Scientific Research

Introduction

Dementia with Lewy bodies (DLB) is the second most common form of dementia, however it can be difficult to recognise and is often misdiagnosed. Many cognitive, motor and psychiatric symptoms occur in the prodromal phase of DLB, years before clinical diagnosis. Delirium-onset DLB is one of three purported prodromal pathways by which DLB develops (McKeith et al., 2020). As delirium itself is an under-recognised clinical syndrome, this scoping review aimed to determine the epidemiology and clinical phenotype of delirium-onset DLB.

Methods

Electronic databases MEDLINE (ALL), Embase, Web of Science and PsycINFO were searched in December 2023. Two reviewers then independently screened titles, abstracts and full-text reports. Conflicts were resolved by a third reviewer. Data were then extracted by the lead reviewer and quality assessments were conducted.

Results

Following the removal of duplicates, the search yielded 719 results. Of these, 154 studies underwent full-text review and 38 were eligible for inclusion. This review describes 64 cases of delirium-onset DLB in case studies/reports (n=18), observational studies (n=3), retrospective cohort studies (n=12) and clinicopathological studies (n=5).

Conclusion

Delirium-onset DLB is an under-researched area. There is a dearth of evidence regarding both the epidemiology and clinical phenotype of this prodromal phase. Clear and systematic methods for the diagnosis of both delirium and DLB are needed in order to elucidate this pathway. At present, it is not clear what role biomarkers play in the detection of delirium-onset DLB. Further investigation of these tools, combined with neuropathological studies, could shed light on the pathogenesis of this disease.

Introduction

Motor Neurone Disease (MND) is a neurodegenerative condition affecting the spinal cord and brainstem, commonly associated with a reduced life expectancy. This study describes demographic trends in MND-associated mortality in the United States over 20 years.

Methods

Data were extracted from the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research Underlying Cause of Death database. Death certificates from 1999-2020 with MND (International Classification of Diseases-10th Revision code G12.2) recorded as the cause of mortality were extracted and annual MND-associated crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) per 100,000 persons with 95% confidence intervals (CI) were calculated. Joinpont regression was used to calculate the annual trends in MND-associated mortality by calculating the annual percentage change.

Results

Between 1999 to 2020, there were a total of 140,945 MND-associated deaths. Overall AAMR was 1.9 per 100,000 persons (95% CI 1.9-1.9). Male sex had a consistently higher AAMR (2.3 per 100,000 95% CI 2.3-2.3) than female sex (1.6 per 100,000 95% CI 1.5-1.6). White patients had higher AAMR (2.1 per 100,000 95% CI 2.0-2.1) than Black/African Americans (1.1 per 100,000 95% CI 1.0-1.1), American Indians/Alaska Natives (0.8 per 100,000 95% CI 0.7-0.9), Asians/Pacific Islanders (0.8 per 100,000 95% CI 0.7-0.9). The 3 US States with the highest AAMR were Vermont, followed by Minnesota and Maine.

Conclusions

This national study demonstrates that there were a significant number of MND-associated deaths in the United States, with higher rates associated with certain patient demographics. The knowledge of these trends facilitates the design of appropriate services in areas of higher need, allowing for the introduction of pathways that support more suitable care and enhanced quality of life.

Introduction:

Many UK care home (CH) residents live with multiple long-term conditions, leading to high levels of healthcare utilisation. Previous studies have used routine data to describe their health and social care characteristics separately. Accurately identifying when an individual is admitted to a CH from routine data is challenging. This study aims to provide a combined health and social care profile of a cohort of long-stay CH residents, at the point of admission, using linked primary, secondary and social care data.

Methods:

Individuals aged 65 and over registered to a GP practice contributing to the ‘Connected Bradford’ dataset who were admitted to a CH between January 2016 and December 2019 were included. Start and end dates for social care packages (nursing and residential) were identified from local authority social care data. Respite and reablement packages were excluded. Complete self-funders were not identified with this method. Linked secondary and primary care data were used to describe health characteristics. CH residents identified using primary care records and local authority data will be compared.

