Scientific Research

Introduction: There is growing awareness of the harms caused by racial abuse and discrimination from patients towards healthcare professionals, including anecdotal reports of patients ‘requesting a white doctor’ (Kline, BMJ Opinion, 2020); yet there is limited understanding of the impact in Geriatric settings. We conducted a survey in an inpatient Older Persons Service (OPS) on the prevalence, impact and actions taken in response to patient racism towards staff.

Methods: A cross-sectional survey (Total N=47; Black and Minority Ethnic (BME) staff: N=32; White staff: N=15) of staff experiences of racist behaviour from patients and carers (July 2021) in a tertiary level inpatient OPS in an ethnically diverse London borough, both in terms of patients and staff, in the United Kingdom. The survey was developed in collaboration with OPS staff and the BME network. The anonymous survey was offered to all nurses, doctors, allied healthcare professionals and non-clinical staff on two 26-bed wards.

Results: Sixty-nine percent (22/32) of BME staff had personally experienced racist behaviour from older patients, while witnessing racism towards colleagues was reported by 62% (18/29) of BME staff and 80% (12/15) of White Staff. Sixty-seven percent (30/45) of respondents had witnessed a patient request a different ethnicity of healthcare professional. The majority of racist incidents went unchallenged and unreported with only 39.1% challenging the patient or carer, 21.7% reporting to a senior and 8.7% reporting via the electronic incident reporting system. The impact of such incidents on staff well-being included self-reported depression (56%, n=11/21), anxiety about work (28%, n=6/21) and insomnia (14%, n= 3/21).

Conclusion: With an ageing population, staff recruitment and retention in Geriatrics is critical. Comprehensive policies that have a zero-tolerance approach to racism, support staff and encourage reporting are crucial. Future research that considers the impact of mental capacity and cognitive impairment would be beneficial.

Introduction

Despite the knowledge that oral anti-coagulation (OAC) is effective in secondary prevention of stroke, prescribing rates are low in frail older patients with atrial fibrillation (AF), dementia, and high fall risks. A joint decision-making approach between clinicians, patients and carers is needed to negotiate the risk-benefit balance. The aim of this participatory study was to engage with a group of older adults, their carers and healthcare professionals to identify key themes that will inform a planned qualitative study exploring frail older patients’ acceptance of and adherence to OAC.

Methods

We identified a group of twenty-eight adults (aged >65 years) and carers from community partners: ‘Ageing Well’ platform, Health Watch team, and the University of the Third Age (U3A) in Brighton and Hove, East Sussex, UK. Using two case vignettes of hypothetical OAC decisions, we hosted two virtual focus group meetings with the above cohort, followed by a virtual meeting with four geriatricians, two pharmacists, a GP and a patient champion. Inductive thematic analysis was performed on the group discussions by two researchers independently. 

Results 

Five key themes were identified as crucial to include in the future qualitative study discussions : (i) age should not be a barrier to anti-coagulation (ii) individualised, holistic assessment by a specialist is mandatory (iii) annual review of anti-coagulation should be performed, revisiting patients and carers' understanding of the risks and benefits (iv) patient and carer education should be tailored to their medical and social background, and (v) quality of life should be a key factor in OAC decisions.

Conclusion

Engaging with a group of older adults in a co-development exercise helped identify key themes for a future study of anti-coagulation in frail older adults with AF.

Introduction :

This study demonstrates how a network of geriatric medicine trainee representatives was established across the UK. The intention of the network was threefold: accurately represent the interests of trainees by gathering national feedback, develop a job description of deanery trainee representatives and create a community of practice between representatives.

Method:

Deanery trainee representatives were identified through TPDs then contacted to participate in an online questionnaire which also consented for whatsapp group invitation.

Results:

Deanery representatives were identified for 12 out of 13 deaneries, the final post was vacant. The survey response rate was 83% and all respondents gave permission to be added to the whatsapp group. We gathered information regarding eligibility, appointment and the role of deanery trainee representatives. Most deaneries (73%) do not require representatives to be a minimum grade whereas 27% required representatives to be ST4 or above. Over half (55%) were appointed following an expression of interest without an election, 27% required an election and 9% were approach and appointed directly either by the TPD or current representative. Once appointed 82% had no fixed term whilst 18% would have a term limited to two years. Once appointed the role entails an invitation to the local higher specialty training committee for 73% of respondents and 73% also reported a role in organising regional training.

Conclusions:

The aim of this project to create a network between deanery representatives has been achieved and produced an engaged network of representatives facilitating accurate representation of trainees at a national level. Further applications include collaboration between trainees to share training practices. In a period of training recovery following the Covid-19 pandemic and a new geriatric medicine curriculum a community of practice between trainee representatives has enormous potential to improve training quality and experiences for geriatric medicine trainees in the UK.

