Scientific Research

Aims

Understanding patients’ wishes regarding CPR before surgery is crucial. This study aims to assess the impact of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision on anaesthetists' actions during theatre.

Methods

We used WhatsApp, to present a scenario of an 83-year-old with ischemic heart disease, cognitive impairment, and an acute hip fracture. Anaesthetists were asked how they would handle various intraoperative events and whether a prior DNACPR decision would influence their actions.

Results

A total of 74 UK anaesthetists, all but one of them consultants, completed the anonymous survey. A surprising number N=27, (37%) of respondents indicated that prior knowledge of a DNACPR decision would have altered their preparedness to anaesthetise the patient.

Despite a pre-existing DNACPR decision N=68 (92%) stated that they would attempt electrical cardioversion if a patient became hypotensive with a regular broad complex tachycardia, as would N=65 (88%) in response to ventricular fibrillation during surgery. N=36 (49%) would initiate chest compressions in theatre if patient failed to respond to electrical cardioversion, but only N=2 (3%) would continue with intubation, ventilation and discussion with critical care if the patient failed to respond to three cycles of compressions and cardioversion.

Conclusion

It is important for anaesthetists to discuss the nuances of different elements of CPR as part of patients’ pre-operative assessment, as it is much more likely to be successful in theatre than in the ward or community settings that most DNACPR discussions will consider.

Raising the topic of resuscitation can lead to anxiety among patients and their families, Our study has shown that most anaesthetists will set aside a DNACPR decision anyway if problems arise in theatre.

An 80 year old man living independently with his wife presented with progressive unsteadiness, generalised weakness and muscle aches over 2 months, following a short episode of flu-like symptoms. Systems review revealed shortness of breath, a hoarse voice, 2kg weight loss and occasional non-drenching night sweats. Bloods showed elevated WCC, CRP and ESR. He was started on 20mg of prednisolone for a working diagnosis of polymyalgia rheumatica. These symptoms did not improve, even after this increased to 30mg. He was admitted to hospital after he developed left leg weakness evolving over the course of 1 day. On examination, he had generalised muscle wasting, no fasciculations, preserved reflexes, left sided foot drop and right sided ulnar nerve palsy. MRI head and spine did not reveal a structural cause. CT thorax-abdomen-pelvis showed no evidence of malignancy, lymphadenopathy or hepatosplenomegaly. An autoimmune screen revealed a strongly positive rheumatoid factor, but negative ANA, ANCA, anti-DSDNA antibodies. A myositis panel and anti-neuronal antibodies were negative. CSF biochemistry showed normal cell count and protein level, with negative oligoclonal bands. Nerve conduction studies suggested a chronic axonal length-dependent peripheral neuropathy and a degree of myopathy. He then developed symmetrical bilateral foot drop and median nerve palsies. FDG-PET-CT showed increased activity within various visualised skeletal muscles- due to either myositis, denervation or physiological changes. Muscle & sural nerve biopsy showed no myositis, but intense inflammation and arterial wall destruction with moderate axonal degeneration suggestive of vasculitic neuropathy. A diagnosis of mononeuritis multiplex caused by tissue-specific vasculitis was made. He received pulsed IV methylprednisolone before starting rituximab. He was discharged when his mobility improved. This case demonstrates that vasculitis can present without rash and mimic polymyalgia rheumatica, which is more common in older patients. Thorough examination and revisiting the diagnosis if steroids do not show improvement is advised.