Results:

2,801 individuals were admitted to a CH during the study period of whom 1998 (71%) were long-stay residents (>6 weeks). Only 72% of participants identified using local authority data, had a primary care code indicating CH residency in their primary care records. Median length of stay was 272 days (IQR 63 to 480). Mean age at admission was 85 years (SD 8), median Index of Multiple Deprivation decile five. 59% of residents required nursing care from admission. 79% of individuals were taking 5 or more medications.

Conclusions:

Using local authority data offers a novel way to identify and characterise CH residents. Linkage of primary care records to local authority data improves identification of CH residents using routine data. Additional linkage with address history would further improve accuracy.

BACKGROUND

• RSV is one of the most common causes of seasonal respiratory infections worldwide, with a marked global burden in older adults and those with significant underlying medical conditions.1-5 It is increasingly clear that RSV infections in older adults in the United Kingdom significantly impact the already strained public health system, especially during the winter months.
• However, the true burden remains underestimated,6,7 as estimates in the UK are likely to be conservative due to the limitations in testing and diagnostic coding practices.

OBJECTIVES

• We conducted a TLR of existing literature to investigate the disease burden of RSV infection in older adults, aged 60 years and older in the UK, and to highlight potential evidence gaps. METHODS • We searched OVID MEDLINE, Embase, and EconLit to identify existing literature from January 2011 to August 2023, including an additional search for grey literature. Eligibility criteria were defined based on population (intervention/comparator [no limit]), outcomes (clinical, epidemiological, economic, and quality of life) and limited to UK-only results. See PRISMA flowchart for details.

RESULTS

• In the OVID search, we identified 1,001 records, and in the supplementary search, 12 records of possible interest were identified. All records were screened against the predefined eligibility criteria. Despite the relatively broad screening criteria, only 14 studies could be included.
• There were four model studies, five cohort studies, and five time series analyses included. Of these, nine studies reported on epidemiology, one study informed both on epidemiology and costs, and four studies reported on model outcomes. Nine studies reported unique data on the UK and five studies included data from several countries, including the UK.
  • All identified studies emphasised the challenges in estimating the true RSV burden in the UK due to limitations in testing and a lack of standardised disease definition in older adults. There is a lack of evidence for adult risk groups, particularly clinical and economic consequences in patients at a higher risk of RSV infection and severe sequelae.
  • Due to the overall small number of studies and the heterogeneity of study design and outcomes reported, it was not possible to establish reliable data on incidence, prevalence, and mortality in the UK.

• The results of the TLR suggest that RSV infection in older adults may place a high economic burden on the UK’s healthcare system.

CONCLUSIONS

• A limited number of studies meeting the criteria on RSV infection in older adults in the UK were found, with nearly no data on adult risk groups and related cost. The scarcity of data, lack of standardised disease definitions and surveillance methodologies likely lead to an underestimation of RSV disease burden in older adults in the UK.
• It is imperative that surveillance systems are improved to understand the true burden. Therefore, a deeper comprehension of the impact of RSV infection within this population would enhance the ability to demonstrate the cost-effectiveness of a national immunisation programme more reliably.
• This paucity of data creates great challenges for the Joint Committee on Vaccination and Immunisation, and UK policymakers to make informed decisions on the population benefit of RSV vaccination programmes for older adults.

ADDITIONAL INFORMATION

Copies of this presentation obtained through the QR code are for personal use only and may not be reproduced without permission of the authors.

REFERENCES

1. Nguyen-Van-Tam, J.S., et al., Burden of respiratory syncytial virus infection in older and high-risk adults: a systematic review and meta-analysis of the evidence from developed countries. European Respiratory Review, 2022. 31(166): p. 220105.

2. Falsey, A.R., et al., Respiratory syncytial virus infection in elderly and high-risk adults. New England Journal of Medicine, 2005. 352(17): p. 1749-1759.

