Scientific Research

The coexistence of two or more morbidities, including at least one mental morbidity, is defined as mental-physical multimorbidity (MP-MM). It is linked to significant poor outcomes, such as a high burden of healthcare utilisation, particularly in the elderly. To evaluate the complex connections between the 16 physical and mental morbidities among Brazilian older people from the Brazilian Longitudinal Study of Ageing, we performed a network analysis (NA), a sophisticated multivariate statistical technique to estimate all relationships between morbidities represented by an undirected grafus. The objective was to estimate patterns in a complex set of multiple aleatory variables and display them in a network map within nodes and edges representing the variables and the interrelationships among them. In this study, we applied the NA to model interrelationships among chronic physical morbidities and depression. We utilised data from 6.104 participants of the second wave (2019-2020) of the Brazilian Longitudinal Study of Ageing (ELSI-Brazil). The data were adjusted according to the Ising model with the IsingFit function by R Software. Centrality and stability measures were assessed by the bootstrap method through the bootnet library. In this network, depression, low back pain, and hypertension were the morbidities that had the most effects on the network's overall structure, according to an examination of the centrality metrics of the nodes (strength, proximity, and betweenness). Depression was the morbidity with the higher betweenness. The model's interpretation indicates that depression is the illness that has the highest influence on the model and would likely be the most beneficial area for intervention.

Introduction

One in four Care Home (CH) residents have diabetes, making diet crucial for controlling glucose levels (GLs). Continuous blood glucose monitoring (CGM) now offers deeper insights into GL fluctuations. Diabetes in severe frailty is often overtreated, particularly with insulin, posing risks such as hypoglycemia, avoidable hospital admissions, and labour-intensive clinical supervision. While protein and vegetables can slow glucose absorption, dietary advice for CH residents typically emphasizes carbohydrates and may not be tailored to their frailty. This study investigates the impact of modifying protein intake in insulin-using diabetics to improve glycaemic control.

Method

A small pilot study assessed if protein-rich foods (e.g. eggs, peanut butter) given for breakfast stabilise GLs throughout the day. Eight diabetic CH residents using insulin were randomly selected over four months. A diabetic frailty pharmacist monitored GLs with the CGM device (Freestyle Libre) and analysed GLs after a protein-rich breakfast. Descriptive analysis and t-tests were conducted using R before and after the food intervention, and ANOVA was used to analyse significant differences in GLs.

Results

Six out of eight patients showed statistically significant reductions in GL spikes, sustained throughout the day. For the remaining two patients, the food intervention helped maintain target GLs. This led to the discontinuation of insulin in one patient, and in the second, problematic frequent hypoglycemia was mitigated by the food intervention. Clinical decisions on patient safety influenced outcomes for these two patients but were not excluded from analysis.

Conclusion

Six of the eight residents given additional protein at breakfast showed significant GL reductions, leading to decreased insulin dosing and simpler regimes. Carers reported improvements in mood, sleep, and energy levels anecdotally. A holistic dietary approach in managing diabetes in CH residents, emphasizing increased morning protein intake, should be considered to enhance GL control and allow deprescribing. A larger study is planned.

Introduction

Multiple long-term conditions (MLTCs) are common in the population, which increase with age and are associated with increased hospital admissions. Identifying early signs of decline, such as restricted physical activity, could help reduce avoidable hospitalisations, however it is not clear how best to do this.

Aim

To co-design with patients, caregivers and primary care professionals (PCPs), an intervention aimed at identifying changes in activity in order to recognise decline in older adults with MLTCs. Methods The Person-Based Approach was followed to plan and develop this intervention. Qualitative interviews were conducted with older patients with MLTCs, caregivers, and PCPs to examine perspectives on an intervention measuring changes in physical activity. A prototype app was developed, using these results and patient and public involvement. This was further optimised through iterative think-aloud interviews with patients, caregivers, and PCPs.

Results

Thirty-six interviews were conducted comprising of 17 patients (mean age 79-years, 23% female), eight caregivers and 11 PCPs (GPs, nurses, occupational therapists, and pharmacists). Interviews were recorded, transcribed, and thematically analysed. Findings highlighted the importance of restricted activity as an indicator of decline. Patients often described their experiences of decline through non-specific symptoms, including changes in physical activity. PCPs emphasised the value of knowing about such changes to clinical decision-making. Different technology options for measuring activity were explored, considering data quality, and acceptability of passive/active data collection. The initial prototype intervention was designed for iterative testing and think-aloud interviews will be completed by November and presented.

