Scientific Research

Aim

Dysphagia affects up to 70% of nursing home residents and incorrect management can result in choking and aspiration pneumonia. (SLT). This study aimed to understand the mealtime experience of residents with dysphagia, how this compared with best practice for preventing aspiration pneumonia and what factors influenced their care.

Methods: 

Mealtime care of residents with dysphagia from 2 care homes was observed using structured tool to capture 12 elements of expected practice related to safe nutrition/hydration care and compare observed practice with recommendations in Speech and language therapists (SLT)/care plans. Interviews with care staff) sought to understand factors that contributed to the delivery of care.

Results

66 episodes of mealtime care for 11 residents were observed. SLT recommendations were mostly incorporated into the care plans and predominantly focused on food and fluid, other safe swallowing strategies such as positioning, prompting and ensuring mouth clear were mentioned in less than 40%. Observed adherence to many elements of best practice was less than 60%. Nutrition care was less safe when residents were being fed in the dining room when multiple care staff were present. Interviews with care home staff found training was focused on food and fluid modification not other safer swallowing strategies. Communication about care needs occurred verbally during daily handovers and time pressures during mealtimes influenced how staff assisted residents with dysphagia. 

Conclusions 

Safer swallowing care for residents with dysphagia is essential to prevent aspiration and reduce the risk of pneumonia. Staff have limited knowledge and training on how to manage safe swallowing. Workforce and system issues need to be addressed to create a safe swallowing culture and improve the experience of care home residents with dysphagia. 

Intracerebroventricular streptozotocin (ICV-STZ) injection is among the best animal models to simulate sporadic Alzheimer’s disease (sAD). Abnormality in brain insulin signaling, neurodegeneration, neuroinflammation, cholinergic damage, mitochondrial dysfunction, genetic abnormality, respiratory problem, oxidative stress, gliosis, sleep disturbances are associated with cognitive abnormalities seen in ICV-STZ injected rats. Available experimental evidence has used varying doses of STZ (<1 to 3mg/kg) and studied its effect for different study durations, ranging from 14-21 (short), 30-42 (mild), 90-105 (moderate) and 250-270 (long) days. These studies indicated that 3mg/kg of body-weight is the optimum dose for inducing sAD in the rodents. However, studies on the pathological process with related the morphological and functional abnormalities reported were illusive. Hence in the present study, we have investigated the morpho-functional changes after 3mg/kg ICV-STZ treatment with a follow-up of two months in 54 male Wistar rats (ethical no. 937/IAEC/PhD-2016). Results exhibited a spatial, episodic and avoidance memory decline and increase in anxiety (p<.05) in icv-stz group progressively with time from 15th day to 60th post-injection. morphometry showed hippocampal atrophy ca1, ca3 layer thinning (p="0.007)" ≤0.01) and loss of neurons (p<0.0001) associated third ventricular enlargement rats versus sham, along-with extracellular amyloid plaque ad congored staining. addition, spine golgi-cox impregnation mossy fiber a reduction density control sham (p<0.0001). finally, immunohistochemistry gsk3ß, pi3k mtcox-1 antigen coronal sections revealed an increase mean intensity gsk3ß decrease brain areas limbic system on day. these findings suggests, progressive dementia anxiety 3mg />kg STZ treated rats, which may be due to hippocampal atrophy, amyloidopathy, ventricular enlargement, synaptic dysfunction and deficits in energy homeostasis of brain.

Introduction:

Recent evidence suggests extensive grey matter abnormalities in Parkinson’s Disease Psychosis (PDP), as well as dysfunction of dopaminergic and serotonergic receptors. However, findings remain unclear. This meta-analysis aimed to identify neuroanatomical correlates of PDP and to examine the relationship between grey matter and key candidate receptors.

Method:

Peak coordinates were extracted from structural magnetic resonance imaging (MRI) studies (identified through systematic searches on PubMed, Web of Science, and Embase) for PDP patients and Parkinson's Disease patients without psychosis (PDnP) and were analysed using Seed-based d mapping with permutation of subject images (SDM-PSI). Gene expression data for dopaminergic (D1/D2) and serotonergic (5-HT2a/5-HT1a) receptors were extracted from the Allen Human Brain Atlas, probe-to-gene re-annotation data were downloaded from Arnatkevic̆iūtė et al. (Neuroimage, 2019;189:353-67) and parcellated on 78 regions of the Desikan-Killiany brain atlas. Effect-size estimates, extracted from the SDM-PSI analysis for these 78 regions as a measure of grey matter in PDP patients, were entered in multiple regression models.

