifactorial interventions in reducing the rate of falls may be smaller when compared with usual care plus non-tailored falls prevention advice as opposed to usual care only.

A systematic review and network meta-analysis was conducted to determine the most effective interventions for preventing falls in community-dwelling adults aged 60 and over.98 The interventions assessed included education, risk assessment, medical care (including vitamin D3 supplements and treatment of vision problems), hazard assessment (including personal or environmental safety recommendations and modifications), a combination of risk assessment and exercise, a combination of hazard assessment and exercise, and multifactorial interventions including three or more interventions. Compared to usual care, multifactorial interventions demonstrated the greatest efficacy for reducing the incidence of falls, followed by interventions combining education and exercise and interventions combining exercise and hazard assessment. Notably, although the analysis ranked multifactorial interventions as the most effective intervention, single interventions such as exercise and risk assessment achieved nearly the same effectiveness. The analysis did not consider other fall-related outcomes such as fractures or hospitalization.

Objective #2: Identify and describe specific programs, interventions, and initiatives that are being used in Canada and internationally to promote healthy aging and prevent frailty.

The findings presented are based on the survey results, the literature search, and an additional internet search. Of 102 surveys sent out, 29 responses were received. Three of these responses were incomplete and could not be used. The jurisdictions and organizations represented by the survey respondents are presented in Appendix 2. Details of the identified Canadian and international programs, interventions, and initiatives are summarized in Appendix 4. Healthy aging resources identified from the literature review, survey results, and the internet search that were not within the scope of this scan but that may be of interest (including Canadian self-management resources, guidance resources, community and environmental design initiatives, and pet ownership studies) are presented in Appendix 5.

Canadian Best Practices Portal of Evidence-Based Programs

The Canadian Best Practices Portal provides access to evidence-based public health interventions.99 The portal provides several useful resources to help stakeholders plan for the implementation of certain programs or interventions including evidence of effectiveness, implementation history, expertise required, implementation supports, and associated resources. A number of evidence-based healthy aging programs that are suitable for implementation within the home or community setting were identified (Appendix 4, Table 5). Most of the programs focus on falls prevention. The remaining programs focus on increasing physical activity, improving nutrition, and decreasing social isolation. Some of the identified programs have been implemented either nationally or provincially in Canada and are subsequently described.

Finding Balance

Finding Balance is a campaign designed to increase awareness of falls prevention strategies in older adults.114 It was developed by the Injury Prevention Centre at the University of Alberta in partnership with seniors’ groups, health care organizations, and practitioners across Canada. The program is administered nationally by provincial stewards (various partners such as regional health authorities, public health organizations, and community health groups) tasked with delivering the program in their respective regions.

Stay on Your Feet

Stay on Your Feet is a program that aims to reduce falls and fall-related injuries among older adults living in the community.116 The core strategies of the program include raising awareness, community education, policy development, home hazard reduction, media campaigns, and working with health professionals.100 The use of local knowledge, leadership, and expertise is emphasized, along with fostering community partnerships. A variety of falls prevention resources are offered including free exercise classes in the community, and there are opportunities for networking. The program has been implemented in Ontario and other jurisdictions are at various stages of the implementation process.

Get Fit For Active Living

Get Fit For Active Living is an eight-week education and exercise program designed to introduce older adults to the benefits of exercise and an active lifestyle.125 The program was developed by the Canadian Centre for Activity and Aging and is delivered nationally in Canada.

Food Skills for Families

Food Skills for Families is a hands-on curriculum-based program developed by community-based dietitians and educators.133 The program empowers older adults to eat well by creating easy meals using fresh whole ingredients. The program has been delivered in more than 150 communities throughout British Columbia. Collaborative work with health authorities and other provincial, regional, and community programs continues to extend the reach of the program and enhance its equitable distribution.

Canadian Healthy Aging Programs and Initiatives

A number of programs and initiatives delivered at the national, provincial, regional, and community level were identified for falls prevention, increasing physical activity, deprescribing, improving nutrition, decreasing social isolation, and improving access to services that allow older adults to age in place (e.g., help with yard work, housekeeping, and home repairs)(Appendix 4, Table 6). Various strategies for promoting and implementing healthy aging programs are being used. These strategies include training programs, tool kits, and other resources to raise awareness of the programs available in the community; access to transportation for social events, medical appointments, and fitness classes; access to assessments by health care professionals (including physicians, pharmacists, occupational therapists, and dietitians) in community or home settings; financial assistance for home safety renovations or practical needs (such as housekeeping and home maintenance) to allow older adults to stay in their homes longer; and networking opportunities for health professionals, caregivers, researchers, and policy-makers.

