Scientific Research

Background: Malnutrition (i.e., protein-energy malnutrition) in older adults is associated with significant complications and increased mortality, highlighting the need for effective treatments. Many randomized controlled trials (RCTs) testing the effectiveness of nutritional interventions for the treatment of malnutrition showed mixed results and there is a need for meta-analyses. However, evidence synthesis is hampered by the wide variety of outcomes and assessment methods in RCTs. This project, led by EuGMS Special Interest Group Nutrition, aims to develop a Core Outcome Set (COS) for nutritional intervention studies in older adults with malnutrition and those at risk.

Methods: The project consists of five phases: 1) a scoping review (completed) to identify frequently used outcomes in published RCTs and select additional patient-reported outcome measures (PROMs). Patient and Public Involvement (PPI) representatives have been involved to provide feedback on the proposed list of outcomes resulting from the review and PROMs; 2) a modified Delphi Survey whereby experienced researchers and health care professionals working in the field of malnutrition in older adults will be invited to rate the importance of the proposed outcomes; 3) a consensus meeting to discuss and agree what critical outcomes need to be included in the COS; 4) a systematic review to determine how each COS outcome should be measured and a second consensus meeting; 5) a dissemination and implementation phase.  

Conclusions: The result of this project will be a COS that should be included in any RCT testing the effectiveness of interventions to tackle malnutrition in older people as a minimum. This COS will facilitate comparison of RCT results, will promote efficient use of research resources and might reduce bias in measurement of the outcome and publication bias. Ultimately, the COS will support clinical decision making by identifying the most effective approaches for treating and preventing malnutrition in older adults.

Background

The Covid-19 pandemic led to many consultations being conducted remotely. Cognitive impairment is recognised as a potential barrier to remote healthcare interactions and is common but heterogeneous in Parkinson’s. Little is known about these consultations in real life. We explored the experiences of remote consultations for people with Parkinson’s and cognitive impairment, investigating the perspectives of people with Parkinson’s, caregivers and healthcare professionals.

Method

Semi-structured interviews were conducted remotely (video or telephone) with 11 people with Parkinson’s and cognitive impairment, 10 family caregivers and 24 Healthcare Professionals in 2020-2021, using purposive sampling. Interviews were audio-recorded, transcribed and analysed using thematic analysis.

Results

Four themes were identified: (1) The Nature of Remote Interactions; (2) Challenges Exacerbated by Being Remote; (3) Expectation versus Reality; and (4) Optimising for the Future. Remote consultations were considered ‘transactional’ and less personal, with difficulties building rapport, and perceived to have a different role to in-person consultations. The loss of non-verbal communication and ability of Healthcare Professionals to ‘sense’ led to remote consultations being perceived as riskier by all groups. Specific to this population, issues arise from both communication and cognitive impairment; balancing of the person with Parkinson’s and caregiver voice; and around significant discussions, for example, regarding the future. Remote consultations were reported to have been more successful than anticipated in all three groups. Obstacles were not always as expected, for example age was less of a barrier than anticipated. Potential improvements for these three groups and healthcare services were identified, for example, consideration of camera positioning for video calls; and service flexibility to allow consultations to be timed to optimal medication function.

Conclusion

Advantages and challenges of remote consultations for this population are identified. Consultations could be improved with increased support, practice, preparation, awareness of issues, and more time and flexibility within services.

Introduction

Despite recognition of the status of gerontological nursing as a speciality , there is no specific UK competency framework for early career nurses working with older people. As part of a feasibility intervention to improve recruitment and retention of nurses within the speciality (ECHO Early Careers in Healthcare of Older People and PEACH Programme for early careers for care home nurses) , we developed a bespoke competency framework appropriate for nurse working within all sectors.

