Scientific Research

Introduction :

This study demonstrates how a network of geriatric medicine trainee representatives was established across the UK. The intention of the network was threefold: accurately represent the interests of trainees by gathering national feedback, develop a job description of deanery trainee representatives and create a community of practice between representatives.

Method:

Deanery trainee representatives were identified through TPDs then contacted to participate in an online questionnaire which also consented for whatsapp group invitation.

Results:

Deanery representatives were identified for 12 out of 13 deaneries, the final post was vacant. The survey response rate was 83% and all respondents gave permission to be added to the whatsapp group. We gathered information regarding eligibility, appointment and the role of deanery trainee representatives. Most deaneries (73%) do not require representatives to be a minimum grade whereas 27% required representatives to be ST4 or above. Over half (55%) were appointed following an expression of interest without an election, 27% required an election and 9% were approach and appointed directly either by the TPD or current representative. Once appointed 82% had no fixed term whilst 18% would have a term limited to two years. Once appointed the role entails an invitation to the local higher specialty training committee for 73% of respondents and 73% also reported a role in organising regional training.

Conclusions :

The aim of this project to create a network between deanery representatives has been achieved and produced an engaged network of representatives facilitating accurate representation of trainees at a national level. Further applications include collaboration between trainees to share training practices. In a period of training recovery following the Covid-19 pandemic and a new geriatric medicine curriculum a community of practice between trainee representatives has enormous potential to improve training quality and experiences for geriatric medicine trainees in the UK.

Introduction:

The presence of comorbidities and longevity is associated with worse outcomes in patients with COVID-19 infection.

Materials and Methods:

retrospective study of 306 adults infected by SARSCOV2. The main objective was to evaluate the role of the ROX index as well as comorbidities according to the age group as predictors of respiratory failure and mortality. In the inferential statistical analysis, the odds ratios OR with their confidence intervals greater than 95% were used as association measures. Qualitative variables were evaluated using the Chi-square test or Fisher's exact test, and in the case of numerical or quantitative variables, the Student's T or Mann-Whitney test was used.

Results:

When performing the correlation between comorbidities and ROX index and accumulated mortality of the patients, it was observed that in the group of less than 1 n 89/306, (29.08%) having ROX index values of 5.42 (SD: 3.54 .- 6.5) mortality was 9%. In the group with between 1 and 4 comorbidities, n 167/306 (54.57%), the ROX index values were 4.2. (SD: 3.1-5.3) the accumulated mortality was 21%. Finally, the group with more than 4 comorbidities n 50/306, (16.33%) presented the lowest ROX index levels 2.88 (SD: 2.43-3.33) being the one that showed the highest mortality estimated at 64%. The highest mortality occurred in those over 70 years of age.

Conclusions:

The present study showed a correlation between the ROX index and longer-lived age groups, showing higher mortality in those over 70 years of age and a higher rate of comorbidities and lower ROX. Studies with larger groups are required for better validation..

Background

Understanding human factors involved in patient care is a focus of the Geriatric Medicine Training curriculum including the leadership of and communication within an interprofessional team. Geriatric Medicine Specialty Trainees (ST4+) need advanced communication skills and confidence in managing complex situations. Simulation-enhanced Interprofessional Education (Sim-IPE) can be used to provide insight into other disciplines roles. We hypothesised that the implementation of a Sim-IPE programme dedicated to communication skills could improve confidence.

Method

We organised a one-day Sim-IPE programme for our Geriatric Medicine ST4+. Faculty consisted of doctors, advanced nurse practitioner, social worker, occupational therapist, physiotherapist and speech and language therapist. Communication scenarios, with faculty as simulated participants, were undertaken including establishing a ceiling of treatment, management of delirium, breaking bad news, ethical feeding dilemmas, complex discharge planning and capacity assessment. Debrief discussions followed each scenario. Mixed-method evaluation was used with questionnaires collected from learners’ pre and post session in a 10-point Likert scale to compare confidence levels. Qualitative feedback was collected from learners and faculty.

