Scientific Research

Background: This study aims to investigate the relationship between frailty and in-hospital cardiopulmonary resuscitation (CPR) outcomes in the COVID-19 pandemic.

Methods: The study was carried out in a tertiary hospital in Scotland and included all patients over the age of 18 who had an in-hospital CPR attempt between April 2020 and March 2022. Patients were identified via the pre-existing National Cardiac Arrest Audit Database which was collected prospectively. Data collected from this included age, sex, initial arrest rhythm, return of spontaneous circulation (ROSC) and in-hospital mortality. The electronic and paper patient notes were retrospectively reviewed to calculate a Rockwood clinical frailty scale (CFS) and Charlson comorbidity index (CCI). The data was stratified in to frail (CFS ≥5) and non-frail (CFS <5) cohorts.

Results: 65 patients were included in the study. In univariate analysis, there was a significant difference between the frail and non-frail groups in age (p=0.006), ROSC (p=0.02) and survival to discharge (p=0.004). Only 10 out of 34 (29.4%) frail patients had ROSC and of those only 3 (8.8%) survived to discharge compared to 35.3% of non-frail patients. In a binary logistic regression, there was a significant association between frailty and both ROSC (adjusted OR 3.31 [95% CI: 1.12-9.78}) and survival to discharge (adjusted OR 6.33 [95% CI: 1.48-27.13]) and no significant association with age, CCI or sex.

Conclusion: The findings support the relationship between frailty and poor CPR outcomes independent of age and co-morbidity.

Introduction: Sedentary behaviour has been associated with several deleterious health outcomes and older adults are the fastest-growing and most sedentary group in society. This review aimed to systematically review quantitative and qualitative studies examining interventions to reduce sedentary behaviour in community-dwelling older adults.

Methods: This mixed-method systematic review (PROSPERO registration number: CRD42021264954) considered quantitative articles (randomised-controlled trials (RCTs) and cluster RCTs), qualitative articles (semi-structured interviews and focus groups) and mixed-method studies that explored interventions to reduce sedentary behaviour in community-dwelling older adults. Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Cinahl, SportDiscus and PEDRO were searched from inception to March 2023. Articles were appraised using the Mixed Method Appraisal Tool. Quantitative evidence was meta-analysed, qualitative evidence was thematically synthesised and both were combined in a mixed-method synthesis.

Results: Forty-one studies (15 RCTs, 21 qualitative and 5 mixed-method studies) were included. Interventions were somewhat effective at reducing sedentary time (-29.10 mins/day, 95% CI -51.74, -6.46). Three analytical themes were identified (what sitting means to older adults, expectations of ageing and social influence in older adults). The mixed-method synthesis identified that existing interventions have been limited by a recruited sample that is not representative of the wider population of older adults, and outcome measurement and intervention content that is not consistent with older adults’ priorities.

Conclusions: Future research should focus on inclusive recruitment strategies to recruit underrepresented populations (such as adults aged 75 years and above), incorporate outcome measures that are valued by older adults, and incorporate older adults’ preferences in intervention content.

Introduction: In 2021 the NHS Business Services Authority Data Science team openly published the first comprehensive nationwide analysis of over 65 care home versus non-care home prescribing. The analysis has been expanded to include three years of prescribing data and key falls risk prescribing metrics, offering new insight into falls risk prescribing for the over 65s in England.

Method: Patient address information from 1.8bn prescription forms was matched against 35m Ordnance Survey Address Base addresses. Patient addresses from prescription forms were classified as belonging to a care home or otherwise. Prescribing metrics around volume, cost, polypharmacy and falls risk were generated, with falls risk metrics informed by the STOPPFall study drug groups. These metrics were the mean number of falls risk medicines and proportion of patients prescribed three or more falls risk medicines within a given month.

Results: Over 65 care home patients received more prescribing of falls risk drugs than non-care home patients, whilst the proportion of care home patients on three or more falls risk drugs within a given month was double that of non-care home patients. Nearly 40% of care home patients aged 65-69 were prescribed three of more falls risk drugs within a given month, far more than both older care home patients and non-care home patients. Falls risk prescribing metrics displayed a great deal of variation by ICS and Local Authority.

