Digital Health

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.

Introduction

Advance care planning (ACP) is about what matters to patients, enabling their wishes to be respected, even when they become unable to engage in decision-making. Evidence shows ACP improves end of life care for patients and reduces relatives' bereavement reactions (Detering KM et al. BMJ. 2010; 340:1345). A simulation course for multidisciplinary healthcare professionals, using actors, was developed to improve understanding of ACP, and confidence in having these conversations. In response to the COVID-19 pandemic, the course was adapted to an online format.

Method

Participants were asked about their ACP confidence and understanding pre- and post-course, using a Likert scale (1-Not at all to 5-Very confident). Data between 2018-2022 was analysed to compare face-to-face and online course responses. Free-text responses to 'How do you feel about attending the course online?' were analysed qualitatively. Ethics approval was not required.

Results

Five face-to-face and five virtual sessions trained 128 and 133 attendees respectively. Confidence in having ACP discussions improved significantly following the course in both cohorts; from a mean Likert rating of 2.77 (95% CI 2.60-2.94, n=132) to 4.11 following face-to-face training (95% CI 3.97-4.25, n=128), and from 2.79 (95% CI 2.66-2.91, n=149) to 4.11 following the online course (95% CI 4.01-4.21, n=133). Additionally, 97% (n=132) of face-to-face attendees and 99.2% (n=133) of virtual attendees said their practice would change because of the course. Following the training, 100% of participants across both cohorts reported that they 'fully understood' what was meant by ACP, from a baseline of 77.3% (n=132) in the face-to-face cohort and 81.9% (n=149) of virtual participants. Free-text analysis highlighted the convenience of attending online (n=22,21%), and only a minority reported technical difficulties (n=8,8%).

Conclusion

This course was successfully adapted to a virtual format, improving participants' ACP confidence and understanding as effectively as in-person training, whilst being more accessible.

Introduction

Age is a risk factor for digital exclusion, but many older people have excellent access to digital services. Frailty may offer a clearer mechanism of exclusion. The aim of this study was to assess the association between living with frailty and digital exclusion from video consultation.

Methods

We undertook a multicentre cross-sectional study across primary care, interface, and secondary care services in South-West England. Patients were enrolled between 21st February and 12th April 2022. The primary outcome was complete digital exclusion from video consultation (defined as the no access for the individual and no option for help from their support network). A secondary analysis looked at digital exclusion of the individual only. Frailty was measured using the Clinical Frailty Scale. Outcomes were analysed with logistic regression.

Results

255 patients were included of which 39% were living with frailty. Only one person not living with frailty (CFS 1-3) experienced complete digital exclusion compared to 10.7% living with frailty (CFS ≥4). Frailty was not associated with complete digital exclusion, but was associated with individual digital exclusion: compared to CFS 1-3, CFS 4-5 aOR=36.5 (95%CI 4.40-304.9) and CFS 6-8 aOR=65.4 (95%CI 6.63-645.9). The imprecise estimates were caused by only one person not living with frailty digitally excluded.

Conclusion

Frailty was associated with individual digital exclusion. However, when considering a person living with frailty’s support network digital exclusion from video consultation was rare. To improve access to video consultation for people living with frailty their support network should be explored when booking appointments.

Introduction

Comprehensive Geriatric Assessment (CGA) is widely used in the management and assessment of older people living with frailty, however optimal ways of delivering CGA are not well understood. Gait and balance impairments, common in those living with frailty, are assessed in CGA. Advancements in digital technology provide opportunities to improve patient outcomes by digital monitoring, rather than observation-based assessments - which may be less accurate. As part of the Digital and Remote Enhancements for the Assessment and Management of older people living with frailty (DREAM) study, the aim of this review was to identify devices to assess gait and balance remotely, to enhance CGA

Methods

Searches were conducted across six databases. Papers published since 2008 were included if: participants were over 65; evaluated gait or balance using wearable technology suitable for community use; presented data on validity, reliability, or acceptability of the device.

Results

Of 6,203 papers identified, 48 papers were included evaluating 49 devices. 35 evaluations assessed gait, 7 assessed balance, and 7 assessed gait and balance. The most common modality was a single sensor (n= 30) on a participants’ back (n=22). Seven studies assessed more than one aspect of validity, but the majority examined criterion validity (n=35) and reliability (n=12). Good-excellent agreement between the wearable and a comparable method of analysing gait/balance was found in 15 studies.  Devices could distinguish between healthy populations and those with Parkinson’s disease (n=8), cognitive impairment (n=4), falls (n=4), mobility disability (n=3) and frailty (n=3).