Results:

10 studies were included in the meta-analysis (PDP, n= 211; mean age = 69.01 years, 52.1% males; PDnP, n = 298, mean age = 67.34 years, 41.9 % males). Reduction in grey matter was observed in parieto-temporo-occipital regions in PDP patients (uncorrected, p < 0.05). When controlling for PD medications, expressed in Levodopa equivalent daily dose (LEDD), results remained significant (uncorrected, p < 0.05). 5-HT2a and 5-HT1a gene receptor expressions were associated with estimates of grey matter volume (5-HT2a, b=-0.20, p=0.01, adjusted for LEDD, b=-0.18, p=0.03; 5-HT1a, b=0.11, p=0.02, adjusted for LEDD, b=0.12, p=0.01).

Conclusion:

We observed lower cortical volume in parieto-temporo-occipital areas, which are involved in information processing, integration, and attention in PDP compared to PDnP patients. We also reported an association between regional brain expression of serotonergic receptors and grey matter volume suggesting a role of serotonin in PDP.

Background
This study aimed to determine trajectories of depressive symptoms among older adults in England, overall and for those with hip fracture. The study aimed to explore the differential characteristics of each trajectory identified.
Methods
Analysis of adults aged 60 years or more (n=7,050), including a hip fracture subgroup (n = 384), from the English Longitudinal Study of Ageing. Latent class growth mixture modelling was completed. Depressive symptom prevalence was estimated at baseline. Chi-squared tests were  completed to compare baseline characteristics across trajectories.
Results
Three trajectories of depressive symptoms (no, mild, and moderate-severe) were identified overall and for those with hip fracture. The moderate-severe trajectory comprised 13.7% and 7% of participants for overall and hip fracture populations, respectively. The proportion of participants with depressive symptoms in the moderate-severe trajectory was 65.4% and 85.2% for overall and hip fracture populations, respectively. Depressive symptoms were stable over time, with a weak trend towards increasing severity for the moderate-severe symptom trajectory. Participants in the moderate-severe symptom trajectory were older, more likely to be female, live alone and had worse health measures than other trajectories (p < 0.001).
Conclusions
Older adults, and those with hip fracture, follow one of three trajectories of depressive symptoms which are broadly stable over time. Depressive symptoms’ prevalence was higher for those with hip fracture and, when present, the symptoms were more severe than the overall population. Results suggest a role of factors including age, gender, and marital status in depressive symptoms trajectories.

Background: Frailty and dementia have a bidirectional relationship. However, frailty is rarely reported in clinical trials for dementia and mild cognitive impairment (MCI) which limits assessment of trial applicability. This study aims to use a frailty index (FI) to measure frailty using individual participant data (IPD) from clinical trials for MCI and dementia and to quality the prevalence of frailty and its association with serious adverse events (SAEs) and trial attrition. Methods: We analysed IPD from three dementia (n=1) and MCI (n=2) trials. An FI comprising physical deficits was created for each trial using baseline IPD. Poisson and logistic regression was used to examine associations with SAEs and attrition, respectively. Estimates were pooled in random effects meta-analysis. Analyses were repeated using an FI incorporating cognitive as well as physical deficits, and results compared. Results: The mean physical FI was 0.13 and 0.14 in the MCI trials and 0.25 in the dementia trial. Frailty prevalence (FI>0.24) was 5.1%, 5.4% in MCI trials and 55.6% in dementia. After including cognitive deficits, prevalence was similar in MCI (4.6% and 4.9%) but higher in dementia (80.7%). 99th percentile of FI (0.29 in MCI, 0.44 in dementia) was lower than in most general population studies. Frailty was associated with SAEs (physical FI IRR = 1.63 [1.43, 1.87]; physical/cognitive FI IRR = 1.67 [1.45, 1.93]). Frailty was not associated with trial attrition (physical FI OR = 1.18 [0.92, 1.53]; physical/cognitive FI OR = 1.17 [0.92, 1.49]). Conclusion: Measuring frailty from IPD in dementia and MCI trials is feasible. Severe frailty may be under-represented. Frailty is associated with clinically significant outcomes. Including only physical deficits may underestimate frailty in dementia. Frailty can and should be measured in trials for dementia and MCI, and efforts should be made to facilitate inclusion of people living with frailty.

