Scientific Research

Background & Objectives

Research suggests that specialized education for nurses decreases frailty and improves functionality in hospitalized older adults. This study explored the impact of a specialized geriatric education program on  mobilization rates for older adult patients in acute care in 5 hospitals.

Methods

A mixed methods approach with pre- and post- intervention questionnaires (Geriatric In-hospital Nursing Care Questionnaire (Ger-INCQ) and study specific knowledge assessment) was used to explore facilitators and challenges of caring for older adults, the knowledge base and experiences of staff, and the impact of providing specialized education. Acute care nursing staff participated in a 4-hour education intervention focusing on the Geriatric 5Ms (Mind, Mobility, Medications, Multi-complexity and Matters Most) and frailty prevention. Patient level data was collected through mobility audits (I-MOVE) and observation of shift handover communication.  Semi-structured interviews with staff were completed to explore the results of the questionnaires. 

Results

Registered nurses, licensed practical nurses and personal care attendants (N=64, Mean age=36.9, 87% female) who participated in the specialized training did not show significant change in their assessment scores. Patient (N=99, mean age=76.2, 54.5% female ) mobilization did not differ between phases of intervention (p=0.08), nor was there any significant change in reporting mobility at shift handover. Ger-INCQ indicated neutral responsibility for falls incidents and retention of patient mobility, with interviews (n=26) revealing that patients are kept immobilized for safety and workload management.

Conclusion

Staff had positive attitudes toward caring for older adults; however, their understanding and application of geriatric principles were limited and remained unchanged. Interview participants stated their work environment limits their capacity to deliver the best practice care presented in the education sessions. These findings suggest that education alone is unlikely to influence prioritization of mobility for frail older adults in a strained acute care setting.

Introduction

• Preoperative systemic inflammation has been shown to worsen postoperative outcome in emergency surgical patients.
• C-reactive protein (mg/L)/Albumin (g/L) ratio is a well validated inflammation marker.
• Studies have shown an inverse relationship between 25-hydroxyvitamin D level and markers of inflammation. Vitamin D deficiency has been previously shown to be associated with inflammation.

Aims and Objectives

• To determine the relationship between 25-hydroxyvitamin D level and CRP/Albumin ratio in older acute hip fracture patients.
• To explore the impact of gender on this relationship.

Methods

• A retrospective review of electronic notes from the hip fracture database was carried out on hip fracture patients attending a single trauma centre from January to December 2022.
• Anonymised data were extracted from the database. Patients aged 60 years and older who sustained an acute hip fracture were included. Patients with incomplete data were excluded. The IBM SPSS 29 software was used for statistical analysis.
• Descriptive statistics was used for baseline characteristics. Linear regression was used to determine correlation.

Results

• A total of 293 patients were analysed: 82 males and 211 females with a mean age of 81.6(SD 8.28) and 83.2(SD 7.85) years respectively.
• Mean 25-hydroxyvitamin D levels were 39.1 (SD 25.0) and 49.7 (SD 29.01) nmols/L respectively.
• Mean CRP/Albumin ratio was 0.94 (SD 1.51) and 0.71 (SD 1.34).
• There was a negative, statistically significant correlation between 25-hydroxyvitaminD and CRP/Albumin ratio in male patients but not in the females (r = -.274; p = .013 & r = - .035; p = .61) respectively.

Conclusion

• In this study, 25-hydroxyvitamin D levels are inversely correlated with markers of inflammation (CRP/Albumin ratio) in older male hip fracture patients but not older female hip fracture patients. More studies are needed to clarify whether vit D lowers inflammation or inflammation lowers 25-hydroxyvitamin D concentrations and to investigate the gender difference.

Background:

This cross-sectional study aimed to assess the socio-demographic, anthropometric, and patient characteristics of 94 Yoruba speakers aged 60 years and older, and to validate the Yoruba version of the Clinical Frailty Scale (CFS).

