Scientific Research

Introduction:

There is a high level of clinical need among residents but little is known about the role of physicians or nurse practitioners (NP) in the nursing home (NH) setting. Our objective was to test for associations between physician and nurse practitioner (NP) presence on care units and outcomes among nursing home (NH) residents. A retrospective cross sectional analysis of secondary data collected in the Translating Research in Elder Care (TREC) study during 2019-20. The sample consisted of 10,888 residents across 320 care units in 92 facilities.

Methods:

We used TREC Survey data (which included items on daily presence of physicians and NPs on units, physician involvement in care planning, and ability to contact physician or NP when necessary) linked to routinely collected Resident Assessment Instrument – Minimum Data Set version 2.0 (RAI-MDS 2.0), which included the outcomes antipsychotic medication (APM) use without indication, physical restraint use, hospital transfers, and polypharmacy. Eight logistic regression models were created to test the association between measures of daily presence of physician or NP on unit and physician involvement in care planning and each outcome.

Results:

Of the 320 sampled units, 277 (86%) reported a physician or NP visited daily, 160 (72.1%) units reported that the resident’s physician was involved in care planning, and 318 (99%) units reported that the physician or NP could be reached when needed. Following adjustment for multiple confounding variables, there were no associations between presence of medical professional and any resident outcome. There was no association between either physician or NP presence on the unit and hospitalization and ED transfers (AOR=1.17, 95% CI: 0.46-3.10) or polypharmacy (AOR=1.37, 95% CI: 0.64-2.93).

Conclusions:

No association was found between any of the medical care provider presence measures and resident outcomes. This was surprising given the existing, but limited, research

Introduction. Concerns about falling are common among older adults. Many older adults with concerns about falling will restrict their activities. This can trigger a vicious cycle of physical deconditioning, falls, social isolation, reduced confidence, and a loss of one’s sense of self. However, not every older adult with concerns about falling will restrict their activities. In this prospective cohort study we therefore investigated the factors that predict the development of activity restriction due to concerns about falling in older people aged ≥75 years.

Methods. Data were collected as part of the Community Ageing Research 75+ (CARE75+) study. For the baseline (T1) timepoint, we extracted data for 543 older adults who did not report activity restriction due to concerns about falling completed a set of physical and psycho-social assessments. We then assessed which baseline variables predicted the onset of activity restriction at T2 (12-months later).

Results. Of the total sample, 55 older adults reported to have started to restrict activity due to concerns about falling at T2 (10.1% of overall sample), while 488 people reported to (still) not restrict their activities (89.9%). Three key predictors significantly predicted activity restriction status at 12-months follow-up: greater frailty (Fried Frailty Index; OR=1.58, 95%CI: 1.09-2.30), faller status (experiencing a fall between T1 and T2; OR=2.22, 95% CI: 1.13-4.38) and poorer functional mobility/balance (Timed up and Go; OR=1.08, 95%CI: 1.01-1.15).

Conclusions. These findings show that frailty, experiencing a fall and poorer functional mobility/balance may result in the development of activity restriction due to concerns about falling. Clinicians working in balance and falls-prevention services should regularly screen for frailty, and patients referred to frailty services should likewise receive tailored treatment to help prevent the development of such activity restriction.

Background and Aim: Falls are a significant public health concern, with literature primarily concentrating on older adults due to their perceived higher fall risk. However, recent studies indicate similar prevalence rates of fall-related injuries between older adults (>65 years) and middle-aged adults. Despite this, there is a scarcity of literature examining the differences in experiences of falls and concerns about falling between middle-aged adults and older adults who have experienced falls. The COVID-19 pandemic and the resulting lockdown measures created an unprecedented setting to explore these experiences due to the unexpected period of physical deconditioning and heightened risk of falling among adults aged 50 and above. This current qualitative study aimed to evaluate the variations in falls and concerns about falling among middle-aged and older adults during the pandemic. Methods: Semi-structured interviews were conducted with 10 middle-aged fallers (Mage = 59 years) and 10 older fallers (Mage = 73 years), following an online falls survey. All participants had experienced one or more injurious fall(s) during the COVID-19 pandemic. Reflexive thematic analysis was used to analyse the transcribed interview data. Results: Both middle-aged and older adults demonstrated a level of age acceptance and vulnerability to falls. These experiences prompted older adults to adopt protective behavioural adaptations, while middle-aged adults potentially adopted maladaptive behavioural adaptations in situations that posed balance threats. The pandemic restrictions affected both middle-aged and older adults similarly, with reports of both groups experiencing changes in physical activity levels. Conclusion: These findings provide a new perspective on the disparities in falling experiences and concerns about falling between middle-aged and older adults during the COVID-19 pandemic. They highlight the significance of investigating concerns about falling from middle age (>45 years) to help develop intervention strategies that mitigate detrimental outcomes in later stages of life.