Introduction

Dementia with Lewy bodies (DLB) is the second most common form of dementia, however it can be difficult to recognise and is often misdiagnosed. Many cognitive, motor and psychiatric symptoms occur in the prodromal phase of DLB, years before clinical diagnosis. Delirium-onset DLB is one of three purported prodromal pathways by which DLB develops (McKeith et al., 2020). As delirium itself is an under-recognised clinical syndrome, this scoping review aimed to determine the epidemiology and clinical phenotype of delirium-onset DLB.

Methods

Electronic databases MEDLINE (ALL), Embase, Web of Science and PsycINFO were searched in December 2023. Two reviewers then independently screened titles, abstracts and full-text reports. Conflicts were resolved by a third reviewer. Data were then extracted by the lead reviewer and quality assessments were conducted.

Results

Following the removal of duplicates, the search yielded 719 results. Of these, 154 studies underwent full-text review and 38 were eligible for inclusion. This review describes 64 cases of delirium-onset DLB in case studies/reports (n=18), observational studies (n=3), retrospective cohort studies (n=12) and clinicopathological studies (n=5).

Conclusion

Delirium-onset DLB is an under-researched area. There is a dearth of evidence regarding both the epidemiology and clinical phenotype of this prodromal phase. Clear and systematic methods for the diagnosis of both delirium and DLB are needed in order to elucidate this pathway. At present, it is not clear what role biomarkers play in the detection of delirium-onset DLB. Further investigation of these tools, combined with neuropathological studies, could shed light on the pathogenesis of this disease.

Introduction

Motor Neurone Disease (MND) is a neurodegenerative condition affecting the spinal cord and brainstem, commonly associated with a reduced life expectancy. This study describes demographic trends in MND-associated mortality in the United States over 20 years.

Methods

Data were extracted from the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research Underlying Cause of Death database. Death certificates from 1999-2020 with MND (International Classification of Diseases-10th Revision code G12.2) recorded as the cause of mortality were extracted and annual MND-associated crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) per 100,000 persons with 95% confidence intervals (CI) were calculated. Joinpont regression was used to calculate the annual trends in MND-associated mortality by calculating the annual percentage change.

Results

Between 1999 to 2020, there were a total of 140,945 MND-associated deaths. Overall AAMR was 1.9 per 100,000 persons (95% CI 1.9-1.9). Male sex had a consistently higher AAMR (2.3 per 100,000 95% CI 2.3-2.3) than female sex (1.6 per 100,000 95% CI 1.5-1.6). White patients had higher AAMR (2.1 per 100,000 95% CI 2.0-2.1) than Black/African Americans (1.1 per 100,000 95% CI 1.0-1.1), American Indians/Alaska Natives (0.8 per 100,000 95% CI 0.7-0.9), Asians/Pacific Islanders (0.8 per 100,000 95% CI 0.7-0.9). The 3 US States with the highest AAMR were Vermont, followed by Minnesota and Maine.

Conclusions

This national study demonstrates that there were a significant number of MND-associated deaths in the United States, with higher rates associated with certain patient demographics. The knowledge of these trends facilitates the design of appropriate services in areas of higher need, allowing for the introduction of pathways that support more suitable care and enhanced quality of life.

Introduction:

Many UK care home (CH) residents live with multiple long-term conditions, leading to high levels of healthcare utilisation. Previous studies have used routine data to describe their health and social care characteristics separately. Accurately identifying when an individual is admitted to a CH from routine data is challenging. This study aims to provide a combined health and social care profile of a cohort of long-stay CH residents, at the point of admission, using linked primary, secondary and social care data.

Methods:

Individuals aged 65 and over registered to a GP practice contributing to the ‘Connected Bradford’ dataset who were admitted to a CH between January 2016 and December 2019 were included. Start and end dates for social care packages (nursing and residential) were identified from local authority social care data. Respite and reablement packages were excluded. Complete self-funders were not identified with this method. Linked secondary and primary care data were used to describe health characteristics. CH residents identified using primary care records and local authority data will be compared.

Results:

2,801 individuals were admitted to a CH during the study period of whom 1998 (71%) were long-stay residents (>6 weeks). Only 72% of participants identified using local authority data, had a primary care code indicating CH residency in their primary care records. Median length of stay was 272 days (IQR 63 to 480). Mean age at admission was 85 years (SD 8), median Index of Multiple Deprivation decile five. 59% of residents required nursing care from admission. 79% of individuals were taking 5 or more medications.

Conclusions:

Using local authority data offers a novel way to identify and characterise CH residents. Linkage of primary care records to local authority data improves identification of CH residents using routine data. Additional linkage with address history would further improve accuracy.

