Scientific Research

Background

Patients living with Parkinson's disease (PD) who are sarcopenic are at significantly higher risk of falling (Cai et al., Frontiers in Neurology,2021,12,598035). Handgrip strength is a useful tool to assess for sarcopenia but is not commonly measured in clinical practice, despite the consequences that sarcopenia poses. This study aims to incorporate handgrip strength into the assessment of outpatients living with PD. Secondary objectives are to increase the understanding of whether exercise is associated with increased handgrip strength and to implement interventions for patients who are identified as sarcopenic; to improve their health outcomes.

Methods

Questionnaires were designed to gather quantitative data about patients' demographics, how frequently they fall, disease severity and their weekly exercise. These were given to patients attending the movement disorders clinic at Crawley hospital, between February and October 2023. Patients without a diagnosis of PD were excluded. Their grip strength was measured using a standardised technique with a calibrated manometer. Data was input to Microsoft Excel and analysed using Spearman's rank and Kruskal-Wallis test.

Results

Handgrip strength was obtained for 125 of 271 patients (46%) attending clinic over this period. Initially healthcare workers took 9.2 minutes to complete the questionnaire but this improved to 4.3 minutes after updating the form. Sixteen patients were excluded, leaving 51 females and 58 males; both with a mean age of 80. Grip strength reduced with PD severity when adjusted for gender; this was significant in males (H=51.9, p=0.00) but not females (H=4.8,p=0.31). Grip strength was weakly correlated with exercise, although not significant (r2=0.15,p=0.15) but did not appear to be related to frequency of falls (r2=0.01,p=0.92).

Conclusions

Handgrip measurement can be successfully implemented into outpatient assessment. Handgrip strength could be used to monitor the effect of lifestyle change in individuals. Limitations include self-reporting bias; which activities each individual classifies as exercise.

Background:

Previous clinical trials assessing potential disease-modifying therapies (DMTs) for Parkinson’s disease (PD) have been hugely inefficient in terms of time and resources, resulting in >10 years for a single therapy to complete phase 3 assessment. Additionally, un-representative trial populations limit the generalisability of findings. Increased efficiency of clinical trial conduct has been successfully demonstrated in multi-arm, multi-stage (MAMS) trials, which assess multiple therapies in parallel and identify ineffective therapies at early-stage analyses. New arms can be added within existing trial infrastructure, providing opportunities to build on delivery frameworks and expertise. The Edmond J Safra Accelerating Clinical Trials in PD (EJS ACT-PD) initiative was set-up to address trial design inefficiencies and produce an inclusive protocol for a neuroprotective MAMS PD trial.

Methods:

Over 90 key stakeholders from across the UK, including people with PD and care partners form the EJS ACT-PD consortium. Six working groups have addressed trial design, outcome measures, therapy selection, infrastructure, funding and sustainability, and patient and public inclusion. Design decisions have been further informed by: a community advisory panel; an international advisory group; the MHRA; results of a UK-wide Site Capability Survey; a robust treatment selection process; statistical modelling; and literature reviews.

Results:

We have designed a phase 3 multi-centre, MAMS, randomised, double-blind, placebo-controlled trial to assess the clinical and cost effectiveness of potential DMTs in a representative PD population. The trial aims to recruit across 40 UK sites from December 2024. Wide-spread site inclusion and diverse recruitment will be supported by remote visit options; broad inclusion criteria; core-funded staff; and a tiered delivery approach based on site capabilities. The primary outcome of a patient-reported measure of PD impact will ensure meaningful results.

Conclusion:

MAMS trials offer exciting opportunities to accelerate the assessment of potential therapies whilst building on national infrastructure and encouraging diverse participant recruitment.

Introduction:

The kinin-kallikrein system has been implicated in muscle performance: bradykinin promotes glucose uptake and blood flow in muscle through bradykinin receptor 2 (BDKRB2). BDKRB2 variants include rs1799722 and rs5810761, where the T and -9 alleles respectively have associated with increased transcriptional rates and were overrepresented in endurance athletes. However, these variants have rarely been studied among older people or those with sarcopenia.

Methods:

The Leucine and ACE inhibitor (ACE) trial enrolled 145 participants aged ≥70 years with low grip strength and low gait speed. Participants’ blood samples had DNA extracted and were genotyped for rs179972 using TaqMan and rs5810761 by amplification through Hotstar Taq (and visualised through 4% agarose gel electrophoresis). The differences in genotypes for each variant against physical performance measures (e.g. six-minute walk distance [6MWD]) was calculated using t-tests or Mann-Whitney tests where appropriate. Genotypes were also tested for Hardy-Weinberg equilibrium (HWE) using Chi-squared test.

