Scientific Research

Background and aims

Delirium carries an eightfold risk of future dementia. Small vessel disease (SVD), best seen on MRI, increases delirium risk, yet delirium is understudied in MRI research. We aimed to determine MRI feasibility, tolerability, image usability, and prevalence of acute and chronic SVD lesions in acute delirium.

Methods

This case-control feasibility study performed MRI (3D T1/T2-weighted, FLAIR, Susceptibility-weighted, and Diffusion-weighted imaging (DWI) on 20 medical inpatients >65 years: 10 with delirium ≥3 weeks and 10 without delirium, matched for vascular risk, Clinical Frailty Scale (CFS), and cognitive status. We excluded acute stroke, agitation necessitating sedation, assistance of >2 staff to mobilise, and MRI contraindications. We measured scan duration, tolerability, image usability, acute infarcts on DWI, and chronic SVD features. Six months later, we recorded CFS and cognitive diagnoses.

Results

Mean age was 83.5 years (delirium 78.7 vs non-delirium 88.4); 13/20 were female; 17/20 had premorbid cognitive decline/impairment or dementia. Acquisition took mean 26.8 minutes. MRI was well-tolerated in 16/20 (7/10 in delirium arm; 9/10 in non-delirium arm). 4/20 had early scan termination but 20/20 had clinically interpretable images. We detected DWI-hyperintense lesions in 3/10 (33.3%) with delirium (2/10 small subcortical and 1/10 cortical) and in 3/10 (33.3%) without delirium (2/10 small subcortical; 1/10 cortical). Mean SVD score was 2.4 in delirium vs 3.3 without.

Conclusions

MRI is feasible, usable, and tolerable in delirium, and we detected DWI hyperintense lesions in one third of patients overall. This study indicates acute vascular contributions, including SVD, to delirium, supporting the need for larger studies.

Introduction

Despite the UK’s increasing life expectancy, and increase in the elderly population, there is an overwhelming lack of Geriatricians in the UK; as of 2022, there is only 1 consultant Geriatrician per 8,031 individuals over the age of 65 (BGS, 2023). To meet the complex care needs of this population, there must be a focus on increasing the interest that doctors have towards Geriatric Medicine, with the overall aim being to recruit more doctors into the speciality.

Method

The aim of this review was to investigate what factors medical students perceive as barriers to pursuing a career in Geriatric Medicine and then, from identifying these, generate a set of comprehensive suggestions as to how to tackle these barriers at a medical school level to increase the interest and ultimately uptake of Geriatric Medicine. The qualitative review contains literature published between 2003 and 2023 accessed using MedLine.

Results

Six themes were identified in answering our question: (a) high emotional burden, (b) caring for patients with complex needs, (c) negative preconceptions of non-clinical factors (prestige, salary, career progression), (d) negative influence of clinical educators, (e) lack of intellectual stimulation and (f) lack of exposure to the speciality and the elderly.

Conclusion

The barriers perceived by medical students when considering Geriatrics as a speciality are complex and multifaceted; these barriers must be tackled promptly in order to secure the next generation of Geriatricians. We suggest that this work can be used as a foundation for further qualitative studies with UK medical students to investigate barriers that are specific to UK students. From this, interventional courses designed to increase Geriatric Medicine uptake could be developed to strengthen the UK Geriatric Medicine workforce.

INTRODUCTION: Medical students may find practical aspects of the transition to FY1 doctor challenging. In recent years medical curriculums have been updated to address this issue by increasing the emphasis on assistantships and practical learning. We explored how prepared final year medical students felt for managing common scenarios in geriatrics, such as a patient with delirium or inpatient falls. This allowed us to develop a tailored teaching programme to be delivered by junior doctors with relevant practical experience.

METHODS:

1) We surveyed assistantship students in geriatrics to identify areas in which knowledge and confidence were lacking. We subsequently developed a tailored teaching programme to address these gaps, focusing on practical tasks and common scenarios.

2) We delivered teaching to 3 sets of assistantship students, each receiving two teaching sessions per week for their 4 week placement.

3) Quantitative & Qualitative (Likert Scale) feedback was sought using a standardised feedback form. We used QI methodology to update and improve our curriculum & delivery to match students’ learning needs.

