Scientific Research

Introduction

Teaching and Research in Care Homes (ToRCH) is a living labs partnership between University of Nottingham and three nursing homes in Derbyshire and Nottinghamshire. We aim to engage care home teams in research, including knowledge exchange and co-designing research proposals.

Methods

We conducted 7 workshops / focus groups with 10 staff members. These were supplemented by site visits, where the researcher observed staff meetings and met with residents and relatives (for patient and public involvement). We elicited discussion by appreciative inquiry method and recorded findings through field notes. Ideas built over time, iteratively, through ongoing discussion.

Results

Digital care records, in place in all member care homes, were a focus of discussion and we identified three topics for improvement projects and accompanying research: A) Emerging from lockdown, care homes identified newly appointed staff may have missed aspects of training about digital documentation, e.g. using language consistent with the model of care. Additional support may optimise use of digital records consistent with relationship-based practice. B) Using digital care record for benchmarking to support improvement projects. C) Realtime analysis of digital care records to identify deterioration and deliver proactive care. Our partnership is working with the software providers to develop these projects to improve continuity of proactive care and to develop indicators to assess outcomes of improvement projects.

Conclusion

Our living labs partnership has enabled care home teams to reflect on their use of digital care records and how these mediate communication within the care team as well as with family carers and primary care colleagues. Fresh perspectives have emerged which may accelerate the impact of digitalisation of care homes.

Introduction
Older people are the fastest growing group of hospitalised trauma patients, most commonly due to falls from standing height. The Scottish Trauma Audit Group (STAG) collect extensive national data, but this does not currently include frailty and longer-term dependency.

Method
We retrospectively reviewed consecutive cases in the STAG database for the Royal Infirmary of Edinburgh between September 2018 and February 2019. Casenote review was used to calculate baseline Charleston Comorbidity Index (CCI) and frailty status using the Clinical Frailty Scale (CFS). Outcomes of residence and mortality were collected to 1 year.

Results
We included 442 patients (mean age 62±20 years old, 43% female), of whom 218 (49%) were ≥65 years old (mean 78±8 years, 57% female). CFS could be ascertained in 209 (96%) patients ≥65 years, of whom 73 (35%) were frail (CFS ≥5). Frail patients were older (82±8 years vs. 77±8 years,
p<0.001) and had more comorbidities (mean CCI 5.4±1.8 vs. 4.4±1.8, p<0.001) prior to trauma compared to non-frail patients >65 years old. Median Injury Severity Scores (ISS) did not vary by age (9 [5-12] ≥65 years vs. 9 [8-16] <65 years, p=0.07) or frailty status (9 [9-10] frail vs 9 [4-14] non-frail, p=0.59). Frail older patients were twice as likely to die within one year of trauma (32% vs 14%
in non-frail, p<0.001), and this was independent of age (adjusted odds ratio 2.4, 95% confidence intervals 1.2–4.9, p=0.02). In survivors to 1 year, 16% of frail older patients required increased care at home (vs. 8% of non-frail older patients, p<0.001) and 14% were newly admitted to a care home
(vs. 4% of non-frail, p<0.001).

Conclusion
A third of older patients with trauma are frail and this is an important predictor of patient outcomes beyond death. Frailty provides more prognostic information than age in this setting.

Introduction

People recently diagnosed with Parkinson’s disease (PD) may withdraw from physical activity because of PD symptoms or loss of confidence. We are conducting a feasibility trial of a remote physiotherapy intervention. To gain a broader understanding of attitudes to physical activity and physiotherapy, we surveyed people with early PD in UK.

Methods

We developed a questionnaire (JISC Online Surveys) about physical activity and remote physiotherapy. This was distributed on paper to local Parkinson’s UK groups, and online via Parkinson’s UK newsletter and social media. 

