Scientific Research

Introduction:

Inpatient falls are the most common adverse patient safety incidents in hospitals in the UK. The assessment and management following an inpatient fall is often the responsibility of the most junior doctor on call, particularly out of hours. Frequently, there are key omissions in the assessment of these patients, leading to missed diagnoses, poor management and avoidable patient harm. This study aimed to improve the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls.

Method:

31 patients were identified who had suffered ‘severe harm’ following an inpatient fall and a retrospective review of their notes was performed. A preliminary survey on self-perceived confidence levels on different areas of the assessment and management of inpatient falls was distributed to all foundation doctors at Ipswich Hospital. The key themes of the simulation scenario were subsequently determined by the areas of weakness identified in both the survey and documentation review. A total of 9 foundation doctors at Ipswich Hospital participated in a high-fidelity inpatient fall simulation with a patient actor. Pre- and post-simulation knowledge and confidence surveys consisting of ten multiple choice questions and Likert scales respectively were distributed using QR codes.

Results:

Post-simulation confidence levels improved in all domains measured (p < 0.05) with an overall increase in average confidence levels from 3.3/5.0 to 4.3/5.0 (p=0.007). Average post-simulation knowledge score increased from 4.6/10 to 7.4/10 (p= 0.01). Domains in which the greatest improvements in knowledge and confidence were seen included: moving & handling, neurological observations, assessment of suspected hip fractures and escalating concerns.

Conclusion:

The use of simulated patients improves the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls. The pilot project is due to be expanded with plans to incorporate this simulation scenario into the local foundation teaching programme.

Introduction: Concerns about falling (CaF) is a psychosocial concept, precipitating a spiral of increasing inactivity, social isolation and falls, and is common in those who have experienced, or are at risk of, a fall. One method of assessing CaF is the Falls Efficacy Scale International version (FES-I),with previous studies finding associations between higher FES-I scores and poor scoring on commonly used clinical assessments of functional mobility and balance (Gait speed (GS), Timed up and Go test (TUG), and Five time sit to stand (FTSS)). Using the FES-I to predict poor functional mobility and balance has the potential to identify those at risk before an initial fall, at which point an intervention may be provided.

Methods: A prospective study was carried out over 24 weeks, in which 119 participants were recruited from the North Tyneside Community Falls Prevention Service (NTCFPS). Participants completed questionnaires and underwent physical testing whilst attending the falls clinic (baseline) and at week 24, completing bi-weekly falls diaries throughout. Participants were users of the NTCFPS, and residents of North Tyneside.

Results: Findings showed (i) the FES-I had a limited ability to predict poor scores on GS, TUG and FTSS; (ii) attending referred Age UK strength and balance classes was significantly associated with improvements in FES-I score and FTSS; (iii) CaF at the outset of Age UK training was not significantly associated with clinically significant improvements in GS, FTSS and TUG.

Conclusions: Whilst the predictive capabilities of the FES-I were limited, the measure showed an ability to track improvements in participants CaF in the short to medium term. Further work is needed to explore the measures applications within the general population of community dwelling older adults, rather than a cohort of falls service users.

Introduction

The fall risk factors in older adults living in residential care homes for the elderly (RCHEs) are multifactorial. In Hong Kong, around 9.5% of RCHEs have a fall rate over 30% (Elderly Health Service, 2022)1. The objective of this survey is to identify the common fall risk factors among frequent fallers in RCHEs in biological, environmental, and behavioural domains, based on the World Health Organization (WHO)’s risk factor model for fall (World Health Organization, 2021)2.

Methods

197 frequent fallers from 67 RCHEs with fall prevalence over 30% in Hong Kong were included in this cross-sectional retrospective survey. Twenty fall risk factors in biological, environmental and behavioural domains were investigated through tailor-made questionnaires and staff interviews. The most common fall risk factors, the time period and places of fall of all fallers were identified. The fall management strategy including fall risk assessment and fall incident report of RCHEs were also examined and compared.

Results

In the biological domain, chronic illnesses, decreased mobility, gait instabilities, lack of physical activities and cognitive impairment are the most common fall risk factors. In the behavioural domain, unsafe behaviour such as over-estimation of self-ability and hesitation to seek assistance are the most prevalent. Key environmental fall risk factors include movable furniture and poor lighting. The most common places of falls are bedsides while the peak hours of falls occurs around meal times. Nearly 24% of RCHEs did not perform fall risk assessments for residents.

