Scientific Research

Introduction

Emergency department (ED) frailty screening is recommended in guidelines for its potential to trigger earlier and more appropriate comprehensive evaluation and intervention for the most vulnerable patients. Post-implementation studies of the Clinical Frailty Scale (CFS) typically observe around 50% concordance with screening. Little is known regarding the characteristics of those people omitted.

Methods

The Frailty in European Emergency Departments (FEED) cohort study observed prevalence of frailty, administering the CFS to consecutive attenders over twenty-four hours. Retrospective “normal day” data from two weeks prior were also collected, where sites used retrievable electronic health records. Age, sex, ethnic group, mode and time of arrival and departure, NEWS2 score, and use of resuscitation areas were recorded. CFS missingness was assessed for distribution and dependency with other variables using chi-squared tests. The frailty distributions in prospective and retrospective data were compared with the Kruskal-Wallis test.

Results

Only five of sixty-two sites collected CFS scores in retrievable electronic records. The cohorts included 368 individuals prospectively and 399 retrospectively. At these sites, 14% prospective and 55% retrospective CFS observations were missing. CFS entries were more frequently missing in people with non-white ethnic group (p=0.007) and self-presentation (p<0.001). The distributions of CFS differed significantly (p=0.009); on the retrospective day, no individuals were assigned CFS scores 1 or 9, and CFS scores 4 and 6 were over-represented.

Conclusion

Acknowledging the limited participation and use of snapshot data, these findings alert the presence of systematic, non-random missing data in routine CFS screening. Systematic missingness in frailty data has critical implications for research in geriatric emergency medicine, presenting real limitations in validity where studies seek to analyse routinely collected data to reach representative inferences. Screening practices and retrievability of data warrant further study and improvement.

Introduction

The frailty index (FI) is a frailty assessment tool calculated as the proportion of the number of deficits, or “things that individuals have wrong with them”, to the total number of variables in the index. Routine health and administrative databases are valuable sources of deficits to automatically calculate FIs. There is large heterogeneity in the deficits used in FIs. This sub-analysis of a scoping review on routine data-based FIs aimed to describe and map the deficits used in multi-dimensional FIs.

Methods

Seven databases were searched to find literature published between 2013 and 2023. The main inclusion criterion was multi-dimensional FIs constructed from routinely collected data. Multi-dimensional FIs should have deficits in at least two of the following categories: “symptoms/signs”, “laboratory values”, “diseases”, “disabilities”, and “others”.

Results

Of the 7,526 publications screened, 61 distinct FIs were identified from 60 included studies. Most FIs were developed in hospital settings (n=19). The most dominant data source of deficits to calculate the FIs was hospital records (n=23). The median number of deficits used in the FIs was 36 (range = 5–72). We identified 611 unique deficits that comprised the FIs. Most deficits were either “diseases” (34.4%; n=205) or “symptoms/signs” (32.1%; n=196), followed by “disabilities” (17.0%; n=101), “others” (10.1%; n=60), and “laboratory values” (8.3%; n=49). Forty-seven deficits were present in ≥20% of the FIs (≥12 FIs). The most common “disease” was diabetes, “symptom/sign” was depression, “disability” was hearing loss, and “laboratory value” was anaemia & haematinic deficiency.

Conclusion

These findings highlight the reactive approach to frailty assessment, as most of these FIs were calculated from hospital data and used symptoms/signs and diseases as deficits. Given the heterogenous manifestations and long-term impacts of frailty, using a more proactive approach that leverages non-clinical routine data is warranted to prevent frailty development and progression.

A Scoping Review of Guidelines and Resources to Promote Evidence-Based Prescribing for Older People with Sensory Impairment (OPwSI)

BC Morrison1; E Asante2; MR Lennon2; MC Watson1

1. Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow; 2. Department of Computer and Information Sciences, University of Strathclyde, Glasgow

Introduction

By 2030, hearing impairment is expected to affect one in four people globally (WHO, 2022) and one in five in the UK (Hearing Link, 2023). Visual impairment is projected to impact 2.7 million people in the UK by 2030 (ONS, 2020), rising to 4 million by 2050. The prevalence of hearing and visual impairment (hereafter referred to as sensory impairment (SI)) increases with age and older people with SI often experience substantial challenges with medicine management compared with older people without SI (Alhusein, 2019). This review aimed to identify guidelines and resources for prescribing decisions for older people with sensory impairment (OPwSI).

Methods

Standard Joanna Briggs Institute [JBI] methodology (Page, 2021) for scoping reviews was used. Electronic databases were searched: MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Qualitative and quantitative studies published between January 2012 and April 2023 were included. Grey literature sources, including Google and Google Scholar, were also searched. Eligible studies focused on prescribing behaviour for OPwSI (aged ≥ 65 years) in primary care settings. Duplicate independent screening and data extraction was undertaken and critical appraisal was completed for all included studies.

