Scientific Research

Background and Objectives: Polypharmacy is common in frail older adults who often live with multiple co-morbidities. This polypharmacy can carry a significant anticholinergic burden. Frail older adults are particularly sensitive to the anticholinergic side effects of medications which can include constipation, urinary retention and dry mouth. Medications with a high anticholinergic burden scores have also been evidenced to contribute to an increased frequency of falls, cognitive decline and increased mortality. For frail older adults, a medication review, considering anticholinergic burden, is therefore an essential part of Comprehensive Geriatric Assessment. A local frailty census was completed for all medical inpatients over the age of 65 years old and as part of this anticholinergic burden scores were collated.

Materials and Methods: As part of this whole hospital frailty census, an anticholinergic burden score (ACB) was calculated for 77 inpatients. This was calculated using the Anticholinergic Cognitive Burden Scales and Anticholinergic Burden scores.

Results: The average age of the patients was 80.19 (± 9.35). 80.01% of patients were taking one or more medications with an anticholinergic burden. Of those, 40.25% had a significant ACB score of 3 or more (3-8). The patients with the highest ACB scores were those with multi-morbidity, an already established diagnosis of dementia and patients with recurrent falls.

Conclusions: The ACB score for patients included within this frailty census appeared to correlate with certain co-morbidities as would be expected from the known complications associated with these medications in frail older adults. The proportion of our inpatients with a significant ACB score informs us that we need to develop a more robust approach to delivering polypharmacy reviews as part of Comprehensive Geriatric Assessment within our hospital and will help us to inform future service planning and delivery.

Background: Studies show that newly qualified doctors feel unprepared for clinical practice in several key areas in the care of older people, despite older people occupying two thirds of inpatient beds [1,2]. Grounded in experiential learning theory, simulation has been hugely effective in undergraduate education in geriatric medicine [3]. We aimed to evaluate a novel simulation series exploring practically challenging aspects of geriatric medicine, such as ‘silver trauma’ and using de-escalation strategies in the management of delirium. Methods: Using quality improvement methodology, we developed two inpatient simulation scenarios for fourth-year medical students on their geriatric medicine clerkships. The scenarios (managing delirium and post-falls assessment) are commonly encountered during on-call shifts, with learning outcomes aligned to Outcomes for Graduates. Our initial cycle involved eight students piloting the two scenarios and evaluation tool. Using their feedback, we will iteratively improve the methods and evaluation before repeating and obtaining pre- and post-simulation data on students’ ‘preparedness for F1’. Results: Following the pilot, 100% of participants agreed that they felt more prepared for clinical work in geriatrics as an F1 doctor. 12.5% felt confident assessing a patient following a fall pre-session, which increased to 100% afterwards. Confidence in using de-escalation techniques in managing delirium improved from 50% (pre-) to 100% (post-session). Common themes in free-text feedback were that the simulation felt realistic and effectively tested prioritisation. Conclusion: Our work highlights the merits of using simulation in geriatric medicine to help undergraduates prepare for the complexities and uncertainty involved in caring for the ageing population.

References 1. Monrouxe LV, Grundy L, Mann M et al. BMJ Open. 2017;7(1). 2. British Geriatrics Society. Protecting the rights of older people to Health and Social Care [Internet] 2023. 3. Fisher JM, Walker RW. Age and Ageing. 2013 Dec 18;43(3):424–8.

Introduction:

Older patients attending the Emergency Department (ED) and discharged home are at higher risk of adverse outcomes. Geriatric Ambulatory ED services were developed with the aim to deliver goal-directed care of older patients from ED using onward referral to Community Providers.

Method:

A retrospective review was undertaken from 13th January 2022 to 23rd December 2022 in older patients discharged from the ED following a targeted geriatric assessment and recommended community follow-up interventions. Demographic information, functional ability, hospital utilisation and mortality (up to one year), and any post-visit fragility fractures were reviewed. Data collection included identification of osteoporosis or osteopenia during or following the index ED visit.

Results:

108 patients were assessed, of whom, 74% were female, average age 76 years, range 61-93 years. 65% of patients were CFS scored, 9% were CFS 6 or 7, 15% CFS 4 or 5 and 41% CFS 1-3. GP review was advised for 76% of patients and 61% attended and therapy interventions were recommended for 9.3%, of whom, 3% attended. The majority presented with falls (82%) and half of those who fell, sustained a fracture. Osteoporosis or osteopenia was newly identified in 30% but in 44% of patients bone health remained unevaluated and only 8% had newly initiated anti-resorptive and 9% existing treatment. 4% experienced fragility fracture following their ED visit. Uptake was low for therapy (30%) and nursing interventions (14%). Following the index ED visit, 7% patients attended ED within 7-days, and 5% admitted to hospital within 30-days. 35% of patients re-attended ED and 22% were hospitalised within one year. One year mortality was 5%.