Innovative approaches are being used across Canada to ensure that healthy aging interventions in the community are practical and sustainable, given limited health care resources. Some programs in Canada are using collaborative partnerships between diverse sectors such as government, not-for-profit, and community organizations. Others are focused on engaging older adults in the leadership, outreach, training, and delivery of healthy aging programs and initiatives. The peer-health educator model has been shown to be effective for breaking down communication barriers, reaching isolated groups of older adults, and improving healthy behaviours through positive role modelling.101-103 Some of these programs are subsequently highlighted.

Better at Home

The Better at Home program helps older adults in British Columbia with simple day-to-day tasks (such as yard work, housekeeping, and minor home repairs) so that they can continue to live independently in their own homes and remain connected to their communities.104 The Government of British Columbia funds the program, the United Way of the Lower Mainland manages it, and local non-profit organizations provide the services. The program is delivered by volunteers along with dedicated staff and contractors. A seniors-planning-for-seniors approach means older adults contribute to the design, operation, and evaluation of their local program. Through local, regional, and provincial collaboration, the Better at Home program identifies ways to integrate program services with existing support services for older adults throughout the spectrum of care, including medical, non-medical, and social services. The program continues to build linkages with other seniors’ programs and services, including with health authorities, ensuring that the program is better integrated into existing networks. An evaluation of the program showed that more than 90% of seniors were satisfied with the frequency, length, affordability, and accessibility of services.105 The most meaningful impacts of the program reported by older adults were managing the tasks of daily living, and feeling safe, supported, and able to stay in their homes longer. Social connectedness was identified as a significant and positive outcome of all program services. An evaluation of a pilot project in hard-to-serve rural and remote communities found the program has reduced gaps in services to older adults, enabling them to remain living independently in their homes; has had positive impacts on isolation and/or loneliness of older adults, connection with the community, and ability to safely live alone; and provided awareness and access to services that did not exist previously.106

Choose to Move

Another example of a program that uses collaborative partnerships and a capacity-building approach within communities is the Choose to Move program in British Columbia.107,108 In partnership with the British Columbia Ministry of Health, the Active Aging Research Team at the University of British Columbia co-created the Choose to Move health promotion program.109 Choose to Move is a free, evidence-based, six-month personal planning and support program designed for adults older than 65 who are not regularly active. It is a custom choice-based program that fits all interests, goals, and abilities. An action plan for physical activity is created by working with an activity coach (certified older adult fitness instructors or kinesiologists) who also provide ongoing support through monthly group meetings (to connect with fellow participants to learn about health topics and share successes and challenges), one-on-one consultations, and regular check-ins. Delivery partner organizations were identified based on their capacity to adapt, deliver, and sustain a physical activity program for older adults and to maximize reach to older adults in communities across all regions of the province.109 The program is delivered in partnership with the British Columbia Recreation and Parks Association and the YMCA. The effectiveness of the program was evaluated using a hybrid effectiveness–implementation study design.109 Results indicate that the program has beneficial effects on physical activity, mobility, and social connectedness.

Allies in Aging

Allies in Aging is a collective impact initiative that connects older adults across communities in British Columbia through leadership, outreach, training, and advocacy.110 The focus of the initiative is on older adults who are at risk of isolation due to disability, low-income, language, or cultural barriers. Four lead agencies developed neighbourhood-based and regional projects to improve social connections and supports for older adults in the community. Projects nurtured older adult leadership, provided intentional connections and outreach, and strengthened training opportunities with a focus on community-based capacity building. One of these projects, The Seniors Hub Model, empowered older adults to find meaningful ways for reaching out and connecting with vulnerable older adults in their communities.111 The goal of the project was to support the independence and active participation of older adults in community life. The main outcomes of this program included the identification and connection of isolated or under-represented older adults to appropriate services, information, and community activities, and the opportunity for volunteer older adults to gain the leadership skills, knowledge, and connections needed to sustain their neighbourhood seniors’ hub.

Supporting Healthy Aging by Peer Education and Support

Supporting Healthy Aging by Peer Education and Support, or SHAPES, is a study investigating an innovative partnership between seniors’ community organizations and clinical faculty at the University of Alberta.112,113 The project was designed to engage and empower older people to deliver sustainable health education and support for their peers living in the community. Health coaches, drawn from community-dwelling older adults, educated and supported their peers in healthy aging behaviours. The 12-week program contained four three-week interactive modules that focused on heart and bone health, nutrition, physical activity, and social engagement. Each module consisted of a one-hour workshop followed by three facilitated weekly discussion sessions. Participants were encouraged to take up healthy aging behaviours, undertake self-management techniques, or seek formal assistance if necessary. The study was completed in October 2019 and results will be shared with seniors’ organizations throughout Edmonton.

