SP - Other medical conditions

Introduction

Hyponatremia is the most common electrolyte imbalance caused by serum sodium level of less than 135mmol/L, prevailing 15 and 30% among hospitalised patients [Zhang X, Li XY. Eur Geriatr Med. 2020;11(4):685-692]

Methods

PRISMA guidelines were followed for this study. Pubmed was searched with the search term : (hyponatremia) AND (treatment OR control OR management[MeSH]) AND (elderly[MeSH]) with filters, timeline: 2000 to 21/07/2023, free full text articles and human species.Data extraction was done using  Covidence app and depicted in PRISMA Flow diagram. Quality assessment was done by Cochrane Risk of Bias version 1.Odd’s ratio with 95% conifidence interval was calculated for dichotomous outcomes. Mantel-Haenszel statistical  method  along with random effects model was used. Cochrane Q test was employed and I² index was computed. Forest and Funnel plots were plotted. The analysis was done by Cochrane Review Manager.

Results

Out of 3222 results , 9 studies were included with total 980 patients. 8 were of vaptans and 1 of empagliflozin. Of the vaptans, tolvaptan was studied in 5 studies, satavaptan, lixivaptan and conivaptan in other three. Three studies had low risk of bias and were included in meta-analysis.Mean age  and BMI were 70.55(SD=14.5)  years and 24.73(SD=3.95)  kg/m²  respectively.

Most frequently occuring etiology , comorbidity and symptom were congestive heart failure, hypertension and fatigue/malaise respectively.  Mean baseline serum sodium was 124.89 mmol/L mean rise was 9.142  mmol/L.

Meta-analysis showed that placebo was significantly associated with achieving normonatremia as compared to treatment group(OR=2.5, 95%CI:1.54,4.04, p=0.0002,I²⁼0%).

The most frequent reported side effects were nausea, dry mouth, pyrexia and thirst.Side effects both mild/moderate (OR=1.12, 95%CI:0.69,1.81, p=0.65, I² =0%) and serious  (OR= 1.51, 95%CI: 0.77,2.98, p=0.23,I² =0%) showed no difference between treatment and placebo groups.

Treatment was not associated with rapid risk of overcorrection (OR=1.65, 95% CI:0.57,4.81, p=0.36, I² =0%). None showed osmotic demyelination syndrome.

Discussion

The main conclusions drawn out were:
 (1) The most commonly available drugs beside fluid restriction, hypertonic saline were vaptans- vasopressin receptor 2 antagonists. 
 (2) The possible new drug of choice for treatment of Hyponatremia could be empagliflozin.

Meta-analysis carried out for three studies [28, 29, 34] showed no significant improvement in Hyponatremia by treatment with hyponatremia drugs i.e., satvaptan, lixivaptan and empagliflozin as compared to placebo.

Instead placebo reported a significant improvement Hyponatremia.These results were similar to a review by Jovanovich [37] et al which concluded that they have no role in treatment.

Currently only tolvaptan and conivaptan are approved by the FDA for treatment of hypervolemic and euvolemic hyponatremia The use of vasopressin receptor antagonists remains limited due to its controversial efficacy and potential risks for overcorrection [9].

Rapidly correcting hyponatremia (>12 mEq/L/24 hours) can cause osmotic demyelination, leading to dysarthria, mutism, dysphagia, lethargy, emotional abnormalities, spastic quadriparesis, seizures, coma, and death. 

We did not find any significant rapid overcorrection of Hyponatremia in treatment group as compared to placebo.  This was in contrast to Krisapan et al[38]which reported a greater risk of rapid overcorrection. This could be due to small sample size of the study and yet 3 studies in this review (Estilo et al, Humayun et al and Sag et al) recommended starting with a small dose and imply strict sodium monitoring and for those with a history of hyperlipidemia and who have recently taken thiazide diuretics.

No significant association of treatment group was found with mild/moderate/severe side effects.

Refardt et al showed that empagliflozin could be a promising new treatment due to its reported long term cardiovascular and nephroprotective effects, broader availability and good tolerability. With the daily treatment cost of empagliflozin being similar to urea(2USD vs 4USD), it was th cost of Tolvaptan and therefore it could prove a cost effective treatment option in future when fluid restriction and hypertonic saline fail [37,39].

Conclusion

We conclude that vaptans and Empagliflozin ,although safe, show limited efficacy in hyponatremia treatment.

Introduction

Delirium is a common condition in older hospitalised patients causing high morbidity and mortality. The neurobiological basis for delirium is uncertain and, for numerous reasons, research in this area has been limited. Several recent studies have demonstrated that functional neuroimaging in delirium is achievable and has suggested that a brain region termed the default mode network (DMN), may play a cardinal role in delirium pathogenesis. We set out to develop a pilot study to demonstrate that it is feasible to undertake functional magnetic resonance imaging (fMRI) scans in older patients with acute delirium.

