Scientific Research

Introduction

The Scottish Care of Older People (SCoOP) collaborative regularly reports outcomes of acute geriatric medicine admissions across Scottish hospitals. The covid pandemic caused major and highly variable restructuring of acute services across the country. Their impact on activity and outcomes is unknown.

Methods

We collated all SMR01/SMR01E hospital episodes from Public Health Scotland from 1^st April 2017 to 31^st March 2022 where over 50% of the total episode was spent under acute geriatric medicine (code AB) and the diagnosis was not stroke. Activity and outcomes in 19 major hospitals were compared across financial years 2017-19 (before-), 2020/21 (during-) and 2021/22 (after lockdowns). 

Results

Admissions fell 15% to 36954 in 2020/21 from an average 42566 before recovering to 41971 in 2021/22. Age, sex and social deprivation profiles differed between hospitals (p<0.001) but remained similar within each hospital at all timepoints. Few hospitals were busier than ever in 2020/21 but some saw large reductions in activity. Mortality at 30 days post-admission was 10% higher in 2020/21 (17.9% v 16.5% in other years, p<0.001), with 2-fold differences across hospitals. Mean median length of stay (LOS) across hospitals was 11.7 days, compared to 12.8 days in 2017-20, p<0.001. There were up to 17-fold differences in median LOS between hospitals (2-34 days) in 2020/21, p<0.001. The impact of the pandemic on LOS within each hospital was also highly variable. Readmission rates at 7 days post-discharge were broadly similar across all years but two-fold differences between hospitals were also seen (4.8%-9.8%, mean 6.8%, p<0.001).

Conclusion

The year 2020/21 saw a 15% fall in acute geriatric medicine admissions overall, with 10% increase in mortality and shorter lengths of stay. However, the impact on the activity and outcomes of individual hospitals were widely disparate, probably reflecting variation in how each hospital service responded to the pandemic.   

Background

Dietary nitrate (inorganic nitrate) supplementation has been proposed as an intervention to improve muscle function via increased nitric oxide (NO) availability. Although some studies show benefit in younger adults, the effectsin older people are unclear. This systematic review evaluated the effects of dietary nitrate supplementation on physical performance and muscle strength measures in older people.

Method

The review was conducted according to a prespecified protocol by two reviewers. We included interventional studies using dietary nitrate supplementation, mean participant age 60 and over, with or without sarcopenia or impaired physical performance. Outcomes of interest were physical performance and measures of muscle strength and mass. Risk of bias was assessed using a structured tool. Results were grouped by intervention and outcome measures and were described by narrative synthesis.

Results

Our search strategy found 1174 titles; 25 studies were included in the review. Study size ranged from 8 to 72 participants. Data on baseline functional status were not available, but 7 studies were in healthy older adults. The intervention duration ranged from a single dose to twelve weeks. Most studies had high or unclear risk of bias; three had low risk of bias. One hundred and nineteen outcomes were reported; 62 were physical performance measures and 57 were muscle strength measures. Twenty-nine outcomes showed significant improvement, two showed significant worsening and 88 showed no statistically significant difference. Results that showed significant improvement did not group together under any particular outcome measure, supplementation product or duration. Meta-analysis was not possible due to heterogeneity of populations, intervention duration and outcome measures.

Conclusion

Current evidence suggests that increasing intake of dietary nitrates may be beneficial for physical performance and muscle strength in older people, however data are limited. Future studies should be longer, larger and target older people with sarcopenia or impaired physical performance.

Introduction: Oral nutritional supplement (ONS) prescription is commonly recommend for malnourished patients in hospital. However, compliance to ONS is often low. Ice cream may be a promising nutritional intervention. We undertook a study designed to compare the acceptability of high protein, fortified, ice cream called Nottingham-Ice Cream (N-ICE CREAM) with routinely prescribed milkshake ONS.

Methods: Fifty older (≥ 65 years) inpatients with hip or spine fractures were recruited from Queens Medical Centre, Nottingham. Patients were randomised into two groups, receiving two days of N-ICE CREAM and milkshake ONS. Group A received N-ICE CREAM first and Group B, milkshake ONS first. We measured compliance, acceptability (hedonic characteristics; rating 0 dislike a lot to 7 like a lot), attitudes towards length of prescription (rating 0 very unconfident to 4 very confident) and preference.

