Scientific Research

Background: Prostate cancer and bladder outlet obstruction, often treated surgically, are increasing in the aging population, leading to more cases of stress urinary incontinence (SUI). While implantable continence devices are beneficial for many, a growing number of frail patients are unsuitable for surgery and rely on incontinence pads or penile clamps, which are limited to three-hour use to prevent tissue ischaemia. We present the first UK evaluation of the new PaceyCuff penile clamp, designed for 24-hour wear while maintaining blood flow, to assess its efficacy, safety, and impact on patient quality of life.

Methodology: Men with urodynamically-proven SUI were identified. Baseline penile and finger peripheral oxygen saturation (SpO2), three-hour pad weight, 24-hour pad count and patient-reported outcomes (ICIQ-UI, QoL) were measured. Participants were then fitted with the PaceyCuff, and reassessed immediately, at three hours post-application and (via telephone) after two weeks.

Results: 13 men (average age 74, range 62-82) were recruited. ICIQ-UI scores decreased from 17 to 10, and QoL scores from 13 to 9. Average three-hour pad weight dropped from 94g to 10g and daily pad usage decreased from 4 to 0.9 pads. Participants reported good tolerance, with an average pain score of 1.8/10 and only 2 minor adverse effects (skin abrasion, transient pain). Penile SpO2 remained stable before, immediately after, and three hours post-use (76%, 82%, and 81% respectively). Sub-group analysis of patients over the age of 80 (n=4) confirmed equal effectiveness. (ICIQ-UI decreased 18 to 10, QoL decreased 13 to 9, three-hour pad weight decreased 77g to 9g, daily pad usage decreased 4 to 1.5 pads, average pain 1.5/10).

Conclusions: The PaceyCuff has demonstrated both efficacy and tolerability in managing SUI in a UK cohort for the first time and offers a potential treatment option for elderly patients ineligible for surgical intervention.

Introduction

Frailty, independent of age, is associated with adverse outcomes following admission with Acute Coronary Syndrome (ACS) but is often not accounted in risk stratification scores. Those identified as frail may not be considered for invasive interventions despite evidence that they stand to benefit (1) and are at risk of worsening geriatric syndromes on discharge (2,3).

Purpose

We aimed to categorise clinical outcomes in older adults admitted with ACS, with or without frailty to suggest if there is a role for geriatrician input in reducing length of stay and preventing adverse events.

Methods

Anonymised data was obtained from an NHS trust’s MINAP registry of patients admitted with ACS between April 2022 to March 2023. Baseline demographics, Clinical Frailty Score (CFS), GRACE and HEART scores, total length of stay (LOS), days as inpatient pre- and post-procedure, adverse events during admission, readmission rates and all-cause mortality rate at 30 days and 1 year were calculated.

Results

288 patients over age 65 admitted with ACS were included in analysis.

Median age was 73 [IQR 67-80.75]. Patients over 75 years had higher rates of frailty (38.5% of 75-84 years and 50.0 % over 85 years had CFS ≥ 5 versus 14.9% 65-74 years (p<0.00001)).

253 (87%) patients underwent invasive angiogram during admission. Although, age was not a limiting factor, frail patients were less likely to have an angiogram: 24.9% CFS ≥ 5 versus 57.1% of CFS ≤ 3 (p=0.00199).

Mean LOS was 9.02 days with a median of 7[IQR 4-12] v mean LOS 6 days for all under 65 (p<0.0001). There was a trend for longer LOS post-angiogram particularly for patients with CFS 4-5 versus CFS 3 or less (11.3 days v 8.92 days p=0.053).

Conclusions

Older people admitted with ACS are more likely to have a prolonged admission. Input from geriatricians and the wider multidisciplinary team may help to identify and optimise care and decision making of patients admitted with ACS and mild to moderate frailty.

1. Damluji et al. J Am Heart Assoc. 2019;8:e013686

Introduction

Around 30,000 emergency laparotomies are performed each year across the United Kingdom. Over half are in people aged 65 years or above, with a third of this group living with frailty.  The association between frailty and 90-day mortality following surgery is well documented, but longer-term mortality risk has been less extensively studied, despite clear implications for person-centred care.  This study aimed to estimate the influence of frailty on longer-term mortality (> 90 days) following emergency laparotomy.