Results:

Data from 136 individuals were included in the analysis. For rs1799722, the genotype frequency (TT: 17, CC: 48, CT: 71) remained in HWE (p=0.248). No difference between TT and CC/CT group was seen for 6MWD, grip strength or SPPB. Among men, the TT genotype had greater 6MWD compared to CC/CT (400m vs 312m, p=0.007), and also greater leg muscle mass (17.6kg vs 15.3kg, p =0.005), but no difference was noted in women. For rs5810761, the genotype frequency (-9-9: 31, +9+9: 43, -9+9: 60) also remained in HWE (p=0.269). No difference between -9-9 and +9+9/+9-9 was seen for 6MWD, grip strength or SPPB. In men, but not women, -9-9 genotype had reduced arm fat baseline (1.85kg vs 2.72kg; p=0.005).

Conclusion: Among men, the TT genotype was associated with longer 6MW distance and higher leg muscle mass. The -9-9 genotype was associated with lower regional fat mass in men.

Introduction

Reference nutrient intake for protein amongst the general population is 0.75 grammes of protein per kilogram of body weight per day (g/kg BW/d). Expert groups recommend healthy adults over 65years have 1.0-1.2g/kg BW/d to support good health and maintain functionality (Deutz, Bauer and Barrazoni, Clinical Nutrition, 33(6):929-36). A recent paper suggested age specific recommendations of 1.2g/kg BW/d (Dorrington, Fallaize and Hobbs, Journal of Nutrition, 150(9):2245-2256).

This study aimed to quantify percentage of community dwelling older adults meeting recommendations for protein intake and explore factors associated with low consumption.

Methods

The study population comprised >65s completing the NDNS survey years 9-11 (2016-2019)*. Dietary intake was recorded in food diaries. Protein consumption was calculated as grammes per kilogram adjusted body weight per day (g/kg aBW/d). Adjustment made for body mass index (BMI) below 22kg/m² and above 27kg/m². Percentage of participants meeting protein recommendations for 0.75, 1.0 and 1.2g/kg BW/d was calculated. Chi-squared test for independence was utilised to determine association between social, health and lifestyle factors and low protein intake.

Results

Data from 385 participants were included; 43% male, 98% white. Mean protein intake was 0.98g/kg aBW/d (SD ±0.25). Prevalence of protein intake below 0.75g/kg aBW/d was 16.4% (n=63), below 1.0g/kg aBW/d was 52.2% (n=201) and below 1.2g/kg aBW/d 82.1% (n=316).

Current and ex-regular smoking was associated with protein intake <1g/kg aBW/d (p=0.01). No other analysis reached statistical significance although prevalence of low protein intake was higher in those without their own teeth (p=0.08), use of dentures (p=0.14) and BMI of 27-30kg/m² (p=0.09).

Conclusion

A large percentage of older adults are below expert recommendations for protein intake. There is a need for clarity over recommendations so that a clear public message can be given to optimise health and function in ageing. Factors influencing poor protein intake require further examination.

*University of Cambridge, MRC Epidemiology Unit, NatCen Social Research. (2023). National Diet and Nutrition Survey Years 1-11, 2008-2019. [data collection]. 19th Edition. UK Data Service. SN: 6533, DOI: http://doi.org/10.5255/UKDA-SN-6533-19

Introduction:

Socio-economic costs of hip fractures are formidable. Despite osteoporosis and falls being major risk factors, preventative screening in Primary Care does not occur. Evidence shows screening older women for osteoporosis prevents hip fractures, but to make a greater clinical and economic impact simultaneous screening of falls and fracture risks is logical. This cross-sectional study evaluates an innovative digital questionnaire and computer programme to combine person-reported data with medical data, and auto-calculate fracture and falls risks without the need for clinician time.

Method:

Digital questionnaires were distributed via email or SMS to adults aged ≥65 who had consented to receive electronic correspondence over a 16-week period in one medical centre. Excluded were adults in nursing/residential care or receiving palliative care. A computer programme combined patient-reported information with existing medical data required to calculate FRAX® & FRAT scores. A robot computer function retrieved fracture risk scores from the FRAX® online tool. A weekly report showed those at high/medium risk of fracture and high risk of falls. Personalised bone health and lifestyle advice was automatically distributed.