Results

We received 274 valid responses. The most frequent age category was 60-69 years (69%), and just over half of respondents were male (53%). Respondents of diverse ethnicities amounted to 2% of the total sample. For physical activity, the majority of participants reported a high or average level of physical activity, with only 11% reporting a low level. The majority of participants reported that regular exercise was extremely or very important for keeping well with PD. When asked about barriers to being active, the most common response was apathy (29%), followed by difficulties due to PD symptoms and feeling exhausted. These barriers may be amenable to physiotherapy intervention, and we asked participants about their experience of physiotherapy. 47% reported that they had never had physiotherapy for PD; the remainder ranged from single assessment to more than one course of physiotherapy. In terms of telemedicine, 36% reported having a videoconsultation with a doctor or therapist in the last year, with the majority of these participants reporting a good experience; whereas 7% reported concerns with technology.

Discussion

The majority of respondents were enthusiastic about physical activity and believed this was helpful for their wellbeing. Barriers to exercise may be amenable to physiotherapy intervention. Digital monitoring and telemedicine were acceptable to many respondents.

Introduction: The administration of melatonin and melatonin receptor agonists (MRA) may result in a small improvement in sleep quality among middle-aged and older adults living with neurocognitive disorders, but debate remains as to whether effects are clinically meaningful. The purpose of this PROSPERO-registered systematic review and meta-analysis (CRD42022373972) was to synthesise evidence from randomized controlled trials (RCTs) of melatonin or MRA against placebo and other interventions for the treatment of sleep disturbances in adults with neurocognitive disorders.

Method: CENTRAL, MEDLINE, EMBASE, AMED, CINAHL and PsycINFO were systematically searched on November 4th 2022, examining the effect of melatonin and MRA on sleep efficiency: the percentage of time spent asleep while in bed. Results were analysed using Review Manager 5.4. Risk of bias was assessed using RoB 2 and the certainty of evidence was assessed with the GRADE framework.

Results: Among the 1,579 references evaluated, 13 RCTs were selected, corresponding to 16 studies, none including MRA, with a total of 592 patients. Compared with placebo, bright light treatment, or clonazepam, sleep efficiency significantly improved with melatonin administration (MD = 2.85, 95% CI: 0.88 to 4.81, p = 0.004). In subgroup analyses, only low doses of melatonin (< 5 mg) yielded a statistically significant improvement to sleep efficiency (MD = 3.81, 95% CI: 1.13 to 6.49, p = 0.005, I² = 34%), and melatonin administration statistically significantly improved sleep efficiency in patients with Mild Cognitive Impairment, Parkinson's Disease, or Multiple Sclerosis (MD = 3.27, 95% CI: 0.11 to 6.43, p = 0.04, I² = 41%), but not patients with Alzheimer's Disease. We found the overall quality of evidence to be moderate according to GRADE.

Conclusion: Melatonin may modestly ameliorate sleep quality in patients with neurocognitive disorders by improving sleep efficiency, which may be clinically significant to patients and those who care for them.

Introduction:
Risk prediction tools help guide prognostic conversations and benchmarking in hip fracture care. The Nottingham Hip Fracture Score (NHFS) shows only moderate predictive ability for 30-day mortality. We assessed whether routine markers of inflammation could improve the discriminant ability of the NHFS to predict 30-day mortality following hip fracture surgery.

Methods:
We studied consecutive patients admitted with hip fractures at a large-volume trauma unit between 2015 and 2020. Baseline NHFS and postoperative outcome data were extracted from a local registry and linked to routine laboratory data from patients’ electronic clinical records. We selected measurements taken closest to admission pre-operatively. The biomarkers studied were albumin (negative acute-phase reactant), C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR). Univariate and multivariate logistic regression analyses were performed separately for each combination of NHFS and inflammatory marker. C-statistics were calculated to assess the discriminant ability of the NHFS with and without each inflammatory marker for 30-day mortality.

Results:
We included 1710 patients, mean age 82.5 years (SD 8.2). 1199 (70.1%) were women. 104 (6.1%) patients died within 30 days of admission. In univariate analysis, admission NHFS, albumin, CRP and NLR were significantly different between those alive and dead at 30 days. Higher admission albumin was an independent predictor of 30-day mortality in multivariate analysis (OR=0.86 [95%CI 0.81-0.91], p≤0.001) as was higher CRP (OR=1.93 [95%CI 1.04-1.44], p=0.013). The addition of albumin significantly improved the discriminant ability of the NHFS for 30-day mortality (p≤0.001) (c-statistic 0.742 [95%CI 0.683-0.800] vs 0.681 [95%CI 0.617-0.745] for the NHFS alone). Other inflammatory biomarkers did not significantly improve discrimination of 30-day mortality when added to the NHFS.