Results: Mean (standard deviation, SD) age of patients was 80.6 (7.7) years. The majority (n = 21, 67.7%) preferred N-ICE CREAM. Mean compliance to N-ICE CREAM was greater in both Groups (Group A (n = 22) 69.9 (30.0) % and Group B (n = 26) 56.3 (39.3)%) compared to the milkshake ONS (Group A (n = 22) 43.4 (4.7) % and Group B (n = 26) 53.6 ± (40.2) %). This was statistically significant in Group A (p < 0.05). Mean hedonic ratings were higher for N-ICE CREAM with an overall impression score of 5.8 compared with 4.6 for milkshake ONS. Confidence score for both products decreased with increasing time length. Both had an overall confidence score of 2.9.

Conclusions: High protein N-ICE CREAM is more accepted and preferred by older patients with a hip or spine fracture compared to standard milkshake ONS. Further research should explore optimal timing for N-ICE CREAM administration and long-term compliance, as well as clinical outcomes.

Background:

As global populations age, healthcare systems are facing challenges posed by multimorbidity, disability and geriatric syndromes. In high-income countries, frailty is a strong predictor of poor hospital outcomes. Comprehensive Geriatric Assessment is effective but resource-intensive and unavailable in sub-Saharan Africa where specialist geriatric training and allied health infrastructure are limited.

Objective:

To establish clinical outcomes of older adults with frailty admitted to hospital in northern Tanzania.=

Methods:

All adults aged ≥60 years admitted to medical wards at four hospitals were invited to participate. Participants were screened for frailty using the Clinical Frailty Scale (CFS). The primary outcome was inpatient death, with secondary outcomes including length of stay, 30-day readmission and delirium (confirmed using the Confusion Assessment Method [CAM]). Outcomes for frail (≥5 on CFS) and non-frail participants (1-4 on CFS) were compared.

Results:

Over 6 months, 308/540 patients admitted participated. Reasons for non-participation included death (n=34) and discharge (n=159) before researcher attendance. Mean age of participants was 74.9 years and 154 (50.1%) were female. Of these, 205 (67%) participants had a CFS ≥5. 21 (14.9%) frail participants died, compared with 5 (6.4%) in the non-frail group (Chi-squared, p=.095). Length of stay and re-admission rates were higher in frail participants, but differences were not statistically significant. Delirium was diagnosed in 35 (17%) frail participants, compared with 4 (4%) in the non-frail group (Fisher’s Exact test, p=<.001).

Conclusion:

Frailty in older adults admitted to hospitals in northern Tanzania is common and associated with significantly higher rates of delirium. Mortality, readmissions, and length of stay were higher in the frail group, but differences did not reach statistical significance. Type II Error (exacerbated by selection bias from non-inclusion of individuals who were discharged, or died, early in their admission) may explain this. Participants will now be followed-up for 12-months to assess outcomes longitudinally.

Introduction:

At present no single symptom appears to be favoured in choosing primary outcomes for dementia with Lewy bodies (DLB) trials, nor are the perspectives of people affected by DLB reflected in their design. The aim of this study is to elicit the preferences of DLB patients and their care partners with respect to the DLB symptoms that they would most like to see improved upon by a potential therapy. We will do so using two complimentary health economic approaches in a single online survey: a best-worst scaling (BWS) exercise and a discrete choice experiment (DCE).

Methods:

Using global voluntary sector networks, we will recruit 100 individuals who either have a diagnosis of DLB or who are a care partner for an individual with DLB. The BWS and DCE will be applied together in a self-administered online survey. Both will be informed by evidence from a scoping review of existing literature and piloted in person with a group of local volunteers.

In the BWS, participants will be presented with a series of choice sets of three symptom domains and asked to determine which domain they consider the most and least important to treat.

In the DCE, participants will be presented with a scenario and asked to choose their preference from one of two hypothetical treatments, each with different characteristics (such as target symptom and side effect profile).

Expected Results:

We will determine the relative importance of DLB symptoms and the potential trade-offs made in benefit-risk decisions related to treatments. Our findings will inform choice of primary and secondary outcomes in DLB trials. They will inform our understanding of the levels of risk and benefit individuals will tolerate, which is important as trials of potentially disease modifying agents, such as amyloid therapies, are pursued.