Conclusion:

ED targeted geriatric assessment can identify patients with falls and fragility fractures but better collaboration and communication between primary and secondary care is needed. Recommended bone health assessment occurred in a relatively small proportion of patients.

Introduction

The prevalence of dementia is increasing and yet healthcare professionals (HCP) do not always have sufficient education and training to deliver optimal care for patients with dementia (PWD). There is an evidence base as to how to deliver effective undergraduate education about dementia but this is infrequently integrated into the medical curriculum.

Methods

We undertook a realist synthesis to review the barriers to integrating effective interventions on dementia into the medical curriculum. A realist synthesis differs from a traditional systematic review in terms of explaining how interventions might succeed (or not) in a particular context, involving iterative cycles of literature review and synthesis to develop and refine a “programme theory” (PT).

Results

We analysed and synthesised twenty relevant studies of undergraduate educational interventions on dementia to identify common themes. We constructed an “initial programme theory” (IPT) to illustrate the contexts where teaching on dementia occurs, and outline four main categories of barriers to curriculum integration: culture, concern for patient welfare, student attitudes, and logistics.

Conclusion

We have identified key barriers to implementation of undergraduate education about dementia, and potential mechanisms to overcome them. The next stage of our realist synthesis is to gather stakeholder feedback on the validity of the IPT before returning to the next cycle of literature review to refine and finalise our PT. This model will serve as a guide for those aiming to successfully integrate effective education about dementia into the medical curriculum.

Introduction Medication-related harm (MRH) is defined as any negative outcome, harm or injury caused by taking a medication (Falconer et al. Eur J Clin Pharmacol, 2018;75(2):137-145). People living with dementia (PLWD) take more medications than those without dementia, increasing their risk of MRH (Mueller et al. Exp Gerontol 2018;106:240-245). There is urgent need to explore the scale of MRH affecting PLWD. This systematic review aimed to determine the prevalence of MRH in PLWD and evaluate various outcomes to assess its impact.

Methods Twelve databases were systematically searched for articles published in English from date of inception to April 2023. Papers of any study design reporting on the prevalence and/or outcomes of MRH in PLWD were eligible for inclusion. Quality was assessed using the Cochrane Risk Of Bias tool for randomised trials (ROB-2) or the Risk Of Bias In Non-randomised Studies of Exposures (ROBINS-E). Due to lack of consensus on the definition of MRH and the heterogeneity of included studies, a narrative synthesis will be undertaken.

Results In total, 5,951 articles were identified, and 4,946 remained following removal of duplicates. After title/abstract screening, 419 full-text articles were assessed for eligibility. Ninety-eight studies were included in the review. Quality assessment is ongoing. Overall, 29 studies investigated adverse drug events, affecting 5-83% of participants, and 22 studies assessed mortality associated with drug use, with most reporting an increase in mortality. Antipsychotics were the most commonly implicated medication class, studied in 24 papers.

Conclusion This systematic review is the first to report on the prevalence of MRH in PLWD. However, it will not be possible to conduct a meta-analysis to fully analyse the scale of this issue. This review will identify gaps in the current evidence base and inform future research aiming to explore factors contributing to, and ways to reduce, PLWD experiencing MRH.

Introduction:

Neck of femur fractures (NOF) remain a significant cause of mortality in the elderly, especially in those who develop delirium post operatively. The aim of our study is to identify risk factors that may contribute to developing a delirium.

Method:

A prospective cohort study of 717 patients presenting to Morriston Hospital who underwent operative management for a NOF fracture.

Results:

A total of 103 patients developed a post-operative delirium, an incidence of 14.4%. Clinical Frailty Score (CFS) and Abbreviated Mental Test Score (AMTS) proved to be significantly associated with developing delirium (p<.0001). delirium was highly prevalent in patients with moderate frailty (cfs6≥) and an abnormal amt score (<8), present 70% 73% respectively individual odds ratios of 4.1 5.2. delirious suffered higher inpatient mortality (16% v 5%, p 0.0004), increased length stay (32 vs 23 days, <0.0001) were more likely to be directly institutionalised (10% 3% 0.002) without rehabilitation. admission inflammatory markers prolonged waiting times for theatre both groups not pursued.

Conclusions:

Presenting amts at greatest risk developing a which associated poorer outcomes. we propose identifying high-risk from the point ensure early targeting potential reversible factors. toolkit could aid these there may also argument prioritisation individuals list given their mortality. 

Introduction

Emergency department (ED) frailty screening is recommended in guidelines for its potential to trigger earlier and more appropriate comprehensive evaluation and intervention for the most vulnerable patients. Post-implementation studies of the Clinical Frailty Scale (CFS) typically observe around 50% concordance with screening. Little is known regarding the characteristics of those people omitted.

Methods

The Frailty in European Emergency Departments (FEED) cohort study observed prevalence of frailty, administering the CFS to consecutive attenders over twenty-four hours. Retrospective “normal day” data from two weeks prior were also collected, where sites used retrievable electronic health records. Age, sex, ethnic group, mode and time of arrival and departure, NEWS2 score, and use of resuscitation areas were recorded. CFS missingness was assessed for distribution and dependency with other variables using chi-squared tests. The frailty distributions in prospective and retrospective data were compared with the Kruskal-Wallis test.