Abstract Content - Introduction Falls are the leading cause of preventable death in older adults and can also lead to psychological consequences, including concerns about future falls. Although literature traditionally focuses on those over 65 yrs, recent research shows adults as young as 50 yrs could be at risk. Most falls occur at home and are often due to environmental hazards. Despite evidence supporting a 38% reduction in falls through home modifications, their efficacy in not fully understood. Exploring barriers and facilitators to home modifications aimed at reducing falls and concerns about falling, could better inform future interventions. Methods As part of a mixed-methods systematic review, six electronic databases were searched on February 4th 2024: Scopus, PubMed, CINAHL, MEDLINE, SportsDiscus and Psycinfo. The search explored studies on home modifications for adults over 50 living at home, without residential health or rehabilitation services, specifically aimed at reducing falls incidences and concerns about falling. Barriers and facilitators to home modifications were explored from the perspectives of fallers, those at risk of falling, families, caregivers and key stakeholders. Results Thirteen of the 31 papers included in the full systematic review were focused on barriers and facilitators to home modifications. For barriers, five themes were identified: cost; stigma associated with ageing and disability; lack of awareness; fear of change and professional incompetence and inconsistency. Five themes were identified for facilitators: support from family and caregivers; early planning; involvement in decision making professional collaboration and enhanced caregiver well-being. Conclusion These findings underscore the need for multi-faceted approaches to home modifications, addressing both practical and psychological issues. Only three studies included adults 50+ yrs, with little known about the barriers and facilitators for this age onwards. Future interventions should encompass a person-centered approach, focus on increasing affordability, raising early awareness, fostering supportive networks, and ensuring high-quality professional services.

Introduction NELA (National Emergency Laparotomy Audit) and British Geriatric Society guidance states patients aged ≥ 80 years, or ≥ 65 years and frail, should have a comprehensive geriatric assessment (CGA) from a perioperative frailty team within 72 hours of admission or critical care step-down. Patients aged ≥ 65 years represented 55.3% of those undergoing emergency laparotomy; and frailty doubled the mortality rate in this group, but post-operative geriatrician review was associated with reduced mortality (NELA project team, RCoA, 2023).

Method The Perioperative Care of Older People Undergoing Surgery (POPS) service was established in our trust in October 2020 in response to NELA recommendations. Over three years our service has grown from one whole-time equivalent geriatrician and one 0.6WTE nurse practitioner, to a team of six, adding a clinical nurse specialist, physician associate, junior clinical fellow and memory link worker. With staff training, all surgical admissions aged ≥ 65 are screened for frailty to enable identification of patients who will benefit most from CGA and subsequent support during the admission. An internal database was established to prospectively capture patient demographics and outcomes.

Results Added team capacity has allowed us to see more patients year-on-year, including more patients not requiring laparotomy. Median frailty score and age have increased from 5 to 6, and 77 to 80 years, respectively, without a significant change in median length of stay. Mean trust compliance with NELA guidance around geriatrician review has improved significantly from 3% to 88% post POPS establishment.

Conclusions Introduction and expansion of a POPS service at our trust has resulted in an increased number of patients receiving geriatrician-led CGA, though meeting 100% of NELA standard likely requires a second consultant or cross-cover arrangement. However, we are reviewing more patients, who are on average older and frailer, without an increase in length of stay.

Introduction.

In older adults, dizziness is often experienced as a vague feeling of subjective unsteadiness, where people perceive themselves to be swaying more than they actually are. One factor that potentially drives such distorted perceptions of instability is (hyper)vigilance towards balance. This study aimed to investigate if older adults who report higher levels of trait balance vigilance (i) are more likely to report sensations of general unsteadiness when their balance is acutely threatened, and (ii) if this is accompanied by maladaptive changes in postural control.

Methods.

Forty-eight healthy older adults without vestibular diagnosis (Mean age = 71.0, range = 60–83) completed the recently validated Balance-Vigilance Questionnaire to quantify trait balance vigilance. Participants were fitted a VR headset and completed 60-second, narrow-stance balance trials on a force platform, under conditions designed to create a threatening (standing at a 20-meter virtual height) or non-threatening (virtual ground level) environment. For each condition, we assessed self-reported stability (0-100%) and fear of falling (0-100%), postural control (sway amplitude and frequency), muscular control (tibialis anterior activity), and prefrontal and somatosensory cortical activity using fNIRS.

Results.

Preliminary results are reported. When presented with a postural threat, high-vigilant older adults (Balance Vigilance Score≥18; N=13) reported significantly greater fear of falling (+25%; p=.027) and more reduced perceived stability (-25%; p=.006) compared to low-vigilant older adults – despite there being no differences in actual sway amplitude (p=.157). Only the low-vigilant group showed evidence of an adaptive ‘stiffening’ strategy in response to threat: i.e. increased sway frequency (p=.028) and tibialis anterior activity (p=.027). fNIRS analysis is ongoing.