Method

The national and international literature on published competency frameworks was reviewed to identify core domains of knowledge and skill. We integrated these within a CGA model to develop a draft competency framework which we then tested for face and content validity. It was reviewed by expert practitioners and managers from NHS and care home providers, and a national reference group (British Geriatrics Society Nurse Special interest group). It was then implemented by students under taking the ECHO and PEACH programmes. A mixed-methods approach was used involving online surveys, one-to-one interviews and focus group interviews with students, mentors, ward managers and care home managers. Ethical approval was obtained from the university ethics committee

Results

From an initial draft of 80 competency statements 69 were adopted across 10 domains. Thirty students across the ECHO and PEACH programmes used the framework and participated in evaluation. Our analysis found that students benefited from recognising unique gerontological knowledge, expanded insights into practice and affirmation through mentor feedback. Some students faced logistical challenges including access to mentors. The framework was found to be appropriate and acceptable across both hospital, community and care home settings

Conclusion(s)

The competency framework was valid in clinical gerontological settings across hospital, community and care homes, and supported knowledge and skills development and evidencing for early career nurses.

Introduction

Both frailty and HF are common in the elderly population. Elderly HF patients have an increased risk of frailty, and frail elderly patients are at a higher risk of developing HF. Frailty is an independent predictor of mortality in cardiovascular disease. Sarcopenia(defined as decreased muscle mass and muscle strength and/or performance)is also prevalent in HF patients and may progress to cardiac cachexia. HF may induce sarcopenia, and sarcopenia may contribute to the poor prognosis of HF.

Aims:

To assess the prevalence of frailty in older HF inpatients • To determine the risk of sarcopenia in these patients Methods: A cross-sectional, retrospective analysis of consecutive patients, 60 years and over, admitted with HF to a UK hospital. Data was manually extracted from anonymized electronic records. The Rockwood Clinical Frailty Scale (CFS) was used for the assessment of frailty, and the SARC-F tool was used for screening for sarcopenia. Patients with a medical history of HF but who did not present with decompensated HF were excluded. Also, patients with incomplete data were excluded. The IBM SPSS 28 statistical package was used for statistical analysis. Descriptive statistics and risk estimates were calculated.

Results:

163 patients were analysed, 82 males and 81 females. The mean age was 81.4 years (SD 9.69). 71.5 % of patients were frail, while 28.5 % were non-frail. The risk of sarcopenia was 10.9 times greater in the frail than in the non-frail patients (OR = 10.9; 95% C.I 4.85 – 24.67). There was a lower risk of sarcopenia in male patients than in female patients (OR =0.45; 95% C.I 0.22 – 0.94).

Conclusions:

Frailty is prevalent in older heart failure inpatients. It significantly increases the risk of sarcopenia in these patients. Women are at higher risk of sarcopenia than men. More research is needed into frailty and sarcopenia.

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form is widely adopted to document advanced care plans, including Do Not Attempt Resuscitation (DNACPR) decisions. Communication between clinicians and patients, or next of kin is required for completion. It is widely documented UK medical students have little exposure to these experiences, including being asked to leave whilst they are occurring. During the COVID19 pandemic, Foundation Year 1 (FY1) doctors led discussions with increased frequency and autonomy, with no documented concurrent training. We present a novel learning experience designed to aid these discussions. Students were timetabled to a 1.5 hour workshop, facilitated by a clinical teaching fellow. They were invited to complete a ReSPECT form for a celebrity to familiarise themselves with the layout. They then considered a patient admission scenario in 3 different groups from the perspective of the patient, family and medical team, and used this to contemplate potential, future, emergency treatments. Subsequently a discussion surrounding CPR effectiveness, ways of communicating this, and legal advanced decision documents occurred. The session concludes with scrutinising example ReSPECT forms provided by the Resuscitation Council UK.

Method: Students' confidence levels were measured pre and post session using a Likhert scale questionnaire.

Results: 90 students attended workshops across 6 rotations. 80% students completed post - session questionnaires, of which 100% reported an increase in confidence with having a DNACPR/advanced care planning discussion compared to before the session.

Conclusion: DNACPR conversations can incite anxiety in any seniority of health care professionals. Medical educators need to adequately prepare medical students during their training in advanced care planning and DNACPR discussions. This can be done with simulated workshop experiences, reinforced with opportunistic or organised observational experience. Adequate preparation will lead to increased confidence in discussions, ultimately leading to better experiences for patients and their families.

