Scientific Research

TITLE:

Process Evaluation of the BASIL+ trial: a Behavioural Activation approach to addressing low mood and depression among older people with long-term conditions

AUTHORS:

Kate Bosanquet ¹, Elizabeth Newbronner ¹, Peter Coventry ^1,3, Leanne Shearsmith ⁵, Elizabeth Littlewood ^1,4, Della Bailey ¹, Andrew Henry ⁶, Lauren Burke ⁷, Eloise Ryde ^1,9, Dean McMillan ^1,2, David Ekers ^1,4, Simon Gilbody ^1,2, Carolyn A. Chew-Graham ⁸

¹ Department of Health Sciences, University of York, UK

² Hull York Medical School, University of York, Heslington, York, UK

³ York Environmental Sustainability Institute, University of York, York, UK

⁴ Tees Esk and Wear Valley NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK 

⁵ Leeds Institute of Health Sciences, University of Leeds, Leeds UK

⁶ Homerton Healthcare NHS Foundation Trust, Hackney, London, UK

⁷ Manchester Institute of Education, University of Manchester, Manchester, UK

⁸ School of Medicine, Keele University, Staffordshire, UK

⁹ Improvement Academy, Yorkshire & Humber ARC, Bradford Institute for Health Research, Bradford, UK

Abstract

Older adults are at risk of low mood and depression, which can be exacerbated by long-term physical health conditions, leading to poorer health outcomes and increased mortality. The restrictions on social mixing during the COVID-19 pandemic heightened these risks. BASIL+ (Behavioural Activation in Social IsoLation) was a pragmatic randomised controlled trial conducted with patients recruited from general practices in England and Wales. It was designed to assess the effectiveness of behavioural activation in mitigating depression and loneliness among older people during the COVID-19 pandemic. A behavioural activation intervention, within a collaborative care framework, was delivered by telephone. Participants were offered up to eight weekly sessions with trained BASIL+ Support Workers. A qualitative process evaluation (conducted within the BASIL+ trial), used one-to-one semi-structured interviews to explore the experiences of trial participants, caregivers and BASIL Support Worker experiences. Three main themes emerged from the data analysis: 1) Engagement Dynamic: from Altruism to Self-Realisation; 2) Changing Behaviour and Improving Mood; and 3) Synergistic Nature of the Intervention Components. Findings suggest that the intervention effectively fostered self-awareness among older adults, giving them the confidence and skills to address low mood. Participant engagement with intervention materials varied, highlighting the importance of flexibility in delivery. BASIL+ Support Workers acted as key facilitators, guiding participants through the intervention process, fostering understanding, and providing crucial support. The collaborative care element ensured participants received comprehensive and holistic support, promoting improved mental and physical well-being. These findings underscore the adaptability and flexibility of the BASIL+ intervention, demonstrating its potential to address mental and physical health problems among individuals with varying needs and different starting points. The BASIL+ trial is registered with the ISRCTN registry (ISRCTN63034289).

Introduction

The British Geriatric Society (BGS) highlighted the need for workforce improvement and development of a skilled multidisciplinary team (MDT) in older people’s healthcare in their 2024 roundtable, “Transforming care for older people”. This survey aimed to gather views from pharmacy professionals on career progression and how the BGS and UK Clinical Pharmacy Association (UKCPA) can support their advancement in this speciality.

Method

A Google Forms questionnaire was designed to collect data on demographics, education, working practices, and specialisation. Respondents were asked about the need for defined core competencies and an advanced curriculum for the speciality, as well as the support professional groups should provide. The survey was distributed through BGS and UKCPA communication channels.

Results

Thirty-eight pharmacy professionals responded, with pharmacists comprising the majority (n=37, 97%), working primarily in secondary (n=21, 55%) and primary care (n=12, 32%). Most respondents were female (n=31, 82%) and 61% (n=23) identified as white British. Over 80% (n=31) were at a senior level (band 8a or above), with 68% (n=26) having over 10 years’ experience. Many identified as specialists in care of older people (n=29, 76%). There was unanimous support for an advanced pharmacist curriculum specific to older people’s care for those seeking to credential at an advanced level, and 90% (n=34) agreed on the need for core competencies for all pharmacy staff in this area. Key themes to enable progression included structured support, mentorship, clear career pathways, accredited courses, and opportunities to share expertise.

Conclusion

The BGS and UKCPA are well-positioned to develop an advanced curriculum in older people’s healthcare, aligned with existing professional pathways already implemented by the Royal Pharmaceutical Society. Joint initiatives to provide structured development opportunities could enhance the specialist workforce, ensuring high-quality pharmacy services are provided routinely as part of multidisciplinary teams caring for older people.

