Scientific Research

Title: Unseen Spine: A Case of Infective Discitis masked by diverticulitis in older patient

Introduction:

Spinal infections include vertebral osteomyelitis, septic discitis, facet joint septic arthritis, and spinal epidural abscesses. The common presentation usually involves back pain, fever, and elevated inflammatory markers, with signs of neurological deficits implying presence of spinal epidural abscess. Spinal infections are infrequent (0.2–3.7 per 100,000 hospital admissions for spondylodiscitis), with relatively higher incidence in elderly patients.

Case presentation:

We present a case of an 80-year-old female patient with a complex past medical history, including chronic back pain, osteoarthritis, bladder cancer, breast cancer, and lymphedema. She presented to the emergency department with a 3-day-history of lower back pain radiating to the abdomen. There was no history of trauma. Examination revealed no signs of intra-abdominal infection. There was a significant elevation of white blood cell count and C-reactive protein (CRP). The initial CT scan identified acute, uncomplicated sigmoid colonic diverticulitis, which was treated under the surgical team conservatively with antibiotics, following which the patient was discharged. Thirteen days later, the patient represented again with the same symptoms with additional pain radiation to the right leg affecting mobility. There was lumbar spinal process tenderness on examination with persistently high inflammatory markers in blood. Blood cultures resulted positive for Streptococcus agalactiae. An MRI spine revealed infective discitis with a right paravertebral abscess, causing thecal sac compression evident on CT scan also with bilateral psoas abscess. Following starting an appropriate antibiotic course guided by the cultures, and CT-guided drainage of the abscess, the patient improved symptomatically and clinically.

Conclusion:

Spinal infections are uncommon, yet significant aetiology of back pain. They should be considered a differential diagnosis in anyone with new or increasing back pain. The investigation and treatment approach must be guided by history taking and clinical examination.

About 73% of people living with osteoarthritis are older than 55 years. Osteoarthritis can greatly reduce the quality of life. While surgical interventions (including joint replacement) present one approach to advanced and disabling osteoarthritis, non-surgical interventions help people living with the condition to manage pain and maintain optimal levels of functioning. Pharmacological options should be used in combination with non-pharmacological measures at the lowest effective dose for the shortest period of time possible. Lidocaine 5% plasters are used off license in clinical practice to treat chronic pain, and pain from osteoarthritis. The lidocaine contained in the medicated plaster diffuses continuously into the skin, providing a local analgesic effect. The low systemic exposure to lidocaine following use of the lidocaine patch 5% is particularly beneficial for patients with polypharmacy, or for patients who have low tolerance for systemic analgesics. 

The aim of this review was to examine the current evidence for using transdermal lidocaine patch in managing pain from osteoarthritis. A comprehensive literature search was performed using electronic databases to identify studies that assessed the effectiveness of transdermal lidocaine in osteoarthritis. Reference lists of included studies were also reviewed. 

6 studies were included in the review, with a total of 359 patients. 3 studies used the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, and showed significant improvement from baseline with use of 5% lidocaine patch in WOMAC pain scores(p<0.01), and 1 study showed significant improvement all 4 Neuropathic Pain Scale composite measures(p<0.001). 3 studies were included in a meta-analysis. This showed a significant improvement across pain, stiffness and physical function on WOMAC Osteoarthritis Index. 

Although these studies included small numbers, they have shown a positive effect. Older patients are more likely to have co-morbidities, frailty and polypharmacy which would prevent surgical/systemic pharmacological interventions. Further trials in this area would be beneficial.

Introduction Chronic insomnia and nocturia are frequently associated, particularly in older adults impacting sleep quality, daytime functioning and quality of life. This study evaluated the efficacy and safety of daridorexant in patients with insomnia and comorbid nocturia. Methods This double-blind, placebo-controlled, two-way cross-over study randomised 60 patients aged ≥55 years with chronic insomnia and self-reported nocturia to 4-weeks nightly treatment of daridorexant 50 mg or placebo. This was followed by a 14–21-day washout period, after which patients received the alternate 4-week treatment. The primary endpoint was change from baseline to Week 4 in self-reported total sleep time (sTST). Other insomnia endpoints included change from baseline in ISI score, sTST, depth of sleep and daytime functioning (Insomnia Daytime symptoms and Impacts Questionnaire [IDSIQ] total score. Nocturia endpoints, evaluated using the Minze diary Pod, included change from baseline in number and time to first nocturnal void. Safety endpoints included adverse events (AEs) and AEs of special interest (AESI: falls, urinary incontinence). Results Daridorexant (vs. placebo) significantly increased mean sTST (56.6 vs. 35.7 mins; p=0.002) at Week 4; significant improvements were seen from Week 1. Daridorexant (vs. placebo) significantly (p<.05) decreased isi scores (weeks 2, 4) and significantly (p<0.05) improved depth of sleep 1-4) idsiq total score 1, 3). daridorexant (vs. placebo) reduced the number nocturnal voids (week 1: -1.5 vs. -1.0, p<0.001; week 4: -1.6 -1.3, p="0.2026)." increased median time to first void (difference placebo, +31 mins, +23 no serious aes />/AEs leading to discontinuation were reported in the study. No AESIs were reported during daridorexant administration. Conclusion In patients with insomnia and comorbid nocturia, daridorexant improves sleep, daytime functioning and nocturia symptoms, with no increased risk of falls or urinary incontinence. Funding: Idorsia Pharmaceuticals Ltd 