Introduction

Keeping our standing balance is a crucial capability in preventing falls. Nevertheless, older adults may focus attention internally to their movement mechanisms during stance, through conscious movement processing (CMP), when facing balance difficulties. However, this may interfere with movement automaticity that could cause balance problems. The primary aim of this pilot study is to examine the effects of attention focus balance training on CMP propensity in older adults at risk of falling.

Method

Twenty-four older adults (mean age = 79.92 ± 7.61) with moderate to high risk of falling were included in this preliminary analysis. Participants were randomly assigned to either the No Specific Attention Focus Balance Training Group (NBTG; n=8), External Attention Focus Balance Training Group (EBTG; n=8), or the Internal Attention Focus Balance Training Group (IBTG; n=8). Participants in different groups participated in twelve tailor-made 45-minute training sessions with different attention focus instructions during standing balance training. The primary outcome measure of the real-time (state) CMP propensity (T3-Fz Electroencephalogram (EEG) coherence) at the baseline (T0) and after completion of all balance training sessions (T1) was evaluated. A 3x2 Group (NBTG, EBTG, IBTG) x Time (T0, T1) mixed Analysis of Variance (ANOVA) was conducted.

Results

We discover a decreasing trend of the real-time (state) CMP propensity (T3-Fz EEG coherence) in the EBTG but an increasing trend of the T3-Fz EEG coherence in the IBTG from T0 to T1. The T3-Fz EEG coherence for the NBTG remains similar from T0 to T1.

Conclusion

This preliminary result suggests that the external attention focus balance training has a potential to mitigate the real-time (state) CMP propensity in older adults at risk of falling. Consequently, it could further benefit the standing balance of the at-risk older adults after their rehabilitation.

An 86-year-old lady, presented with an unwitnessed fall with no obvious head injury. Her Glasgow Coma Scale (GCS) was 15 on arrival. She denied precipitating factors, taking blood thinners or seizure medication. Her examination revealed tongue biting, suprapubic tenderness, and pain in both hips and arms. An X-ray of the possible affected joints was ordered. Bloods and venous blood gas (VBG) were unremarkable. Within a few hours, she had a witnessed tonic-clonic seizure with a swollen tongue, for which lorazepam and adrenaline were administered. Repeat VBG (post-ictal) revealed a high lactate with hypoxia and hypotension. Intravenous fluids and oxygen were administered with a full body trauma series and a Contrast-Enhanced Pulmonary Angiogram. This showed a large retroperitoneal haematoma, a comminuted fracture of the superior pubic ramus and an unstable thoracic fracture.  She was referred to surgeons and orthopaedics for further management.

Trauma in older patients with polymorbidities can be missed as they are poor historians with conflicting collateral histories and atypical presentations. The “Silver trauma” emphasises early diagnostics, intervention and outcome including rehabilitation, decreasing mortality and morbidity. (1) The most common trauma is a fall of less than two metres from standing. (2)  They should be searched for more than one injury (2) in this case, suprapubic tenderness. They can have atypical observations compared to younger people sustaining trauma. (1) Example, a higher baseline blood pressure due to significant aortic disease. Similarly, tachycardia can be masked by medications such as beta blockers.

They should be investigated for polytrauma following an unwitnessed fall with a low threshold for a full CT trauma series.

