Eyes

Introduction

Xerostomia, also known as dry mouth, is prevalent in older populations and associated with key determinants such as continual use of medication, radiation, and chronic diseases. Xerostomia significantly increases the risk of experiencing demineralisation, dental caries, tooth sensitivity, candidiasis, and other oral conditions that may negatively affect quality of life. An effective strategy to manage the risk of dental caries for patients with xerostomia is the prescription of high-fluoride products with proven efficacy. The aim of this study was to provide evidence on the burden of xerostomia, patient characteristics, treatments, and healthcare resource use in this patient population in the United Kingdom.

Method

A retrospective observational study was conducted including all patients aged ≥16 years with a first diagnosis of xerostomia between 01/04/2015-31/03/2020 in the Optimum Patient Care Research Database, a primary care database. Patients with <12 months’ baseline and follow-up data were excluded.

Results

11,731 patients with a mean age of 67.93 years (SD 15.64) newly diagnosed with xerostomia were included. 72.27% of patients were >60 years and 65.3% were females. Patients aged ≥65 years received a median of 5 (Q1-Q3: 4-6) drug classes in the baseline period. Analgesic agents (80.6%), cardiovascular drugs (70.3%), antidepressants and antipsychotic agents (57.3%), and antihypertensive agents (47.6%) were common prescriptions reported before the diagnosis of xerostomia. Patients had 24.2 primary care visits with the associated costs of £727.66 per patient-year during follow-up. Only 2.2% of patients received high-fluoride toothpaste, whereas 99.6% of patients were prescribed artificial saliva and 16.3% received saliva stimulants.

Conclusions

The majority of patients aged ≥65 years had chronic diseases for which they received ≥4 medications in the baseline period. Although xerostomia is predominantly managed in primary care, few patients are prescribed high-fluoride toothpaste, which is a cost-effective and simple way to reduce the inevitable risk of dental caries.

Background:

- Falls and associated injuries are a significant area of concern for older adults. Approximately 30% of those aged over 65 and 50% of those aged over 80 experience at least one fall each year.

- NICE guidelines state, “Older people who present for medical attention because of a fall, should be offered a multifactorial falls risk assessment”, which includes review of visual impairment.

Aims:

- To identify if visual impairment was documented on the orthopaedic clerking document for patients admitted following fall.

- To raise awareness of visual impairment as being a significant risk factor for falls in the elderly population.

Methods:

- Data collection was carried out retrospectively for patients presenting following a fall at Tunbridge Wells Hospital, via the orthopaedic admission list.

- Initially, data was collected from April to May 2024 and then from July to August 2024 following the first teaching intervention.

Results:

- 6% of patients (n = 50) admitted following a fall had visual status documented in the orthopaedic clerking document.

- Following the first intervention, 20% of documentation noted visual impairment.

Conclusion:

- Visual impairment was not routinely documented on orthopaedic clerking.

- The first intervention involved delivering a teaching session to the orthopaedic department, highlighting the significance of visual impairment contributing to falls.

- Data collection from July to August 2024 has shown an improvement in documentation, whereby 20% of documentation noted visual impairment.

- The second intervention will involve including these findings in the departmental induction and designing a poster to raise awareness.

Introduction

Falls are a common cause of morbidity and mortality in frail patients, with visual impairment doubling the risk of falls. NICE advises a multifactorial approach to identify risk factors to be treated, improved and managed. This includes sensory/visual assessment, which is poorly done in practice. The aim is for 50% of relevant patients admitted with fractures following falls to have a vision assessment within 5 days of admission.

Methods

A modified RCP ‘Look out! Bedside vision check for falls prevention’ aid for healthcare professionals was utilised. Patients excluded were those with significant delirium/dementia or medically unwell. We regularly collected data on how many patients had a vision assessment performed whilst implementing interventions such as Teaching Sessions, Posters and including visual assessments in the Comprehensive Geriatric Assessment(CGA).

Results

Initial results demonstrated poor rate of visual assessments in patients. With implementation of the modified tool, rates of visual assessments improved from 11%(n=1) to an average of 22%(n=4). Further interventions increased the overall average to 80%(n=36). The most effective intervention was including a visual assessment checkbox in the CGA. This improved rates of visual assessment in a subgroup of patients considered to have had falls due to visual impairment, from 33% to consistent rates of 100%. Additionally, the average days to assessment greatly reduced from 10.2 days to consistently under 5 days.

Conclusion

Identification of visual impairment reduces recurrent falls and hospital admissions. The project demonstrated the clinical significance of vision assessments - aiding the diagnosis of PSP, prescribing eye drops, and optician follow-up. Utilisation of the modified ‘Look Out’ tool is a simple way to assess vision on the ward. Posters and teaching sessions improved clinicians’ confidence. However implementing sensory impairment in the CGA proforma proved the most sustainable effort. Next steps include implementation in other Geriatric wards and Falls clinics. 