Abstract Content -

 Background/purpose: To prepare future physicians to care for a growing aging population, the Canadian Geriatrics Society (CGS) Education Committee formed a working group in 2019 to update the 2009 Core Competencies in the Care of Older Persons for Canadian Medical Students. The goal is to assist medical educators with developing relevant undergraduate medical curriculum. Methods: The working group chose 5Ms model and canMEDs framework to develop the competencies. A modified Delphi process was used. National participants were recruited and three rounds of Delphi surveys were conducted via survey monkey. A 7 point Likert scale was used for each competency statement.

Results: The first round was conducted in October 2019, n=72, identifying the importance and skill level of the components of the competencies under three headings; knowledge, skills and attitudes. The second round was conducted in September 2020, n=54, with proposed competencies under seven headings; aging, caring for older adults, (5Ms): mind, mobility, medications, multi-complexity and matters the most with > 70 % agreement for all. Based on the strength of the agreement and comments, minor revisions were made and the final survey was conducted in June 2021. The agreement level for competencies varied from 85 - 98 %. Thirty-three core geriatric competencies were developed under 7 headings. The CGS education committee approved the competencies in Dec 2021. 

Conclusion: The 2021 Aging Care 5M Competencies framework integrates new concepts and knowledge that inform current practice in the field of geriatrics. Thirty-three core geriatric competencies for the graduating undergraduate medical student were developed and classified under 7 headings. The framework was distributed to the accreditation and examination bodies and Canadian medical schools and was published in Academic medicine. 2024 Feb 1;99(2):198-207. doi: 10.1097/ACM.0000000000005475. Epub 2023 Nov 19. Currently we are working on implementation of the competencies. 

Urgent Community Assessment: A realist review of what works, for whom, and in what circumstances for older adults after a fall. 

P Garraway1; L Woods1; B Raut1; R Dewar-Haggart2; S Lunuwila1; S McKelvie1 

1University of Southampton 2University of Oxford 

Introduction: Falls have a considerable effect on the physical and mental health of older adults. Urgent Community Response (UCR) services are increasing offered as a Community Alternative to aCute Hospitalisation (CAtCH) for falls management. These services often provide a home based assessments following an fall but there is limited understanding of how and for whom these services should be utilised. 

Aims: This study used a realist approach to review the literature and generate theories as to how, why and in what context, urgent community assessment could work for older people who have fallen at home. 

Methods: We searched 3 databases (Medline, Embase and CINAHL) for literature that discussed older people who were assessed in community settings by UCR, following a non-traumatic fall. Our search strategy used synonyms for Aged, Falls and UCR service types. Papers were selected based on relevance when forming theories. 

Results: 472 papers were found and 27 discussed UCR. Full text screening resulted in 14 articles for inclusion, which were assessed for relevance and quality. We found appropriate referral could be improved with training, effective triage and adapting to patient needs. Additional referral pathways may enable service access, whilst UCR provision offers the choice of home-based treatment. Home-based care is well established, which may support acceptability of UCR. However, availability was sometimes limited in rural areas. Finally, although UCR decreased hospital costs through admission avoidance, it could add informal costs to carers.  

Conclusions: Falls have a large impact on patients, families and carers. UCR may allow for home-based care and be helpful at directing onward care, even within hospital. Team working in UCR services may support reducing hospitalisations and falls prevention. Further research is needed to improve UCR triage processes, and health systems should consider how UCR services can be integrated for falls management for older people.  

Background: Our recent research found significant visit-to-visit variability in nurse-assessed Clinical Frailty Scale (CFS) scores in Emergency Departments (ED), potentially limiting their reliability across patient encounters. This study investigated whether laboratory-based frailty indices could provide more stable assessments while maintaining clinical utility.

Methods: We conducted a retrospective cohort study focusing on patients with multiple ED attendances between July 2017 and December 2021 across two London hospitals. From 23,956 patients with repeated visits (total visits = 60,381), we used linear mixed effects models to compare the visit-to-visit stability of nurse-assessed CFS scores against various automated frailty index configurations. We tested base, short-period, mean-type, high-features, and low-features configurations, plus a novel drug-adjusted version incorporating medication data.

Results: Nurse-assessed CFS scores showed marked visit-to-visit variability, with only 35% of score variance attributable to underlying patient characteristics (ICC=0.35). In contrast, automated measures demonstrated significantly higher stability (ICC range 0.48-0.74), with the drug-adjusted frailty index showing the highest consistency (ICC=0.74). While nurse assessments were significantly influenced by presenting complaints and illness severity (NEWS scores β=0.12, p<0.001), automated measures remained stable across these acute factors while maintaining meaningful associations with age (β range 0.006-0.013, p<0.001) and clinical outcomes (c-statistic 0.718 for 90-day mortality).