Conclusion

This study highlights the utility of measuring changes in activity in older patients, and some benefits and lessons learned from co-design. A proactive approach to detecting early decline within community settings may provide opportunities to unplanned hospital admissions. 

Background: Prostate cancer and bladder outlet obstruction, often treated surgically, are increasing in the aging population, leading to more cases of stress urinary incontinence (SUI). While implantable continence devices are beneficial for many, a growing number of frail patients are unsuitable for surgery and rely on incontinence pads or penile clamps, which are limited to three-hour use to prevent tissue ischaemia. We present the first UK evaluation of the new PaceyCuff penile clamp, designed for 24-hour wear while maintaining blood flow, to assess its efficacy, safety, and impact on patient quality of life.

Methodology: Men with urodynamically-proven SUI were identified. Baseline penile and finger peripheral oxygen saturation (SpO2), three-hour pad weight, 24-hour pad count and patient-reported outcomes (ICIQ-UI, QoL) were measured. Participants were then fitted with the PaceyCuff, and reassessed immediately, at three hours post-application and (via telephone) after two weeks.

Results: 13 men (average age 74, range 62-82) were recruited. ICIQ-UI scores decreased from 17 to 10, and QoL scores from 13 to 9. Average three-hour pad weight dropped from 94g to 10g and daily pad usage decreased from 4 to 0.9 pads. Participants reported good tolerance, with an average pain score of 1.8/10 and only 2 minor adverse effects (skin abrasion, transient pain). Penile SpO2 remained stable before, immediately after, and three hours post-use (76%, 82%, and 81% respectively). Sub-group analysis of patients over the age of 80 (n=4) confirmed equal effectiveness. (ICIQ-UI decreased 18 to 10, QoL decreased 13 to 9, three-hour pad weight decreased 77g to 9g, daily pad usage decreased 4 to 1.5 pads, average pain 1.5/10).

Conclusions: The PaceyCuff has demonstrated both efficacy and tolerability in managing SUI in a UK cohort for the first time and offers a potential treatment option for elderly patients ineligible for surgical intervention.

Introduction

Frailty, independent of age, is associated with adverse outcomes following admission with Acute Coronary Syndrome (ACS) but is often not accounted in risk stratification scores. Those identified as frail may not be considered for invasive interventions despite evidence that they stand to benefit (1) and are at risk of worsening geriatric syndromes on discharge (2,3).

Purpose

We aimed to categorise clinical outcomes in older adults admitted with ACS, with or without frailty to suggest if there is a role for geriatrician input in reducing length of stay and preventing adverse events.

Methods

Anonymised data was obtained from an NHS trust’s MINAP registry of patients admitted with ACS between April 2022 to March 2023. Baseline demographics, Clinical Frailty Score (CFS), GRACE and HEART scores, total length of stay (LOS), days as inpatient pre- and post-procedure, adverse events during admission, readmission rates and all-cause mortality rate at 30 days and 1 year were calculated.

Results

288 patients over age 65 admitted with ACS were included in analysis.

Median age was 73 [IQR 67-80.75]. Patients over 75 years had higher rates of frailty (38.5% of 75-84 years and 50.0 % over 85 years had CFS ≥ 5 versus 14.9% 65-74 years (p<0.00001)).

253 (87%) patients underwent invasive angiogram during admission. Although, age was not a limiting factor, frail patients were less likely to have an angiogram: 24.9% CFS ≥ 5 versus 57.1% of CFS ≤ 3 (p=0.00199).

Mean LOS was 9.02 days with a median of 7[IQR 4-12] v mean LOS 6 days for all under 65 (p<0.0001). There was a trend for longer LOS post-angiogram particularly for patients with CFS 4-5 versus CFS 3 or less (11.3 days v 8.92 days p=0.053).

Conclusions

Older people admitted with ACS are more likely to have a prolonged admission. Input from geriatricians and the wider multidisciplinary team may help to identify and optimise care and decision making of patients admitted with ACS and mild to moderate frailty.