Methods:

This study used a cross-sectional design with a purposive sampling technique and a sample size of 94 participants. This study also made use of the World Health Organization methodologic guidelines on cultural adaptation of clinical scales. Convergent validity was assessed by evaluating the context that the Clinical frailty scale (CFS) relates to the Edmonton frailty scale, using the Spearman rank correlation coefficient. The known group validity was assessed using one-way ANOVA.

Results:

The mean age of participants was 70.81±8.11 years, with a mean BMI of 27.04±5.61. The cohort included 38 males (44.4%) and 56 females (59.6%). Educational attainment varied, with 20.2% having no education and 9.6% holding postgraduate degrees. The validated CFS has excellent content validity (S-CVI/AVE=0.96; S-CVI-UA=0.78). Convergent validity demonstrated a moderate correlation between the CFS and the Edmonton Frail Scale (Spearman's rho=0.61, p<.01). Known-group validity indicated significant associations between frailty, age (p="0.007)." and BMI.

Conclusion:

The Yoruba version of CFS is a valid tool for assessing frailty in elderly Yoruba-speaking populations.

Introduction:

Navigating dementia care is challenging, but patient navigation (PN) offers valuable support for this population. The "Navigating Dementia NB / Naviguer la démence NB" program piloted a PN program in New Brunswick, Canada, targeting people living with dementia (PLWD) and their carers. The program aimed to assist participants in navigating health and social care systems, matching their needs with available services.

Methods:

Navigating Dementia NB was co-developed by researchers, patient partners, and clinicians. This pilot program embedded six PNs in primary care clinics/centers across the province between July 2022 and July 2023.  Using a mixed methods approach, participant surveys and interviews were used to explore program benefits and recommendations for improvement. Focus groups were used to explore facilitators and barriers to program development and implementation.

Results:

There were 150 participants (PLWD and carer dyads) enrolled in the PN program who provided informed consent. Interviews were conducted with 36 PLWD and their carers. Focus groups were conducted with nine members of the research team and five patient navigators.  Program benefits included: emotional support from navigators, provision of relevant information, and facilitating connections to appropriate services. Recommendations for improvement included: the need for PLWD and their carers to have access earlier in the patient journey and the need to reassess provincial policies related to home care support. Facilitators for implementing a PN program included: providing appropriate staff training and leveraging established connections within the health and social systems.  Barriers included a compressed timeline and existing systemic issues to service access.

Conclusions:

The findings suggest that embedding PN for PLWD in community based primary care can be done.  The program was beneficial for PWLD and their carers. Future plans involve partnering with government to support the implementation and evaluation of a province-wide scale-up of the PN program for this population.

Introduction:

It is expected that by the fourth decade of the 21st century, chronic obstructive pulmonary disease (COPD) will become the third leading cause of death worldwide. These data require awareness among treating physicians of these patients. 

Material and Methods:

A pilot study was conducted from January 2020 - December 2022 in a South American health institution in which cardiovascular risk was estimated using GLOBORISK and ATP-III criteria. Data derived from the metabolic profile included in the ATP-III criteria were collected. Quantitative variables are presented as mean ± standard deviation or median (interquartile range) according to their distribution and qualitative variables as percentages. Student's t-test was performed to evaluate differences between two variables. All statistical analyses were performed with (SPSS for Windows, v.22.1; Chicago, IL).

Results:

The present study showed that metabolic syndrome variables in these patients were elevated. Male sex was 77% and female 23%, smoking 61%. The GLOBORISK equation found mostly patients with low to moderate cardiovascular risk. It was found that there was a higher cardiovascular risk in those patients with FEV1 less than 30%, showing a statistical correlation of this alteration for the GLOBORISK scale.

Conclusions:

This is the first pilot study that estimates cardiovascular risk using GLOBORISK in the COPD population. We consider integrating national and international networks to compare the results found here.
 

Introduction:

Delirium, an acute neuropsychiatric syndrome, affects one in four hospitalised older adults. Effective management requires timely detection using validated tools and a structured approach to causes and sequelae. There is limited evidence on contextual factors surrounding assessment tool implementation and delirium management. The primary aim of this study was to describe the use of validated delirium assessment tools across Scotland, with a secondary aim of describing protocols for delirium management and barriers to implementation.