Results

Only five of sixty-two sites collected CFS scores in retrievable electronic records. The cohorts included 368 individuals prospectively and 399 retrospectively. At these sites, 14% prospective and 55% retrospective CFS observations were missing. CFS entries were more frequently missing in people with non-white ethnic group (p=0.007) and self-presentation (p<0.001). The distributions of CFS differed significantly (p=0.009); on the retrospective day, no individuals were assigned CFS scores 1 or 9, and CFS scores 4 and 6 were over-represented.

Conclusion

Acknowledging the limited participation and use of snapshot data, these findings alert the presence of systematic, non-random missing data in routine CFS screening. Systematic missingness in frailty data has critical implications for research in geriatric emergency medicine, presenting real limitations in validity where studies seek to analyse routinely collected data to reach representative inferences. Screening practices and retrievability of data warrant further study and improvement.

Introduction

The frailty index (FI) is a frailty assessment tool calculated as the proportion of the number of deficits, or “things that individuals have wrong with them”, to the total number of variables in the index. Routine health and administrative databases are valuable sources of deficits to automatically calculate FIs. There is large heterogeneity in the deficits used in FIs. This sub-analysis of a scoping review on routine data-based FIs aimed to describe and map the deficits used in multi-dimensional FIs.

Methods

Seven databases were searched to find literature published between 2013 and 2023. The main inclusion criterion was multi-dimensional FIs constructed from routinely collected data. Multi-dimensional FIs should have deficits in at least two of the following categories: “symptoms/signs”, “laboratory values”, “diseases”, “disabilities”, and “others”.

Results

Of the 7,526 publications screened, 61 distinct FIs were identified from 60 included studies. Most FIs were developed in hospital settings (n=19). The most dominant data source of deficits to calculate the FIs was hospital records (n=23). The median number of deficits used in the FIs was 36 (range = 5–72). We identified 611 unique deficits that comprised the FIs. Most deficits were either “diseases” (34.4%; n=205) or “symptoms/signs” (32.1%; n=196), followed by “disabilities” (17.0%; n=101), “others” (10.1%; n=60), and “laboratory values” (8.3%; n=49). Forty-seven deficits were present in ≥20% of the FIs (≥12 FIs). The most common “disease” was diabetes, “symptom/sign” was depression, “disability” was hearing loss, and “laboratory value” was anaemia & haematinic deficiency.

Conclusion

These findings highlight the reactive approach to frailty assessment, as most of these FIs were calculated from hospital data and used symptoms/signs and diseases as deficits. Given the heterogenous manifestations and long-term impacts of frailty, using a more proactive approach that leverages non-clinical routine data is warranted to prevent frailty development and progression.

A Scoping Review of Guidelines and Resources to Promote Evidence-Based Prescribing for Older People with Sensory Impairment (OPwSI)

BC Morrison1; E Asante2; MR Lennon2; MC Watson1

1. Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow; 2. Department of Computer and Information Sciences, University of Strathclyde, Glasgow

Introduction

By 2030, hearing impairment is expected to affect one in four people globally (WHO, 2022) and one in five in the UK (Hearing Link, 2023). Visual impairment is projected to impact 2.7 million people in the UK by 2030 (ONS, 2020), rising to 4 million by 2050. The prevalence of hearing and visual impairment (hereafter referred to as sensory impairment (SI)) increases with age and older people with SI often experience substantial challenges with medicine management compared with older people without SI (Alhusein, 2019). This review aimed to identify guidelines and resources for prescribing decisions for older people with sensory impairment (OPwSI).

Methods

Standard Joanna Briggs Institute [JBI] methodology (Page, 2021) for scoping reviews was used. Electronic databases were searched: MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Qualitative and quantitative studies published between January 2012 and April 2023 were included. Grey literature sources, including Google and Google Scholar, were also searched. Eligible studies focused on prescribing behaviour for OPwSI (aged ≥ 65 years) in primary care settings. Duplicate independent screening and data extraction was undertaken and critical appraisal was completed for all included studies.

Results

A total of 3,590 records were identified through database searching and 10 full-text articles were retrieved. Grey literature identified a further 61 records. Despite extensive searches, no studies or resources fulfilled the inclusion criteria. Several generic guidelines and resources were identified related to medicines and safe prescribing for older adults in general i.e., without specified SIs.

Conclusions

This review highlights a dearth of guidelines or other resources to support safe and effective prescribing for OPwSI. There is an urgent need to provide bespoke guidance and/or the modification of existing guidelines, to address the additional medicine-related needs of OPwSI.

Purpose

To investigate physiotherapists’ perspectives of effective community provision following hip fracture.

Methods

Qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented.

Results

Four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented.

Conclusion

Physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.