Culturally Informed Programs

There is a growing population of older Indigenous adults in Canada. From 2006 to 2016, the percentage of Indigenous adults over the age of 65 years increased from 4.8% to 7.3%.114 According to population projections, the proportion of First Nations, Métis, and Inuit populations 65 years of age and older could more than double by 2036.115 Key themes for healthy aging in the Indigenous population include connection with family, community, and the land; engagement in traditional medicine, social gatherings, and community events; preparation of traditional foods; spirituality; and language.116,117 There is evidence that maintaining roles as leaders in the community (in traditional ceremonies, teaching, and passing on traditional knowledge) as well receiving support from their families and social networks (including assistance with everyday activities such as grocery shopping, transportation, or home maintenance) are integral to successful aging among older Indigenous people.117 A number of programs and initiatives targeted at older Indigenous adults providing social and cultural supports in rural and urban settings were identified (Appendix 4, Table 7). Some are using collaborative partnerships between diverse sectors such as government, not-for-profit, and Indigenous communities. Many initiatives are addressing social isolation experienced by older Indigenous adults by creating opportunities to engage in culturally relevant social events in settings where they feel safe learning new skills and sharing their stories. Some programs and initiatives are giving Elders the opportunity to teach and pass on traditional knowledge to younger generations. Others are providing non-medical services (such as Meals on Wheels, transportation to medical appointments) so that they can remain in their homes longer. Training programs and tool kits for communities, groups, and individuals interested in developing and maintaining culturally informed programs for healthy aging in Indigenous populations are also available.

Technology-Based Programs

A few initiatives in Canada that are specifically investigating technology-based interventions to promote community-based healthy aging were identified (Appendix 4, Table 8). Two organizations based in Ontario, AGE-WELL (Aging Gracefully across Environments using Technology to Support Wellness, Engagement and Long Life)118 and the Centre for Aging + Brain Health Innovation119 are providing funding for the evaluation of innovative technologies (including a virtual reality bike, apps, online training programs, robotics, and devices) that could potentially support healthy aging in the community.

International Evidence-Based Healthy Aging Programs

A number of international programs with evidence of efficacy for community-dwelling older adults were identified for healthy aging in general, falls prevention, mental health, and medication review (Appendix 4, Table 9). Of the identified programs, one is currently in the process of being tested for implementation by a research team at the University of British Columbia.120 The Otago Exercise Program, which consists of strength and balance training delivered by a physiotherapist, has been shown to reduce falls in older adults who are at risk of a fall.121 The research team recently demonstrated that exercise coaching with the use of a wearable device, such as a Fitbit, was feasible and could help older adults stay active. A key element of the project was to empower older adults to develop realistic exercise goals. The current project is testing two methods of delivering the Otago program, which includes a new coaching approach by a physiotherapist and the use of a Fitbit to provide feedback (versus the traditional program delivery). The team will measure success by the degree to which the program is delivered as intended and the degree to which it is followed by older adults at 12 months, 18 months, and 24 months. The number of falls, risk of falling, and participation in walking activities between the two groups will also be assessed over time. In addition, the team will assess whether the coaching approach is a cost-effective option for delivering the Otago program.

Limitations

This Environmental Scan is not intended to be a comprehensive review on the topic of healthy aging. Due to the extensive body of literature relating to the topic of healthy aging, the literature review was restricted to recent evidence from systematic reviews, meta-analyses, and network meta-analyses. Hence, potentially relevant evidence from other study designs or from articles published prior to 2014 may not have been captured. Although the cut-off age for inclusion of intervention studies was set conservatively at 50 years, studies including all adult populations were excluded and relevant evidence for the subpopulation of older adults may have been missed. Although the literature identified was not subject to critical appraisal, insights offered by the authors of the included reports indicate that most of the findings were based on low- to moderate-quality evidence. Furthermore, due to high heterogeneity in intervention components and delivery and inconsistencies in the measurement of outcomes across the studies, the results should be interpreted with caution. This report focuses on health or health technology interventions or programs delivered in the community to healthy older adults. Hence, some interventions (such as clinical interventions in health care settings, chronic disease management, age-friendly communities, and social assistance) were considered beyond the scope of this report. In addition, this report did not include studies evaluating the economic value of interventions for healthy aging. Thus, conclusions or recommendations about the cost-effectiveness of an intervention are outside the scope of this report. The survey was available in English only and there was lack of representation from Quebec and Canada’s three territories. Furthermore, the survey response rate (28%) was low and many of the survey responses included information for frail older adults. This information was not within the scope of this report and was therefore excluded. Hence, an additional internet search was conducted to identify additional healthy aging interventions, programs, and initiatives. Findings are intended to represent a snapshot of current Canadian and international interventions, programs, and initiatives for healthy aging. The concept of healthy aging may be viewed differently within different cultural and ethnic communities. Although culturally relevant resources were included in this report, the exploration of healthy aging resources specific to different groups was beyond the scope of this scan.