RESULTS:

• Over the course of the teaching programme, 89 feedback forms were completed.

• 54.8% of students felt “unprepared” or “somewhat unprepared” whilst only 18% felt “prepared” or “somewhat prepared”.

• Following the teaching session, only 2.3 % felt “unprepared” or “somewhat unprepared. Those feeling “prepared” or “somewhat prepared” improved to 92%.

• 91% found the teaching relevant to their learning needs. • 91% rated teaching quality 5/5.

CONCLUSIONS: Students felt ill-equipped to manage many practical aspects of FY1. Junior Doctors are uniquely placed to address the practical knowledge gaps final year medical students may have. Our teaching programme greatly improved the students’ confidence on practical tasks and scenarios commonly encountered while working as an FY1 doctor. It was a valuable supplement to assistantship placements, and will be incorporated for future years.

Introduction:

The prevalence of older patients with Colorectal Cancer (CRC) is increasing. While surgery can offer benefits, older patients living with frailty undergoing Colorectal Surgery are more at risk of postoperative mortality and complications. The literature suggests comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Our aim is to evaluate how a joint Geriatrician/Anaesthetic pre-assessment clinic would impact outcomes for elective colorectal surgery in older patients.

Method:

Patients aged >= 65 years had a CGA as part of the pre-operative assessment when undergoing Colorectal Surgery between September 2021 to December 2023. Data including Clinical Frailty Score (CFS), LOS, P-POSSUM Score, medication reconciliation, A&E Re-admissions and 30-day and 90-day mortality was analysed.

Results:

197 patients were seen over 28 months. 147 (75%) of patients underwent surgery and 50 (25%) declined after SDM. 30-day and 90-day mortality was 0% and 0.5% respectively. The average age was 80 (65-94), compared to 74 (65-88) prior to clinic inception. The median CFS was 4. LOS with CFS <=4 averaged 7.7 days and CFS >=5 averaged 16.5 days (t-test -4.88, p 9.91e-06). 12 new diagnoses (5%) were made. Common diagnoses included Dementia and Atrial Fibrillation. 123 referrals were made, accounting for 49% of the cohort. 22% of the cohort’s medication were altered (16% of which were deprescriptions). A&E Reattendance was 18%, compared to 29% in other studies. 0 patients required ICU admission.

Conclusion:

Perioperative Frailty Involvement for patients undergoing CRC Surgery greatly improves outcomes and reduces postoperative mortality following Colorectal Surgery. CFS, LOS and P-POSSUM Score are major predictors of poor postoperative outcome in this population. There has been a reduction in A+E admissions and onward referrals. Further work needs to be completed on the financial implications and impact on other surgical specialties.

Introduction:

Incident frailty is common among older adults with diabetes mellitus. We have previously demonstrated that elevated serum levels of the soluble receptor for advanced glycation-end products (sRAGE) predict mortality in frail older adults. However, the evidence that sRAGE is associated with higher mortality in older adults with diabetes mellitus is rather inconsistent. Therefore, the aim of this study was to investigate whether frailty status influences the relationship between sRAGE and mortality in older adults with this diabetes mellitus.

Methods:

Three hundred and ninety-one participants with diabetes mellitus (median age, 76 years) from four European cohorts, who enrolled in the FRAILOMIC project were analysed. Frailty was evaluated at baseline using Fried’s frailty phenotype. Serum sRAGE was quantified by ELISA. Participants were stratified by frailty status (n = 280 non-frail and 111 frail). Multivariate Cox proportional hazards regression and Kaplan-Meier survival analysis were used to assess the relationship between sRAGE and mortality.

Results:

During 6 years of follow-up, 98 participants died (46 non-frail and 52 frail). Non-survivors had significantly higher baseline levels of sRAGE than survivors (median [IQR]: 1,392 [962–2,043] pg/mL vs. 1,212 [963–1,514], P = 0.008). High serum sRAGE (>1,617 pg/mL) was associated with increased mortality even after adjustment for relevant confounders (HR 2.06, 95% CI: 1.36–3.11, p < 0.001), and there was an interaction between sRAGE and frailty (P = 0.006). Furthermore, the association between sRAGE and mortality was stronger in the frail group compared to the non-frail group ((HR 2.52, 95% CI: 1.30–4.90, P = 0.006) vs. (HR 1.71, 95% CI: 0.91–3.23, P = 0.099, respectively)).

