Scientific Research

Introduction: Written documentation and verbal handovers can be ineffective at communicating the specifics of frail, older patients’ complex functional abilities and support needs. Video-recordings of individual patients may help to convey a patient’s condition in a more nuanced, objective way, potentially improving safety at care transitions. The Isla platform interfaces with electronic health record systems, allowing care providers to capture video-recordings during patient care. We evaluated the acceptability, feasibility, and potential effectiveness of video-based patient records (the Isla platform) for supporting the care of older frail inpatients within the acute hospital setting and at care transitions.

Method: Over a three-month pilot period, a non-randomised, mixed-methods feasibility study of video-based patient records (alongside usual care) was conducted within three elderly medicine wards of a large acute hospital in England. Patient and public involvement and engagement (PPIE) was central to study design and implementation. Participant enrolment figures; semi-structured interview data; and video capture and view metrics were examined within an embedded process evaluation, appraising intervention acceptability amongst patients, carers, and ward staff; barriers and facilitators to intervention implementation; and perceived intervention impacts.

Results: The study enrolled 58 ward staff and 29 patients (56.9%); one patient withdrew. Enrolment figures and early interview analyses indicate apparent acceptability of video-based patient records to patients and carers. Intervention barriers (e.g. patient pain), facilitators (e.g. staff-patient rapport) and potential intervention impacts (e.g. improved person-centred care, team communication) were identified. Modal use-cases for video-recordings were to document patients’ transfers (n=16), mobility (n=13), and eating/drinking supports (n=3); however, view metrics suggested limited engagement with videos once captured.

Conclusion(s): Preliminary findings indicate the acceptability and feasibility of video-based patient records, although several implementation considerations warrant address. Perceived intervention impacts (e.g. improved person-centred care) were promising; although greater engagement with videos is a probable precondition to demonstrating efficacy in future research.

Introduction:

Little evidence exists about decision-making with older adults diagnosed with cancer (Bridges et al 2015). However, older age is associated with changes in physical, social, and psychological health domains in ways that influence treatment decisions potentially impacting on quality and quantity of life. We sought to explore the experiences of older adults, their significant others and healthcare professionals when decisions regarding cancer treatment and support are made.

Methods:

Synonyms relating to search terms Cancer, Older People, Complexity and Qualitative research were used to search the databases CINAHL, Medline, Embase and PsychINFO. The Mixed Methods Appraisal Tool (MMAT) identified strengths and limitations of the evidence allowing concurrent appraisal of qualitative, quantitative, and mixed methods studies.

Results:

Searches identified 534 articles: 64 studies underwent full text screening, and 14 of these were included. The synthesis identified six themes: Preconditions in decision-making; Identifying frailty and setting goals; Maintaining independence; Information provision; Support during the decision-making process/role distribution; Trust in physicians; Preferences and choice. Most included studies reported the views of the older person, or health care professionals (predominantly physicians/oncologists/surgeons). However, there is a paucity of evidence representing the views of the older adult’s significant other and a dearth of evidence exploring the efforts and contributions of all people involved in the process of decision-making.

Conclusions:

Research is needed urgently to understand how and why decisions are made regarding cancer treatment and support, as well as how older adults are involved in these decisions throughout their cancer trajectory. Understanding this would assist healthcare professionals to prioritise individual’s healthcare preferences with the potential to positively influence service delivery and workforce development. This review has informed the research design for The CHOICES study which aims to understand how clinicians, older individuals and their significant others make decisions following a new diagnosis of cancer.

Introduction:

Older adults are at increased risks of drug-related problems, contributed by increasing incidence of multimorbidity with age, and the consequent polypharmacy. We aim to investigate the drug classes associated with 30-day readmissions in hospitalised older adults.

Method:

We prospectively studied patients aged 65 years and above admitted to a general medical department in Sengkang General Hospital, Singapore, between October 2018 and January 2020. Medication lists were obtained from electronic medical records at admission. Unplanned readmission within 30 days of discharge was tracked through the hospital’s electronic health records. Medications were classified according to the World Health Organisation’s Anatomical Therapeutic Chemical classification system. Univariate logistic regression was performed for the association of drug classes with 30-day readmission.