Introduction  

Many people with parkinsonism require care as the disease progresses with much provided unpaid by family and friends. Caring for someone can have a negative impact on physical and psychosocial wellbeing. Caregiver burden can impact ability to continue this role, which can precipitate hospitalisation or institutionalisation of the recipient.  

Methods  

In this single-site study, primary, informal caregivers, defined as those providing any care or support, were enrolled alongside the person with parkinsonism or individually. Self-reported questionnaires included the 22-item Zarit Burden Interview (ZBI), which can range from 0-88, with higher scores representing greater burden. Linear regression was used to explore the association between recipient characteristics/need and caregiver burden.  

Results  

Of 1,032 eligible patients approached, 813 participants indicated whether they had an informal caregiver (708) or not (105). 376 caregivers consented (53.1%), of whom 323 have returned questionnaires, with patient data available for 301.    

The median age of caregivers was 72.9 (range 27.0- 91.1 years), 238 (73.7%) female. 275 (85.1%) were the spouse/partner of the patient. 216 (66.9%) were the sole caregiver. The median time per week spent caring was 21 hours (interquartile range 7, 41 hours). 18 (5.6%) of caregivers provided 24-hour care daily and 113 (35.0%) had provided support for over 5 years. Median ZBI score was 18, (interquartile range 8-31).  The care recipient’s duration of parkinsonism was associated with higher burden score (0.36 increase per year of parkinsonism; 95% CI 0.05, 0.66; p value 0.022), as was the time per week spent caring (0.15 increase for each additional hour; 95% CI 0.11, 0.20; p value <0.001).  

Conclusions 

Many informal caregivers in this study were the sole caregiver and many were themselves older adults. Burden increased with increasing duration of parkinsonism and as time spent caring increased. This highlights the ongoing need to improve support for this group.  

Introduction Critical Illness Acquired weakness (ICU-Acquired Weakness (ICU-AW)) is an umbrella term used to describe Critical Illness Myopathy (CIM) and Critical Illness Polyneuropathy (CIP). The condition exerts high prevalence in the elderly admitted in the ICU and is associated with deteriorating patient outcomes, namely mortality and morbidity. The prevalence of the syndrome is highly variable in the current literature hindering our ability to objectively quantify the scale of the problem. Moreover, several preventative methods and treatment for ICU-AW as a result of sarcopenia have been proposed in literature with some of them providing favorable outcomes.

Our Objectives main objectives are: 1. Evaluate the prevalence of ICU-AW in the elderly through a systematic review 2. Explore the treatment options currently available

Methods We conducted a systematic review using the PubMed, Embase and Cochrane databases to explore the current studies available on the diagnosis of ICU-AW syndromes. Cochrane’s Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was our template.

Results Overall, twenty-one studies (1544 patients) were included. The minimum reported prevalence is 20%, whereas the maximum is 76%. The overall median prevalence was 52% (Q1: 32% and Q3: 61%) with an interquartile range (IQR) of 29%. The highest IQR was found in studies using clinical examination (IQR=37%) whereas the lowest in studies using electrophysiological assessment (IQR= 21%). Moreover, several preventative measures for ICU-AW were identified and analyzed namely: nutritional alterations (high protein dies), glucose control, early mobilization, neuromuscular electrical stimulation and the ABCDEF bundle.

Conclusion The variability in the diagnostic modalities used to measure the syndrome as well as the inconsistency in the diagnostic parameters within each modality prevent us from objectively quantifying the prevalence of ICU-AW. With regards to treatment early mobilization protocols offer promising evidence. Reference: Vanhorebeek, Latronico, Van den Berghe G. ICU-acquired weakness. Intensive Care Med. 2020;46(4):637-53.

Aim

STOPPFrail criteria identify potentially inappropriate medications (PIMs) in frail older adults with poor predicted one year survival. This study aimed to determine the proportion of older adults in which STOPPFrail criteria are applicable; measure the prevalence of STOPPFrail PIMs and identify potential medication cost savings.

Methods

We prospectively reviewed patients who received Comprehensive Geriatric Assessment following an attendance at the Emergency Department (ED) at a large regional hospital. We recorded Charlson Comorbidity Index, Medications, Rockwood Frailty Status and applied STOPPFrail in patients who fulfilled STOPPFrail criteria after a geriatrician led multidisciplinary assessment. Medication costs were identified using the Medoptimise medication review software.