Conclusions:

Frailty status influences the relationship between sRAGE and mortality in older adults with diabetes mellitus. This has significant clinical potential in the risk stratification of diabetic patients.

Background: Sialorrhoea is the increase of drooling due to poor clearance of saliva and is a common symptom in people with Parkinson’s Disease. It can lead to a decline in confidence, as well as increasing the risk of aspiration pneumonia. Botulinum injections are currently used in select patients to control the sialorrhoea, and the purpose of this project was to assess the benefit this treatment has had on patients.

Methods: Data was collected from 40 patients who have received treatment at the sialorrhoea clinic and included Drooling Severity and Frequency Scale (DSFS), EQ5D and Visual Analogue score (VAS) - quality of life scores that are routinely collected before and after each injection. Using the Welsh Clinical Portal, data was collected on mood, swallow problems, dementia and comorbidities.

Results: Out of a total of 86 injections, 66 resulted in a decreased DSFS score showing better controlled sialorrhoea after most injections. Among the discharged patients, there was an equal distribution between those discharged due to successful and unsuccessful treatment (n=9 each). In 74% of successful injections it took less than a week to take effect and 63% of successful injections lasted 3 months or longer. The average onset of sialorrhoea after a Parkinson’s Disease diagnosis was 7.7 years and out of 40 patients, 11 experienced low mood and 19 had swallowing difficulties before treatment. Over a cumulative 40 years of treatment across all patients, there were only 4 reported admissions due to pneumonia.

Conclusion: Most injections resulted in an improved DSFS score with the average decrease in the score being 1.9 in successful injections. As many patients with sialorrhoea experience low mood, effectively controlling the sialorrhoea can improve patients’ quality of life and confidence, as well as reducing hospital admissions due to aspiration pneumonia.

Introduction Frailty is a clinical state that predisposes to patients to clinical deterioration in response to minor stressor events. Frailty tends to be more prevalent in patients with chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD). Therefore, we aim to investigate the influence of clinical frailty on mortality in COPD patients. Methods Data collection from electronic records for patients seen in Ysbyty Ystrad Fawr, Neville Hall Hospital, Grange University Hospital or Royal Gwent Hospital between 5-17th June 2024 was completed as part of patient input to the National Respiratory Audit Programme, focussing on patients who were admitted with an acute COPD exacerbation. The data collected were clinical frailty as measured by the Clinical Frailty Scale (CFS), smoking status, and the life status of patients at the time of data collection. This data was then exported to an excel spreadsheet, anonymised and simplified for statistical analysis using chi squared tests. Results Of the total 209 patients, 84 were male and 125 were female; the mean age was 72. 113 patients were ex-smokers, 71 were current smokers, 7 had never smoked and 18 were not recorded. 97 patients had a CFS of 5 or above, 112 had a CFS of 4 or below. 48% of ex-smokers were frail whereas 40% of current smokers were frail (p=0.478). 161 patients were alive at the time of data collection. 29% of those classed as frail had died since their admission whereas 17.6% of those classed as not frail had died following their admission (p=0.030). Of those alive, 41.2% were still smokers on admission. Of those dead, only 25.6% were still smokers on admission (p=0.055). Conclusion COPD patients who are frail tend to have higher rates of mortality compared to those who are not. Future studies exploring the relationship between smoking and frailty are needed.

BACKGROUND:

At Sheffield Teaching Hospitals, an Older Surgical Patients Pathway (OSPP) began in 2014, introducing a Consultant Geriatrician working in a liaison role within General Surgery.

BGS reports in its 'Case for more Geriatricians' that the number of people aged over 85 is set to double by 2045. An increase in patient age and complexity is already being seen across a range of services including admissions to general surgery.
We look to characterise this increase to make the case for an expansion of the OSPP service.