Conclusion

Wearable technologies offer accurate and reliable assessment of gait and balance that could be used to enhance CGA. These tools could be applied remotely in domiciliary settings, freeing up healthcare professionals to focus on other components of CGA, such as ensuring the delivery of interventions to address identified gait and balance impairment. 

Introduction

NHS England is committed to the expansion of virtual wards, necessitating patient engagement with home care technology. Literature suggests there is a technology adoption lag among older populations. We investigated if this lag was evident in geriatric virtual ward patients.

Methods

Data from three NHS trusts using a virtual care  platform (March 2021-August 2023) were aggregated to assess differences in perceived ease of use, technology adoption style, and measures of adherence. All patients received the Telehealth Usability Questionnaire Ease of Use (EOU) subsection (higher scores indicate higher EOU). Patients completed surveys via tablet, wore monitoring devices, and took blood pressure readings. We dichotomized age (<75 vs. 75+) and used Fisher’s exact and Wilcoxon-Mann-Whitney tests.

Results

Of 857 patients, 36.9% were geriatric (mean age 81.5 years). The younger group (mean age 59.1 years) had 541 patients. Gender was evenly split between age groups (p=0.62). Median EOU scores were 5.5 (geriatric) and 6.2 (younger) (p<0.001). Geriatric patients were more likely to avoid or delay technology adoption (82% vs. 56% in younger patients, p<0.001). Geriatric patients had higher adherence to the wearable device (median 95.3%) compared to younger patients (93.3%, p<0.001). Blood pressure (median 81.6%) and survey adherence (median 83.3%) did not significantly differ between groups (p=0.076, p=0.0501).

Conclusions

Despite perceptions and literature suggesting older patients are less comfortable with technology, our findings demonstrate high engagement in virtual ward technology. While differences exist in technology adoption and EOU scores, geriatric patients exhibit equal or higher adherence to remote monitoring tasks. These results challenge stereotypes and underscore the importance of incorporating technology in geriatric care.

Introduction: Research suggests that physical and cognitive exercise can have a positive effective on those with dementia, but less is known about such interventions in those at risk for dementia. Understanding the feasibility of administering clinical assessments remotely using Zoom for Healthcare^TM in the context of a dementia prevention trial for at risk older adults is not well understood.

Methods: SYNERGIC@Home/SYNERGIE~Chez soi (NCT04997681) is a home-based, remotely delivered clinical trial targeting older adults at risk for dementia. Participants underwent a screening/baseline assessment and were randomized to one of four physical and cognitive exercise intervention arms for 16 weeks (3 times per week). They were reassessed immediately post-intervention and 6-months later. The standardized assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, and quality of life were done at all three points. A research coordinator completed the assessments on a one-on-one basis via Zoom for Healthcare^TM. The quality of life questionnaire was mailed to the participant.

Results: Forty-eight of 60 participants (80%) (mean age 68.7 ± 5.7 years, 81.3% female) completed the study. Most participants (75.0%) were cognitively intact with at least 2 dementia risk factors. No participants withdrew from the trial because of difficulty with the remote delivery of the assessments. There were no statistically significant changes in any of the assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, or quality of life throughout the study.

Conclusion: This study demonstrates it is possible to administer standardized clinical assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, and quality of life remotely in the context of a clinical trial. The study was not powered to detect meaningful differences in these assessments. Nevertheless, this confirms the feasibility of remotely administering clinical assessments to older adults at risk for dementia

Introduction: Wearable technology that continuously monitors physiological metrics has become increasingly popular and allows remote patient monitoring in virtual ward settings. Wearable technology has been shown to be effective in disease monitoring among younger adults. However, its use among older adults, including those with cognitive impairment, is yet to be explored. Aim: We aim to explore the acceptability of remote monitoring using wearable technology among older adults with delirium. Methods: Participants were recruited from an in-patient rehabilitation unit. Inclusion criteria included documented delirium and age over 65 years. Participants were enrolled until delirium resolved or until discharge. Wearable technology was worn continuously, except when being charged or the patient was washing. Device data was recorded every minute. Premorbid Barthel index and Hierarchical Assessment of Balance and Mobility (HABAM) was collected for each participant. Participants were assessed daily for delirium and mobility using the Memorial Delirium Assessment Scale and HABAM respectively. At point of discharge from the study, participants completed a questionnaire to gather feedback on their experience. Results: 20 participants were included, with a mean age of 83.0 years and an average premorbid Barthel’s index of 72. 6. Mean data capture from the wearable technology was 44.1% (12.8-65.8). None of the participants could independently manage the device. Three participants stated that the device interfered with their normal activities with five reporting the device uncomfortable to wear. However, nine participants stated they would wear the device again if asked to by a healthcare professional. Conclusions: Our findings demonstrate that wearable devices are tolerated by delirious older adults with delirium. We found that this group cannot manage these devices independently and need support from either a carer or healthcare professional. These results provides useful information to help pilot these devices among older adults with delirium in virtual ward settings.