1. Damluji et al. J Am Heart Assoc. 2019;8:e013686

Introduction

Around 30,000 emergency laparotomies are performed each year across the United Kingdom. Over half are in people aged 65 years or above, with a third of this group living with frailty.  The association between frailty and 90-day mortality following surgery is well documented, but longer-term mortality risk has been less extensively studied, despite clear implications for person-centred care.  This study aimed to estimate the influence of frailty on longer-term mortality (> 90 days) following emergency laparotomy.

Methods

A retrospective analysis of National Emergency Laparotomy Audit (NELA) data was undertaken, including records entered between 01/12/18 and 30/11/20. Baseline patient characteristics including Clinical Frailty Scale (CFS) are routinely collected within NELA. Data are linked via NHS Digital with Office for National Statistics mortality data. A multivariate analysis was undertaken using a Cox proportional hazards model with hospital-level random effects. Potential confounders were identified via a directed acyclic graph and included in the model as covariates.

Results

23,290 patients remained alive at 90 days post-surgery and were therefore included in the analysis. After adjusting for other covariates, increasing frailty was associated with an increased risk of longer-term mortality. Compared with CFS 1-3, adjusted HR were 1.86 (95% CI 1.68 – 2.05) for CFS 4, 2.23 (95% CI 2.03 – 2.45) for CFS 5, 3.26 (95% CI 2.99 – 3.57) for CFS 6, 4.53 (95% CI 3.97 (95% CI 5.17) for CFS 7, 5.80 (95% CI 4.44 – 7.57) for CFS 8 and 5.36 (95% CI 4.06 – 7.08) for CFS 9. 

Conclusion

Older people living with frailty remain at increased risk of death beyond 90 days following emergency laparotomy. This information should be incorporated into shared decision-making, enabling patients to make informed choices about their care. Future work must explore how outcomes for this group might be improved through targeted post-operative support.

Introduction: People living with multiple long-term conditions (MLTC) are more likely to experience hospital admission, which is often associated with unintended consequences. Preventing or providing alternatives to admission by predicting adverse admission-related outcomes is important. This study aims to provide an overview of the association between MLTCs and adverse outcomes following hospital admission through a systematic review of systematic reviews.

Method: We searched Medline, Embase, CINAHL, Web of Science and PsycINFO for systematic reviews assessing risk factors/predictors of functional decline (FD), nursing home admission (NHA), or changes in quality of life among adults (≥18 years) experiencing unscheduled acute hospital admission. Eligible reviews had to assess MLTC (LTC counts, indices, or individual LTCs), either alone or with other predictors. Titles/abstracts and full texts were screened in duplicate and candidate predictors were extracted.

Results: 14 systematic reviews assessed predictors of FD (n=8) or NHA (n=6). Reviews focused on studies of general inpatients/mixed presentations (n=8: 6 FD, 2 NHA); hip fracture (n=2: 1 FD, 1 NHA); stroke (n=2: 1 FD, 1 NHA) and cognitive impairment (n=1, NHA) or delirium (n=1, NHA). Assessment of MLTC was heterogenous: comorbidity indices (n=4), counts of LTC (n=2), specific LTC (n=8), and ‘comorbidity’ without further qualification (n=3). Higher comorbidity indices, higher counts, and a range of specific comorbidities (most notably dementia) were associated with FD and NHA. Reviews assessing MLTC alongside other predictors highlighted a broad range of sociodemographic, functional, social, and admission-related factors that were associated with FD and NHA. In general, reviews did not assess the relative importance of MLTC alongside other predictors.

Conclusion: While MLTC may predict unwanted outcomes following admission their qualification is often inconsistent and their relative importance as predictors, alongside broader factors such as social complexity, is rarely assessed in existing systematic reviews.

Introduction:

The aging population has increased the demand for family caregivers, who often suffer from psychological distress, especially compassion fatigue. This systematic review and meta-analysis evaluate the effectiveness of web-based compassion interventions in improving the mental well-being of family caregivers.

Methods:

MEDLINE, Embase, PsycINFO, Web of Science, Cochrane Library, and Proquest were searched from database inception until manuscript submission date. Eligible studies included family caregivers participating in web-based compassionate interventions with reported mental wellness indicators, such as self-compassion. Two independent researchers conducted a literature review, extracted data, and assessed the quality of each study using the Risk of Bias 2 tool. Random effects meta-analysis was performed to pool the data, followed by subgroup analyses, sensitivity analyses and Egger's tests.

