Scientific Research

Introduction

About 300,000 people living with Frailty undergo operations annually. Current evidence suggests that comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Multiple NCEPOD reports, the National Emergency Laparotomy Audit (NELA) and National Hip Fracture Database (NHFD) programs have highlighted the unmet need in caring for these patients. Our aim was to introduce a novel combined Geriatrician/Anaesthetist pre-assessment clinic to provide better SDM and perioperative optimisation to improve outcomes for elective colorectal surgery.

Method

We performed combined CGA and Anaesthetic pre-operative assessment in patients undergoing elective colorectal surgery aged ≥65 years between July 2021 to August 2022. Data including Clinical Frailty Score (CFS), LOS, Type of surgery, P-POSSUM Score, 30-day mortality and 90-Day mortality were analysed.

Results

We reviewed 48 patients in 14 months. 69% patients underwent surgery and 27% declined after a comprehensive SDM process. The median age of operated patients was 80 (65-94) compared with 74 in 2020-21. 58% of patients operated were over 80, compared to 24% in 2020-21, prior to clinic inception. The median CFS was 4. 55% of patients had a LOS ≤7days (73% in 2020-21), 32% was 8-14days (18%) and 13% was >14days in hospital (9%) respectively. 32% had a P-POSSUM score of ≥5% whereas 10% had a score of >15%. The overall 30-day and 90-day mortality rates for our cohort was 0%, compared with 0% and 3% respectively in 2020-21.

Conclusion

Our data suggests that our clinic has enhanced equity of access to curative colorectal cancer surgery for older adults. 90 days mortality remained 0% owing to excellent patient selection and enhanced perioperative care. Importantly, 27% of patients declined surgery after an extensive process of SDM. Further work needs to be completed assessing decision regret and satisfaction with SDM (SDMQ9).

INTRODUCTION: Frailty assessment in stroke is not commonly integrated into clinical practice, despite current clinical recommendations. Pre-stroke frailty is associated with longer-term mortality, length of admission, and disability. Similarly, anticholinergic burden (ACB) is not routinely reviewed, even though it is associated with cognitive and physical impairment, increased hospital admissions, and higher mortality in older people. Healthcare Improvement Scotland-Frailty (HIS-Frailty) is a novel tool for the evaluation of frailty in older people. Our aim was to compare and correlate the identification and severity of frailty with HIS-Frailty to the Rockwood Clinical Frailty Scale (CFS) in stroke. We also used the ACB Score to determine if there was a difference in ACB between hospital admission and discharge in these patients.

METHODS: We conducted a prospective, observational, single-center study in a stroke unit. Patients with a cerebrovascular diagnosis were included. We compared frailty assessment through linear correlation and ACB through mean difference in scores. Results were considered statistically significant if p-value < 0.05 and highly statistically significant if p-value < 0.005. SPSS® 26.0 was used to perform data analysis.

RESULTS: We included 145 patients. 110 (76%) were older than 60 years and 75 (52%) were male. Most admissions were due to ischemic stroke (67%), closely followed by TIA (14%). Forty-eight (32%) were classified as frail. There was a strong positive correlation between HIS-Frailty and the CFS (r = 0.95; p <0.00001; R2 = 0.91). Seventy-nine (55%) patients had significant ACB. There was no significant difference between ACB at admission and discharge (MD = 0.010, CI 95% -0.52 to 0.54; p = 0.97).

CONCLUSION: HIS-Frailty may prove to be a consistent and easy tool for the systematic identification of frailty in stroke patients, in accordance with best clinical practice guidelines. We should standardise measures to reduce ACB after stroke.

Introduction

There is relatively little known about physical health of older people who are unpaid carers. The English Longitudinal Study of Ageing (ELSA) Wave 9 (2019) was used to examine the relationship between unpaid caring and health. This study contains information on frailty, caring, comorbidities and Instrumental Activities of Daily Living (IADL) from 8,736 participants 50 years and over.

Methods

We included participants who received a nurse visit in Wave 9 (n=3,047), 21 were excluded due to missing data. Frailty was calculated using the ELSA-Frailty Index (FI). Carers were those in receipt of Carers Allowance or self-reported unpaid caring.