Conclusions.

These preliminary findings suggest that, in response to a postural threat, older adults with high balance-vigilance are more likely to experience excessive fear of falling and perceptions of instability, and may fail to make adaptive changes to their postural control. Screening for excessive balance vigilance may therefore be recommended.

Abstract Content - Introduction. When required to multitask while walking, older adults (OA) will walk slower and use maladaptive stepping strategies such as cross-steps that may increase the risk of falling. However, most studies to date have been limited to steady-state straight-line walking, which requires limited to no visual planning, which is unrepresentative of common outdoor environments. Therefore, this study aimed to (i) investigate the impact of dual-tasking during walking of complex routes, and (ii) assess if such impact can be reduced when older adults deliberately preview their route to improve planning. Methods. We aim to recruit 45 community-dwelling OA. Preliminary results are reported for 19 (13F & 6M) community-dwelling OA without neurological or musculoskeletal diagnosis (Mean age = 75.7, range = 64–84). Participants walked along different winding paths on an 8-meter-long walkway under three conditions for 6 trials per condition: Single-task (ST), Dual-task (counting backwards) without previewing their route (DT) and Dual-task with deliberate previewing of the walking route (DTP). For each condition, we recorded walking speed, stepping errors (deviations from the pathway), and cross-steps. Results. Participants walked significantly slower during the DT condition (M=58.3 cm/s, SD=15.4) vs. ST condition (M=82.6 cm/s, SD=12.6; p<.001). during the dt condition participants also made more errors (m="1.3/trial," sd="1.4;" p=".029)" and frequent cross-steps compared to ST (no noted; m="0.4" />trial, SD=0.4). However, when allowed to preview their route prior to dual-tasking (DTP condition), participants walked faster (M=69.9 cm/s, SD=18.7; p=.002) and with fewer errors (M=0.1/trial, SD=0.1; p=.006). Conclusions. The imposition of an attentional load during adaptive walking reduces speed and increases the likelihood of potentially risky stepping strategies. Taking the time to deliberately preview the walking route seems to reverse some of these negative changes, and particularly to allow older adults to walk faster with fewer stepping errors.

Introduction

The Action Falls programme has demonstrated effectiveness in reducing falls amongst care home residents in a trial but has not been implemented widely (Logan et al, BMJ, 2021, 375, e066991). Co-production of implementation has been identified as a mechanism for achieving buy-in. This study aimed to co-produce an implementation model.

Methods

Systemic action research with an appreciative approach framed co-production workshops in three stakeholder groups: residents and relatives, care home staff and representatives from health and social care organisations. Topics explored were stakeholder priorities, design of the implementation model and evaluation outcomes. Data collection and analysis occurred concurrently to identify key themes. Participating stakeholders were invited to a celebration event to discuss key themes, share ideas and finalise the model.

Results

One action research cycle was completed. Eighteen workshops were undertaken with 16 stakeholders (7 care staff, 7 health and social care representatives, 1 resident and 1 relative). Falls training was reported as an area requiring improvement. The main priority identified was the need for a shared approach to learning about falls. Other themes were: tailoring training to individual and care home learning needs, involving key people in falls learning, safe spaces to share experiences and build relationships, providing regular learning opportunities, confidence in falls management as an appropriate measure of implementation success, and the need for a mixed methods approach to evaluate the model. A shared learning model was developed at the celebration event. The model included three components: accessible information for residents and relatives, bespoke training for each care home, and provision of ongoing support.

Conclusions

A shared learning model was co-produced as part of the Action Falls implementation strategy. This now needs evaluation.

Introduction:

Inpatient falls are the most common adverse patient safety incidents in hospitals in the UK. The assessment and management following an inpatient fall is often the responsibility of the most junior doctor on call, particularly out of hours. Frequently, there are key omissions in the assessment of these patients, leading to missed diagnoses, poor management and avoidable patient harm. This study aimed to improve the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls.

