SP - Health Service Research

Introduction: Many people with dementia (PwD) are affected by anxiety and depression, leading to significant changes in patient behaviour, carer burden and negative patient outcomes. Anxiolytics and antidepressants are commonly prescribed for PwD and may contribute to potentially inappropriate prescribing. This study aims to explore patients’ and carers’ experiences and perspectives of the management of depression and anxiety in PwD. Methods: An online discussion forum, Talking Point, hosted by the Alzheimer’s Society, was searched for relevant archived threads and posts. These were identified using 64 search terms such as “depression” and “SSRI”. Data were extracted into Microsoft Word and inductive thematic analysis is ongoing to code the data and identify pertinent key themes. Results: In total, 3539 posts were identified from 931 registered forum users. Initial findings have highlighted that anxiety and depression were commonly experienced by PwD and many described the difficulties in differentiating depression from dementia during the early stages of dementia. “Initially my wife was treated for depression and anxiety but that soon changed to MCI [mild cognitive impairment], then dementia…” [TP019]. Forum users described the use of anxiolytic and antidepressant medications as a process of trial and error: “The GP gave her sertraline but that didn’t work so now on mirtazapine. Only been 10 days and really makes her sleep just with half a tablet but now crying again” [TP022]. Frank accounts of the symptoms that PwD experienced were shared, highlighting the impact depression and anxiety has on both patients and their carers. Conclusion: This online discussion forum is a source of rich and valuable data, which may not be accessible through traditional qualitative methods. This study will provide authentic insights on patients’ and carers’ lived experiences of managing anxiety and depression in PwD and will inform further qualitative work with key stakeholders.

Introduction: Older patients often struggle to manage and take polypharmacy. Intervention studies have measured a variety of outcomes to improve adherence to polypharmacy. However, the scarcity of well-designed trials and inconsistencies in outcomes reported and measured have resulted in low-quality evidence. It is now recommended that researchers consider using a Core Outcome Set (COS); the minimum number of outcomes that should be measured and reported in all studies in a specific area. This study explored stakeholders’ perspectives regarding the challenges older patients face when taking polypharmacy, potential strategies to address such challenges, and outcomes of importance with a view to developing a COS for studies focusing on adherence to appropriate polypharmacy.

Method: Semi-structured virtual and telephone interviews were convened with relevant stakeholders, recruited through several approaches. Interview topic guides sought information on challenges and strategies associated with adherence to polypharmacy. A list of potential outcomes (n=7) associated with adherence research (derived from a previous Cochrane review and two other relevant studies) was presented to participants for comment. Content analysis of audio-recorded and transcribed interviews identified key themes on challenges, strategies and outcomes.

Results: Participants (15 academics, eight healthcare professionals, and six public participants) identified 11 challenges (encompassing medication, healthcare system, patient and socioeconomic issues) and 16 educational and behavioural strategies relevant to polypharmacy. They agreed that the seven outcomes presented to them were important and suggested six additional outcomes, generating a final list of 13 outcomes for potential use in trials focusing on adherence to appropriate polypharmacy.

Conclusion(s): A range of challenges associated with polypharmacy was reported by participants, and a suite of strategies was suggested to address these challenges. The list of 13 outcomes will be used to inform the development of a COS for trials targeting interventions aiming to improve adherence to appropriate polypharmacy in older patients.

Introduction: Pharmacogenomics is using a patient’s genetic information to predict their likely response to a medicine. There is evidence that patients who receive pharmacogenomic-guided care benefit from a reduction in clinically significant adverse drug reactions. Therefore, pharmacogenomic testing can be used as a medicines optimisation tool to prevent adverse drug reactions in older people and reduce associated hospital admissions. This qualitative study aimed to identify the facilitators and barriers to implementing pharmacogenomic-guided prescribing in acute care for older patients by examining the views of patients, pharmacists and physicians.

Method: Following consent, patients (aged 65+), pharmacists and physicians across two hospital sites, participated in a semi-structured interview. The interviews were transcribed and analysed using the Framework approach to identify themes describing barriers or facilitators to implementing pharmacogenomic-guided care. Patient interviews were analysed separately from the healthcare professional interviews and supporting quotes were selected to illustrate each theme.

Results: Nine patients, six pharmacists and five physicians participated in the study. Framework analysis of the patient interview transcripts identified three themes: (1) Information delivery (2) Standard of care (3) Participation in pharmacogenomic-guided care. Framework analysis of the professional interviews produced the themes: (1) Level of interest (2) Workforce pressures (3) Support required for the workforce. Professionals do not have enough knowledge of pharmacogenomic-guided care to confidently apply it to their clinical practice. Patients want to be involved in pharmacogenomic-guided prescribing decisions so pharmacogenomics does not feel imposed on them.

Conclusion(s): Older patients view pharmacogenomic-guided care as therapeutically beneficial and would like to be involved in pharmacogenomic-guided prescribing decisions, with information about pharmacogenomic-guided care tailored to their information-seeking preferences. Professionals envisage pharmacogenomic-guided care as potentially useful in improving their prescribing and medicines reviews but are concerned that operational pressures could make its implementation impractical.