 Furthermore, early reversal of anticoagulation should be implemented with adequate pain relief hydration to prevent delirium. (2) Knowing local pathways for referral to specialist services, and considering of patient’s and relatives’ previous wishes are key for early mobilisation and discharge. (1)

Background: The serious outcomes of outbreaks of COVID-19 in care homes have been described internationally. The experiences of professionals working through outbreaks has received less attention, missing opportunities to acknowledge and learn lessons. Our aim was to explore the experiences of care home staff in Scotland of managing COVID-19 within their homes to help inform understanding and future practice.

Methods: From April to August 2022, 34 individual semi-structured interviews were conducted with care home staff working in homes which experienced an outbreak(s) of COVID-19. Reflexive thematic methods were used to analyse verbatim deidentified transcripts.

Findings: There was no singular experience of COVID-19 outbreaks within care homes. We identified four broad groupings of homes with outbreaks (significant outbreaks, managed outbreaks, outbreaks in remote/rural homes & outbreaks in homes supporting younger adults), with overlaps in timing and severity and variation in the support received and impact. The national response to the COVID-19 pandemic resulted in fundamental change to care home relationships. Staff responded by adaptation in uncertainty. However, they were challenged by emerging inequalities influencing residents’ care. There were tensions between staff experience and evolving external approaches to regulation and oversight. All this change resulted in psychological impacts on staff. However, there was also widespread evidence of compassionate leadership and teamwork in their responses. Effective sources of support were underpinned by respectful relationships and continuity, tailored to individual contexts.

Conclusions: The lived experiences of care home staff during the COVID-19 pandemic provide valuable insights applicable beyond the pandemic context. This includes: recognition of the specialism, complexity and diversity of care home practice; the value afforded by embedding genuine representation and involvement in planning, policy-making and research; the need for individualising to people in their contexts and the value of fostering respectful relationships across professional groups to support residents.

Introduction:

The number one reason for older people to be taken to hospital emergency departments is a fall¹.

An “Ambulance Improvement Programme Pillar”² is trying to reduce conveyance to hospital for falls, however it is not understood how the attending clinician’s confidence impacts decision-making.

The objectives were to assess recruitment rate and feasibility of online survey delivery, and determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey, undertaken in one English ambulance service in May 2023. 

Demographics were collected from participants and their role, with 5-point Likert scales of confidence.

Descriptive statistics and Chi-square analyses were used for quantitative data.

Results:

81 responses were received from across the regional ambulance service’s 16 localities.

76% of respondents were paramedics, and 53% were aged 25-34.

60% of respondents rated being ‘somewhat confident’ to ‘How confident do you feel in assessing older adults who have fallen?’, responses ranged between ‘Neither confident nor unconfident’ to ‘Completely confident’.

No significant difference was found between the locality and confidence levels for assessing this patient population. However, there appeared to be significant variation between confidence levels relating to utilisation of hospital pathways and localities (p-value=.0045).

Length of experience in both frontline ambulance and overall healthcare provision was not significantly associated with different levels of confidence.

Conclusion:

The overarching confidence of clinicians did not significantly vary around the region.

Locality of work had a relationship with confidence in utilising hospital avoidance pathways, however, did not relate to confidence in assessing this patient population.

Confidence was not found to increase for either total years providing healthcare, nor providing emergency frontline care.

References

1. Dewhirst. (2023). National Falls Prevention Coordination Group. https://committees.parliament.uk/writtenevidence/117837/pdf/

2. NHS England and NHS Improvement. (2019). Ambulance Improvement Programme. https://www.england.nhs.uk/wp-content/uploads/2019/09/planning-to-safetly-reduce-avoidable-conveyance-v4.0.pdf

Introduction:

The use of pneumonia scores to stratify the prognosis is very useful in general terms, since it allows objectively evaluating the risks in these patients. The main objective was to determine the usefulness of pulse oximetry as a substitute for urea of the CURB 65 score in the evaluation of the severity of comunity acquired pneumonia (CAP) in patients.