Results

Ten Geriatric Medicine ST4+ attended plus nine faculty including two facilitators. Positive feedback was received from learners and faculty. There was improvement in confidence across all six scenarios (one being “not at all confident” and ten “extremely confident”). Pre-session average confidence was 7.2, post-session 8.7. All trainees would recommend the programme to a colleague. Common learning themes included gaining feedback from debrief discussions and shared learning from our allied-health professionals. Learners and faculty commented on the enjoyment, usefulness and value of learning within a safe team environment.

Conclusion

Sim-IPE can improve confidence in complex communication scenarios and human factor skills. Feedback highlighted that this programme would be useful for all General Internal Medicine Specialty Trainees.

Introduction:

There is a high level of clinical need among residents but little is known about the role of physicians or nurse practitioners (NP) in the nursing home (NH) setting. Our objective was to test for associations between physician and nurse practitioner (NP) presence on care units and outcomes among nursing home (NH) residents. A retrospective cross sectional analysis of secondary data collected in the Translating Research in Elder Care (TREC) study during 2019-20. The sample consisted of 10,888 residents across 320 care units in 92 facilities.

Methods:

We used TREC Survey data (which included items on daily presence of physicians and NPs on units, physician involvement in care planning, and ability to contact physician or NP when necessary) linked to routinely collected Resident Assessment Instrument – Minimum Data Set version 2.0 (RAI-MDS 2.0), which included the outcomes antipsychotic medication (APM) use without indication, physical restraint use, hospital transfers, and polypharmacy. Eight logistic regression models were created to test the association between measures of daily presence of physician or NP on unit and physician involvement in care planning and each outcome.

Results:

Of the 320 sampled units, 277 (86%) reported a physician or NP visited daily, 160 (72.1%) units reported that the resident’s physician was involved in care planning, and 318 (99%) units reported that the physician or NP could be reached when needed. Following adjustment for multiple confounding variables, there were no associations between presence of medical professional and any resident outcome. There was no association between either physician or NP presence on the unit and hospitalization and ED transfers (AOR=1.17, 95% CI: 0.46-3.10) or polypharmacy (AOR=1.37, 95% CI: 0.64-2.93).

Conclusions:

No association was found between any of the medical care provider presence measures and resident outcomes. This was surprising given the existing, but limited, research

Introduction. Concerns about falling are common among older adults. Many older adults with concerns about falling will restrict their activities. This can trigger a vicious cycle of physical deconditioning, falls, social isolation, reduced confidence, and a loss of one’s sense of self. However, not every older adult with concerns about falling will restrict their activities. In this prospective cohort study we therefore investigated the factors that predict the development of activity restriction due to concerns about falling in older people aged ≥75 years.

Methods. Data were collected as part of the Community Ageing Research 75+ (CARE75+) study. For the baseline (T1) timepoint, we extracted data for 543 older adults who did not report activity restriction due to concerns about falling completed a set of physical and psycho-social assessments. We then assessed which baseline variables predicted the onset of activity restriction at T2 (12-months later).

Results. Of the total sample, 55 older adults reported to have started to restrict activity due to concerns about falling at T2 (10.1% of overall sample), while 488 people reported to (still) not restrict their activities (89.9%). Three key predictors significantly predicted activity restriction status at 12-months follow-up: greater frailty (Fried Frailty Index; OR=1.58, 95%CI: 1.09-2.30), faller status (experiencing a fall between T1 and T2; OR=2.22, 95% CI: 1.13-4.38) and poorer functional mobility/balance (Timed up and Go; OR=1.08, 95%CI: 1.01-1.15).

Conclusions. These findings show that frailty, experiencing a fall and poorer functional mobility/balance may result in the development of activity restriction due to concerns about falling. Clinicians working in balance and falls-prevention services should regularly screen for frailty, and patients referred to frailty services should likewise receive tailored treatment to help prevent the development of such activity restriction.