METHODS:

1. We identified patients aged over 75 admitted under General Surgery in July to December of 2014 and 2023.

2. We analysed these patients for their 30 day mortality, theatre episodes, length of stay and Hospital Frailty Risk Score (an automatic calculation from hospital records using a weighted count of frailty- related diagnoses).

RESULTS:

The number patients aged over 75 admitted in the 6 months from July to December has increased from 646 in 2014 to 847 in 2023.

The increase in this age group is associated with an increase in the number of patients with a hospital frailty score greater than 20 (from 18 to 69) and those with a length of stay longer than 15 days (from 93 to 124).

Additionally, between 2014 and 2023 patients aged over 75 had an increase in total theatre episodes (from 107 to 125) and 30 day mortality (from 48 to 63).

We propose that this increase in number and complexity of older patients supports the expansion of OSPP Service, for example by the addition of a ST3+ level doctor.

One in four seniors fall annually, leading to unnecessary hospitalizations and decreased independence, with existing in-person fall prevention programs limited by access, scheduling, and cost. KINIMA Seniors is a newly developed automated interactive exercise and movement app providing real-time visual and audio feedback to assess and reduce risk of falls in seniors, using our proprietary augmented reality motion capture system. KINIMA Seniors introduces an innovative, scalable solution through a mobile app, assessing and reducing fall risks without the need for on-body sensors. It allows seniors to engage in exercises that enhance strength, balance, and gait, displayed alongside a virtual trainer with visual and audio cues for improving physical performance.

Methods:

20 sessions lasting 45 minutes were conducted over 10 weeks in 4 US Senior Centers using the KINIMA Seniors interactive movement platform. During the 1st and last sessions, the KINIMA system's computer vision data capture technology was employed to assess our 4 measures related to the risk of falls, and these measurements were compared with human observer-derived data in both the initial and final assessments. 26 participants completed the sessions with 4 dropouts. Assessment measures were: 1) One-Legged Stance test (left and right), 2) # of Leg Lifts in 30 seconds (left and right), 3) # of Sit to Stand repetitions in 30 seconds, 4) Timed Up and Go.

Results:

This study demonstrated improved fall risk outcomes were achieved in pre/post measures, technical feasibility, likeability of our automated exercise features, and accuracy of automated fall risk measures.

Conclusion:

KINIMA Seniors can deliver a cost-effective and scalable offering for fall prevention targeting enterprises that cater to seniors, such as senior day centers, senior living, and physical therapy. This technology facilitates independent aging in place and also offers a personalized exercise regimen with performance tracking to significantly enhance quality of life. 

INTRODUCTION

People with Parkinson’s disease (PwPD) often report low levels of physical activity and poor health and 90% of PwPD will fall at least once[1]. Interventions to reduce falls in PwPD often involve physical therapy and exercise, however the environment is an independent risk factor for falls[2]. Exploring whether fall circumstances differ in PwPD due to health status and physical activity level will inform occupational health services and the design and development of environmental modifications.

METHODS

An online survey was developed to evaluate falls in adults ≥60y. Of 358 respondents, 117 were diagnosed with PD. The survey covered basic descriptors, fall history and contextual information about falls. Health (good/ average/ poor) and physical activity (active/ inactive) status were self-reported and used to stratify respondents.

RESULTS

68% of respondents with PD had fallen and of these 90% had poor health or were physically inactive. The 3 most problematic environments (steps/stairs, uneven/sloped surfaces and objects on the floor) and 4 most common pre fall activities (turning, walking, moving too quickly and transferring) were the same regardless of health or physical activity status, although more frequently reported by those with poor health or physically inactive.

Misjudging objects and falling over trip hazards was more common in PwPD of poor health than those of average/good health. Falls on steps and stairs were more common in physically inactive PwPD than those who were physically active.

CONCLUSION

This survey has highlighted several problematic aspects of the home environment contributing to falls in PwPD. Routine person-environment risk assessments are required to identify home hazards early. Research through co-design with PwPD and relevant stakeholders is required to develop novel home modifications targeting problematic environments so interventions may be prescribed effectively.

[1] Allen 2013 PMID:23533953 [2] van der Marck 2014 PMID:24484618