Results

279 patients were prospectively assessed over a 12 week period between June- August 2022. 47 patients met STOPPFrail eligibility criteria (16.8%) ( mean age 87.7 yrs IQR 82-93; 34% male; CFS 7.2; CCI 6.7). Those STOPPFrail eligible were prescribed 397 medications (mean of 8 medications IQR 6-10.5) of which 104 were PIMs. At least one PIM was identified in 42 eligible patients (89.3%). The mean number of PIMs per person was 2.2. Most common PIMS were i) Antihypertensives in patients with a systolic blood pressure lower than 130mmHg (23 patients;22% of identified PIMs) ii) statins in 21 patients ( 20% of PIMs) and Calcium and Vitamin D supplementation 11 (10.5%) and 15 (14.4%) PIMs respectively. £12,589.39 of medication cost savings were identified by the use of the STOPPFrail criteria.

Conclusion

16.8% of screened patients were STOPPFrail eligible; with PIMS identified in 89.3%. This study has shown the efficacy of the STOPPFrail criteria to identify potentially inappropriate prescriptions and medication cost savings, however the ability of the criteria to prevent adverse events for patients is unknown. STOPPFrail has been incorporated into the routine structured medication review process within our local service.

Introduction

Dopamine transporter scan (DaT scan) nuclear imaging can be a useful tool in the diagnostic work up of conditions such as Parkinson’s disease (PD) where the underlying physiology of the disease involves striatal dopamine transporter loss. Selective serotonin reuptake inhibitors (SSRIs) bind with high affinity to the dopamine transporter, competing with test compound, ioflupane. There is inconsistent guidance on stopping SSRIs prior to DAT scan due to lack of robust evidence. However, case studies suggest the interaction may result in false positive results. We investigated potential SSRI related false positive DaT scan results in view of developing a local guideline.

Methods

DaT Scan reports of patients attending two district general hospitals in South Wales over a one year period were retrospectively analysed and cross-referenced with their diagnosis and drug history on Welsh Clinical Portal (WCP).

Results

Seventy two patient records were analysed. Mean age was 73 and 64% were male. Eight patients (11%) were taking an SSRI at the time of their DaT scan. Patients taking SSRIs were not more likely to have a positive DaT scan result than patients not on SSRIs (7/8 and 40/64 respectively, p = 0.598). Those taking SSRIs were also not more likely to have a clinical diagnosis of PD than those not taking SSRIs (5/8 and 27/64 respectively, p=0.451).

Conclusion

In our evaluation SSRIs did not increase the likelihood of false positive DaT scan results. As absence of evidence is due to few and small number studies, we employ a pragmatic approach of considering stopping or continuing SSRIs prior to DaT on a case-by-case basis and interpreting results in context, with consideration of repeat scan off SSRI if appropriate.

Introduction

On graduation medical students need to be equipped to recognise and manage acute stroke and TIA (Transient Ischemic Attack). Despite inclusion of acute stroke and TIA in our local curriculum less than 10% of students (2/30) reported directly observing stroke thrombolysis during their placement. Due to COVID restrictions no student had been able to attend TIA clinic. To improve students practical understanding of the assessment and management of acute stroke and TIA a simulation-based teaching session was designed.

Method

The simulation session consisted of a hyperacute stroke assessment and management simulation (2 scenarios) and a simulated TIA clinic (3 scenarios). Students were asked to complete a pre-course and post-course questionnaire regarding their confidence in 8 domains, on a continuous scale 0 to 5.

Results

There were 23 participants over 2 sessions. 18/23 completed the pre-course questionnaire and 16/23 the post-course questionnaire. The mean confidence reported by students increased in all domains: recognition of acute stroke from 3.3 to 4.8; identifying candidates for thrombolysis from 3.1 to 4.6; discussing thrombolysis with a patient or carer from 2.3 to 4.1; knowing when to call for senior support from 3.1 to 4.3; asking for a patient to be transferred to facilitate acute stroke care from 2.2 to 4.2; recognising a TIA from 2.8 to 4.9; requesting investigations for TIA from 2.5 to 4.6; and discussing anticoagulation with a patient from 2.9 to 4.4.

Conclusion

Improvements in the confidence of medical students in assessing and managing acute stroke (including thrombolysis) and TIA can be achieved through a stroke medicine themed simulation session.