Results

351 carers and 2675 non-carers were included. Carers were younger (64.5 (10.2) vs 66.7 (10.5), p<.001) and more likely to be married (78.1% vs 62.8%, p<0.001). carers had a lower median fi score (0.07 (0.04-0.14) 0.15 (0.12-0.21), p="0.000)" however, 45 />536(8%) of moderately and severely frail participants were carers. Of 966 non-frail (FI <.12) participants: 9 />246(2.6%) carers experienced difficulties with IADLs, compared to 5/720(0.69%) non-carers; 79/246(31%) of carers had impaired mobility, compared to 39/720(5%) of non-carer; and 51/246(20%) had 2+ comorbidities, compared to 17/720(2.4%) non-carers. Of 1524 mildly frail (FI>0.12-0.24) participants: 16/60(26.7%) carers experienced difficulties with IADLs, compared to 116/1464(0.69%) non-carers; 58/60(97%) of carers had impaired mobility, compared to 807/1464(55%) non-carers; and 42/60(70%) had 2+ comorbidities, compared to 607/1464(41.4%) non-carers. On frailty-adjusted multivariable analysis there was a strong association between carer status and comorbidities with Odds Ratio (OR)3.01 (95%CI 2.21-4.10); impaired mobility, OR 11.08 (95%CI7.52-16.32); and impaired IADLs, OR 5.44(95%CI3.48-8.48)

Conclusions

Carers are less likely to be frail but more likely to struggle with at least one IADL, experience comorbidity or mobility impairment than equivalently frail peers. This suggests that, in the over 50s, either caring contributes to impairment or the burden of care falls on the more impaired.

Introduction: Pharmacogenomics is using a patient’s genetic information to predict their likely response to a medicine. There is evidence that patients who receive pharmacogenomic-guided care benefit from a reduction in clinically significant adverse drug reactions. Therefore, pharmacogenomic testing can be used as a medicines optimisation tool to prevent adverse drug reactions in older people and reduce associated hospital admissions. This qualitative study aimed to identify the facilitators and barriers to implementing pharmacogenomic-guided prescribing in acute care for older patients by examining the views of patients, pharmacists and physicians.

Method: Following consent, patients (aged 65+), pharmacists and physicians across two hospital sites, participated in a semi-structured interview. The interviews were transcribed and analysed using the Framework approach to identify themes describing barriers or facilitators to implementing pharmacogenomic-guided care. Patient interviews were analysed separately from the healthcare professional interviews and supporting quotes were selected to illustrate each theme.

Results: Nine patients, six pharmacists and five physicians participated in the study. Framework analysis of the patient interview transcripts identified three themes: (1) Information delivery (2) Standard of care (3) Participation in pharmacogenomic-guided care. Framework analysis of the professional interviews produced the themes: (1) Level of interest (2) Workforce pressures (3) Support required for the workforce. Professionals do not have enough knowledge of pharmacogenomic-guided care to confidently apply it to their clinical practice. Patients want to be involved in pharmacogenomic-guided prescribing decisions so pharmacogenomics does not feel imposed on them.

Conclusion(s): Older patients view pharmacogenomic-guided care as therapeutically beneficial and would like to be involved in pharmacogenomic-guided prescribing decisions, with information about pharmacogenomic-guided care tailored to their information-seeking preferences. Professionals envisage pharmacogenomic-guided care as potentially useful in improving their prescribing and medicines reviews but are concerned that operational pressures could make its implementation impractical.

Introduction: Older patients are vulnerable to falls after discharge as hospitalization could induce declines in physical function, mobility, and muscle strength. Falls may cause readmissions and subsequent healthcare burden. However, such incidence rates and costs have not been studied. This study aimed to investigate the incidence and costs of fall-related readmissions in older patients.

Method: A population-based retrospective cohort study was conducted among patients aged 65 or over and discharged from public hospitals in Hong Kong from 2007 to 2017. The administrative data for inpatient admission were obtained from the Hospital Authority Data Collaboration Lab. The fall-related readmissions within 12 months following discharge were identified by the International Classification of Diseases code of diagnosis. The incidence rates were calculated in terms of person-years. The costs were computed based on the public ward maintenance fees adopted since 2007.

Results: In total, 611,349 older patients with a mean (SD) age of 75.3(7.6) were analyzed. Within 12 months after discharge, 18,608 patients (3.0%) had 20,666 fall-related readmissions, giving an incidence rate of 35.2 per 1000 person-years. Meanwhile, such rates (per 1000 person-years) were 44.7 for women, 25.5 for men, 20.5 for patients aged 65-74, 41.0 for patients aged 75-84, and 76.2 for patients aged ≥85. The annual cost exceeded HKD 145.6 million (USD PPP 23.9 million in 2018) for older patients, and the mean cost per fall-related readmission was HKD 7,048 (USD PPP 1,158).

