Scientific Research

Introduction

Provision of community-based health services to support independence of older people, and further research in this area, would be improved by a typology of these complex interventions - thereby enabling evidence synthesis and the identification of effective intervention components. We aimed to produce such a typology in preparation for a systematic review and network meta-analysis.

Methods

The typology was developed based upon the descriptions of these interventions in published reports. This involved four stages: (1) systematic identification of relevant RCTs and related publications; (2) the extraction of descriptions of the interventions (including control/comparison) using the Template for Intervention Description and Replication (TIDieR); (3) a qualitative synthesis generating categories of key intervention features and (4) grouping the interventions based on the categories.

Results

Our search identified 496 reports of 129 studies, involving 266 intervention arms. 19 intervention components were identified: Formal homecare; Physical exercise; Health education; ADL training; Providing aids and adaptations; Nutritional support; Psychological therapy; Technology for communication and engagement; Cognitive training; Engagement in meaningful activities; Care voucher provision; Alternative medicine; Social skills training; Welfare rights advice; Medication review; Monitoring; Routine risk screening; Multifactorial-action from care planning; and Routine review following multifactorial-action from care planning. Multifactorial-action from care planning refers to a process of individualised, multidomain assessment and management resulting in a tailored selection of action components, as in comprehensive geriatric assessment. 63 different intervention types (combinations of these components) were identified.

Conclusions

The typology provides an empirical basis for service planning and evidence synthesis. Target populations are not explicitly integrated and should be considered separately. The components, being broad actions, are likely to endure; further components may be identified. However, the huge potential number of intervention types constitutes a challenge to typical approaches to effectiveness research. We recommend better reporting about organisational aspects of interventions and usual care.

Background Prehabilitation in clinical trials improves fitness, improves quality of life, reduces complications, and reduces hospital length of stay It is not standard of care in routine clinical practice. This prospective observational study reports the outcomes of a clinical AHP prehabilitation service for older people undergoing major cancer surgery. Methods The LUHFT Prehab service commenced in August 2017, patients prior to major abdominal surgery for cancer were eligible for referral, this was inclusive of 8 different surgical specialties. Referred patients were invited to attend a multi-disciplinary prehabilitation clinic inclusive of physiotherapy, occupational therapy and dietetic support. In a review of the past 12 months clinical frailty score was recorded at baseline and pre surgery. Patients were given individualised exercise, wellbeing, and nutrition plans, and provided with support via 121 or group based follow up. Where distance was a barrier, telephone clinics were undertaken. Results Over a 12-month period 477 patients were referred over the age of 65, of these 436 underwent baseline frailty assessment. Of these 380 went on to have surgery with an average period of 40 days between initial prehab assessment and their elective admission. In these patients 50 scored 5 or above on the clinical frailty scale, 105 fell within the vulnerable category and 163 in managing well at baseline. Of those patients reassessed pre surgery 100% of patients with a frailty score of 5 or above either improved or maintained their score. Of those that scored a frailty score of 4, 94% either improved or maintained their score. Conclusion A prehabilitation service is feasible and improves frailty in the lead up to major abdominal elective surgery in a cohort that would otherwise be expected to decondition due to the nature of their disease. Prehabilitation should be part of standard care for older patients undergoing cancer surgery.

Introduction

Alcohol use disorder (AUD) in older adults is increasingly common, under-recognised and under-treated within acute hospitals.

Methods

Consecutive patients seen by the Alcohol Care Team (ACT) at an acute NHS trust between January-April 2021 were invited to take part in a service evaluation.

Baseline demographic and clinical data was collected in addition to community alcohol service referrals for all patients.

For older adults (>64years), Older People’s Mental Health (OPMH) referral and hospital use data (ED attendances and admissions) in the 12 months prior/post index admission were also collected.

Results

Of 280 patients seen by the ACT during the 3-month period, 87 (31%) were older adults and 75% were male. Older adults resided in more affluent neighbourhoods compared to patients under 65 (p = 0.002).

Referral to community alcohol services was predicted by younger age (p<0.001), medically assisted withdrawal during admission (MAW) (p <0.001) and scoring as possibly alcohol dependent (p= 0.006) on the Alcohol Use Disorder Identification Test (AUDIT) screening tool.

In binary multivariate logistic regression considering age, sex, MAW and AUDIT category, referral onto alcohol services remained highly significant for age, with older adults less likely to be referred (odds ratio 0.029, CI: 0.007 to 0.125, p<0.001).

In older adults drinking at higher risk/possibly dependent levels, only 4.3% (n=2/47) were referred to alcohol services compared to 66.2% (n = 96/145) in under 65s. Older adults were more often signposted or not referred due to confirmed/perceived cognitive impairment.

No significant difference in use of hospital services was found for the 12 months after the index admission.

Conclusions

Older adults are less likely to be referred to community alcohol services, despite evidence they are drinking at higher risk/dependent levels. Further exploration into the reasons behind this is required to help inform development of appropriate pathways and services for this patient group.

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)