Diagnostic tools

Introduction

The SARC-F questionnaire can be rapidly implemented by clinicians to identify patients with probable sarcopenia. A score ≥4 is predictive of sarcopenia and poor outcome. We sought to identify the prevalence and demographic correlates of probable sarcopenia (SARC-F score ≥4) in community-dwelling older adults.

Methods

480 participants (219 men, 261 women) identified from Primary Care completed a questionnaire ascertaining demographic, lifestyle factors, comorbidities, nutrition risk score (DETERMINE) and SARC-F score. Participant characteristics in relation to probable sarcopenia were examined using sex-stratified logistic regression. Age was included as a covariate.

Results

The median (lower quartile, upper quartile) age was 79.8 (76.9, 83.5) years. 12.8% of men and 23% of women had probable sarcopenia. Self-reported walking speed strongly associated with probable sarcopenia (men: odds ratio (OR) 10.39 (95% CI: 4.55, 23.72), p<0.001; women: 11.42 (5.98, 21.80), p<0.001 per lower band). Older age was associated with probable sarcopenia in both sexes (p=0.01) as was higher DETERMINE score (men: 1.30 (1.12, 1.51), p=0.001; women: 1.32 (1.17, 1.50), p<0.001 per unit increase). Among men, being married or in a civil partnership or cohabiting was protective against probable sarcopenia (0.39 (0.17, 0.89), p=0.03) as was reporting drinking any alcohol (0.34 (0.13, 0.92), p=0.03) while in women generally similar relationships were seen though these were weaker. Higher BMI (1.14 (1.07, 1.22), p<0.001 per unit increase) and presence of comorbidities (1.61 (1.34, 1.94), p<0.001 per extra medical condition) were also associated with probable sarcopenia in women. All associations were robust after adjustment for age.

Conclusions

Probable sarcopenia (SARC-F score ≥4) was common in older adults living in their own homes. As expected, self-reported walking speed was highly predictive of probable sarcopenia. In addition to advancing age and malnutrition, socio-demographic factors were also important. Identifying these factors in clinical practice should trigger sarcopenia screening in older adults.

Introduction.

The National Early Warning Score (NEWS) (2017) incorporated new confusion as a category for consciousness. NEWS2 is evidenced to have high specificity but low sensitivity in detecting delirium.

Methods

Morriston Hospital 261 patients assessed. Consciousness, overall NEWS2 score and AMT4 recorded. 227 NEWS2 charts available. 208 patients recorded as alert. 44% (n=87) scored less than 4 on AMT4 ,55% (n=48) didn’t have documented past medical history (PMH) of cognitive impairment. Data missing for 14 patients. Ysbyty Gwynedd 178 patients assessed.161 recorded as alert. 58.4% patients scored less than 4 on AMT4, 77% had no PMH of cognitive impairment. Data missing for 15 patients. University Hospital Llandough. 40 patients; 38 patients were marked as Alert, 2 were excluded from observations.32.5% (n=13) had a diagnosis of possible or definite delirium. An electronic survey coupled with training delivery of 103 Health Care Workers (HCW) and 112 Registered Nurses (RN) was undertaken at Morriston. 39 HCWs ( 37.8%) and 31 RNs ( 27.6%) weren’t confident in the use of NEWS2 in regards to acute confusion. Training was offered on a 1 to 1 basis for these 215 staff members.

Results

Post intervention, 221 patients were assessed at Morriston, 209 marked as alert. 2 patients had been identified as having a new confusion and 10 patients did not have their consciousness recorded. Of the 209 marked alert 42% (88 patients) scored less than 4 on AMT4; 53 had no PMH of cognitive impairment. Training yielded little benefit.

Conclusion

The accuracy of recording consciousness has wider implications on the use of the NEWS2. NEWS2 uses routine observations and delirium assessment is variably implemented meaning routine information is not always available. The NEWS2 should be used in conjuction with other tools developed for delirium e.g 4AT and SQiD.

Introduction:

Delirium, characterized by disturbances in attention and consciousness, is common in individuals with pre-existing medical conditions, particularly the elderly, but can affect people of any age. It can lead to significant morbidity, mortality, prolonged hospital stays, increased healthcare costs, and long-term cognitive decline. Despite its impact, delirium is often underdiagnosed and undertreated, underscoring the need for better diagnostic strategies. The 4AT tool, recognized by NICE, is valued for its rapid delirium assessment, unlike the AMT-10, which is more suited for chronic cognitive disorders.