Conclusion: Aside from headline figures and key findings, the analysis (due for public release in September 2023) allows granular analysis of over 65 falls risk prescribing, by patient age band, gender, geography and care home setting. The exploratory nature of the analysis lends itself to further investigation by healthcare analysts and clinicians, with the aim to gather feedback, iterate and expand the content annually.

Introduction

In the UK, fifty-three percent of hospitalised older people with dementia have multimorbidity, and are at an increased risk of hospital readmission within 30 days from discharge. Between 20-40% of these readmissions are preventable [1]. Current research focused on the biological causes of readmissions. However, older people with dementia have additional psychosocial factors increasing their risk of readmission. The aim of this scoping review was to identify psychosocial determinants within the context of known biological factors.

Methods

Electronic databases MEDLINE, EMBASE, CINAHL and PsychInfo were searched from inception until July 2022. Quantitative and qualitative studies in English including adults aged 65 years and over with dementia, their care workers and informal carers were considered if they investigated readmission. An inductive approach was adopted to map determinants of hospital readmission. Identified themes were described as narrative categories.

Results

Seventeen studies including 7,194,878 participants met our inclusion criteria from a total of 4736 articles. Sixteen quantitative studies included observational cohort and randomised controlled trial designs. One American study was qualitative. Ten studies were based in the USA, and one study each from Taiwan, Australia, Canada, Sweden, Japan, Denmark, and The Netherlands. Large hospital and insurance records provided data in over 2 million patients in one American study. Identified psychosocial determinants included inadequate hospital discharge planning, limited interdisciplinary collaboration, and socioeconomic inequalities among ethnic minorities. Biological determinants included reduced mobility and accumulation of comorbidities. Use of antipsychotic medications might explain the interplay between biological and psychosocial determinants.

Conclusion

Poorly defined roles and responsibilities of health and social care professionals and poor communication during care transitions increase the risk of readmission in older people with dementia.

Reference

1. Godard‐Sebillotte C, Strumpf E, Sourial N, et al L. Primary care continuity and potentially avoidable hospitalization in persons with dementia. J Am Geriatr Soc. 2021;69(5):1208-20.

Introduction: Around 10% of calls received by English ambulance services are for older adults who have fallen¹; with an ageing population there are significant care provision needs. Decision-making on the treatment for people who fall, can impact their future physical and mental health. Previous research in decision-making of ambulance staff found perception of role, confidence, service demands and training to be key drivers². The previous work highlighting drivers, but not the experiences that explain why they occur, leads this study aim to determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method: Online cross-sectional survey of frontline emergency clinicians from one English ambulance service in May 2023. Open questions generated qualitative data for thematic analysis³. Ethical and regulatory approvals, and informed consent, were obtained.

Findings: 81 participants completed the survey. Analysis identified three themes.

• Care Provision: Provision of hospital avoidance pathways varies throughout the region. Concerns arose from not knowing what different areas had and reduced accessibility out of hours.
• Communication: Decision-making confidence was impacted by the participants’ experiences of interactions with hospital and community colleagues; positive experiences encouraged use of hospital avoidance pathways, whilst negative experiences impeded willingness to avoid hospital for fear of repercussion.
• Shared Decision-Making: Patients, family and clinicians were all valued as part of shared decision-making, with past feedback on decision-making informing future practice.

Conclusion: Confidence of frontline ambulance staff was impacted by the challenge of a regional and 24/7 ambulance service not having consistent pathways available. Communication with other services impacts ambulance clinician’s future decision-making and confidence. This variation led to concerns when responding to patients outside of the clinician’s usual area, and further challenges ambulance clinicians must balance in their practice.

References:

1. Snooks, Anthony, Chatters, et al. (2017) Health Technology Assessment, 21; 1-218.

2. Simpson, Thomas, Bendall, et al. (2017) BMC Health Services Research. 17; 299.

3. Braun and Clarke. (2022) Thematic Analysis: A practical guide.

Older people with diabetes are often admitted with falls, dizziness or confusion that may stem from undiagnosed episodes of hypoglycaemia. We examined the use of a 10-day period of round the clock glucose monitoring (CGM), to detect hypoglycaemia in older people with diabetes with symptoms potentially related to hypoglycaemia. 