3. Falsey, A.R., et al., Respiratory syncytial virus–associated illness in adults with advanced chronic obstructive pulmonary disease and/or congestive heart failure. Journal of Medical Virology, 2019. 91(1): p. 65-71.

4. Global Burden of Disease 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infectious Diseases, 2018. 18(11): p. 1191-1210.

5. Savic, M., et al., Respiratory syncytial virus disease burden in adults aged 60 years and older in high‐income countries: a systematic literature review and meta‐analysis. Influenza and Other Respiratory Viruses, 2023. 17(1): p. e13031.

6. Korsten, K., et al., Burden of respiratory syncytial virus infection in community-dwelling older adults in Europe (RESCEU): an international prospective cohort study. European Respiratory Journal, 2021. 57(4): p. 2002688.

7. Sharp, A., et al., Estimating the burden of adult hospital admissions due to RSV and other respiratory pathogens in England. Influenza and Other Respiratory Viruses, 2022. 16(1): p. 125-131.

ACKNOWLEDGEMENTS

Writing and/or editorial assistance was provided by MEDiSTRAVA and was funded by Moderna, Inc. This study was funded by Moderna, Inc.

DISCLOSURES

ICON (MM, BB) was commissioned by Moderna, Inc., to conduct the TLR. SC, MD, OB and TA are employees of Moderna, Inc., and hold stock/stock options in the company.

OBJECTIVE: To assess in Alzheimer’s disease (AD), the treatment impact of donanemab, an amyloid plaque-reducing monoclonal antibody, on readily interpretable item-measures and constructs that matter to patients, care-partners, and clinicians.

BACKGROUND: Positive outcomes were reported from TRAILBLAZER-ALZ2, a randomized, double-blind, placebo-controlled, 18-month, phase 3 study evaluating donanemab as an investigational treatment for mild cognitive impairment (MCI) or mild dementia due to AD. In 1736 participants, donanemab significantly slowed the rate of clinical decline (by 22-36%) as measured by the integrated AD Rating Scale (iADRS) and the Clinical Dementia Rating Scale—Sum-of-Boxes (CDR-SB); both measures of cognition and function as indications of global clinical severity. In these subsequent post-hoc exploratory analyses, the impact of donanemab treatment on individual iADRS cognition and function items, CDR domains, and risks of advancing to greater disease severity were assessed.

METHODS: Mixed model repeated measures and Cox proportional hazard modeling methodology assessed treatment effects on iADRS items and CDR domains.

RESULTS: Donanemab treatment was associated with significant beneficial effects on: 1) iADRS cognitive items related to episodic memory and executive function, and instrumental activities of daily living items related to communication and others (e.g., being left alone, making a meal, using household appliances); 2) all CDR-SB cognitive and functional domains (i.e., memory, orientation, judgment/problem solving, community affairs, home/hobbies, and personal care); and 3) lowering risk of progression to a more advanced clinical stage of disease.

CONCLUSIONS: These analyses explored the impact of donanemab treatment on constructs that matter to and are considered more readily interpretable by patients, care-partners, and clinicians. These results provide further support that treating those with MCI or mild dementia due to AD with donanemab can meaningfully reduce risk of progression to more severe clinical stages (e.g. moderate stage dementia), and potentially allow greater independence for a longer period of time.

 Introduction: The ageing population means all doctors, regardless of specialty, will need knowledge, skills, and attitudes to care for older people with complex health conditions. An essential component of preparing the medical workforce to best care for older people is by including teaching on ageing and geriatric medicine in undergraduate medical curricula. Here we present results of the British Geriatrics Society (BGS) national curriculum survey 2021-22, highlighting progress made in undergraduate teaching in geriatric medicine.

Methods: All 35 UK GMC-registered medical schools at the time of data collection were invited to participate in an online survey on content, methodology, timing, and duration of teaching in ageing and geriatric medicine. The survey was structured around the 2013 BGS recommended undergraduate curriculum, for consistency with previous surveys.