Objective:

This study was conducted to assess the usage of the 4-AT tool in the assessment of delirium to aid in the early detection of delirium in the elderly population.

Methodology:

The retrospective review of medical records over six months was conducted and divided into two cycles to evaluate delirium assessment using the 4AT. Initially, data from 59 patients 49 at FPH and 10 at WPH established a baseline of 4-AT usage across the trust. Post-intervention, 60 patient records were reviewed to reassess 4AT usage. Interventions included: 1. In-person Training sessions in completing 4AT 2. Informative posters placed in ED and Medical wards (AMU and Elderly-care) 3. Continuous reminders to enhance early detection.

Results:

Before the intervention, only 6.8% of patients were assessed using the 4AT tool, 55.9% with the AMT, and 37.2% without assessment. Post-intervention, the overall assessment rate rose to 62.7%, significantly increasing 4AT usage. Among 28 delirium-diagnosed patients, only 14.3% were screened with the 4AT, indicating room for further improvement. Discussion and

Conclusion:

The increased use of the 4AT tool post-intervention highlights the effectiveness of educational initiatives in improving delirium screening. Early detection through the 4AT facilitates timely interventions and better patient outcomes. However, the small sample size and underutilization among diagnosed patients suggest the need for ongoing efforts to improve its usage.

Delirium is an acute onset of fluctuating consciousness associated with impaired cognition and perception, commonly encountered in elderly patients. Prompt recognition allows early treatment of reversible causes. 4AT is a screening tool for rapid assessment of delirium.

By assessing the use of the 4AT score in Orthogeriatric patients, this quality improvement project aimed to improve assessment and management of delirium with both verbal and written interventions.

Weekly data was collected from Orthogeriatric inpatients across three PDSA cycles including the admission 4AT score, reviewing notes for mention of delirium, acute confusion and cognitive decline and whether the causes were considered and managed.

Cycle one demonstrated that 98% of patients had a 4AT assessment on admission. 38% had a score suggestive of delirium or cognitive impairment. 5.7% of patients had delirium considered at clinical review. 2% had a cause of delirium documented.

Daily board-round announcements to the clinical team highlighted delirium, prompt review of 4AT and screening for causes using the ‘PINCHME’ model.

After cycle 2, 100% of patients had 4AT completed on admission, 55% had evidence that delirium, acute confusion or cognitive decline was considered at review and 50% had a cause for delirium documented.

This project demonstrated an improved awareness of delirium and its causes amongst clinicians through written and verbal interventions. The next steps for sustainable change are to propose the introduction of an automatic online delirium alert in patients scoring ≥4 on 4AT and designing a digital confusion screen proforma to ensure thorough assessment of these patients.

Introduction:

Delirium, an acute neuropsychiatric syndrome, affects one in four hospitalised older adults. Effective management requires timely detection using validated tools and a structured approach to causes and sequelae. There is limited evidence on contextual factors surrounding assessment tool implementation and delirium management. The primary aim of this study was to describe the use of validated delirium assessment tools across Scotland, with a secondary aim of describing protocols for delirium management and barriers to implementation.

Methods:

This was a secondary analysis of national Scottish data from a global point-prevalence study conducted on World Delirium Awareness Day, March 15, 2023. Data were collected via an anonymous survey distributed through social media and professional networks, covering inpatients in acute hospitals, including ICUs, at two timepoints (8am/8pm). The survey collected data on the presence of delirium, delirium assessment tools used, management protocols, and barriers to effective delirium care.

Results:

A total of 120 survey responses were received from 13 hospitals, reporting on 3257 patients at 8am and 2436 patients at 8pm. Most respondents were doctors (72.5%). The most frequently reported assessment tool was the 4AT (75%), and 14.2% of units reported using personal judgement rather than a validated tool. The overall delirium prevalence was 22.3% at 8am and 23.2% at 8pm, with the highest rates observed in geriatric units. Most units had delirium management protocols, but reported barriers to implementing delirium assessment and management including staff shortages, lack of time and insufficient training.

Conclusion:

This study highlights widespread use of the 4AT for delirium assessment in Scotland. There is variation in existing delirium management protocols, and significant barriers remain to effective implementation. Findings emphasise need for ongoing awareness, education, and resources to improve delirium care. Future research should focus on developing delirium management protocols and exploring context-specific barriers to improve patient outcomes.