Key to managing frailty is to first measure it. Until recently, there was no hospital coding for frailty, which meant that it was not visible to commissioners in routine datasets, despite the wealth of studies highlight poor outcomes for older people living with frailty. AFN has created the Hospital Frailty Risk Score (HFRS), which generates a frailty risk from routine codes included in NHS datasets. This allows commissioners and providers to ‘see’ frailty across their system.

We have designed and implemented easy to use tools that allow any NHS staff to look at frailty risk profiles in any NHS organisation, to support improvement activity. The HFRS tool has been downloaded by 122 health systems in England.

Patient safety is fundamental to AFN and reducing the harm older people are exposed to in hospital is the main aim of the programme and sites participating in the network. To achieve this and spread best practice the AFN delivery team use a specific QI approach, primarily the Model for Improvement, focusing on Plan-Do-Study-Act cycles to build change in local systems.

The team deliver events each year for all participating teams to support teams and enable sharing of experience. Site visits comprise discussion about the local context, plans for change and a discussion about possible barriers, as well as a walk-though the patient pathway with patient safety as the absolute focus. Each participating hospital has an allocated QI Associate to support the team to plan, deliver and measure improvements.

AFN has linked closely with other campaigns that support the safety and improve the care of older people, such as ‘end PJ paralysis’ and ‘no decision about me without me’.

 1. Introduction. Advance care planning (ACP) allows patients to prepare for their future and articulate their care preferences. Despite it being a major policy focus there are significant barriers that affect ACP delivery, including paperwork burden and information sharing difficulties. Electronic Health Records (EHRs) are fundamental to how ACP conversations are recorded and communicated. We present data from inpatient geriatric medicine unit during a change in trust-wide EHR (namely, EPIC) and a contemporaneous ACP educational drive.

2. Methods. Clinical notes for all patients on three geriatric wards were analysed on a single day in July 2023 and April 2024. EPIC was rolled out in October 2023.Demographics including age, admission and discharge destination, clinical frailty score (CFS) and social circumstances were retrieved and notes were reviewed for ACP decisions. Teaching took the form of regular small group seminars for ward teams, and departmental sessions to build confidence and optimise ACP documentation using the new software.

3. Results. 83 and 85 patients were identified in July 23 and April 24 respectively. Demographic data were similar between groups including mean age (82; 84), CFS of ≥6 (67%; 61%). In July cohort, one patient had an ACP . In April, 20 patients had an ACP and 8 patients had a Universal Care Plan.

4. Conclusion(s). Significant improvements were noted in ACP delivery and documentation. Following the launch of EPIC alongside targeted teaching to staff members, the proportion of patients with an ACP increased by 23% and UCP by 10% over a 9-month period. EPIC includes improved ability to search for relevant information and dedicated space to document ACP plans, both of which may have contributed to these results. Future work aims to expand this learning into GSTT community services and across other trusts, capitalising on the potential of improved EHR technology in the NHS. 

Introduction:

The local issue tackled was the suboptimal compliance with the Patient Fall Management Assessment (PFMA) on the Electronic Patient Record (EPR) due to assessments being completed on alternative electronic documents.The goal was to emphasize on this to improve patient safety.

Methods:

Audit data was collected by reviewing incident reports of inpatient falls across various complex care wards over a 12-month period each, with 109 notes reviewed in the first cycle and 204 in the second.

Interventions:

The approach involved conducting repeated training sessions for all grades of training doctors within the trust.

Results:

The first audit cycle revealed fair compliance with the PFMA document (87%), documenting events (94%), examinations (87-96%), further investigations and management (80-86%). However, these were lacking for past medical history (61%), medications, especially anticoagulation/antiplatelets (58%), although antihypertensives/sedative reviews were better (75%).

The interventions led to a small (2%) increase in the use of the PFMA document but a 100% compliance in recording fall events and a 13% improvement in documenting histories. Review of blood thinners and other medications improved by 17% and 8% respectively. Significant improvements were also seen in examinations and developing management plans. Despite these advancements, 14% of patients experienced recurrent falls, indicating a need for ongoing efforts.

Conclusions:

The audit highlighted the effectiveness of continuous training to ensure regular understanding of the importance of completing the PFMA. Given the frequent rotation of junior doctors as well as the increasing variety of allied health care professionals reviewing patients, especially out of hours, this presents a particular challenge. Future efforts will focus on more sustainable methods of increasing awareness of the PFMA such as discussion at multi-disciplinary staff inductions and welcome packs. Sustaining these improvements will involve regular audits and feedback loops as well as feedback on the document itself to assess for future improvements.