Background
Cognitive impairment (CCL) and dementia are conditions typically occurring throughout the aging process, becoming major concerns in elderly healthcare. Advanced age, genetic factors, lifestyle habits, and comorbidities are risk factors that may increase the risk for both conditions. Thus, the aim of this study is to assess sociodemographic characteristics and comorbidities associated with CCL and dementia in older adults.
Methods
Cross-sectional analysis of the second wave (2019-2021) of the Brazilian Longitudinal Study of Aging (ELSI-Brazil). To assess the definition of CCL and dementia, the z-score of global cognitive function was calculated, evaluated through measurements of temporal orientation, verbal fluency, episodic, retrospective, and semantic memory domains. In addition, the IQCODE instrument and Activities of Daily Living were used to evaluate dementia. The Chi-Square test was used for the association of variables. The study was approved by the ethics committee.
Results
A total of 2951 participants were included, of whom 158 (5.4%) had CCL and 204 (6.9%) had dementia. Prevalence analyses of CCL revealed higher rates among individuals aged 65 to 74 years (6.18%), females (6.71%), divorced individuals (10.65%), rural residents (8.39%), hypertensive individuals (5.95%), non-diabetics (5.70%), and noncardiac individuals (5.60%). Meanwhile, for dementia, prevalence was higher in individuals aged 75 or older (26.76%), females (8.50%), widowers (18.06%), rural residents (9.75%), hypertensive individuals (8.57%), diabetics (9.01%), and cardiac individuals (13.51%).
Discussion
It was observed that long-lived elderly individuals have higher rates of dementia compared to CCL, as dementia symptoms increase with advancing age. Females and rural residents are in more  vulnerable positions in society, explaining the high prevalence of both diseases. Comorbidities are significant risk factors for dementia development, with cardiovascular diseases, in particular, playing a prominent role in vascular dementia. This broad view highlights the importance of specific management and prevention approaches to preserve cognitive functions during the aging process.

Introduction:

With population aging comes challenges like dementia, prompting the urgent identification of risk factors and its associations with other psychiatric disorders. This review aims to explore the connection between depression and the onset of mild cognitive impairment (MCI) or dementia through recent literature analysis.

Methods:

Systematic review and meta-analysis, following PRISMA recommendations, with studies from 2013 onwards. The search strategy “Depression” AND “Dementia” AND “Aged” was employed in the Cochrane, Embase, LILACS, PubMed, Scopus, and Scielo databases. Cohort studies in Portuguese, English, or Spanish were included, while reviews or clinical trials were excluded.The meta-analysis was conducted using RevMan software, employing unadjusted OR effect measures for exposure in the Forest Plot graph. Study heterogeneity was calculated using the I² statistic, with a cutoff point of >75% indicating high heterogeneity.

Results:

The search strategy identified 3,394 articles, screened by title and abstract. Of these, 187 were fully read, and 26 were included in the review. The most used tool for assessing depressive symptoms was the Geriatric Depression Scale (38.4%), while the Mini-Mental State Examination was the most frequently used tool for assessing symptoms of MCI and dementia (26.9%). The quantitative analysis included 14 studies evaluating dementia and 8 studies evaluating MCI. The likelihood of older adults with depression developing dementia was 1.75 times higher than in the non-depressed population (OR = 1.75; 95% CI 1.46 - 2.11). Additionally, a twofold increase in the likelihood of developing MCI was found in depressed older adults (OR = 2.03; 95% CI 1.44 - 2.88). All analyses revealed high heterogeneity.

Conclusion:

Depression was found to be associated with higher likelihood of developing MCI or dementia in older adults. Understanding this complex relationship with new studies and reviews is crucial for developing targeted interventions and improving the prognosis for individuals affected by both conditions.

Introduction: Clinical decision making for older adults with multimorbidity can be complex and demanding. When facing complex decision-making, patients may experience decisional conflicts, leading to low treatment adherence, adverse health outcomes, and increased utilization of health services, etc. To address these issues, patient decision aids (DAs) have been developed and utilized in the decision-making process to facilitate informed decisions. The aim of this study is to identify DAs developed for patients with multimorbidity and assess their quality.

Method: We searched full-text papers on nine databases. Any article utilizing a DA for patients with multimorbidity was eligible and DAs for making medical decisions at any point were eligible. We used the International Patient Decision Aid Standards (IPDAS) checklist to assess the quality of DAs.