Introduction

Approximately one-third of older patients leave hospital with a new functional impairment. Tracking rehabilitation progress following acute illness could improve recognition and understanding of hospital-acquired disability. However, traditional mobility and functional scores include measures that are not part of routine rehabilitation therapy, adding a time burden for staff to report. Capturing data already recorded in routine electronic records could provide an efficient patient tracking measure of rehabilitation success.

Methods

A scoping literature review appraised existing scores of mobility and functional status. Analysis of 15 admissions through the Royal Infirmary of Edinburgh identified mobility and functional domains which were reliably recorded in free text electronic health records. A pilot score was drafted, comprising admission and discharge scores (0-30 points), medical progress (0-10), physiotherapy and occupational therapy tracking (0-30). Higher scores indicate greater functional independence. Expert feedback was obtained through focus group discussion with physiotherapists and occupational therapists. The approach was tested in a fresh set of six case studies. Two independent scorers applied the scoring schema and agreement was assessed using Cohen’s weighted-kappa coefficient.

Results

The selected electronic health records contained 438 medical, 352 nursing and 183 therapist entries. Existing measures such as the Barthel Index were not recorded for any patient. Focus group discussion identified value in the overall approach and informed item-weighting. The pilot functional score allowed visualisation of rehabilitation trajectories over the course of each admission. Excellent inter-rater reliability was demonstrated for the medical (Cohen’s Kappa 0.99, 95% confidence interval [CI] 0.96–1.00) and physiotherapy (Kappa 0.96, 95% CI 0.93–0.99) components.

Conclusions

A functional tracking score generated from routine health records proved feasible and reproducible in this pilot. Future development should assess validity, reliability and prognostic power in larger populations, exploring automation using natural language processing. Development of graphic visualisations may aid communication within multidisciplinary teams. 

Introduction: The ageing population poses challenges to the health care industry worldwide. The huge demand for residential care home for the elderly (RCHE) services induces pressure on health care workers (HCWs) recruitment and retention. HCWs are personnel who have prominent roles in direct basic care to the older adults, and all kinds of hands-on care. Due to the “unpleasant” work nature, shift work, and physical demands for HCWs, it is essential to unfold how HCWs comprehend their working experiences. Methods: An integrative review was conducted to synthesize various streams of literature in order to generate new knowledge. Multiple databases such as CINAHL, ERIC, LWW nursing were adopted to search for relevant literature published between 2012 and 2022. Results: A total of 24 articles were retrieved at the initial stage, and 7 articles were sorted after in-depth review. In general, results supported that HCWs experienced positively on the works at RCHEs though there were job stresses. The HCWs perceived the roles at RCHEs as routinized and task-oriented by providing direct care to older adults. They perceived their roles at RCHEs as care providers who provided direct care to older adults. Also, their responsibilities to maintain the safety and dignity of older adults was expressed as utmost importance. The meaning of works lay on three levels: interpersonal (e.g. self-achievement), interpersonal (e.g. communication with team members), and job performance (e.g. task compliance). Conclusions: This study reveals the experiences of working at RCHE from the HCWs’ perspective. The HCWs’ experiences reflected in this study as well as the meaning of works discovered can generate insights for policy-makers on HCWs recruitment and retention. Acknowledgement: The work described in this abstract was fully supported by a grant from the Research Grants Council of HKSAR, China [RGC: UGC/FDS16/M12/20].

Introduction

People who recover poorly after delirium are likely to require an increased level of care. It is presently unknown whether interventions to improve recovery after delirium are effective and cost-effective. This research aimed to develop a programme theory to inform the design of an intervention to improve recovery after delirium.

Method

A rapid realist review of literature was conducted to develop an initial programme theory. Following this, a qualitative investigation of the perceived rehabilitation needs of older people who have experienced delirium during a hospital stay was conducted via semi-structured interviews with 41 key stakeholders (older people (5), carers (12), and healthcare professionals (24)). Data were analysed using a realist approach to identify what works, for whom, and in what context. This was deductively informed by the initial programme theory while also employing an inductive analysis to identify novel insights. Through an iterative, retroductive process, context-mechanism-outcome configurations (CMOCs) were coded to reflect stakeholders’ views to refine the programme theory.

Results

The initial programme theory highlighted the importance of cognitive and physical rehabilitation and emotional support as key domains of recovery. New CMOCs included optimisation of good medical care to manage delirium and monitoring and management of underlying medical conditions to promote recovery. Others included developing educational resources and support networks for older people and their carers to aid sense-making, and encouraging social interaction to reduce isolation and empower independent functioning. These recovery elements should be addressed in a person-centred manner that is tailored to individual needs and preferences, engages carers, integrates intervention goals into daily functioning, and ensures continuity of care.

Conclusion

A refined programme theory was developed and is currently being used to design a manualised intervention to improve recovery after delirium. The acceptability of the intervention will be tested in a multi-centre, single-arm feasibility study.