BACKGROUND

• RSV is one of the most common causes of seasonal respiratory infections worldwide, with a marked global burden in older adults and those with significant underlying medical conditions.1-5 It is increasingly clear that RSV infections in older adults in the United Kingdom significantly impact the already strained public health system, especially during the winter months.
• However, the true burden remains underestimated,6,7 as estimates in the UK are likely to be conservative due to the limitations in testing and diagnostic coding practices.

OBJECTIVES

• We conducted a TLR of existing literature to investigate the disease burden of RSV infection in older adults, aged 60 years and older in the UK, and to highlight potential evidence gaps. METHODS • We searched OVID MEDLINE, Embase, and EconLit to identify existing literature from January 2011 to August 2023, including an additional search for grey literature. Eligibility criteria were defined based on population (intervention/comparator [no limit]), outcomes (clinical, epidemiological, economic, and quality of life) and limited to UK-only results. See PRISMA flowchart for details.

RESULTS

• In the OVID search, we identified 1,001 records, and in the supplementary search, 12 records of possible interest were identified. All records were screened against the predefined eligibility criteria. Despite the relatively broad screening criteria, only 14 studies could be included.
• There were four model studies, five cohort studies, and five time series analyses included. Of these, nine studies reported on epidemiology, one study informed both on epidemiology and costs, and four studies reported on model outcomes. Nine studies reported unique data on the UK and five studies included data from several countries, including the UK.
  • All identified studies emphasised the challenges in estimating the true RSV burden in the UK due to limitations in testing and a lack of standardised disease definition in older adults. There is a lack of evidence for adult risk groups, particularly clinical and economic consequences in patients at a higher risk of RSV infection and severe sequelae.
  • Due to the overall small number of studies and the heterogeneity of study design and outcomes reported, it was not possible to establish reliable data on incidence, prevalence, and mortality in the UK.

• The results of the TLR suggest that RSV infection in older adults may place a high economic burden on the UK’s healthcare system.

CONCLUSIONS

• A limited number of studies meeting the criteria on RSV infection in older adults in the UK were found, with nearly no data on adult risk groups and related cost. The scarcity of data, lack of standardised disease definitions and surveillance methodologies likely lead to an underestimation of RSV disease burden in older adults in the UK.
• It is imperative that surveillance systems are improved to understand the true burden. Therefore, a deeper comprehension of the impact of RSV infection within this population would enhance the ability to demonstrate the cost-effectiveness of a national immunisation programme more reliably.
• This paucity of data creates great challenges for the Joint Committee on Vaccination and Immunisation, and UK policymakers to make informed decisions on the population benefit of RSV vaccination programmes for older adults.

ADDITIONAL INFORMATION

Copies of this presentation obtained through the QR code are for personal use only and may not be reproduced without permission of the authors.

REFERENCES

1. Nguyen-Van-Tam, J.S., et al., Burden of respiratory syncytial virus infection in older and high-risk adults: a systematic review and meta-analysis of the evidence from developed countries. European Respiratory Review, 2022. 31(166): p. 220105.

2. Falsey, A.R., et al., Respiratory syncytial virus infection in elderly and high-risk adults. New England Journal of Medicine, 2005. 352(17): p. 1749-1759.

3. Falsey, A.R., et al., Respiratory syncytial virus–associated illness in adults with advanced chronic obstructive pulmonary disease and/or congestive heart failure. Journal of Medical Virology, 2019. 91(1): p. 65-71.

4. Global Burden of Disease 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infectious Diseases, 2018. 18(11): p. 1191-1210.

5. Savic, M., et al., Respiratory syncytial virus disease burden in adults aged 60 years and older in high‐income countries: a systematic literature review and meta‐analysis. Influenza and Other Respiratory Viruses, 2023. 17(1): p. e13031.

6. Korsten, K., et al., Burden of respiratory syncytial virus infection in community-dwelling older adults in Europe (RESCEU): an international prospective cohort study. European Respiratory Journal, 2021. 57(4): p. 2002688.

7. Sharp, A., et al., Estimating the burden of adult hospital admissions due to RSV and other respiratory pathogens in England. Influenza and Other Respiratory Viruses, 2022. 16(1): p. 125-131.

ACKNOWLEDGEMENTS

Writing and/or editorial assistance was provided by MEDiSTRAVA and was funded by Moderna, Inc. This study was funded by Moderna, Inc.

DISCLOSURES

ICON (MM, BB) was commissioned by Moderna, Inc., to conduct the TLR. SC, MD, OB and TA are employees of Moderna, Inc., and hold stock/stock options in the company.

OBJECTIVE: To assess in Alzheimer’s disease (AD), the treatment impact of donanemab, an amyloid plaque-reducing monoclonal antibody, on readily interpretable item-measures and constructs that matter to patients, care-partners, and clinicians.