Background and Aim: Falls are a significant public health concern, with literature primarily concentrating on older adults due to their perceived higher fall risk. However, recent studies indicate similar prevalence rates of fall-related injuries between older adults (>65 years) and middle-aged adults. Despite this, there is a scarcity of literature examining the differences in experiences of falls and concerns about falling between middle-aged adults and older adults who have experienced falls. The COVID-19 pandemic and the resulting lockdown measures created an unprecedented setting to explore these experiences due to the unexpected period of physical deconditioning and heightened risk of falling among adults aged 50 and above. This current qualitative study aimed to evaluate the variations in falls and concerns about falling among middle-aged and older adults during the pandemic. Methods: Semi-structured interviews were conducted with 10 middle-aged fallers (Mage = 59 years) and 10 older fallers (Mage = 73 years), following an online falls survey. All participants had experienced one or more injurious fall(s) during the COVID-19 pandemic. Reflexive thematic analysis was used to analyse the transcribed interview data. Results: Both middle-aged and older adults demonstrated a level of age acceptance and vulnerability to falls. These experiences prompted older adults to adopt protective behavioural adaptations, while middle-aged adults potentially adopted maladaptive behavioural adaptations in situations that posed balance threats. The pandemic restrictions affected both middle-aged and older adults similarly, with reports of both groups experiencing changes in physical activity levels. Conclusion: These findings provide a new perspective on the disparities in falling experiences and concerns about falling between middle-aged and older adults during the COVID-19 pandemic. They highlight the significance of investigating concerns about falling from middle age (>45 years) to help develop intervention strategies that mitigate detrimental outcomes in later stages of life.

Introduction

Keeping our standing balance is a crucial capability in preventing falls. Nevertheless, older adults may focus attention internally to their movement mechanisms during stance, through conscious movement processing (CMP), when facing balance difficulties. However, this may interfere with movement automaticity that could cause balance problems. The primary aim of this pilot study is to examine the effects of attention focus balance training on CMP propensity in older adults at risk of falling.

Method

Twenty-four older adults (mean age = 79.92 ± 7.61) with moderate to high risk of falling were included in this preliminary analysis. Participants were randomly assigned to either the No Specific Attention Focus Balance Training Group (NBTG; n=8), External Attention Focus Balance Training Group (EBTG; n=8), or the Internal Attention Focus Balance Training Group (IBTG; n=8). Participants in different groups participated in twelve tailor-made 45-minute training sessions with different attention focus instructions during standing balance training. The primary outcome measure of the real-time (state) CMP propensity (T3-Fz Electroencephalogram (EEG) coherence) at the baseline (T0) and after completion of all balance training sessions (T1) was evaluated. A 3x2 Group (NBTG, EBTG, IBTG) x Time (T0, T1) mixed Analysis of Variance (ANOVA) was conducted.

Results

We discover a decreasing trend of the real-time (state) CMP propensity (T3-Fz EEG coherence) in the EBTG but an increasing trend of the T3-Fz EEG coherence in the IBTG from T0 to T1. The T3-Fz EEG coherence for the NBTG remains similar from T0 to T1.

Conclusion

This preliminary result suggests that the external attention focus balance training has a potential to mitigate the real-time (state) CMP propensity in older adults at risk of falling. Consequently, it could further benefit the standing balance of the at-risk older adults after their rehabilitation.

An 86-year-old lady, presented with an unwitnessed fall with no obvious head injury. Her Glasgow Coma Scale (GCS) was 15 on arrival. She denied precipitating factors, taking blood thinners or seizure medication. Her examination revealed tongue biting, suprapubic tenderness, and pain in both hips and arms. An X-ray of the possible affected joints was ordered. Bloods and venous blood gas (VBG) were unremarkable. Within a few hours, she had a witnessed tonic-clonic seizure with a swollen tongue, for which lorazepam and adrenaline were administered. Repeat VBG (post-ictal) revealed a high lactate with hypoxia and hypotension. Intravenous fluids and oxygen were administered with a full body trauma series and a Contrast-Enhanced Pulmonary Angiogram. This showed a large retroperitoneal haematoma, a comminuted fracture of the superior pubic ramus and an unstable thoracic fracture.  She was referred to surgeons and orthopaedics for further management.