Results

A total of 3,590 records were identified through database searching and 10 full-text articles were retrieved. Grey literature identified a further 61 records. Despite extensive searches, no studies or resources fulfilled the inclusion criteria. Several generic guidelines and resources were identified related to medicines and safe prescribing for older adults in general i.e., without specified SIs.

Conclusions

This review highlights a dearth of guidelines or other resources to support safe and effective prescribing for OPwSI. There is an urgent need to provide bespoke guidance and/or the modification of existing guidelines, to address the additional medicine-related needs of OPwSI.

Purpose

To investigate physiotherapists’ perspectives of effective community provision following hip fracture.

Methods

Qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented.

Results

Four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented.

Conclusion

Physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.

Introduction: Many countries are facing an ageing population, and this is also evident in Singapore. To alleviate this matter and to cope with the increasing number of older persons today, nursing homes are also expanding. Residents of nursing homes are often frail and are at higher risk of multiple hospital admissions. On many occasions, the benefit of conveying the frail residents to acute hospitals is unclear and may even cause more harm. We implemented an acute hospital-nursing home collaborative pilot in two nursing homes with an objective to reduce emergency department visit and inpatient hospitalization among nursing home residents. We aim to study the experiences of healthcare personnel who were involved in an acute hospital-nursing homes collaboration in managing acutely ill residents.

Methods: Explorative qualitative interviews were conducted with fifteen nursing staff from two nursing homes involved in the pilot collaboration. The interview transcripts were thematically analyzed.

Results: The study delved into five key thematic areas: knowledge and understanding, service satisfaction, challenges, enablers, and service improvements. It revealed that a significant portion of staff lacked a comprehensive understanding of the collaboration's objectives. Nevertheless, there was a consensus that they found reassurance in the accessibility of hospital providers without immediate activation of emergency services. Nursing home staff acknowledged enhancing their ability to identify residents requiring escalated care through this collaboration. The interventions utilized, such as the NEWS assessment tool, hospital transfer forms, and teleconsultation portal, were noted for their user-friendliness. Challenges encountered included pressure from next-of-kin favouring treatments in acute hospitals over nursing homes and insufficient on-site resources. Identified enablers included a robust support system and the competency and motivation of nursing home staff to enhance residents' care, facilitating collaboration. Recommendations for improvement highlighted the need for training and skill development among nursing staff and workforce enhancement to bolster collaboration adherence.

Conclusion: These key themes highlight the significance of the collaboration between nursing homes and hospitals in improving care for residents, while also acknowledging the challenges and areas for future improvements.

Introduction:

BGS reports in its 'Case for more Geriatricians' that the number of people age over 85 is set to double by 2045. As well as Geriatric specific policies in the Ageing Well programme of the NHS Longterm Workforce Plan there are plans to expand the number of allied health professionals including Physician Associates (PA). We set out to improve PA students knowledge of and confidence in managing geriatric patients with a bespoke teaching programme culminating in a novel bleep simulation.

Methods:

We identified the students needs with a preliminary survey and then created a teaching programme on medical topics and issues common to geriatric wards with weekly lectures and small group work. The programme culminated in a bleep simulation where students were contacted via bleep to come to different parts of the medical education centre and respond to scenarios which would be common on geriatric wards. These included reviewing unwell patients and issues such as aspiration, constipation and urinary retention. The students were required to amend or create prescriptions and interpret test results with access to the BNF and relevant local guidelines.

Results:

Students were asked how useful the simulation was and how much it had improved their confidence in working on geriatric wards. The average score for both statements was greater than 9/10. The students were asked before and after the simulation how confident they were responding to bleeps and managing clinical scenarios in geriatric patients. Both scores doubled following the simulation to 6.7/10 (from 2.5 and 3.3 respectively).

Conclusion:

The Faculty of Physician Associates curriculum does not necessitate placements in geriatrics and its matrix of core clinical conditions does not include any specific to geriatrics. Through a bespoke teaching programme and a novel bleep simulation we increased PA students confidence in managing geriatric patients.

 Introduction: The COVID-19 pandemic has raised concerns about its long-term effects, leading to conditions such as "Long COVID." Neurological manifestations, including "Brain Fog" with impaired cognitive function, have been reported, but their relationship with age and memory decline remains unclear. Method: This study aimed to investigate the effects of COVID-19 infection on memory function and explore the relationship between age and memory scores. The research utilized data from the 'COVID-19 Online Rapid Objective Neuro-memory Assessment' (CORONA) study, employing an online survey with a memory task. Ethical approval was obtained, and participants aged 18 and older were recruited globally, with 5,308 participants included in the analysis. Memory scores were obtained through a task featuring four categories. Statistical analysis, including T-tests and linear regression, was employed to evaluate the data. Results: Participants testing positive for COVID-19 (n = 678) exhibited lower mean total memory scores than those testing negative (n = 4,630), with a statistically significant difference (P < 0.05). Hospitalized COVID-19 patients (n = 37) had significantly lower memory scores compared to non-hospitalized patients (n = 641), suggesting a greater impact of hospitalization on memory function. Age was associated with declining memory scores, with an overall trend of decreasing scores as age increased. Three age groups exhibited significant differences in memory scores between COVID-19 positive and negative participants. Conclusion This study provides evidence that COVID-19 infection may be associated with worsened memory outcomes and cognitive function. Hospitalization due to COVID-19 appears to have a more substantial impact on memory than the infection alone. A steeper decline in memory scores with age was observed among COVID-19-positive participants, suggesting potential age-related vulnerability to memory decline associated with COVID-19. However, discrepancies in results may be attributed to sample size limitations, emphasizing the need for larger cohorts in future research.