Methods 

Population: Age 75 years and older, on sulfonylureas and/or insulin, presenting to hospital with a fall and/or symptoms suggestive of unrecognised hypoglycaemia. 

Design: Single-centre, observational study (no change to standard diabetes care). Intervention: 10 days of CGM with Dexcom G6 sensor and Android app on smartphone to continuously transmit data. 

Primary outcomes: Proportion of participants with captured hypoglycaemia; within that group, time spent in the hypoglycaemic range (Battelino T, Danne T, Biester T, et al. Diabetes Care. 2019;42(8):1593-603.). 

Secondary outcomes: Overall time in range; emergency department re-attendances and/or hospital re-admissions for falls, fractures, heart attacks, ischaemic strokes and death within 30 days. REC IRAS project ID: 301286. 

Results 

26 eligible participants of which 13 consented to participate. At the time of writing, nine participants (mean age 81 years) completed the study.

There were no reports of pain or skin reactions from the participants.

Hypoglycaemic events were captured in 3 of 9 participants, with two participants suffering >1 hour below 3.9mmol/L. Only 3 participants achieved >50% time in range target (3.9-10.0mmol/L). 

Discussion 

We have detected significant hypoglycaemic episodes in our participants. CGM should be used more widely in older patients with diabetes who present with falls, dizziness or confusion. 

Limitations include issues around data capture due to participants struggling to navigate the mobile phone app. Despite this, all participants felt that CGM was better than finger-prick glucose testing. Future work is needed to explore how CGM can be deployed after acute admissions in this patient group.

Introduction

CompreHensive geriAtRician-led MEdication Review (CHARMER) is a behaviour change intervention to support geriatricians and pharmacists to proactively deprescribe inappropriate medicines with older adults in hospital. The intervention comprises: formulating a deprescribing action plan, workshops, benchmarking reports and weekly briefings between geriatricians and pharmacists. We assessed feasibility and acceptability of the CHARMER intervention and study processes.

Method

A two-arm purposive allocation feasibility study was undertaken in four hospitals (three intervention, one control) in England in 2022. Data were collected to check completeness and quality, and assess intervention fidelity. Rapid qualitative analysis of staff and patient interviews, intervention implementation observations (action plan launch, pharmacist workshop and geriatrician videos), and study meeting minutes was undertaken.

Results

Study data were feasible to collect, of sufficient completeness and quality. Geriatrician and pharmacist principal investigators managed intervention implementation. They were able to implement most intervention components with ease and fidelity. Principal investigators felt that dedicated support for intervention implementation would better equip them with the resource and expertise to fidelitously implement all intervention components. Detailed instructions for preparing the action plan and how it might be delivered were desired. Geriatricians and pharmacists who received the intervention found it acceptable. Pharmacists felt that the weekly briefings encouraged them to dedicate time to review medicines and raise with geriatricians, opportunities to deprescribe. Geriatricians indicated that participating in CHARMER allowed them to focus on deprescribing conversations with patients and they involved junior doctors more in the deprescribing process.

Conclusion(s)

The CHARMER intervention and trial processes were feasible and acceptable. Revisions to support intervention implementation include providing a template action plan for hospitals to adapt; funds for a project manager one day a week to work with CHARMER principal investigators for three-months to oversee implementation, and support from Eastern Academic Health Science Network in the definitive trial (winter 2023).

Background:

Type II Diabetes Mellitus (T2DM) is a common condition managed by geriatricians. Drugs and treatment goals for T2DM are individualized to patient profile and physician preference. Some diabetic medications are also known to affect appetite and subsequently, nutrition. The authors examined whether there is a correlation between glycemic control and malnutrition in older adults.

Methods:

This cross-sectional study enrolled patients > 70 with T2DM in a teaching hospital in Singapore. Data was collected on age, sex, ethnicity, body-mass index (BMI), function (iADL-impairment), Barthel’s score and cognitive scores (Abbreviated Mental Test), as well as the last glycated hemoglobin (HbA1c) reading. Nutritional assessment was performed using Mini Nutritional Assessment (MNA) screen. Univariate analysis and logistic regression analysis were performed to determine predictors of malnutrition.