Methods

A retrospective analysis of National Emergency Laparotomy Audit (NELA) data was undertaken, including records entered between 01/12/18 and 30/11/20. Baseline patient characteristics including Clinical Frailty Scale (CFS) are routinely collected within NELA. Data are linked via NHS Digital with Office for National Statistics mortality data. A multivariate analysis was undertaken using a Cox proportional hazards model with hospital-level random effects. Potential confounders were identified via a directed acyclic graph and included in the model as covariates.

Results

23,290 patients remained alive at 90 days post-surgery and were therefore included in the analysis. After adjusting for other covariates, increasing frailty was associated with an increased risk of longer-term mortality. Compared with CFS 1-3, adjusted HR were 1.86 (95% CI 1.68 – 2.05) for CFS 4, 2.23 (95% CI 2.03 – 2.45) for CFS 5, 3.26 (95% CI 2.99 – 3.57) for CFS 6, 4.53 (95% CI 3.97 (95% CI 5.17) for CFS 7, 5.80 (95% CI 4.44 – 7.57) for CFS 8 and 5.36 (95% CI 4.06 – 7.08) for CFS 9. 

Conclusion

Older people living with frailty remain at increased risk of death beyond 90 days following emergency laparotomy. This information should be incorporated into shared decision-making, enabling patients to make informed choices about their care. Future work must explore how outcomes for this group might be improved through targeted post-operative support.

Introduction: People living with multiple long-term conditions (MLTC) are more likely to experience hospital admission, which is often associated with unintended consequences. Preventing or providing alternatives to admission by predicting adverse admission-related outcomes is important. This study aims to provide an overview of the association between MLTCs and adverse outcomes following hospital admission through a systematic review of systematic reviews.

Method: We searched Medline, Embase, CINAHL, Web of Science and PsycINFO for systematic reviews assessing risk factors/predictors of functional decline (FD), nursing home admission (NHA), or changes in quality of life among adults (≥18 years) experiencing unscheduled acute hospital admission. Eligible reviews had to assess MLTC (LTC counts, indices, or individual LTCs), either alone or with other predictors. Titles/abstracts and full texts were screened in duplicate and candidate predictors were extracted.

Results: 14 systematic reviews assessed predictors of FD (n=8) or NHA (n=6). Reviews focused on studies of general inpatients/mixed presentations (n=8: 6 FD, 2 NHA); hip fracture (n=2: 1 FD, 1 NHA); stroke (n=2: 1 FD, 1 NHA) and cognitive impairment (n=1, NHA) or delirium (n=1, NHA). Assessment of MLTC was heterogenous: comorbidity indices (n=4), counts of LTC (n=2), specific LTC (n=8), and ‘comorbidity’ without further qualification (n=3). Higher comorbidity indices, higher counts, and a range of specific comorbidities (most notably dementia) were associated with FD and NHA. Reviews assessing MLTC alongside other predictors highlighted a broad range of sociodemographic, functional, social, and admission-related factors that were associated with FD and NHA. In general, reviews did not assess the relative importance of MLTC alongside other predictors.

Conclusion: While MLTC may predict unwanted outcomes following admission their qualification is often inconsistent and their relative importance as predictors, alongside broader factors such as social complexity, is rarely assessed in existing systematic reviews.

Introduction:

The aging population has increased the demand for family caregivers, who often suffer from psychological distress, especially compassion fatigue. This systematic review and meta-analysis evaluate the effectiveness of web-based compassion interventions in improving the mental well-being of family caregivers.

Methods:

MEDLINE, Embase, PsycINFO, Web of Science, Cochrane Library, and Proquest were searched from database inception until manuscript submission date. Eligible studies included family caregivers participating in web-based compassionate interventions with reported mental wellness indicators, such as self-compassion. Two independent researchers conducted a literature review, extracted data, and assessed the quality of each study using the Risk of Bias 2 tool. Random effects meta-analysis was performed to pool the data, followed by subgroup analyses, sensitivity analyses and Egger's tests.

