Scientific Research

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.

Introduction

Despite the high prevalence of frailty among older people, the clinical definitions and implications of frailty are not well understood by the public. Existing communication material is predominantly technical in nature and aimed at healthcare professionals.  This project integrated expertise in geriatric medicine, data science, user design and patient and public involvement (PPI) to develop an accessible visual communication resource on frailty that linked data stories, clinical perspectives and public views of frailty in later life.

Methods

We recruited three public contributors from the University of Edinburgh Advanced Care Research Centre’s PPI network to contribute to formulating the aims and objectives of the communication resource. We developed user personas and case scenarios to consider the intended audience for the communication resource and how they might interact with it. To ensure that all key messages were data-driven, we analysed quantitative survey data from the English Longitudinal Study of Ageing (ELSA) (n=7289), which included information on sex, age and health deficits used to calculate standardised Frailty Index scores. We developed a storyboard to present each piece of information.

Results

Using an iterative co-design process with our PPI contributors, we tested different ways of communicating frailty information and ELSA data insights. Visual elements were incorporated to enhance engagement and informativeness. Core themes of the final 6-page resource included placing frailty in the context of resilience, healthy ageing and interactions with common health issues such as living with multiple long-term conditions. The prevalence of frailty and differences between mild, moderate and severe levels were communicated using person-examples inspired by ELSA data.

Conclusions

We produced a communication resource, informed by a co-design process, that addresses a key gap in existing frailty resources. Our work shows the value of integrating user experience research methods, public patient involvement and data insights to enhance health communications.

Introduction:

The need to develop and evaluate frailty-related interventions is becoming more pertinent as life expectancy increases. Patient-reported outcome measures (PROMs) are arguably essential in this field of research, and can be defined as “any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else” (FDA 2009). Numerous validated questionnaires can be classed as PROMs, but seem inconsistently used, and of uncertain relevance to/for those living with frailty. This rapid review aimed to identify existing PROMs used in research with older people living with frailty.

Method:

PubMed and Cochrane were searched (up to 24/11/22). Inclusion criteria were quantitative studies, use of a PROM, and either measurement of frailty or inclusion of older adults as participants. Distinguishing PROMs from questionnaire-based clinical assessments was necessary, and criteria were created to do this. 197 records were screened. PROMs were categorised according to the domain they assess, based on a standard set of health outcome measures for older people (Akpan et al, 2018).

Results:

90 studies were included. 119 unique PROMs were used 289 times, most frequently the SF-36 (n=23), EQ-5D (n=21) and Barthel Index (n=14). The most frequently assessed outcome domains included “Mood and Emotional Health”, and “Activities of Daily Living”. Outcome domains with fewer usages included “Participation in Decision Making” and “Carer Burden”.

Conclusions:

PROM usage in frailty research is highly heterogeneous. The most frequently used PROMs omit outcomes that are important to people with frailty (e.g. Akpan et al 2018, Herrler et al 2021, Mayo et al 2022). Further research should investigate the importance of specific outcomes (and thus identify particularly relevant PROMs) to people living at different stages of frailty severity. More consistency of PROM use could facilitate evaluation of different frailty interventions.

Introduction:

The Enhanced Health in Care Homes Framework recognises personalised advance care planning (ACP) as a key component of optimal healthcare for care home residents. We established a multi-disciplinary care home team providing comprehensive geriatric assessment (CGA), structured medication review (SMR) and advance care planning (ACP) to a pilot cohort of frail residents in 17 care homes. We aimed to explore the acceptability and perceptions of proactive ACP alongside CGA from the perspective of resident’s next-of-kin (NOK), primary care staff and care home managers (CHMs).

Methods:

Data was collected using standardised questionnaires between February-September 2022. Data were analysed using qualitative content analysis. This was undertaken independently by two lead authors, after which codes and categories were identified through a collaborative approach and triangulation.