Methods

Observational pilot study obtaining a fMRI scan of inpatients in an Australian, tertiary hospital, geriatric ward. Eligible patients diagnosed as delirious by a geriatrician were compared against non-delirious controls. Informed consent was obtained. A novel scanning paradigm was developed. Sequences assed brain structure and functional networks in resting state and during a simple task of sustained attention and response inhibition.

Results

11 participants have been scanned. 6 participants were delirious: mean age 81 years (range 77 – 85 years), 3 female. 5 participants were non-delirious: mean age 83.4years (range 79 -90 years), 2 female. 10 of the 11 participants completed the full imaging protocol, including task engagement. Head movement during scanning, was generally within acceptable limits. Data demonstrates considerable cortical atrophy and ventricular enlargement consistent with age. Preliminary fMRI analyses show a variable pattern of cortical recruitment during task engagement in delirious patients.

Conclusions

These findings show it is ethically and logistically feasible to engage elderly patients with acute delirium into a high end structural and functional imaging study.

Introduction: Optimal intrinsic capacity (IC) is crucial for preserving the functional abilities of older adults. The presence of multimorbidity is closely associated with IC impairments. Various multimorbidity indices have been developed for diverse health outcomes. This study aimed to compare the performance of six commonly used multimorbidity indices to discriminate IC impairments among community-dwelling older adults.

Method: We used data from a multidimensional geriatric assessment program including 627 community-dwelling older adults in five cities of Hunan, China. Six multimorbidity indices were extracted from the data, including disease counts, Functional Comorbidity Index (FCI), the Deyo Charlson comorbidity index, two indices (total score and comorbidity index) derived from the Cumulative Illness Rating Scale-Geriatric (CIRS-G), and medication counts. The IC was measured with five individual domains, i.e., locomotion, vitality, sensory, cognition, and psychological capacity. Individuals were regarded as having IC impairments if they had impairments in one or more domains. Associations between multimorbidity indices and IC impairments were examined using logistic regression analyses. The discriminative ability of multimorbidity indices for IC impairments was compared using the c-statistics.

Results: A total of 374 (59.6%) participants had IC impairments. All multimorbidity indices were significantly associated with IC impairments after adjusting for confounding factors. All indices showed acceptable discriminative power (c-statistic ranged from 0.711 to 0.759) for IC impairments. The comorbidity index derived from CIRS-G resulted in the highest c-statistic, followed by the total score of CIRS-G and FCI.

Conclusions: Our study results suggest that multimorbidity indices differed in their ability to discriminate IC impairments. The comorbidity index derived from CIRS-G performed better than other multimorbidity indices included in this study. The comorbidity index has the potential as a simple proxy measure of indicating the need for interventions to optimise IC for older adults in community settings.

Background Cardiovascular complications are one of the most common causes of morbidity and mortality perioperatively during non-cardiac surgery. This risk is significantly increased in those ≥65 and those who are frail. NICE and ESC both recommend that all patients ≥65 have a pre-operative ECG to assess each patient's risk of perioperative cardiovascular complications before any intermediate or high-risk surgery. This study aims to assess the risk of perioperative cardiovascular complications in those ≥65 with abnormal ECGs. Methods We analysed data from patients attending our combined Geriatrician and Anaesthetist run pre-operative assessment clinic for elective colorectal cancer resections between 23/09/2021 - 11/09/2023. All patients were aged ≥65, those who then underwent surgery had their pre-operative ECGs assessed for abnormalities including; New AF, LBBB, RBBB, LAD, Heart block, ectopics, ST depression, and T wave Inversion. There were no patients with episodes of non-sustained VT or long QT intervals, two categories ordinarily considered higher risk for complications. The discharge letters, operation notes, and any post-operative cardiology letters were then assessed for any perioperative/post-operative cardiac complications including myocardial infarction, cardiac arrest, acute heart failure, and established new arrhythmias. Results 140 patients between 23/09/2021 and 11/09/2023 underwent elective colorectal resection. 56 of these patients had abnormal pre-operative ECGs (40%) with; New AF (2), LBBB (3), RBBB (16), LAD (15), Heart block (6), Ectopics (7), ST depression (3), and T-wave Inversion (4). On assessment, none of these patients had any perioperative or postoperative cardiac complications. Conclusion Our study suggests pre-operative ECGs alone were not predictive of perioperative/post-operative cardiac complications in patients undergoing elective colorectal resection for cancer. All of the patients were managed by perioperative Geriatricians without the need of further onward referrals to Cardiology, suggesting a perioperative cost saving.