Results:

Out of 1095 studies evaluated, eight randomized controlled trials (encompassing 1978 participants) were included, with 75% exhibiting low risk of bias and high-quality evidence. Meta-analysis results indicated positive effects of web-based compassion interventions on family caregivers' self-compassion (SMD = 0.33, 95% CI 0.08 to 0.58, P = 0.009) and mindfulness (SMD = 0.46, 95% CI 0.03 to 0.90, P = 0.04). These interventions also demonstrated a positive impact on reducing stress (SMD: -0.32, 95% CI -0.59 to -0.04, P = 0.02) and anxiety (SMD: -0.28, 95% CI -0.47 to -0.09, P = 0.003). Subgroup analyses highlighted superior self-compassion outcomes for caregivers supporting individuals with mental illness and cancer compared to those caring for individuals with Alzheimer's disease. Interventions lasting ≥ 8 weeks were the most common and effective.

Conclusions:

Web-based compassion interventions benefit family caregivers by enhancing self-compassion, mindfulness, and reducing anxiety and stress. More well-designed studies are suggested for future clinical applications.

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo in older adults. Due to the high incidence of BPPV in older adults presenting with falls, vestibular assessment, and diagnosis of BPPV and other vestibular disorders has become a recommendation in the World Guidelines for Falls Prevention. There has been a paucity of evidence in well conducted randomised controlled trials (RCTs) to evaluate vitamin D for prevention of BPPV recurrence and its relation to falls and function. This is a Phase IIa single centre, placebo controlled, double blind RCT to evaluate vitamin D supplementation together with diet and Canalith Repositioning Procedure [Group A] or diet alone combined with CRP [Gorup B] can reduce recurrence rates of BPPV. Post hoc analyses were performed evaluating BPPV recurrence, falls and function. 53 participants were recruited. 14 were vitamin D replete at baseline [Group C- diet alone], the remaining 39 were randomised into Groups A and B. Group A was associated with 0.75 fewer clinical BPPV recurrences per one person year (IRD -0.75, 95% CI -1.18 to -0.32, P=0.035). Older adults in the study who suffered a fall during the 12 month follow up had lower Activities of Daily Living scores. They also had poorer Short Physical Performance Battery scores at baseline. Participants in Group A had better 5x sit to stand time compared to Group B even accounting for underlying frailty scores. 25% of participants who fell in the 12 month follow up reported fear of falling compared to 43% in those with no falls in the 12 month follow up. Vitamin D supplementation improved physical performance in 5xchair stand test. In this study population, more participants without an incident fall during follow up experience fear of falling, prompting further consideration into the complex concept that is fear of falling.

Introduction: Research suggests that physical and cognitive exercise can have a positive effective on those with dementia, but less is known about such interventions in those at risk for dementia. Understanding the feasibility of administering clinical assessments remotely using Zoom for Healthcare^TM in the context of a dementia prevention trial for at risk older adults is not well understood.

Methods: SYNERGIC@Home/SYNERGIE~Chez soi (NCT04997681) is a home-based, remotely delivered clinical trial targeting older adults at risk for dementia. Participants underwent a screening/baseline assessment and were randomized to one of four physical and cognitive exercise intervention arms for 16 weeks (3 times per week). They were reassessed immediately post-intervention and 6-months later. The standardized assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, and quality of life were done at all three points. A research coordinator completed the assessments on a one-on-one basis via Zoom for Healthcare^TM. The quality of life questionnaire was mailed to the participant.

Results: Forty-eight of 60 participants (80%) (mean age 68.7 ± 5.7 years, 81.3% female) completed the study. Most participants (75.0%) were cognitively intact with at least 2 dementia risk factors. No participants withdrew from the trial because of difficulty with the remote delivery of the assessments. There were no statistically significant changes in any of the assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, or quality of life throughout the study.

Conclusion: This study demonstrates it is possible to administer standardized clinical assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, and quality of life remotely in the context of a clinical trial. The study was not powered to detect meaningful differences in these assessments. Nevertheless, this confirms the feasibility of remotely administering clinical assessments to older adults at risk for dementia