Multimorbidity

Background

Older people have complex health needs, with the inter-play between physical and mental health being a prominent issue. The ageing population has resulted in a large proportion of older people living with co-occurring physical and mental health disorders, which can prove challenging to manage simultaneously, particularly for serious mental illness. The aim of this systematic review was to explore models of integrated physical-mental health care available for older people, and whether these result in improved health outcomes. Sources of heterogeneity in the current evidence base alongside limitations were also explored.

Methods

Medline, Embase, CINAHL, PsycINFO and Scopus were searched with a predefined search strategy, generating 5257 articles. Studies were suitable for inclusion where an integrated physical-mental health care service model was utilised in a population of older people (aged >60 years) with a mental health diagnosis and at least one concomitant physical health condition requiring physical health care input. All studies were quality assessed for risk of bias and results were synthesised narratively.

Results

Nine studies met the inclusion criteria. All studies incorporated service models involving integrated and/or multidisciplinary care. These included joint medical-mental health wards as well as the implementation of multidisciplinary teams in hospital and care facilities. Overall, this enhanced the quality of care for elderly patients with benefits including but not limited to, enhanced patient experience, the expansion of multidisciplinary team practice, improved management of illness, and timely intervention.

Conclusions

Multidisciplinary and integrated care resulted in improvement of a range of health outcomes for older people with combined physical and mental health needs. Larger and more robust studies are needed to explore the development of these service models further, with cost-effectiveness analyses.

Introduction: Severe Mental Illness (SMI), particularly schizophrenia, has been associated with reduced bone mineral density and increased risk of fractures, although some studies have shown inconsistent results. We aimed to examine the effect of SMI on recorded diagnosis of osteoporosis and fragility fracture in older people in the UK, accounting for age, sex, social deprivation and lifestyle factors (smoking, alcohol and Body Mass Index (BMI)).

Methods: We used de-identified data provided as part of routine primary care (IQVIA Medical Research Database). Patients with a diagnosis of SMI (schizophrenia, bipolar disorder, other psychosis) aged 50-99y between 1/1/2000-31/12/2018 were matched 1:8 to age- and sex-adjusted controls without SMI, using Exposure Density Sampling (EDS). We estimated Hazard Ratios (HR) and 95% Confidence Intervals (95%CI) based on Cox Proportional Hazards model. We stratified the analysis by sex, accounting for age, social deprivation, year (model 1), and the above plus smoking, alcohol, and BMI (model 2). We imputed missing lifestyle data using Multiple Imputation.

Results: In total 444,480 people aged ≥50 years were included in the analysis (SMI N=50,006; controls N=394,474). In men, prior diagnosis of SMI increased the risk of osteoporosis diagnosis by 64% (HR 1.64; 95%CI 1.44-1.88) and the risk of fragility fractures by 87% (HR 1.87; 95%CI 1.70-2.06) in model 1. SMI also increased osteoporosis risk by 49% (HR=1.49; 95%CI 1.30-1.71) and fragility fracture risk by 82% (HR=1.82; 95%CI 1.65-2.00) in model 2 in men. In contrast, prior diagnosis of SMI had no significant effect on recorded osteoporosis risk in women. Prior SMI in women increased fragility fracture risk by 53% (HR 1.53; 95%CI 1.45-1.61) in model 1 and by 51% (HR=1.51; 95%CI 1.43-1.58) in model 2.

Conclusions: SMI is associated with increased risk of osteoporosis in men, and fragility fractures in both men and women, with a greater effect in men. 

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. 

Introduction

High-dose corticosteroids have significant benefits for infective exacerbations of COPD, reducing risk of relapse, length of hospital stay and earlier symptom improvement. However, recurrent use has been shown to increase risk of comorbidities including osteoporosis, type two diabetes mellitus (T2DM), cardiovascular disease, hypertension, and elevated body mass index (BMI). 

This audit assessed how many patients at Anchor Mill Medical Practice in Paisley, who had been prescribed two or more courses of prednisolone in the six months prior to the start of data collection, had been assessed for T2DM, renal impairment, elevated BMI, hypertension and osteoporosis within the previous year. 

Methodology 

An EMIS search was performed for patients over eighteen who were coded as having COPD and who had received two or more acute prescriptions of prednisolone from 03/04/2023 to 03/10/2023. 

Data was then collected from the patient's medical summaries and investigations, looking at if they had had HbA1c, urea and electrolytes, lipids, BMI and blood pressure checked within the preceding year. The audit also looked at how many patients had had a QFracture score calculated over the past year, or if they had been referred for or had had a DXA scan within the previous five years. 

Results 

Over 50% had had their lipid profile and HbA1c checked, with over 75% having had their U+Es, BMI and BP checked. The major outlier was OP risk assessment, for which only 31.25% of patients had been screened. 

Conclusions 

Within this primary care setting, improvements could be made on screening for associated comorbidities with COPD. The patients were referred for these investigations, with the biggest improvement being a 140% increase in patients referred for a DXA scan, and annual follow up with the practice nurse was changed to include these investigations as appropriate.

Introduction:

Multimorbidity is complex and impacts patients' quality of life, health outcomes, and health care utilisation. This project aims to identify multimorbidity patterns and their impact on long-term care admissions in community-dwelling older adults.

Methods:

Multimorbidity was ascertained using primary care data Tū Ora COMPASS Health. Adults aged 65+ (55+ for Māori and Pasifika) were included in the analysis. Aged residential care (ARC) admission was determined from interRAI. Twelve conditions ascertained were hypertension, ischaemia, congestive heart failure, stroke, diabetes, cancer, chronic obstructive pulmonary disease, depression, hypothyroid, osteoporosis, dementia, and neurological diseases. Latent class analyses were completed to identify multimorbidity patterns by ethnicity, i.e., Māori, Pasifika, and nonMāori/non-Pasifika (nMP). For the latter group, analyses were also completed by age groups (<80 years and ≥80 years. Cox-regression models were used to examine the association between multimorbidity patterns and 5-year ARC admission.

Results:

The sample comprises 45,178 older adults: nMP (88%), Māori (8%), and 1,755 Pasifika (4%). The average age for Māori and Pasifika was 65.1, respectively, and nMP was 74.1. We identified three multimorbidity patterns for Māori and Pasifika, and four for nMP (<80 and ≥80). All twelve conditions clustered differently in these samples. Eleven-per-cent Māori were in a 'complex-cluster', and they had a three times higher risk of ARC admission than 'healthier-cluster' [aHR(95%CI): 2.96 (1.81-4.36)]. We did not observe an association between condition clusters and ARC admission risk in the Pasifika sample. In the nM/nP<80y sample, those in 'complex-cluster' (4%) had a 5.5 times higher risk of ARC admission (5.48, 4.68-6.41) than in the 'healthier-cluster'; a similar association was observed in nM/nP≥80y in 'complex-cluster' (8%) when compared to 'healthier-cluster' (4.08, 3.67-4.53).

Conclusions:

Complex clusters were associated with an increased risk of five-year ARC admission. Multimorbidity patterns are helpful for a more strategic approach to managing multimorbidity better in primary care settings.

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.