Swansea is one of oldest cities by population in the UK (more than 1 in 5 people over 65) leading to an increasing number of frail patients and has a high prevalence of Welsh speakers in the over 65 age group 12% of Swansea Bay employees identify as speaking Welsh.

The Welsh language act awarded equal status to both English and Welsh, encouraging public bodies to publish official documents bilingually.As part of our work in developing frailty screening for elective surgical patients we use the clinical frailty score (CFS) and noted there was not a Welsh language version available. As we are hoping to progress to patients completing the score independently it was clear this was important.

Method

The Bayways Frailty alliance created a version of the CFS in Welsh which followed the same format, was visually appealing and clinically correct. We showed this to both Welsh speaking clinicians of various specialities and allied health professionals; we also shared it with Welsh speaking members of the public who were not clinicians to gain feedback.

Finally we gained approval from Dr Rookwood and his team for this official translation.

Results

There was widespread support for this from both clinicians and non-clinical members of the public. They felt the Welsh was easy to understand and professional. Clinical staff felt empowered that a part of their culture was now part of the workplace.

Conclusion

This valuable piece of work will now be made widely available and encourages changes such as this going forward in keeping with the Welsh Government policies. Alongside that the widespread positive feedback from both clinical staff and patients speaks for itself.

Introduction:

Metabolic syndrome has been associated with an increased risk of cancer. This study evaluated this association in a South American cohort.

Methods:

Retrospective observational study in 100 patients older than 60 years with metabolic syndrome for more than 10 years from a hospital outpatient center. Anthropometric (waist circumference, body mass index), biochemical (triglycerides, HDL cholesterol, fasting glucose) and clinical (arterial hypertension, type 2 diabetes mellitus) parameters were evaluated. The association between metabolic syndrome, its components and cancer risk was analyzed using proportional hazards and chi-square models.

Results:

A statistically significant association was found between abdominal obesity (average waist circumference of 103.8 cm and BMI of 36.05), hypertension and hyperglycemia with an increased risk of cancer. The highest prevalence of cancer occurs in people over 60 years of age. In this group, 72.1% of the cases of the disease are diagnosed in men and 65.8% in women. A higher risk is reported in patients with grade I obesity (BMI 30-34 kg/m2.

Conclusion:

MS is strongly associated with increased cancer risk in older South American adults, especially due to central obesity, hypertension and hyperglycemia.

Background

Patients living with Parkinson's disease (PD) who are sarcopenic are at significantly higher risk of falling (Cai et al., Frontiers in Neurology,2021,12,598035). Handgrip strength is a useful tool to assess for sarcopenia but is not commonly measured in clinical practice, despite the consequences that sarcopenia poses. This study aims to incorporate handgrip strength into the assessment of outpatients living with PD. Secondary objectives are to increase the understanding of whether exercise is associated with increased handgrip strength and to implement interventions for patients who are identified as sarcopenic; to improve their health outcomes.

Methods

Questionnaires were designed to gather quantitative data about patients' demographics, how frequently they fall, disease severity and their weekly exercise. These were given to patients attending the movement disorders clinic at Crawley hospital, between February and October 2023. Patients without a diagnosis of PD were excluded. Their grip strength was measured using a standardised technique with a calibrated manometer. Data was input to Microsoft Excel and analysed using Spearman's rank and Kruskal-Wallis test.

Results

Handgrip strength was obtained for 125 of 271 patients (46%) attending clinic over this period. Initially healthcare workers took 9.2 minutes to complete the questionnaire but this improved to 4.3 minutes after updating the form. Sixteen patients were excluded, leaving 51 females and 58 males; both with a mean age of 80. Grip strength reduced with PD severity when adjusted for gender; this was significant in males (H=51.9, p=0.00) but not females (H=4.8,p=0.31). Grip strength was weakly correlated with exercise, although not significant (r2=0.15,p=0.15) but did not appear to be related to frequency of falls (r2=0.01,p=0.92).

Conclusions

Handgrip measurement can be successfully implemented into outpatient assessment. Handgrip strength could be used to monitor the effect of lifestyle change in individuals. Limitations include self-reporting bias; which activities each individual classifies as exercise.