Conclusions

Behavioural and biological fall risk factors play a more important role than environmental risk factors in these frequent fallers, and many of them are modifiable. Large variations exist in the fall management of different RCHEs. Interventions to prevent falls in RCHEs should target at improving the fall management protocol and addressing the specific fall risk factors of frequent fallers. 
 

A 75-year-old male presented with chronic fatigue and gradually worsening generalised muscle weakness over three years. He was treated by his GP for two months for a suspected case of polymyalgia rheumatica with a two-month course of steroids, which resulted in no significant improvement. His medical history included post-COVID syndrome and mixed anxiety and depressive disorder. He lives at home with his wife and requires assistance to navigate stairs, using a walking stick for mobility. On examination, he exhibited grade 4/5 muscle weakness in both proximal and distal muscles. Blood tests revealed low haemoglobin, elevated C-reactive protein (CRP), and white blood cell (WBC) counts. A blood film showed positive cold agglutination, leading to a haematology consultation for haemolytic screening and direct antiglobulin testing, which later yielded negative results. Persistently elevated CRP and WBC levels prompted intravenous antibiotics and a comprehensive CT scan of the chest, abdomen, and pelvis, which showed no signs of infection or malignancy. A rheumatology consultation and extensive investigations revealed a positive Mi2a antibody. An MRI of the lower limbs demonstrated bilateral symmetrical oedema and increased signal within the anterior compartment muscles, particularly affecting the right tibialis anterior along with minor atrophy of the proximal muscles. Rheumatology was not convinced due to normal creatine kinase (CK) levels. After consulting a musculoskeletal radiologist, it was decided that a biopsy from the anterior tibialis was necessary to establish the diagnosis. Surprisingly, the biopsy was suggestive of inflammatory myositis. The patient was subsequently started on mycophenolate mofetil. This case highlights the unusual presentation of myositis, involving proximal muscles and negative CK levels. It underscores the importance of thorough diagnostic evaluation in elderly patients, emphasising that such patients should not be prematurely classified under chronic fatigue syndrome or fibromyalgia, as appropriate treatment can significantly improve their quality of life.

Introduction and Background- Bowel obstruction poses a considerable medical dilemma, demanding swift identification and intervention due to its propensity for severe complications. This challenge is exacerbated in elderly individuals who may be frail and less amenable to surgical interventions. Alvimopan, a peripherally acting μ-opioid receptor antagonist renowned for its pro-kinetic effects on the bowel, has shown promise in clinical trials. Nevertheless, despite its efficacy, it remains underutilised in many clinical hospital settings. Thus, our systemic review aims to underscore the potential benefits of Alvimopan, reintroducing its significance in managing bowel obstruction, particularly in elderly patients.

Methods- Four databases were searched to identify relevant studies investigating the use of Alvimopan for treating ileus. Included studies measured time for first bowel motion, and was compared with controls. Animal and non-original research articles were excluded.

Results- Ten randomised controlled trials (RCTs) were incorporated, each showcasing the significant reduction in both time to initial bowel movement and hospital stay attributed to Alvimopan. Findings indicated that Alvimopan can decrease the duration until the first bowel movement by an average of 14 hours compared to placebo, as well as abbreviate the time until discharge by an average of six hours.

Conclusion- Consistently, Alvimopan has demonstrated favourable results for patients experiencing bowel obstruction. Its utilisation could potentially circumvent the necessity for laparotomy in frail patients. Moreover, employing this medication contributes to shorter hospital stays, thus potentially mitigating associated complications. Consequently, we strongly advocate for its use and advocate for additional research to incorporate it into clinical guidelines.

Introduction:

As we strive to generate more geriatricians we must understand the journey of the training programme. Whilst information is available from the RCP census and BGS workforce survey this study will compliment that data and obtain a broader picture. A similar survey was last undertaken by the BGS in 2019 and since that time much has changed, from a pandemic to the first published NHS Long term workforce plan.