Results： In total, ten articles including six DAs were included. Two DAs targeted for the older patients with multimorbidity. Most DAs didn’t focus on specific treatment choices but rather aimed at improving the overall quality of life for patients with multimorbidity. The targets of these DAs are including setting goals about health care, preparing for conversation with doctors and taking ownership for the decisions. IPDAS checklist revealed that only one DA met all qualifying criteria and provided comprehensive choice. Three DAs were deemed to have poor quality due to their failure to provide the pros and cons of decisions. The quality of the remaining DAs was difficult to judge due to incomplete versions.

Conclusions: DAs for patients with multimorbidity were few and had poor quality. Designing DAs for this patient population presents challenges given the complex nature of multimorbidity and its lack of specific treatment options. Future development should focus on adhering to the IPDAS checklist, provide more information and possibility, and aim at improving the quality of life for patients with multimorbidity.

Introduction: Simulation training is a valuable resource to teach clinical skills and mimic emergency settings. Human factors (HF) are non-technical skills that are affected by human attitudes and behaviours. Weaknesses in human factors can cause fatal medical errors. We wanted to assess if simulation can be used as a tool to improve these. We conducted two simulation training days for medical higher specialty trainees (HST) focusing on HF.

Methods: 20 HSTs participated in 10 simulated scenarios. Scenarios involved using a high-fidelity manikin and actors. The scenarios were a mixture of long and short cases, including both clinical and non-clinical scenarios with a HF focus. Pre- and post-session questionnaires were used to rate confidence levels in a series of specific HF. A 10-point Likert scale was used.

Results: The majority of participants had a firm understanding of the importance of human factors in healthcare, especially the importance of teamwork, compassion, communication and situational awareness. 70% of participants felt that human factors training may not be adequately considered in current training pathways due to limited formal exposure, limited time, and its importance being underestimated. There was an increase in confidence in: managing disagreements (31%), negative emotions (38%), prioritisation (28%), delegation (23%), teamwork (34%) and leadership skills (30%), dealing with uncertainty (29%), challenging hierarchy (27%), anticipation (31%). 100% felt simulation training helped to develop their attainment of human factor skills.

Conclusion: This form of simulation training was successful in improving confidence and understanding of human factors in healthcare and showcased the value of using high-fidelity training to realistically recreate the clinical environment. Going forward, this type of teaching could be integrated within the specialty training curriculum to formally improve skills in human factors and therefore improve patient outcomes and relationships between team members, thus contributing to a more positive working environment.

Introduction

Iron deficiency anaemia (IDA) is common in older people, but traditional ferritin cutoffs may not be applicable in older people and iron studies are increasingly being used to diagnose iron deficiency anaemia. We wish to update guidance for diagnosing IDA, but first wished to survey current knowledge.

Methods

Clinical staff working with older people were asked to filled in a survey. They answered questions relating to confidence in interpreting ferritin and iron studies. Their knowledge of interpreting iron studies was assessed with two multiple choice questions illustrating common scenarios.

Results

When asked on a scale of 1-5 how confident the 135 participants were at interpreting ferritin, the mean was 3.7. For iron studies, it was 3.2. Amongst consultants, the mean confidence in interpreting ferritin was 4.18, in doctors of other grades (excluding GPs) this was 3.5, and for other medical professionals (PAs, ACPs and pharmacists) 2.8. Regarding iron studies, the mean confidence in consultants was 3.7, 2.9 in doctors of other grades (excluding GPs), and 2.7 in other medical professions. 88% of consultants, 73% doctors of other grades (excluding GPs), and 65% of other healthcare professionals correctly answered the case on a patient with anaemia of chronic disease. 94% consultants, 88% doctors of other grades (excluding GPs), and 70% of other healthcare professionals correctly answered the case on a patient with IDA. 

Conclusions

The data suggests that clinicians of all grades felt less confident in interpreting iron studies than ferritin. A significant proportion of medical professionals did not correctly interpret iron studies. We have consulted with our colleagues in haematology and gastroenterology and drafted a revised guideline to help interpretation, and suggest that IDA guidance should have advice on iron study interpretation. We will also examine IV iron prescription use and provide clear guidance on indications, tracking related costs.

Introduction

Fall-related injuries such as fractures are on the rise as the older adult population grows in New Brunswick, Canada. These injuries can lead to hospitalization and transitions in care that are complicated for patients and families. The objective was to investigate the impact of patient navigators (PNs) working alongside the healthcare team on patient and family experiences, as compared to the usual standard of care (SOC), for adults aged 65 and older admitted with a fracture to an Orthopedic Unit at one hospital in New Brunswick.