Results:

Four categories emerged from NOK data: 1) Perceived benefit of frailty specialist review, 2) Perceived improved knowledge of the individual through holistic assessment, 3) Sensitive conversations were perceived to have been handled well, but this was sometimes challenging over the phone, 4) Families felt empowered in shared decision making. Six categories emerged from primary care feedback: 1) Perceived benefit of holistic reviews, 2) Improved information sharing using same clinical system, 3) Specialist frailty involvement supporting GP learning, 4) Challenges with set-up, 5) Perceived avoidance of admissions following reviews, 6) Time and financial savings for NHS Four categories emerged from CHM feedback: 1) Perception that medical reviews were overdue, 2) Reduced care home staff workload through saving of time, 3) Specialist review and 4) Empowering staff to avoid admissions.

Conclusions:

This evaluation identified key feedback themes in relation to the perceived value and acceptability of a dedicated care home team performing CGA based ACP. Stakeholders expressed positive views about the service, suggesting benefits for individual residents, primary and community healthcare staff, and the wider healthcare system.

Introduction

In older adults, medicines non-adherence is prevalent and harmful. Current methods of identification have limitations with direct questioning often being met with a reluctance to “admit” non-adherence to healthcare professionals. The Making Medicines Work for You screener has been developed to support patients and clinicians identify and discuss adherence issues in a clinical setting.  This study aimed to pilot the screener and identify barriers to medication adherence in an unspecified geriatric outpatient population.

Method

Patients attending the Older Person’ Assessment Unit at a large London teaching hospital between June – October 2022 completed the 7-item paper-based screener, with the support of a carer or researcher where necessary. Descriptive analysis was used to determine the incidence and type of barriers to adherence.  Associations and correlations between the screener and existing measure of adherence and medicines beliefs were assessed using Chi square and Spearman’s Rank, respectively.

Results

Of 245 patients approached, 226 consented to participate: 120 (53.1%) male; mean age 78.3 years (SD 6.7 years). 64 (28.3%) reported having someone help with their medicines and 67 (29.6%) used a multicompartment compliance aid.  193 barriers were reported: 115 (50.9%) identified at least one barrier to adherence (median 1, range 0-5).  “I’ve found my own way to use my medicines” (n=53, 27.5%) and “I sometimes forget to take my medicines” (n=45, 23.3%) were the most frequently reported barriers. The screener demonstrated strong association with MARS5 (p<0.001), and  moderate correlations with the MARS5 (r -0.34, p<0.001) and BMQ Concerns (r 0.29, p<0.001).

Conclusion

Despite support with medication being common, half of the participants reported barriers to medication adherence.  The high rate of completion, strong association and moderate correlation with existing adherence measures suggest that the screener may have value in this setting. Further work is required to explore the barriers identified and develop appropriate interventions.

Introduction

Resistance exercise is an effective intervention for older people at risk of, or living with, sarcopenia and frailty. Surveys of current UK practice in exercise prescription for these conditions found that  resistance exercise was offered in only 9% of departments and was often not optimised for sarcopenia and frailty. The Benchmarking Exercise Programmes for Older People (BEPOP) project is a joint British Geriatrics Society and AGILE initiative to promote best practice in the prescription of resistance exercise for older people.

Methods

Using an online data collection tool, 10 services delivering exercise interventions to older people from across the UK submitted anonymized details of baseline assessment (including demographics), exercise prescription and progression, and outcomes, for up to 20 consecutive patients referred to their services with probable sarcopenia, frailty, falls, and reduced mobility. Descriptive data were reviewed and analysed by an expert panel comprising physiotherapists, geriatricians, and exercise specialists.

Results

Data were analysed for 188 patients with a mean age of 80 years (range 60-101). At the time of referral, 154 (83%) patients did not have a diagnosis of sarcopenia. At baseline, 115 (61%) patients received an objective assessment of muscle strength. The most common modality of resistance exercise prescribed was bodyweight exercises (n=173, 92%) followed by resistance bands (n=49, 26%). Progression of exercise programmes was predominantly through increased repetitions (n=163, 87%) rather than increased load. Forty-one (24%) patients did not undergo any review to inform progression of exercise dose. Fifty patients (30%) patients did not have re-assessment of the outcome measures recorded at baseline on completion of the prescribed exercise programme.