Conclusions:
Admission albumin improves the discrimination of 30-day mortality in patients undergoing hip fracture surgery when combined with the NHFS, whereas other markers of inflammation including CRP, MLR and NLR did not.

Background: The MDTea is a free open access medical education podcast designed for all healthcare professionals caring for older adults. To date there are 120 episodes.

Introduction/Method: The MDTea Podcast has CPD survey logs on its website where listeners who access the website can record their learning and receive a CPD certificate, Listeners provide their professional roles. Listener numbers for episodes were much higher than those recorded in the CPD log, so alternative measures were sought to understand who listens to the podcast. Series 11 was released in January to July 2022 and was themed around ‘A Day in the Life’ of health professionals working with older adults in the hospital environment. The MDTea Podcast Twitter account had 6333 followers before series 11 release and has good discussion and engagement with followers, and is regularly tagged in other geriatrics care from discussion by professionals. Measuring the followership and social network of the account may be useful to understand the MDTea’s place in the social network of UK care of older adults healthcare. Therefore with each episode release the new follower numbers and if available self identified professional roles of each were recorded and counted.

Results: Over the course of the 11th series, the MDTea Podcast twitter account gained 432 new followers, from 22 different self defined professional groups who engaged with our social media.121 followers did not identify their title. In contrast 12 self identified professions were recorded in our series 11 CPD log results from 30 responses.

Conclusion: This work has demonstrated the wide range of professionals that engage with FOAMed resources produced by the MDTea. Given the breadth of professionals working in elderly care roles in both primary and secondary settings, having an understanding content users can enable authors to design content that is appropriate for their audience.

Introduction

Dementia and hearing loss (HL) are becoming increasingly prevalent in society and commonly co-exist. People living with concurrent conditions have complex needs and face additional barriers to diagnosis and management. There is a paucity of research regarding the current and optimal management of HL in people living with dementia. This research aimed to: (1) examine the current clinical provision for people living with HL and dementia within UK audiology services, and (2) explore recommendations for the management of co-existing HL and dementia from professionals and people living with these conditions.

Methods

This was an online, qualitative study with three stages: (1) open-ended survey of 37 audiologists, (2) semi-structured interviews with 13 audiologists, and (3) semi-structured workshops with seven people with lived experience of HL and/or dementia.

Results

Audiologists used various adapted and additional hearing assessments for people with dementia. Audiological interventions for people with dementia included adapted hearing aids, alternative interventions/devices, and involvement of other services/professions. Approaches to ongoing audiological care for people with dementia included providing frequent follow-ups and face-to-face, rather than remote, follow-ups. Overarching approaches to audiological care for this population involved patient-centredness, specialist training, increased carer involvement, and adjusted appointment duration. However, there are no standard procedures/guidelines relating to dementia in UK audiology services. Recommendations included enhanced training in dementia and HL across health and social care, improved multidisciplinary collaboration, appropriate carer involvement, and greater personalised care.

Conclusions

Currently, there is no standard practice for assessing and managing HL in people with dementia in UK audiology services. Although this study identified several beneficial strategies and approaches, there remain significant areas for improvement. The study results could be used in the future to produce national guidelines and training programmes for the assessment and management of HL in people with dementia, which would reduce disparities in care.