Results:

632 (37%) of 1692 questionnaires were returned. Ages ranged from 65 to 92 years (M=72.5, SD=5.7), 47.8% identified as male and 52.2% female. Using NOGG UK Guidelines (2021), 217 (34%) adults were identified at amber and 46 (7%) at red fracture risk. 131 (20.7%) adults had fallen within the previous year and 122 (19%) had a high-risk FRAT score ≥3. Personalised bone health and lifestyle advice was delivered to all 632 adults.

Conclusion:

This automated screening process accurately identifies adults who are falling and/or at risk of osteoporosis and enables personalised bone health and lifestyle advice to be distributed without the need for clinician time. Prevention of falls and hip fractures would result in significant savings to the NHS and Social Care budgets.

Introduction: Reducing inappropriate polypharmacy is a major public health goal and deprescribing is considered one potential solution. Although patient attitudes towards deprescribing have been well studied, little consideration has been given to the informal caregiver perspective, how this differs from the views of patients and how that might influence care.

Method: A survey including demographic questions and the revised Patients’ Attitude Towards Deprescribing (rPATD) questionnaire was undertaken. The primary outcome was to identify the willingness of respondents to deprescribe. This survey was distributed as online, telephone or paper versions, via social media, community centres, day care centres, local organisations, and personal networks. It had two sections composed of equivalent questions: one for the ‘patient’ (age 65+, based in England, taking one or more prescription medication) and one for their ‘informal caregiver’ (age 18+). Data were analysed using descriptive statistics and binomial logistic regression.

Results: After exclusion of ineligible respondents, a total of 1,307 survey responses were received (861 patients and 446 caregivers). The average patient was 76±9 years, female (526; 61.6%), white (831; 97%), and educated to degree level (482; 56.9%). The average informal caregiver was 73±14 years, female (278; 62.9%), white (426; 96.4%) and educated to degree level (258; 58.2%). A total of 77.1% patients agreed that they were willing to deprescribe medications if their doctor said it was possible. In contrast, significantly fewer informal caregivers were happy for their patient to have medications deprescribed (59.7%; p-value for difference <0.001). Trust in physician, concerns about stopping medication and belief in the appropriateness of withdrawal were all associated with respondent willingness to deprescribe.

Conclusion: This large study suggests patients are more willing to deprescribe than their informal caregivers. Better understanding these attitudes and how they differ between patients and caregivers, will help inform interventions to improve involvement in medication-related decisions.

Background: Managing agitation and other behavioural and psychological symptoms of dementia (BPSD) is a significant challenge and impacts on quality of life for people living with dementia. The priority is to find effective non pharmacological interventions as drug treatments can have significant side effects.

Objectives: This review evaluates the effectiveness of structured physical activity on agitation in people living with dementia Methods A rapid review of the literature was carried out following PRISMA guidelines. Four electronic databases were searched (Cochrane CENTRAL, MEDLINE, CINAHL and Embase) looking for interventional studies that used a structured physical activity programme in people with a diagnosis of dementia, studied the effects of this activity on BPSD and compared this with a control group that did not follow an exercise programme.

Results: From 112 identified articles, 13 were included in this review, involving a total of 1546 participants. The results were analysed and synthesised according to the type of exercise intervention (aerobic, multicomponent or strength training) and by the frequency and intensity of the intervention. Quality assessment using CAPS guidelines indicated four studies as higher quality with seven being of moderate quality. The results showed that aerobic exercise in particular appears to be effective in reducing agitation and those studies with higher adherence to exercise tended to demonstrate more positive effects on agitation and BPSD.

Conclusions: There is evidence that physical activity can be effective in the reduction of agitation in older adults with a dementia diagnosis. Further research is needed to clarify the type of intervention that is most beneficial and strategies to make physical activity more acceptable and available to older people with dementia need to be established

Introduction

Institutional care for older people is a relatively new social phenomenon in Egypt that is associated with societal stigma. Traditionally dependent older people are looked after by family members at home. There are currently 145 care homes in Egypt, mostly based in Cairo serving 2% of the older population. The aim of this study was to understand the perspectives of paid caregivers on the strengths, weaknesses, opportunities, and threats (SWOT) associated with their professional roles. This knowledge is crucial to deliver a culturally sensitive training program for caregivers, and enhance their job satisfaction, ultimately leading to person-centred high-quality care.

Method

Two focus group meetings, 90 minutes each, were conducted with 39 caregivers in a private care home in Cairo. Each group was further divided into four working sub-groups using a SWOT approach to guide the discussion. Generic themes were identified, analysed, and agreed on by the group participants.