Introduction: Poor oral health is linked to multiple health conditions, for example pneumonia, cardiovascular and cerebrovascular disease, cancer and diabetes. Older people are particularly vulnerable to developing poor oral health due to comorbidities, medications used, and access to dental services, an effect magnified during hospital admissions. The aim of this project is to improve oral health and care received by inpatients on Healthcare for Older People (HfOP) wards.

Methods: A baseline audit of patient-response surveys on oral health access and behaviours, and care during hospital admissions was performed. HfOP inpatients aged >75 with capacity to consent were included. Plan-Do-Study-Act cycles informed interventions, focusing on education of multidisciplinary staff. First round interventions included presenting/discussing initial audit findings at a regional HfOP meeting, and working with Oral Health Practitioners to do ward-based micro-teaching and develop/distribute posters raising awareness. Second round interventions included a more in-depth certified educational session available to all HfOP staff on oral health care and promotion, and posters on how to document oral health aspects on the electronic patient record.

Results: 82% (82/100) patients reported being registered with a dentist, 50% attending a dentist in the last 12 months. Initially, only 17% (17/100) reported ward staff taking measures to ensure/help support their oral health, rising to 46% (46/50) in the second audit.

Conclusions: Though patient surveys may under-represent oral health access/issues by excluding people unable to consent, and may under-represent staff support offered/provided by recall bias, our audit did highlight gaps in staff awareness/practice. Our interventions were designed to benefit all inpatients, via opportunistic ward-based education through the audit process and formal educational sessions. Limitations included logistics of ensuring access to all staff groups. Our goal is to formalise oral health training in core MDT teaching to generate systemic lasting improvement.

Other information: Registered with local trust audit programme.

Introduction:

In 2019, the Royal College of Physicians (RCP) advised that all patients should have their vision screened if identified as a falls risk. Our aim was to implement a bedside visual screening test and establish an onward inpatient referral to Hospital Eye Services (HES).

Method:

This is a collaborative Quality Improvement project involving Geriatric Medicine, HES and the Royal National Institute of Blind People (RNIB). A pilot study cross referenced falls admissions with previous known ophthalmic data to estimate the proportion of known vision loss in this group. In the second phase of the project, a bedside visual screening test has been introduced for all patients admitted to COTE with a fall. Patients failing the screening are reviewed by an RNIB Eye Clinic Liasion Officer (ECLO) and if necessary, a prompt inpatient HES review is arranged.

Results:

Of 182 patients admitted following a fall, in the pilot study, 112 (61%) were known to ophthalmology previously. Of patients known to ophthalmology, 28 (25%) had vision of 6/18 or worse and would be considered to struggle with daily living tasks. 12 (10%) had a certificate of visual impairment (CVI) and 3 (3%) were eligible for CVI but had not been previously registered. One year following implementation of bedside vision testing, 287 patients had been reviewed after failing bedside screening. 97 of these had an onward referral sent or an intervention performed. The first ‘COTE ECLO’ post has been funded as a result of this work.

Conclusion:

Assessing vision is a critical element of the assessment of patients with falls. Through collaboration with the RNIB and Ophthalmology a successful pathway has been developed to address visual impairment in this vulnerable group of patients.

Background

This healthcare evaluation focussed on the effectiveness of an orthoptic-led inpatient vision screening service at Nottingham University Hospitals for older adults admitted with a fragility hip fracture. The service was developed in response to national guidance, which recommended a multifactorial assessment, including a vision assessment for older adults presenting following a fall.

Method

Vision screening was carried out by orthoptists on eligible patients ≥65 years of age admitted to the Trauma and Orthopaedic wards with a hip fracture. Retrospective data for patients screened between 2015-2019 were analysed, including: patient demographics, screening eligibility and outcome, ophthalmology referrals made, ophthalmology appointment attendance and outcome.

Results

Of 3321 patients admitted with hip fracture between 2015-2019, 2033 (61%) were eligible for vision screening and 1532 (75%) of these were screened. 784 (51%) patients screened had an ocular abnormality requiring ophthalmology referral via their GP, or a sight test at an optician. Only 144/383 (38%) requiring ophthalmology referral were successfully referred and only 107/186 (58%) patients given appointments attended. 98/107 had pathology and cataracts was the most common finding (51%). 61/98 (62%) patients had treatable vision impairment. 

Conclusions

We found a large proportion of hip fracture patients who had impaired vision; much of which was easily treatable and could be detected effectively with orthoptic-led bedside screening. The most common eye problem in those referred to ophthalmology was cataracts. An internal referral pathway to ophthalmology is proposed. There is a need to investigate reasons for disengagement with eye care services in this population.

Introduction

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

Objective

This narrative synthesis reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions: 1. What is the existing evidence for eye care interventions or services (including service configuration) for care home residents? 2. Does the provision of these interventions or services improve outcomes?

Methods

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data was extracted and evaluated using narrative synthesis.

Results

13 original papers met the inclusion criteria. On-site optometrist-led services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions such as cataract surgery, refractive error correction and low vision rehabilitation improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes.

Conclusion

Care home based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research and/or clinical service scoping is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.