Results:

We recruited 1507 consecutive admissions with follow-up data. 30-day readmission occurred in 331 patients (22.0%). Greater length of stay, higher comorbidity burden, hospitalisation in the one year preceding index admission, frailty and polypharmacy were more commonly observed among patients who were readmitted within 30 days of discharge. Admission diagnoses associated with 30-day readmission include infections, fluid overload, acute coronary events and constipation. Drug classes associated with a higher risk of 30-day readmission include drugs for acid-related disorder (OR=1.62, 95%CI 1.27-2.07), drugs for constipation (OR=1.96, 95%CI 1.41-2.73), antithrombotic agents (OR=1.40, 95%CI 1.09-1.79), antianaemic preparations (OR=2.22, 95%CI 1.68-2.91), cardiac therapy (OR=1.70, 95%CI 1.23-2.34), diuretics (OR=1.41, 95%CI 1.04-1.90), beta-blocking agents (OR=1.55, 95%CI 1.21-1.99) and analgesics (OR=1.56, 95%CI 1.02-2.39).

Conclusion:

Drug classes associated with 30-day geriatric readmissions include drugs for acid-related disorder, constipation, antithrombotic agents, antianaemic preparations, cardiac therapy, diuretics, beta-blocking agents and analgesics. Patients on the above drug classes should herald a higher index of scrutiny during admissions, and necessitate closer follow-up upon discharge.

Background: The disease burden of respiratory syncytial virus (RSV) in older adults is substantial but not well quantified previously. We aimed to estimate country-specific hospitalisation burden of RSV-associated acute respiratory infection in older adults (>60 years) in Europe.

Methods: We collected published data (through a systematic review) and unpublished data (from GSK-sponsored studies and international collaborators) on RSV hospitalisation burden. We used multiple imputation for missing age bands. We applied stepwise statistical adjustment to account for case underascertainment related to the variations in case definitions, clinical specimens and RSV diagnostic tests in individual studies. We reported country-level RSV hospitalisation rates for countries with ≥1 eligible study reporting point estimate and 95% confidence interval (CI) of the rates (a random-effects meta-analysis was conducted when ≥2 studies were available). As an alternative method, we additionally included studies not reporting 95% CI and calculated the median of the rate point estimates.

Results: Seven studies were included from five countries: Denmark (1), Finland (1), Netherlands (1), Spain (1) and UK (3). Denmark and Spain had the highest and lowest adjusted RSV-associated hospitalisation rate (408/100000, 95% CI: 319-516; and 176/100000, 137-226) in >60 years, which was about 2.4 times the unadjusted estimate. The alternative method with 5 more studies added had similar estimates for the five countries; another country (Norway) was added and it had the highest adjusted hospitalisation rate (742/100000). RSV-associated hospitalisation rate increased with increasing age across all countries.

Conclusions: With RSV vaccines now approved for use in older adults, our findings help inform the need for country-level RSV prevention.

Introduction: Hospital at home (HAH) is growing apace in the United Kingdom, offering hospital-delivered treatments at home. In parallel, increasingly structured alternative training pathways are being created to enable doctors to train outside of formal specialty training programmes. With a need to train doctors to work in community settings, a HAH rotation within a locally developed internal medicine training (IMT) programme at one large NHS Foundation Trust was evaluated.

Method:

A questionnaire was designed to review the alignment of HAH rotation experience with the IMT curriculum and its acceptability as a clinical rotation within an IMT stage 1 equivalent programme. The questionnaire was distributed to all doctors who had previously undertaken a HAH rotation at junior clinical fellow level in the previous five years. Free-text responses were analysed with thematic analysis.

Results:

23/27 responded (85%). 74% had pursued IMT following their non-traditional training year. 78% agreed that HAH would be a suitable placement for a 4-month IMT rotation, with 74% interested in a HAH role following completion of training. HAH offers core content in internal and geriatric medicine. Curriculum coverage within a HAH rotation included improved confidence in clinical decision making, leadership, risk management, multidisciplinary team working and increased exposure to advanced care planning and palliative medicine. Being part of contextual, personalised medicine with shared decision making central was also cited as beneficial over traditional hospital rotations. Disadvantages were a lack of exposure to core IMT procedural skills, resuscitation and fewer opportunities to attend outpatient clinic.