Results:

Out of 1095 studies evaluated, eight randomized controlled trials (encompassing 1978 participants) were included, with 75% exhibiting low risk of bias and high-quality evidence. Meta-analysis results indicated positive effects of web-based compassion interventions on family caregivers' self-compassion (SMD = 0.33, 95% CI 0.08 to 0.58, P = 0.009) and mindfulness (SMD = 0.46, 95% CI 0.03 to 0.90, P = 0.04). These interventions also demonstrated a positive impact on reducing stress (SMD: -0.32, 95% CI -0.59 to -0.04, P = 0.02) and anxiety (SMD: -0.28, 95% CI -0.47 to -0.09, P = 0.003). Subgroup analyses highlighted superior self-compassion outcomes for caregivers supporting individuals with mental illness and cancer compared to those caring for individuals with Alzheimer's disease. Interventions lasting ≥ 8 weeks were the most common and effective.

Conclusions:

Web-based compassion interventions benefit family caregivers by enhancing self-compassion, mindfulness, and reducing anxiety and stress. More well-designed studies are suggested for future clinical applications.

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo in older adults. Due to the high incidence of BPPV in older adults presenting with falls, vestibular assessment, and diagnosis of BPPV and other vestibular disorders has become a recommendation in the World Guidelines for Falls Prevention. There has been a paucity of evidence in well conducted randomised controlled trials (RCTs) to evaluate vitamin D for prevention of BPPV recurrence and its relation to falls and function. This is a Phase IIa single centre, placebo controlled, double blind RCT to evaluate vitamin D supplementation together with diet and Canalith Repositioning Procedure [Group A] or diet alone combined with CRP [Gorup B] can reduce recurrence rates of BPPV. Post hoc analyses were performed evaluating BPPV recurrence, falls and function. 53 participants were recruited. 14 were vitamin D replete at baseline [Group C- diet alone], the remaining 39 were randomised into Groups A and B. Group A was associated with 0.75 fewer clinical BPPV recurrences per one person year (IRD -0.75, 95% CI -1.18 to -0.32, P=0.035). Older adults in the study who suffered a fall during the 12 month follow up had lower Activities of Daily Living scores. They also had poorer Short Physical Performance Battery scores at baseline. Participants in Group A had better 5x sit to stand time compared to Group B even accounting for underlying frailty scores. 25% of participants who fell in the 12 month follow up reported fear of falling compared to 43% in those with no falls in the 12 month follow up. Vitamin D supplementation improved physical performance in 5xchair stand test. In this study population, more participants without an incident fall during follow up experience fear of falling, prompting further consideration into the complex concept that is fear of falling.

Introduction: Research suggests that physical and cognitive exercise can have a positive effective on those with dementia, but less is known about such interventions in those at risk for dementia. Understanding the feasibility of administering clinical assessments remotely using Zoom for Healthcare^TM in the context of a dementia prevention trial for at risk older adults is not well understood.

Methods: SYNERGIC@Home/SYNERGIE~Chez soi (NCT04997681) is a home-based, remotely delivered clinical trial targeting older adults at risk for dementia. Participants underwent a screening/baseline assessment and were randomized to one of four physical and cognitive exercise intervention arms for 16 weeks (3 times per week). They were reassessed immediately post-intervention and 6-months later. The standardized assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, and quality of life were done at all three points. A research coordinator completed the assessments on a one-on-one basis via Zoom for Healthcare^TM. The quality of life questionnaire was mailed to the participant.

Results: Forty-eight of 60 participants (80%) (mean age 68.7 ± 5.7 years, 81.3% female) completed the study. Most participants (75.0%) were cognitively intact with at least 2 dementia risk factors. No participants withdrew from the trial because of difficulty with the remote delivery of the assessments. There were no statistically significant changes in any of the assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, or quality of life throughout the study.