Conclusion

Multiple opportunities exist to improve both the diagnosis and assessment of sarcopenia, and the prescription, delivery, and monitoring of resistance exercise. BEPOP will provide individualized benchmarking reports to each site to facilitate quality improvement and local service development.

Introduction: Living with frailty is a risk factor for increased short and long term mortality. We aim to describe the uptake of escalation of care and resuscitation status discussions in frail older patients admitted to general, colorectal, and upper gastrointestinal wards.

Methods: Prospective observational study of all patients aged 65 years and over admitted under general surgery 11th February to 11th March 2022 and a second cohort of patients hospitalised between 1st and 31st of October 2022. We scored frailty using the clinical frailty scale (CFS) and identified escalation of care discussions through review of electronic patient records.

Results: We included 196 patients, average age 75.9 (65-97), 90 (46%) females and 106 (54%) males, 107 (54.6%) emergency (EM) and 89 (45.4%) electives (EL). 64 (32.7%) patients were frail (F = CFS ≥5) and 132 (67.3%) non frails (NF = CFS≤ 4). Length of stay was 14 days, 14.9 in F and 11.4 in NF, 14 EM and EL 18.3. Surgery was carried out in 14 (25.9%) F and 33 (40.7%) NF. In total 6 patients died in hospital: 4 F (7.3%) and 3 (3.7%) NF individuals, one without resuscitation decision. Resuscitation discussions had in 20 (36.4%) F vs 4 (4.9%) NF, 19 (16.8%) EM and 6 (6.7%) EL. Percentage of discussions increased in frail patients from 24% to 42.4% overall, and 92% non-frail patients were not offered discussion.

Conclusion: 1 in 3 patients in our cohort of older adults hospitalised under surgery were frail. Higher frailty scores were associated with increased in-hospital mortality. 30% frail and 8% non-frail older patients underwent resuscitation discussions. We advocate early proactive discussions of resuscitation status and advance care planning in high risk surgical patients.

Introduction: Medication non-adherence is estimated to cost the NHS >£500 million a year in preventable morbidity, mortality and health service use. Multi-compartment medication compliance aids (MCAs) are provided in an effort to promote adherence, despite opposing recommendations from NICE and the Royal Pharmaceutical Society. This study aimed to understand the views of patients and carers of MCAs, including those who have declined or discontinued the use of a pharmacy-filled medication compliance aid (pMCA).

Method: A researcher-administered questionnaire survey of older adults (“users”) and carers, who used, declined or discontinued a pMCA. Participants were recruited from inpatient, outpatient and community services at a central London NHS trust. Thematic analysis was conducted by two independent researchers to identify overarching themes.

Results: 88 users and 88 carers were interviewed. The majority of pMCAs were started by healthcare professionals or requested by the carer due to polypharmacy. 12 of 61 users (20%) did not know why a pMCA had been provided, with only 6 requesting the aid themselves. 5 (8%) current pMCA users considered returning to taking medicines from their original packaging. Themes common to both groups included polypharmacy and poor product design. A theme identified solely in the patient group was autonomy and independence, while carers commented on time, waste and sustainability, and responsibility and associated mistakes. For the most part, carers and users perceived MCAs as useful tools to assist medication adherence.

Conclusion: pMCAs are often issued to manage complex medication regimens which are cognitively overwhelming, sometimes at the expense of patient autonomy. Healthcare professionals should aim to reduce the need for pMCAs through individualised medication reviews and rationalisation and improvement of pathways to obtain medicines. If their use is unavoidable, the design of the product and healthcare systems surrounding their use should be optimised to improve the user experience.