Conclusion: The fall-related hospital readmissions were important adverse events during the transitional period and caused a considerable healthcare burden to the patients, family caregivers, and the health system. Health professionals are suggested to implement interventions during hospitalizations or at the early stage after discharge to reduce falls, particularly for women and patients aged ≥75. For instance, increasing physical activity during the hospital stay can be considered for fall prevention.

Introduction

Older adults with multimorbidity can experience poor health-related quality of life (HRQOL). Yoga has the potential to improve HRQOL. The British Wheel of Yoga’s Gentle Years Yoga© (GYY) programme was developed for older adults with chronic conditions. We investigated the effectiveness and cost-effectiveness of the GYY programme in older adults with multimorbidity.

Method

This was a multi-site, individually randomised, open, superiority trial with embedded economic and process evaluations. Community-dwelling adults aged ≥65 years with ≥2 chronic conditions were recruited from general practices. All participants continued with usual care. Intervention participants were offered a 12-week GYY programme, which changed from face-to-face to online delivery during COVID-19. Most outcomes were participant reported. The primary outcome and endpoint was health-related utility measured using the EQ-5D-5L over 12 months. Secondary outcomes were HRQOL, depression, anxiety, loneliness, falls, adverse events and healthcare resource use.

Results

The mean age of the 454 participants was 73.5 years, 60.6% were female, and the median number of conditions was three. The primary analysis (n=422) showed no statistically or clinically significant difference in the EQ-5D-5L utility score over 12 months (adjusted mean difference of 0.020 favouring intervention; 95% CI -0.006 to 0.045, p=0.14). No statistically significant differences were observed in key secondary outcomes. No serious, related adverse events were reported. The intervention cost £80.85 more per participant (95% CI £76.73 to £84.97) than usual care, generated an additional 0.0178 quality-adjusted life years (QALYs) per participant (95% CI 0.0175 to 0.0180), and had a 79% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY gained.

Conclusion

The GYY programme showed no statistically significant benefits in terms of HRQOL, mental health, loneliness or falls. However, the intervention was safe, acceptable to most participants, and highly valued by some. The economic evaluation suggests that the intervention could be cost-effective.

Background:

Populations in sub-Saharan Africa are ageing rapidly and Tanzania is one country experiencing this acute demographic shift. Multimorbidity (the presence of two or more chronic conditions (1)) is common in the community and associated with greater risk of hospitalisation. To-date, the prevalence amongst older hospital inpatients is unknown.

Objective:

To establish the prevalence of multimorbidity amongst older hospitalised adults in northern Tanzania.

Methods:

For 6-months, adults aged ≥60 admitted to medical wards in four hospitals were invited to participate. A standardised questionnaire, structured around the Comprehensive Geriatric Assessment, was completed. This included items regarding health insurance and exemption from health user fees (granted based on age and low socioeconomic means). Multimorbidity was self-reported using a list of 16 conditions from the Study of Global Ageing and Adult Health Questionnaire, with additional screening for hypertension.

Results:

Between March and August 2021, 540 adults aged ≥60 years were admitted and 308 (57%) underwent assessment. Reasons for non-participation included discharge (n=159) and death (n=34) prior to researcher attendance. Of 277 participants, 145 (52%) had self-reported multimorbidity. Data were unavailable for 31 participants who were unsure of their past medical history. Hypertension was reported by 146 (52%) and an additional 35 (11%) had mean readings ≥140/90 when screened. Mann-Whitney U revealed a significantly greater burden of multimorbidity in those with health insurance (p<0.001) or exemption from user fees (p=.34), compared with participants without.

Conclusion:

Multimorbidity is common amongst hospitalised older adults in Tanzania. Higher rates amongst those with insurance or exemption are likely because of greater access to healthcare services and therefore diagnosis. Simple screening for hypertension identified further individuals with multimorbidity, demonstrating that it may remain underestimated. Widening access to healthcare is a government priority, but the impact of multimorbidity also poses a challenge to hospitals and policymakers.

References:

1. Johnston, MC et al. 2018. European Journal of Public Health, 29, 182-189.

Introduction:

Cognitive impairment and dementia are prevalent in Parkinson’s disease (PD) and significantly impact patients’ quality of life. Accurate prognostic indicators of cognitive decline in this population are needed. Electroencephalography (EEG), a non-invasive measure of brain activity, is one such measure. The current study aimed to systematically review which EEG indices are associated with mild cognitive impairment (PD-MCI) and dementia in PD (PDD).