Results: 30/35 of UK medical schools responded (83% response rate). Most teaching occurred in the fourth year of study (21/30, 70%). The majority (15/30, 50%) reported a discrete module for geriatric medicine lasting 4-8 weeks, an increase on previous surveys. However, several programmes have reduced the amount of in-person teaching since the COVID-19 pandemic. Notably, three schools reported geriatric medicine exposure lasting >12 weeks. Of these, two were integrated clerkships and one a dedicated geriatric medicine module. There is increasing focus on multidisciplinary education, with emphasis on combining virtual or simulated teaching with other healthcare professions (n=7). Every school (n=30) taught at least one topic as small-group or case-based learning.

Conclusion: There is a trend towards increasing exposure to geriatric medicine compared to previous surveys in 2008 and 2013. However, several of the programmes reporting greater exposure incorporate geriatric medicine in an integrated clerkship rather than as a dedicated module. Programmes demonstrated a move from didactic teaching towards small-group and case-based learning, employing a wider variety of assessment methods than previous.

Introduction

Geriatric syndromes are traditionally taught through didactic teaching and bed side tutorials. However, these do not consider the science of learning and the strategies needed for a novice learner. It is prudent to manage cognitive load, create associations through testing and enforce deliberate practice for a novice as opposed to an advanced learner. Case- Based discussions (CBD) serve as an apt tool to deliver knowledge covering geriatric syndromes; aimed at testing learner's understanding through its application to a simulated patient profile.

This pilot aimed to test the applicability of CBD to teach geriatric syndromes to novice learners.

Method 

A scoping review was completed by medical officers starting on their geriatric medicine rotation in a Singapore tertiary hospital to determine syndromes which they request dedicated teaching for within curriculum. Learners ranked Incontinence and Falls with Osteoporosis management as the top 2 geriatric syndromes of interest. Focus group discussion using Rogers’s theory of diffusion principle was undertaken to understand both the advantages and challenges of CBD. Clinical scenarios were curated specific to the 2 topics with learner's completing a pre session quiz beforehand to determine their baseline knowledge. The topic specific CBD was done via zoom platform with questions applied in a graded fashion; components include that of diagnosis, evaluation, and management of select syndrome. Learners completed a post session quiz 1 week after the CBD to determine retention of knowledge.

Results

Quantitative Feedback received from the learners highlighted that more than 90% would want CBD to be implemented for other geriatric syndromes. There was an improvement in the average score obtained in post session quiz for Osteoporosis from 6.09 to 6.75. However, there was notably poor participation in the post session quiz.

Conclusion

This pilot highlights that CBD should be utilized to enhance teaching of clinical concepts in geriatric medicine.

Introduction:

The preference for place of death and the concept of dying in place have been subjects of debate in numerous jurisdictions. Despite the growing prevalence of ageing populations and the increasing demand for dying in place, there is a limited body of literature exploring older adults’ knowledge of dying in place and their preferences for the place of death. In Hong Kong, there are ongoing legislative efforts to revise the policy on dying in place. This study aims to investigate the knowledge of dying in place and the preferences for the place of death among older adults in Hong Kong.

Methods:

This cross-sectional study recruited 503 older adults. A questionnaire was disseminated through online social media platforms and face-to-face interview. ANOVA was conducted to compare the differences in knowledge scores among participants with varying preferences for the place of death.

Results:

Participants demonstrated a sub-optimal knowledge level (mean = 3.55; range 0-8). Notably, 54.7% of participants were unware of the existing law that regulates dying in place in Hong Kong, and 43.5% did not know about the availability of community resources to support patients who choose to die at home. The majority of participants (55.5%) preferred to die at home. Other preferences included hospital (18.9%), hospice (17.1%), and care home (8.5%). Participants who preferred to die at home exhibited a higher knowledge score (mean 3.84) compared to those who preferred to die in hospital (mean = 2.79) (F = 5.323, p = 0.001).