Introduction:

Falls account for 17% of emergency department (ED) attendances and cause significant morbidity and mortality in older people. An accurate falls risk assessment can identify those at risk of inpatient falls. At Northumbria Healthcare NHS Foundation Trust, the ‘Avoiding Falls Level of Observation Assessment Tool’ (AFLOAT) was developed to identify patients requiring higher levels of observation to prevent falls (Richardson DA. ClinMed (Lond). 2020; 20(6): 545-550). Whilst AFLOAT was commonly used for inpatients, it was rarely completed in ED. A multi-disciplinary and inter-speciality group was formed from ED and Geriatric Medicine teams aiming to improve falls risk assessment for elderly patients within ED.

Aim:

To improve completion of AFLOAT to >70% for patients >75 years admitted to ED

Method:

Of ED attendees > 75 years from RCEM QIP data, 6 patients were randomly selected daily from December 2023 - January 2024 to assess AFLOAT completion. Those attending during the Holiday period and NEWS scores >6 were excluded. Educational interventions were implemented in January 2024 involving face-to-face teaching for all clinical staff in ED and posters placed in the ED seminar room. Data was re-collected for February 2024 and is ongoing for subsequent months. Results: 19.12% of patients had AFLOAT recorded between December 2023 – January 2024. Following our interventions, in February 2024 AFLOAT completion rates rose to 24.69%.

Conclusions:

Whilst improvement has been seen after interventions, we have not yet achieved our target of 70%, suggested ongoing actions: • Questionnaire amongst ED staff on AFLOAT to promote familiarity and look for reasons for incompletion. • Add an electronic prompt into clerking and falls proformas. • We have asked technicians to remove a comment on AFLOAT implying that it should only be completed by nurses. • Attend Junior Doctor inductions to broadcast completion of AFLOAT. Ongoing PDSA cycles in progress.

Introduction: The Centre for Perioperative Care recommends the assessment and documentation of delirium using a validated tool such as the 4-AT in older people undergoing surgery.

Aim: This quality improvement project (QIP) aimed to improve the assessment and documentation of delirium in patients aged 65 and above following vascular surgery in a tertiary centre.

Methods: Patients aged ≥65 years who had undergone vascular surgery were identified and data was collected with access to the electronic patient record system. Analysis was carried out using Microsoft Excel and SPSS. Following baseline measurements taken in August 2023, 1 plan-do-study-act (PDSA) cycle was completed between September 2023-January 2024.

Baseline measures: Baseline data collected between August 1-31st 2023 identified 51 patients, of which delirium was screened using the 4-AT tool in 39.2% (n=20), on average 90 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review (100%,n=51). There were clinical concerns of post-operative delirium documented in 7 patients, with the 4-AT documented in 5 of those cases.

Intervention: Interventions included stakeholder discussions to identify key barriers in the assessment and documentation of delirium, multidisciplinary team education and poster reminders across the ward. These were introduced between November-December 2023.

Results: Post-intervention results reviewed between 10th-31st January 2024 showed that the 4-AT was used to screen for delirium in 61.9% of patients (n=13), on average 45 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review. In addition, 2 patients developed delirium post-operatively with the 4-AT reported in both cases.

Conclusions: This QIP has demonstrated a marked improvement in compliance with national guidelines on the assessment of delirium, highlighting the impact of multidisciplinary education in improving the perioperative clinical pathway for older people undergoing surgery. Future PDSA cycles will focus on improving the documentation of 4AT in the post-operative surgical review.

Introduction:

Parkinson’s disease (PD) patients with or without psychosis are at higher risk of recurrent falls and fracture and as a consequence higher mortality and morbidity NICE (13) Henderson et al. (2019). We conducted a qualitative study to understand barriers and facilitators of introducing ‘bone health assessment’ for PD patients.

Method

We conducted a pilot study to identify and implement a bone health assessment tool to communicate falls and fracture risks to GPs. • SWOT and Stakeholder analysis was conducted to identify an appropriate bone health assessment tool . • PDSA cycles were completed to assess barriers and facilitators of bone health assessment in all PD clinical areas. • 4 Participants were identified from all possible PD clinical settings and trained on how to use the FRAX assessment tool. • Semi structured interviews were conducted to explore themes from 6 week pilot study.