Background & Aim: While the significance of prehospital trauma care is increasingly recognised for older patients, limited research has been conducted to gain in-depth understanding of current paramedic practice. We aimed to explore Saudi paramedics and emergency medical technicians’ understanding of impacts of ageing changes, how they acquire and apply relevant knowledge as well as the barriers and facilitators to providing improved care for older trauma patients.

Methods: We undertook semi-structured qualitative interviews with 20 paramedics and ambulance technicians from the Saudi Red Crescent Authority’s ambulance stations. We used MAXQDA software to manage and code data, and framework approach’s five stages for analysis.

Results: Participants identified ageing, societal, behavioural, and organisational challenges when responding to older trauma patients. They perceived that older and younger trauma patients receive care differently due to comorbidities and polypharmacy, along with the influence of organisational and societal challenges on geriatric care. They identified a lack of adequate acquired relevant knowledge prior to employment in ambulance services, and no relevant courses or sponsors providing such courses after employment but were reluctant to admit their own knowledge gaps. They reported that family members and local culture can create challenges in applying acquired knowledge and experience when responding to female older patients.

Conclusion: Few studies have explored the challenges encountered while responding to and caring for older trauma patients. Prehospital trauma care could be improved through the development of clear guidelines, trauma care pathways, training for paramedics and EMTs, and increased awareness of cultural barriers.

Introduction

From our observations and personal experience Parkinson’s Disease (PD) patients have complex medical needs and are often mismanaged during acute admissions.Medications are wrongly prescribed, particularly out of hours, leading to increased mortality and morbidity.¹

The aim of this project was to assess junior doctors’ understanding of managing the acutely unwell PD patient, with a particular focus on common prescribing errors. We addressed gaps in knowledge by providing teaching sessions and reassessing learning.

Methods

We designed a 9-point questionnaire which assessed confidence and prescribing knowledge. This was given to 14 participants in 2 different settings; informally on the wards and at an FY1 teaching session.  Following this, education was delivered either in the form of 5-minute tutorials on the wards which we named ‘educational soundbites’ (ES) or as a 30-minute interactive case study (ICS) delivered in a lecture hall. Participants were then asked to repeat the same questionnaire and results were compared.

Results

Pre-education, clear gaps in knowledge were identified. None of the participants were aware of the use of Madopar as a rescue drug. There was little awareness of Parkinsonism-Hyperpyrexia Syndrome and of the consequences of missed medications. Knowledge of alternative routes of administration in nil-by-mouth PD patients was poor, as was awareness of contra-indicated drugs.

Of the 14 participants, 7 were given the ES session and 7 the ICS. Following both of these interventions there was an overall increase in confidence levels and understanding of safe prescribing in PD.

Conclusion

PD is one of the most common neurodegenerative disorders in the world and its prevalence is rising.²  It is therefore essential that junior doctors are proficient at managing these patients in the acute setting. This quality improvement project highlights that there are concerning gaps in knowledge surrounding this, particularly in regards to prescribing. Knock-on effects can lead to increased patient morbidity and mortality. This project has demonstrated that educational interventions are simple and effective at addressing this issue.  We would therefore propose that teaching surrounding this subject should be a mandatory component of medical training programmes across the UK.

References

1. Medication Management Performance in Parkinson's Disease: Examination of Process Errors - PubMed (nih.gov)
2. Change in the incidence of Parkinson’s disease in a large UK primary care database | npj Parkinson's Disease (nature.com)

Abstract

Introduction:

Chronic pain is associated with frailty. We hypothesised that painful comorbidities would be more strongly associated with frailty than non-painful comorbidities.

Method:

Data were from Investigating Musculoskeletal Health and Wellbeing, a UK-based cohort of people with or at risk of musculoskeletal problems or frailty. Average pain over the previous month was assessed using an 11-point numerical rating scale (NRS). The original FRAIL questionnaire comprises five self-report items: Fatigue, Resistance, Ambulation, Illnesses and Loss of weight. In this study, risk of frailty was operationalised using a modified FRAIL questionnaire, omitting the “illnesses” item which related to comorbidities. Comorbidities were classified as either ‘painful’ or ‘non-painful’ based on the International Association for the Study of Pain chronic pain classification criteria. Ordinal logistic regression models explored associations of comorbidity counts with frailty.