Method:

TPDs were contacted directly by the BGS VP for workforce at the geriatric medicine specialty advisory committee and invited to complete an electronic survey. The survey had been designed by the BGS workforce committee in line with the BGS strategic plan to strengthen the workforce for older people. The survey was open for 6 weeks.

Results:

Surveys were returned from 14 out of 19 deaneries, some were incomplete. National training numbers have increased since the 2019 survey, in total and with less vacancies. Six trainees had left the training programme in 2023 before obtaining CCT for various reasons. The percentage of trainees working less than full time has doubled from 21.9% in 2019 to 44.8%, the majority for parenting responsibilities. Most deaneries reported at least one trainee spending time out of programme, the majority pursuing additional experience directly related to the curriculum such as stroke. Qualitative data suggested solutions to increasing national training numbers and encouraging doctors to consider the specialty early in their career.

Conclusions:

This study was limited by incomplete data, a mixture of non and partial responses. What this study adds is an insight into the paths to becoming a geriatrician and solutions TPDs have found to supporting individual needs. These solutions can now be shared to help our members tend to the workforce crisis by successfully recruiting, training and retaining the geriatricians of the future.

Introduction: Over one-third of older people with unplanned admissions to hospital are frail, but data on the burden of delirium, dementia and other cognitive frailty are lacking. Reliable hospital-wide and specialty-specific prevalence estimates are needed for service-planning including understanding the role of non-geriatricians in caring for this population.

Methods: ORCHARD includes pseudo-anonymised EPR data for consecutive admissions with a length of stay of >1 day (2017-2019) to four hospitals in Oxfordshire (population=800,000). Data are collected using a standard cognitive screen comprising dementia history, delirium diagnosis (Confusion Assessment Method-CAM), and 10-point Abbreviated Mental Test-AMTS that is mandated on admission for all patients >70 years. Cognitive frailty was defined as delirium, diagnosed dementia, delirium+dementia or AMTS<8 without delirium/dementia. We analysed the ORCHARD data to determine the prevalence of delirium/cognitive frailty trust-wide and by specialty (n=29 with >50 admissions).

Results: Among 51,202 admissions with mean/sd age=82/7 years and Hospital Frailty Risk Score=8/6, any cognitive frailty was present in 34.5% (95%CI 34.0-34.9%; n=17,466) of which delirium accounted for 14.6% (n=7,411), delirium+dementia=9.4% (n=4,757), dementia=7.5%, (n=3,784), AMTS<8=3% (n=1,514). The prevalence of cognitive frailty in general medicine, general surgery and trauma/orthopaedics, which accounted for 80% of admissions (n=41,016), was 41% (n=13,879), 21% (n=801) and 35% (n=1,304) in each, respectively. The prevalence was 44% in geriatric medicine admissions (n=133/301), 36% in palliative (n=128/356), 29% in stroke (n=135/468), 27% in infectious disease (n=41/152), 22% in neurosurgery (n=154/702) and 10-20% in all other specialties except two. Delirium was the most prevalent form of cognitive frailty in 24/29 specialties.

Discussion: Cognitive frailty is common in older unplanned hospital admissions across a broad range of specialties, with delirium accounting for most cases. Our findings support the need for hospital-wide and specialty-specific training and service development to reflect the needs of these older complex patients and increased emphasis on delirium in policy.

Introduction

The number of older adults accessing the healthcare service far exceeds the available geriatric specialist services. It is recognised that for the foreseeable future most hospital inpatient contacts with older adults will be completed by doctors not specifically trained in Geriatric Medicine. To ensure the provision of adequate healthcare, it is imperative that all hospital doctors are trained in the minimum Geriatric Medicine competencies. Allowing for the broad, complex, and multidisciplinary nature of Geriatric Medicine, we conducted a group concept mapping (GCM) study to permit multiple stakeholders with various expertise to convey their thoughts on the competencies required by all hospital doctors caring for older adults.

Methods

GCM is a mixed methods approach utilising six phases to generate expert group consensus, enabling participants to organise and represent their ideas. We invited healthcare professionals, patient advocacy groups and clinical educators to participate in GCM via an online platform. Hierarchical cluster analysis and multi-dimensional scaling were utilised to analyse participant input regarding competencies required by doctors caring for older adults.