Trauma in older patients with polymorbidities can be missed as they are poor historians with conflicting collateral histories and atypical presentations. The “Silver trauma” emphasises early diagnostics, intervention and outcome including rehabilitation, decreasing mortality and morbidity. (1) The most common trauma is a fall of less than two metres from standing. (2)  They should be searched for more than one injury (2) in this case, suprapubic tenderness. They can have atypical observations compared to younger people sustaining trauma. (1) Example, a higher baseline blood pressure due to significant aortic disease. Similarly, tachycardia can be masked by medications such as beta blockers.

They should be investigated for polytrauma following an unwitnessed fall with a low threshold for a full CT trauma series.

 Furthermore, early reversal of anticoagulation should be implemented with adequate pain relief hydration to prevent delirium. (2) Knowing local pathways for referral to specialist services, and considering of patient’s and relatives’ previous wishes are key for early mobilisation and discharge. (1)

Background: The serious outcomes of outbreaks of COVID-19 in care homes have been described internationally. The experiences of professionals working through outbreaks has received less attention, missing opportunities to acknowledge and learn lessons. Our aim was to explore the experiences of care home staff in Scotland of managing COVID-19 within their homes to help inform understanding and future practice.

Methods: From April to August 2022, 34 individual semi-structured interviews were conducted with care home staff working in homes which experienced an outbreak(s) of COVID-19. Reflexive thematic methods were used to analyse verbatim deidentified transcripts.

Findings: There was no singular experience of COVID-19 outbreaks within care homes. We identified four broad groupings of homes with outbreaks (significant outbreaks, managed outbreaks, outbreaks in remote/rural homes & outbreaks in homes supporting younger adults), with overlaps in timing and severity and variation in the support received and impact. The national response to the COVID-19 pandemic resulted in fundamental change to care home relationships. Staff responded by adaptation in uncertainty. However, they were challenged by emerging inequalities influencing residents’ care. There were tensions between staff experience and evolving external approaches to regulation and oversight. All this change resulted in psychological impacts on staff. However, there was also widespread evidence of compassionate leadership and teamwork in their responses. Effective sources of support were underpinned by respectful relationships and continuity, tailored to individual contexts.

Conclusions: The lived experiences of care home staff during the COVID-19 pandemic provide valuable insights applicable beyond the pandemic context. This includes: recognition of the specialism, complexity and diversity of care home practice; the value afforded by embedding genuine representation and involvement in planning, policy-making and research; the need for individualising to people in their contexts and the value of fostering respectful relationships across professional groups to support residents.

Introduction:

The number one reason for older people to be taken to hospital emergency departments is a fall¹.

An “Ambulance Improvement Programme Pillar”² is trying to reduce conveyance to hospital for falls, however it is not understood how the attending clinician’s confidence impacts decision-making.

The objectives were to assess recruitment rate and feasibility of online survey delivery, and determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey, undertaken in one English ambulance service in May 2023. 

Demographics were collected from participants and their role, with 5-point Likert scales of confidence.

Descriptive statistics and Chi-square analyses were used for quantitative data.

Results:

81 responses were received from across the regional ambulance service’s 16 localities.

76% of respondents were paramedics, and 53% were aged 25-34.

60% of respondents rated being ‘somewhat confident’ to ‘How confident do you feel in assessing older adults who have fallen?’, responses ranged between ‘Neither confident nor unconfident’ to ‘Completely confident’.

No significant difference was found between the locality and confidence levels for assessing this patient population. However, there appeared to be significant variation between confidence levels relating to utilisation of hospital pathways and localities (p-value=.0045).

Length of experience in both frontline ambulance and overall healthcare provision was not significantly associated with different levels of confidence.

Conclusion:

The overarching confidence of clinicians did not significantly vary around the region.

Locality of work had a relationship with confidence in utilising hospital avoidance pathways, however, did not relate to confidence in assessing this patient population.

Confidence was not found to increase for either total years providing healthcare, nor providing emergency frontline care.

References

1. Dewhirst. (2023). National Falls Prevention Coordination Group. https://committees.parliament.uk/writtenevidence/117837/pdf/

2. NHS England and NHS Improvement. (2019). Ambulance Improvement Programme. https://www.england.nhs.uk/wp-content/uploads/2019/09/planning-to-safetly-reduce-avoidable-conveyance-v4.0.pdf