Results:

Cross-sectional data were from 2473 participants, 57% female, median age 72 (range 40 to 96) years. 518 (21%) participants were classified as frail. Mean (SD) pain score was 5.5 (2.5). Median (IQR) painful comorbidities was 2 (1 to 3) and non-painful 1 (0 to 2). Highest comorbidity frequency: arthritis (66%) and hypertension (38%). Pain was associated with frailty (OR 1.52 (1.45 to 1.58)). Painful comorbidities (aOR 1.64 (1.54 to 1.75) and non-painful comorbidities (aOR 1.31 (1.21 to 1.41)) were both associated with frailty when included in the same multivariable model adjusted for age, sex and BMI.

Conclusions:

Painful comorbidities were most strongly associated with frailty, although non-painful comorbidities also contributed. Pain and frailty are interconnected, and this might, in part, be due to comorbidities or their treatments. These findings provide justification for further research to identify the mechanisms through which pain is involved in frailty and to include pain management in interventions to ameliorate frailty.

Introduction: Resilient ageing is conceptualised as strive towards achieving satisfactory quality of life (QoL) at old age by embracing positive adaptation and coping mechanisms against adversities regardless of health conditions. Preventive Home Visit (PHV) including various types of home-care interventions were introduced to delay health deterioration and improved QoL. However, research related to resilience as an outcome measured for PHV is scarce. Therefore, this systematic review aims to evaluate the effectiveness of PHV in improving resilience among community dwelling older adults and the association with health and other QoL related outcomes.

Method: Database search was conducted by using five databases (PubMed, PsycINFO, CINAHL, Web of Science and Scopus) up to 31 March 2022 involving community dwelling older adults who received PHV. Three authors reviewed the articles for inclusion and performed methodological quality assessment.

Results: Out of 1,568 records, 14 articles involving 7,254 participants met the inclusion criteria with age range between 79 to 85 years old. Quality assessment by using Joanna Briggs Institute (JBI) Critical Appraisal Tools indicated that all articles were assessed as moderate to high quality and were included in the review. More than two third of the studies focused on health or combination of health and QoL and only three studies revealed positive effect of PHV. The remainder were either produced mixed results or had no effect following the intervention. There was only one study examined resilience. However, no significant effect of PHV was reported based on this study.

Conclusion: Based on this current review, there were mixed results of PHV effectiveness. Due to the paucity of research in this area, there is no conclusive evidence of the effectiveness of PHV in enhancing resilience in older adults. Since there has not been any research on PHV and resilience done in Low-middle Income Countries (LMICs), it is necessary to fulfil this gap. Future research should concentrate on developing more robust and holistic PHV interventions that involve resilience in addition to QoL and multi-domain health-related outcomes.

Introduction

In 2017 NHS England introduced proactive identification of frailty into the General Practitioners (GPs) Contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty, or perceptions of impact on patient care. Evidence from international settings suggests primary care clinicians may have mixed interpretations of frailty, with important implications for their willingness to support different frailty interventions. We aimed to explore the conceptualisation of frailty, and how community-dwelling frail older adults are identified in primary care.

Methods

Semi-structured interviews were conducted with primary care staff across England, including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 12).

Results 31 practitioners participated (12 GPs, 19 non-GPs). Frailty was seen as difficult to define, with uncertainty in its value as a medical diagnosis. The most common working model was the frailty phenotype, associated with deterioration at end of life. There were a mixture of formal and informal processes for identifying frailty. A few practices had embedded population screening and structured reviews. Informal processes included use of ‘housebound’ as a proxy for frailty, identification through chronic disease and medication reviews, and holistic assessment through good continuity of care. Many clinicians described poor accuracy of the electronic Frailty Index, yet it was commonly used to grade frailty during protocolised chronic disease reviews. The Clinical Frailty Score, in contrast, was felt to be easy to use and interpret, but inconsistently recorded within electronic health records. Most clinicians favoured better tools for identifying frailty, alongside resources to support these individuals.

Conclusions

Concepts of frailty in primary care differ. Identification is predominantly ad-hoc, opportunistic and associated with terminal illness. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools, may encourage wider recognition.