Abstract Content - Introduction Frailty is an important clinical syndrome of increased vulnerability to stressors. The impact of frailty on stroke is a growing research area. We carried out a systematic review for an up to date picture of the prevalence of frailty and its impact on a wide range of outcomes Methods We searched Medline, Embase and CINAHL for studies referencing frailty and stroke. We assessed quality of studies using National Heart, Lung, and Blood Institute (NHLBI) quality assessment tools. We collated prevalence of frailty and impact on outcomes after stroke or transient ischaemic attack (TIA). Meta-analysis was conducted to determine pooled odds ratios (OR) and 95% confidence intervals (CI). Where possible, we carried out metanalysis on outcome data. Results We included 28 studies (n=111,787). Studies used the Clinical frailty scale (CFS), (n=6, 10,967). a frailty index (n=10, 19134), Hospital Frailty Risk Score (HFRS) (n=4, 18,373), frailty phenotype (n=4, 10,838), or other assessment methods (n=8, 50,568). Pooled prevalence of frailty was 36% (95% CI 29-43%). Including pre-frailty, prevalence was 48% (40-56%). Increased CFS (n=738) was associated with increased in-hospital mortality, OR=2.43 (95% (CI 1.54-3.84).Higher frailty was associated with higher 28 day, 90 day and one year mortality, higher stroke severity, and NIHSS, mRS and dependency on discharge. Conclusion Increased frailty is associated with multiple adverse outcomes following a stroke, including mortality, worsened functional outcome, and increased dependency at discharge. There was heterogeneity in frailty measures used, precluding meta-analysis.

Introduction: Incontinence affects a significant proportion of older adults who reside in care homes. Incontinence symptoms have been linked to comorbidities, an increased risk of infection and reduced quality of life and mental wellbeing of residents. However, continence care provision can often be poor for residents, further compromising the health and wellbeing of this vulnerable population.

Method: A systematic qualitative evidence synthesis and thematic analysis established the current evidence-base of barriers and facilitators for the provision of continence care in care homes.

Results: The evidence synthesis revealed complex barriers and facilitators at three influencing levels: macro (structural, societal and external influences), meso (organisational and institutional influences) and micro (day-to-day actions of individuals impacting care provision). Macro-level barriers included negative stigmas relating to incontinence, aging and working in the older adult social care sector, restriction of continence care resources such as containment products (i.e. pads), short staffing in care facilities, shortfalls in the professional education and training of care home staff and the complex health and social care needs of older adult residents. Meso-level barriers included task-centred organisational cultures, ageist institutional perspectives regarding old age and incontinence, inadequate care home management and poor communication and teamwork among care staff. Micro-level barriers included both staff and residents’ poor knowledge of continence care and negative attitudes towards incontinence symptoms, management and treatment.

Conclusions: These findings help to outline the complexities of continence care provision in older adult care homes. Macro, meso and micro level influences demonstrate problematic and interrelated barriers across international contexts, indicating that improving continence care in this setting is extremely challenging due to the multiple levels at which care provision, services and individuals are impacted. Older adult social care policy-makers, researchers and service-providers must recognise this complexity in any intervention that aims to improve continence care in care homes.

Background: The role of rehabilitation medicine in treating post-acute COVID-19 survivors is currently ill-defined. Recently developed evidence-based initiatives, such as Cochrane REH-COVER, aim to describe the management of COVID-19 patients, but the variance and overlap in intervention types result in clinical uncertainty.

Objective: To provide a summary of delivered rehabilitation services for COVID-19 patients during the pandemic.

Methods: We collected evidence from the full set of REH-COVER Rapid living Systematic Reviews between March 2020 and February 2022 using the supplementary tables. We included studies that reported treatments in rehabilitation care within hospital and community settings. We collected additional information on the intervention type, multidisciplinary care, use of routine data and length of rehabilitation to define our outcomes.

Results: Out of 580 REH-COVER studies, 63 met the inclusion criteria. In-hospital interventions were present in 43 (68%) of cases, 14 (22%) were performed in community or home settings, and 6 (10%) were not explicitly defined. 83% of studies were conducted during the initial wave of COVID-19 in the first half of 2020. Among the intervention categories, pulmonary rehabilitation (N=41, 65%) and physical therapy (N=38, 60%) were the most common. Multidisciplinary interventions were described in 33 (52%) of studies where the median rehabilitation time was 21 (14; 26) days compared to 10 (5; 15) days for single specialisms (p=0.005). However, 27 (43%) studies did not report these data. Works that utilised routine data reported a slightly extended treatment (20 [12; 33]) compared to those that did not (14 [7; 22] days).

Conclusions: There is currently a wide variation in descriptions of rehabilitation interventions for COVID-19 patients. The limited number of papers clearly describing the content and length of rehabilitation programmes reduce the ability to share best practices. Harmonising therapy descriptions could improve the quality and standardisation of research in COVID-19 rehabilitation.