Results

Twelve competency domains were identified by participants as integral for all hospital doctors to care for older adults. Domains rated most important related to interpersonal communication skills, medicolegal concerns, recognition and management of delirium and medication management.

Discussion

The twelve competency domains indicate the diverse skillset required by all doctors to provide comprehensive care to older adults within a hospital setting. The emergence of interpersonal communication skills underscores the importance of effective- doctor patient and interprofessional communication. Furthermore, the emphasis on medicolegal issues highlights the potential complex ethical and legal aspects in treating older adults. Recognition of delirium and medication management underline the specific challenges associated with caring for this specific population.

Conclusion

This study identifies competencies that may serve as a foundational framework for ensuring quality healthcare for the ageing population. Future initiatives should consider incorporating these competencies to improve inpatient care provided by hospital doctors to older adults.

Introduction

There is limited understanding of long-term delirium care after discharge from hospital for older people. A realist approach was used to investigate the contextual factors and mechanisms of care that influence recovery from delirium. Realist evaluation is fundamentally theory-driven. A preliminary programme theory was used as the foundation for theory testing and refinement, in order to develop the RecoverED intervention.

Method

Realist interviewing techniques were used to obtain real-world and lived experiences of delirium recovery and service use in the community for theory-building and testing. Semi-structured interviews were conducted with a purposive sample of people with delirium (N=7), informal carers (N=14), and healthcare professionals (N=24). Data from the interviews were analysed using a deductive codebook of Context-Mechanism-Outcome (CMO) configurations. Open coding was also performed to identify inductive themes, which were then aggregated to elicit explanatory statements.

Results

There was support for a multicomponent delirium intervention including cognitive and physical rehabilitation, and psychosocial support. The analysis revealed the need for an additional component which focused on improving awareness and understanding about delirium amongst those with lived experience. In the context of insufficient knowledge about delirium, people experienced increased fear and anxiety among other negative outcomes. Offering a focused educational component as part of the intervention is expected to contribute to recovery outcomes. This was associated with CMOs identifying the need for positive relationships with staff, improving communication with staff and sense-making through staff emotional support.

Conclusion(s)

The preliminary programme theory was refined based on the realist analysis data. Additional components were included, one of which was targeted education for people with delirium and carers. Following a consultation with an expert panel, the intervention is being tested in a feasibility trial and process evaluation, which will analyse data from multiple sources using realist methods to further refine the intervention

Introduction:  Preoperative frailty is a key determinant of post-surgical outcomes and often co-exists with sarcopenia and malnutrition. Older patients account for a significant proportion of patients undergoing surgery for colorectal cancer and are therefore more likely to be affected by these risk factors.      

Methods:  Patients aged 65 and over undergoing planned surgery for colorectal cancer were recruited across five sites. Participants were screened preoperatively using the Clinical Frailty Scale (CFS) and Groningen Frailty Indicator (GFI). Nutritional status was assessed using the short form mini nutritional assessment (MNA-SF) and participant collection of spot urine samples to objectively measure habitual dietary intake. Sarcopenia was assessed through grip strength, gait speed and psoas muscle measurement using preoperative CT imaging. The non-radiological screening measures were repeated eight-weeks postoperatively, with additional urine samples collected in the first and fourth weeks.      

Results:  Forty-three participants (mean age 76 years, 60 % male) were recruited, of which 32% were frail. Using the mini-nutritional assessment 42 % of participants were identified as at risk of malnutrition and 9 % as malnourished. Urine assessment of habitual dietary intake is ongoing. There was a high prevalence of sarcopenia - 67 % determined by hand grip strength and 42% by CT analysis. Mean length of stay following surgery was 6.9 days. 28 % of participants were unable to complete the in-person post-operative follow up due to ill health, poor appetite and exhaustion.      

Conclusions:  This ongoing study has demonstrated the feasibility of incorporating frailty, nutritional status and sarcopenia screening alongside routine clinical care, in older adults undergoing surgery. However, retaining participants in observational studies during postoperative periods of convalescence, or whilst undergoing adjuvant treatment, is challenging. This study has also highlighted the potential of home urine sampling as a viable method of dietary assessment within community settings to aid malnutrition screening.