Introduction

By 2030, it is estimated that 25% of Europeans will be aged over 65.[Dugarova;UNDevelopmentProgramme;2017] Frailty in this group is a key contributor to poorer outcomes.[Eamer;BMCAnesthesiology;2017;17:99] The term is common in healthcare but research into the issues faced by staff around assessment and management of frailty has been limited. We undertook a survey to identify challenges faced in providing care to those living with frailty and considered potential interventions.

Method

The survey was across three hospitals in our health board (which serves a population of around 390,000 with a range of services).[SBUHB;2022] It was developed iteratively through consultation in a multidisciplinary group and adapted questions from other similar validated surveys.[Eamer;BMCAnesthesiology;2017;17:99][Taylor;FutureHealthcareJournal;2017;4(3):207-212]

Results

220 responses were received covering a variety of medical and surgical specialties. Participants showed a strong (80%) self-reported understanding of frailty as a clinical concept, but only 46% felt confident in their ability to assess patients for frailty. 74% stated they would benefit from more education on frailty. Other barriers included systemic challenges such as staffing and social care, but also a lack of understanding of frailty by patients and relatives which impacted shared decision-making.

Conclusions

The survey showed a significant demand for more education, especially awareness of pathways and assessment methods. It also highlighted the issue of patients’ (and relatives’) lack of understanding of frailty. In response, we are planning a targeted multi-disciplinary educational programme on frailty across the health board, as well as introducing patient information leaflets.

Introduction

Objectives of this retrospective study were to describe clinical presentations and mortality outcome of hospitalised patients with COVID-19 omicron variant within two acute district general hospitals and to evaluate demographic factors associated with these presentations and mortality.

Methods

Data was obtained over a month in 2021-22 from a retrospective survey of all patients hospitalised and detected to have SARS-COV-2 omicron variant infection. The trust serves a diverse multi-ethnic inner-city population. Data included socio-demographic details, vaccination status, admitting specialty and mortality outcome. Patients were sub-divided into three groups; Group 1 were admitted with ‘true’ COVID pneumonitis; Group 2 were found to have ‘incidental’ COVID on admission screening; Group 3 were negative for COVID on admission but developed COVID >7days after admission.

Results

Of 553 patients, only 24.1% [133/553] were in Group 1; 322[58.2%] in Group 2; 98[17.7%] in Group 3. Patients with Group 1 and Group 3 were significantly older than those in Group 2 (p<.001). 30% patients from BAME ethnicity had covid pneumonitis compared to 19% white ethnicity[p="0.002]." 20% were admitted within non-medical specialties i.e., Surgical specialties, Paediatrics and Obstetrics. of 36 requiring critical care, only 21 in group 1; 20 />21[95%] of these were unvaccinated;7/21 who died were all unvaccinated [100%]. This study showed that common COVID presentations included delirium, falls (and fractures), seizures, COPD, and antenatal problems. 13.7% [76/553] patients died; only 21 were in Group 1[27.6%]. Only 26 deaths were directly attributable to COVID: 4.7% [26/553] of all patients.

Discussion

This large multi-ethnic study has described clinical presentations and mortality of hospitalised patients with omicron. It has determined socio-demographic factors associated with these presentations including ethnicity and vaccination rates. The study useful information for future COVID studies examining outcomes and presentations of omicron and future COVID variants.

Introduction: The COVID-19 pandemic has resulted in many people experiencing bereavement in challenging circumstances. In April 2020 at a large London Trust, a “Bereavement Welfare Hub” (BWH) was established to offer support and advice by telephone to relatives and carers of all adults who died as inpatients. Data from these calls has been used to examine and learn from experiences of the bereaved at this time.

Methods: Data from BWH call records regarding 809 adults who died at the Trust in March - May 2020 were collated and analysed quantitatively. A random selection of 149 call records were examined using thematic analysis.

Results: 809 adults died at the Trust between March and May 2020. The mean age at death was 76 (SD=14) and 86% of deaths occurred on medical wards (outside intensive care). Bereavement calls were completed in 663 (82%) of cases. From analysis of call records, several themes that influenced the bereavement experience were identified. These included support from family and community, communication and contact with the dying person, support from bereavement services and ability to carry out usual rituals associated with dying.