Results:

Overall, 135 patients were recruited (57.1% male, mean age 85.6 [6.1] years). 75 patients (56.7%) were classified to have moderate or severe disability by Barthel’s and 19 (14.1%) had a BMI classified as underweight. 76 (56.7%) patients were considered to have good glycemic control (HbA1c < 7%) and 58 (43.3%) were not on any medications. Prevalence of patients with or at risk of malnutrition was high with 105 (77.8%) scoring MNA < 12. On univariate analysis, factors such as age, BMI, Barthel’s score, iADL-impairment and AMT scores were significantly associated with malnutrition. Multivariate logistic regression analysis showed that there was no association between good glycemic control and malnutrition (aOR 0.95, [0.14, 2.47], p=0.467)

Conclusion:

Good glycemic control was not significantly associated with malnutrition after adjusting for confounders. Older adults at baseline have increased risk of malnutrition and more education delivered towards a proper diet.  

Introduction

The health benefits of owning dogs include improved physical activity, mental well-being, companionship, and so forth. However, musculoskeletal injuries caused by dog-related activities might negate the aforementioned benefits. The aim of this study was to estimate the number of femoral fractures directly linked to dog-related activities in people above the age of 60.

Methods

In this observational study, we included all patients above the age of 60 with femoral fractures caused by dog-related activities, over a one-year period (June 2022 to May 2023). We chose to include people above the age of 60 because they are more likely to have a fragility fracture and are entered in the National Hip Fracture Database.

Results

387 patients (above the age of 60) were admitted with femoral fractures during the study period. Of these, 16 were directly related to dog-related activities. The common mechanisms of injuries include being tripped, pulled down and jumped over by a dog, and tangled and tripped by the dog leash.

Conclusion

4% of femoral fractures (1 in 25) in people above the age of 60 were caused by dog-related activities. This is probably an underestimate, because some owners may not have volunteered this information out of love for their dogs and inadequate history regarding the circumstances that led to the fall. Despite the injuries, all patients still loved their dogs and wanted to go home as soon as possible to be with them. There were more fractures in spring and summer (11) compared to autumn and winter (5) which reflects increased activity with better weather. Having a dog is a risk factor for falls and fractures. We recommend that dog owners carefully consider their choice of dogs and if there are issues with handling them, both dogs and their owners should receive appropriate training.

Introduction

The burden of PD has exponentially risen from 2.5 million in 1990, to 6.1 million in 2016 (PD Collaborators. Lancet Neurol. 2018; 17(11):939-53). This is due to ageing population, increased longevity, increased duration of the disease and improved diagnosis. The aim of our study was to identify the trend on deaths related to PD and Parkinsonism over the last decade.

Methods

We collected our data from the Office of the National Statistics, using codes G20 (PD), G21 (Secondary Parkinsonism) and G22 (Parkinsonism classified elsewhere), to extract the number of deaths coded under these conditions from 2013 to 2021. The data was only available for England and Wales.

Results

Total number of deaths including all codes from 2013 to 2021 were 4518, 4950, 5542, 5734, 5936, 6508, 6207, 7414 and 7117. Deaths coded under G.20 are far higher compared to deaths coded under the others.

Conclusion

The number of deaths related to PD has been gradually increasing and has nearly doubled over the last 9 years. Although Covid 19 may have contributed to this increase over the last two years, there is an overall rising trend. We think this is primarily due to people with PD living longer leading to an increased prevalence and duration of the condition. This is linked to sarcopenia, frailty, immobility, cognitive impairment and dysphagia contributing to increased mortality in later years. Another reason could be due to more accurate documentation in death certificates. Even though there has been concerns that deaths certificates have not been accurately coded to include PD, (Hobson, Meara. 2018; 8(2):e018969), there is probably an improvement after the introduction of Medical Examiner services. It is important to recognize the increasing burden of PD to enable us to plan and invest in resources to improve the care of these patients.