Methods

A concurrent embedded mixed methods design, in which the quantitative randomized control trial had an embedded qualitative component. The results for the family caregiver qualitative component, which used an interpretive description approach, are presented.

Results

Semi-structured interviews were conducted and thematically analyzed for 15 family caregivers (8 PN group, 7 SOC group). The SOC caregivers, six women and one man, had a mean age of 64.6 years (SD=6.9 years). The mean age of the 8 women in the PN group was 61.3 years (SD=10.1). All participants in both SOC and PN groups self reported their ethnicity as white. Thematic analysis found that SOC group caregivers discussed patients relying on support from family and friends throughout their care journey, whereas caregivers in the PN group predominantly discussed finding PNs supportive and helpful. Both groups discussed the ongoing stress that they felt throughout the care journey of the patient for which they cared for; however, for the PN group this topic was less prevalent.

Conclusions

This study provides an understanding of the positive impacts a patient navigator can have on older adult inpatient care and transitions in care. Patient Navigators were shown to be helpful to families, particularly those of patients with higher care needs and fewer family supports.

Introduction: Written documentation and verbal handovers can be ineffective at communicating the specifics of frail, older patients’ complex functional abilities and support needs. Video-recordings of individual patients may help to convey a patient’s condition in a more nuanced, objective way, potentially improving safety at care transitions. The Isla platform interfaces with electronic health record systems, allowing care providers to capture video-recordings during patient care. We evaluated the acceptability, feasibility, and potential effectiveness of video-based patient records (the Isla platform) for supporting the care of older frail inpatients within the acute hospital setting and at care transitions.

Method: Over a three-month pilot period, a non-randomised, mixed-methods feasibility study of video-based patient records (alongside usual care) was conducted within three elderly medicine wards of a large acute hospital in England. Patient and public involvement and engagement (PPIE) was central to study design and implementation. Participant enrolment figures; semi-structured interview data; and video capture and view metrics were examined within an embedded process evaluation, appraising intervention acceptability amongst patients, carers, and ward staff; barriers and facilitators to intervention implementation; and perceived intervention impacts.

Results: The study enrolled 58 ward staff and 29 patients (56.9%); one patient withdrew. Enrolment figures and early interview analyses indicate apparent acceptability of video-based patient records to patients and carers. Intervention barriers (e.g. patient pain), facilitators (e.g. staff-patient rapport) and potential intervention impacts (e.g. improved person-centred care, team communication) were identified. Modal use-cases for video-recordings were to document patients’ transfers (n=16), mobility (n=13), and eating/drinking supports (n=3); however, view metrics suggested limited engagement with videos once captured.

Conclusion(s): Preliminary findings indicate the acceptability and feasibility of video-based patient records, although several implementation considerations warrant address. Perceived intervention impacts (e.g. improved person-centred care) were promising; although greater engagement with videos is a probable precondition to demonstrating efficacy in future research.

Introduction:

Little evidence exists about decision-making with older adults diagnosed with cancer (Bridges et al 2015). However, older age is associated with changes in physical, social, and psychological health domains in ways that influence treatment decisions potentially impacting on quality and quantity of life. We sought to explore the experiences of older adults, their significant others and healthcare professionals when decisions regarding cancer treatment and support are made.

Methods:

Synonyms relating to search terms Cancer, Older People, Complexity and Qualitative research were used to search the databases CINAHL, Medline, Embase and PsychINFO. The Mixed Methods Appraisal Tool (MMAT) identified strengths and limitations of the evidence allowing concurrent appraisal of qualitative, quantitative, and mixed methods studies.

Results:

Searches identified 534 articles: 64 studies underwent full text screening, and 14 of these were included. The synthesis identified six themes: Preconditions in decision-making; Identifying frailty and setting goals; Maintaining independence; Information provision; Support during the decision-making process/role distribution; Trust in physicians; Preferences and choice. Most included studies reported the views of the older person, or health care professionals (predominantly physicians/oncologists/surgeons). However, there is a paucity of evidence representing the views of the older adult’s significant other and a dearth of evidence exploring the efforts and contributions of all people involved in the process of decision-making.

Conclusions:

Research is needed urgently to understand how and why decisions are made regarding cancer treatment and support, as well as how older adults are involved in these decisions throughout their cancer trajectory. Understanding this would assist healthcare professionals to prioritise individual’s healthcare preferences with the potential to positively influence service delivery and workforce development. This review has informed the research design for The CHOICES study which aims to understand how clinicians, older individuals and their significant others make decisions following a new diagnosis of cancer.