Conclusions: Age is a significant risk factor for death from COVID-19 and the majority of deaths have occurred on medical wards. Improving hospital care of dying patients during the pandemic or at any time is relevant to geriatricians and other healthcare professionals working with older people. Our analysis identifies several factors which positively or negatively influenced the experiences of people bereaved during the first wave of COVID-19. From these findings, recommendations have been made which have the potential to improve the bereavement experience, particularly during the pandemic era.

Introduction: With the unprecedented population growth of older adults worldwide, higher life-expectancies are creating increasingly more multigenerational interaction. Funded by the General Research Fund of the Research Grant Council in Hong Kong, the study examined the effects of telephone-administered perspective-taking intervention in the context of intergenerational caregiving. The data was collected from 2019 to 2021 in Hong Kong.

Method: Through a cluster-randomized trial, one-hundred seventy-six adult child caregivers of persons living with Alzheimer’s disease (AD) were randomized into two twelve-week interventions: 1) Connecting through Caregiving with intergenerational perspective-taking reappraisals (n=91) and 2) Basic Skill Building (n=85). All interventions are administered via telephone, Both groups receive the basic skills training including 1) monitoring mood and scheduling pleasant events and 2) communication with the care recipient & 3) communication skills with other family member and helping professionals. The CTC group spends less time on basic skills and focused on perspective-taking reappraisals aiming to promote balance between self-care and caring of others. These reappraisals include: 1) connecting with self through enhancing self-awareness, 2) connecting with the care-recipient and 3) connecting with others who can help.

Results: In terms of primary outcomes, as compared to the BSB group, the CTC group reported significantly greater reductions in depressive symptoms and higher levels of psychological well-being. For the secondary outcomes, the CTC group scored higher in emotional and instrumental support and also lower levels of perceived presence  and reaction to behavioral and memory problems of the care recipient. Perspective-taking was found to mediate between intervention effects and reduction of depressive symptoms of the caregiver.

Conclusion: The results provided evidence for the efficacy of the CTC program. The telephone-administered intervention was very useful in supporting caregivers during COVID.  With population aging, there is a rapid increase of people suffering from dementia and those who will provide caregiving. The study contributes towards enhancing sustainability of caregiving in dementia

Background: Guidelines recommend that all older hospital patients are screened for cognitive comorbidity (i.e. dementia, delirium) and frailty to inform care and target multidisciplinary team resources, based mainly on evidence from studies in elective or specialty-specific settings. Unselected hospital-wide data are needed to inform guidance and service design and delivery, so we set up the Oxford Cognitive Comorbidity and Ageing Research Database (ORCHARD) using routinely-acquired electronic patient record (EPR) data.

Methods: ORCHARD includes pseudonymised EPR data on all patients >65 years with unplanned admission to one of four general hospitals in Oxfordshire, serving a population of 660,000. Data collected include cognitive screening (mandatory for >70 years) comprising dementia history, delirium diagnosis (Confusion Assessment Method—CAM), and 10-point Abbreviated Mental Test; together with nursing risk assessments, frailty, diagnoses, comorbidities (Charlson index), observations, illness acuity, laboratory tests and brain imaging. Outcomes include length of stay, delayed transfers of care, discharge destination, readmissions, death and dementia through linkage to electronic mental health records.

Results: ORCHARD (2017-2019) includes data from 99,147 consecutive, unselected hospital admissions across all specialties (n=67,585 [68%] inpatient versus n=31,562 [32%] day case; n=73,385 [81%] medical versus n=16,918 [19%] surgical/other). Admissions data were linked to 48,333 unique individuals (n=24,466 [51%] female) with a mean/SD age of 78/10, Index of Multiple Deprivation Decile of 7.6/2.1 and Braden Score of 18.7/3.5 at first admission. Frailty was prevalent, with 15,320 (32%) scoring moderate and 3,233 (7%) high on the Hospital Frailty Risk Score. Complete cognitive screening data are available for 13,102 (67%) unique individuals ≥70 years with inpatient admission.

Conclusion: ORCHARD is a large and rich data resource that will enable studies on the burden and impact of cognitive and physical frailty in-hospital, with relevance to the design and delivery of clinical services and understanding of healthcare resource use hospital-wide and by specialty.