Methods:

This was a secondary analysis of national Scottish data from a global point-prevalence study conducted on World Delirium Awareness Day, March 15, 2023. Data were collected via an anonymous survey distributed through social media and professional networks, covering inpatients in acute hospitals, including ICUs, at two timepoints (8am/8pm). The survey collected data on the presence of delirium, delirium assessment tools used, management protocols, and barriers to effective delirium care.

Results:

A total of 120 survey responses were received from 13 hospitals, reporting on 3257 patients at 8am and 2436 patients at 8pm. Most respondents were doctors (72.5%). The most frequently reported assessment tool was the 4AT (75%), and 14.2% of units reported using personal judgement rather than a validated tool. The overall delirium prevalence was 22.3% at 8am and 23.2% at 8pm, with the highest rates observed in geriatric units. Most units had delirium management protocols, but reported barriers to implementing delirium assessment and management including staff shortages, lack of time and insufficient training.

Conclusion:

This study highlights widespread use of the 4AT for delirium assessment in Scotland. There is variation in existing delirium management protocols, and significant barriers remain to effective implementation. Findings emphasise need for ongoing awareness, education, and resources to improve delirium care. Future research should focus on developing delirium management protocols and exploring context-specific barriers to improve patient outcomes.

Background:

Heart Failure (HF) is a major cause of poor health, hospitalisation, and death, particularly amongst older people. Routinely prescribed HF medication can improve these outcomes, but many patients do not take their medications. Aims: To develop a tailored multi-component intervention to enhance medication adherence in older HF patients in preparation for a future pilot RCT. Objectives: To determine what intervention components and strategies are necessary and acceptable to create a support package to help and encourage HF patients to take their medication regularly. To develop an intervention manual to support the delivery of the proposed intervention.

Research methodology:

The study is an intervention development study using qualitative methods and an intervention development tool. To ensure that the experiences, beliefs, and preferences of HF patients are included the intervention is being co-developed with stakeholders including patients, informal carers, cardiologists, geriatricians, health psychologists, HF nurses and pharmacists using an iterative process where decisions about content, format, style and delivery are made together. Findings from previous work are being mapped to the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework(TDF). Key factors known to improve adherence will be combined with motivational strategies and factors personal to each individual to develop a novel intervention. An expert panel including two HF patients will meet to co-design discuss, review, and agree the mapping decisions. Once the behaviours to be targeted for change are identified the TDF will be used to specify these behaviours in terms of who needs to do what differently, when, where how and with whom? During the process HF patients will also be recruited to participate in several focus groups to evaluate the outcomes of the mapping exercise and identify any concerns or potential barriers to delivery as the intervention is refined. Finally the intervention will be manualised ready for piloting.

Introduction

Orthopaedic surgery is an important treatment for musculoskeletal (MSK) conditions. In the NHS, 25% of all surgical interventions are for MSK conditions and account for 16.1% of the total cost of surgery. Complications following joint surgery include venous thromboembolism, infection, stroke, myocardial infarction, falls and delirium. Remote ischaemic conditioning (RIC) is a technique which induces intermittent ischaemia of a limb, through inflating a tourniquet above systolic blood pressure for intervals that avoid physical injury but trigger several intrinsic protective mechanisms.

Method

A systematic literature search was performed in Pubmed, Medline and Embase for studies investigating RIC in fracture, trauma or orthopaedic surgery, published between 1966 and November 2023. Pre-clinical trials and clinical randomised controlled trials (RCTs) were included. There was insufficient data to conduct meta-analyses, so a narrative review was undertaken. PEDro risk of bias scale was performed on RCTs.