BACKGROUND: Positive outcomes were reported from TRAILBLAZER-ALZ2, a randomized, double-blind, placebo-controlled, 18-month, phase 3 study evaluating donanemab as an investigational treatment for mild cognitive impairment (MCI) or mild dementia due to AD. In 1736 participants, donanemab significantly slowed the rate of clinical decline (by 22-36%) as measured by the integrated AD Rating Scale (iADRS) and the Clinical Dementia Rating Scale—Sum-of-Boxes (CDR-SB); both measures of cognition and function as indications of global clinical severity. In these subsequent post-hoc exploratory analyses, the impact of donanemab treatment on individual iADRS cognition and function items, CDR domains, and risks of advancing to greater disease severity were assessed.

METHODS: Mixed model repeated measures and Cox proportional hazard modeling methodology assessed treatment effects on iADRS items and CDR domains.

RESULTS: Donanemab treatment was associated with significant beneficial effects on: 1) iADRS cognitive items related to episodic memory and executive function, and instrumental activities of daily living items related to communication and others (e.g., being left alone, making a meal, using household appliances); 2) all CDR-SB cognitive and functional domains (i.e., memory, orientation, judgment/problem solving, community affairs, home/hobbies, and personal care); and 3) lowering risk of progression to a more advanced clinical stage of disease.

CONCLUSIONS: These analyses explored the impact of donanemab treatment on constructs that matter to and are considered more readily interpretable by patients, care-partners, and clinicians. These results provide further support that treating those with MCI or mild dementia due to AD with donanemab can meaningfully reduce risk of progression to more severe clinical stages (e.g. moderate stage dementia), and potentially allow greater independence for a longer period of time.

 Introduction: The ageing population means all doctors, regardless of specialty, will need knowledge, skills, and attitudes to care for older people with complex health conditions. An essential component of preparing the medical workforce to best care for older people is by including teaching on ageing and geriatric medicine in undergraduate medical curricula. Here we present results of the British Geriatrics Society (BGS) national curriculum survey 2021-22, highlighting progress made in undergraduate teaching in geriatric medicine.

Methods: All 35 UK GMC-registered medical schools at the time of data collection were invited to participate in an online survey on content, methodology, timing, and duration of teaching in ageing and geriatric medicine. The survey was structured around the 2013 BGS recommended undergraduate curriculum, for consistency with previous surveys.

Results: 30/35 of UK medical schools responded (83% response rate). Most teaching occurred in the fourth year of study (21/30, 70%). The majority (15/30, 50%) reported a discrete module for geriatric medicine lasting 4-8 weeks, an increase on previous surveys. However, several programmes have reduced the amount of in-person teaching since the COVID-19 pandemic. Notably, three schools reported geriatric medicine exposure lasting >12 weeks. Of these, two were integrated clerkships and one a dedicated geriatric medicine module. There is increasing focus on multidisciplinary education, with emphasis on combining virtual or simulated teaching with other healthcare professions (n=7). Every school (n=30) taught at least one topic as small-group or case-based learning.

Conclusion: There is a trend towards increasing exposure to geriatric medicine compared to previous surveys in 2008 and 2013. However, several of the programmes reporting greater exposure incorporate geriatric medicine in an integrated clerkship rather than as a dedicated module. Programmes demonstrated a move from didactic teaching towards small-group and case-based learning, employing a wider variety of assessment methods than previous.

Introduction

Geriatric syndromes are traditionally taught through didactic teaching and bed side tutorials. However, these do not consider the science of learning and the strategies needed for a novice learner. It is prudent to manage cognitive load, create associations through testing and enforce deliberate practice for a novice as opposed to an advanced learner. Case- Based discussions (CBD) serve as an apt tool to deliver knowledge covering geriatric syndromes; aimed at testing learner's understanding through its application to a simulated patient profile.

This pilot aimed to test the applicability of CBD to teach geriatric syndromes to novice learners.

Method 

A scoping review was completed by medical officers starting on their geriatric medicine rotation in a Singapore tertiary hospital to determine syndromes which they request dedicated teaching for within curriculum. Learners ranked Incontinence and Falls with Osteoporosis management as the top 2 geriatric syndromes of interest. Focus group discussion using Rogers’s theory of diffusion principle was undertaken to understand both the advantages and challenges of CBD. Clinical scenarios were curated specific to the 2 topics with learner's completing a pre session quiz beforehand to determine their baseline knowledge. The topic specific CBD was done via zoom platform with questions applied in a graded fashion; components include that of diagnosis, evaluation, and management of select syndrome. Learners completed a post session quiz 1 week after the CBD to determine retention of knowledge.

Results

Quantitative Feedback received from the learners highlighted that more than 90% would want CBD to be implemented for other geriatric syndromes. There was an improvement in the average score obtained in post session quiz for Osteoporosis from 6.09 to 6.75. However, there was notably poor participation in the post session quiz.

Conclusion

This pilot highlights that CBD should be utilized to enhance teaching of clinical concepts in geriatric medicine.