Results

Thirty-nine caregivers (31 % males), age range 18-50 years, were interviewed including undergraduate and qualified nurses and social workers. Five themes were identified: administration, team values, training, place and equipment, and residents and families. SWOT findings related to each theme are summarised below: Theme Strength Weakness Opportunities Threats Administration Support and flexibility Poor incentives Access to healthcare services Lack of rest facilities Team values Peer support Mixed qualities in different leaders Outdoor recreational activities Lone working Training Mentoring program Unfulfilled training needs Regular updates on comprehensive geriatrics assessment No medical cover Place & equipment Resident accommodation Not always fit for purpose Health and safety compliance Cost of accommodation Residents & families Sharing knowledge Discriminatory attitudes towards staff Documentation of residents’ priorities Unfounded complaints

Conclusion

Reflecting on the views of paid caregivers provided valuable insight that could enhance the quality of institutional care for older people in Cairo.

Introduction. Falls are a common complication of Parkinson’s disease, driven in part by an underlying cholinergic deficit that contributes to gait and cognitive impairment. Phase 2 studies have established that amelioration of this deficit using cholinesterase inhibitors may reduce falls.

Methods.  CHIEF-PD (CHolinesterase Inhibitor to prEvent Falls in Parkinson's Disease) is a phase 3 randomised, double-blind placebo-controlled trial of rivastigmine to prevent falls in Parkinson's disease that recruited from NHS sites. Relationships between the Principal Investigators’ specialty and the participants baseline characteristics were evaluated using linear, logistic and ordinal logistic regression. Cognitive impairment was defined as MoCA ≤26, while falls in the prior 12 months were separated into ordinal quartiles (1-2, 3-5, 6-12, 13+).

Results. Recruitment to CHIEF-PD commenced in January 2020 and completed in April 2023. Recruitment increased up until the start of the pandemic and thereafter there were 2 peaks. Potential participants were identified through clinic lists, databases, via national and local media and charities. 600 participants were enrolled across 38 sites. Sites enrolled between 1 and 74 participants, each. The median recruitment rate was 19 participants per month (IQR 6-27). 14 (37%) sites had Principal Investigators that were neurologists and 24 (63%) sites had PIs that were geriatricians. Most participants (76%) were over the age of 65 years. Compared with neurologists, geriatricians recruited older patients (difference in means 2.08 (95% CI 0.68, 3.48); p=0.004), with similar levels of cognitive impairment (OR 1.20 (95% CI 0.85, 1.69); p=0.293) and a lower fall rate (OR 0.46 (95% CI 0.34, 0.62); p<.001) at baseline.

Conclusion. Recruitment of older participants to a clinical trial an investigational medicinal product (ctimp) throughout the covid-19 pandemic across 38 uk centres was feasible using multiple strategies. characteristics varied according sub-speciality principal investigator site.

Introduction

The housebound population are growing in number, with a large proportion living rurally or in coastal areas, which increases the risks of isolation and health inequalities. This population are an under researched and underserved group (Public Health England, 2019). Being unable to leave the home is a factor for living in the poorest of health, which contributes to advancing levels of frailty, Curtis et al (2018). Considering the current focus of empowerment to ‘age well’ (NHS England Long Term Plan, 2019), a granular understanding of community focused ageing well interventions is the focus of this review to empower clinicians to ‘make every contact count’ (NHS England 2020).

Method

A narrative evidence review of findings has been completed entitled ‘ageing well interventions to improve and maintain independent living for community housebound populations.’ The review was registered with PROSPERO international prospective register of systematic reviews (CRD 42022371047) and reported according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA). Data screening was undertaken by two reviewers at each stage to ensure accuracy, quality, and reliability.

Results

The results have identified key health interventions designed and delivered by community clinicians, including benefits of exercise, medication review, oral health, and health empowerment to improve outcomes for the housebound population. The results have outlined a total of twenty-nine outcome measures, which have been examined intrinsically and extrinsically to explore greatest impact for housebound health.

Conclusion

At the time of the Autumn conference, the research study will have completed the systematic review and be able to present findings to illustrate the areas of intervention synthesized for the target population. Key to this will be understanding the effectiveness and generalizability to a wider population of the literature findings. The poster presentation will be able to share progress of the wider study with opportunities to take part.

Curtis, L and Price, H. (2018) Meeting the challenges of housebound patients with diabetes. Practical Diabetes. 35:2. Pp55-57.

National Health Service England (2019) Long Term Plan. NHS England. London.

National Health Service England (2020) Making Every contact count: a consensus statement. NHS England. London.

Public Health England. (2019) Health Profile for England. Public Health England. London.