Conclusion:

Whilst limited to one geographical service, results indicate that HAH is a prime learning environment for internal medicine training as part of a carefully balanced programme ensuring access to all curriculum competencies. Where sufficiently developed, HAH rotations can be included in IMT programmes delivering much needed generalist skills. 

Introduction: There are abundant anecdotal reports of healthcare professionals undergoing strain, specifically moral distress, in advance care planning (ACP) related work. This study measured perceptions of morally challenging scenarios (MCS) faced by ACP facilitators and frontline clinicians. Method: An online survey, which is currently ongoing, was sent to the ACP community and also frontline clinicians in Singapore. Purposive and snowballing sampling approaches were employed. Result: Participants rated their opinions on 23 MCS in ACP-related work that were earlier identified from 30 interviews. Findings showed that the top three MCS perceived to go against one’s conscience were: (i) providing treatment not in concordance with wishes of patient, (ii) being uncertain if decisions by family members were driven by ulterior motives and (iii) taking the view of dominant family members as the final decision. Most commonly encountered MCS were dilemmas related to (i) perceived medical best interest, (ii) honouring of patient’s preferred place of death, and (iii) having to deal with collusion. Each of 14 MCS were encountered by at least 50% of our participants and 66% of all who had encountered at least one MCS agreed that their psychological health was affected. Guidance from mentors and support from peers were rated most favourably out of the 15 coping strategies to deal with moral dilemma in ACP work. Coping strategies were largely positive with only a minority favouring the use of alcohol or giving in to demands of patients and families. Conclusion: Findings show those who engaged in ACP-related work encountered a wide variety of MCS and perceived their psychological health as being affected. There is a pressing need to address the sources and risk factors of moral distress in such work, and to enhance the protective factors which can help ACP facilitators and frontline clinicians cope with moral distress successfully.

1. Introduction

Both increased frailty and multi-morbidity are independently associated with high mortality and increased risk for nursing home placement.

There is limited data on the best ways of assessing frailty and complex comorbidities to guide patient selection for rehabilitation.

It is important we do not deprive an individual of the chance of inpatient rehabilitation, but this needs to be balanced with potential poor outcomes at one year due to frailty and comorbidities.

2. Method

Data was collated retrospectively on all discharged patients over a 90-day period from May to July 2023.

A sub-analysis was undertaken to evaluate one-year outcomes, based on clinical frailty scales on discharge, Barthel's index, their length of admission and number of subsequent hospital admissions.

3. Results

153 patients were discharged over the 90 day period with mean age of 84.

At one year 31 % had died, 12% had gone to placement and 57% remain alive at home.

Higher clinical frailty scores and lower Barthel's index at discharge were correlated with poorer outcomes with mortality & placement.

Higher length of stay, increased subsequent hospital admissions, and more advanced age were associated with unfavourable outcomes.

Among those died, 42% were transferred back to the acute hospital due to acute instability, and 15% had been discharged to placement.

Among those gone to placement, 27% were transferred back to the acute hospital due to acute instability.

Length of stay in rehab is shorter in those still alive and living at home.

4. Conclusion

The results make us consider in more details the risks and benefits of an admission for rehabilitation, as this may account for 10% of an individual’s last year of life.

We aim to relook and refine our pathways to ensure the right patients are accessing rehabilitation.

We will repeat this study in a years’ time.

Background and aims

Delirium carries an eightfold risk of future dementia. Small vessel disease (SVD), best seen on MRI, increases delirium risk, yet delirium is understudied in MRI research. We aimed to determine MRI feasibility, tolerability, image usability, and prevalence of acute and chronic SVD lesions in acute delirium.

Methods

This case-control feasibility study performed MRI (3D T1/T2-weighted, FLAIR, Susceptibility-weighted, and Diffusion-weighted imaging (DWI) on 20 medical inpatients >65 years: 10 with delirium ≥3 weeks and 10 without delirium, matched for vascular risk, Clinical Frailty Scale (CFS), and cognitive status. We excluded acute stroke, agitation necessitating sedation, assistance of >2 staff to mobilise, and MRI contraindications. We measured scan duration, tolerability, image usability, acute infarcts on DWI, and chronic SVD features. Six months later, we recorded CFS and cognitive diagnoses.