Method:

31 patients were identified who had suffered ‘severe harm’ following an inpatient fall and a retrospective review of their notes was performed. A preliminary survey on self-perceived confidence levels on different areas of the assessment and management of inpatient falls was distributed to all foundation doctors at Ipswich Hospital. The key themes of the simulation scenario were subsequently determined by the areas of weakness identified in both the survey and documentation review. A total of 9 foundation doctors at Ipswich Hospital participated in a high-fidelity inpatient fall simulation with a patient actor. Pre- and post-simulation knowledge and confidence surveys consisting of ten multiple choice questions and Likert scales respectively were distributed using QR codes.

Results:

Post-simulation confidence levels improved in all domains measured (p < 0.05) with an overall increase in average confidence levels from 3.3/5.0 to 4.3/5.0 (p=0.007). Average post-simulation knowledge score increased from 4.6/10 to 7.4/10 (p= 0.01). Domains in which the greatest improvements in knowledge and confidence were seen included: moving & handling, neurological observations, assessment of suspected hip fractures and escalating concerns.

Conclusion:

The use of simulated patients improves the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls. The pilot project is due to be expanded with plans to incorporate this simulation scenario into the local foundation teaching programme.

Introduction: Concerns about falling (CaF) is a psychosocial concept, precipitating a spiral of increasing inactivity, social isolation and falls, and is common in those who have experienced, or are at risk of, a fall. One method of assessing CaF is the Falls Efficacy Scale International version (FES-I),with previous studies finding associations between higher FES-I scores and poor scoring on commonly used clinical assessments of functional mobility and balance (Gait speed (GS), Timed up and Go test (TUG), and Five time sit to stand (FTSS)). Using the FES-I to predict poor functional mobility and balance has the potential to identify those at risk before an initial fall, at which point an intervention may be provided.

Methods: A prospective study was carried out over 24 weeks, in which 119 participants were recruited from the North Tyneside Community Falls Prevention Service (NTCFPS). Participants completed questionnaires and underwent physical testing whilst attending the falls clinic (baseline) and at week 24, completing bi-weekly falls diaries throughout. Participants were users of the NTCFPS, and residents of North Tyneside.

Results: Findings showed (i) the FES-I had a limited ability to predict poor scores on GS, TUG and FTSS; (ii) attending referred Age UK strength and balance classes was significantly associated with improvements in FES-I score and FTSS; (iii) CaF at the outset of Age UK training was not significantly associated with clinically significant improvements in GS, FTSS and TUG.

Conclusions: Whilst the predictive capabilities of the FES-I were limited, the measure showed an ability to track improvements in participants CaF in the short to medium term. Further work is needed to explore the measures applications within the general population of community dwelling older adults, rather than a cohort of falls service users.

Introduction

The fall risk factors in older adults living in residential care homes for the elderly (RCHEs) are multifactorial. In Hong Kong, around 9.5% of RCHEs have a fall rate over 30% (Elderly Health Service, 2022)1. The objective of this survey is to identify the common fall risk factors among frequent fallers in RCHEs in biological, environmental, and behavioural domains, based on the World Health Organization (WHO)’s risk factor model for fall (World Health Organization, 2021)2.

Methods

197 frequent fallers from 67 RCHEs with fall prevalence over 30% in Hong Kong were included in this cross-sectional retrospective survey. Twenty fall risk factors in biological, environmental and behavioural domains were investigated through tailor-made questionnaires and staff interviews. The most common fall risk factors, the time period and places of fall of all fallers were identified. The fall management strategy including fall risk assessment and fall incident report of RCHEs were also examined and compared.

Results

In the biological domain, chronic illnesses, decreased mobility, gait instabilities, lack of physical activities and cognitive impairment are the most common fall risk factors. In the behavioural domain, unsafe behaviour such as over-estimation of self-ability and hesitation to seek assistance are the most prevalent. Key environmental fall risk factors include movable furniture and poor lighting. The most common places of falls are bedsides while the peak hours of falls occurs around meal times. Nearly 24% of RCHEs did not perform fall risk assessments for residents.

Conclusions

Behavioural and biological fall risk factors play a more important role than environmental risk factors in these frequent fallers, and many of them are modifiable. Large variations exist in the fall management of different RCHEs. Interventions to prevent falls in RCHEs should target at improving the fall management protocol and addressing the specific fall risk factors of frequent fallers.