Results

Three pre-clinical trials studied RIC in animal models. Results showed a reduction in markers of oxidative stress and up-regulation of genes involved in osteoblast expression, causing improved fracture healing. 20 clinical RCT manuscripts considered the used of RIC in elective and emergency orthopaedic surgery. In total, 1276 participants were studied, and protocols used one dose of RIC prior to surgery. 17 studies demonstrated statistically significant positive outcomes in RIC compared to control, including known mechanisms of RIC such as oxidative stress, inflammation and oxygenation. Additionally, when measured, post-operative pain was improved and there were fewer cardiovascular complications in at-risk individuals.

Conclusions

There is evidence that RIC has a positive effect in orthopaedic surgery, however the populations and outcomes measured were varied. Repeated use of RIC, including post-operative doses, may result in more profound beneficial effects. There is a need for designed RCTs to test whether this intervention can improve the clinical outcomes in wider populations.

Aims

Understanding patients’ wishes regarding CPR before surgery is crucial. This study aims to assess the impact of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision on anaesthetists' actions during theatre.

Methods

We used WhatsApp, to present a scenario of an 83-year-old with ischemic heart disease, cognitive impairment, and an acute hip fracture. Anaesthetists were asked how they would handle various intraoperative events and whether a prior DNACPR decision would influence their actions.

Results

A total of 74 UK anaesthetists, all but one of them consultants, completed the anonymous survey. A surprising number N=27, (37%) of respondents indicated that prior knowledge of a DNACPR decision would have altered their preparedness to anaesthetise the patient.

Despite a pre-existing DNACPR decision N=68 (92%) stated that they would attempt electrical cardioversion if a patient became hypotensive with a regular broad complex tachycardia, as would N=65 (88%) in response to ventricular fibrillation during surgery. N=36 (49%) would initiate chest compressions in theatre if patient failed to respond to electrical cardioversion, but only N=2 (3%) would continue with intubation, ventilation and discussion with critical care if the patient failed to respond to three cycles of compressions and cardioversion.

Conclusion

It is important for anaesthetists to discuss the nuances of different elements of CPR as part of patients’ pre-operative assessment, as it is much more likely to be successful in theatre than in the ward or community settings that most DNACPR discussions will consider.

Raising the topic of resuscitation can lead to anxiety among patients and their families, Our study has shown that most anaesthetists will set aside a DNACPR decision anyway if problems arise in theatre.

An 80 year old man living independently with his wife presented with progressive unsteadiness, generalised weakness and muscle aches over 2 months, following a short episode of flu-like symptoms. Systems review revealed shortness of breath, a hoarse voice, 2kg weight loss and occasional non-drenching night sweats. Bloods showed elevated WCC, CRP and ESR. He was started on 20mg of prednisolone for a working diagnosis of polymyalgia rheumatica. These symptoms did not improve, even after this increased to 30mg. He was admitted to hospital after he developed left leg weakness evolving over the course of 1 day. On examination, he had generalised muscle wasting, no fasciculations, preserved reflexes, left sided foot drop and right sided ulnar nerve palsy. MRI head and spine did not reveal a structural cause. CT thorax-abdomen-pelvis showed no evidence of malignancy, lymphadenopathy or hepatosplenomegaly. An autoimmune screen revealed a strongly positive rheumatoid factor, but negative ANA, ANCA, anti-DSDNA antibodies. A myositis panel and anti-neuronal antibodies were negative. CSF biochemistry showed normal cell count and protein level, with negative oligoclonal bands. Nerve conduction studies suggested a chronic axonal length-dependent peripheral neuropathy and a degree of myopathy. He then developed symmetrical bilateral foot drop and median nerve palsies. FDG-PET-CT showed increased activity within various visualised skeletal muscles- due to either myositis, denervation or physiological changes. Muscle & sural nerve biopsy showed no myositis, but intense inflammation and arterial wall destruction with moderate axonal degeneration suggestive of vasculitic neuropathy. A diagnosis of mononeuritis multiplex caused by tissue-specific vasculitis was made. He received pulsed IV methylprednisolone before starting rituximab. He was discharged when his mobility improved. This case demonstrates that vasculitis can present without rash and mimic polymyalgia rheumatica, which is more common in older patients. Thorough examination and revisiting the diagnosis if steroids do not show improvement is advised.