Method:

A systematic literature search was conducted in Embase, MEDLINE, PsycINFO and Web of Science in November 2022 to identify studies using EEG to assess cognition in PD-MCI and PDD.

Results:

Of the 1716 studies retrieved, 30 were eligible for inclusion. Spectral power in delta, theta, alpha, beta and gamma bands was most frequently investigated (n=13), followed by functional connectivity (n=9) and event related potentials (ERPs; n=6). Slowing of spectral power, characterised by global increases in delta and theta bands with a concomitant decrease in alpha and beta bands, was found in PD-MCI and PDD (n=11). Reduced functional connectivity between anterior and posterior regions was also associated with cognitive impairment in PD (n=2), together with decreased functional connectivity in the alpha band (n=9) in PD-MCI and PDD. However, two studies displayed normal functional connectivity of delta sources in PD-MCI and PDD respectively. ERP studies revealed deficits in attention and semantic processing associated with PD-MCI/PDD.

Conclusions:

This review demonstrates that slowing of EEG activity, reduced functional connectivity and aberrant ERPs are associated with PD-MCI and PDD. Study limitations include small sample sizes and discrepancies in the criteria used to define PD-MCI, together with the wide variety of EEG tasks, montages and analysis pipelines used between sites. Overall, this study highlights the potential application of EEG to predict and monitor cognition in PD. Further work should be undertaken to determine the sensitivity, specificity and prognostic value of these EEG indices.

Background:

Dementia with Lewy bodies (DLB) is one of the most common degenerative dementias, and it is associated not only with cognitive symptoms, but motor, neuropsychiatric, sleep and autonomic symptoms. There is increasing emphasis on the involvement of patients and their representatives in dementia research, but little is known about the extent and nature of surveys and qualitative research methods capturing the views of those affected by DLB. The objective of the scoping review is to determine the extent and nature of published literature that uses surveys and qualitative methods to elicit the views of people diagnosed with DLB and their care partners.

Methods:

The electronic databases MEDLINE ALL, EMBASE, CINAHL Plus, PsycINFO and Web of Science will be searched for relevant publications (from inception onwards). Papers using qualitative and survey-based research methods to investigate the view of patients and caregivers affected by DLB on any aspect of their healthcare or research will be included. Google Scholar and The Networked Digital Library of Theses and Dissertations will be searched for additional literature. The search strategy for published peer-reviewed articles will be limited to qualitative and survey-based study designs. Reviews, scoping reviews, narrative reviews, research reports, grey literature and editorial, reflection or perspective articles written by a person with DLB or their caregiver will be considered. An established methodological framework will guide the scoping review process. Two reviewers will independently screen all citations, full-text reports and abstract data. Data analysis will involve descriptive numerical analysis and qualitative content analysis.

Expected Outcomes:

It is anticipated that the extent of qualitative and survey-based research in this context is limited in quantity. It is expected that work will predominantly focus on the importance of post-diagnostic support and general information and support needs with relatively little work around individual symptoms, drug therapies or trials.

Introduction

Training in the subspecialty of Movement Disorders (MD) has been previously identified to be lacking in geriatric medicine, through a survey in Northern and Yorkshire regions (2006). In anticipation of the new geriatric medicine curriculum, the MD Special Interest Group Committee of the British Geriatric Society (BGS) sought to evaluate current experiences of training and perspectives of trainees for their subspecialty training.

Method

An online survey was designed by trainees with input from supervisory clinicians. Alongside demographic details, a combination of multiple choice and open questions were included to explore experiences, barriers and ideas for improvement for MD training. The impact of the Covid-19 pandemic was included within response options. The survey was circulated by email to all trainees within the BGS September 2021, with a one-month response window.

Results

Number of respondents was low (n=25) but included all years of training and diverse regions. 12% intend to specialise in movement disorders and 24% were working in posts with a specific MD component. Satisfaction with movement disorders training was low with none reporting complete satisfaction and more than half being dissatisfied. Clinic experience varied greatly, but was frequently perceived to be insufficient. Exposure to advanced therapies was rare. Course attendance, QIP or research, and delivery of teaching within MD were all infrequent. Whilst Covid-19 was a barrier to MD clinics and courses for half of all respondents, further factors included limited clinic capacity (46%), no training clinics (33%) and no local MD services (29%). The most significant barrier to accessing advanced therapies experience was lack of local provision (79%). Finding a suitable course, cost and ability to take study leave restricted course attendance.

Conclusions

The identification of areas of deficit, barriers to training and suggestions from trainees could help to improve training and aid implementation of the new curriculum.