Conclusions: The higher stability of automated measures suggests they could serve as valuable adjuncts to clinical assessment, particularly in helping establish a patient's baseline status from two weeks prior to admission - a key requirement of proper CFS scoring that can be challenging in busy ED settings. Whereas nurse assessments showed superior outcome discrimination, combining automated baseline data with clinical expertise could enhance the accuracy and efficiency of frailty assessment in emergency care. This synergistic approach could be particularly valuable in settings where comprehensive patient history may be difficult to obtain.

Background: Falls in people with dementia often result in physical and psychological impacts, reducing independence and increasing healthcare costs. Falls place a significant economic burden on the healthcare system. Although individuals with dementia face a heightened risk of falling, there is limited evidence supporting effective home-based interventions for this population. Methods: A mixed-methods process evaluation was embedded within a pilot cluster randomised controlled trial, guided by a realist framework. The evaluation was conducted across six UK sites (three intervention, three control). It included fidelity checks of routine data collection, observation of intervention sessions, multidisciplinary team (MDT) meetings, and therapist supervision. Semi-structured interviews were conducted with people with dementia, caregivers, and therapists. Results: High fidelity was achieved in home assessments and intervention delivery, with participants completing an average of 15 out of 22 planned sessions. Regular home visits enhanced engagement and motivation, while MDT support boosted therapist confidence in managing complex cases. Most participants met their functional goals and reported improved confidence. However, challenges included geographical and capacity variability in service delivery and inconsistent referral pathways. Therapists’ attitudes toward advanced dementia influenced intervention delivery. The dyadic approach supported activity engagement but occasionally increased caregiver responsibilities. Conclusions: The Maintain intervention was feasible and acceptable, with preliminary evidence of improved daily living activities and quality of life. A future trial should focus on standardising MDT support, addressing falls-related anxiety, and developing sustainable post-intervention strategies. Protocol adaptations, such as video consultations, demonstrated potential to mitigate workforce challenges.

INTRODUCTION:

We now face an increasing challenge of managing type 1 diabetes (T1DM) in older people. 3% of patients with T1DM are over 80 years old - a number that is set to rise over the coming decades. Diabetes is a risk factor for frailty, and advanced age comes with a higher incidence and severity of comorbidities affecting patients’ ability to manage their treatments, such as arthritis or dementia. A recent systematic search in England highlighted the scarcity of data surrounding this, finding no articles specifically researching frailty in older adults with T1DM.

CASE STUDY:

●90-year-old lady with T1DM

●Living alone with mild frailty

●Mild cognitive impairment

Despite living alone and being independent with many of her activities of daily living, her mild cognitive impairment made her unable to manage her insulin safely. Consequently, she had recurrent hospital admissions due to labile blood sugars. Local services (even in central Manchester) offer a maximum of two visits each day, which is not a safe insulin regime for most patients living with T1DM. As family were not available to support, she had prolonged inpatient hospital stays and ultimately had to explore 24-hour nursing care, despite being otherwise independent.

The case provides a poignant illustration of an issue which is only going to become more frequent as the early users of insulin now reach older age.

Introduction

The British Geriatrics Society (BGS) Flexible Workforce Statement supports national policy such as the NHS People Plan in promoting less than full time (LTFT) working.1,2 As LTFT trainee representatives on the BGS Trainees' Council we were interested to know how consultant work patterns are advertised. We analysed job adverts for Consultants in Geriatric Medicine over a two-year period to identify how many were LTFT posts.

Method

A freedom of information (FOI) request was submitted to online recruitment website ‘NHS Jobs’. The request identified jobs in ‘Elderly Care Medicine’ OR those containing ‘Geriatric’ in their title between 01/04/2019 and 31/03/2021. The FOI data were filtered to include only Consultant posts, grouped by training deanery and analysed using Excel. Regional numbers of LTFT trainees were identified by emailing Training Programme Directors and a FOI request to deaneries for non-responders. The number of LTFT consultants was identified using the online Royal College of Physicians census.3

Results

The FOI request returned 7589 jobs; of these 1083 were consultant posts. These ranged from 42 in Thames Valley to 171 in East of England. Twenty-one jobs (1.9%) were advertised as LTFT, the highest proportion was 11% in Yorkshire and Humber. Twenty-eight (2.6%) were negotiable, the highest proportion was 23% in the South West. Twenty nine percent of LTFT jobs were advertised as permanent posts. Currently, 37% of trainees, and 25% of consultants, work LTFT.

Conclusion

Number of LTFT job adverts was low compared to the number of LTFT consultants and trainees, although there is regional variation. A limitation was that details of adverts were not seen, which made it unclear whether each job was a fresh advert or readvertising an unfilled post. The latter is likely given there are 1747 consultants working in the UK.3 Further avenues of work include identifying LTFT opportunities for SAS grade doctors and allied health professionals.

References

1. https://www.england.nhs.uk/ournhspeople/online-version/lfaop/

2. https://www.bgs.org.uk/resources/flexible-working-in-geriatric-medicine

3. https://www.rcplondon.ac.uk/projects/outputs/working-differently-shadow…