Introduction Chronic insomnia and nocturia are frequently associated, particularly in older adults impacting sleep quality, daytime functioning and quality of life. This study evaluated the efficacy and safety of daridorexant in patients with insomnia and comorbid nocturia. Methods This double-blind, placebo-controlled, two-way cross-over study randomised 60 patients aged ≥55 years with chronic insomnia and self-reported nocturia to 4-weeks nightly treatment of daridorexant 50 mg or placebo. This was followed by a 14–21-day washout period, after which patients received the alternate 4-week treatment. The primary endpoint was change from baseline to Week 4 in self-reported total sleep time (sTST). Other insomnia endpoints included change from baseline in ISI score, sTST, depth of sleep and daytime functioning (Insomnia Daytime symptoms and Impacts Questionnaire [IDSIQ] total score. Nocturia endpoints, evaluated using the Minze diary Pod, included change from baseline in number and time to first nocturnal void. Safety endpoints included adverse events (AEs) and AEs of special interest (AESI: falls, urinary incontinence). Results Daridorexant (vs. placebo) significantly increased mean sTST (56.6 vs. 35.7 mins; p=0.002) at Week 4; significant improvements were seen from Week 1. Daridorexant (vs. placebo) significantly (p<.05) decreased isi scores (weeks 2, 4) and significantly (p<0.05) improved depth of sleep 1-4) IDSIQ total score 1, 3). daridorexant (vs. placebo) reduced the number nocturnal voids (week 1: -1.5 vs. -1.0, p<0.001; week 4: -1.6 -1.3, p="0.2026)." increased median time to first void (difference placebo, +31 mins, +23 no serious aes />/AEs leading to discontinuation were reported in the study. No AESIs were reported during daridorexant administration. Conclusion In patients with insomnia and comorbid nocturia, daridorexant improves sleep, daytime functioning and nocturia symptoms, with no increased risk of falls or urinary incontinence. Funding: Idorsia Pharmaceuticals Ltd 

Introduction: Physical activity and social connectedness play an important role in healthy ageing. Access to facilities such as libraries, parks, and community centres can facilitate physical activity, social interaction, and community building. Little is known about how older adults use places for physical or social activities. This study aimed to explore the places mid-to-older adults go to, and why they choose to engage or not engage in physical and/or social activities in particular places. 

Methods: Semi-structured interviews were conducted with community-dwelling adults aged 55-75 years (n=22; 65.0 ± 5.5 years) from two communities with high levels of deprivation in Scotland, Renfrewshire and South Lanarkshire between September 2023 and March 2024. Taking a systems-based approach, we explored place utilisation among mid-to-older adults to support physical and social activity. Maps of participant’s local community populated from Ordnance Survey data, such as depicting parks, were used to guide the interviews. 

Results: Participants varied according to levels of physical activity, frailty, and loneliness. Places for physical and social activities included community centres, green spaces, gyms, clubs, religious buildings, shops and places for eating and drinking. Social enablers to place utilisation included having inclusive, well-advertised activities in multi-purpose spaces like community centres to foster intergenerational connections, community cohesion, and social engagement. Physical enablers included the importance of accessibility and convenience, mobility-friendly design, and diverse transport options. Barriers to place utilisation included activities that perpetuated ageist sentiments, the rising costs of physical and social activities, and seasonal barriers such as poor weather and reduced daylight. 

Conclusions: It is essential to provide affordable and engaging activities, as well as versatile spaces that combine recreation, learning, and social interaction to foster intergenerational and social connections for older adults. Additionally, infrastructure and transportation should prioritise accessibility, while communities should promote respect, inclusion, and active participation in society.

INTRODUCTION 
Video-recordings of patients may offer advantages over text-based documentation to supplement assessment and decision-making – particularly for older patients with complex needs. Our systematic review aimed to evaluate the application, acceptability, and impact of video-based records; here we highlight current evidence on using video-recordings to support direct care delivery for older patients.

METHODS 
Five electronic databases (Medline/Embase/PsycInfo/Cochrane/HMIC) were searched from 2012-2022. Studies involving videorecording patients aged ≥ 18 years for diagnosis, care, or treatment were identified. Study quality was assessed using published appraisal tools. Acceptability was evaluated through i) recruitment/retention rates, and ii) synthesis of patients’ and professionals’ perspectives and experiences. Sekhon’s Theoretical Framework of Acceptability (TFA), consisting of seven constructs (affective attitude/burden/ethicality/ intervention coherence/opportunity costs/self-efficacy), underpinned the synthesis. 