Conclusions and Implications for Decision- or Policy-Making

This Environmental Scan was informed by a review of the literature, responses received from a survey, and an internet search. There is evidence from the literature that numerous interventions have a positive impact on healthy aging outcomes in community-dwelling older adults. These include the influenza, herpes zoster, and pneumococcal vaccinations; home-delivered meal services; the Mediterranean diet; physical activity; musical programs; cognitive behavioural therapy; virtual reality games; some interventions targeting a reduction in social isolation (including music and singing, intergenerational interventions, art and culture, and multi-activity interventions); and multi-component or multifactorial interventions. Falls prevention is an outcome that has been extensively studied in healthy aging research. Exercise that mainly involves balance and functional training has been shown to reduce falls in community-dwelling older adults. However, effects on other falls-related outcomes (such as risk for fracture and hospitalization) are uncertain. While multi-component and multifactorial interventions with exercise as a main component have also been shown to reduce falls in older community-dwelling adults, there is a lack of evidence indicating that either intervention is superior to exercise alone for preventing falls.

Healthy aging is being promoted across Canada through programs and initiatives at the national, provincial, regional, and community level. Areas of focus include falls prevention, increasing physical activity, deprescribing, improving nutrition, decreasing social isolation, and improving access to services that allow older adults to age in place (e.g., help with yard work, housekeeping, and home repairs). Innovative approaches are being used across Canada to ensure that healthy aging interventions in the community are practical and sustainable, given limited health care resources. Some are using collaborative partnerships between diverse sectors such as government, not-for-profit, and community organizations. Others are focused on engaging older adults in the leadership, outreach, training, and delivery of healthy aging programs and initiatives. Those that have been evaluated have yielded positive results for healthy aging outcomes. Several programs and initiatives targeted at older Indigenous adults provide social and cultural supports in rural and urban settings. While there currently appears to be limited evidence to support the use of technology-based interventions for healthy aging in the community, research investigating various innovative health technologies is currently underway in Canada. International evidence-based healthy aging programs are available, some of which have been implemented in Canada.

In addition to this Environmental Scan, CADTH has prepared several reports related to the topic of healthy aging. All of these reports are available free of charge on the CADTH website:

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About this Document

Authors: Sarah Ndegwa, Danielle MacDougall

Acknowledgements: Leigh-Anne Topfer

Cite As: Healthy Aging Interventions, Programs, and Initiatives: An Environmental Scan. Ottawa: CADTH; 2020 July. (Environmental scan; no. 92).

Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services.

While care has been taken to ensure that the information prepared by CADTH in this document is accurate, complete, and up-to-date as at the applicable date the material was first published by CADTH, CADTH does not make any guarantees to that effect. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document. The views and opinions of third parties published in this document do not necessarily state or reflect those of CADTH.

CADTH is not responsible for any errors, omissions, injury, loss, or damage arising from or relating to the use (or misuse) of any information, statements, or conclusions contained in or implied by the contents of this document or any of the source materials.

This document may contain links to third-party websites. CADTH does not have control over the content of such sites. Use of third-party sites is governed by the third-party website owners’ own terms and conditions set out for such sites. CADTH does not make any guarantee with respect to any information contained on such third-party sites and CADTH is not responsible for any injury, loss, or damage suffered as a result of using such third-party sites. CADTH has no responsibility for the collection, use, and disclosure of personal information by third-party sites.

Subject to the aforementioned limitations, the views expressed herein are those of CADTH and do not necessarily represent the views of Canada’s federal, provincial, or territorial governments or any third party supplier of information.

This document is prepared and intended for use in the context of the Canadian health care system. The use of this document outside of Canada is done so at the user’s own risk.

This disclaimer and any questions or matters of any nature arising from or relating to the content or use (or misuse) of this document will be governed by and interpreted in accordance with the laws of the Province of Ontario and the laws of Canada applicable therein, and all proceedings shall be subject to the exclusive jurisdiction of the courts of the Province of Ontario, Canada.

The copyright and other intellectual property rights in this document are owned by CADTH and its licensors. These rights are protected by the Canadian Copyright Act and other national and international laws and agreements. Users are permitted to make copies of this document for non-commercial purposes only, provided it is not modified when reproduced and appropriate credit is given to CADTH and its licensors.

About CADTH: CADTH is an independent, not-for-profit organization responsible for providing Canada’s health care decision-makers with objective evidence to help make informed decisions about the optimal use of drugs, medical devices, diagnostics, and procedures in our health care system.

Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.

Contact requests@cadth.ca with inquiries about this notice or legal matters relating to CADTH services.