Conclusion: This study demonstrates it is possible to administer standardized clinical assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, and quality of life remotely in the context of a clinical trial. The study was not powered to detect meaningful differences in these assessments. Nevertheless, this confirms the feasibility of remotely administering clinical assessments to older adults at risk for dementia

Background

Older adults were more likely to be socially isolated during the COVID-19 pandemic, with increased risk of depression and loneliness. The Behavioural Activation in Social Isolation (BASIL+) trial investigated whether a Behavioural Activation (BA) intervention delivered remotely could mitigate depression and loneliness in at-risk older people during the COVID-19 pandemic.

Methods

We undertook a multicentre randomised controlled trial [ISRCTN63034289] of BA to mitigate depression and loneliness among older adults (65+) with multiple long-term health conditions, including low mood or depression. BA was delivered remotely (telephone or video call) with intervention participants (n=218). Control participants received usual care, with existing COVID wellbeing resources (n=217). 

Results

Participants engaged with an average of 5.2 (SD 2.9) of 8 remote BA sessions. Adjusted mean difference (AMD) for depression (Patient Health Questionnaire-9, PHQ-9) at 3 months [primary outcome] was -1.65 (95% CI -2.54 to -0.75, p<0.001). There was an effect for BA on emotional loneliness at 3 months (AMD -0.37, 95% CI -0.68 to -0.06, p=0.02), but not social loneliness (AMD -0.05, 95% CI -0.33 to 0.23, p=0.72). For participants with lower severity depression symptoms (5-9 on the PHQ-9) at baseline, there was an effect AMD PHQ9 1.13 (95% CI –2.26 to 0.01, p=0.051), though this was less pronounced than for those scoring 10 or more at baseline (-2.48, 95% CI -3.81 to 1.16, p=0.0002).

Conclusion

Behavioural activation is an effective and potentially scalable intervention that can reduce symptoms of depression and emotional loneliness in at-risk groups in the short term. The findings of this trial add to the range of strategies to improve the mental health of older adults with multiple long-term conditions. These results can be helpful to policy makers beyond the pandemic in reducing the global burden of depression and addressing the health impacts of loneliness, particularly in at-risk groups.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by frightening or traumatic events. Delirium is a state of acute confusion associated with acute illness, surgery, and hospitalisation. Delirium is known to be associated with a risk of PTSD in patients in the Intensive Care (ICU) setting. However, there is limited information on the prevalence of delirium in older adults outside of Intensive Care. Therefore we undertook a systematic review to ascertain the prevalence of PTSD in elderly patients after an episode of delirium on a general ward.

METHODS: The systematic review was conducted using MEDLINE (1946-10/01/2024), Embase (1974- 10/01/2024), and PsycINFO (1806- 10/01/2024) to identify studies. Studies were eligible if they included adults aged ≥ 65 years, admitted to an acute hospital, diagnosed with delirium using a validated screening tool, (e.g. 4AT, CAM-ICU) and subsequently screened for PTSD at any point following discharge with a validated screening tool (e.g. the PTSS-14). The exclusion criteria excluded ICU cohorts and terminal illness with < 3 months life expectancy. Two researchers (SM, NM) independently reviewed all studies with any disparities resolved though a 3rd researcher (AM)

RESULTS: After removal of duplicates, the search identified 1042 titles from which only 3 eligible studies were identified. All 3 studies were in older patients after surgical procedures (n=132 participants in total). Two of the studies reported no association between delirium and the subsequent risk of PTSD. However, the largest study (n=77) reported a significant independent association between delirium and the 3-month risk of PTSD.

CONCLUSION: The current body of research on the prevalence of PTSD following episodes of in-patient delirium in older adults is limited. The findings of this review highlight the need for further research. A prospective cohort study on Geriatric Medicine wards is being planned.