RESULTS 
Of 14,221 citations, 27 studies (mainly low-quality) met inclusion criteria. 10/27 studies recruited older patients including those with Parkinson’s Disease (PD), dementia, stroke, end-of-life care, average age was 69. Video-recording was used in diagnosis, management/monitoring, and rehabilitation of older patients. Mean recruitment rate was 58.8% (34.2%-73.7%): mean retention rate was 81.3% (73.4%-100%). Reasons for non-participation/withdrawal related to the video-recording intervention itself (privacy concerns/poor video quality) and other factors (patients lost to follow-up). Framework synthesis generated 17 sub-themes linked to the seven TFA constructs. Attitudes to video-based records were largely positive. Video-recordings were perceived to be helpful in facilitating diagnosis/treatment/care for patients with movement disorders (PD; high-risk fallers), including in dementia populations. Digital literacy, illness severity and cognitive impairment influenced patients’ capacity to consent to video-recording.  Healthcare professionals were concerned about technical challenges but burden was minimised through using portable devices (e.g.iPad) for video capture. 

CONCLUSION 
Video-based records may be acceptable to older patients and professionals, providing valid consent is obtained and the potential benefits are recognised. Further research is needed to evaluate the acceptability, feasibility, and effectiveness of this approach.

Introduction

With recent advances in surgical techniques and immunosuppressive therapy, solid organ transplantation (SOT) is increasingly accessible to older and more complex patients. Multiple previous studies have shown quality of life improvements in SOT patients post-transplant across age group and despite significant pre-transplant frailty. As such, we are investigating if SOT is associated with a reduction in frailty status post-tranplant.

Methods

Studies across five databases between 2000 and 2023 were included if an objective frailty status measurement was used, SOT was performed during the study, and no rehabilitation took place pre- or post-transplant. Included studies were graded for risk of bias using the Newcastle Ottawa Scale. Data extracted from the studies was pooled in a random-effects meta-analysis using the Mantel-Haenszel method.

Results

Across the 12 studies included in the review (6 kidney transplant, 2 liver transplant, 3 lung transplant and 1 heart transplant), there was a total of 3065 transplant recipients (62% male 38% female) with a mean age of 51.35 years old. There is an worsening of frailty status in transplant patient immediately post-transplant. Thereafter, there is a reduction in frailty status 3 months post-transplant sustained 6 – 12 months post-transplant. However, frailty status plateaus after this period up to 36 months, based on the 3 studies that did track frailty status beyond 12 months. Five studies were included in the meta-analysis which demonstrated an odds ratio = 0.27 (95% CI, 0.12, 0.59, P = .001, I^2= 82%), When the single paper deemed to be of poor quality was removed the remaining four studies demonstrated a reduced odds ratio of being frail at 6-12 months posttransplant (OR 0.45 (95% CI, 0.32, 0.65, P = .001, I^2= 13%).

Conclusions

Transplant is associated with a reversal in frailty status 6 to 12 months post-transplant, although heterogeneity was demonstrated across studies.

Introduction: Adverse drug events from medication-related harm (MRH) can lead to hospital readmissions, compromised quality of life, and even death. After hospital discharge, older people can experience heightened vulnerability, and are often unprepared for self-care and medication self-management. Effective medication self-management involves more than adherence; it requires patients to monitor their condition(s), build routines, recognise errors, seek help, understand when to alter medications, and discuss these issues with healthcare professionals. Determining medication self-management capability in older people can guide supportive interventions and improve medication-related outcomes. This systematic review identifies measures which assess medication self-management capability for older people transitioning from hospital-to-home.

Method: A comprehensive search was conducted in electronic databases (Medline, EMBASE, PsychINFO, CINAHL, Cochrane Library of Systematic Reviews, and PROSPERO) for articles from database inception to 2023. Eligible studies included participants aged 65 or older experiencing a hospital-to-home transition, and measures containing at least one medication self-management component. Data extraction was performed using a standardised form. Characteristics of measures were tabulated and summarised descriptively. This review is registered with PROSPERO (CRD42023464325).

Results: 14 studies were included, identifying 12 unique measures. These measures predominantly had an adherence-focus, with other medication self-management components included to a lesser degree. Timing of measure administration and the individual administering the measure varied greatly across studies. Medication self-management capability was assessed through physical and cognitive skills. The number and type of skills assessed differed between measures. None of the measures considered all medication self-management components, with self-monitoring and adaptability specifically lacking.

Conclusion: Current measures for medication self-management capability assessment primarily focus on cognitive and physical skills, with significant emphasis on medication adherence. This can lead to other important skills being overlooked. Findings further highlight the importance of comprehensive definitions when considering medication self-management across the hospital-to-home transition, and recommendations are provided for developing future measures.

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.