Results

Bone health assessments were not conducted routinely in PD clinical settings in our Trust Literature review/ SWOT and Stake holder analysis identified ‘FRAX’ score as an appropriate bone health assessment tool for PD patients. Interviews with participants identified time constraints during the clinical consultation as a major barrier to conducting bone health assessment using the FRAX assessment tool. All participants agreed that this improved communication with patients and GPs in understanding bone health and risk of falls and fractures. Face to face PD Nurse Clinics were deemed the most appropriate clinical settings for these assessments.

Conclusion

As a result of this service improvement project bone health is now assessed in all PD Nurse clinics. This has enabled GPs to start the most appropriate bone protection treatment for PD patients

Introduction: Delirium affects up to 50% of older individuals within hospital environments, with a notable occurrence in 30% of those aged 65 and above in emergency departments. This QIP aimed to enhance the early recognition of delirium by implementing the 4AT assessment and optimize assessments and investigations by implementing the Delirium Bundle.

Methodology: A survey involving 39 doctors was conducted to evaluate their comprehension of delirium and awareness of the Delirium Bundle. PDSA 1 involved retrospective data analysis of medical records for patients admitted with delirium and used as a preliminary baseline to evaluate how the delirium bundle is being utilized. PDSA 2 integrated multiple teaching sessions and the implementation of the Delirium Bundle, assessing the effectiveness of these interventions.

Results: In PDSA 1, twenty-nine patients were identified. None of the patients had a 4AT assessment done. Twenty patients (69%) had a hematological screen done, eight patients (27%) had an ECG done, twenty patients (69%) had a CXR done, eighteen patients (62%) had an MSU test done, eight patients (28%) had cultures done, and twenty-three (79%) had a CT head scan done. In PDSA 2, thirty patients were identified. Seven patients had a 4AT assessment done, sixteen patients (53%) had a hematological screen done, nineteen patients (63%) had an ECG done, twenty-two patients (73%) had a CXR done, fifteen patients (50%) had an MSU test done, fourteen patients (47%) had cultures done, and 20 patients (67%) had a CT head scan done.

Conclusion: The implemented changes showed effectiveness with increased 4AT assessments and enhanced confusion screening. Improvements in assessments and investigations for diagnosed delirium patients were evident. To further enhance efforts, future initiatives include incorporating the 4AT assessment in clerking booklets, conducting continuous teaching sessions, and displaying posters in relevant wards.

Older people with diabetes are often admitted with falls, dizziness or confusion that may stem from undiagnosed episodes of hypoglycaemia. We examined the use of a 10-day period of round the clock glucose monitoring (CGM), to detect hypoglycaemia in older people with diabetes with symptoms potentially related to hypoglycaemia. 

Methods 

Population: Age 75 years and older, on sulfonylureas and/or insulin, presenting to hospital with a fall and/or symptoms suggestive of unrecognised hypoglycaemia. 

Design: Single-centre, observational study (no change to standard diabetes care). Intervention: 10 days of CGM with Dexcom G6 sensor and Android app on smartphone to continuously transmit data. 

Primary outcomes: Proportion of participants with captured hypoglycaemia; within that group, time spent in the hypoglycaemic range (Battelino T, Danne T, Biester T, et al. Diabetes Care. 2019;42(8):1593-603.). 

Secondary outcomes: Overall time in range; emergency department re-attendances and/or hospital re-admissions for falls, fractures, heart attacks, ischaemic strokes and death within 30 days. REC IRAS project ID: 301286. 

Results 

26 eligible participants of which 13 consented to participate. At the time of writing, nine participants (mean age 81 years) completed the study.

There were no reports of pain or skin reactions from the participants.

Hypoglycaemic events were captured in 3 of 9 participants, with two participants suffering >1 hour below 3.9mmol/L. Only 3 participants achieved >50% time in range target (3.9-10.0mmol/L). 

Discussion 

We have detected significant hypoglycaemic episodes in our participants. CGM should be used more widely in older patients with diabetes who present with falls, dizziness or confusion. 

Limitations include issues around data capture due to participants struggling to navigate the mobile phone app. Despite this, all participants felt that CGM was better than finger-prick glucose testing. Future work is needed to explore how CGM can be deployed after acute admissions in this patient group.