Methods:

open-label, mixed-type study, first cross-sectional phase Test vs. Test, second phase follow-up at 8 and 30 days. Carried out between November 2017 and April 2018.

Results:

5 patients, gender distribution was comparable, the main age group was made up of over 65 years. The frequency of comorbidities was greater than 90%, among which hypertension, diabetes and smoking stand out. The mean hospitalization time was 10 days. The variable that most defined the need for hospital admission was hypoxemia with a percentage of 72%, regardless of the score on the CURB 65 scale, it was shown that oxygen saturation <92% is associated with a high 30-day mortality rate ( 43.07%) n=28, (p 0), with a relative risk of at least 4 times more to die. When correlating the CURB 65 and CORB 65 scales with Spearman's Rho test, a correlation coefficient (0.898) was obtained.

Conclusions:

pulse oximetry proved to be a good substitute for urea in the CURB 65 score, useful for defining hospitalization, severity, and mortality in patients with CAP.

Introduction

Postural BP readings are important in assessing older people, but are infrequently measured (1) The National Audit of Inpatient Falls (NAIF) 2022 has shown measurement of lying standing blood pressure (LSBP) remains below 50% (2)  

NICE guidelines suggest checking LSBP in patients with:  

1) Hypertension and postural hypotension symptoms  

2) Hypertension and Type 2 diabetes  

3) Hypertension and age ≥ 80 years (3)  

4) Patients presenting with falls (4).  

We aimed to update local data for LSBP recording and investigate LSBP measurements in hypertensive patients.

Method   

Data was collected across 4 wards in University Hospital of Wales between 22^nd May and 9^th June. Patient notes and NEWS charts were reviewed to establish whether an LSBP was necessary and carried out according to NICE guidelines (2) and whether appropriate reasons were documented.   

Results   

The table below shows the number of patients required and completed LSBPs.  

Total Number of Patients  98  

Number of Patients requiring a LSBP  76 

Total number of postural measurements completed 18 (16 LSBP, 2 sit/stand) 

Number of acceptable reasons for not completing postural BP reading  12 

All categories of patient requiring a LSBP have <40% completion; no LSBP’s were completed in patients that were hypertensive and diabetic.

 Conclusion  

Results indicate that local LSBP measurement requires improvement, with only 24% of requiring patients having a postural reading completed. Significant variations in guidelines (NAIF (2), MFRA (4), Cardiff and Vale Falls Policy (5)) have been highlighted as a potential factor, hence clearer guidance is needed on when LSBP is required, to improve detection of postural hypotension and therefore improve falls prevention and hypertension management.  

 References  

1. Detecting Risk of Postural hypotension. BMJ. 2020  
2. National Audit of Inpatient Falls report 2022.  
3. NICE. Hypertension in adults 2022  
4. NICE. Falls in older people 2013. 
5. CAVUHB. Falls Policy 2021  

Introduction

Falls in older people are common and can lead to significant harm including death. Coroners in England and Wales have a duty to report cases where action should be taken by organisations to prevent deaths, but dissemination of the findings from these Prevent Future Deaths (PFD) reports remains poor, limiting their possibility to effect change. We set out to identify preventable fall-related deaths, classify coroners’ concerns, and explore organisational responses to these deaths.

Methods

A protocol for a retrospective case series of fall-related PFDs was pre-registered. A novel, openly available, computer code was created to download and read PFDs from the Courts and Tribunals Judiciary website from July 2013 to November 2022. Demographic information, coroners’ concerns and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data.

Results

527 PFD cases (12.5% of all PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (71%). A high proportion of cases experienced fractures, major bleeding, or head injury. Coroners frequently raised concerns regarding falls risks assessments, failures in communication, and documentation issues. Only 56.7% of PFDs received a response from the intended recipients. Organisations most commonly produced new protocols, improved training, and commenced audits in response to PFDs.

Conclusion(s)

One in eight preventable deaths reported in England and Wales involved a fall. Adequately addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults. Poor responses to coroners may indicate that actions are not being taken at the local level. Wider dissemination and learning from PFD findings may help reduce preventable fall-related deaths nationally.