Introduction

Hyponatremia is the most common electrolyte imbalance caused by serum sodium level of less than 135mmol/L, prevailing 15 and 30% among hospitalised patients [Zhang X, Li XY. Eur Geriatr Med. 2020;11(4):685-692]

Methods

PRISMA guidelines were followed for this study. Pubmed was searched with the search term : (hyponatremia) AND (treatment OR control OR management[MeSH]) AND (elderly[MeSH]) with filters, timeline: 2000 to 21/07/2023, free full text articles and human species.Data extraction was done using  Covidence app and depicted in PRISMA Flow diagram. Quality assessment was done by Cochrane Risk of Bias version 1.Odd’s ratio with 95% conifidence interval was calculated for dichotomous outcomes. Mantel-Haenszel statistical  method  along with random effects model was used. Cochrane Q test was employed and I² index was computed. Forest and Funnel plots were plotted. The analysis was done by Cochrane Review Manager.

Results

Out of 3222 results , 9 studies were included with total 980 patients. 8 were of vaptans and 1 of empagliflozin. Of the vaptans, tolvaptan was studied in 5 studies, satavaptan, lixivaptan and conivaptan in other three. Three studies had low risk of bias and were included in meta-analysis.Mean age  and BMI were 70.55(SD=14.5)  years and 24.73(SD=3.95)  kg/m²  respectively.

Most frequently occuring etiology , comorbidity and symptom were congestive heart failure, hypertension and fatigue/malaise respectively.  Mean baseline serum sodium was 124.89 mmol/L mean rise was 9.142  mmol/L.

Meta-analysis showed that placebo was significantly associated with achieving normonatremia as compared to treatment group(OR=2.5, 95%CI:1.54,4.04, p=0.0002,I²⁼0%).

The most frequent reported side effects were nausea, dry mouth, pyrexia and thirst.Side effects both mild/moderate (OR=1.12, 95%CI:0.69,1.81, p=0.65, I² =0%) and serious  (OR= 1.51, 95%CI: 0.77,2.98, p=0.23,I² =0%) showed no difference between treatment and placebo groups.

Treatment was not associated with rapid risk of overcorrection (OR=1.65, 95% CI:0.57,4.81, p=0.36, I² =0%). None showed osmotic demyelination syndrome.

Discussion

The main conclusions drawn out were:
 (1) The most commonly available drugs beside fluid restriction, hypertonic saline were vaptans- vasopressin receptor 2 antagonists. 
 (2) The possible new drug of choice for treatment of Hyponatremia could be empagliflozin.

Meta-analysis carried out for three studies [28, 29, 34] showed no significant improvement in Hyponatremia by treatment with hyponatremia drugs i.e., satvaptan, lixivaptan and empagliflozin as compared to placebo.

Instead placebo reported a significant improvement Hyponatremia.These results were similar to a review by Jovanovich [37] et al which concluded that they have no role in treatment.

Currently only tolvaptan and conivaptan are approved by the FDA for treatment of hypervolemic and euvolemic hyponatremia The use of vasopressin receptor antagonists remains limited due to its controversial efficacy and potential risks for overcorrection [9].

Rapidly correcting hyponatremia (>12 mEq/L/24 hours) can cause osmotic demyelination, leading to dysarthria, mutism, dysphagia, lethargy, emotional abnormalities, spastic quadriparesis, seizures, coma, and death. 

We did not find any significant rapid overcorrection of Hyponatremia in treatment group as compared to placebo.  This was in contrast to Krisapan et al[38]which reported a greater risk of rapid overcorrection. This could be due to small sample size of the study and yet 3 studies in this review (Estilo et al, Humayun et al and Sag et al) recommended starting with a small dose and imply strict sodium monitoring and for those with a history of hyperlipidemia and who have recently taken thiazide diuretics.

No significant association of treatment group was found with mild/moderate/severe side effects.

Refardt et al showed that empagliflozin could be a promising new treatment due to its reported long term cardiovascular and nephroprotective effects, broader availability and good tolerability. With the daily treatment cost of empagliflozin being similar to urea(2USD vs 4USD), it was th cost of Tolvaptan and therefore it could prove a cost effective treatment option in future when fluid restriction and hypertonic saline fail [37,39].

Conclusion

We conclude that vaptans and Empagliflozin ,although safe, show limited efficacy in hyponatremia treatment.