Results

Mean age was 83.5 years (delirium 78.7 vs non-delirium 88.4); 13/20 were female; 17/20 had premorbid cognitive decline/impairment or dementia. Acquisition took mean 26.8 minutes. MRI was well-tolerated in 16/20 (7/10 in delirium arm; 9/10 in non-delirium arm). 4/20 had early scan termination but 20/20 had clinically interpretable images. We detected DWI-hyperintense lesions in 3/10 (33.3%) with delirium (2/10 small subcortical and 1/10 cortical) and in 3/10 (33.3%) without delirium (2/10 small subcortical; 1/10 cortical). Mean SVD score was 2.4 in delirium vs 3.3 without.

Conclusions

MRI is feasible, usable, and tolerable in delirium, and we detected DWI hyperintense lesions in one third of patients overall. This study indicates acute vascular contributions, including SVD, to delirium, supporting the need for larger studies.

Introduction

Despite the UK’s increasing life expectancy, and increase in the elderly population, there is an overwhelming lack of Geriatricians in the UK; as of 2022, there is only 1 consultant Geriatrician per 8,031 individuals over the age of 65 (BGS, 2023). To meet the complex care needs of this population, there must be a focus on increasing the interest that doctors have towards Geriatric Medicine, with the overall aim being to recruit more doctors into the speciality.

Method

The aim of this review was to investigate what factors medical students perceive as barriers to pursuing a career in Geriatric Medicine and then, from identifying these, generate a set of comprehensive suggestions as to how to tackle these barriers at a medical school level to increase the interest and ultimately uptake of Geriatric Medicine. The qualitative review contains literature published between 2003 and 2023 accessed using MedLine.

Results

Six themes were identified in answering our question: (a) high emotional burden, (b) caring for patients with complex needs, (c) negative preconceptions of non-clinical factors (prestige, salary, career progression), (d) negative influence of clinical educators, (e) lack of intellectual stimulation and (f) lack of exposure to the speciality and the elderly.

Conclusion

The barriers perceived by medical students when considering Geriatrics as a speciality are complex and multifaceted; these barriers must be tackled promptly in order to secure the next generation of Geriatricians. We suggest that this work can be used as a foundation for further qualitative studies with UK medical students to investigate barriers that are specific to UK students. From this, interventional courses designed to increase Geriatric Medicine uptake could be developed to strengthen the UK Geriatric Medicine workforce.

INTRODUCTION: Medical students may find practical aspects of the transition to FY1 doctor challenging. In recent years medical curriculums have been updated to address this issue by increasing the emphasis on assistantships and practical learning. We explored how prepared final year medical students felt for managing common scenarios in geriatrics, such as a patient with delirium or inpatient falls. This allowed us to develop a tailored teaching programme to be delivered by junior doctors with relevant practical experience.

METHODS:

1) We surveyed assistantship students in geriatrics to identify areas in which knowledge and confidence were lacking. We subsequently developed a tailored teaching programme to address these gaps, focusing on practical tasks and common scenarios.

2) We delivered teaching to 3 sets of assistantship students, each receiving two teaching sessions per week for their 4 week placement.

3) Quantitative & Qualitative (Likert Scale) feedback was sought using a standardised feedback form. We used QI methodology to update and improve our curriculum & delivery to match students’ learning needs.

RESULTS:

• Over the course of the teaching programme, 89 feedback forms were completed.

• 54.8% of students felt “unprepared” or “somewhat unprepared” whilst only 18% felt “prepared” or “somewhat prepared”.

• Following the teaching session, only 2.3 % felt “unprepared” or “somewhat unprepared. Those feeling “prepared” or “somewhat prepared” improved to 92%.

• 91% found the teaching relevant to their learning needs. • 91% rated teaching quality 5/5.

CONCLUSIONS: Students felt ill-equipped to manage many practical aspects of FY1. Junior Doctors are uniquely placed to address the practical knowledge gaps final year medical students may have. Our teaching programme greatly improved the students’ confidence on practical tasks and scenarios commonly encountered while working as an FY1 doctor. It was a valuable supplement to assistantship placements, and will be incorporated for future years.