Conclusions:

The findings of this study provide insights that can inform the revision of current policies, the enhancement of community resources supporting dying in place, and the strengthening of life and death education targeted at older adults.

Acknowledgement:

The work described in this paper was fully supported by a fund from Hong Kong Metropolitan University (RD/2022/2.17).

INTRODUCTION: Frailty is common in hospitalised older patients and hospitalisation can lead to negative outcomes. Our study aimed to provide insights into current decision-making processes on treatment, care and discharge by clinical teams. 

METHODS: We conducted a prospective cohort study in frail older patients ≥ 65 years old admitted to acute medical and surgical wards. Clinical Frailty Scale ≥ 5 was used to identify frail patients and process mapping was undertaken to identify common themes, trajectories and potentially modifiable factors. We followed patient journeys from admission to discharge and examined factors contributing to longer hospitalisation. We documented existing processes, environmental, system and clinical factors influencing patient care. Comprehensive geriatric assessments identified underlying geriatric syndromes and where gaps in management were identified, we recommended frailty interventions. 

RESULTS: Fifteen patients provided informed consent, of whom 73% were female and average age 80 years, ranging 69-95 years. 67% were frail (CFS 5-6) and 33% were severely frail (CFS 7-9). Most patients were sarcopenic with a SARC-F score of ≥4 and had functional and gait impairment. 60% were underweight (BMI <22). Process mapping revealed gaps in frailty-focused care and included delayed transfer to acute wards, delayed investigations, and multiple unidentified geriatric syndromes which were prevalent in this cohort.Patients fell into three broad groups, short (1-6 days), intermediate (7-14 days), or long (>14 days) length of stay and delays in discharge-planning were common, mean of 4.17 days, as were delays in identification of a caregiver. Recommendations for community support services were provided to >50% patients. 

CONCLUSION: Our study shows that mapping the frail patient's journey can identify gaps in existing processes and opportunities for improvement and collaboration. Integrating geriatric care into general wards could improve patient outcomes. We aim to use this work to guide frailty-attuned care for hospitalised older patients.

Introduction

Horticultural therapy (HT) is not uncommonly used as non- pharmacological therapy for patients with dementia. However, less is known about its effects on older adults with normal cognition. This systematic review and meta-analysis synthesises available evidence to evaluate the effects of HT on psychosocial and physical function in cognitively intact older adults.

Method

A systematic search in 9 electronic databases for experimental and quasi- experimental studies was performed between January 1, 2001, and July 19, 2021. Studies involving participants above 60 years old with normal cognition, analysing psychosocial and physical effects of HT, were included. Cochrane Risk of Bias 2 (RoB2) tool and Risk Of Bias In Non-randomised Studies- of Interventions (ROBINS-I) were used to assess risk of bias. Meta-analysis was conducted using Stata software. Cochran’s Q test and I2 were used to explore statistical heterogeneity. Narrative synthesis was conducted for trials unsuitable for quantitative pooling.

Results

Nineteen articles (2191 participants) were included. Meta-analyses found that HT showed moderate-large effects on psychosocial outcomes, with improved self- efficacy (Hedges’ g=0.49, 95% Confidence Interval:0.07,0.91, 3 trials, I2 :0.00%) and self-esteem (g=1.01, 95%CI:0.33,1.68, 2 trials, I2 :0.00%), and decreased depressive symptoms (g=-3.33, 95%CI:-6.29,-0.37, 4 trials, I2:98.51%). Narrative synthesis suggested benefits in Health-related Quality of Life. Regarding physical effects, HT improved exercise duration and intensity (g=1.37, 95%CI:0.92,1.82, 2 trials, I2:0.00%). Effects on anxiety, social engagement and fitness did not achieve statistically significance.

Conclusion

The findings support the potential role of HT in promoting psychosocial and physical function among older adults with intact cognition. Given high statistical heterogeneity, more work is needed to explore the effect of possible moderators on treatment effects.